DIP – 37 (June 2018)

OK, welcome. My name is Divine. Welcome to the 37th episode of the Divine
Intervention Podcasts. I decided to name it, the Preventive Medicine podcast. I
would say that with this podcast, you'll probably get many, many questions on
many exams you take across your 3rd year, or even for Step 1, and definitely
for Step 2 CK, and almost certainly for Step 3. Because for this podcast, there
are three big things I'm going to focus on. I'm going to focus on risk factors
across the different specialties. I am going to focus on the MCCs of death
across different specialties. And then I'm also going to focus on just some
other weird, high-yield or grab-bag pieces of information. I will highly, highly
encourage you to listen to this, like the night before an exam or something. You
will almost certainly get many questions right from this. So let's begin.

I will sort of mix and match everything.

What is the biggest risk factor for suicide?

So the most important risk factor for suicide is actually a prior history of
attempting suicide. If you've previously attempted suicide, that's the biggest
risk factor for a new suicide attempt.

What is the biggest risk factor for Afib?

Well, I hope you're thinking about mitral stenosis. OK.

Although a peripherally related question is to ask about the most common

arrhythmia in a patient with hyperthyroidism. The most common arrhythmia
in patients with hyperthyroidism is Afib as well.

What is the most important risk factor for mitral stenosis?

The answer to that is rheumatic fever. OK, rheumatic fever very commonly
affects the mitral valve and usually causes mitral stenosis. So the most common
risk factor for Afib is mitral stenosis, but the most common risk factor for
mitral stenosis is rheumatic fever.

What is the most common risk factor for an abdominal aortic aneurysm?
That is smoking. OK, they will try to trip you up with hypertension. Don't be
fooled by that on a test. The biggest risk factor for a AAA is smoking.
What is the most important modifiable risk factor for coronary artery
disease?
That's smoking as well. OK. In fact, if they mention a patient with an MI and
they ask for risk factors, the big thing you want to think about is smoking. But
if you don't see smoking as an answer choice, then go with unstable angina.
Unstable angina is actually one of the most important risk factors for a
myocardial infarction. But the biggest risk factor for coronary artery disease,
and it's actually modifiable, is smoking.

For stroke and aortic dissection, what is the biggest risk factor?
Hypertension is the biggest risk factor for stroke and aortic dissection.

And if you get an unusual exam question about a patient that has iron deficiency
anemia and they say, "Oh, this patient has a history of H. pylori infection," and
they ask for the biggest risk factor, well, I hope you think about peptic ulcer
disease. H. pylori can cause PUD, and that PUD can then trigger iron deficiency
anemia because you're basically bleeding from the GI tract.

What is the most important risk factor for esophageal adenocarcinoma?

That is Barrett's esophagus. OK, they will try to trip you up by putting
Barrett’s esophagus as an answer choice and GERD as an answer choice. Do not
pick GERD, pick Barrett’s esophagus. That’s the biggest risk factor for
esophageal adenocarcinoma.

What's the MCC of community-acquired pneumonia?

That is Strep pneumo. OK.

What's the MCC of UTIs overall? That would be E. coli.

What is a commonly tested exam risk factor for osteoporosis?

That’s a low BMI. They classically test this in the context of a patient with
anorexia nervosa or a postmenopausal patient who has a low BMI, usually around
18 or 19. If you see that, that’s the biggest predisposing risk factor for
osteoporosis in those populations.

Controlling blood glucose does not decrease the risk of stroke or myocardial
Another bizarre thing you want to keep in mind—this is just something I’m
going to say out loud—is that when you control blood glucose in a diabetic, it
actually does not decrease the risk of stroke or myocardial infarction. Those
are macrovascular complications. The macrovascular complications of diabetes
are not prevented by controlling blood glucose. The only things that controlling
blood glucose helps with are microvascular complications, like nephropathy,
retinopathy, or neuropathy. Those risks can be decreased by controlling blood
glucose.

The biggest risk factor for AAA is smoking

The greatest risk factor that predisposes a AAA to rupture is the diameter
of the aneurysm.
For AAA, remember, you screen for AAA in men, not women. OK? You screen
only in men, and you basically screen a man who has ever smoked and is between
the ages of 65 to 75. Usually, you do that with a one-time screening ultrasound.
If the aneurysm is greater than 5.5 cm, you proceed to surgery. If it's less
than 5.5 cm, you watch it. If it grows by more than 0.5 cm in a six-month
period, you also proceed to surgery. If it's symptomatic at any point, you also
proceed to surgery.

What is the most important risk factor for SCC of the skin?
It should be cumulative sun exposure.

What's the most important risk factor for ovarian cancer?

It is actually having a family history of ovarian cancer.

What is the most important risk factor for prostate / breast cancer?
Age is the most important risk factor for prostate cancer and for breast
cancer. Basically, the older a person gets, the higher the risk of prostate
cancer or breast cancer.

What is the most important risk factor for bladder cancer?

Smoking is the biggest risk factor for bladder cancer.

What’s the MCC of death in patients with acromegaly?

That’s heart failure.

The MCC of death in patients receiving a kidney transplant

Is cardiovascular disease.

What’s the MCC of death in patients with chronic kidney disease?

That’s cardiovascular disease as well.
The MCC of death in patients with end-stage kidney disease is
Arrhythmias, like sudden cardiac death from an arrhythmia.

The second MCC of death in patients with end-stage kidney disease is

infection.

What is the most important risk factor for obstructive sleep apnea?
That’s obesity.

What is the most important modifiable risk factor for knee osteoarthritis?
That’s obesity as well.

What’s the MCC of death in patients with AD polycystic kidney disease?

It’s cardiovascular disease. So here’s what they will try to do to you on an
exam. They will try to trick you by putting subarachnoid hemorrhage as an
answer choice. That is not the MCC of death in ADPKD. It’s actually
cardiovascular disease.

What’s the MCC of death in patients with lupus?

That’s ischemic heart disease, like a myocardial infarction.

What’s the commonly tested risk factor on many exams for pancreatic
cancer? That’s smoking.

What’s the most common pulmonary malignancy in patients with a history of

asbestos exposure?
That’s bronchogenic carcinoma. Not mesothelioma, but bronchogenic carcinoma.
And remember, smoking is very high-yield to know here. Smoking is not a risk
factor for mesothelioma. And don’t forget that mesotheliomas are calretinin-
positive. And you can also see psammoma bodies, which are laminated
calcifications on microscopy. And then, since we’re talking about the lungs, don’t
forget that silicosis increases susceptibility to TB.

What is the MCC of acute pancreatitis in the US?

That’s gallstones. Not alcoholism. They are roughly equal, to be honest, but at
least there is a study I read that said gallstones are the MCC of acute—not
chronic—acute pancreatitis in the US.
The most important risk factor for chronic pancreatitis in the US
is alcoholism. People drink—it’s like a habit. People will drink over time.

I will just mention this, but there is a classically tested risk factor for
papillary thyroid cancer. Do you know what it is? Well, I hope you’re thinking
about a history of chest or neck radiation for lymphoma.

And for breast cancer, you want to know your screening guidelines.

✓ According to the USPSTF, you want to screen every two years from the age
of 50 to 74.
✓ For the American Cancer Society, they recommend screening every year
starting at 40.

And I have actually seen this American Cancer Society recommendation be the
most correct on most of the exams I have taken in the past. So, it’s just
something to keep in mind. But I would definitely know both

For cervical cancer screening,

✓ You want to do a Pap smear every three years between the ages of 21 to 30.
Basically, if a patient is older than 30 years, you can also do the same thing—
you can do a Pap smear every three years.
✓ Alternatively, if you’re older than 30, you can do a Pap smear plus HPV core-
testing every five years.
✓ And basically, you screen between the ages of 21 to 65.
✓ If a patient has a history of HIV, you actually screen more frequently, so
you don’t screen every three years—you screen like every one or two years.
✓ And basically, you can stop screening before the age of 65 if a woman has
had a hysterectomy.
✓ But here’s the kicker—you can only stop screening before the age of 65 if
the hysterectomy was done for benign reasons. So, let’s say leiomyoma, for
example.
✓ If the hysterectomy was done for a non-benign cause, like endometrial
cancer or something like that, you want to keep doing Pap smears.
✓ And the buzzword you want to recognize on exams is a Pap smear of the
vaginal cuff. OK. It’s a very common exam question.
With regards to chlamydia screening,

In general, if a patient has high-yield risk factors—I’ll say the big one they
tend to put on exams is inconsistent condom use—and they are younger than 25,
you can go ahead and screen them for chlamydia.

With regards to screening for hyperlipidemia

✓ In men, you screen men over the age of 35.

✓ For women, you screen starting at the age of 45, and I believe you do that
every five years thereafter. I’m not sure about the last part, though, but
I’m almost certain you screen every five years. But I’d encourage you to look
that up.
✓ And it's mega, mega high-yield to know that you can actually start before
the age of 35 in men or before the age of 45 in women if they are high-risk
for coronary artery disease.
✓ So, you may see exam questions where a patient is 22, and the answer is to
screen for lipids. Don’t be surprised by that.
✓ If they have a lot of risk factors for coronary artery disease, you go ahead
and screen them earlier than 35.

Colon cancer screening is super high-yield.

✓ In general, you want to screen with colonoscopy—that’s the preferred

method—every ten years between the ages of 50 to 75.
✓ Alternatively, you can do a flexible sigmoidoscopy every five years.
✓ Alternatively, you can also do an annual fecal occult blood test.

✓ I imagine in the future that CT colonography—it’s not yet approved—but CT

colonography might become an option in a few years because it has a very
high sensitivity.
✓ And basically, like I said, colonoscopy is preferred.
✓ But if you say, "OK, let me go with the FOBT route or the flexible
sigmoidoscopy route," if any of those tests are positive, the next step in
management is to do a colonoscopy.
For patients with ulcerative colitis, you definitely want to know that colon
cancer screening actually starts eight years after the initial diagnosis of UC
has been made—eight years after the initial diagnosis.

If a patient has a family history of colon cancer, they also classically test
this. You want to start screening at the age of 40, or you want to start
screening ten years before the age at which the family member was diagnosed
with colon cancer. So, for example, if the family member was diagnosed at the
age of 49, if you backtrack ten years, that’s 39, ? If you compare 39 and 40,
39 is earlier. So, you start screening at 39. But if the patient’s family member
had cancer at 52 and you’re like, "Oh, when do I start screening?" You start
screening at the age of 40. OK. Because if you backtrack ten years from 52,
that’s 42 years. But if you compare 40 and 42, 40 is earlier, so you start
screening at the age of 40.

If a patient has a history of familial adenomatous polyposis, you actually want

to start annual colonoscopies or sigmoidoscopies every year, starting between
the ages of 10 to 15. OK. So, once the child hits anywhere from 10 to 15, start
an annual colonoscopy or sigmoidoscopy. Basically, the recommendations are
roughly the same for HNPCC, but I think that’s a little low-yield, so I’m not
going to say too much about that. But basically, the rule of thumb is to start
screening for colon cancer before the age of 21 in HNPCC patients.

For all pregnant women,

At the first prenatal visit, you definitely want to screen for syphilis. And you
also want to screen for asymptomatic bacteriuria and HIV. And if you detect
bacteriuria in an asymptomatic pregnant woman in her urine, you go ahead and
treat. But that recommendation does not extend to a non-pregnant female.
Non-pregnant females with asymptomatic bacteriuria are not treated. And if a
pregnant woman has asymptomatic bacteriuria after you treat—usually, you
treat with nitrofurantoin, for example—you go ahead and perform a test of
cure. But if a pregnant woman has pyelonephritis, after treatment, she actually
has to be on chronic prophylaxis against UTIs for the rest of the pregnancy.
For RhD immunoglobulin, you want to give that around 28 weeks. And you also
probably want to give that within 72 hours of delivery. If you want to
determine the dose of Rh immunoglobulin that you should give to the mother,
you perform a quantitative test to determine how much of the fetus’s blood has
mixed with the mother’s blood. It’s a test know as the Kleihauer-Betke test.
That’s a test you can use to quantitatively determine how much Rhogam should
be given postpartum to mom.

For melanoma, what’s the most important prognostic factor that indicates the
likelihood of spread? Well, I hope you're thinking about the depth of the lesion.
The depth of the lesion—the Breslow depth—determines the likelihood of
melanoma spreading. It is the biggest prognostic factor.

What is the most important preventive measure for hepatocellular

carcinoma? That’s actually the Hep B vaccination. Remember, Hep B can cause
HCC, and it's a vaccine-preventable illness. And remember, if you are
vaccinated against Hep B, you've essentially prevented Hep D as well.

What is the most important risk factor for erectile dysfunction?

That’s cardiovascular disease.

What’s the MCC of death in patients with cervical cancer? That’s actually
renal failure from genitourinary spread. Classically, the cancer spreads to the
ureters.

And just as a general rule, the most important prognostic factor in patients
with cancer is the stage of the cancer.

For lung cancer, there is actually screening for lung cancer.

The USPSTF recommends a low-dose CT scan for men and women between the
ages of 55 to 80 if they have a greater than 30-pack-year smoking history. And
you need to remember some addendums, though. These people either have to
still be smoking or have quit within the past 15 years. If the patient has quit
more than 15 years ago, this recommendation does not apply to them anymore.

What’s the most important risk factor for endometritis?

That’s a C-section.
What’s the most important risk factor for preeclampsia?
It’s actually a prior history of preeclampsia. But if you don’t see that as an
answer choice, nulliparity is also an important risk factor for preeclampsia.

What’s a high-yield exam risk factor for uterine inversion?

It’s actually a prior history of uterine inversion.

What’s a high-yield exam risk factor for chorioamnionitis?

They love this one—it’s actually a history of prolonged rupture of membranes.

What increase the risk for preterm delivery.

This I'll just say out loud—having a bicornuate uterus actually increases the
risk for preterm delivery.

What is the biggest risk factor for placenta previa?

It’s a history of C-section.

High-yield risk factor for preterm labor.

And this is something I guess I’ll say out loud—bacterial vaginosis, Remember,
Gardnerella vaginalis, vaginal pH greater than 4.5, clue cells on microscopy—
bacterial vaginosis, which you treat with metronidazole, is actually a high-yield
risk factor for preterm labor. That’s a very common exam question.

What is the biggest risk factor for endometrial cancer?

That’s actually exposure to unopposed estrogen. If you don’t see exposure to
unopposed estrogen as an answer choice, go with endometrial hyperplasia. But
the biggest risk factor is exposure to unopposed estrogen. So, a woman with
PCOS or taking tamoxifen has a high risk of endometrial cancer.

What is the biggest risk factor for cervical cancer?

That would be exposure to HPV, especially the high-risk types like HPV 16, 18,
and those in the 30s. And actually, they may give you a peripheral answer
instead of saying "exposure to HPV." They could give you an answer choice
about something that increases the risk of HPV exposure. For example, they
could say a person with multiple sexual partners or an early age of sexual
intercourse—those things increase the risk of acquiring HPV, which increases
the risk of cervical cancer. And remember, HPV causes squamous cell carcinoma
of the cervix, not adenocarcinoma.
Increased risk of vaginal infections, especially cervical infections
And just one bizarre thing that I came across recently that you might want to
keep in mind is that the reason why young females have an increased risk of
vaginal infections, especially cervical infections, is because they have more
cervical ectopy. The cervix has two parts—there’s an endocervix made of
columnar epithelium, and there’s an ectocervix made of squamous epithelium.
The thing is, squamous epithelium is tougher and more resistant to infection
compared to the endocervix. But in younger females, the endocervical columnar
epithelium tends to bulge out more. This columnar epithelium is not very good at
guarding against infection, so vaginal and cervical infections are more common in
young females because they have more cervical ectopy. However, as they get
older, the endocervix retracts back, and they don’t get as many of those
infections.

One of the strongest exam risk factors for ectopic pregnancy

Is a prior history of ectopic pregnancy. But other things you want to keep in
mind include smoking, because smoking messes with the motility of the fallopian
tube cilia.

High-yield risk factor for cervical incompetence

Is a history of a LEEP procedure or a cervical conization procedure.

High-yield risk factor for shoulder dystocia—That’s macrosomia.

What is the high-yield exam risk factor for fetal macrosomia?

That would be preexisting or gestational diabetes in the mother.

High-yield risk factors for developing pyelonephritis in pregnancy. For that,

you want to think about asymptomatic bacteriuria and a prior history of
pyelonephritis.
Some other weird things

Avoid combined OCPs in certain patients.

✓ The buzzword you may see is triphasic contraception—triphasic

contraceptives contain estrogen.
✓ You want to avoid combined OCPs in smokers, patients with a history of
strokes, or patients with a history of migraines with neurological symptoms—
so, complex migraines.

✓ If a patient has a history of a thrombogenic disease, like Factor V Leiden,

you want to avoid an estrogen-containing contraceptive.
✓ Another high-yield one they love to test is a history of hepatic adenoma—
that’s definitely a contraindication to an estrogen-containing contraceptive.

A super bizarre question that might throw many people off on an exam is
Avoiding the copper IUD in a patient with Wilson’s disease. It kind of makes
sense. Because Wilson’s disease is a copper overload disorder.

For urinary incontinence, I will say that age is a high-yield and important risk
factor. You also want to remember that having multiple vaginal deliveries is a
major risk factor, especially for stress incontinence. Multiple sclerosis is
classically associated with urge incontinence on exams, and diabetes is
classically associated with overflow incontinence.

In general, the most significant risk factor for placental abruption is trauma.
If you don’t see that as an answer choice, go with cocaine use on your exams.

For Asherman syndrome, which is intrauterine adhesions, a high-yield risk

factor is a history of uterine curettage.