Internal Medicine Summer Board Review

1. Internal Medicine Summer Board Review Mashkur Husain

2. General Medicine Goals • High Yield Topics Review from Board Basics 3 • General Medicine 3 sessions • Total of 21 topics

3. MKSAP Questions

4. Question 1 A 46-year-old woman is evaluated during a routine examination. Her 72-year-old mother was just diagnosed with lung cancer, so the patient asks you for help with quitting smoking. She has a 27-pack-year smoking history. She made one previous quit attempt several years ago using over-the-counter nicotine gum, but she was unable to quit for more than a few days. Medical history is significant for seizure disorder. Review of systems discloses mild shortness of breath with exertion and occasional wheezing. Medications are a multivitamin and phenytoin. On physical examination, vital signs are normal. Lung examination reveals occasional wheezing and a prolonged expiratory phase. The rest of the examination is normal.

5. Answer Choice In addition to counseling regarding tobacco use, which of the following is an appropriate adjunct to increase her likelihood of successful smoking cessation? A benzodiazepine B Bupropion C Electronic smokeless cigarette use D Nicotine replacement therapy

6. Answer Choice In addition to counseling regarding tobacco use, which of the following is an appropriate adjunct to increase her likelihood of successful smoking cessation? A benzodiazepine B Bupropion C Electronic smokeless cigarette use D Nicotine replacement therapy

7. Explanation • Although both counseling and pharmacotherapy are effective strategies for smoking cessation, the combination of counseling with medication use is more effective than either intervention alone. Nicotine replacement is effective for smoking cessation; its availability in multiple formulations (gum, lozenge, patch, aerosol) allows for alternative options in patients who have not benefited from one type of therapy, as in this patient. Although centrally acting agents (bupropion, varenicline) are also effective treatment options, bupropion would be contraindicated in this patient with an underlying seizure disorder. The choice of cessation method is less important than that an effective method is used correctly by the patient; the array of treatment options allows for individualization based on patient preference, previous experience, cost, and potential side effects. Counseling may be brief or intensive; the two most effective counseling components include practical problem-solving skills and social support.

8. Many smokers indicate that stress reduction is a primary reason for their tobacco use. Although selected individuals with true anxiety disorders may benefit from anxiolytic therapy, the use of benzodiazepines as a smoking cessation medication has not been documented. Electronic smokeless cigarettes deliver a warmed aerosol through a cigarette-like device that bears the appearance, physical sensation, and possibly the taste of tobacco smoke, with the intention of helping smokers maintain the activities associated with smoking but without the harmful effects. However, their use in smoking cessation has not been established.

9. Key Point and Education Objective • Counsel a patient regarding methods for smoking cessation. • Smoking cessation is achieved more effectively with a combination of counseling and anti-smoking medication use than with either intervention alone.

10. Therapy Smoking cessation reduces all-cause mortality by up to 50%. The Five A's and the 5 R's are two motivational interviewing techniques to use when counseling for behavior change. Study Table: Behavioral Interventions for Smoking Cessation Five A’s Five R's Ask about tobacco use. Encourage patient to think of Relevance of quitting smoking to their lives. Advise to quit. Assist patient in identifying the Risks of smoking. Assess willingness to quit. Assist the patient in identifying the Rewards of smoking cessation. Assist in attempt to quit. Discuss with the patient Roadblocks or barriers to attempting cessation. Arrange follow-up. Repeat the motivational intervention at all visits.

11. Study Table: Pharmacologic Therapies for Smoking Cessation Agent Notes Nicotine gum, patch, spray, inhaler, lozenges Increases smoking cessation 1.5 times more than control. Avoid with recent MI, arrhythmia, and unstable angina. Bupropion Increases smoking cessation rates about 2 times more than control. Avoid with seizure disorder and eating disorder. May be associated with suicidal ideation. Safety in pregnancy is unclear. Varenicline Increases smoking cessation rates about 3.5 times more than control and almost 2 times more than bupropion. Associated with suicidal ideation and increased risk of cardiovascular events. Don't Be Tricked SSRIs show no significant benefit for smoking cessation.

12. Question 2 A 30-year-old man is evaluated during a routine examination. He is asymptomatic. He is a nonsmoker and has no history of illicit drug use. He has had two lifetime female sexual partners and is sexually active in a monogamous relationship with a woman for the past 5 years. His father is 58 years old and has hypertension; his mother is 57 years old and has hyperlipidemia. Results of the physical examination, including vital signs, are normal. Results of a fasting lipid panel 4 years ago were normal.

13. Answer Choice Which of the following is the most appropriate screening test to obtain? A Fasting lipid panel B Fasting plasma glucose C HIV enzyme immunoassay antibody testing D Thyroid-stimulating hormone level

14. Answer Choice Which of the following is the most appropriate screening test to obtain? A Fasting lipid panel B Fasting plasma glucose C HIV enzyme immunoassay antibody testing D Thyroid-stimulating hormone level

15. Explanation According to guidelines published by the Centers for Disease Control and Prevention (CDC), this man should be screened for HIV infection using enzyme immunoassay antibody (EIA) testing. The guidelines recommend that all persons between the ages of 13 and 64 years be screened for HIV infection. This recommendation is based on evidence from several studies that have demonstrated that screening for HIV is effective even in low-prevalence settings. This is particularly true when screening is coupled to the availability of antiretroviral therapy. All positive results using EIA testing should be confirmed by Western blot testing. Western blot testing should not be used as the initial screening test owing to its high rate of false-positive and false-negative results. In contrast to the CDC guidelines, the U.S. Preventive Services Task Force (USPSTF) assigns a C grade to HIV screening, making no recommendation for or against routine HIV screening. The National Cholesterol Education Program (NCEP) recommends that screening be initiated at the age of 20 years and then continued at least every 5 years thereafter if normal. This patient's lipid levels were normal 4 years ago; therefore, it would not be appropriate to screen him according to the NCEP guideline. The USPSTF recommends lipid screening for all men 35 years or older and for men 20 to 35 years of age with increased cardiovascular risk. Because this patient is not at increased risk for atherosclerotic heart disease, according to the USPSTF guidelines, screening for hyperlipidemia should begin at the age of 35 years.

16. The USPSTF recommends diabetes screening for all adults with a sustained blood pressure of 135/80 mm Hg or greater. In contrast, the American Diabetes Association recommends screening all adults who are 45 years and older and all adults who have a BMI of 25 or greater who have one or more additional risk factors (gestational diabetes, hypertension, hyperlipidemia, family history of type 2 diabetes mellitus in a first-degree relative). Screening for diabetes would be inappropriate in this patient owing to his age, absence of hypertension or obesity, and lack of other risk factors. There is no agreement among major groups related to screening for hypothyroidism. The American Academy of Family Physicians and the American Association of Clinical Endocrinologists recommend screening for hypothyroidism in older women. The American Thyroid Association recommends screening adults by measuring thyroid-stimulating hormone (TSH) beginning at age 35 years, but the USPSTF does not recommend routine screening. This patient is not in a high-risk group defined by either age or sex, and screening for thyroid disease with a TSH level is not appropriate.

17. Key Point and Education Objective • Screen for HIV infection • The Centers for Disease Control and Prevention recommend that all persons between the ages of 13 and 64 years be screened for HIV infection.

18. Study Table:Routine Adult Immunizations Vaccine Recommendation Hepatitis A Occupational (travelers to endemic areas or food handlers) Chronic liver disease Men who have sex with men Users of illicit drugs Safety of vaccine during pregnancy uncertain Hepatitis B Same populations as hepatitis A All children up to 18 years End-stage kidney disease Safe in pregnancy HPV Male and female patients aged 9-26 years regardless of sexual activity, presence of genital warts, or previous positive HPV infection Not indicated in pregnant women Influenza All adults wishing to reduce their likelihood of influenza infection (including pregnant women) Inactivated vaccine appropriate for all except persons allergic to eggs or to those with a history of Guillain-Barré syndrome Intranasal live vaccine limited to nonpregnant patients aged <50 years Intranasal live vaccine is contraindicated if patient has close contact with immunosuppressed persons (home, work) as well as patients with chronic metabolic diseases, diabetes mellitus, kidney dysfunction, hemoglobinopathies, or immunosuppression

19. Study Table:Routine Adult Immunizations MMR (mumps, measles, rubella) Adults born after 1956 without proof of immunity Contraindicated during pregnancy Pneumococcal All adults aged ≥65 years Residents of long-term care facilities Adults with risk factors (asthma, cardiovascular disease, COPD, diabetes mellitus, chronic liver disease, chronic kidney disease, nephrotic syndrome, functional/anatomic asplenia, immunosuppressive conditions, chemotherapy) Patients who smoke cigarettes One-time revaccination for patients aged >65 years if vaccinated more than 5 years ago and were age <65 years at the time of primary vaccination as well as for adults with risk factors Safety of vaccine during pregnancy unknown Tdap All adults who have not completed primary series Single dose of Tdap for patients aged 19-64 years regardless of scheduled Td booster (may administer in place of Td booster if patient is due) Any wound if primary series not completed or status unknown Dirty wound if primary series completed >5 years previously Booster every 10 years

20. Meningococcal Travelers, college dormitory residents, Safety during pregnancy unknown Varicella Persons aged >13 years without previous chickenpox infection Contraindicated in immunocompromised patients Contraindicated during pregnancy Zoster vaccine Persons aged >60 years regardless of previous episode of zoster (do not measure antibodies) Contraindicated in immunocompromised patients Contraindicated during pregnancy

21. Travel Immunizations • Routine vaccines are recommended for a patient whose vaccines are not up to date, including influenza, pneumococcal, varicella (chickenpox), MMR, and Tdap booster. Select the following vaccinations when appropriate: • polio, hepatitis A and/or immune globulin, and typhoid for travelers to all developing countries • yellow fever for travelers to Africa and South America • meningococcal for travelers to sub-Saharan Africa • rabies for extended-stay travelers or those who will have difficulty accessing postexposure treatment in endemic areas, including Asia, Africa, and South and Central America Don't Be Tricked • For pregnant women, do not select live vaccines, including MMR, intranasal influenza, yellow fever, varicella, and zoster vaccines.

22. Study Table:USPSTF-Recommended Screening • Recommendations for General Population • Height and weight (periodically) • Blood pressure (every 2 years) • Problem drinking • Depression • Diabetes mellitus (if blood pressure >135/80 mm Hg) • Total and HDL cholesterol (every 5 years for men aged ≥35 years, women aged ≥45 years who are at increased cardiovascular risk, others with cardiovascular risk factors) • Colorectal cancer screening (average-risk men and women aged ≥50 years) • Mammogram ± clinical breast examination (every 1-2 years for women aged ≥50 years) • Pap test (at least every 3 years starting at age 21 until age 65 years). The USPSTF suggests combination Pap smear and HPV testing every 5 years for women aged 30 years or older who wish to increase the interval of screening. • Chlamydia (sexually active women aged ≤24 years and older at-risk women) • Bone mineral density test (women aged ≥65 years and women aged <65 years whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors for fracture using the WHO FRAX algorithm) • AAA screening (one-time screening for men aged 65-75 years who ever smoked)

23. Question 3 • A 42-year-old-man is evaluated for obesity. His weight has gradually increased over the past two decades and is currently 168.2 kg (370 lb). Five years ago, he was diagnosed with type 2 diabetes mellitus, hypertension, and hyperlipidemia. Over the past 6 months, he has unsuccessfully tried diet and exercise therapy for his obesity. He tried over-the-counter orlistat but could not tolerate the gastrointestinal side effects. Medications are metformin, lisinopril, and simvastatin. His total weight loss goal is 45.4 kg (100 lb). • On physical examination, temperature is normal, blood pressure is 130/80 mm Hg, pulse rate is 80/min, and respiration rate is 14/min. BMI is 48. Waist circumference is 121.9 cm (48 in). There is no thyromegaly. Heart sounds are normal with no murmur. There is no lower extremity edema. • Results of complete blood count, thyroid studies, and urinalysis are unremarkable.

24. Answer Choice Which of the following is the most appropriate management of this patient? A Bariatric surgery evaluation B Prescribe phentermine C Reduce caloric intake to below 800 kcal/d D Refer to an exercise program

25. Answer Choice Which of the following is the most appropriate management of this patient? A Bariatric surgery evaluation B Prescribe phentermine C Reduce caloric intake to below 800 kcal/d D Refer to an exercise program

26. Explanation • This patient should be referred for bariatric surgery. For patients with class III obesity (BMI ≥40) or class II obesity (BMI 35.0-39.9) with obesity-related complications, the National Institutes of Health Consensus Development Conference recommends consideration of bariatric surgery if diet, exercise, and/or medication are ineffective. Patients should be motivated and well informed about this option and undergo multidisciplinary evaluation by a medical, surgical, psychiatric, and nutritionist team. The most common procedure is gastric bypass surgery, but laparoscopic banding is becoming common, as well. Bariatric surgery results in more dramatic and sustained weight loss than nonsurgical interventions and leads to improvement in obesity-related complications (diabetes mellitus, obstructive sleep apnea, hypertension, and hyperlipidemia). This patient has not attained his goal weight loss after a 6-month trial of diet and medication and has obesity-related complications that likely will improve with weight loss. • Phentermine is a sympathomimetic drug that is FDA-approved for short-term use (up to 12 weeks) as an adjunctive treatment of obesity. This patient's weight loss goal is 45.4 kg (100 lb), which will take much longer than 12 weeks. In addition, most persons regain any weight that is lost with this medication upon its discontinuation. • Restricting caloric intake to below 800 kcal/d (a very-low-calorie diet) is no more effective for long-term weight loss than a moderate strategy of restricting intake to 500-1000 kcal/d below what is estimated to maintain current body weight. In addition, long-term compliance with a very-low-calorie diet is nearly impossible. • Exercise is an important part of a comprehensive weight loss program that focuses on lifestyle modification. However, the patient has already not benefited from an exercise program. It is unlikely that exercise alone will meet his weight loss goals.

27. Key Point and Education Objective • Manage obesity with bariatric surgery. • Bariatric surgery should be considered for patients with BMI of 40 or greater or BMI of 35.0 to 39.9 with obesity-related complications in whom diet, exercise, and/or medication are ineffective.

28. Obesity Diagnosis Study Table:Obesity Definitions Diagnosis BMI Overweight 25-29.9 Obese Class I 30-34.9 Class II 35-39.9 Class III ≥40 Screen patients diagnosed with obesity for evidence of secondary diseases. In the occasional patient in whom a secondary cause of obesity is found, the most common causes are hypothyroidism, Cushing syndrome, and polycystic ovary syndrome.

29. Obesity Therapy Discontinue nonessential medications associated with weight gain. Behavioral therapies, including dietary and exercise interventions, are effective approaches. Both low-carbohydrate and low-fat diets work in the short term. Exercise is helpful as an adjunct to diet change but not as monotherapy. Drug treatment is offered if a 5% threshold in weight loss has not been reached by the end of 3 months of therapy. Orlistat inhibits pancreatic lipases and alters fat digestion. Major side effects include cramping, flatus, oily stool, and fecal incontinence. Treatment is associated with an average weight reduction of 2.9 kg; reduced incidence of diabetes; and better blood pressure, lipid levels, and glycemic control. Locaserin is a selective serotonin receptor agonist that induces the feeling of early satiety. Its use is associated with an average weight loss of 5.8 kg and improvement in glycemic control. The combination medication phentermine, a stimulant/appetite suppressant, and topiramate, an anticonvulsant with a weight-loss effect, has been approved for pharmacological treatment of obesity. Locaserin and phentermine-topiramate are indicated for use in adult patients with a BMI ≥30 or ≥27 with ≥1 obesity-related comorbidity. Bariatric surgery is considered for patients with a BMI >40 and also for BMI >35 with serious obesity-related comorbidities (severe sleep apnea, diabetes, severe joint disease). Bariatric surgery is associated with a 29% reduction in mortality.

30. Study Table: Bariatric Surgery Complications Surgery Complications Banding procedures Intractable nausea and vomiting Marginal ulcers, stomal obstruction Severe GERD Pulmonary embolism Gastric bypass Stomal stenosis Cholelithiasis Deficiencies of vitamin B12, iron, calcium, folic acid, 25-hydroxyvitamin D, magnesium, copper, zinc, vitamin A, other B-complex vitamins, and vitamin C Pulmonary embolism

31. Question 4 • A 28-year-old woman is evaluated for a 3-month history of fatigue and muscle cramps. She states that she is eating well, drinking plenty of fluids, and exercising regularly, but the fatigue is starting to interfere with her ability to complete her daily 3-mile run. She has a previous history of anorexia nervosa diagnosed at age 16 years requiring two inpatient hospitalizations. She has had a normal weight and menstrual cycle for the last 4 years. She currently takes daily calcium and vitamin D supplements. • On physical examination, temperature is 36.6 °C (98.0 °F), blood pressure is 106/64 mm Hg, pulse rate is 66/min, and respiration rate is 12/min. BMI is 22. She has poor dentition with multiple dental caries. The remainder of the examination is normal. Pregnancy test is negative. • Laboratory studies: Complete blood count Normal Electrolytes Sodium 132 meq/L (132 mmol/L) Potassium 3.2 meq/L (3.2 mmol/L) Chloride 95 meq/L (95 mmol/L) Bicarbonate 31 meq/L (31 mmol/L) Blood urea nitrogen 6 mg/dL (2.1 mmol/L) Creatinine 0.8 mg/dL (70.7 µmol/L) Thyroid-stimulating hormone 2.5 µU/mL (2.5 mU/L)

32. Answer Choice Which of the following is the most likely diagnosis? A Anorexia nervosa, binge-eating/purging subtype B Binge-eating disorder C Bulimia nervosa, purging subtype D Night-eating syndrome

33. Answer Choice Which of the following is the most likely diagnosis? A Anorexia nervosa, binge-eating/purging subtype B Binge-eating disorder C Bulimia nervosa, purging subtype D Night-eating syndrome

34. Explanation • This patient most likely has bulimia nervosa, which is an eating disorder characterized by recurrent episodes of binge eating with subsequent compensatory behavior aimed at preventing weight gain. The compensatory behaviors may include self-induced vomiting and misuse of medications, such as laxatives (purging subtype), or fasting and excessive exercise. The purging subtype of bulimia nervosa may be suspected by metabolic abnormalities, including hypokalemia, hypomagnesemia, and metabolic alkalosis, as seen in this patient. Diagnostic behavior includes engaging in bingeing and compensatory behaviors at least twice a week for 3 months, and having one's self-perception be excessively influenced by body weight and shape. Most patients with bulimia nervosa have a normal weight; the presence of dental caries, enlarged salivary glands, and scarring on the dorsum of the hand are highly suggestive of purging behaviors. • Anorexia nervosa is characterized by an abnormally low body weight (<85% of expected) in association with an intense fear of gaining weight, an overemphasis of body weight on self-evaluation, and amenorrhea for three consecutive menstrual cycles. The restricting subtype of anorexia nervosa is associated with regular caloric restriction; the binge-eating/purging subtype is characterized by binge-eating, which may or may not be associated with self-induced vomiting or the misuse of medications. This patient's normal body weight and regular menses are more suggestive of bulimia nervosa rather than anorexia nervosa. Notably, 30% of patients with the restricting subtype of anorexia nervosa go on to develop bulimia nervosa, as seen with this patient. • Binge-eating disorder is more common than either anorexia nervosa or bulimia nervosa, affecting 2% to 3% of the general population. It is differentiated from bulimia nervosa in that there is no associated compensatory behavior after the binge. • Night-eating syndrome is characterized by excessive eating at night, difficulty sleeping, and morning anorexia. It is a prevalent disorder in obese patients and those seeking bariatric surgery.

35. Key Point and Education Objective • Diagnose bulimia nervosa. • Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating with subsequent compensatory behavior aimed at preventing weight gain.

36. Eating Disorder Diagnosis Anorexia nervosa consists of two types: • restricting, in which patients restrict intake (anorexia nervosa) • binge eating/purging, in which patients binge and purge to control weight (bulimia nervosa) Diagnostic criteria for the restricting type of anorexia consist of refusal to maintain weight within 15% of normal level, fear of weight gain, distorted body image, and amenorrhea or lack of onset of menstruation. The medical complications include anemia, osteopenia, hypotension, and arrhythmias. During the first few weeks of eating, patients are at risk for the refeeding syndrome, which can include cardiac arrest and delirium caused by exacerbation of hypophosphatemia and hypokalemia. Diagnostic criteria for bulimia nervosa are episodes of binging with loss of control occurring minimally 2 times per week for 3 months, followed by purging (vomiting, diuretic or laxative abuse), fasting, or excessive exercise. Patients usually have normal weight. The medical complications can involve acid-induced dental disease, esophageal tears, and electrolyte derangements (low chloride and potassium). Laboratory clues include metabolic alkalosis. Therapy For anorexia nervosa, daily supplementation with calcium and vitamin D is used to treat osteopenia. Cognitive behavioral therapy is considered first-line treatment. Psychotropic drugs have minimal efficacy in underweight patients with anorexia. Patients with bulimia respond to cognitive behavioral therapy, and antidepressants (fluoxetine or imipramine) and nutritional rehabilitation are effective adjunctive therapy. Don't Be Tricked Do not choose bupropion for eating disorders because of the increased incidence of tonic-clonic seizures.

37. Question 5 An 85-year-old man is admitted to a nursing home. He has diabetes mellitus, coronary artery disease, chronic heart failure, and dementia. On physical examination, vital signs are normal. He has a full thickness 5 × 8 cm pressure ulcer on his left buttock covered with a thick eschar. There is visible subcutaneous fat beneath the eschar; no bone or tendon is exposed. His skin is dry and there is evidence of mild dehydration and malnutrition. He has urinary but not fecal incontinence. His current medications are lisinopril, metformin, hydrochlorothiazide, glipizide, and carvedilol.

38. Answer Choice Which of the following is the most appropriate management of this patient's ulcer? A Debridement B Hyperbaric oxygen therapy C Negative-pressure wound vacuum therapy D Oral vitamin C and zinc supplementation E Surgical flap therapy

39. Answer Choice Which of the following is the most appropriate management of this patient's ulcer? A Debridement B Hyperbaric oxygen therapy C Negative-pressure wound vacuum therapy D Oral vitamin C and zinc supplementation E Surgical flap therapy

40. Explanation • This patient has a stage III or IV pressure ulcer, and debridement is the most appropriate management. Both stage III and stage IV pressure ulcers include full-thickness tissue loss. In stage III ulcers, subcutaneous fat may be visible but bone, tendon, and muscle are not exposed, whereas in stage IV ulcers, bone, tendon, or muscle is exposed and undermining and tunneling are often present. The eschar covering this patient's wound precludes the definitive differentiation of a stage III from a stage IV ulcer. • Treatment of pressure ulcers is best managed with an interdisciplinary team approach, with a care plan directed toward addressing the factors that predisposed to the development of the ulcer. Dressings should be chosen to maintain a moist wound environment and manage exudates. When present, infection should be controlled with topical therapies and the addition of systemic antibiotics when cellulitis is present. The possibility of underlying osteomyelitis should be considered. Surgical or nonsurgical debridement of eschar and nonviable tissue may be needed. Wet-to-dry dressings may aid in debridement but caution must be used to avoid removing excessive viable tissue with dressing changes. • Cochrane reviews do not support a role for electromagnetic therapy, ultrasound therapy, or hyperbaric oxygen therapy in pressure ulcer treatment. • Negative-pressure wound vacuum healing has been used for stage IV ulcers. However, three clinical trials have not shown superiority to standard therapy. Wound vacuum therapy may be more convenient due to less frequent dressing changes but is also very costly. It is not the recommended first line therapy. • Although frequently utilized, vitamin C and zinc oral supplements have not been shown to aid in ulcer healing. • Referral for surgical flap and repair may be necessary for refractory pressure ulcers but is usually reserved for patients in whom conservative treatment has failed.

41. Key Point and Education Objective • Stage III pressure ulcers, defined by full-thickness tissue loss but without exposure of bone, tendon, or muscle, generally require debridement, proper dressing selection, and treatment of infection, if present.

42. Pressure Ulcers Diagnosis Pressure ulcers are ischemic soft tissue injuries resulting from pressure, usually over bony prominences. The external appearance of a pressure ulcer may underestimate the extent of injury. Therapy Study Table: Pressure Ulcer Staging and Therapy Ulcer Stage Therapy Stage 1: The skin is intact with nonblanchable redness For all ulcer stages: positioning and support to minimize tissue pressure Stage 2: Shallow ulcer with a red-pink wound bed or serum-filled blister Occlusive or semipermeable dressing that will maintain a moist wound environment Stage 3: Subcutaneous fat may be visible Pain control, correction of nutritional deficiencies (supplements, tube feeding, or hyperalimentation if necessary), debridement, topical or systemic antibiotics Stage 4: Exposed bone, tendon, or muscle Same as Stage 3 Dressings should maintain a moist wound environment and manage exudates. Use systemic antibiotics when cellulitis is present; consider the possibility of underlying osteomyelitis. Debridement of eschars and nonviable tissue may be needed. Air-fluidized beds improve healing compared with other pressure-relief devices. Don't Be Tricked Hyperbaric oxygen therapy is not effective in the treatment of pressure ulcers.

43. Question 6 A 72-year-old woman is evaluated in the emergency department after an episode of syncope. While watching a movie, the patient felt palpitations; the next thing she remembers is being on the floor. She experienced a similar episode about 1 month ago. History is significant for hypertension, hypothyroidism, osteoporosis, and chronic kidney disease. Medications are amlodipine, lisinopril, levothyroxine, and calcium supplements. She currently feels well. On physical examination, temperature is normal, blood pressure is 148/78 mm Hg, pulse rate is 84/min and regular, and respiration rate is 12/min. Oxygen saturation on ambient air is normal. There is no thyromegaly, carotid upstrokes are +2 without bruits, and there is no jugular venous distention. Cardiac auscultation reveals a grade 2/6, early peaking, crescendo-decrescendo systolic murmur at the right upper sternal border with occasional extra beats. The remainder of the physical examination is normal. A resting electrocardiogram and rhythm strip show a sinus rate of 85/min with occasional premature ventricular contractions but no sustained arrhythmia, normal axis and intervals, and no ischemic changes.

44. Answer Choice Which of the following is the most likely cause of this patient's syncope? A Aortic stenosis B Cardiac arrhythmia C Myocardial ischemia D Transient ischemic attack

45. Answer Choice Which of the following is the most likely cause of this patient's syncope? A Aortic stenosis B Cardiac arrhythmia C Myocardial ischemia D Transient ischemic attack

46. Explanation • In this elderly woman, given the short prodrome, palpitations, and history of a previous event, a cardiac arrhythmia is the most likely cause of syncope. Arrhythmias are the most common causes of syncope in the elderly population. Patients with an arrhythmogenic cause of syncope usually have had only one or two episodes. A prodrome is usually brief or absent. The patient often experiences palpitations immediately preceding the episode. • Aortic stenosis may cause syncope; however, despite a low-grade systolic murmur, this patient's carotid upstrokes are normal and her episode occurred at rest and not with exertion, making aortic stenosis unlikely. • Myocardial ischemia is a rare cause of syncope, especially in the absence of typical ischemic symptoms. Myocardial ischemia is a consideration in patients with an arrhythmia leading to presyncope or syncope as ischemic myocardium may be arrhythmogenic. However, myocardial ischemia as a cause of hypoperfusion in a patient without symptoms at rest would likely not account for her clinical presentation. • This patient has several risk factors for a possible transient ischemic attack (TIA). However, TIAs typically present with focal neurologic symptoms and findings, and are rarely a cause of syncope.

47. Key Point and Education Objective • Diagnose the cause of a syncopal episode. • Arrhythmia is a common cause of syncope in the elderly; arrhythmogenic syncope is characterized by a brief or absent prodrome and palpitations immediately preceding the event.

48. Syncope Diagnosis An uncomplicated faint (vasovagal or neurocardiogenic syncope) is common and can be diagnosed by the history and absence of any suggestion of heart disease from the physical examination and ECG. Look for the 3 P's: posture (prolonged standing) provoking factors (blood draw, pain, emotion) prodromal symptoms (sweating, nausea, feeling warm) Patients with uncomplicated faint can be discharged home without additional evaluation. A history of heart disease, significant cardiac risk factors, or exertional syncope suggests structural cardiac disease or arrhythmias as the cause of syncope. Causes of exertional syncope include AS, HCM, mitral stenosis, and pulmonary hypertension (especially due to acute PE). Patients with suspected cardiac causes of syncope should be admitted to the hospital. Syncope caused by arrhythmias occurs without presyncopal symptoms and irrespective of patient position.

49. Study Table:Causes of Syncope If you see this… Diagnose this… A prodrome of nausea, diaphoresis, and pallor Uncomplicated faint (vasovagal or neurocardiogenic syncope) Preceding pressure on the carotid sinus (tight collar, sudden turning of head) Carotid sinus hypersensitivity Association with specific activities (urination, cough, swallowing, defecation) Situational syncope (neurocardiogenic) Upon assuming an upright position Orthostatic hypotension caused by hypovolemia, pharmacologic agents, or autonomic nervous system disorders (e.g., parkinsonism, diabetes) Brainstem neurologic signs and symptoms Posterior circulation vascular disease; consider subclavian steal syndrome if preceded by upper extremity exercise Witnessed “seizure” Syncope can cause tonic-clonic jerking of extremities; primary seizure is unlikely if findings of diaphoresis or nausea before the event, a brief episode of unconsciousness, and immediate postsyncopal orientation are present Related to exercise or associated with angina Obstruction to left ventricular outflow: AS, HCM, PE, and pulmonary hypertension Syncope with sudden loss of consciousness without Arrhythmia, sinoatrial and AV node dysfunction (ischemic heart prodrome disease and associated with use of β-blockers, calcium channel blockers, and antiarrhythmic drugs) Syncope following a meal Postprandial syncope, often in older adult patient

50. Consider the appropriate indications for the following diagnostic tests: ECG: Done in all cases. The finding of an arrhythmia and conduction block may establish the diagnosis, but a normal ECG does not rule out a cardiac etiology. Echocardiography: Obtain if structural heart disease is suspected. Ambulatory ECG recording: Indicated if cardiac arrhythmia is suspected or the cause is unclear. The choice of the recording device is determined by the frequency of the patient's symptoms (See Cardiovascular Medicine, Arrhythmia Recording). Stress testing: Indicated for patients with exercise-associated syncope or those with significant risks for ischemic heart disease. Carotid sinus massage: For suspected carotid sinus syncope or for unexplained syncope in those aged >60 years. Tilt-table testing: Reserved for presumed neurocardiogenic syncope only if it is recurrent or represents high risk for injury and to assess whether it is associated with asystole. Electrophysiologic testing: Rarely helpful and almost always the incorrect answer. Don't Be Tricked Do not order carotid vascular studies to diagnose cause of syncope. Do not order brain imaging, cardiac enzymes, or EEG to evaluate syncope. Therapy Treatment of structural cardiac disease and arrhythmias is covered in the Cardiovascular Medicine section. For hypovolemia or orthostatic syncope, eliminate α- and β-blockers and anticholinergic agents, if possible. Increase fluid and sodium intake and consider compression stockings. As a last resort, add mineralocorticoids and α-adrenergic receptor agonists. For recurrent neurocardiogenic syncope, choose β-blockers.