Table of Contents

EP. 325 EXTREMELY HY SCREENING GUIDELINES..................................................1

Pregnancy........................................................................................................................ 1
Smokers........................................................................................................................... 2
Special Genetic Diseases................................................................................................. 2
Risky Sexual Group.......................................................................................................... 3
Metabolic Diseases.......................................................................................................... 4
Cancer Screening............................................................................................................. 4
Children........................................................................................................................... 5
Miscellaneous................................................................................................................... 5
EP. 19: NEUROLOGY SHELF REVIEW PART 1.........................................................6

Ep. 325 Extremely HY Screening Guidelines

Outline:
1. Pregnancy
2. Smokers
3. Genetics
4. Risky Sex
5. Metabolic Disease
6. Cancer
7. Children
8. Misc

Pregnancy
 Gestational Diabetes: Start screening at 24 weeks with a 1-hour glucose
test --> If positive follow with a 3-hour glucose tolerance test
 HIV: At first prenatal visit. Retest for HIV in the Third Trimester.
 HBV: At first prenatal visit for Hep B Surface Antigen.
 Syphilis: At first visit
 Asymptomatic bacteria: Increase the risk of preterm labor and delivery.
(Nonpregnant asymptomatic not treated): Treated with nitrofurantoin o or
1st/2nd gen cephalosporin. Test of cure
 Group B STREP: 35-37 weeks anal and vaginal.
 Women’s Rh status and antibody status (BY INDIRECT COOMBS
TEST): Check at first visit. Rhogam given at 28 weeks and second dose
within 3 days postpartum if baby group is positive.

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Smokers
 Screen for AAA (Abdominal aortic aneurysm)
o Between ages 65-75
o Only men!!!
o If you have smoked as a male or have a family history of AAA
o With an ultrasound
o If more than 5.5 cm you need intervention (endovascular repair of
some sort)
 Screen for Osteoporosis
o Screen in woman.
o Normally you start screening with DEXA scan at age 65 for general
population.
o But in smokers you can start screening for osteoporosis at younger age
o You can also screen for osteoporosis at less than 65 if: Very thin like
with Anorexia Nervosa or premature ovarian failure
 Lung Cancer
o You need to be between ages 50-80
o Have a 20 or more pack-year history
o Currently smoking or have quit less than 15 years ago.
o Screen with a low dose CT scan and you only do it every year for a
total of 3 times. If it is negative all three times you can stop.

Special Genetic Diseases

Familial Hypercholesterolemia
 People get MI at age 25
 People have LDL receptor mutation generally
 Remember rule of 3: Start checking LDL cholesterol at age of 3, 9 and 18 years
 You will continue to screen even after 18 years but not tested on NBME.

Inflammatory Bowel Disease (Both of them)

 You start screening for colon cancer 8 years after making initial diagnosis.
 Continue screening every 1-3 years after that
 You have a small exception of rule: If they are diagnosed with primary
sclerosing cholangitis (PSC) they need to be screened for colon cancer at
the time of diagnosis. Then you continue screening every 1-2 years

Lynch Syndrome (HNPCC)

Px tend to have microsatellite instability problems
 Start colon cancer screening at age of 20 -> Continue every 1-2 years
 Make sure you go straight to COLONOSCOPY
 You can give aspirin as a prophylaxis!!!
 They have other cancers as well

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 Start screening endometrial cancer at age 30
o Continue every 1-2 years
o Endometrial biopsy or sampling
o You offer a prophylactic (THBSO) total hysterectomy with bilateral
salpingo-oophorectomy after childbearing due to astronomic risk of
endometrial cancer and ovarian cancer
Patients with MEN 2A or 2B
 It’s not a matter of if but when will you get a medullary thyroid cancer
 You offer a prophylactic thyroidectomy!!!
Familial Adenomatous Polyposis
APC gene mutation-> Polyps -> KRAS mutation -> p53 mutation-> Adenocarcinoma
 Start colon cancer screening at age 10 years and Continue every year

BRCA Mutations
Breast cancer screening guidelines
 Between ages 25-29 you deserve an annual breast MRI
 If you are over the age of 30 you deserve annual breast MRI and annual
mammography

Risky Sexual Group

 Individuals with HIV
 Men that have sex with men
 Sex workers
 IV drug users
Screening guidelines
 If you are between ages 15-64
 You deserve annual HIV
 Syphilis every three months
 Chlamydia and gonorrhea in women (DO NOT SCREEN MEN!)
o You screen higher risk patients annually no matter the age
o ALL patients (not only high risk) younger than 24 need annual testing
o Non risky patients don’t need to be screened for these two annually
after age of 24
Screen for Hep B surface antigen every year. Also screen the antivaxxers every year
for hep b

Metabolic Diseases
Hypertension

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 Screening is started at age 18 through 40 every 3-5 years
 After age 40 you screen every 1-2 years
o Prevalence and incidence increases dramatically over age 40
o Guideline will change due to increase of burden of cardiovascular disease

Diabetes
 Obese individuals between age 40-70 years old
o Screen every 6 months
o Fasting blood glucose/ Oral glucose tolerance test/ HbA1c
 Hypertension over 135/80 and over age 45
o Needs screening every 6 months!!!!

Osteoporosis
 Screening at age 65: only screen Women
 DEXA scan looking at t score
o -2.5 or less
o Needs treatment
Hyperlipidemia
 There are three screening guidelines separated into groups:
 Everyone gets initial screening at age 20
 For metabolic disease the screening guidelines gets more frequent the older
you become.
 Men
o Ages 20-45: Every 5 years
o Ages 45-65: Every 1 to 2 years
o Over age 65: Every year
 Women: Risk increases more after menopause
o Ages 20-55 every 5 years
o Ages 55-65: Every 1-2 years
o Older than 65: Every year
 Diabetics: You screen every year, the end!
o If LDL is 70mg/dl or higher they will be placed on a high intensity statin
like rosuvastatin or atorvastatin.

Cancer Screening
Colon Cancer
 Start screening at age 50
 Age 45 - 75 higher might need colon cancer screening
 Many ways to screen:
o Colonoscopy every 10 years
o Flexible sigmoidoscopy every 5 years
o Flexible sigmoidoscopy every 10 years if you do a Fecal immune test
every year

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 o Fecal immuno-test or fecal occult blood test every year.
o CT colonography every 5 years will start to be implemented. CT scan that
has certain protocols that make it highly sensitive for detecting colon
cancer.
 If any of the tests other than colonoscopy show an alteration, the next best
step is to DO A COLONOSCOPY WITH BIOPSY!!!
Breast Cancer
The problem is NBME uses ACS so know both of them, the question stem will
probably give you enough information to know both of them
 American Cancer Society: Mammogram Start at age 40 and then do it every
year
 USPSTF guidelines: Mammogram: Ages 50-75 then every 2 years
Cervical Cancer
 Age 21-29: Pap smear every three years
 30 to 65 years:
o Preferred modality: Pap smear + HPV contesting every 5 years
o Pap smears every three years
o HPV testing every 5 years
 Special Cervical Screening guidelines
o HIV or immunodeficiencies:
 They get pap smears every year!!!
 Especially T cell deficiencies like DiGeorge
o Hysterectomy and pap smears:
 If it was done due to benign conditions like leiomyomas: You do
NOT NEED TO DO A PAP!
 If it was done due to malignant reason (cervical or endometrial
cancer): Pap smear of the vaginal cuff until 20 years after the
surgery
 Stop screening at 65: No history of cervical cancer or No history of HSIL OR
CIN 3
o If they did, then you need to have 3 negatives in a row or 2 pap
smears plus HPV contesting in a row

Children
Patients with Language difficulties: Screening hearing with audiometry
All kids between ages 3-5 years old: Screen for amblyopia-> Lazy eye

Miscellaneous
Women Less than 24 years old: Screen annually for gonorrhea and chlamydia
ONLY IN women
Who needs to be screened for Hep B?

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  All people between ages Hep C 18-79: Once
 Patients who receive multiple blood transfusions or are constantly on dialysis:
Every Year
 Long term chemotherapy or long-term immunosuppressive therapy due to
transplant: Every year
Screening for depression: Questionnaires: PHQ-9, Beck depression inventory

NEUROLOGY SHELF

Ep. 19: Neurology Shelf review part 1

 Brain tumor that causes loss of “vertical gaze” → pinealoma (causes Parinaud’s
syndrome)
o Pathophys? Compression of superior colliculus, which is the vertical
conjugate gaze center

 13 mo child with history of hypopigmented macules + seizures. → tuberous

sclerosis
o Hypopigmented macules = ash leaf spots
o Associated seizure syndrome? West syndrome (infantile spasms)
 EEG finding? Hypsarrhythmia
 Tx? ACTH or vigabatrin

 Most common primary brain tumor in kids → pilocytic astrocytoma

o Histology? Rosenthal fibers
o Marker? GFAP (glial cell marker)

 Medulloblastoma
o Location? Cerebellar vermis
o Histology? Homer-Wright rosettes

 Brain tumor presenting as hydrocephalus → ependymoma

o Histology? Perivascular pseudorosettes or ependymal rosettes

 Brain tumor causing visual problems in kid → craniopharyngiomas

o Derived from? Rathke’s pouch
o Imaging? Calcified suprasellar mass

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 o Complications?
 Bitemporal hemianopsia (2/2 optic chiasm compression)
 Anterior pituitary hormone deficiencies (2/2 pituitary stalk/gland
compression)

 MC cause of brain tumor in adults → metastasis

o Location? Grey-white junction
o Imaging? Multiple well-circumscribed lesions

 Most common primary brain tumor in adults → GBM

o Imaging? Butterfly-shaped mass that crosses corpus callosum + edema +
central necrosis
o Marker? GFAP (glial cell marker)
o MC brain tumor excluding mets

 Bilateral acoustic neuromas

o Pathophys? Schwannoma of CN8
o Location? Cerebellopontine angle
 #1 MC tumor at cerebellopontine angle → acoustic neuroma
 #2 MC tumor at cerebellopontine angle → meningioma
o Tumor marker? S-100
o Associated syndrome? NF-2

 Brain tumor that presents as parasagittal mass along falx cerebri → meningioma
o Histology? Psammoma bodies (“laminated calcifications”)

 2 yo child with abdominal mass that crosses midline + myoclonus + weird eye
movements + calcified mass on imaging → neuroblastoma
o Alternate location: posterior mediastinum
o Associated syndrome?
 NF-1
 Beckwith-Weideman syndrome
 Neuroblastoma / Wilms tumor / hepatoblastoma
 Hemihypertrophy
 Macroglossia
 Enlarged abdominal organs
 Abdominal wall defects
 Hypoglycemic seizure in newborn
o Pathophys? hyperplasia of beta cells of pancreatic
islets
 2 yo child with abdominal mass that does not cross midline + no calcifications →
Wilms tumor
 Frontal lobe tumor → oligodendroglioma

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 o Histology? fried egg appearance
 Brain tumor that produces EPO → hemangioma blastoma
o Associated syndrome? VHL syndrome
o Treat because they can cause a life-threatening hemorrhage!

 Recent viral illness + vertigo + tinnitus → labyrinthitis

 Feeling like room is spinning with positional changes + nystagmus with
provocative maneuvers → BPPV (caused by otolith displacement)
o Diagnostic maneuver? Dix-Hallpike
o Tx? Epley / Semont maneuver

 Anesthesia over medial thigh + weak thigh adduction → obturator nerve injury
o Nerve roots? L2-L4

 Anesthesia over lateral thigh → lateral femoral cutaneous nerve injury

 7 yo kid with ataxia + hypertrophic cardiomyopathy + LE hyporeflexia →

Freidrich’s ataxia
o Pathohpys?
 GAA repeats → LOF mutation in frataxin gene (iron binding protein)
→ iron overload causes oxidative damage
 Destruction of dorsal columns of spinal cord → hyporeflexia
 Cerebellar destruction → ataxia
o Inheritance? AR
 Unlike other trinucleotide repeat disorders, which are AD
o Repeat? GAA
o MC cause of death? CHF 2/2 hypertrophic cardiomyopathy

 35 yo F with a BMI of 35 with visual difficulty and severe intermittent headaches.

She takes tetracycline for acne. → idiopathic intracranial hypertension
(“pseudotumor cerebri”)
o Imaging/Procedure Mgmt:
 1st step? Fundoscopic exam → shows papilledema
 2nd step? Head CT → is normal
 3rd step? LP → shows elevated OP
o Tx?
 Weight loss
 Acetazolamide (carbonic anhydrase inhibitor)
 Serial LPs
 VP shunt
o Tx for severe visual difficulties? optic nerve fenestration (relieves
pressure)
o Triggers?

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  Tetracyclines (i.e. female patient getting acne tx)
 Vit A derivatives

 Management of ischemic stroke (caused by blockage w/i blood vessel)

o Initial imaging? Non-contrast head CT to DDx ischemic stroke vs.
hemorrhagic stroke b/c blood looks just like contrast ☺
o Next imaging? MRI
o Time window for tPA administration? 3-4.5 hrs
 Up to 6 hrs if you can inject tPA directly into involved vessel
o HY contraindications to TPA administration
 Bleeding disorder
 GI bleeding
 Recent brain surgery
o Blood pressure management?
 Permissive HTN (BP up to 220/120) in patients with ischemic
strokes only in pt’s that cannot NOT get TPA
 Why? Increased BP keeps vessels perfused, which optimizes
blood flow to ischemic penumbra of brain
 If getting tPA, BP < 185/110
 If hemorrhagic stroke with high BP, can lower BP with labetalol,
nitroprusside, nicardipine

 78 yo has 15 min episode of complete vision in one eye that has since resolved.
→ amaurosis fugax (TIA)
o Classic presentation? Painless loss of vision in one eye, “curtain coming
down”
o Dx?
 Non-contrast head CT
 Brain MRI
 Echo (to look for origin of clot)
 Carotid US
o NBSIM? Probably carotid US on shelf exam
o Prevention of further episodes?
 Aspirin
 Aspirin + dipyridamole
 If aspirin contraindicated, clopidogrel
o Indications for carotid endo
 >70% stenosis
 Symptomatic
o #1 modifiable RF for a stroke? HTN

 6 yo M with difficulty walking + uses arms to “walk up” his legs/thighs (Gower’s
sign) + hypertrophy of calves bilaterally. → Duchenne muscular dystrophy

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 o Gene? DMD
o Mutated protein? Dystrophin (stabilizes sarcolemma to cytoskeleton)
o Inheritance? X-linked recessive
o Dx?
 Increased creatine kinase levels
 Genetic testing for dystrophin gene mutation
o Tx?
 Steroids
 High-calorie nutrition
o MC cause of death? Respiratory failure or cardiac causes
 Muscular dystrophy + intelligence + life expectancy in the 50s → Becker
muscular dystrophy
o Pathophys? Have some functional dystrophin
o Gene? DMD
o Mutated protein? Dystrophin
o Inheritance? X-linked recessive

 Ataxia + confusion + ophthalmoplegia → Wernicke encephalopathy

o Reversible
o Imaging? Hemorrhagic infarct of mamillary bodies
o Pathophys? Vitamin B1 deficiency
o Function of which enzyme affected? Transketolase in pentose phosphate
pathway
 Decreased transketolase activity
o Tx? IV thiamine then glucose
o Note: “ophthalmoplegia” means eye problem; pt’s with Wernicke-
Korsakoff can have any eye problem, e.g. nystagmus, lateral gaze palsy,
etc.
 Complication of untreated Wernicke encephalopathy? Korsakoff syndrome
o Irreversible
o Sxs: ataxia + confusion + ophthalmoplegia + amnesia + confabulation

 40 yo F with diplopia or droopy eyelids worse at end of day + difficulty

swallowing + weird speech → myasthenia gravis
o Pathophys? Antibodies to post-synaptic nicotinic ACh receptor
o Dx? anti-AChR or anti-MUSK Ab testing
 NOT edrophonium test/Tensilon test (no longer standard of care)
o Tx? AChE inhibitors (e.g. pyridostigmine)
o Associated malignancy finding? Thymoma (anterior mediastinal mass)

 NBSIM for patients with myasthenia gravis? CT chest to look for thymoma
o b/c removal of thymoma can resolve myasthenia gravis

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 Smoker with proximal muscle weakness that improves with use → LEMS
o Pathophys? Antibodies to presynaptic voltage-gated Ca++ channel

 Lateral medullary syndrome (Wallenberg syndrome) causes dysphonia,

dysphagia, and loss of gag reflex
o Blood vessel occluded? PICA occlusion
o Loss of pain and temperature on left face → L trigeminal nerve
o Loss of pain and temperature on right side of the body→ L spinothalamic
tract
 Located in lateral brainstem
 Decussates at anterior white commissure → contralateral sxs
o Absent gag reflex, dysphonia, dysphagia → CN9/10
 Medulla
o Vertigo → CN8
 Pons/Medulla
o Ptosis and miosis on left (Horner’s) → L sympathetic tract to superior
cervical ganglion
 Located in lateral brainstem

 Medial medullary syndrome causes tongue deviation to ipsilateral side

o Blood vessel occluded? Anterior spinal artery occlusion
o Right sided paralysis → L corticospinal tract
 Runs through medial brainstem
 Decussates at level of medullary pyramids
o Tongue deviation to the left. → L CN12
 Tongue deviation to ipsilateral side

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

 A 35 yo African American female with 3-day history of eye pain. Funduscopic

exam is notable for conjunctival erythema and miosis. CBC is notable for
increased ACE levels and Ca2+ of 12.9. CXR with bilateral
lymphadenopathy. What is the cause of her eye symptoms? → optic
neuritis 2/2 sarcoidosis
o Exam finding? APD + pain with eye movements (this is optic
neuritis!)
o Another condition a/w optic neuritis? Multiple sclerosis

 35 yo F with tremors in her hands bilaterally that are worsened by stretching out
her hand. Better with alcohol. → benign essential tremor
o Inheritance? AD
o Tx?
 Beta blocker (e.g. propranolol)
 Barbiturates (e.g. primidone)
 Mechanism? Increase duration of opening of chloride
channels → hyperpolarization

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 Benign essential tremor:  Parkinson’s disease tremor:

 Bilateral  Unilateral/asymmetric
 Worse with activity  Worse at rest
 Tx: propranolol  Tx: levodopa/carbidopa; dopamine
agonists; COMT inhibitors; NMDA
antagonists; MAO-B inhibitors;
antimuscarinics

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