Case Files 25-30 (C) Flashcards
Dysthymic Disorder
A chronic depression of mood which does not meet the criteria for major depression, in terms of either severity or duration of individual episodes, yet the patient still has loss of interest, lack of appetite or pleasure, and low energy
When a patient presents with multiple unrelated physical symptoms, what diagnosis needs to be considered?
Depression
How do antidepressant agents work?
- Enhance neurotransmitter release
- Reduce neurotransmitter breakdown
- Inhibit the reuptake of the neurotransmitter by the presynaptic neuron
Persons with depression have a greater chance of developing or dying from…
Cardiovascular disease (even after controlling traditional risk factors such as smoking, blood pressure, and lipid levels)
Women, especially those younger than age __, attempt suicide more frequently than men, but men are __ likely to complete suicide.
30
more
Why do all antidepressants carry an FDA “black box” warning?
Because they increase the risk of suicidal thoughts and behaviors especially in the first months of treatment (patients should be treated for at least 6-9 months during their first episode of major dpression)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Fluvoxamine (Luvox)
Citalopram (Celexa)
Escitalopram (Lexapro)
SSRIs (increase the amount of serotonin by blocking the presynaptic neuron’s ability to reuptake serotonin)
Considered first-line agents for the treatment of depression because they have a low toxicity
Side effects: sexual dysfunction, weight gain, GI disturbance, fatigue, and agitation
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Mirtazapine (Remeron)
Desvenlafaxine (Pristiq)
SNRIs (affect both the serotonergic and noradrenergic systems)
Can be used as first-line treatment for depression and, because of their effects on two neurotransmitter systems, may be used as second-line agents in SSRI failure
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Desipramine (Norpramin)
Clomipramine (Anafranil)
Doxepin (Sinequan)
Imipramine (Tofranil)
TCAs (affect, to varying degrees, the reuptake of NE and serotonin)
They have numerous side effects and are highly toxic (potentially fatal) in overdose
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegiline (Eldepryl)
MAOIs (caused increased amounts of serotonin and NE to be released during nerve stimulation)
Patients must be on a tyramine-restricted diet to reduce the risk of severe, and sometimes fatal, hypertensive crisis
Bupropion (Wellbutrin)
Amoxapine (Asendin)
Trazodone (Desyrel)
Atypical Agents (act similarly to SSRIs, TCAs, and MAOIs)
Their primary benefit is a lower incidence of sexual disturbance as a side effect
When is Bupropion contraindicated?
In patients with a history of seizure disorder
How is bipolar disorder medically managed?
Valproate, carbamazepine, or lithium
*A single episode of mania is sufficient for the diagnosis of bipolar disorder
*The use of antidepressant agents in bipolar disorder may precipitate acute manic behaviors
How is the postpartum period defined?
6-12 weeks after the delivery of the placenta
Postpartum fever is most often a sign of…
endometritis
*can also be caused by urinary tract or wound infections, thromboembolic disease, and mastitis
Lochia
Yellow-white discharge, consisting of blood cells, decidual cells, and fibrinous products, that occurs following delivery
In women who are not breast-feeding, menstruation usually restarts by…
the 3rd postpartum month
The most common causes of postpartum hemorrhage
“The Four Ts”
- Tone (uterine atony)
- Trauma (lacerations or uterine inversion)
- Tissue (retained placenta or membranes)
- Thrombin (coagulopathies)
Initial management of uterine atony includes:
IV administration of oxytocin
Initiation of bimanual uterine massage
Methylergonovine (Methergine) IM
Prostaglandin F (Hemabate) IM
Misoprostol (Cytotec) rectally or orally
When are Methergine and Hemabate contraindicated?
Methergine contraindicated in pts with HTN
Hemabate (prostaglandin F) contraindicated in pts with asthma
Benefits of breastfeeding
Maternal benefits: bonding, uterine involution, quicker return to prepregnant body weight, reduced risks of ovarian and breast cancer
Neonatal benefits: ideal nutrition, resistance to infection, reduced risk of GI difficulties
Which OCPs should be given to breast-feeding women and when?
The progestin-only pills (combination OCPs might reduce lactation) after 6 weeks postpartum
*Non-breast-feeding women should wait 3 weeks after delivery to start combined OCPs
*Lactation-induced amenorrhea provides a high level of natural contraception in the first 6 months postpartum
Most cases of CHF are caused by either ____ or ____
CAD or HTN
Two main categories of CHF
Systolic: dilated LV with impaired contractility
Diastolic: normal or intact LV that has an impaired ability to relax, fill, and eject blood
Fluid retention
Weight gain
Peripheral edema
JVD
Abdominojugular relux
Hepatic ascites
Splenomegaly
Common signs of R-sided heart failure
Dyspnea on exertion
Paroxysmal nocturnal dyspnea
Orthopnea
Wheezing
Tachypnea
Cough
Common signs of L-sided heart failure
In a dyspneic patient, a level of BNP less than ___ suggests that the symptoms are unlikely to be caused by CHF; a BNP level greater than ___ is consistent with the diagnosis of CHF
< 100 pg/mL
> 500 pg/mL
One of the earliest chest x-ray findings in CHF is…
cephalization of the pulmonary vasculature
What is considered the gold-standard diagnostic modality for CHF?
Echocardiography
The most useful diagnostic tool for evaluating patients with HF is 2-dimensional echocardiography with Doppler to assess LVEF, LF size, ventricular compliance, wall thickness, and valve function
What are the two most widely used classification systems for CHF?
New York Heart Association (NYHA): I-IV
American Heart Association (AHA): A-D
When acute pulmonary edema caused by CHF is diagnosed, the next step in management is…
the administration of a loop diuretic
*Furosemide is generally the treatment of choice, both for its potent diuretic effect and for its rapid bronchial vasculature vasodilation
Benefits of nitroglycerin for a patient with CHF
When given IV, it reduces oxygen demand by reducing preload and afterload
Rapidly reduces blood pressure (treatment of choice when a CHF patient has an elevated BP; used with caution in a hypotensive patient)
Benefits of morphine in a patient with CHF
Analgesic + Anxiolytic
Also a venodilator (primary effect) and arterial dilator, resulting in a reduction in preload and an increase in cardiac output
What should the daily salt intake be for a CHF patient?
2-4 g/d
*A normal American diet contains 6-10 g/d
First-line therapy in patients with CHF and reduced LV function
ACE inhibitors
*ARBs can be used in place of ACE inhibitors in a patient who does not tolerate an ACE inhibitors because of side effects (e.g., cough)
When are ACE inhibitors contraindicated?
Pregnancy
Hypotension
Hyperkalemia
Bilateral renal artery stenosis
When should β-blockers be used in the setting of CHF
Can reduce sympathetic tone and the cardiac muscle remodeling associated with chronic heart failure
Reduce mortality in patients with an EF < 35% and are primarily indicated in patients with NYHA Class II or III heart failure, or in patients with coronary artery disease
*Administration in high doses, in the setting of acute CHF, can worsen symptoms
Loop vs Thiazide Diuretics in the setting of CHF
Loop (furosemide, bumetanide, torsemide, ethancrynic acid): used in all stages of CHF
Thiazide (HCTZ, chlorthalidone): used in mild heart failure and may be used in combination with others
Calcium channel blockers, in general, are ______ in systolic heart failure
contraindicated because they increase mortality
Exception = amlodipine
*Nondihydropyridine calcium channel blockers (diltiazem, verapamil) are useful in HF caused by diastolic dysfunction, as they promote increased CO by lowering HR, which allows for more ventricular filling time
Cardiac Resynchronization Therapy
Shown to reduce mortality and hospitilization in patients with symptomatic CHF in spite of maximal medical therapy
Beneficial for patients with NHYA Class III or IV HF and reduced EF with ECG evidence of abnormal ventricular conduction (i.e., prolonged QRS duration)
Combination oral contraceptives offer significant protection against…
ovarian cancer, endometrial cancer, iron-defiency anemia, PID, and fibrocystic breast disease
If a pill is missed, it should be taken…
as soon as possible and the next dose should be taken as usual
The patch’s efficacy and side effects are comparable to that of combined OCPs, although there may be an increased risk of…
vascular thrombosis
How often does a woman need to change a NuvaRing?
Every 3 weeks, remove and discard it
Go one week ring-free
Insert new ring
The diaphragm should be left in place for how many hours after intercourse?
At least 6
The hallmark PE finding in hypertrophic cardiomyopathy (HCM) is?
- A systolic murmur that decreases in intensity with the athlete in the supine position (increased ventricular filling, decreased obstruction)
- Increases with the Valsalva maneuver (decreased ventricular filling, increased obstruction)
*outflow murmurs increase in intensity upon lying down
Sexually active, symptomatic, and high risk females should be screen for gonorrhea and Chlamydia by…
urine nucleic acid amplification
A Td booster is recommended at ages…
11-12 years and then every 10 years thereafter
Where is the murmur for HCM best heard?
Along the left sternal border
A high school student is being seen for a sports preparticipation exam. Which of the following should prompt a referral to a cardiologist prior to clearance to participate in high school sports?
- Grade 2/6 systolic murmur in an asymptomatic 16F
- Grade 1/6 diastolic murmur heard at the apex in a 17F
- Grade 2/6 systolic murmur in a 17M that is heard while lying down and that gets softer when standing
Grade 1/6 diastolic murmur
Any patient with a diastolic murmur, grade 3/6 or louder systolic murmur, murmur suggestive of HCM, or signs of Marfan syndrome should be evaluated
The risk of cardiovascular disease doubles with each increase in blood pressure __/__ mm HG above 115/75 mm Hg
20/10
Elevated systolic or diastolic blood pressure puts you at greater risk for cardiovascular disease
systolic
Four Categories of Blood Pressure
Normal < 120/80
Prehypertension: 120-139/80-89
Stage I: 140-159/90-99
Stage II: >160/100
In the primary treatment of HTN, _____ are the recommended first-line therapy in most settings
thiazide diuretics
*Stage 2 HTN patients should be started on combination therapy
At a routine checkup a 6M is found to have a BP of 130/90. Repeated BP readings are consistently elevated. The child was delivered at 36 weeks by normal SVD with no complications. All major milestones were met on time. What is the most appropriate diagnosis and therapeutic step?
The child most likely has renal parenchymal disease and should have a UA and renal US ordered
The most common cause of HTN is renal parenchymal disease, and a UA, UCx and renal US should be ordered for all children presenting with HTN
