General Internal Medicine

1. Amoxicillin; if PCN allergic consider azithromycin or clarithromycin
2. If no Sx improvement after amoxicillin after 48 hrs consider amoxicillin-clavulanate, cefuroxime, or ceftriaxone

1. Strep pneumonia
2. H. influenzae
3. Staph Aureus
4. Moraxella catarrhalis

1. Cognitive Behavioral Therapy
2. SSRIs

Excessive anxiety and worry about a variety of events or activities that last for at least 6 months with associated symptoms of fatigue, restlessness, sleep disturbance, difficulty concentrating, and functional impairment

DIAPERS
Drugs
Infection
Atrophic vaginitis
Psychological (depression. delirium, dementia)
Endocrine (hyperglycemia, hyeprcalcemia)
Restricted mobility
Stool impaction

Intranasal corticosteroids (fluticasone)

1. Calculate non-HDL cholesterol
Total cholesterol - HDL = non-HDL
2. non-HDL goal is set at 30 plus LDL goal; can consider triglyceride lowering medication

When a patient is above their LDL goal

1. Colonoscopy q10 years
2. Flex sigmoidoscopy q5 years with FOBT q 3 years
3. FOBT x 3 every year followed by colonoscopy if positive

Empiric treatment with a first generation anti-histamine/decongestant

1. Nicotine replacement therapy
2. Varenicline (Chantix) for 12 weeks
- Do not use with nicotine replacement therapy
3. Buproprion - increases the risk of seizures
- SSRIs are not Tx for smoking cessation

1. Muscle Weakness
2. Functional impairment
3. Increased risk of falls/fractures

1. 25 OH Vitamin D
2. Ergocalciferol or cholecalciferol 50,000 U qweek for 6-8 weeks followed by 800-1000 U of Vitamin D with calcium supplementation (at least 1200 mg of elemental calcium)

1. Genitourinary/pelvic pain
2. Voiding symptoms
3. Negative urine cultures with absence of leukocytes in the urine

1. Alpha blockers i.e. terazosin, tmsulosin

1. Levonorgesterol (preferred)
2. Ethinyl estradiol + Levonorgesterol

Scleritis

1. Permanent visual loss
2. Globe rupture

Episcleritis

Anterior Uveitis

1. All pts older than 60 y/o for prevention of shingles.
2. Live vaccination
3. Active untreated TB, Pregnant women, Immunocompromised patients, pt receiving chemotherapy, radiotherapy, or large doses of corticosteroids

1. Piriformis Syndrome
2. Conservative. NSAIDs

Trochanteric Bursitis

Sciatica with concern for herniated disk

Meniere disease

Presbycusis (aging ear)

Pulsatile tinnitus

1. Oxybutynin (anticholinergic)
2. Bladder Training
- Note pessarys are not used for urge incontinence rather stress incontinence

Olecranon bursitis

Switch to another SSRI

Meniscal tear

Anserine bursitis

Patellofemoral pain syndrome

Pts aged 65-75 who have a history of smoking should be screened once for AAA

Oral Hairy Leukoplakia

1. At least 6 months of fatigue with non-refreshing sleep, exertional malaise, joint & muscle pain
2. Treatment is cognitive behavioral therapy and graded exercise

1. Peripheral neuropathy
2. Visual loss
3. Decline in bilateral vestibular neuropathy
4. Deconditioning
5. Autonomic Neurropathy
6. medications side effects

1. Patients who have difficulty remembering to take pills everyday
2. Mothers breastfeeding who cannot take an estrogen containing birth control

1. Splints
2. Carpal Tunnel Surgical Decompression

1. Most common cause of inferior heel pain
2. Pain worsens with walking especially with the first steps in the morning
3. Noted pain along the plantar fascia or the calcaneal insertion site
4. Obesity, prolonged standing, and repetitive trauma like running are risk factors
5. Conservative treatment, heel stretching exercises; steroids cause risk for fascial rupture

1. Rotator Cuff Tendinitis
2. NSAIDs, Ice, exercises

1. Iron
2. Calcium
3. Cholestyramine
4. Sucralfate
5. PPIs

1. Assess compliance
2. Drugs that interfere with absorption
3. Achlorhydia?
4. Celiac sprue?

TEAZ COCA
TMP/SMX
Erythromycin
Amiodarone
Ketaconazole/Fluconazole/Itraconazole/Metronidazole

Ciprofloxacin
Omeprazole
Clarithromycin
Azithromycin

1. Rhabdomyolysis
2. Hepatotoxicity
3. Liver failure
4. Myopathy

TP / (TP + FN)

SNOUT
Sensitive tests that are negative rule out disease

TN/ (TN + FP)

SPIN

Specific tests that are positive rule in disease

TP / (TP + FP)

TN / (TN + FN)

The more prevalent a disease is the greater the PPV and the less the NPV

prevalence does not affect sensitivity or specificity

Answers the question: How much more likely is someone to have a disease given a positive test result

Sensitivity / (1- specificity)

(1 - Sensitivity)/ Specificity

If > 1 indicates increase chance of getting the disease; If < 1 then decreases the chance of getting the disease

# with intervention & bad outcome/ # who received intervention

(# with intervention & bad outcome/ total # who received intervention) / (# without outcome/ # who had no intervention)

RR > 1 suggests treatment was harmful
RR < 1 suggests treatment is beneficial
RR = 1 no harm or benefit

A type of relative risk that calculates the risk of outcome in a group exposed to a risk compared with a control group not exposed to the risk

Relative risk represents risk over all time while the hazard ratio demonstrates the risk in an instantaneous moent

ow many people with a condition require treatment before one person benefits from treatment.

NNT = 1/ ARR

ARR is the absolute risk difference between those who received an intervention and those that did not

(O+T+/ O+T+ + O-T+) - (O-T-/ O+T- + O-T-)

when you incorrectly conclude a statistical significance is present

when you incorrectly conclude NO statistical significance is present

Avoid use in seizure disorders and eating disorders
May be associated with suicidal ideation

Associated with suicidal ideation and increased risk of cardiac events

1. homosexual men
2. Chronic liver disease
3. Illicit drug users
4. Travelers to endemic areas or food handlers

1. Same population as Hep A vaccination
2. Children < 18 y/o
3. ESRD
4. Safe in pregnancy

Male AND Female 9-26 y/o no matter sexual activity, presence of genital warts, or previous + HPV infection

Pregnant
> 50 y/o
DM, CKD, interaction with immunocompromised, immunocompromised

Travelers
College dormitory residents

Greater than or equal to 65
Residents at long term care facilities
Chronic medical conditions
One time re-vaccination at 65 if previous vaccination was > 5 years ago and they were less than 65 at the time

all adults who have not completed primary series
Single Tdap from 19-64
Booster every 10 years
Dirty wounds with last vaccination > 5 years ago
Any wound if primary series not completed or status unknown

> 13 y/o with no revious chickenpox infection
Contraindicated in immunocompromised
Contraindicated in pregnancy

> 60 no matter if had previous episode of zoster
Contraindicated in immunocompromised
Contraindicated in pregnancy

All developing countries: Polio, hep A, typhoid
Africa/South America: Yellow fever
Sub-saharan africa: meningococcal
Rabies for those going to areas where access to health care would be difficult if needed postexposure treatment

MMR
Live influenza nasal
Yellow fever
Varicella
Zoster vaccines

BMI > 40 or BMI > 35 with significant comorbidities

Cognitive-behavioral therapy (CBT) with an exposure element is the treatment of choice for obsessive-compulsive disorder (OCD); high-dose selective serotonin reuptake inhibitors should be used in patients who are resistant or only partially responsive to CBT and in those with more severe OCD or in whom a rapid response is critical.

atypical anti psychotic

1.Anterior pressure for 5 minutes
2. Anterior pressure for 15-30 mins
3. Cauterization and nose packing

Hypoactive sexual desire disorder, a common cause of female sexual dysfunction, is defined as a persistent lack of desire for or receptiveness to sexual activity or a persistent lack of sexual thoughts.

Vaginismus is involuntary and recurrent spasm of the outer third of the vaginal musculature that interferes with vaginal penetration. Pain may accompany this involuntary spasm, and there is often associated avoidance and anticipatory fear of penetration. May notice symptoms on placement of speculum.

hronic fatigue syndrome (CFS) is defined as medically unexplained fatigue that persists for 6 months or more, accompanied by at least four of the following symptoms: subjective memory impairment, sore throat, tender lymph nodes, muscle or joint pain, headache, unrefreshing sleep, and postexertional malaise lasting longer than 24 hours.

Patients with pulsatile tinnitus should be evaluated for the possible presence of an intracranial vascular anomaly, such as stenosis, arteriovenous malformation, or glomus tumor as a cause of their symptoms.

It is valuable to listen over the patient's ears, eyes, and neck, because if a vascular abnormality is present, the bruit causing tinnitus may sometimes be detected externally (objective tinnitus).

Viral conjunctivitis, characterized by acute onset and unilateral redness, watery discharge, itching, crusting, a diffuse foreign body sensation, and mild photophobia, is managed conservatively with cool compresses.

Vitamin A & C

Vitamin C deficiency

Niacin

Thiamine

B12

NSAIDs
Amphetamine/cocaine
Oral contraceptives
Corticosteroids

Renovascular disease

Aortic coarctation

ACEI
ARB
B blockers

Use loop diuretics like furosemide and not thiazide diuretics

Goal in 1st hour is a 25% reduction
Goal after 1st hour is 160/100-110

Vitamin D

Macrolide antibiotic
Bordetella pertussis

Painful anterior cervical lymphadenopathy
No cough
tonsillar exudates
Subjective fever

0-1 do not test or treat
2-3 Rapid strep test or culture but not both; if positive treat; follow up testing is not reccomended
4 Treat with no need for testing

Tx: Oral penicillin x 10 days; if PCN allergic give oral macrolide

Fusobacterium Necrophorum
Ampicillin-sulbactam

amoxicillin-clavulanate if PCN allergic then doxycycline

If conduction hearing loss: Weber (forehead test) lateralizes to ear with hearing loss while rinee shows bone conduction > air conduction

If sensorineural hearing loss: Weber lateralizes to good ear; Rinne test shows sound is similar or louder in bad ear as good ear

CT or MRI to evaluate for acoustic neuroma

Ramsay Hunt Syndrome - Zoster infection
Tx with antivirals

Malignant otitis externa
IV cipro - usually caused by pseudomonas

Topical fluroquinolone or bacitracin polymycin

Neisseria conjunctivitis
Systemic and topical antibiotics with STAT optho consult

Chlamydial conjunctivitis
Tx: PO tetracycline, erythromycin, or doxycycline

Acute closed angle glaucoma. Emergency Optho consult

Scleritis - Associated with collagen vascular diseases and rheumatoid diseases; emergency optho referral

Episcleritis; Self-limited No Tx required

Blepharitis - Staph or sebhorreic dermatitis

Warm compresses; wash with mild detergent; topical antibiotics

Keratitis or Iridiocycltitis / Iritis
Consider seronegative spondyloarthropathies, sarcoidosis, herpes zoster; emergency optho referral

NEVER

oral fluroquinolone or TMP/Sx for 4-6 weeks ; if spetic hospitalize and add gentamycin to fluroquinolone

Cremasteric reflex

If < 35 treat for chlamydia and gonorrhea
If > 35 treat with oral fluroquinolone
Pain localizing to posterior and superior aspects fo the testes; pain is subacute with fever, pyuria, and dysuria

The most effective treatments for edema due to chronic venous stasis are sodium restriction, leg elevation, weight reduction, and compression stockings; diuretics should be avoided.

Left supraspinatus rotator cuff tear
Drop test: When a complete supraspinatus tear is present, the patient's arm often drops to the waist.
Need MRI to confirm diagnosis

Acromioclavicular joint degeneration is characterized by pain to palpation of the acromioclavicular joint and pain that occurs with shoulder adduction and abduction above 120 degrees.

Acromioclavicular joint degeneration typically results from trauma (in younger patients) or osteoarthritis (in older patients). Bilateral involvement should raise concern for rheumatoid arthritis. On examination, there is typically pain to palpation of the acromioclavicular joint. Pain on palpation is a very sensitive but not specific sign of acromioclavicular joint disease; absent pain on palpation makes acromioclavicular joint disease unlikely.

Adhesive capsulitis is caused by thickening of the capsule surrounding the glenohumeral joint. Pain is characteristically slow in onset and is located near the insertion of the deltoid muscle, and patients often avoid lying on the affected side. On examination, there is loss of both active and passive range of motion.

Surgical patients at high risk for venous thromboembolism, including those with previous venous thromboembolism, patients who have undergone orthopedic surgery, and patients with some cancers (especially gynecologic malignancy), should receive extended (up to 5 weeks) prophylaxis.

Tilt-table testing is useful in evaluating recurrent syncope in the absence of heart disease, to discriminate neurocardiogenic from orthostatic syncope, and to evaluate frequent syncope in patients with psychiatric disease.

Sjögren syndrome is characterized by keratoconjunctivitis sicca, which causes xerophthalmia (dry eyes), and xerostomia (dry mouth). The absence of oral mucosal moisture often causes difficulty with mastication and swallowing and increases the risk for dental caries and periodontal disease. Vaginal dryness and parotid gland enlargement are frequently present, and fatigue and arthralgia are common.

The presence of xerophthalmia and xerostomia accompanied by anti-Ro/SSA and anti-La/SSB antibody positivity and abnormal findings on the Schirmer test have a 94% sensitivity and specificity for primary Sjögren syndrome.

Ultrasound
A palpable breast mass should be evaluated until diagnosis or resolution.

The only therapy proved effective for reducing the risk of postoperative pulmonary complications in the immediate perioperative period is pre- and postoperative lung volume expansion, either via deep breathing or incentive spirometry.

Acute vertigo accompanied by vertical nystagmus and nystagmus that is immediate, prolonged, and nonfatigable on the Dix-Hallpike maneuver is characteristic of central vertigo.

Central vertigo may be caused by ischemia or infarct in the brainstem or cerebellum.

MRI with angiography

Consistent reduction in daily dietary caloric intake is the most successful long-term and safest weight loss strategy in obese and overweight patients.

Pravastatin to decrease medication cross interactions

Medroxyprogesterone acetate for 10 to 21 days is effective treatment for moderate menstrual bleeding.

Patellofemoral pain syndrome is more common in women than in men and is characterized by anterior knee pain that is made worse with prolonged sitting and with going up and down stairs.

The pain is reproduced by applying pressure to the patella with the knee in extension and moving the patella both medially and laterally (patellofemoral compression test).

Pes anserine bursitis characteristically produces pain that is located near the anteromedial aspect of the proximal tibia.

On examination, tenderness is elicited at the level of the tibial tuberosity (approximately 3.8 cm [1.5 in] below the level of the medial joint line). Swelling may be present at the insertion of the medial hamstring muscles.

Certain antidepressants, including serotonin-norepinephrine reuptake inhibitors such as venlafaxine, are effective nonhormonal medications for reducing menopausal vasomotor symptoms.

entral retinal vein occlusion is characterized by acute onset of painless blurry vision and optic disc swelling, dilated and tortuous veins, flame-shaped retinal hemorrhages, and cotton-wool spots (“blood and thunder”).
CRVO is most commonly encountered in older patients with hypertension and atherosclerotic vascular disease.

Central retinal artery occlusion (CRAO) classically presents in a 50- to 70-year-old patient as a painless, abrupt blurring or loss of vision that occurs in the early morning hours—usually between midnight and 6 AM. It results from an embolic or thrombotic event in the ophthalmic artery.

visual acuity is markedly diminished in the affected eye to either finger counting or light perception. There is an afferent pupillary defect. On funduscopic examination, the retina appears pale, either segmentally or completely. The fovea may appear as a cherry red spot. Interruption of the venous blood columns may be recognized with the appearance of “box-carring”—rows of slowly moving corpuscles separated by clear intervals.

1. Medications (FeSO4, CaCO3, PPIs, Cholestyramine)
2. Achlorhydria
3. Sprue

Penicillins/cephalosporins OK
Nitrofurantoin OK
Avoid quinolones and TMP/Sx if able

Doxycycline

hyperkalemia

ACE Inhibitor/ARB
K sparing diuretics
TMP/Sulfa
NSAIDs
Salt substitutes

Renal insufficiecny
Pt on wrfarin
Pt on methotrexate

Thioglitazones i.e. piaglitazone and rosaglitazone

DaNCE
Diuretics i.e. HCTZ
a
Niacin
Cyclosporine
Ethambutol/pyrazinamide

Nonanion gap acidosis

HCTZ
SSRIs
Carbamazepine

Effective treatment options for chronic fatigue syndrome include graded exercise programs and cognitive-behavioral therapy.

Immunocompetent persons who received the pneumococcal polysaccharide vaccine before age 65 years should receive a single booster vaccination at age 65 years, or 5 years after their first vaccination if they were vaccinated between the ages of 60 and 64 years.

Immunocompromised patients (including those with HIV infection and kidney disease) as well as patients with asplenia should receive a single pneumococcal vaccine booster 5 years after their first vaccine.

Bile acid sequestrants are an option for reducing LDL cholesterol levels in women with hyperlipidemia who wish to become pregnant.

statins (such as simvastatin) are typically the first-line treatment for lowering LDL cholesterol levels, statins are teratogenic (FDA pregnancy class X) and should be avoided in women who may be or wish to become pregnant. Colesevelam, which is a bile acid sequestrant that lowers LDL cholesterol levels by up to 18%, is the best initial treatment option for this patient. Colesevelam is FDA pregnancy class B and so is safe to use in premenopausal women who are sexually active.

The pain of pes anserine bursitis is typically located along the anteromedial aspect of the proximal tibia distal to the joint line of the knee and characteristically worsens with step climbing and at night.

The most appropriate treatment for this pregnant woman is a topical imidazole, such as clotrimazole. She has classic symptoms and signs of vulvovaginal candidiasis (VVC), including itching, discomfort, and a thick, white vaginal discharge with evidence of vulvar edema and erythema on examination. The vaginal pH is normal, and potassium hydroxide preparation shows evidence of hyphae and yeast, supporting this diagnosis

Regimens for treatment of complicated C. albicans vulvovaginitis include topical imidazole therapy for up to 14 days or two 150-mg doses of oral fluconazole given in two sequential doses 72 hours apart (compared with single-dose therapy).

Oral fluconazole is an appropriate treatment for uncomplicated VVC, and is associated with high treatment success rates. However, it should not be given in pregnancy as the effect on the fetus is unknown (FDA pregnancy category C medication), and topical therapy is equally efficacious.

Morton neuroma is characterized by burning pain on the plantar surface in the space between the third and fourth toes.

. It commonly occurs in overuse syndromes (such as running) and with wearing tight shoes. It classically presents with burning pain on the plantar surface in the space between the third and fourth toes but may also occur between the second and third toes. Women are more commonly affected than men, and the wearing of high heels is a recognized risk factor. Treatment is typically conservative, with the goal of reducing pressure across the metatarsal heads through the use of padding, orthotics, and the removal of likely inciting footwear or activities. If conservative measures fail, a local corticosteroid injection is usually successful.

A hammer toe is characterized by a flexion deformity of the proximal interphalangeal joints with normal distal interphalangeal joints and metatarsophalangeal joints. Presenting symptoms include pain and difficulty wearing shoes because of the resulting toe structure. A corn may also develop on the dorsal surface of the proximal interphalangeal joint.

a somatoform disorder in which a patient is focused on a single real or imagined symptom. In order to qualify as a psychiatric disorder, somatoform symptoms need to be medically unexplained or out of proportion to medically expected findings, should persist over time, and cause impairment in a patient's ability to function.

Although no therapy has been shown to be consistently helpful in treating somatoform disorders, multiple trials have found benefit in patients who undergo cognitive-behavioral therapy.

Pelvic floor muscle training is first-line treatment for stress urinary incontinence.

Findings on physical examination include weakened anterior or posterior vaginal wall support (cystocele or rectocele, respectively). PFMT is considered first-line therapy for urinary stress incontinence.

Sling procedures are effective for moderate to severe stress incontinence, but surgery is usually reserved for patients who do not benefit from more conservative approaches, including behavioral or appropriate pharmacologic therapy.

de Quervain tenosynovitis is pain that occurs with thumb use, characterized by pain and swelling over the radial styloid that is is elicited with both resisted thumb abduction and extension.

de Quervain tenosynovitis, which refers to swelling or stenosis of the abductor pollicis longus and extensor pollicis brevis tendon sheaths at the level of the wrist. It is most commonly caused by repetitive motion of the thumb but can also be associated with underlying conditions including pregnancy and rheumatoid arthritis.

Patient has pain on the radial side of the thumb when he is asked to make a fist over the fully flexed thumb and then to ulnar deviate the hand (positive Finkelstein test).

Epley maneuver
Vestibular rehabilitation

1. Penicillin/cephalosporins
2. Ciprofloxacin
3. Nitrofurantoin

Bacterial vaginosis is the likely diagnosis in women with at least three of the following features: (1) homogeneous thin discharge that coats the vaginal walls; (2) clue cells on saline microscopy; (3) pH of vaginal fluid >4.5; and (4) fishy odor of vaginal discharge (positive “whiff” test).

Bacterial vaginosis (BV) is a polymicrobial infection characterized by an overgrowth of multiple anaerobic bacteria.

Treatment should be offered with either oral metronidazole, vaginal metronidazole gel, or vaginal clindamycin cream; patient preference should dictate treatment choice.

Topical clindamycin should be avoided during pregnancy as it may increase the risk of adverse outcomes. Women treated with oral metronidazole should be cautioned to avoid alcohol, which can cause a disulfiram-like reaction.

Osteonecrosis of the hip commonly presents with dull, aching groin pain (most commonly) or thigh or buttock pain that is indolent in onset. Occasionally, as is the case in this patient, severe pain may be reported in the early stages as bone death is occurring. Corticosteroid use and excessive use of alcohol account for more than 90% of hip osteonecrosis cases.

Patients with chronic pain syndromes should be evaluated for concurrent psychosocial stressors, particularly in those in whom symptoms have worsened without explanation.

Testicular torsion is characterized by severe pain and an elevated high-riding testicle with the longitudinal axis abnormally oriented transversely and an absent cremasteric reflex.

Referral for polysomnography is indicated when a primary sleep disorder is suspected (obstructive sleep apnea, restless legs syndrome, periodic limb movement disorder).

Rotator cuff impingement syndrome due to underlying tendinitis is a common cause of nontraumatic shoulder pain; characteristic findings are pain with arm abduction and a positive Hawkins test.

Adhesive Capsulitis

Rotator cuff tears are usually accompanied by weakness and loss of function. Examination findings include supraspinatus weakness, weakness with external rotation, and a positive drop-arm test.

CD4 count

Primary Dysmenorrhea

The first-line treatment for primary dysmenorrhea is NSAID therapy

Ulnar nerve entrapment at the elbow is characterized by pain that occurs with flexion of the arm and paresthesias on both the palmar and dorsal surfaces of the hand, in the distribution of the ulnar nerve.

Patients with lateral epicondylitis (tennis elbow) typically present with pain in the lateral elbow that radiates down the forearm to the dorsal hand. On examination, there is tenderness to palpation at the location of the insertion of extensor muscles on the lateral epicondyle. Pain is reproduced by forced extension of the wrist.

atients with medial epicondylitis (golfer's elbow) typically present with pain in the medial elbow and proximal forearm. On examination, there is tenderness to palpation from the medial epicondyle to the pronator teres and flexor carpi radialis muscles. Pain can be reproduced with wrist flexion and resisted forearm supination.

Interstitial cystitis

mood stabilizers like lithium, lamotrigine, valproic aid, carbamazepine

65

A major depressive episode is diagnosed by the presence of five or more of the following symptoms occurring nearly every day during the same 2-week period, at least one of which is either depressed mood or loss of interest or pleasure: depressed mood most of the day, loss of interest or pleasure in most activities, significant unintentional weight or appetite gain or loss, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, diminished concentration, or recurrent thoughts of death or suicide without a specific plan or prior attempt.

GAD is characterized by excessive anxiety and worry about a variety of events or activities on most days for at least 6 months, with difficulty controlling worrying. Associated symptoms include fatigue, irritability, restlessness, insomnia, and difficulty concentrating. Patients with GAD often have comorbid anxiety disorders, depression, or substance abuse. Patients with GAD often have somatoform symptoms, which can make them high utilizers of health care resources.

For women with hypoactive sexual desire disorder, individual or couples sex therapy may be beneficial.

Age-related macular degeneration causes painless progressive vision loss, characterized by distortion of vision and loss of central vision.

In both dry and wet AMD, drusen are common findings. Drusen are amorphous deposits behind the retina that lead to visual loss through direct (space occupying) and indirect (inflammatory response) means. A few small, hard drusen are common as people age, but numerous large, soft drusen are a harbinger of severe AMD. Wet AMD, which is less common than dry AMD and typically more aggressive, is characterized by neovascularization with subsequent vessel leakage and hemorrhage. Smoking is a risk factor for AMD.

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.

One-time abdominal ultrasonography to screen for an abdominal aortic aneurysm is recommended in men between the ages of 65 to 75 years who have ever smoked (defined as 100 lifetime cigarettes).

Meralgia paresthetica is characterized by paresthesia (burning/numbness) located over the anterolateral thigh. There are no motor symptoms because the lateral femoral cutaneous nerve is a purely sensory nerve. Risk factors for developing meralgia paresthetica include diabetes mellitus, obesity, and the wearing of tight-fitting pants or belts. On examination, dysesthesia or hypoesthesia is present in the distribution of the lateral femoral cutaneous nerve. The remainder of the examination is typically normal.

he has fever, leukocytosis, sore throat, unilateral neck tenderness, and multiple densities on her chest radiograph, suggestive of septic emboli. The combination of these factors points strongly toward Lemierre syndrome, which is septic thrombosis of the internal jugular vein.

The diagnosis of septic thrombosis of the jugular vein (Lemierre syndrome) should be suspected in anyone with pharyngitis, persistent fever, neck pain and septic pulmonary emboli.

Treatment should include intravenous antibiotics that cover streptococci, anaerobes, and β-lactamase-producing organisms. Penicillins with β-lactamase inhibitors and carbapenems are both reasonable choices (such as ampicillin-sulbactam, piperacillin-tazobactam, and ticarcillin-clavulanate).

statin-related hepatotoxicity (defined as alanine aminotransferase level more than three times the upper limit of normal and total bilirubin level more than twice the upper limit of normal)

In patients with a prolonged interval since the previous dose of a multiple-dose vaccine, the series should be resumed rather than restarted.

Estrogen-containing contraceptives are contraindicated in women older than 35 years who smoke more than 15 cigarettes daily because of the increased risk of thromboembolic disease.

A family history of stroke itself is not a contraindication to the use of estrogen-containing preparations, although a personal history of stroke or thromboembolic disease is; progesterone-only contraceptives are considered safe in these women.

Progesterone-only options for women with contraindications to estrogen include the “mini-pill,” long-acting progesterone compounds (such as depot medroxyprogesterone acetate), subcutaneous progesterone implants, and progesterone-containing intrauterine devices.

Timolol, a topically applied β-blocker for treatment of glaucoma, may have systemic adverse effects, including bradycardia and heart block.