Top 100 Medical Secrets (Internal Medicine)

1. Informed consent is not merely a signature on a form, but a process by which the patient and physician discuss and deliberate the indications, risks, and benefits of a test, therapy,or procedure and the patient’s outcome goals.
2. Patients should participate in informed consent whenever they have sufficient decision-making capacity.
3. Decision-making capacity is determined by assessing the patient’s ability to (1) comprehend the indications, risks, and benefits of the intervention; (2) understand the significance of the underlying medical condition; (3) deliberate the provided information; and (4) communicate a decision.
4. Some patients with impaired memory or communication skills may retain decision-making capacity.
5. Closely examine the feet and pedal pulses of diabetic patients regularly, looking for ulcerations, significant callous formation, injury, and joint deformities that could lead to ulceration, and reduced blood flow.
6. Patients aged 19 to 64 years should receive at least one dose of tetanus, diphtheria, pertussis (Tdap) vaccine in place of a booster dose of tetanus-diphtheria (Td) vaccine to improve adult immunity to pertussis (whooping cough).
7. Adolescent girls and women aged 11 to 26 years should receive three doses of human papillomavirus (HPV) vaccine to prevent HPV infection and reduce cervical cancer risk.
8. Subclavian artery stenosis should be suspected in patients with a blood pressure (BP) difference between the right and the left arms of > 10 mmHg.
9. Antibiotic prophylaxis before dental procedures is recommended only for patients with (1) significant congenital heart disease; (2) previous history of endocarditis; (3) cardiac transplantation, and, (4) prosthetic valve.
10. The effectiveness of clopidogrel can be altered by medications such as proton pump inhibitors and inherited mechanisms of clopidogrel metabolism.
11. Patients should be closely assessed during the preoperative consultation for risk factors for postoperative venous thromboembolism and treated appropriately.
12. Patients receiving current or previous (within the past year) glucocorticoid therapy may need additional stress doses during surgery owing to suppression of the hypothalamic pituitary axis.
13. Beta blockers may be helpful to reduce perioperative cardiac risk in patients with peripheral vascular disease and known coronary disease.
14. Patients receiving current or previous (within the past year) glucocorticoid therapy may need additional stress doses during surgery owing to suppression of the hypothalamic pituitary axis.
15. Asking the patient about personal and family history of bleeding episodes associated with minor procedures or injury is as effective in identifying bleeding diatheses as measuring coagulation studies.
16. Noninvasive stress testing has the best predictive value for detecting coronary artery disease (CAD) in patients with an intermediate (30–80%) pretest likelihood of CAD and is of limited value in patients with very low (<30%) or very high (>80%) likelihood of CAD.
17. Routine use of daily low-dose aspirin (81–325 mg) can reduce the likelihood of cardiovascular disease in high-risk patients with known CAD, diabetes, or peripheral vascular disease.
18. Routine daily low-dose aspirin use is associated with an increased risk of gastrointestinal bleeding, which can be reduced through the use of proton pump inhibitors.
19. Right ventricular infarction should also be considered in any patient with signs and symptoms of inferior wall myocardial infarction.
20. Diabetes is considered an equivalent of known CAD and treatment and prevention guidelines for diabetic patients are similar to those for patients with CAD.
21. Renovascular stenosis should be considered in patients with the new onset of hypertension at a younger (<20 yr) or older (>70 yr) age.
22. Consider aortic dissection in the differential diagnosis of all patients presenting with acute chest or upper back pain.
23. Increasing size of an abdominal aortic aneurysm (AAA) increases the risk of rupture. Patients with AAA greater than 5 cm or aneurysmal symptoms should have endovascular or surgical repair. Smaller aneurysms should be followed closely every 6 to 12 months by computed tomography (CT) scan.
24. Patients presenting with pulselessness, pallor, pain, paralysis, and paresthesias of a limb likely have acute limb ischemia due to an embolus and require emergent evaluation for thrombolytic therapy or revascularization.
25. Patients presenting with symptoms of transient ischemic attack are at high risk of stroke and require urgent evaluation for symptomatic carotid artery disease and treatment that may include antiplatelet agents, carotid endartectomy, statin drugs, antihypertensive agents, and anticoagulation.
26. All patients with peripheral arterial disease and cerebrovascular disease should stop smoking.
27. Asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and upper airway cough syndrome (UACS) can all cause wheezing.
28. Inhaled corticosteroid therapy should be considered for asthmatic patients with symptoms that are more than mild and intermittent.
29. Pulmonary embolism cannot by diagnosed by history, physical examination, and chest x-ray alone. Additional testing such as D-dimer level, spiral chest CT scan, angiography, or a combination of these tests will be needed to effectively rule in or rule out the disease.
30. Sarcoidosis is a multisystem disorder that frequently presents with pulmonary findings of abnormal chest x-ray, cough, dyspnea, or chest pain.
31. Hepatitis C virus infection can lead to cirrhosis, hepatocellular carcinoma, and severe liver disease requiring transplantation.
32. Travelers to areas with endemic hepatitis A infection should receive hepatitis A vaccine.
33. Celiac sprue should be considered in patients with unexplained iron-deficiency anemia or osteoporosis.
34. In the United States, gallstones are common among American Indians and Mexican Americans.
35. Esophageal manometry may be needed to complete the evaluation of patients with noncardiac chest pain that may be due to esophageal motility disorders.
36. The estimated glomerular filtration rate (eGFR) is now frequently routinely reported when chemistry panels are ordered and can provide a useful estimate of renal function.
37. Angiotensin-converting enzyme (ACE) inhibitor use should be evaluated for all diabetics, even those with normotension, for their renoprotective effects.
38. Diabetes is the most common cause of chronic kidney disease (CKD) in the United States.
39. When erythrocyte-stimulating agents are used for the treatment of anemia associated with chronic kidney disease (CKD) and end-stage renal disease, the hemoglobin should not be normalized, but maintained at a level of 11 to 12 g/dL.
40. Low-dose dopamine may not prevent acute kidney injury in critically ill patients, but may cause tachycardia and digital, bowel, and myocardial ischemia.
41. Hyponatremia can commonly occur after transurethral resection of the prostate.
42. Thrombocytosis, leukocytosis, and specimen hemolysis can falsely elevate serum potassium levels.
43. Intravenous calcium should be given immediately for patients with acute hyperkalemia and electrocardiographic changes.
44. Hypoalbuminemia lowers the serum total calcium level but does not affect the ionized calcium.
45. Hypokalemia, hypophosphatemia, and hypomagnesemia are common findings in alcoholics who require hospitalization.
46. Lupus mortality is bimodal in distribution—patients who die early die from the disease or infection; patients who die later in life tend to die from cardiovascular diseases.
47. In a patient who is a smoker and presents with what looks like Raynaud’s phenomenon, think of Buerger’s disease (thromboangiitis obliterans).
48. Patients with autoimmune disorders who smoke should be counseled to quit because tobacco has recently been linked to precipitation of symptoms and poorer prognosis.
49. Antinuclear antibody (ANA) titers are not associated with disease activity.
50. Early, aggressive intervention with disease-modifying antirheumatic drugs reduces the morbidity (deformity leading to reduced functionality and disability) and mortality associated with rheumatoid arthritis.
51. Packed red cells in freshly acquired blood may include lymphocytes that can mount a graft-versus-host reaction in patients who are immunocompromised.
52. Intranasal steroids are the single most effective drug for treatment of allergic rhinitis. Decongestion with topical adrenergic agents may be needed initially to allow corticosteroids access to the deeper nasal mucosa.
53. ACE inhibitors can cause dry cough and angioedema.
54. Beta blockers should be avoided whenever possible in patients with asthma because they may accentuate the severity of anaphylaxis, prolong its cardiovascular and pulmonary manifestations, and greatly decrease the effectiveness of epinephrine and albuterol in reversing the life-threatening manifestations of anaphylaxis.
55. Patients with persistent fever of unknown origin should first be evaluated for infections, malignancies, and autoimmune diseases.
56. Viruses are the most common causes of acute sinusitis; therefore, antibiotics are ineffective.
57. Most cases of Rocky Mountain spotted fever (RMSF) do not occur in the Rocky Mountain region but in the south Atlantic and south central regions. Patients with febrile illnesses and a rash who have been in these regions in the summer (May to September) should receive empirical doxycycline therapy for presumptive RMSF.
58. Asplenic patients (either anatomic or functional) are susceptible to infections with encapsulated organisms (Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitides) and should receive appropriate vaccinations.
59. Allergic bronchopulmonary aspergillosis (ABPA) occurs in asthmatics and is evident by recurrent wheezing, eosinophilia, transient infiltrates on chest x-ray, and positive serum antibodies to aspergillus.
60. Chagas’ disease, caused by Trypanosoma cruzi, can cause cardiomyopathy and conduction abnormalities.
61. Human immunodeficiency virus (HIV) infection is preventable and treatable but not curable.
62. Routine HIV testing should be considered for all patients older than 13 years.
63. Nucleic acid–based testing (NAT) is needed for diagnosis of acute primary HIV infection.
64. HIV-infected patients with undetectable viral loads can still transmit HIV.
65. HIV-infected patients with tuberculosis are more likely to have atypical symptoms and present with extrapulmonary disease.
66. All patients with HIV infection should be tested for syphilis, and all patients diagnosed with syphilis (and any other sexually transmitted disease) should be tested for HIV.
67. The presence of thrush (oropharyngeal candidiasis) indicates significant immunosuppression in an HIV-infected patient.
68. Ferritin is an effective screening test for hemochromatosis.
69. Methylmalonic acid can be helpful in the diagnosis of vitamin B12 deficiency in patients with low normal B12 levels.
70. Pneumococcal polysaccharide, Haemophilius influenzae B (HiB), and meningococcal vaccines should be given to patients before elective splenectomy, preferably 14 days before the procedure.
71. Chronic lymphocytic leukemia is the most common leukemia in adults and is often found in those older than 70 years.
72. Patients with antiphospholipid syndrome have an antiphospholipid antibody and the clinical occurrence of arterial or venous thromboses or both, recurrent pregnancy losses, or thrombocytopenia.
73. Mesothelioma, a pleural malignancy associated with asbestosis exposure, is not associated with smoking.
74. The preferred treatment for esophageal cancer is resection.
75. Renal cell carcinomas frequently present with symptoms of multiple other organs, making its diagnosis difficult.
76. Tobacco and alcohol use are significant risk factors for head and neck cancers.
77. Aggressive cervical cancer is found in women with HIV infection. Invasive cervical cancer is an acquired immunodeficiency syndrome (AIDS)–defining condition.
78. The best initial screening test for evaluation of thyroid status is the thyroid-stimulating hormone (TSH), because it is the most sensitive measure of thyroid function in the majority of patients. The one exception is patients with pituitary and hypothalamic dysfunction in whom TSH cannot reliably assess thyroid function.
79. Patients with type 1 and type 2 diabetes should be screened at regular intervals for the microvascular complications of retinopathy, neuropathy, and nephropathy.
80. Some patients with subclinical thyroid disease (elevated TSH in the absence of hypothyroidism symptoms) do have mild thyroid disease and may benefit from treatment.
81. Erectile dysfunction and decreased libido in men and amenorrhea and infertility in women are the most common symptoms of hypogonadism.
82. Hyperparathyroidism is the most common cause of hypercalcemia.
83. Ataxia can be localized to the cerebellum.
84. Gait dysfunction, urinary dysfunction, and memory impairment are symptoms of normal-pressure hydrocephalus.
85. In the appropriate setting, thrombolysis can markedly improve the outcome of stroke. Prompt initiation of thrombolytic therapy is essential.
86. The sudden onset of a severe headache may indicate an intracranial hemorrhage.
87. Optic neuritis can be an early sign of multiple sclerosis.
88. Vitamin D deficiency is common in older adults and can contribute to osteoporosis, fractures, and falls. Vitamin D levels are measured by the 25-OH vitamin D.
89. Older adults are particularly susceptible to the anticholinergic effects of multiple medications, including over-the-counter antihistamines.
90. Anemia is not a normal part of aging, and hemoglobin abnormalities should be investigated.
91. Decisions regarding screening for malignancies in the elderly should be based not on the age alone, but on the patient’s life expectancy, functional status, and personal goals.
92. Systolic murmurs in the elderly may be due to aortic stenosis or aortic sclerosis.
93. Delirium in hospitalized patients is associated with an increased mortality.
94. When delirium occurs, the underlying etiology should be thoroughly evaluated and treated.
95. Pneumonia is the most common infectious cause of death in the elderly.
96. Discussion and preparations for palliative care should begin at the time of diagnosis of a terminal illness.
97. Medications to prevent constipation should be prescribed at the same time as the initial prescription of chronic opioid therapy.
98. Patients can discontinue hospice care if their symptoms improve or their end-of-life goals change.
99. Opioids are the safest, most effective medications for pain control at the end of life.
100. Opioid analgesics are available in many forms including tablets to swallow, tablets for buccal application, oral solutions, lozenges for transmucosal absorption, injection, transdermal, intramuscular, and rectal suppositories.