Family Medicine Flashcards
Chlamydial pneumonia typically presents in infants of what age
3-16 wks
Presentation of Chlamydial pneumonia of newborn
- Nontoxic, afebrile infant
- gradual onset
- conjunctivitis (50%)
- cough & tachypnea
- diffuse crackles & wheezes on PE
- Hyperinflation, diffuse interstitial or patchy infiltrates on CXR
What is the criteria to prescribe 5-alpha-reductase inhibitors (finasteride, dutasteride, etc) for BPH
PSA >1.5 ng/ml or signs of prostate enlargement
Treatment for acute mania of Bipolar Disorder
Lithium, valproic acid, haloperidol, or atypical antipsychotics
*atypicals are first line for severe mania b/c of shorter onset of action
Treatment for bipolar depression
Lithium, quetiapine (antipsychotic), lurasidone*, lamotrigine
*safe in pregnancy
Which atypical antipsychotic should be avoided in women of childbearing age
Divalproex
What serum testing must be monitored in pts on Amiodarone
TSH.
Amiodarone can cause hyper or hypo-thyroidism so pts should have baseline TSH, T4 before starting ed and then monitoring every 6 mo.
When to perform a thyroid radionucleotide scan
After nodule confirmed on u/s AND abnormal TSH levels
What are the pharmacological options for smoking cessation
Buproprion, Varenicline (Chantix), or nicotine replacement therapy
What is pregnancy category B
no human studies + no harm in animal studies OR harm in animal studies but no harm in human studies
What is pregnancy category C
No human studies + harm shown in animal studies
OR
No animal or human studies
What is pregnancy category D
Human studies show potential harm, but benefit may outweigh harm
What are some of the negative effects of smoking on pregnancy
Prematurity, intrauterine growth restriction, stillbirth, spontaneous abortion, infant death
What are the 5 A’s of tobacco cessation
- Ask
- Advise
- Assess willingness
- Assist
- Arrange f/u
When is buproprion contraindicated for smoking cessation
- eating disorders
- monoamine oxidase (MAO) inhibitor use
- hx of seizure disorder
What are the most common side effects of buproprion
insomnia & dry mouth
Varenicline
aka Chantix
Nicotinic receptor partial agonist
-reduces cravings and withdrawal symptoms
When is varenicline (Chantix) contraindicated for smoking cessation
-hx of psychiatric behaviors
Common side effects of varenicline (Chantix)
nausea, trouble sleeping, abnormal vivid dreams
What pregnancy category are nicotine replacement therapies (NRT)
Pregnancy Category D
What pregnancy category are buproprion and varenicline (chantix)
Pregnancy Category C
Which drugs are most commonly the cause of Stevens Johnson Syndrome or Toxic Epidermal Necrolysis (in adults)
Allopurinol, aromatic antiepileptic drugs and lamotrigine, antibacterial sulfonamides, nevirapine, oxicam NSAIDs
What are the risks associated inhaled corticosteroids in the treatment of COPD
Increased bruiisng, candidal infection, pneumonia
What is the first line antibiotic choice for diabetic foot ulcer
Pip/Tazo (Zosyn) & vanc (esp. if risks for MRSA eg recent hospitalization)
–> gram +, gram -, and anaerobic coverage
What are some common drugs that cause SIADH
- SSRIs
- chloropropamide
- barbituates
- carbamazepine
- opioids
- tolbutamide
- vincristine
- diurectics
- NSAIDs
What are the recommendations regarding folic acid supplementation prior to conception
Normal risk: 400-800 mcg (0.4-0.8mg) supplementation
Diabetes or epilepsy 1 mg
Prior child with neural tube defect 4mg
What are Goodell’s sign and Hegar’s sign
Goodell;s sign is softening of the cervix with pregnancy
Hegar’s sign is softening of the uterus with pregnancy
What is Chadwick’s sign
The bluish-purple hue in the cervix and vaginal walls due to hyperemia in pregnancy
When is RSV season
November to April in North America
What is the treatment for RSV
Supportive care with bronchodilators
- *corticosteroids and antibiotics are not first line
- *co bacterial infection is rare
What is the treatment for mild to moderate Community Acquired Pneumonia in infants and school children
Amoxicillin - Strep pneumo is most common pathogen
What is the most common pathogen to cause community acquired pneumonia in infants and school children
Strep pneumo - treat with amoxicillin
Why is the treatment for mild to moderate Community Acquired Pneumonia in older children and why
Azithromycin because Mycoplasma pneumoniae is more common than strep pneumo in this age group
Why are SSRIs an option for treating nightmares
they suppress REM sleep
**note benzos are used for night terrors
What is the treatment for mild to moderate Salmonella without systemic spread
Symptomatic treatment and fluid support in low risk patients
What is the treatment for systemic Salmonella, severe Salmonella, or isolated Salmonella in at risk patients (e.g. sickle cell)
Oral Bactrim or quinolone + fluid support
*may use IV ceftriaxone
Which pediatric vaccinations carry a risk of febrile seizures?
- MMR & MMRV (specifically due to measles component)
- inactivated flu vaccine when given with PCV13 or DTaP
- *increased risk w/ history of seizures or first degree relative w/ seizures
What pathogen is likely to cause pneumonia in a pt with COPD taking corticosteroids that is unlikely in a pt w/o COPD
Pseudomonas aeruginosa
*S. pneumo, Mycoplasma pneumo, HiB, S. aureus are common in both populations
Cow’s milk is not recommended for children under the age of ________
12 months
What is Charcot’s triad
Triad of symptoms for Multiple Sclerosis: scanning speech, intranuclear ophthalmoplegia, and nystagmus
What does the triad of scanning speech, intranuclear ophthalmoplegia, and nystagmus suggest
=Charcot’s triad which suggests multiple sclerosis
How does pregnancy affect multiple sclerosis
Symptoms of MS typically decrease with pregnancy
What is the treatment for acute multiple sclerosis exacerbations
High dose IV corticosteroids
-Plasma exchange may be given in pts who do not respone to steroids
What is the medication of choice for the treatment of Serotonin Syndrome if supportive care is not effective
Benzodiazepines
Short acting Beta blockers may be used prn for tachycardia
True or false: Asplenic patients should be given antibiotics for any episode of fever
True: due to the increased risk of pneumococcal sepsis in asplenic patients
What is the leading cause of death for patients w/ Rheumatoid Arthritis and why
Coronary Artery disease (just like the normal pop.) but is due to increased progression of atherosclerosis due to chronic inflammation
What is the most effective psychotherapy for obsessive compulsive disorder
Repeated exposure to fearful stimuli
What are the risks associated with long term PPI use
- Fractures - hip, wrist, spine (due to reduced calcium absorption)
- Hypomagnesemia (due to malabsorption)
- Community Acquired Pneumonia (observational data only)
- C. diff & other enteric infections
Which diseases are most commonly associated with uveitis (in North America)
- Seronegative spondyloarthropathies
- Sarcoidosis
- Syphillis
- Rheumatoid arthritis
- Reactive arthritis
What is the classic presentation of pertussis
infant <6 mo w/ paroxysmal coughing, posttussive emesis, and apnea
infant <6 mo w/ paroxysmal coughing, posttussive emesis, and apnea is the classic presentation of _____?
Pertussis - gram - boacillus Bordetella pertussis
What is the treatment for pertussis infection
Azithromycin x 10 days, hospitalize infants, treat close contacts prophylacticly
**Bactrim if allergic to azithromycin
Which murmurs are typically pathologic and should prompt echocardiogram workup
Continuous and diastolic murmurs
What are the recommendations for when to switch to a forward facing car seat?
> 2 years and >40 pounds
When should solid food be introduced to an infant
No earlier than 6 months
When is objective hearing screening indicated for children
With history of meningitis, ToRCHeS infections, measles, mumps, recurrent otitis media
What is the differential for Leukocoria (lack of red reflex)
Retinoblastoma
Congenital Cataracts
Retinopathy of Prematurity
At what age should a workup for Strabismus (ocular misalignment)be worked up in a child
> 3 months of age. Prior to 3 months this may be a normal variant
What are the contradictions to childhood vaccination
- severe allergy to vaccine component or prior dose
- encephalopathy within 7 days of prior pertussis vaccine
- no live vaccines for immunocompromised or pregnant s
What are the common causes of vesicoureteral reflux in children
Posterior urethral valves,
Urethral or meatal stenosis
Neurogenic bladder
Treatment of UTI in children
Amoxicillin if <2 months old
Tmp-Smx or nitrofurantoin if >2 mo.
Common presentation of child abuse in infants
Apnea, seizures, feeding intolerance, excessive irritability, somnolence, or FTT
What are the intrauterine risk factors for congenital heart disease
Maternal drug use (alcohol, lithium, thalidomide, phenytoin), maternal infection (rubella), maternal illness (DM, PKU,)
What are the cyanotic (right to left shunt) congenital heart defects
Truncus arteriosus Transposition of the great vessels Tricuspid atresia Tetralogy of fallout Total anomalous pulmonary venous return
Which congenital heart defect(s) has a fixed widely split S2
ASD
What is Eisenmenger syndrome
When a left to right shunt (acyanotic - VSD, ASD, PDA) leads to severe pulmonary hypertension that causes shunt reversal (right to left)
What is the most common congenital heart defect
VSD
What are the acyanotic (left to right shunt) congenital heart defects
VSD, ASD PDA
What is an ebstein abnormality
Apical displacement of the tricuspid valve leading to serialization of the right ventricle
What are the common signs of autism in children/infants
No babbling or/and gesturing by 12 months No 2 word phrases by 24 months Impaired social interaction Restricted interests Insistence on routine
What does CHADS-VASc stand for and what is it used for
Scoring system to estimate risk in atrial fibrillation and anticoagulate for score ofb2 or more CHF 1 pt HTN 1 pt Age = 75 2pts Diabetes 1 pt Stroke or TIA hx 2 pts Vascular disease 1 or Age 65-74 1pt Sex of Femlae 1 pt
What are the symptoms of antidepressant discontinuation syndrome
dysphoria, fatigue, insomnia, myalgias, dizziness, flu like symptoms, gi symptoms, tremor, neurosensory disturbances.
*typically within 2-4 days of medication stoppage
What endocrine abnormality is associated with major depressive disorder
Hypercortisolemia due to hyperactivity of the hypothalamic-pituitary-adrenal axis
What is the treatment for postpartum endometritis
Clindamycin + gentamicin
How does estrogen (in pregnancy or by medication) affect the dosing of levothyroxine?
Dosing of levothyroxine must be increased because estrogen leads to an increase in thyroxine-binding protein reduced clearance in the liver
**exception is transdermal estrogen which bypasses liver
For how long must symptoms be present for someone to qualify as having a major depressive episode
> /= 2 wks
What is the first step in evaluation of primary amenorrhea (no first mentruation)
Pelvic ultrasound to assess for presence of uterus
- -> uterus present–> serum FSH
- -> uterus not present –> karyotype & serum testosterone
Which NSAID is not associated with a known increase in the risk of myocardial infarction
Naproxen
**Celecoxib, ibuprofen, meloxicam, and diclofenac are associated with an increased risk
of cardiovascular adverse effects and myocardial infarction, compared with placebo
What are the classifications of anorexia nervosa according to the DSM-5
Based on BMI Mild: BMI>17.0 Mod: BMI 16.0-16.99 Severe: BMI 15.0-15.99 Extreme: BMI <15.0
What are some of the indicating criteria for hospitalization of pts with anorexia nervosa
Refusal to eat
Orthostatic changes in pulse or bp
What are common risk factors for conversion of latent tb to active?
Diabetes mellitus, lung cancer, alcoholism, recent contact w/ active tb ind., immunosuppressive therapy, lung parenchymal diseases (COPD, silicosis,etc)
Low SES, age <5, wt < 90% ideal minimum
For patients with acute coronary artery syndrome who are not at high risk of bleeding, how long should they be on dual antiplatelet therapy
at least 12 months
What is a nonsedating medication that is safe to use in the first trimester of pregnancy for nausea and vomiting
Vitamin B6
**Scopolamine is contraindicated due to birth defects
Who should recieve antibiotic prophylaxis against bacterial endocarditis prior to dental procedures
High risk patients only: prosthetic valves, prior hx of endocarditis, unrepaired congenital cyanotic heart disease, cardiac transplant recipients w/ valvular disease
Mild to moderate hypertriglyceridemia increases the cardiovascular risk, but severe hypertriglyceridemia increases the risk of ___________
Pancreatitis
Which anti-lipid medication is recommended for patients with severe hypertriglyceridemia (at risk of pancreatitis)?
Fibrates
How does Niacin affect lipid levels
Increases HDL
Decreases LDL
No evidence of cardiovascular risk improvement
What are the side effects/adverse effects of methimazole
Agranulocytosis Serum sickness Cholestatic jaundice Alopecia Nephrotic syndrome Hypoglycemia Loss of taste Fetal anomalies
What cancers are associated with Lynch syndrome
Colorectal cancer
Endometrial cancer
Ovarian cancer
What cancers are associated with Familial adenomatous polyposis
Colorectal cancer
Desmoids & osteomas
Brain tumors
Which cancers are associated with von Hippel-Lindau syndrome
Hemangioblastomas
Clear cell renal carcinoma
Pheochromocytoma
Which cancers are associated with Multiple endocrine neoplasia type 1
Parathyroid adenomas
Pituitary adenomas
Pancreatic adenomas
Which cancers are associated with Multiple Endocrine Neoplasia type 2
Medullary thyroid cancer
Pheochromocytoma
Parathyroid hyperplasia type 2A
Which cancers are associated with BRCA1 & BRCA2
Breast cancer
Ovarian cancer
What is the medical management for catatonia
Benzodiazepines (lorazepam)
Alternatively Electroconvulsive therapy
What is Dantrolene commonly used for
To treat muscular rigidity associated with severe neuroleptic malignant syndrome that does not respond to discontinuation of antipsychotic medication
Which organism is most commonly responsible for necrotizing (malignant) otitis externa
Pseudomonas aeruginosa
What are the risk factors for developing necortizing (malignant) otitis media
Age >60
DM
Aural irrigation
Severe, unremitting ear pain (worse at night or with chewing), lower CN deficits (CN VII), granulation tissue in external auditory canal and elevated ESR suggest …_____
Necrotizing (malignant) otitis media
What is the treatment for necrotizing (malignant) otitis media
Anit-psuedomonal antibiotics (e.g. ciporfloxacin) +/- surgical debridement
What characteristics of tinnitus suggest underlying pathology and would require further work up (e.g. MRI)
Unilateral or pulsatile tinnitis or tinnitus associated with unilateral hearing loss
What is akathisia
motor restlessness, often accompanied by inexplicable anxiety and inability to sit still comfortably
Any infant under ___ days old should be admitted to the hospital for fever
29 days
What are the most common organisms associated with lymphadenitis
Staphulococcus aureus and group A Streptococcus
What is the best diagnostic test for vitamin D deficiency
25-hydroxyvitamin D
**NOT 1,25
What are the risks associated with Combined Oral Contraceptives
- Venous thromboembolism
- HTN
- Hepatic adenoma
- Stroke, MI
- Cervical Cancer
- Headache (not verified by study materials)
What is the etiology of Reye Syndrome
Pediatric aspirin use during viral infection (influenza or varicella)
What is the treatment for Reye Syndrome
Supportive
What are the clinical features of Reye Syndrome
Acute liver failure and encephalopathy
At what age should infants be able to walk first steps independently
12 months
At what age should infants be able to run and kick a ball
18 months
At what age should infants/toddlers be able to jump and walk up stairs with 2 feet
2 yrs
At what age should infants/toddlers be able to walk up stairs with alternating feet
3 yrs
What is an alternative name for Pancoast Tumor
Superior Pulmonary Sulcus Tumor
What is the clinical presentation of Pancoast Tumor
- Shoulder pain
- Horner syndrome
- C8-T2 neurological involvement (weakness of intrinsic hand muscles, pain/paresthesias of 4th/5th digits, medial arm, forearm)
- Supraclavicular lymph node enlargment
- Weight loss
What is the strongest risk factor for a Pancoast tumor
Smoking
What are common causes of fetal tachycardia
Maternal infection, poorly controlled maternal hyperthyroidism, medication use, abruptio placentae
Prolonged Membrane Rupture is achieved at what time
> 18 hrs
Fetal anemia is represented by what fetal heart rate tracing pattern
Sinusoidal fetal heart tracing (smooth, undulating waveform w/o variability)
What class of drug is PCP (phencyclidine)
Hallucinogen
What class of drug is LSD
Hallucinogen
What class of drug is Cocaine
Stimulant
What class of drug is methamphetamine
Stimulant
What class of drug is Marijuana (THC or cannabis)
Cannabinoid
What class of drug is Heroin
Opioid
What are the clinical features of PCP (phencyclidine) intoxication
- Violent behavior
- Dissociation
- Hallucinations
- Amnesia
- Nystagmus
- Ataxia
What are the clinical features of LSD intoxication
- Visual Hallucinations
- Euphoria
- Dysphoria/panic
- Tachycardia/HTN
What are the clinical features of Cocaine intoxication
- Euphoria
- Agitation/psychosis
- Chest pain
- Seizures
- Tachycardia/HTN
- Mydriasis
What are the clinical features of Methamphetamine intoxication
- Violent behavior
- Psychosis, diaphoresis
- tachycardia/htn
- Choreiform movements
- Tooth decay
What are the clinical features of Marijuana intoxication
- Increased appetite
- Euphoria
- Dysphoria/panic
- Slow reflexes, impaired time perception, impaired concentration
- Dry mouth
- Conjunctival injection
What are the clinical features of Heroin intoxication
- Euphoria
- Depressed mental status
- Miosis
- Respiratory depression
- Constipation
What are bath salts
Synthetic amphetamine analogues
What is the clinical presentation of opioid withdrawal
- Lacrimation
- Pupillary dilation
- Yawning
- Diaphoresis
- GI symptoms
How do NSAIDs affect lithium
Decrease lithium excretion–> increased lithium concentration
What is akinesia
Extreme case of psychomotor retardation in which an absence of movement is observed
What are automatisms
Spontaneous involuntary movements that occur during an altered state of consciousness and can range from purposeful to disorganized
What differentiates pressured speech from rapid speech
Pressured speech is usually uninterruptible and patient feels compelled to continue
What are the 6 main types of delusions
Grandeur Paranoid Reference Thought broadcasting Religious Somatic
For how long must a person have symptoms for a diagnosis of schizophrenia to be made
6 months
What is psychodynamic psychotherapy
Psychotherapy focused on uncovering unconscious patterns originating in childhood experiences.
**May initially cause increased anxiety
What are the common side effects of the mood stabilizer Lamotrigine
Blurred vision, GI distress, Steve Johnson Syndrome [increase dose slowly to assess for rashes]
Why should Paroxetine be avoided in pregnancy
Causes fetal pulmonary hypertension
Which SSRI should be avoided in pregnancy due to risk of fetal pulmonary hypertension
Paroxetine
What are the sommon side effects of SSRIs
Sexual side effects, GI distress, agitation, insomnia, tremor, diarrhea
The risk of Serotonin Syndrome increases when SSRIs are used in conjunction with __________
MAOIs, illicit drugs, herbal medicines
What is the common side effect of venlafaxine
diastolic hypertension
What are the common side effects of Bupropion
decreased seizure threshold
What is the downside of Mirtazapine compared to other atypicals?
Weight gain and sedation
What is the advantage of Bupropion compared to other atypicals
minimal sexual side effects
What is the downside of Trazodone compared to other atypicals
Highly sedating, priapism
What is the concern side effect of Trazodone in men
Priapism
Which class of psych drugs has a risk of hypertensive crisis if taken with high-tyramine foods
MAO Inhibitors
What are the side effects of MAOIs
Sexual side effects, orthostatic hypotention, weight gain
Hypertensive crisis if taken with high tyramine foods
What is the characterization of unintentional scald injuries
Poorly defined and asymmetric would margins, nonuniform burn depth, splash marks
What are the characteristics of intentional scald injuries, e.g. from child abuse
Spared flexural creases, burns with sharp lines of demarcation, uniform depth, lack of splash marks
Desmopressin is given preoperatively in which patients to prevent exessive bleeding
Pts with hemophilia A
What does IV colloids include
Fresh Frozen Plasma and albumin
What is Gaucher’s disease
Autosomal recessive genetice disease most common in Ashkenazi Jews characterized by Glucocerebrosidase deficiency leasdinto glucocerebroside accumulation in macrophages
What are the DSM-V Psychotic Disorders
- Schizophrenia
- Schizophreniform
- Brief Psychotic Disorder
- Delusional Disorder
- Schizoaffective Disorder
What is the average age of onset of schizophrenia in males and females respectively
21 yo males
27 yo females
What is the current conceptualization of the pathogenesis of schizophrenia
one or more neurodevelopmental defects causing impaired circuitry connecting cortical and subcortical regions (esp. thalamus & striatum) –> disruptions in cognitive processes
What is the potential pathogenesis of positive symptoms in schizophrenia
Prefrontal cortex deficit plus environmental stress causes excessive mesolimbic dopamine activity
What is the potential pathogenesis of negative symptoms in schizophrenia
Prefrontal cortex deficits associated with decreased mesocortical dopamine activity
What genetic abnormalities are commonly seen w/ schizophrenia
Increased nonsense mutations
Overlap with autism & bipolar disorder
What are some known environmental risks for the development of schizophrenia
- maternal infection
- ob complications
- inflammation
- cannabis use
- immigration
What are the positive symptoms commonly associated with Schizophrenia
- Delusions
- Hallucinations
- Disorganized thoughts and behaviors
What is Capgras Syndrome
delusion that people have been replaced by imposters
What is latency of response
A type of thought disorder characterized by delayed response to questions
What is thought blocking
A type of thought disorder characterized by thoughts being lost or interrupted by a hallucination
What is neologisms
A type of thought disorder characterized by made up words
What is clanging
A type of thought disorder characterized by rhyming without meaning
What is perseveration
A type of thought disorder characterized by repetition of words and phrases
What is echolalia
A type of thought disorder characterized by repetition of the examiner’s words
What are some examples of disorganized behavior symptoms
- Catatonic behaviors
- Stereotypy (repeated, non-goal directed ie rocking)
- Mannerisms (grimacing, bizarre movements, gestures)
- Incongruous affect
What are the negative symptoms associated with schizophrenia (5 A’s)
-Avolition/apathy
-Alogia (poverty of speech)
-Anhedonia (inability to experience pleasure)
-Asociality
-Affect (lack of, blunted or flat)
Others: lack of social skills, lack of spontaneity/humor, lack of self care
What are the cognitive symptoms associated with Schizophrenia
- deficits in attention
- impaired verbal memory
- impaired speed of processing
- impairment in executive functions
- lack of abstract thinking
Which symptoms of schizophrenia are most responsive to medication
Positive symptoms
Negative and cognitive symptoms do not respond as well to medications
What defines schizophreniform disorder
psychotic symptoms characteristic of schizophrenia present for >1 month but <6 months
How many patients with schizophreniform develop a diagnosis of schizophrenia or schizoaffective disorder
2/3
What defines delusional disorder
Systematized typically non-bizarre delusions w/o thought disorder or negative symptoms
*hallucinations rare
What is schizoaffective disorder
Evidence of persistenct psychotic symptoms in the absence of prominent mood symptoms for at least 2 wks
**meets criteria for mood disorder and schizophrenia
What is the difference between schizoaffective disorder and mood disorder w/ psychosis
In schizoaffective disorder, psychosis occurs w/ mood episode and in absence of mood disorder
**psychotic mood only has psychosis w/ mood symptoms
What is brief psychotic disorder
psychotic symptoms for >1 day but <1 month with full recovery
*typically related to marked stressors
How common is psychosis in Alzheimer’s disease
40% of pts w/ alzheimer’s will have psychosis at some point
What are some medical conditions that can cause psychosis
- Dementia/delirium
- Temporal lobe epilepsy
- tumor/stroke/TBI
- hypothyroidism (myxedema madness)
- Acute Intermittent porphyria
- Wilson’s disease
- B12 deficiency
- Neuro-syphyllis, hiv
- SLE
- Heavy metal poisoning
What is the common distinction between first generation antipsychotic medications and second generation antipsychotic medications
First generation: “neuroleptic”, older, primary MOA is D2 antagonism
Second generation: newer, fewer EPS, combination serotonin (5HT2A) antagonist & dopamine antagonist
How do amphetamines affect schizophrenia
Increase symptoms b/c amphetamines release DA
What are the side effects of typical (or first generation) antipsychotics and their activity on which pathways that cause these side effects
- Reduction of positive symptoms (goal of treatment) –> mesolimbic D2 antagonist
- Worsening of cognitive & negative symptoms –> mesocortical D2 antagonist
- EPS, psuedoparkinsonism, tardive dyskinesia etc. –> Nigrostriatal D2 antagonist
- Hyperprolactinemia –> Tuberoinfundibular D2 antagonist
What extrapyramidal symptom may occur in the first few days of typical (first generation) antipsychotic use
Acute dystonic reaction - distressing, sustained contraction of the neck, mouth, tongue
What extrapyramidal symptom may occur after several weeks of typical (first generation) antipsychotic use
- Akathisia - subjective restlessness, inability to sit still
- Drug induced parkinsonism
What is Tardive Dyskinesia
abnormal involuntary movements of the mouth, tongue, trunk, extremities related to long term treatment with antipsychotic medication of metoclopramide
What are the signs of neuroleptic malignant syndrome
mental status change, rigidity, fever, dysautonomia, tachycardia, HTN, increased creatinine kinase
What is the management of neurleptic malignant syndrome
Stop antipsychotic
Supportive care
Dantrolene for muscle rigidity
Bromocriptine or amantidine (DA agonist) if resistent to treatment
What are the second generation antipsychotics
- Risperidone
- Paliperidone
- Olanzapine
- Ziprasidone
- Aripiprazole
- Clozapine
- Asenapine
- Iloperidone
- Lurasidone
What is the general side effect profile of second generation antipsychotics
Weight gain and metabolic adverse effects (hypertriglyceridemia, hyperglycemia, increased diabetes risk, increased cardiovascular/cerebrovascular risk)
At what points in treatment with second generation antipsychotics do you assess BP, fasting glucose, and fasting lipid panel
At start, 12 wks into treatment, 12 months into treatment
*lipids again at 5 yrs
Which antipsychotic is superior to other antipsychotics in the treatment of refractory patients
Clozapine (second generation) but it is reserved for refractory patients due to risk of agranulocytosis
Which second generation antipsychotic carries a risk of agranulocytosis
Clozapine
What is the main side effect of concern with Risperidone
Hyperprolactinemia, dose dependent EPS
What is the main side effect concern of Olanzapine
Obesity and metabolic effects
What is the main side effect concern of Quetiapine
sedation
**low EPS risk
What is the main side effect concern of Ziprasidone
Prolongation of QT interval
**lower wt gain and metabolic effects
What is the main side effect concern of aripiprazole
Akathisia
Which second generation antipsychotic lowers the seizure threshold
Clozapine
Which second generation antipsychotics have the lowest risk of weight gain
aripiprazole, ziprasidone
Which second generation antipsychotic is shown to decrease suicide risk
Clozapine
What physical exam finding should raise the suspicion for Factitious disorder (Munchausen) in a psychiatric pt
Multiple surgical scars
What physical exam finding should raise the suspicion for anticholinergic toxicity in a psychiatric pt
Dry, flushed skin
For patients with high addicition risk or who do not want to be on stimulants what medications options are available to treat ADHD
Atomoxetine, a nonstimulant norepinephrine reuptake inhibitor
What is the first line management for PCP-related agitation and psychosis? Second line?
First line: benzodiazapines (typically paraenteral e.g. lorazepam, diazepam)
Second line: antipsychotics
Which Benzodiazepines are preferred in patients with liver disease
LOT: lorazepam, oxazepam, temazepam
What are the most commonly used benzodiazapines used in alcohol withdrawal?
Diazepam, Lorazepam, and chlordiazepoxide
*chlordiazepoxide does NOT come in IV form
What is the function of Granulosa cells
primarily in the ovarian stroma, granulosa cells convert testosterone to extradiol via aromatase and secrete inhibin (which typically inhibits FSH)
What are the common hormonal lab findings of granulosa cell tumors
increased inhibin
increased estradiol
After surgical removal of a granulosa cell tumor, what lab value can be used to monitor recurrence
inhibin - increased in tumor recurrence
What is the management of sternal dehisence (separation of sternal bone fragments following surgery typically cardiac)
This is a medical emergency.
Urgent surgical exploration and repair is warranted to prevent cardiac injury
What is the most common cause of osteomyelytis in children
Staph aureus
Which SSRI/SNRI has should benefit in treating pts with diabetic neuropathy
Duloxetine (SNRI)
Which have analgesic effects as well as antidepressant effects: SSRIs or SNRIs
SNRIs
What is the antibiotic regimen of choice for the treatment of postpartum endometritis
Clindamycin + gentamicin due to polymicrobial nature of infection
What is the first line pharmacotherapy for fibromyalgia
Tricyclic antidepressants (e.g. amitriptyline)
How do you define epileptiform activity on EEG
at least 1 m^2 brain region spike + slow wave
How do you define epilepsy
2 or more unprovoked afebrile seizures
What is a method a parent can use to differentiate absent seizure from day dreaming
Response to tactile stimuli. Children having an absent seizure will not respond to tactile stimuli
What are the clinical characteristics of N. gonorrhoeae conjunctivitis of the newborn?
Symptoms w/in 1 week of birth; bilateral purulent conjunctivitis & marked eyelid edema, more severe than chlamydia; conjunctival injection; chemosis (conjunctival edema)
What are the clinical characteristics of Chlamydial conjunctivitis of the newborn
symptoms w/in 1-2 weeks of birth; eyelid swelling; relatively scant watery discharge
What are the clinical characteristics of HSV conjunctivitis of the newborn
Symptoms w/in 2 weeks of birth; conjunctival injection, watery/serosanguinous eye discharge, vesicular eruptions around eyes
What are the possible complications of untreated N. gonorrhoeae conjunctivitis of the newborn if left untreated
Corneal ulcerations, scarring, blindness
What are the prophylactic methods against N. gonorrhoeae conjunctivitis of the newborn
Screening and treatment of at risk mothers; erythromycin eye drops at birth
**silver nitrate drops may be used but carry a risk of chemical conjunctivitis thus are not used in the U.S.
What is dacryostenosis
Nasolacrimal duct obstruction
How is primary amenorrhea or delayed puberty defined
A) absence of menses by age 16 w/ secondary sexual development present, or
B) absence of secondary sexual characteristics by age 14
What is the differential for primary amenorrhea with an absence of secondary sexual characteristics
- Primary ovarian insufficiency (multiple etiologies e.g. Turner syndrome, hx damage from radiation/chemo, etc.)
- Central hypogonadism (undernourishment, stress, hyperprolactinemia, exercise, CNS tumor, cranial irradiation, etc)
- Kallmann syndrome
- Constitutional growth delay
What is the differenital for primary amenorrhea with the presence of secondary sexual characteristics
- Mullerian agenesis
- Imperforate hymen
- Complete androgen insensistivity
- Congenital adrenal hyperplasia
What is the first step in primary or secondary amenorrhea
Pregnancy test
Is the uterus present or absent in Turner Syndrome
Present
What are the classic features of Turner Syndrome
Streak ovaries Shield chest amenorrhea (w/ uterus present) webbed neck aortic coarctation bicuspid aortic valve
Primary amenorrhea + uterus present + elevated FSH suggests a diagnosis of ….
Primary ovarian insufficiency - get karyotype to assess for Turner syndrome (45,X)
What is Mayer-Rokitansky-Kuster-Hauser syndrome
Mullerian agenesis
What is affected in Mullerian agenesis
absence of upper third of vagina
absence of cervix
absence or abnormalities of uterus
**ovaries are not affected
What is the beneficial effect of hydroxyurea in the management of sickle cell
Increase in fetal hemoglobin production
What is the dose limiting side effect of hydroxyurea
Myelosuppression
For which population does a PPD/TST of >/= to 5 mm induration warrant treatment
- HIV positive pts
- Recent contacts w/ known TB
- Nodular or fibrotic changes on chest x-ray consistent w/ previously healted TB
- organ transplant recipients/immunocompromised
For which population(s) does a PPD/TST of >/=10 mm induration warrant treatment
- Recent immigrants (<5 yrs) from TB endemic area
- injection drug users
- residents/employees of high risk settings
- co-morbid conditions that increase TB reactivation risk (diabetes, leukemia, ESRD, malabsorption)
- Children <4
At what PPD/TST induration should a healthy person be treated for TB
> /= to 15 mm
What is the Centor Criteria used for and what are the features of the Centor Criteria
Used to determine whether to treat ADULTS empirically for strep pharyngitis
Centor Criteria:
-fever by hx
-tender anterior cervical lymphadenopathy
-tonsillar exudates
-absence of cough
Which electrolyte abnormality can lead to flaccid paralysis
Hyperkalemia
**hypercalcemia can also cause weakness
On which neurotransmitters does bath salts work
Increases release or inhibits reuptake of norepinephrine, dopamine, and serotonin
What is the initial treatment for myasthenia gravis
Acetylcholinesterase inhibitors (e.g. pyridostigmine)
What is required for a definitive diagnosis of sarcoidosis
clinical symptoms and Chest x-ray with characteristic findings and biopsy demonstrating noncaseating granulomas
What is presbycusis
sensorineural hearing loss that occurs with aging
What is the medical treatment for cancer related anorexia/cachexia
Progesterone analogues (such as mergestrol acetate) or corticosteroids
**synthetic cannabinoids have not sufficiently studied - benefit only in HIV cachexia
What is the first line medical treatment for diffuse esophageal spasms
Calcium channel blockers (e.g. diltiazem)
**Alternates Nitrates or tricyclics
What is the treatment for Gullian Barre
IV Ig or plasmapheresis
What CSF analysis results are expected in a patient with Gullian Barre
Elevated protein but otherwise normal
At what systolic BP will loss of consciousness occur
50
What ocular finding may be present in opiate overdose
Pinpoint pupils
What laboratory findings may suggest over-diuresis
elevated bicarb and elevated creatinine
What is Erythema Infectiosum
Slapped cheek disease or Parvovirus B19
In Erythema Infectiosum (Parvovirus B19) how does the timing of the rash and the fever relate
Both occur at the same time
What are the 2 severe and feared complications of Parvovirus B19 (erythema infectiosum) in special populations
Hydrops fetalis in pregnant women
Aplastic crisis in kids with hemoglobinopathies (e.g. Sickle cell)
What are the “four c’s” of measles
Cough, coryza, conjunctivitis, & Koplik spots
How does the rash in measles spread
From head down
What is a long term complication of measles that may take years to develop
Subacute sclerosing panencephalitis
How does the rash in ruebella spread
from head down
What is the primary feature of the ruebela prodrome
Generalized tender lymphadenopathy
What type of rash is common in measles
Erythematous morbilliform rash
What is the clinical criteria for typical Kawasaki’s disease
> /=5 days of fever + 4 of conjunctivitis, mucositis (e.g. strawberry tongue), rash, extremity edema /desquamation, lymphadenopathy
What are the symptoms of Pellagra (niacin B3 deficiency)
- diarrhea
- dermatitis
- dementia, depression, distraction
- death
What is the most common primary immune deficiency
Selective IgA deficiency
What are the clinical features of selective IgA deficiency
- usually asymptomatic
- recurrent sinopulmonary & GI infections
- associated w/ autoimmune disease and atopy (eg asthma, eczema)
- anaphylaxis during transfusions
How is selective IgA deficiency diagnosed
- low or absent IgA
- normal IgG, IgM, and B cells
Why do patients with selective IgA deficiency need a medical alert bracelet
Anaphylaxis occurs during blood transfusions
What is hyposthenuria
The inability of the kidneys to concentrate urine
**can be a complication of sickle cell trait
What serum sodium value is expected in central diabetes insipidious
elevated serum sodium
What are the typical GU symptoms of bladder cancer in older adults
- Hematuria
- hydronephrosis
- voiding symptoms
What is Cushing’s triad
elevated blood pressure, bradycardia, and irregular respirations that are suggestive of increased intracranial pressure
What is Opsoclonus-myoclonus syndrome
Paraneoplastic syndrome that occurs frequently with neuroblastoma in younger children (6mo-3yrs) and is characterized by ataxia, myoclonus (jerky movements) and opsoclonus (jerky movements of eyes)
