2018 General Internal Medicine 13% Flashcards
Pt with PAD risk factors and suspect PAD wtd?
Ankle brachial index
norm=1
diagnostic <0.9
1.3=arterosclerosis
68yo M p.w intermittent claudication of legs - quit smoking 10ya - BP left arm 128/84, BPR R arm 138/82 BP RLE 128.80 - ABI =
128/138=0.92
(choose higher UE SBP) LE/UE SBP
If equivocal ABI (0.9->1)
Excercise ABI
How to manage PVD
modify risk factors (BP, gluc, chol)
Anti plt agens ASA+- palvix
Treat claudication - supervised exc program>cilostazol>pentoxyifylline
Whatd medicatio nused in PAD reduced coronary events regardly of BP effect
ACEi
T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced overall mortality
T
T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced vascular mortaility
T
T/F - Pt with PAD aggressive control of hyperlipiddemia with statin drug a/w reduced cornoary events
T
DM goals
LDL<140/80 with PAD
Pt with sudden onlset pain in foot, discoloration of oot h/o afib - petal and poterior tibila pulses not felt wtd?
anticoag –> arteriogram r/o embolic event from afib–> tPA
Pt wit sudden onset black/blue toes, pulses felt, had cardiac cath earlier and BP elevated wtd?
Adequate BP control
Metabolic syndrome
Obestiy waist in males–> 40”/102cm (>35 asian)
–>35”/88cm in female (31” asian)
TGAs –> >150mg/dl
Low HDL in males–> < 40mg/dl
–> <50 mg/dl
BP –> >130/85
FBS –> >100
Tx: Diet, exercise, drugs
Which antilipid medication woudl tx component of metabolic syndrome
Fibrate
Obesity leading cause of death in US
BMI
Normal 19-25
overweight >25 (50-60% of US population, check FBS,BP, lipids), (overweight + sedentary lifestyle = check FBS)
Obese stage I >30 (30% of US population, drugs indicated for tx–> Victoza)
Obese stage II >35
Morbid obesity >40 (bariatric surgery)
Complications of obesity
Type II DM Ca endometrial>breast>postate>colon elevated LDL, TGA decreased HDL inc'd CAD risk, SCD OA NASH (non alcoholic steatohepatitis) OSA FSG (focal segmental glomerulosclerosis) (NOT OSTEOPOROSIS - protective)
45yo F gaining wight - BMI 31 FBS 105 wtd?
reduce caloric intake 500 to 1000 cal/day
Pt BMI 32 on reduced caloric intake and exercise, 3 months later with BMI 31 - what med for long term use
Orlistat (pancreatic lipase inhibitor)
Lorcaserin (serotinin-2C receptor agonist)
Phentermine-topiramate (nor adrenergic-anticonvulsant)
Liraglutide
Phentermine - short term ONLY, no indication for long term
Indications for bariatric surgery
BMI>35 with DM/hyperchol or HTN or CHF or OSA
BMI>40 with no other conditions
Bariatric surgery reduces mortality?
T
Post gastric bypass surgery - next day with horizontal nystagmus and opthalmoplegia dx?
Thiamine deficiency
Post bariatric surgeryc/o wk and dark colored urine, tenderness of back muscles - U dip stick + blood but no RBCs dx?
Rhabdomyolysis
Post bariatric srugery 3 days later with tachcardia nad tachypnea
PE
Post gastric bypass 2 days later with RR 22, HR 120, temp 100.8 dx?
Anastomatic suture /stable leak - gastrograffin study needed
Long term deficit post bariatric surgery
Vit D, B12, copper, iron
40yo F BMI 40 bariatric surgery 5rs ago presents w/ fatigue and painful parathesias.
Exam- shows spasticity and hyper reflexia
Labs - Hg 10, MCV 75, WBC 2450 w/ Neutorphils 30%, plt 110,000
BM bx-hypercellular marrow w/ some blast cells and ringed sideroblasts
cyanocobalamin deficiency
34yo F roux en y surgery 8 months ago - BMI dropped 40 to 28 - now BMI up to 35 - c/o heartburn
dx? Gastrogastic fistula
35yo F post bariatric surgery BMI 40-25 in 6 montsh - no kids - nauseous and bloating wtd?
preg test
Waist to hip ratio >0.9 in men >0.85 W risk factor
at any rate
Inc’d waist to hip ratio considered CAD risk factor in what group of patients -
older age
Exercise is associated w/
protection against CAD dec'd LDL, TGAs, and increased HDL improved gluc tol reduction of weight, BP, stress red'd mortality from all causes
Pt s/p IWMI d/c’d with ASA, B blocker, ACEi and statin - what else would dec mortalty
exc 1hr day, 5 days / week (not just 3 days 1/2 hr)
Pt p/w flashes or streak of light shows, black dots, wavy curtain - cobwebs always move whereever pt looks - initally with normal visual acuity - fundoscopy with retina appearing folded/elevated wtd?
retinal detachment - Urgent opthal eval for laser tx
Pt with afib sudden onlset painless vision loss in one eye - fundscopy CHERRY RED SPOT IN MACULA etio?
retinal artery occlusion
etio: emboli
60yo with waldenstrom’s macroglobulinemia, HTN or P vera with sudden painless los of vision one eye - fundopscopy with multiple hmorrhages - thunder & clouds dx?
retinal vein occlusion
edge of door is blurry
Elderly man with blurry vision in CENTER, peripheral vision spares - fundscopy with yellow spots (druzen dx?
Macular degeneration
tx: quit smoking, anti oxidant vitamins, magnifying glass
Pt going for cataract surgery taking ASA or warfarin or plavix wtd?
continue ASA/warfarin
ASA+clopidogrel also continue
d/c tamsulosin (avoid floppy iris syndrome)
Young woman with blurry vision esp after excercise - regains vision gradually - wtd?
T2 MRI r/o Multiple sclerosis
Optic nerve infarction
temporal arteritis
tx: steroids
Pt with long standing DM, mild vision, fundscopy -> aneurysms with hemorrhage and exudates
non-prolif retinopathy (backgroudn) with macular edema
tx: TIGHTER glucose control
Pt with long standing DM with blurry vision Fundscopy->neovascularization
dx: prolif DM retinopathy
tx; lasery therapy (effect of laser therapy= peripheral and night vision decreased but central vision spared)
Pt with HgA1c of 7% has laser tx for DM retinopathy no response - wtd?
Tighter glucose control <6.5%
Pt with r eye pain, facial pain, n/v/ h/a blurry vision - R pupil mid dilated, sluggishly reactive - ciliary flush (+), hazy cornea with congestion
Glaucoma
25yo F dec’d vision in L eye with pain - paraesthesia in feet
optic neuritis
Elderly man with progessive loss of central vision - edge of door hazy
macular degeneration
Sudden loss of vision in one eye, fundoscopy Cherry red spot
retinal artery occlusion
Sudden loss of vision in one eye fundoscopy multiple hemorrhages and exudates
retinal vein occlusion
New onset shower of floaters with flashes of light and cobweb
retinal detachment
Magnifying glass (low vision aids)
macular degeneration (also anti-oxidant vit’s and quit smoking)
Crystals in retinal artery (Hollenhorst plauques)
Cholesterol emboli
Pt with intermittent visual loss - fundscopy with crystals in retinal artery wtd?
Carotid duplex US
tx: ASA
test to establish infective endocarditis
Blood ctx
60yo pt wit difficulty driving at night from glare from oncoming cars - diff reading road signs and fine print - dx?
Cataract
Pt with cataract surgery one week ago with eye ache and decreasing vision - otherwise well - afebrile - injected conjunctivea - layering of WBC in anterior chamber slit lamp with intraocular WBC - COTTON WOOL SPOTS??/ - dx?
endopthalmitis
Conjunctivitis
Viral - adneovirus (red eye, discharge gritty/sandy/burn, injected)
Bacterial (whitish, yellowish, greenish exudates)
Allergic (B/l, redness, watery discharge, itch, hx asthma), treat with cool compressions
Pt pw conjunctivitis with serous d/c - prescripbed abx eye drops (sulfacetaminde/neomycin) - 4th day is worse - dx?
allergy to drops
tx: d/c drops
Red eye with itchiness
allergic conjunctivitis
Pt with red eye with graves or RA with dry eyes and gritty sensation
Keratoconjunctivitis sicca
tx: artificial tears
Red eye with pain and photophobia, constricted irregular pupil - ciliary flush normal cornea and normal intraocular pressure - slit lamp - WBC in aquous humor or on corneal epithelium - ???consensual eye reflex with pain??? dx?
Iridocylitis (Anterior uveitis) Emergent referal to opthalmologist intensive topical steroid to reduce inflammation cycloplegics to prevent synechiae tx underlying dz
Pt with red eyes and foreign body sensation with pain - corneal exam with DENDRITIC ULCER - branching pattern - fluorescin stain +
HSV I keratitis
Tx: topical triflurodine (no acyclovir)
Pt intubated on mechanic vent wit one eye redness - cornea white
Pseduomonas keratitis
Tx: topical antipseduomonal
IV anti-pseudomonals
Pt with contact lense develops conjunctivitis
Pseudomonas keratitis
Glaucoma
inc’d intraocular pressure- progressive visual loss 2/2 optic nerve damage
Complication - gradual loss of peripheral vision
Open ange glaucoma
gradual loss of peripheral vision
Cup to dis ratio >50%
Inc’d incidence in African americans
45yo F pw/ R eye pain and temporal headache - exam with conjunctival inection in R eye and vision 20/200 - pupil mid-dilated, fixed, non-reacitve wtD?
urgent referral to opthalmologist - before transfter - give PIOLCARPINE drops
22yo p/w ER with teary eyes - hit in eye with paintball - exam with mid conjunctival injection. pupillary reflex normal, vision normal. Slit exam with linear abnormality wtd?
No therapy f/u PRN
Pt p/w teary eye - pupillary reflex normal, wood lamp after fluorescin patttern of parallel lines of vertical abrasion - vision normal wtd?
every eyelid and remove foreign body
High velocity and insdustrial injury with hyphema (blood in anterior chamber
urgent referral to ophthalmologist
Pt witih conjunctiviti - exam layers of WBC in anterior chamber
refer to ophthalmoligst
Hypopyon - layering of white cells in anterior chamber
Could be ophthalmitis or keratitis - urgent referral needed
Pt with cough - exam with redness in conjunctiva - wtd?
nothing - subconjunctival hemorrhage resolves spontaneously in 1-2 weeks
Pt with diplopia of a few days duration with h/a - on exam lookign stright left is inward and right eye is also slightly inward - dx of b/l lateral rectus palsy made - dx?
cavernous sinus thrombosis (increased ICP)
Cellulits of periorbital area with warth swelling around eye wtd?
CT/MRI - orbital cellulitis-> cavernous sinus thrombosis
tx: IV anti-biotics
Pustule on lid margin
Stye
tx: warm compess - may need surgery
Vascular structure in conjunctiva - can spread to cornea and impair vision
dx: pterygum
Tx: surgery
Inflammed eyelid
blephritis
small nodule under tarsus
Chalazion
etio obstruction of meibomian gland -
Tx: warm compress - surgery may be needed
AIDS pt with blurry vision - fundsocpy with cheese, ketchup appearance, CD4 <25
Dx: CMV retinitis
tx: gancyclovir
How to manage otitis media
Amoxicillin
Pt with recurrent chronic ear infection p/w d/c and MASS producing out of tympanic membrane - hearing loss on that side - dx?
Cholesteatoma
????Pt with c/o hearing loss - esp in crowded area - wtd?
2 feet whisper test
?????If 2 feet whisper test abn - tuning fork at mastoid with no response - tunign for at forehead no response dx?
b/l presbycusosis
????30yo F with gradual hearing loss - whisper test abn, can hear better with tuning fork at mastoid process than near ear - keeping tunign for at forehead with better hearing in both ears - dx?
b/l otosclerosis
(abn growth of bone in middle ear - conductive hearing loss)
fixation of stapes bone
Tx - surgery
Pt with hearing loss in R ear - webber’s test localizes to R ear - exam with obstruction of typanic membrane by cerumen wtd?
Saline irrigation w/ manual removal
Webber test - tuning fork on forhead
Normal = hearing same both ears
If defective ear hears sound louder - CONDUCTIVE hearing loss
If normal ear hears sound better than SENSONEURAL hearing loss
RHINE test - first tuning for on mastoid bone - when can’t hear that tuning for in front of canal - normal(or sensoneural) if Air conduction (AC) louder than bone conduction (BC)
If BC>AC then conductive hearing loss
Pt pw c/o discarhge from R ear - exam with pain on pulling ear up and out - d/c and debri in ext auditory canal and partial obsstruction of typmapinc membrane dx?
Swimmer’s ear
Tx: poymyxin drops
partial TM obstruction, you don’t know where d/c is coming from
Pt with otitis externa in DM - red ear
malignant otitis externa
cover w/ antipseudomonal abx
???cover with 2 anti-pseddoonal abx - ceftazidime and amikacin/tobramycin
Pt going for surgery - pt has LBBB and asx wtd?
clear for surgery
Pt with severe PVDz going for vasc surgery or aneursym repair - wtd prior to OR
dipyridamole thallium or dobutamine stress test
Pt for elective surgery - multiple PVCs asx no evidence of ischemia
Clear for surgery
70 HTN OA going fo rhip replacement
Clear for surgery
Pt with colon CA going for colon surgery, father MI 49 wtd?
Clear for surgery
Pt with CABG 7ya with occasion CP on exertion schedule for urgent AAA 7.5cm in AM - abd tenderness and pulsatile mass wtd?
Emergency surgery - high risk - clear for surgery
After MI when should elective surgeries be done?
6 months
Pt with stable angina going for surgery wtd?
c/w angina meds pre and post surgery
before durign and after
Pt post op after CABG in CCU with confusion, disoriented, doesn’t follow commands, inattentive, pulling ET tube HR 100 wtd?
haldol
What med can cause delirium in elderly during post op period?
Meperidine (demerol)
side effect - seizures
Pt in recovery room and BP 160/104 not known HTN
morphine sulfate for adequate analgesia (pain causing htn)
Pt with severe abd pain - xray with air under diaphragm - c/s for clearance - while doing consult pt vomints and becomees bradycardic - EKG HR 48, some non-conducted p-waves and 1mm ST dep
Inc’d vagal tone from vomiting - clear for surgery
What has been shown to decrease risk of perioperative complications?
Lugn exapansion interventions (incentive spirometry, deep breathing, CPAP)
What is recognied as risk factor post non cardiac surgery
inc’d tropoinin T levels < 72hrs after surgery
40yo F s/w PNA - next mornign see’s “little green ppl in her room”
Or 40yo M a/w GIB see’s “spiders on ceiling” exam afebrile HR 84 bp OK==130/84, RR 16 - Mild tremulousness - fhx etoh abuse - thiamine give dx?
etoh hallucinations
DT with inc HR/BP
Pt had urgent surgery yesterday today oriented x 2, temp 101, HR 105 mild tremor dx?
etoh withdrawal
Pt with anxiet, tremors confusion HR 104, BP 150/92 deslusional and seizure
Delirum tremons (hyperadrenergic state) Tx Diazepa or chlordiazepoxide
lorazepam–> haldol–>phenobarb –>propofol
54yo chornic alcoholic to ER with confusion ataxia nystagmus diplopia
propylene glycol poisoning
Wernickes encephalopathy
Tx FIRST thiamine then glucose
nystagmus also seen in ICU pts w/ thiamine def in TPN
Chornic alcoholic with anterograde and partial retrograde amneis - confabulatory speech
Korsakoff psychosis - poor prognosis
Pt with SOB, tach and bounding pulse - CXR cadriomegaly
thiamine def - high output cardiac failure (beri beri)
Pt with h/o etoh in hosptial - gets thiamine, glucose and is fed well - 5 days later muscular weaknes - sob - CPK inc’d, Hg dec, reti ct inc’d
Refeeding syndrome - hypophosphatemia
Chornic etoh wit muscle sapsms - serum ca low, K low wtd?
FIRST give magnesium sulfate then K/Ca+
Pt underoes surgery - post op seizure tachy, consfused tachypnic
etoh withdrawal
the most effective strategy for addressing alcohol abuse is: SBIRT (Screening, Brief intervention and Referral for Treatment)
Lifetiem incidence etoh abuse and drug abuse
20%
???etoh abuse screening
Cage, AUDIT, 4 drinks on one occsion in men (3 in F)
C - cutting donw
A - annoyed
G - guilty
E eye opener?
Addressing etoh - SBIRT - screeing brief intervetion referral fo rtx
???Etoh abuse
Problems - failures to fulfil work/school oblig, use in hazardous situation, legal proglems with etoh use - constineud use despote social problems
???etoh dependence
keeps drinking - work/social school oblsigations sacrified - tolerance - needs more and more
desire to cut down but continues
withdrawal sx if stops
Pt p/w routine checkup - appears depressed - inc’d MCV, inc’d GGT - what wil establish chronic eetoh abuse
inc’d carboydrate free transferrin
Etoh abuser on sidewalk to ER pain in legs. no back pain. exam weakness fo foot and dec’d ankle jerk - dx?
etoh neuropathy
MCC death etoh abusers
heart disease
All true about alcoholism
inc’d malignancy incidence
inc’d MVA
inc’d suicides and drug OD
inc’d STDs
Best drug to tx etoh addiction in addition to support goups?
Naltrexone
Pt with normal FBS - white/gray spots on conjunctiva dx?
Vit A deficiency
Pt taking multiple vitamins p/w dizziness, headache, abd pain n/v elev LFTs. Ca 10.7mg/dl. xerosis of skin dx?
Vit A toxicity
seen in eating bear liver
Pt with nausea labs Ca 11, fundsocpy blurring of disk margin - pt takes multiple vitamins dx?
Vit A toxcity
Pt lives on tea and toast diet pw bleeding gums - perifollicular hemorrhage and non-healing ulcer - PT/PTT, plts’ normal dx?
Vit C deficiency - scurvy
PP+ pt on INH p/w pin pricks and tingling on legs - low MCV
Vit B6 (pyridoxine) def - inc'd homocystine??
????Pt taking multiple vitamins with HEADACHES - fundoscopy papilledema
Pseduotumor cerebri
etio? Vit A intoxication
50yo chronic etoh with sensory ataxia with romberg +, dementia dec’d proprioception, spasticity optic neuropathy but normal pin prick sensation
Dx: subacute degen of cord 2/2 vit B12 def
high stepping gate
elev MMA??
Pt takes multiple vitamins p/w nausea, anorexia fatigue sever constip - Mucous membrane dry, Ca 11.3, pho 5.2 dx?
Vit D intoxication
Pt with dementia diarrhea dermatitis
Pellagra (niacin) deficiency
Diarrhea and LINEAR VERTICAL WHITE LINES on nails
Arsenic posoning
pic shows vertical or horizontal staight lines
Pt with long ICU stay on TPN with ALOPIECIA, hyeprkeratotoic rash, anemia, LOSS OF TASTE
Zinc deficincy
Post surgery NPO on IVF with inc’d PT 2.4 after 3 days, etio?
Factor VII def
vit K def
Pt post surgery in ICU with nausea is given phenothiazine - next day horizontal nystagmus ophthalmoplegia dx?
Wernicke’s encephalopathy
fyi: phenothiazine would cause immediate dystonic rxn and eyes not moving
???Cheilosis, glossitis, dermatitis
Vitamin B2 def (riboflavin)
???Iodine
goiter or hypothyroid
???Bleeding diathesis
Vit K def
???Cardiomyopathy, CHF
Selenium
hypophophatemia
Thiamine
Anxiety d/o
Panic d/o GADisorder Phobias Obsessive compulsive disorder Post Traumatic disorder
Discrete period of intnese fear and anxiety, somatic sx SOB palpitations, trembiling diaphoresis ches tpain discormfort - one xam click+–>MVP
Panic d/o
(In perceived ‘difficult to escape situations’–>Agoraphobia)
Tx: TCAs/SSIs long term
Benzodiazepines short term
Percieved difficult to escape situation
Agoraphobia
TCA/SSR
benzo - short term
Excessive anxiety out of proportion of fear to impact of fear event
Gen anxiety d/o
Tx: SSRI
cognitive behav therapy
1) 40yo F with complaints of CP, palptiatons diaphoresis and numbness while watching movie/concer - happened couple times before EKG normal wtd?
2) what is the best long term management for this pt?
1) start benzos and re-eval in 2 weeks
2) SSRI’s
Pt with feeling of vibration sense inside body - has CP, palptiations, SOB - exam mid systolic click - dx?
Panic attack
best managment: Paroxetine
Persistent distressing thought -> obsession
Repetive response to the persistent thought -> compulsion
Dx. Obesessive Compulsive disorder
Tx: Fluoxetine (SSRI), Fluvoxamine (SSRI), Clomipramine (TCA), behavior modification (cognitive beh therapy)
Fear of public speaking with sweating and trembling
Phoic situation
tx: B Blocker
TCA
Vietname vet - saw friends die - pw nightmares, avoidance of remnder of even, flashbacks intrusive memories
Dx: PTSD
tx: Psychotx- first, SSRI-second
Young woman witih multiple complaints multiple organ systems >8 - exam NO macthcing physical findings to sx
Dx: somatic symptom d/o
These pts have high rate of utilization of health care. Monthly appointments w/ PCP for reassurance and decrease utilization of health care resources.
Pt with alteration or loss of physical fxn wihtout pathologic basis - pt is unawar/unconscious - NOT consciously producing sx -
dx: conversion d/o
Tx: usually responds to suggestive therapeutic modality
Young woman of high socioeconomic status related to health care field with h/o emtional trauma p/w deliberate production of signs and sx
dx: Factitious d/o on self
A man of low socioeconomic status with deliberte production of signs and symptoms pathologic lying and wandering
Factitcious disorder on others AKA Munchausen’s syndrome
Intentional prodxn of signs and sx for SECONDARY gains. Such as avoiding military duty or court case etc
malingering
Physical findings dont’ match multiple complaints
Somatization
Doctor shopping and high utilization of health care
Somatization
Needs PCP q1month appts
Somatization
Weakness one side of body but work up normal with MRI
Conversion d/o
Young white femail nurse deliberate prodxn of sign’s and sx
Facticious d/o
Factious d/o with pathologic lying and wandering
Muchausen
Exaggerated sx compared to physical exam - pending court case or military service
Malingering
Depression
depressed mood loss of interest in pleasurable activities wt loss/gain Insomnia or hypersomnia Fatigue Diminshed ability to concentrate forgetfulness (mistaken for dementia)
Sx >2 weeks=depression
If sx after death in family and sx < 2 months - bereavement
> 2 years - dysthymia
If abv sx with delusions/hallucinations - depression with psychotic features
Depression
10 million/year w/ depression
MCC suicide in US
only 20% seek attention and 1/3 of them misdiagnosed
Tx with any antidepressant - 4-9mo for the first episode
HOw soon see response - 2-6 weeks
When to switch if no response - 6-8wks
Recurrent > 2 episodes of depression - 2 or more years
When stopping drug - taper it
Psychotx - Cognifitive tx - Thought->emtion->behavior
Interpersonal therapy: interpersonal social functioning
DON’T go from SSRI-> bupriopion (ok other way around)
also okay SSRI to SSRI or SSRI to NRI and other way around
Mcc suicide in US
major depression
Depression TOC (tx of choice)
anti antidperessant
Enuresis TOC
Imipramine (TCA)
Panic d/o TOC
Alprazolam-short term
SSRI-long term
Obsessive-compulsive d/o TOC
Fluoxetine
Clomipramine
Fluvoxamine
Chronic pain+/- depression TOC?
Amitriptyline
Smoking cessation TOC
bupropion
???nicotine replacement->bupropion->vareniciline
Insompnia TOC
Amitrptyline
???? trazadone
Overdose with low lethal potential TOC
citalopram (SSRI)
45yo M pw depression - stated on fluoxetine and starts to feel better in 3 weeks how long to continue
4-9 months
????83yo F awake, doesn’t respond to stimuli x few months - refelxes/power intact dx?
depression
Terminally ill pt with lung CA depressed, loss of appetite - loss of interest in life wtd?
Methyphenidate - elevates mood w/in days and can be used with other anti-depressants which take weeks
Drug-drug interactions
MAOIs (phenelzine, tranylcypromine, selegiline)
HTN crisis
MAOI (Phenelizine, tranylcypromine, selegiline)
Orhostatic hypotension
TCA (imipramine, clomipramine, amitrypyline, nortriptyline)
Antichol s/e (dil pupil, tachy, dry secrtions)
TCA (imipramine, clomipramine, amitrypyline, nortriptyline)
sexual dysfxn
SSRI (fluoxetine, citalopram, sertraline)
Least sexual dysfxn
Bupropion
Avoid in anorexia
SSRI/Buproprion
SSRI-fluoxetine, fluvoxamine, citalopram, sertraline
Avoid in Bulimia
Bupropion
Tx Bulimia
CBT–>SSRI (fluxoetine fluvoxamine, citalopram, sertraine)
62yo M HTN depression tx’d with BB and fluoxetine - alwso vitamins pw dec’d erections + unable to have orgasm for few moths wtd?
start PDEi
SSRI s/e
1-4 wks - Suicidal ideation -> d/c or consider other drug
2-6 weeks - restlessness/akastheisia -> switch drug or add benzodiazipine
2-4 wks -angry outbursts/lack of sleep, silliness, giggling
70% seen in bipolar d/o - change to lithium or mood stabilizer
10% seen in SSRIs–>alternative antidepressant or lower dose
Pt started on SSRI with cloudy urine dx?
retrograde ejaculation
Electroconvulsive therapy indicated for…
Refractor depression
Psychotic features
Suicidality
Catatonic stupor
can do in pregnancy
S/E - acute confusion, sz
long term - impaired memory
Relative contraindic - recent MI, aneurysm, CHF, COPD
Stop bupropion in
Mania state
Biplar d/o
Manic depressive - lamotrigine–> TEN
Manid/hypomanic (mild manic)
- euphoria
- inflated self esteem grandiosity
- decreased need for sleep
tx: lithium, valproic acid/atypical antipsychotic
22yo started on fluoxetine(SSRI) for depression now starts playing music all night wtd?
d/c SSRI, start lithium or olanzapine
S/E lithium
Diabetes insipidus - impaired renal concetration
hypothyroid
hyperCa
Hand tremors
????Toxicty 1.5-2 N/V slurred speech nstagmus ataxia >2.5 Fasciculations Delirium Coma/death
Antipsychotic agents
Typical:
Phenothiazine : chlorpromazine, fluphenazine, thioridazine
Non-phenothiazine : haldol, loxapine
Atypicals:
Clozapine, (most efficacious, agranulocytosis) (dont rechallenge after d/c)
Olanzapine - inc’d gasting blood sugar, inc weight
quetiapine (seroquel) - well tolerated
Risperidone - efficacious and used in elderly
Pt on paroxetine (paxil) and olanzapine for major depression develops increasing blood sugears etio?
Olanzapine
increased blood sugars also w/ statin, BB, HCTZ, steroids, protease inhibits NOT ACE inhibitors
Side effects of typical agents
*Acute dystonic rxn - tx diphenhydramine/benztropine
*Akastheisa - motor restless, wantering - tx - dec or d/c drug
*Tardive dyskinesisa - smaking lips/tonue
*Neuroleptic malignant syndrome -> DTR decreased
????? cool down, dantroline
*prolonged QT interval- sotalol, aripiprazole, methadone
Pt with hallucinations, smaking lips, says he takes nerve pills not sure what d/o for - dx?
Schizophrenia
Pt has not been taking her meds - moves in with her son 6 months later says daughter in law trying to kill her - on exam smaks lip and tongue - etio?
Phenothiazine that she used to take 6mo ago
underlyind disease - paranoid schizophrenia
????Pt with schizophrenia develops parkinson’s dz - develops psychosis - refuses blood tets because of needle sticks
Quetiapine
Pt with parkinson’s dz, dementia, BPH and glaucoma becomes agitated and confused - best anti-psychotic
Quetiapine
Hyperthermia with mental status changes, tremor and autonomic instability (inc’d HR, dec BP, n/v/d) and hyperreflexia
Serotonin syndrome (SSRI+MAOI, SSRI+linezolid, SSRI+tramadol)) D/C med and start benzodiazepines-->cyproheptadine
Hyperthermia with mental status change, autonomic dysxn with LEAD PIPE RIGIDITY and rhabdomylysis. hyporeflexia
Neurolptic malignant syndrome
?? - phenotiazine +- haldol
??Tx: bromocryptine or dantrolene
Hyperthermia with sustained muscle contraction, HTN, diff ventillating patient with sudden inc in end tial CO21. hyporeflexia. - CPK inc’d. fhx of sudden death or fever on table during anesthesia
Neuroleptic malginant syndorme (inhalation anestetics
tx: rapid cooling/dantrolene
Pt with hyperthermia, delirium HTN, tachcardia and diaphresis dx?
sympathomemetic crisis
- (amphetamine+cocaine)
- prescription diet pills
Hyperthermia with mental status changes, tachycardia, dec’d bowel movements and urinary retention
antichoinergic delirium (antihistamine/TCAs)
69yo F husband passed away 2 years ago now lives along several meds including ambien (zolpidem) 10g daily - appears confused and period of not routable. CT head mild atrophy - likely cause?
Drug induced
of note women should never take >5mg zolpidem per day
Pt with depression - takes ambien for insomnia - on exam amnesia and confused
D/C ambien (zolpidem)
70yo M wife died couple years ago - loss of appetite, weight last 6 months . he apprears depressed.- hearing voices or seeing thigns on wal.l dx?
Depression with psycotic features
70yo M, wife a died couple yrs ago - loss of appetite/weight loss for last 6 months - pt says he sees her when he closes his eyes and frequnetly wakes up at night thinking she is nex to him - does not indulge any pelasurable acitviiteis dx?
Complicated grief
Rx Increase social activities
????Borderline perosnality d/o
instability in self image, mood state, interperonsl relationship impulse control
social history many stormy relatinship
awknowldeges chornic anger control issue
marked swings in mmod thru day
at one moment frien or parted viewed as trusted then curel or betraying
Best management for pt with borderline personality d.o
Behavioral psychotherapy
Anorexia
<15% of ideal body weight
feel they are too fat
decreased BP, hypokalemia, hypoalbuminemia
at risk for sudden death from VTach
do NOT treat w/ antidepressants–> suppress appetite
Bulimia
NOT < 15% of ideal body weight eat and purge - vomiting -> OR laxatives callus on knuckles, submandibular LN+ Parotid enlargement, loss of inner dental enamel esophagitis** low Cl** low K and metabolic alkalosis Urine Cl very low
Young woman with new onset UGIB at party - Na 136, K2.7 Cl 80, bicarb 35, BMI 24 dx?
Bulemia nervosa (GIB from vomiting) mallory weiss tear
How to treat Bulimia
psychotherapy
Fluoxetine
????38yo woman on various antidepresants and analgestics for pain, consumes several extra pills of one of her meds, on arrival to the ER she is awake, soon after gets hypotensive, tachy and then seizure - tele shows widened QRS, ABG respiratory acidosis pt took what?
TCA Methadone (check QT interval)
50yo brought with overdose of hypertension and angina meds - took 30 pills metoprolol BP 70 HR 35bpm with AV blcok - given atropine and IVF bolus w/ not much change wtd?
glucagon (cAMP) - inc contractility of myocardium
epinephrine drip
Pt took OD of CCB - BP 80 systolic - HR 42/min started on IVF bolus and atropine what else to give pt -
slow i.v. calcium chloride to counteract peripheral vasodilatory effects of CCB.
Pt pw inc’d SECRETION (salivation, etc), profuse sweating, n/v/SOB, tremors, fasciulations - exam pupils consdtricted HR< 50 what is poisoning?
organophosphorus dx test - RBC Acetylchoinesterase level tx: remove contaminated clothing activated charcoal IV atropine (muscarinic antagonist, blocks Ach receptors) IV pralidoxime (nicotinic)
Pt and family feel tired, fatigued and somnolent - pt goes out and shovels the snow and feels better dx?
CO poisoning - call EMS and gt whole family out of house
Firefighter brought after fighting fire - ABG 94% on 40% venti - soot in nares pt intubated - what FIO2 required -
100%
GBS/MG
Heroin addict or pt on morphine or codeine develops URI with profuse lacrimation, sweating rhinorreha, yawing restlessness and diarrhea
Dx: opiate withdrawal
Tx: methadone
24yo pt back from party agitated, talking fast but fluent - acting paranoid, diarphoretic, HR and BP up, low grade temp burn on oral mucosa, poor dentition, excoriations on skin, picking skin, hyperreflexia
Meth/speed (methamphetamine)
24 yo pt back from party agitated - has seizure - +diaphoresis elev tmep/HR/BP - hyperreflexia
MDMA (ecstasy)
24yo pt agitated after party not following commnads - diaphoresis, elev bp, temp, hr hyperreflexia Na 124
MDMA (ecstasy)
Fever
Methamphetamine, MDMA (ecstasy), Bath salts
HTN
Methamphetamine, MDMA (ecstasy), Bath salts
tachy
Methamphetamine, MDMA (ecstasy), Bath salts
Hyponatremia
MDMA (Ecstasy)
agitated, psychotic but alert
Methamphetamine, Bath salts
agitated, mental status change, seizure, or lethargy
MDMA (ecstasy)
Skin pickering
Meth
Oral musocsa burns
meth
mydriasis
Methamphetamine, MDMA (ecstasy), Bath salts
hyperreflexia
Methamphetamine, MDMA (ecstasy), Bath salts
serotonergic and SIADH
MDMA (ecstasy)
Your pt is receiving morphine sulfate and benzos for leg pain from an injury - agrees not to abuse drugs - urine tox 3 mo later - benzos, opiates, cocaine, marijuana + wtd?
taper benzo and d/c morphine
80yo F h/o depression tx’d with imipramine 100mg daily and haldol 10mg daily now a/w delirium neck ridgidty, spasiticty - elev BP/HR - NMS, treatment?
tx: dantrolene or bromocryptine
Most CC admission to hospital in elderly
CHF
Delirium
Flucuating course of inattention and altered conciousness Etio - s/e poly pharmacy meperidine (demerol), morphine Fever, metabolic abn, and electrolyte distrubance hypoxia, Med/surg pt >65 etoh withdrawal anticholingergics/anti histamines antidepressants alzhiemers meds: Donepezil, Rivastigmine sedatives (ambien aka zolpidem), flexeril Tx: correct underlying cuase
72yo F episodes of inattentiveness and confusion esp at night - takes enalapril for HTN and diphenyhydramine for insomnia - this represents?
a drug reaction
tx: d/c diphenhydramine
cyclobenzaprine (flexeril) can also cause delirium in elderly
T/F delirium in hospital related to inc’d mortality
T
T/F delirium in hospital related to inc’d dementia
T
T/F delirium in hospital related to inc’d institutaionalization
T
Pt post hip surgery 2 days later, awake till 2am andconfused - prior to surgery on HCTZ, enalapril , MVI, atorvastatin, lorezepam - post surgery meds for BP and HLD restarted etio of confusion?
Lorazepam withdrawal
Best tx for insomnia?
sleep hygiene (aka cog. behavioral therapy) (bed comfort, noise level, temp in bedroom -optimal T 68F (YES BABY ...I SEE THIS), no caffine, , avoid naps DURING DAY, bed for sex and sleep -Not TV or office work. Fixed bedtime and wakup time
???Best med to initiate sleep
ambien,
Dementia
progressive deterioration in cognitive fxn, impaired memory judgement abstract thinking
Dx: First r/o treatable causes: -Drugs -Vit B12 def -hypothyroid -Normal pressure hydrocephalus (magnetic gait, incontinence..."wet wacky wobbly") -heavy metal poisoning (lead) -Infections (syphilis, whipples, lyme's, meningitis
Degenerative disease:
- alheimer’s–> dilated ventricles and sulci and delusions
- dementia with lewy body –> hallucinations
- parkinson’s
- Pick’s –> frontal temporal lobe dementia (aggressive behavior)
????Dementia
???
dx: assessing cognifitve status MMSE - Score >23/30 normal other screening tests Clock drawing test Making change test Fxn assessment - basic ADLs eating bathing dressing Instrumental ADL complex activities to maintian household - shippping, driving managming finances
Ways to decrease falls
d/c psychotropic/targeted reduction in meds
Muscle strengthinging / balance exc - tai chi
unifocal lenses better than bifocal lenses
improve lighting
decrease hazards (rugs)
extra support in toilet/shower
Best test to predict mobility and falls
Timed get “up and go” test (TUG) - arise from chair, walk 10 feet turn around and sit in chair
>14 sec= high risk for fall
Major predictor for fracture with fall is:
osteoporosis
elderly pt with freq falls - what deficiency?
Vit D (muscle strength)
??(check 25,0H vit D level)
85yo F in nursing home trips and falls - uses cane occasionally - wtd?
Physical therapy
Pt in NH fell and suffered NON-dispaced fem fx of neck of femur wtd?
surgery and 3 parallel pins
???Elderly pt fell and sustained displaced fx of femoral neck, wtd?
arthroplasty
Pt with displaced fx of neck of femur - meta analysis has shown which procedure had better hip outcomes for sustained displaced fx of fremoral neck?
total hip arthroplasty (femur+ball + socket)
better than hemiarthropalsty (femur + ball only
Intertrochanteric fx ->
hip comporession screws
T/F elderly pt with acute compression vertebral fx - no advantage of verebroplasty over rehab and analgesia
T
If no response to conservative tx - then vertebroplasty
pain–> Rx calcitonin
elderly pt with hip fx - s/p ORIF - confused and agitated in evenings (sundowning) wtd?
atypical antipsychotics (SSRI takes too long)
Pt with dementia - can swallow bu teats only half meals - sometimes food in side of mouth wtd?
Aid with feedings
lower rate of feeding tubes in nursing homes reflects what?
values of resident autonomy
In advanced dementia pt who is not eating PEG has shown what?
NO change in nutritional status
82yo h/o freq falls - BP 140/90 what to d/c ASA or diphenyhydramine?
diphenylhydramine
???Drugs that cause depression
BB etoh steroids psychotropics Parkinson's CVA
Urge incontince
problem: Detrusor overactivity
Tx: In order
1) lifestyle changes (weight loss)
2) bladder training aka timed BR visits
3) kegels (pelvic exercises)
4) Anticholinergic (TCA) - oxybutyn, ditropan, detrol
Stress incontinence (coughing make pee)
problem: Decreased sphincter tone
tx: In order
1) weight loss
2) pelvic muscle exercises
??PSA
> 18 - finasteride + alpha blocker
<18 - alpha blocker only
Overflow incontinence
problem: Urethral obstruction, prostate hyperplasia, Detrusor underactivity, DM neuropathy, MS, Drugs: anticholingerics
Tx:
alpha blockers: terzosin/tamsulosin (flomax)
[also (finasteride plus alphablocker to tx prostatic hyperplasia) ]
cholingerics: bethanechol
[mneumonic: Bethany, call me maybe if u want to activate your bowels and bladder}
???(terazosin (better with HTN), tamsulosin (causes floppy iris syndrome if taken during cataract surgery)
T/F Incontinence is normal part of aging
F
MCC incontinence
Urge Incontinence
Detrusor overactivity
Urge incontinence
Decreased sphincter tone
Stress incontinence
Side effect of anticholinergic
Detrusor underactivity
overflow incontinence
???s/e of some meds passing urine involuntarily without urge to go tx: benechol surgery catheterization
Post void normal
urge and stress incontinence
Post void residual >100mL
urethral obstruction and detrusor underactivity (overflow incontinence)
Bladder trianing better than TCA (imipramine)
Urge incontinence
Urodynamic studies
urethral obstruction, detrusor underactivity (overflow incontinence)
Response to prazaosin or finasteride
Urethral obstruction
Responds to cholinergics (bethanechol)
Detrusor underactivity - overflow incontinence
Timed bathroom visits and diapers
Urge incontinence
Oxyburtynin (ditropan), tolterodine (detrol)
Urge incontinence
78yo F CVA with independent ADLs including toileting admitted with PNA - pt confused restraints applied - diazepham given for sleep - now INCONTINENT of urine
Functional incontinence
67yo F DM urge to urinate every 30-60 min - leaks urine in dress - started wearing diaphers
urge incontinence
94yo F in NH back after hip surery takign tylenol w/ codeine - MS intact - upset that is leaking urine and smells bad - never had this before
Overflow incontinence
80yo M in NH dx with depression and started on desipramine (TCA) 2 weeks later nurse complains that pt smells of urine. What is the diagnosis and w.t.d. next?
dx: overflow incontinence
w. t.d next? Change TCA to other class
67yo F NO DM has urine leakage - has to use bathroom with inc’ing freq including gtting up at night - no dysuria or fever wtd?
early morning urinalysis - u/a r/o UTI
65yo M w/ symptomatic BPH - BP 90/65. PSA is normal. tx?
tamusulosin (flomax)
??(better with low BP) alpha blocker
65yo M w/ BPH BP 140/85
terazosin (hytrin)
?? (ok if BP ok - lowers BP) alpha blocker
BPH + hematuria
finasteride (proscar)
Pt wakes up every morning and finds she has wet herself. she does not take any meds except
DIPHENYHYDRAMINE for sleep. w.t.d?
d/c diphenyhydramine (overflow incontinence)
Pressure ulcer
Stages and treatment
Stage 1 - skin intact, non-blanchable redness
tx: static foam or gel mattress
Stage 2 - shallow ulcer red pink with wound bed
Tx: occlusive or semipermeable dressing that maintains a moist wound environment**
Stage III - full thickness tissue loss - SQ fat may be visible but no visible bone, tendon, muscle
Tx: debridement and Abx as needed
Stage IV - Full thickness tissue loss with exposed bone tendon or muscle
Tx: debridement and abx as needed
Drugs to avoid in pregnancy
Valproic acid ACEi Cipro Methimazole (1st trim only avoid) Radio Iodine I-131 most Anti histamines Warfarin > 5mg - 1st trimester (??nasal hypoplasia??) Nitroprusside Most Aminoglycosides Doxycycline/Tetracycline Mycophenolate mofetil
Drugs safe in pregnancy
Carbamazepine (side effects: neutropenia, SIADH) Mg Sulfate Latetolol Furosemide alpha methyl dopa Hydralazine Nitrofurantoin Amoxicillin Ampicillin PTU - 1st trimester Methimazole- 2nd trimester onwards Hydroxazine Chlorpheniramine Heparin (remember "Heppy baby") Warfarin <5mg ANYTIME LMWH Clonidine, BB CCB Procainamide Gentamycin B lactams metronidazole
Preg Pt with asx bacturia
Treat (ampicillin / nitrofurantoin NOT bactrim or cipro)
Preg pt with detnal caries and ache - abx?
Augmentin
Pt with post partum fver and chills
r/o post partum endometritis
MC etio is GBStresp –> 34-37 wks scrren for this , if + –> MCC mortality associated with preg in US
Will immune globulin prevent rubella?
NO
Preg woman exposed to…
Hep A -> immune globulin
Hep B -> Hep B immune globulin
Measles-> Immune glboulin w/in 1 wk
Varicella -> varicella immune globulin wi/ in 10 days
Can preg pt get Hep B vaccine
YES
What vaccines contraindicated in pregnancy
Live vaccines MMR Varicella Oral Polio Yellow Fever Shingles
Can lactating woman receive vaccines?
YES
??? Pt visits 3rd world country comes back with jaundice - hep A/B neg wtd?
Hep E serology 20% mortality
Can HIV + mother breast feed?
NO
if she breast feeds–> should be on ART
Can you treat LTBI/PPD in preg woman?
YES
Can you tx MTB during preg?
YES
When can 60yo get herpes vaccine
When on steroids and methotrexate
22yo RA pt on ethanercept (Enbrel) - can she get HPV?
YES
??? Which vaccine for 65yo pt - ?
Polysaccharid ePPSV23
Which vacc for 65yo w/ no sig. medical hx.
PCV 13 x 1
40yo with HIV, CRF, malignancy or asplenia wtd?
Prevnar 13 (PCV 13)
???45yo with DM, HIV CRF or aspelenia got PPSV23 at age 40 - wtd?
PPSV23 dose now
???65yo Pt with DM, HIV, CRF asplenia PPSV at 40,45
give now
???40yo DM tx for DKA d/cd wit PCV 13 wtd?
PPSV23 x 1 8 weeks later
???40yo DM tx’d for DKA d/c’d with PPSV23 wtd?
PPSV23 at least 1y later
Pt allergy to eggs (no hives) wtd?
can give flu vaccine in clinical settings; physicans office or hosital
Pt with anaphylactic rxn to eggs -
non-egg flu vaccine
Vaccine for joining college
Tdap
**also Meningococcal ACWY, B if inceeased risk, HPV (9-26y/o), and flu shot **
Pt with laceration - had TD shot last year wtd?
Tdap
???Preg pt had TD booster last year wtd?
Tdap
preg pt20 wkks had Tdap shot 2 years ago. wtd?
Tdap now
60yo M Tdap vacc pw swollen arem 50% bigger than other arm with soreness - ROM normal wtd?
reassuance
> 60 ptwith h/o shingles wants to prvent shignles in future . wtd?
- HZV vaccine (good for only 5-10yrs; give 60-70y/o; after 70, no efficacy) even if had before. NO need to ask if they had it before.
Best pt to get IVIG
open wound fx at gym, TdT 12 yr ago
Whic pt NO VZV vacc
pt with CLL/lymphoma
65yo pt comes in for shingle vaccine and also wants pneumococcal vaccine wtd?
Shingles and pneumococcal vacc at the same time, in different arms.
The following ok in pregnancy
electrical cardioversion for unstable rhythm,
procainamide
digoxin, for MS with CHF
verapamil
NONE are contraindicated
Pt wit Mitral stenosis. Categorize mild mod and severa nd the treaments.
> 1.5 sq cm - mild–> no tx
1-1.5 sq cms - mod–> BB/dep on sx - need to inc diastolic filling time
<1 sq cm - severe –> baloon valvulopasty
Pt with Mitral Stenosis and afib - how to tx?
Digoxin and BB, Anticoagulation
Preg Pt with Mitral stenosis =started on BB - now has SOB w/ . inc’d JVD - lasix given wtd?
mitral valvuloplasty
Pt with ASD wants to get pregnant wtd?
If shunt < 2:1 - then can get pregnant
If shunt >2:1 - surgery first
;Contraindications to pregnancy
Name the conditions that are contraindicated
Pulmonary HTN Eisenmenger's syndrome (R pressure >L) Marfan's syndorme with dilated aortic root Dilated Cardiomyopathy with CHF Severe AS
Whic of the following is LEAST tolerated during preg
VSD with central cyanosis
Can HOCM and MVP patients get pregnant?
yes
10 days post partum pt come wit fatigue and SOB JVD+, echo shows dilated CM with EF 30% - dx?
postpartum Cardiomyopathy
occurs mainly in 3rd trim or post partum
If normalized - pt can get pregnant again but chance for Peripartum cardiomyopathy are inc’d
Otherwise normal preg woman 14th week routine prenatal visit has S3+ and II/VI systolic murmur at the apex
functional heart sound and murmur due to normal vol overload of pregnancy
Pt with HTN and preg what can yo use
Labetolol, alpha methyl dopa, hydralazine
CANNOT use ACEi or nitroprusside
mneumonic: Hyperternsive Moms Love Nifedipine
Hypertension during Pregnancy–> H for hydralazine, M for methyl dopa, L for Labetalol, and N for nifedipine.
33wk preg - BP 160/104 and b/l pedal edema. plt 90,000 PT/PTT 16/50, urine –>proteinuria, BUN/Cr: 40/1.3, Uric acid 12
dx: DIC 2/2 pre-eclampsia
Tx: Deliver baby
Causes of DIC in preg
Dead fetus Abruptio placentae Amniotic fludi embolism AFLP (acute fatty liver of pregnancy - inc'd d bili, inc'd NH3, inc'd PT) Pre-eclampsia
Pre-eclampsia with seizure=
Eclampsia
Tx for seizure - MgSO4
What anti-Sz med can’t use during preg
valproic acid
Pt lactating post partum with prolactin >200
Dx: prolactinoma - check MRI
tx: bromocryptine
???? Best tx for Thyrotoxicosis (graves dz) during PREGANCY
PTU
NO Methimazole 1st trimester
NO Radioiodine
T?F Thyroxine requirement inc’s during pregnancy and gets back to normal postpartum
T
T/F MCC amenorrhea is pregnancy
T
T/F Insulin requirements inc’s by about 50% during pregnancy - needs tight control otherwise increased fetal loss and fetal malformations
T
Pregnant woman with DM on oral meds wtd?
D/C oral meds start multiple insulin injections for tight glycemic control
DM pt wants to conveive wtd?
screen for retinopathy and tx if prsent before conception - otherwise tough to treat retinopathy during pregnancy
In non-DM F when to screen for gestational DM?
24-28 weeks (glucose tolderance test)
Do people with gestational DM have higher risk of DM in future?
Yes - 50% with DM at end of 5-10 years
Pt in labor with Iron def. anemia - MC seen in pt’s with….
No pre-natal care
??? Pt with SLE gets pregnant ESR dec’d wtd?
Stop all drugs and monitor for spontaneous remission
Pt had recent exacerbation of SLE (pregnant) wtd?
continue steroids
Pt c/o itching what drugs can you use?
hydroxyzine
Chlorpheniramine
Preg woman wants to fly from NY to LA - what is optimal time if she has to fly
2nd trimester
These pregnant woman cna’t fly
h/o pre-eclampsia
History uncontrolled DM, HTN, anemia
h/o premature delivery
H/o incompetent cervix
T/F Young women with pulm HTN should avoid pregnancy with progesterone ONLY meds - NOT estrogen containing meds
T
copper > progesterone IUD
Pt on ocp going for elective surgery
STOP 1 month prior
T/F Pregnant more prone to DVT/PE
T
T/F Preg woman can use steroids
T
Intrahepatic cholestasis of pregnancy
what is it and tx?
Cholestasis - > inc'd serum bile acids ->pruritis AST/ALT increased but < 200 Alk phos elevated PT normal, Plt normal No DIC
tx:
Cholestyramine
Urodeoxycholate
Early delivery at sign of fetal distress
22yo Pt 34 wk preg wit pruritis, ast/alt 20/22, alk phos mily elevated wtd?
Reassurance - pruritis gravidarum (mild intrahepatic cholestasis of pregnancy
Acute Fatty liver of pregnancy
- Carnitine def or choline def or Tetracycline use
- p/w malaise, h/a nause, poor appet and abd pain
- mod elev of AST/ALD>150, ammonia elev, bili elev, PT elevated
- often a/w pre-eclampsia and DIC
- Liver bx - microvesicular (mitochondrial damage)fatty change
Tx:
Resloves rapidly after DELIVERY of baby
40yo with dysfunctional uterine bleed
tx: Medroxyprogestine acetate 10-21 days
16yo asks for OCP wtd?
give it
Pt wants to know tiem of start of OCP - last mentrual period 1 week ago when to start?
NOW
Pt with dysmenorrhea, dysparenurnia - pelvic exam with enlarged ovaries and palpable bands on ligaments, no pelvic motion tenderness wtd?
Laparoscopy - r/o endometriosis (endometrial tissue in other places)
Pt wants post coital contraception wtd?
Start Levengestrel (plan B) within 72hr works by - inhibit ovulation and implantation
???and delayed onset of next menstrual period
Pt missed OCP x 3 days and no sexual activity during that period wtd?
Take only most recently missed pill and another method of contraception x 1 week
OCP complications
-HTN (in’d renin substrate**)
-DVT, stroke, PE
-Peliosis hepatits (rupture of cyst–>shock –>CT –>surgery)
-Budd chiari syndrome (hepatic vein throbosis) - abd pain, ascites, pedal edema
-Elevates theophylline level and causes toxicity
-Euthyroid thyroxenemia
-Mood swings
-erythema nodosum
-PCT( porphyria cutanea tarda)
????Melasma
When NOT to use OCP
h/o DVT Pregnancy CAD HTN migraine h/a breast CA smoker >35--> (progesterone only) chronic hepatitis
OCP failure can occur w/ use of
St John’s wart
Rifampin
Toclizumab
Pt on oral contraceptive for long time brought to ER with shock BP 80/60, HR 120/min - suspect ruptured liver adenoma
Tx: surgery
Best test to Dx: CT scan
pt wit hcrampy abd pain and vaginal spotting - last period 1 month ago preg test +. What is best dx test?
US to r/o ectopic pregnancy
Effect of HRT on fibroids
May inc size but NO INCREASE in malignancy
26 on OCP for past 2 months - c/o mid cycle spotting wtd?
continue OCP
mid-cycle spotting–> increased estrogen and it dissappears
19yo on OCP c/o moderate to severe mid-cycle bleeding fo rpast 2 months. no fhx endometrial CA. wtd?
D/C OCP and use intrauterine device (also can use higher dose estrogen continaing pill - stabilizes endometrium)
Young woman exc 1hr / day BMI 23 mentstrual cycle 24-28 days - been having trouble conceiving wtd?
Ovulation kit to check basal body temp for ovulation
Young woman trying to conceive for several years getting infertility tx p/w SOB and abd distenstion with pain - US reveals ascites and enlarged ovaries with inc’d number of ovarian folliclees. serum Na 148 Hg 16. dx?
Hyperstimulation syndrome
Middle aged woman with pelvic pressure sensation, constipation, sensation of incomplete evacuation - colonscopy with ehmmorhoids - 3 grown childrne. dx?
Rectocele
???Never events in health care settings
Decub III/IV Vasc catheter associated infxn Catheter ass UTI DVT/PE in hospital HAPNA ABO incompatibility Pt fall Disability or death from hypoglycemia
???Time out before surgery to confirm
Correct pt
Correct side
Correct site
Type of procedure
Insurance
Medicare Part A covers- hospital , skilled NH, Home Health, hospice services
Medicare Part B covers- physicians, Nurse Practicitoners, Social Wrkers, psychologist, lab tests, therapists, durable medical equipment
Medicare Part D covers - some of prescription med cost
Medicare Part C provides the benefits under Medicare parts A B and D thru medicare advantage plans which are managed care plans
Medigap - supplemntal insurance to cover part A/B, deductibles, and co-insurance as well as preventative care and other heatlh related goods/services
Medicaid - joint fed/state program that provides supplemental health insurance (including long tem custodial care in nursing home) to people of all ages who have low income and limited savings
Advanced directive
Means for Pt to state what tx they accept or refuse if they lose decision making capacity.
Can also have proxy/surrogate who makes decisions for them when they cannot make decisions for themselves.
Surrogate/proxy - person autorized to make decision for incapacitated person - usually next of kin
Can a surrogate withdraw alllifesuport including nutritional support in an incapacitated pt?
Yes
If pt awake/alert oriented - HCproxy NO ROLE IN DECISIONS
If pt awake/alert orients - FAMILY HAS NO ROLE IN DECISION MAKING including consent for procedures
DEcisions made by pt while awake and oriented stand if pt becomes unresponsive
Living will
More focused advanced directive in which pt refuses life support in terminal condition - do NOT need lawyer to make a living will.
Pt broughT in barelY conscious and confused - has terminal condition - Living will states pt doesn’t want tube or resuscitation - family insists on doing everything and threatens to sue if not intubated and resuscitated - wtd?
follow living will
Fiduciary relationship btween physician and pt is base on which 4 things?
Justice
Autonomy - right of individual to self determination
Non-maleficence - do no harm
Benefecience - take action in best interest of patient
Pt brought in unconscious with terminal condition - pt family wants everythign done - proxy says pt didn’t want to be intubated and resusitated and wants to make pt DNR wtd?
listen to proxy
??? Pt brought in by family no living will - pt terminally ill and family wnats DNR wtd?
Determine patient wishes
Can a physician give telephone order to nurse for DNR
No!!! - need to write on order sheet and document circumstances in progress note
30yo Pt comes in and says sister has chronic reanl failure - sister parents and nephorlogist wants him to donate kdney - he doesn’t want to go thru surgery - wtd?
Reassure that you will be his advocate and represent his interests
Husband wishes to discuss something perosnal and important about wife who is a patient
Listen to husband and decide whether to keep secret or not - keeping pt best interest in mind
??- if pt has spyhillis tell DOH
Pt with PNA and pleural effusion - pt has that if he is going to be vent dependent - do not intubate. wtd?
intubate and place chest tube (since this could be reversible)
T/F terminally ill patient palliative care along with standard care decreases mortality
T
When woudl you insert ICD (or any expensive device) in pt with severe HF
Life expectancy of at least 1 year
70yo M to ER with AWMI and shock - living will suggests if condition irreversible - not to be resuscitated - you do PCI which is unsuccessful and pt intubated - becomes hypotensive echo EF 25% - UOP 125cc - wtd?
withdraw all life support
Pt with severe dementia and DNR in hospice care - develops PNA, what is comfort care?
Room air via nasal cannula or fan air
Pt with end stage lung CA and SOB/pain - on O2 4l via NC. wtd?
morphine
Terminall ill cancer pt with coarse rales wtd?
Glycopyrrolate (robinol)
suction
Pt with chronic COPD told you in office doesnt want to be intubated or resuscitated - now in ER with severe COPD exacerbation - as you see him in ER he reminds you what he sadi about intubation - few minutes later lethargic and severly hypercapnic on ABG - no living will wtd?
DO NOT INTUBATE
Pt with COPD exacerbation - living will states DNR but in ER he tells you to intubate wtd?
Yes intubate - follow pt wishes
Elderly pt with ESRD refuses HD in will - could months later - in ER comatosed - son wants HD wtd?
No HD
Elderly pt refusing HD in living will - brought to ER - son says recently father told him he wanted HD - pt now confused and lethargic wtd?
Discuss w/ son about outcome.
Elderly pt dx with breast cancer - maeks advanced directive to be DNR - son moves in with her - he lost job recently. couple months later pt condition deteriorates and pt more SOB - son says she told him she now doens’t wnat DNR - and he wants you to intubate pt. wtd?
Refer to ethics committee
Pt wants comfort measures only has durable power of attorney to son - doesn’t want to prlong life and wants only comfort measures if incompacitated - now has severe dementia - PNA and SOB - son wants abx - you will consider startin abx if….
Only if relieves symptoms
Pt with hemiplegia after stroke 2ya - durable power of attorney to son - she takes place in activities at assisted living - excellent cognifitve fxn - she wants colonoscopy - son agrees but want to be there for consent as well b/c he is concerned mother may not take explanation of findings in right way. wtd?
tell son you will take consent from mother and proceed accordingly
Pt with metastatic colon CA on wheelchair and trach - communicates in writing - daugther is durable power of attonry - she refuses his enrollment in an experimental clinical trial - wtd?
Talk to patient
??? Your 74yo cantankerous and reclusive neighbor who lives along calls you to take a look at her - fatigued and uanble to get aroun - no tspoken with daughte rin 15 years - doesn’t want you to call her - BP ok, HR ok, orthostatic - S3, pedal edema refuses admission to hospital wtd?
Initial proceddings to declare her incompetent
45yo GI bleed and hypotensive - refuses blood tx - wtd?
respect patient wishes - give IVF fluids
80yo Vietnamese man dx colon CA - family tells not to give dx to father wtd?
Tell pt he is very sick and ask him who wants to make decisions for him
If pt says family to make decisions then comply with request.
If pt wants to know and make decision for self then comply with this request
35yo F with Multiple Sclerosis and poor prognostic factors requests physician assisted suicide wtd?
Respond with empathy, compassioni and assess if she is getting adquate palliative care
95yo pt noted in NH to have mass in L breast - refuses any w/u or tx - wtd depends on…
her ability to understand disease and its consequences
Pt brain dead - can pt organs be donated wihtout his prior approval if proxy gives permission
Yes
Can you stop tx if pt brain dead?
yes
Is EEG required to confirm brain death?
NO
3 cardianl signs of brain death are:
- Coma
- absense of brianstem reflexes
- Apnea test (no breathing if pcO2 60 or pcO2 increased by 20mm)
Respiratory drive and motor posturing signs are incompatible with brain death
You observe nurse entering airborn isolation room without mask or touching a pt w/ contact isolation w/o gloves. What will you tell the nurse?
You are required to report his actions
25yo w/ Fhx familial adenomatous polyps referred to you for colonoscopy but HMO refusing to pay for procedure. wtd?
Call medical director of HMO and discuss care
60yo recurrent rectal bleeds, hemorrhoids neg. pt says can’t afford further testing, wtd?
advise colonoscopy
Covering for your partner and pt comes to you to get premarital certificate signed - labs reveal RPR - and FTA positive, wtd?
False Positive test. Manual FTA (TP-PA treponema pallidum particle agglutination test or micro heme agglutination test)
Medical Hold
- if pt unable to express preference you CAN perform lifesaving procedure if alternative is death or severe disablity .
- pt with certain psych condition and suicide attempts should be treated despite their wishes
- In transient conditions such as drug induced deliruim/confusion, depression, and abnormal metabolic states, you should get a psych. consult to determine capacity
competency is determined by court
Pt with attempted suicide brought to ER and refuses tx wtd?
Treat - pt in patholgical mental state, which may be treatable
Nurse became + hep BeAg - request not to tell supervisor wtd?
inform infxn control team
Pt dx with meningiococcal menigitis wants to sign out AMA
hold against will for public welfare
Pt h/o indolent NHL and told therapy not needed - he aware that is slow growing tumor - stops eating and drinking cuz he doesnt want to diet a slow death. He started on setraline, 2 weeks later no response - Pt says he is only depressed about his illness wtd?
get Psych consult
45yo Pt with PNA and bctx g neg rods - on 3rd day pt wants to sign out AMA wtd?
Tell pt, there is improper transition to outpt care
Pt with AWMI, mentally competent, refuses admission - situation explained in detail about consequences pt understands but still refuses admission wtd?
gave nitrates, BB, ASA, ACEi and arrnage for home visiting nurse
??? Pt of yours keeps calling 10 times fo rone rx - demands to be seen right away and wants clarification on simple things wtd?
Define limits of physician patient relationship
Pt referred for medical clearance for cataract surgery by opthalmologist hx reveals that he reads a lot and falls asleep while reading
Report physician to ethics commitee
You find your physician colleague with unethical behav or chemically impaired wtd?
report physician to ethics commitee
Pharmaceutical company invites you to exotic location for free wtd?
Don’t go
Pt bought plane ticket and wants to cancel it - wants note tha the was ill and couldn’t travel to get his refund back
don’t write the excuse letter
For which is parental counsent required?
to administer tetanus vaccine booster in 17 y/o.
No consent for: treat STD in 16yo abortion on 15yo prescribe OCP 14yo 17yo tx for substance abuse
35yo F with multiple injuries to arms and legs nods in agreement to husband’s history - you suspect domestic abuse wtd?
- As husband to step outside and interview pt
- If injuries non-lifetreatening - don’t call police - discuss with pt - encourage her to seek help and give her hotline number
Pt with bruises on inner arms - tells you she fell - exam reveals bruises on inner arms both old and new - has 2 children 5 and 2yo - recent dental work done wtd?
Domestic abuse counceling
What is NOT a HIPPA violation
Pt asks for referral to a specialist and later calls for records to be sent to specialit without written consent (ok)
NOT OK to discuss rare case with your colleague so he may benefit
T/F Periodic health evaluation shown improved rate of screening for colon CA, HTN
true
Following pt education improved outcomes
Tobacco, firearm, etoh, physical activity, self skin exam, STD
NOTTTT self breast exam
Quit smoking - better chance with recurrent trying
Most likley reason to quit smoking is
intention to quit
Pt with COPD 2/2 smoking comes fir visit - you discuss quitting smoking - pt says he would like to quit but doesnt have a quite date yet. wtd?
Begin varenicline
Pt wants help quitting nicotine patch/losange failed?
buproprion
????If pt has h/o sz d/o and needs help quitting
NO buproprion
use varencicline
Monitor pt for behavior changes
Chronic smoker doesn’t want to quit wtd?
Address barriers to quitting
In discussion with your pt about quitting smoking what other information would help motivate pt to quit
Quitting smoking is the only way to prevent rate of lung fxn decline (not steroids, albuterol or tiotropium)
Leading cause of mortality for 10-24yo
MVA>homocide>suicide
Leading cause of prevatable premature death in US
Cigarette Smoking
All true
injury from firearm at home > injury from intruder
seat belts dec mortality by 50%
Front airbags decrease mortality even further
child <13yo should be in back seat
helmets for bikes and motocycles reduced morbid and mortality
Fencing of pool and life vest on boat reduce mortality
Drowning victim out of water 70 deg F - wtd - ?
CPR
Elderly homeless man brought on cold day with bradycardia dec’d reflexes dilated pupils - J waves on EKG what does he have?
Hypothermia
Tx: passive rewarming with blankets
28yo F runs marathonand collapses - on exam confused hypotensive tachy, fused, dry skin - temp 41deg C dx?
heat stroke
???tx: tx to hosptial
evaporative cooling - sponge with ice packs/sprink water wtih fans
complication - rhabdomyolysis.
40 y/o F s/p bariatric surgery 5yrs ago presents w/ fatigue and parathesias.
Labs- Hg 10, MCV 105, WBC 2450, Plts 110,000.
BM- hypercellular marrow
dx? copper deficiency
Blurry vision, floaters, and genital ulcer
Posterior uveitis
Periorbital cellutitis (increased incidence in US..CT scans are being innaprop ordered)
erythema, induration, and tenderness, discharge. Extraoccular movements are painLESS
Orbital cellulitis (most dangerous, eye pushed forward)
- erythema, induration, and tenderness, discharge.
- proptosis, edema of the conjunctiva, ophtalmoplegia
- decreased visual acutiy
- relative afferent pupillary defect
- hx of sinusisits
- extraocular movments are painFUL
65y/o w/ heart disease w/ >4METS (flight of stairs, walks a hill w/o stopping, running a short distance, moving heav or able to pay blowing)
clear for sx
which is a greater risk factor for surgery
S3
65 y/o going for hip replacement in 2 wks. He has a cardiac stent and takes clopidogrel and ASA for the past 6 months. wtd?
wait 6 months and do surgery
pt on anti-TNF meds going for major surgery, wtd?
hold before surgery and restart 2-4 wks after surgery, otherwise wound dehisence.
Alcohlism timeline
- Minor w/drawal symptoms–6hrs,–HR baseline–BP baseline
- EtOH hallucinosis–24 to 48hrs –HR baseline– BP baseline
- Delirium tremens – >48hrs –HR increased–BP increased (rebound adrenergic activity_
- acute withdrawal seizure– 12to 24 hrs–HR baseline – BP baseline
- Korsakoff’s psychosis -permenant demyelination
Alcohol use disorders
Questions such as:
-Had times when you ended up drinking more, or longer than intended?
-Spent a lot of time drinking?or being sick or getting over other aftereffects?
-Wanted a. drink so badly you couldn’t think of anything else?
Full list on page 470.
Mild 2-3
Moderate 4-5
Severe 6 or more
Post surgery NPO on IVF with inc’d PT 2.8 and PTT 65 sec after 7 days, etio?
Factor IX deficiency
vit K def
Are antipsychocits (typical and atypical) FDA approved for managemnt of delirium?
NO
A young woman tells you 2 months ago, her parther w as the best, but now he is the worst, last month, another partner was the best but he is also bad now. Dx?
borderline personality disorder
A 24y/o pt came back from a party agitated and violent. Hallucinations and delusions. Diaphoresis. BP 160/110, HR 110, T 100.6, Hyperreflexia. Serum creat 1.8 HCO3 16, CPK 635
what drug?
methylenedioxypyrovalerone (MDPV)/ Bath salts
agitated, violent, hallucination and delusions
Bath salts.
leading cause of hypoglycemic attack in elderly
missing a meal
leading presentation of hypoglycemic attack in elderly
change in mental status
best way to decrease falls in hosptial settings
hospital elderly life program (LIFE)
you found your pt w/ wrist restrains in the morning. nurse says pt was pulling out iv. what do you do?
–>send nurse for inservice on alternatives to physical restrains. protect and hide iv line–> bedside sitter –> restrains as LAST resort.
elderly pt. w/ moderate dementia and knee OA not following directions, rubbing his hands over knees, unable to fall asleep. w.t.d?
topical capsaicin cream
1)weight loss–>2) bladder training–> 3) pelvic m. exercises –> 4) oxybutynin
urge incontinence
1)weight loss–> 2)kegels (pelvic muscles exercises)
stress incontinence
Foul smelling ulcer on skin. wtd?
topical antibiotic containing metronidazole
A 41 y/o pt w/ HIV, CRF, malignancy, or asplenia. Received PCV 13 last year. W.t.d?
pneumococcal vaccine (PPSV23)
A 40 y/o pt w/ HIV, CRF, malignancy, or asplenia. Received PCV 13, 10 years ago, PPSV 23, 9 yrs ago. Wtd?
PPSV 23
A 70 y/o Pt w/ HIV, CRF or Asplenia. Received PCV 13, 10 years ago, PPSV 23, 8 yrs ago. wtd?
PPSV23
Pneumovax 23 serotypes , tell me about it.
-polysaccharide vaccine
-good for 5-10yrs
give at least 3 months after PCV13
-can give 2-3 doses in life
Prevnar 13 serotypes, tell me about it.
- polyconjugated vaccine
- good for life (give only one)
- give for immunocompromised
- give to any 65 y/o or older
50 y/o w/ COPD exacerbation being discharged,wtd?
PPSV23
A 66 y/o w/ no sig. medical hx. PCV13 a year ago. wtd?
PPSV 23 x 1
A73 y/o w/ no sig medical hx. PPSV 23 at age <65 y/o wtd?
PCV13
A 65 y/o woman is being d/c in Nov. wtd?
Give flu shot and PCV 13 same day on different arms.
how often flu shots?
1 yearly
immune compromised pts w/ ESKD, HIV, malignancy, or asplenia. What vaccine should you NOT give?
LIve attenuated vaccine. DON’T use LAIV fo anyone for 2016-2017 as there was no benefit in 2015-2016.
A 68 y/o widower lives alone. Presents w/ cellulitis of legs , has decreased pulses, ABI 0.8. You recommedn revascularization. He refuses sx and wants to go home. He is pleasant, awake, and alert. His MMS score is 23/30. Wtd?
seek guardianship
What prevails in a conflict btwn living will and durable power of attorney when pt can’t make decision for self?
durable power of attorney
You prescribe Varenicline (Chantix), what else do you do?
Monitor pt, his family and friends for behavior disturbances.
