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