Dermatologic and Eyes, Ears, Nose, and Throat, and Immunologic Disorders Flashcards
J.R. is a 68-year-old man with a medical history
significant for type 2 diabetes. He presents to his ophthalmologist for his annual eye examination and is
told he has signs of moderate (intermediate) macular
degeneration. His ophthalmologist wishes to prescribe
supplements. Which combination best resembles the
formulation proven to decrease the progression of
macular degeneration?
A. Vitamin C, vitamin E, beta-carotene, and zinc.
B. Vitamin C, beta-carotene, and zinc.
C. Vitamin C, vitamin E, and beta-carotene.
D. Vitamin C, vitamin E, and zinc.
In the AREDS trial, the supplement combination shown
to delay the progression from intermediate disease to
advanced disease consisted of vitamin C 500 mg, vitamin E 400 international units, beta-carotene 15 mg, and zinc 80 mg. Certain situations warrant excluding a component of the combination (beta-carotene in patients with a history of lung cancer or in patients who smoke) (Answer A is correct; Answers B–D are incorrect).
Correct Answer: A
A.A. is a 54-year-old man with a medical history
significant for open-angle glaucoma, diabetes, and
obesity, all of which are appropriately treated. At his
most recent visit to the ophthalmologist (6 months
earlier), he had increased intraocular pressures (IOPs)
without changes in visual field or acuity. He was
initiated on latanoprost therapy at that visit; he now
returns for a follow-up. Today, his IOP is significantly
decreased but still not within an acceptable range to
prevent progressive vision changes. Which medication is most appropriate to add to his therapy?
A. Travoprost; 1 drop in each eye in the evening.
B. Betaxolol; 1 drop in each eye twice daily.
C. Dorzolamide; 1 drop in each eye three times daily.
D. Brimonidine; 1 drop in each eye three times daily
Answer B, the ophthalmologic β-blocker, is the best choice to add to this patient’s therapy. The patient already takes a prostaglandin analog (decreasing aqueous outflow resistance), and the dose increase is inappropriate because it does not enhance the IOP-lowering effect. According to recommendations from the National Institute for Health and Clinical Excellence, carbonic anhydrase inhibitors and adrenergic agents should be used after an ophthalmologic β-blocker fails to sufficiently decrease the IOP. Answers A, C, and D are options because their mechanism of action (decreased aqueous production) complements the prostaglandin analog, but only betaxolol has clear preference in
the treatment recommendations.
Correct Answer: B
F.T. is a 52-year-old woman who works in a retail shop.
She presents to an ophthalmologist with “scratching”
in her eyes, constant irritation, and difficulty making
it through the workday, leaving early once per week
because of eye irritation and headaches. She has tried
artificial teardrops, but they soothe her symptoms only
temporarily. The ophthalmologist believes that F.T.
has mild to moderate dry eyes and wants to adjust her
therapy to better address the symptoms. Which is the
best next step to recommend for therapy?
A. Artificial tears ointment.
B. Topical cyclosporine 0.05%.
C. Topical cyclosporine 0.1%.
D. Systemic cholinergic agents.
There are several options for treating and relieving the
symptoms of patients with mild to moderate dry eyes. First, assess for and remove any medications or factors that may be causing dry eyes. Next, apply artificial tears and evaluate the response. This patient responded, but not for a sufficient period. However, because she did obtain some relief, she may need a different formulation that will remain present longer. For this, an ointment application may be the best
choice (Answer A is correct). Ophthalmologic cyclosporine would be the next step or should be used if the patient does not obtain relief from artificial tears, in a 0.05%, not 0.1%, concentration (Answers B and C are incorrect). Systemic cholinergic agents should be used in patients with other symptoms of dryness, including most mucus membranes, or in those whose condition does not respond to ophthalmologic cyclosporine (Answer D is incorrect).
Correct Answer: A
P.W. is a 45-year-old man who presents to the pharmacy stating that he has had episodes of “dizziness” for the past several months. His medical history is significant for hypertension, seizures, type 2 diabetes, and headaches. He has discussed the matter with his physician and had many tests, but his symptoms have no readily identifiable cause. All radiographic study results of his head are normal, all of his laboratory values are within normal limits, and his blood pressure readings are “at target.” He believes his dizziness may be caused by one of his medications. In the past several months, he has started using hydrochlorothiazide, naproxen, fluoxetine, and metformin. Which medication is most likely associated with his dizziness?
A. Hydrochlorothiazide.
B. Acetaminophen.
C. Carbamazepine.
D. Metformin.
In any patient with symptoms of vertigo, the goal is to
identify the underlying cause of the disease, not just react to the symptom. This patient’s primary care physician appears to have ruled out most causes of vertigo except for medication-induced symptoms. Of the four medications, carbamazepine (Answer C) is the most likely cause of his symptoms (Answer C is correct; Answer B is incorrect). Although the antihypertensive hydrochlorothiazide (Answer A) may be associated with vertigo because of electrolyte abnormalities or blood pressure changes, neither were present during this patient’s physical and laboratory evaluations. Metformin (Answer D) may also be a cause, but for hypoglycemia, the symptoms are usually accompanied by tachycardia, diaphoresis, and possibly confusion.
Correct Answer: C
A.T. is a 9-year-old girl presenting to her pediatrician’s
office with her mother. The mother believes that A.T.
has allergies because she has had a “runny nose and
puffy and watery eyes” for the past few weeks. The
child’s nose has continuous, clear, thin discharge, and
she is constantly sniffling. Her mother reports “waves”
of sneezes two or three times daily. During the interview, the pediatrician observes several instances of the patient sniffling, rubbing her eyes, and making the “allergic salute” and wishes to prescribe an intranasal corticosteroid. The patient’s mother refuses this medication because her daughter has frequent bloody noses, so she requests an oral agent. Which would be the best oral agent for the child?
A. Clemastine 1.34 mg once daily.
B. Fexofenadine 30 mg twice daily.
C. Montelukast 5 mg once daily.
D. Pseudoephedrine 30 mg every 6 hours as needed.
Although an intranasal corticosteroid would be best for
this patient’s symptoms (moderate to severe), her mother’s fear of epistaxis and reluctance to use the corticosteroid are a treatment barrier. Fexofenadine (Answer B) should be used in this patient because it is a non-sedating H1 antihistamine that will most likely provide better relief than the other available agents (Answer B is correct; Answer D is incorrect). Although most oral antihistamines are equally effective, clemastine (Answer A) is a first-generation H1 antihistamine with a greater chance of causing sedation than fexofenadine. According to treatment guidelines, montelukast (Answer C) and other leukotriene inhibitors should be reserved for use until after a patient’s treatment with an
intranasal corticosteroid and a non-sedating H1 antihistamine has been unsuccessful.
Correct Answer: B
Y.A. is a 26-year-old woman with a medical history
significant only for dysmenorrhea, for which she
takes naproxen 500 mg as needed and low-dose oral
contraceptive therapy. She is a schoolteacher at the
local middle school and regularly contracts respiratory viral illnesses from her students. She is returning
to work after being out with an episode of influenza.
She currently takes fexofenadine 60 mg twice daily
for residual nasal symptoms and an urticarial rash
that she developed with the influenza virus. However,
even though she may return to work, the rash has not
completely resolved and is causing her moderate
discomfort (noticeable, but not interfering with daily
activities). She requests something to help further alleviate the urticaria symptoms. Which is the best agent for her (in addition to fexofenadine)?
A. Montelukast 10 mg once daily.
B. Diphenhydramine 25 mg every 6 hours as needed.
C. Famotidine 20 mg once daily.
D. Doxepin 25 mg once daily
The patient in this case is already being treated with fexofenadine, which ensures antagonism of both the H1 and H2 receptors. She is looking for an additional agent to add to her current regimen. Agents such as diphenhydramine or doxepin may be effective, but they also cause fatigue, which could interfere with the patient’s ability to work (Answers B and D are incorrect). In addition, diphenhydramine would work on the same receptors as fexofenadine, probably producing no additional effect (Answer A is incorrect). Adding famotidine will broaden histamine receptor antagonism and further decrease the presence and symptoms
of urticaria (Answer C is correct). If given the option, the
patient could also increase her oral antihistamine dose by up to 4 times the suggested normal dose for up to 4 weeks to see whether the symptoms improve or resolve.
Correct Answer: C
A.R. is a 24-year-old woman with a history of
hereditary angioedema (HAE). She is treated with a
plasma-derived C1 inhibitor (C1 INH) (Cinryze) every
3–4 days to prevent symptom onset. Given her medical condition and treatment regimen, which immunization is most important for her to receive?
A. Influenza annually.
B. Pneumonia (pneumococcal vaccine polyvalent)
now and after age 55.
C. Herpes zoster.
D. Hepatitis B series.
In patients with HAE, one of the primary treatment strategies for preventing symptoms is using plasma-derived C1 INHs (e.g., Cinryze). Because this is a blood product that may be a vector for disease transmission, treatment guidelines recommend immunizing all patients for bloodborne pathogens, including hepatitis B (Answer D is correct; Answers A–C are incorrect).
Correct Answer: D
F.D. is a 17-year-old female adolescent with a 5-year
history of inflammatory acne conglobata on her face,
neck, and upper torso. Since her initial diagnosis, she
has been treated with a variety of topical and systemic
agents such as benzoyl peroxide (with and without
antibacterials), topical retinoids, and oral minocycline.
Although these agents have partly controlled her symptoms, they have not provided sufficient relief. After much consideration, she and her family have agreed to try isotretinoin therapy. They have been counseled on the adverse events associated with its use and are ready to begin therapy. Which additional measure is the next best step before the clinician prescribes therapy?
A. Enroll the patient in the iPLEDGE program to help
avoid teratogenicity in the event of an unplanned
or planned pregnancy.
B. Have the patient obtain clearance from a mental
health provider to begin using the agent because it
has been associated with suicidal ideations.
C. Test hepatic transaminase concentrations every
other week until therapy is discontinued; discontinue the medication if the patient does not adhere
to testing.
D. Have the patient agree to avoid driving after
sunset for 6 months secondary to vision changes
associated with the drug.
Patients taking an oral retinoid should be enrolled in the
iPLEDGE program and be aware of the severe, increased
risk of teratogenicity with pregnancy while actively taking the medication (Answer A). Individuals enrolled in the
iPLEDGE program are extensively counseled on the risk
of teratogenicity with pregnancy and are encouraged to
take hormonal and barrier contraceptives. Even though
routine monitoring of hepatic transaminase concentrations is recommended until patients reach an effective dose of oral retinoids, missed laboratory visits are no indication to discontinue therapy (Answer C). In addition, although patients starting an oral retinoid should be counseled on the increased risk of mental health disorders (suicidality) with use, they do not need a mental health provider to sign off on the therapy (Answer B). Finally, these analogs have no reported impact on night vision (Answer D).
Correct Answer: A
J.F. is a 22-year-old man with moderate psoriasis of
his back and legs. He has been treated with topical
corticosteroids intermittently for the past 9 years. Each
treatment course has successfully alleviated his symptoms of itching and burning. However, his most recent symptom flare is the worst to date and is not responding to topical corticosteroids as previously. Which is best to add to his topical corticosteroid?
A. Prednisone 20 mg daily for 14 days.
B. Topical calcipotriene twice daily.
C. Methotrexate 20 mg once weekly.
D. Adalimumab 40 mg once every other week.
Topical corticosteroids are the treatment of choice for individuals with mild to moderate psoriasis. Adding a vitamin D analog such as calcipotriene (Answer B) would be the most reasonable choice because it is more effective in combination with a topical corticosteroid than is either agent alone. The oral corticosteroid burst in Answer A is not indicated for a “flare-up” of psoriasis. Biologic agents (Answer D) and methotrexate (Answer C) should be reserved for
individuals with severe or debilitating disease, those with greater than 10% of their body surface area covered with psoriatic lesions, and those with symptoms of psoriatic arthritis. For this patient, use of these agents would be excessive before trying other topical treatment options.
Correct Answer: B
D.T. is a 46-year-old woman with severe and sometimes debilitating psoriasis with arthritis symptoms. She has had painful psoriatic arthritis complications in her hands, wrists, hips, and knees for the past 6 months and has achieved only limited relief from nonsteroidal anti-inflammatory drugs (NSAIDs) and oral corticosteroids. She had a hysterectomy with a bilateral salpingo-oophorectomy 4 years ago and has poorly controlled hypertension, despite being treated with fosinopril, hydrochlorothiazide, and amlodipine. She has medical and prescription insurance. Which is the best first choice to help lessen this patient’s symptoms?
A. Methotrexate 20 mg once weekly.
B. Cyclosporine (equaling 1.25 mg/kg) twice daily.
C. Acitretin 50 mg once daily.
D. Etanercept 50 mg twice weekly.
The best agent for this patient would be etanercept (Answer D). Cyclosporine (Answer B) would not be a good choice because of her poorly controlled hypertension and cyclosporine’s poor efficacy compared with biologic therapy. Methotrexate is an acceptable agent because it can be used in severe disease with or without the presence of arthritis. However, given that methotrexate’s efficacy for controlling symptoms in psoriasis is less than that of the TNF inhibitors, it should be reserved for second-line therapy. Methotrexate (Answer A) should be considered to treat psoriasis only in patients whose condition does not respond to a T-cell inhibitor or a TNF inhibitor or who cannot afford biologic
therapy. Acitretin (Answer C) is a retinoid-like compound effective for psoriatic plaques but does not affect psoriasis related arthritis symptoms
Correct Answer: D
L.L. is a 14-year-old male adolescent visiting his aunt and uncle for a few weeks in the summer. He is up to date with his immunizations and has had a relatively unremarkable childhood. He attends a sleep-away camp every summer for 2 weeks and then visits his cousins the following week. On the second day of his visit with his relatives, L.L. begins to have itching between his fingers, under his arms, and on the underside of his buttocks. The itching is unrelieved with bathing, loratadine, or hydrocortisone cream. His aunt takes him to her children’s pediatrician for evaluation and is surprised to hear that he has contracted scabies. He has not had an infestation such as this before; most likely, he contracted it during the first few days of camp.
Which is the best first choice to eradicate this
infestation?
A. Permethrin 1%.
B. Permethrin 5%.
C. Malathion 0.5%.
D. Lindane 1%
Permethrin 5% (Answer B) would be the treatment of choice for this patient. Permethrin 1% lotion (Answer A) is too low in concentration for a scabies infestation. Permethrin 1% lotion could be used for pediculosis (lice) but would not be effective for this patient’s condition. In addition, the degree of resistance to permethrin 5% for scabies is not yet sufficient to warrant a change to malathion (Answer C), given its inferiority to permethrin and high likelihood of dermatologic drying and irritation. The neurotoxicity associated with lindane (Answer D) makes it a less desirable first-line treatment for the first symptoms of untreated scabies; lindane should be reserved for patients who cannot be treated with less potentially harmful therapies.
Correct Answer: B
L.L. is a 14-year-old male adolescent visiting his aunt and uncle for a few weeks in the summer. He is up to date with his immunizations and has had a relatively unremarkable childhood. He attends a sleep-away camp every summer for 2 weeks and then visits his cousins the following week. On the second day of his visit with his relatives, L.L. begins to have itching between his fingers, under his arms, and on the underside of his buttocks. The itching is unrelieved with bathing, loratadine, or hydrocortisone cream. His aunt takes him to her children’s pediatrician for evaluation and is surprised to hear that he has contracted scabies. He has not had an infestation such as this before; most likely, he contracted it during the first few days of camp.
L.L.’s aunt is concerned that her family may have also
contracted scabies and wants everyone in the house to be treated. Which is the most appropriate response to this request?
A. All individuals in the house should be empirically
treated, regardless of the presence of symptoms.
B. Household prophylaxis is unnecessary in scabies
infestations, and patients should seek treatment
on an individual basis.
C. Only those in the house who have had close contact with the patient’s clothing or bedding need
prophylactic therapy.
D. The family should have an “on-call” prescription
for a scabicide and use it at the first sign of itching
and discomfort.
All individuals in the household and in close contact with
the person with the infestation should be examined and
most likely treated for a scabies infestation, even if they are asymptomatic (Answer A is correct; Answers B and C are incorrect). Household and close contacts within the past 30 days need to be evaluated and treated. Given the long period between initial infestation and presence of symptoms, it is unreasonable to wait for individuals to develop symptoms. During the asymptomatic period, these contacts could possibly contaminate those around them (sometimes for a second or third time). An “on-call” prescription for a scabicide is also not feasible because it still requires individuals to be symptomatic and possibly transmit/retransmit the infestation (Answer D is incorrect).
Correct Answer: A
T.S. is a 38-year-old man with no significant medical
history. After a long weekend of working outside and
not wearing sunscreen, he has developed sunburn
on his upper arms, neck, face, and back. He is relatively uncomfortable and cannot wear a shirt or sleep on his back without discomfort. The sunburned areas are not blistering or weeping. They are erythematous and warm to the touch, and they blanch with pressure. Which would best relieve his pain and make him more comfortable?
A. Topical silver-based cream applied once or twice
daily.
B. Topical aloe vera and an occlusive dressing over
the back, arms, and neck.
C. Ibuprofen 400 mg every 6 hours as needed for
pain.
D. Hydrocolloid dressings (DuoDERM) for 5–10
days.
The patient’s symptoms are consistent with a first-degree
UV light burn. This will probably take 5–10 days to completely heal and requires no therapy beyond miniaturization and pain management (Answer C). Silver-based creams such as silver sulfadiazine (Answer A) are not recommended for burns because they delay healing time and (in more serious burns) may increase the risk of infection. Topical aloe is an option, but occlusive and wet dressings should be reserved for second-degree and more serious burns (Answer B). The same reasoning applies for not choosing the hydrocolloid dressing (Answer D). This patient should obtain sufficient
relief from an NSAID such as ibuprofen.
Correct Answer: C
When a patient is a smoker and has macular degeneration, what supplement should you avoid
Beta carotene
Add what drug to prostaglandin analog eye therapy when % reduction from baseline is less than 25% reduction over past 3 months
Timolol bid dosing
Which is the following is beta 1 selective
Betaxolol
Timolol
Levobunolol
Metipranolol
Carteolol
Betaxolol
Most of the beta receptor in the eye are beta 2 so you want a non selective
Netarsudil (rhopressa) place in glaucoma therapy
Add on top either prostaglandin or beta blockers
Lowers pressure by 5%
One drop at bedtime
Alpha2 agonist eye drops are dosed how often
TID
Carbonic anhydrase inhibitors (acetazolamide, methazolamide) orally lower IOP by 40% however lots of systemic side effects so reserved to give to
For closed angle or for IOP after trauma or surgery
Not for open angle
