Heart & Soul
A 58-year-old patient has an office BP of 152/94 mmHg on two separate visits. What is the diagnosis?
Hypertension
- HTN diagnosis: persistently elevated BP rather than a single reading
- Confirm elevated office readings with home or ambulatory BP monitoring when appropriate, especially when white-coat hypertension is possible.
- Current ACC/AHA guidance generally defines HTN at ≥130/80 mmHg, although treatment thresholds depend on overall cardiovascular risk.
What is the first-line pharmacologic treatment for an acute migraine attack in a patient without contraindications?
NSAID and/or triptan
- NSAIDs are appropriate for mild-to-moderate attacks, while triptans are effective for moderate-to-severe migraine.
At what gestational age is routine screening for gestational diabetes generally performed?
24-28 weeks
- Routine screening occurs at 24–28 weeks in patients not previously diagnosed with diabetes.
- Screen earlier when the patient has significant risk factors for undiagnosed type 2 diabetes.
What is the most common cause of hypothyroidism in the United States?
Hashimoto thyroiditis
- - Autoimmune Hashimoto thyroiditis is the most common cause of hypothyroidism in iodine-sufficient regions such as the United States
At what age should average-risk adults begin colorectal cancer screening?
45
- USPSTF recommends colorectal cancer screening beginning at age 45 for average-risk adults.
A patient with HFrEF has an LVEF of 30%. Name the four medication classes proven to reduce mortality in HFrEF.
ACE inhibitor/ARB/ARNI, beta-blocker, MRA, and SGLT2 inhibitor
- Goal directed medical therapy (GDMT) is characterized by the four pillars of treatment noted above
- Don't wait to "maximize" one drug before starting the others
A 72-year-old woman presents with a new unilateral temporal headache, jaw claudication, and transient visual blurring. ESR and CRP are elevated. What is the most appropriate next step in management?
Start high dose steroids
- New headache + jaw claudication + visual symptoms in an older adult is GCA until proven otherwise
- Treatment should not be delayed as vision loss can become permanent
A healthy newborn is found to have jaundice at 18 hours of life. Is this physiologic or pathologic?
Pathologic
- Jaundice appearing during the first 24 hours of life is always considered pathologic until proven otherwise.
- Think hemolysis, infection, or other serious causes and obtain appropriate bilirubin evaluation.
A patient with type 2 diabetes has an A1c of 9.2% despite lifestyle modification. What is generally the first-line pharmacologic therapy if there are no contraindications?
Metformin
- Metformin is cheap
- Also consider SGLT2 inhibitor or GLP-1
A 76-year-old woman with a 30-pack-year smoking history currently smokes cigarettes. What screening test should be offered annually?
Lung cancer screening with low-dose CT scan
- Per USPTFS recommendations, lung cancer screening is indicated for 50–80 years old + 20 pack-years + quit ≤15 years ago
A 67-year-old with COPD has increased dyspnea, sputum volume, and sputum purulence. What is the most appropriate treatment in addition to bronchodilators?
Antibiotics and Corticosteroids
- Classic criteria of COPD exacerbation: increased dyspnea, sputum volume, or sputum purulence.
- Antibiotics are particularly indicated when all three criteria are present or when purulent sputum accompanies increased dyspnea or sputum volume.
- GOLD recommends short courses, generally ~5 days.
A patient presents with acute unilateral facial weakness involving both the forehead and lower face. What is the most likely diagnosis?
Bell's Palsy
- Acute peripheral CN VII palsy involves the forehead and lower face, distinguishing it from most central lesions
- Corticosteroids are most effective when started within 72 hours. Consider antivirals in severe cases, but steroids are the key treatment.
A 2-year-old has a barking cough and inspiratory stridor that worsens at night. What is the most likely diagnosis?
Croup
- Dexamethasone is recommended for essentially all severities
- Nebulized racemic epinephrine is added for moderate-to-severe disease.
A patient has vomiting, orthostasis, BUN 60, and creatinine 2.0. What broad category of AKI is most likely?
Pre-renal
- Vomiting is key information
- BUN/Cr >20 suggests pre-renal
A 52-year-old woman with no significant medical history presents for a routine visit. She has never smoked, has a normal BMI, and has no family history of colorectal cancer. Which of the following preventive interventions has the strongest evidence for reducing all-cause mortality in this patient?
Colorectal cancer screening
A 72-year-old patient presents with new-onset atrial fibrillation. He has hypertension, diabetes, and a prior stroke. What is the most important long-term therapy to reduce his risk of ischemic stroke?
Oral anticoagulation
- Use CHA₂DS₂-VASc to estimate stroke risk
- DOACs are generally preferred over warfarin for nonvalvular AF unless contraindicated.
A 45-year-old has low back pain with progressive foot drop and new urinary retention. What is the appropriate next step?
Emergent MRI and/or rule-out cauda equina
- Saddle anesthesia, urinary retention/incontinence, and progressive bilateral neurologic deficits should trigger emergency evaluation rather than routine outpatient imaging
A pregnant patient at 32 weeks has BP 168/112 mmHg, headache, and proteinuria. What medication should be given immediately and what does it prevent?
Magnesium sulfate to prevent seizures
- Severe hypertension plus neurologic symptoms in pregnancy represents a high risk for eclampsia
A patient with cirrhosis presents with hematemesis and hypotension. What medication should be started immediately?
Octreotide
- Vasoactive therapy helps control bleeding from esophageal varices
- Ceftriaxone is also indicated to prevent infection as it worsens outcomes
A 67-year-old woman with no history of fragility fracture undergoes screening for osteoporosis. Her DEXA scan shows a T-score of −2.7 at the femoral neck. She has no contraindications to treatment. What is the most appropriate next step?
Initiate treatment for osteoporosis
- T-score ≤ −2.5 at the hip, femoral neck, or lumbar spine meets the diagnostic threshold for osteoporosis
A 64-year-old woman has exertional dyspnea and bilateral lower-extremity edema. Echo shows LVEF 55%, left atrial enlargement, and diastolic dysfunction. What type of heart failure does she have?
HFpEF
- EF ≥50%, and evidence of diastolic dysfunction supports HFpEF
- SGLT2i is helpful in management of HFpEF
A patient with major depressive disorder has been taking an SSRI for 12 weeks with good adherence but has had minimal improvement. What is an appropriate next pharmacologic strategy?
Optimize dose and/or switch to another antidepressant
- An adequate trial with good adherence and minimal response warrants reassessment and a change in strategy
A 6-month-old has fever, poor feeding, and a bulging fontanelle. What is the most appropriate next step?
Evaluate for meningitis and/or empiric IV antibiotics
A patient with hyperkalemia has weakness and ECG changes showing peaked T waves. What medication should be administered first and what is its goal?
Calcium gluconate - stabilize cell membranes
- After stabilization, shift K intracellularly with insulin/glucose ± beta-agonist (albuterol) and remove potassium from the body when indicated
A 45-year-old asymptomatic patient has an average risk of colorectal cancer and asks about screening. Name two acceptable screening strategies and their time-to-repeat if negative.
Cologuard - 3 years
iFOBT/FIT test - 1 year
Colonoscopy - Usually 10 years if no significant findings
- Wait time for colonoscopy in the Central Valley is increasingly getting worse
- Cologuard is not covered by humana insurance (key medical)
- Cologuard is sent to the patient's home via mail and the patient sends it back through mail as well
- iFOBT/FIT is typically a take-home collection kit that is brought back to the lab in-person