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internal medicine Flashcards

0
Q

half lives of drugs

A
  • 5 half lives of a new drug if no loading dose, drug level will be 97% of steady state, and same to stop drug and have it clear
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1
Q

first pass effect

A

oral drugs absorbed via GI tract and pass into the portal vein, goes to the liver for first metabolism
*these drugs require much higher oral dose to be as effective as IV

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2
Q

warfarin interactions increase the INR

  • TMP/SMX *propafenone
  • erythromycin *azole antifungals
  • amiodarone *metronidazole
  • any antibiotic can affect INR
A

as they decrease vitamin producing bacteria in the intestine

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3
Q

Drugs that cause hyperkalemia

  • ACE/ARBs
  • spironolactone & other K sparing diuretics
  • heparin
A
  • can be worse hyperK+ if these drugs are combined as in CHF tx
  • *trimethoprim (Bactrim) can cause and greatest risk is use if high dose bactrim in the elderly
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4
Q

Statin interactions

  • most life threatening reaction=rhabdomyolysis
  • greatest risk is combo with drugs that slow their metabolism:
  • fibrates -amiodarone
  • emycin
A

-cyclosporine -protease inhibitors
_azole antifungals -verapamil, diltiazem
*grapefruit will markedly raise blood levels of statins
*lovastatin & simvastatin most affected
**pravastatin least affected-its metabolized by kidneys

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5
Q

gihydropyridines :
-nifedipine
-amlodipine
cause:

A

edema

constipation

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6
Q

SSRIs cause

A

hyponatremia
sexual dysfxn
may cause platelet dysfunction

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7
Q

Topiramate causes

A

non anion gap acidosis

kidney stones

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8
Q

HCTZ causes

A

hypoK+
hyper Ca++
hypo Na+
high uric acid

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9
Q

NSAIDS increase risk of

A

symptomatic CHF in pt at risk of CAD

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10
Q

bisphosphonates can cause

A

muscle and joint pain

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11
Q

PPIs may inhibit

A

antiplatelet activity of plavix

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12
Q

Risk factors for primary osteoporosis:

  • hx of fragility fracture in 1st degree relative
  • weight less than 127# or BMI<21
  • alcohol intake of 2 or more drinks/day
A
  • menopause before age 40
  • current or prior steroid use: >3 months at dose of 5mg/d or more of prednisone
  • smoking
  • personal hx of fragility fracture
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13
Q

patients with the following should be screened for osteoporosis regardless of age or gender:

  • GI dz: UC, crohns, celiac, gastric bypass, malabsorption
  • endocrine: hyperparathyroid, cushings, hypogonad, hyperthyroid
  • anorexia nervosa
A
  • RA, SLE
  • prolonged bedrest or wheelchair bound
  • medications: glucocorticoids, thyroxine over replacement, lithium,phenobarbital, phenytoin, cyclosporine
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14
Q

3 most accurate methods of diagnosis of osteoporosis:

A
  • quantitative CT
  • dual photon absorptiometry (DPT)
  • dual energy x-ray absorptiometry (DEXA)
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15
Q

Universal recommendations for all patients with osteoporosis:

A
  • dietary calcium 1200-1500mg/d
  • vitamin D 800-1000 IU D3 daily >age 50
  • regular weight bearing exercise
  • fall prevention
  • avoid tobacco and excess alcohol
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16
Q

drug tx of osteoporosis

A

HRT
bisphosphonates
calcionin salmon-nasal spray
raloxifene (evista)

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17
Q

potential S/E of bisphosphonates

A
  • osteonecrosis of the jaw-especially IV-caution in those with jaw problems or upcoming extensive dental surgery
  • severe muscle/joint/bone pain
  • Odd fractures of long bones-femur
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18
Q

most serious consequence of osteoporosis

A

fractures

mortality due to hip fractures is 20% within the first year

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19
Q

other complications of hip fractures

A
  • DVT occur in 48% without anticoag. , 25% with anticoagulants
  • pressure ulcers
  • constipation, fecal impaction
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20
Q

geriatrics-diagnosis of “frailty” if 3 or more of the following are present:

A
  • unintentional loss of 10# or more/ 1 year
  • exhaustion due to lack of endurance
  • decreased hand strength
  • walking slowly
  • reduced activity
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21
Q

geriatric patients need interval assessment of function which is related to longevity:

  • ADLs
  • instrumental ADLs
  • cognition
A
  • hearing
  • vision
  • gait & balance
  • nutrition
  • driving ability
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22
Q

gait & balance assessed well with timed “get up and go test”
*get up from chair, walk 10 feet, then turn around and come back to sit.. If takes >20 seconds they are high risk for falls, 10-20s is moderate risk

A

**performance on vision, hearing, gait assessment will give adequate assessment of pts ability to operate a vehicle

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23
Q

Malnutrition is diagnosed in any of these circumstances:

  • unintentional wt loss of 10# or more/6 months
  • BMI<3.8
A
  • cholesterol <160

* any vitamin deficiency

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24
Q

major predictor for fracture from a fall is

A

osteoporosis

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25
Q

risk factors for falls

  • age
  • females
  • hx of falls
  • rugs, untidy, dim lighting in the home
A
  • poor vision
  • orthostatic hypotension *cardiovasc. disease-syncope
  • unsteady gait *psychotropic drug use
  • cognitive impairment
  • musculoskeletal disease
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26
Q

psychotropic drugs that increase the risk of falls in the elderly:

A
  • benzodiazepines
  • antidepressants
  • neuroleptic agents
  • BP meds
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27
Q

ALL forms of physical restaints in the elderly

A

INCREASE the risk of serious falls and injuries, so avoid if possible

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28
Q

decubitus ulcers

  • main factor is sustained pressure over a prominent bone
  • moist environment increase risk-ie urinary incontinence
  • decub in NH patients increase risk of mortality- osteomyelitis and bacteremia/sepsis
A
  • malnutrition increases risk-plus they wont heal !
  • most common sites:heel, trocanter, sacrum, iliac crest
  • if arterial/venous insufficiency they will not heal unless local blood flow is corrected-usually surgery
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29
Q

decubitus ulcer staging:

I: non blanching erythema
II: partial thickness skin loss-small superficial ulcer
**stage I & II heal quickly

A

III: full thickness skin loss
IV: loss of tissue down to muscle, tendon, or bone
*III & IV take months to heal
*tx: rotate side to side every 2 hours, saline cleaning is best, nutrition and correct all risk factors you can

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30
Q

decreased immunity is age related, thats why

A

herpes zoster and reactivation of TB is often seen in the elderly

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31
Q

General rules for medication in the elderly:

  • start meds low dose-usually 1/2 the dose for non elderly
  • any adverse event should be assumed as drug related
  • look at med list for atypical antipsychotic if pt is falling as is most common causes of falls in NH
A

*taper BDZs over 3-6 months after switching to an equivalent dose of a water soluble BDZ (oxazepam-slower onset and less addictive)

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32
Q

endocrine in the elderly:

  • only specific hormonal change that occurs w aging is ovarian failure
  • pineal gland does not produce melatonin normally-so poor sleep and insomnia seen-can try melatonin at hs
A
  • some have reduction of clearance of thyroid hormone so replacement may be with lower dose (TSH increases w age, but if no decrease in T4 dont treat for hypothyroidism)
  • Vit D defic. is common-if age 70 or older take Vit D3 600 IU daily and 1500mg calcium daily over age 65-check 25(OH)2-D
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33
Q

diabetes in the elderly:

  • insulin sensitivity & production declines with age
  • hypoglycemia more often presents as cognitive impairment in the elderly, rather than tremors or sweats-glipizide causes less hypoglycemia
A

*caution w metformin due to high prevalence of renal insufficiency and they are more prone to develop lactic acidosis, DO NOT give to any patient w a CrCl

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34
Q

Hyperthyroidism in the elderly

*typical hyperthyroid symptoms are less seen in the elderly!

A

Apathetic hyperthyroidism is often seen:

  • apathy, fatigue
  • tachycardia, atrial fib
  • anorexia, weight loss
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35
Q

HRT

A

do not give women >50 old combination HRT as it increases their risks for stroke, heart disease ,breast cancer, venous clotting and gall stones

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36
Q

delerium-confusion with altered consciousness
*main features: abnl attention span (easily distracted), disorganized thinking-may have hallucinations, altered consciousness- incr or decr mental activiy- these features fluctuate during the day an usually worse at night

A
  • common causes: drugs, esp demerol, NSAIDs, any new antibiotic, benadryl, any cv drug or antidepressant, antiemetics, baclofen, H2 blocker, sleep inducer, herbal preps
  • any acute discontinuation of alcohol, BDZ, SSRI, pain med may cause withdrawal delirium
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37
Q

differentiate delirium from “sundowning”

A

sundowning is a disturbance in behavior that PREDICTABLY occurs in the evening in some who live in chronic care environment

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38
Q

Dementia-progressive deterioration of cognition that is insidious and chronic, but no altered consciousness as with delirium

*presents as:

A
  • difficulty learning & remembering new information
  • decreased problem solving of simple and complex tasks
  • decline in spatial organization-they get lost
  • trouble w impulse control-unusual behavior
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39
Q

differentiation of depression vs dementia in the elderly

A
  • depressed patients often complain of memory loss but demential patients brought in by family or friends with this complaint
  • depressed pt have depressed affect & slowing of completion of Mental exams, demented patients have more normal affect and try harder,
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40
Q

score of <24 on Mini mental status exam is consistent with

A

dementia/delirium

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41
Q

First line tx of alzheimers

A
  • cholinesterase inhibitors-aricept, cognex, exelon, razadyne
  • best results are in mild-mod alz. dementia
  • other causes of dementia may improve on these med
  • CIs can be combined with Namenda and combo is better than CI alone. STOP CIs in pt w severe dementia
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42
Q

Depression in the elderly

*depression is most common mental problem in the elderly

A
  • Tx: 1st line-SSRIs
  • start with 1/2 dose and increase slowly
  • watch for side effects: hyponatremia & tremors
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43
Q

Insomnia in the elderly

*assoc with worsening HTN, heart dz, lung dz, urinary incontinence, chronic pain, depression

A
  • meds assoc w insomnia: corticosteroids,BB,beta agonists, stopping seditives or pain meds
  • best tx is sleep hygiene/behavioral
  • Rozerem (ramelteon) not assoc w any major S/E and good choice in elderly
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44
Q

RLS-Restless leg syndrome

  • hallmark-leg discomfort +/- paresthesias at rest, relieved immediately with movement
  • usually pain is deep seated and localized below the knees
  • worse in the evening and night
A
  • primary RLS or caused by:iron def anemia(even without anemia), dialysis, diabetic neuropathy, MS, Parkinsons, pregnancy, etc
  • *always check a ferritin level to rule out iron deficiency
  • tx: dopamine agonists, levodopa
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45
Q

Dizziness
*common, not a normal consequence of aging
good hx to see if which of these they are describing:

A
  • vertigo
  • nonspecific dizziness
  • disequilibrium
  • presyncope
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46
Q

vertigo

A

spinning, whirling, moving of self or the environment that is worse with head movement and occurs in spells (days to weeks), then eventually resolves

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47
Q

Nonspecific dizziness

A

unable to characterize better, sometimes lightheaded is used to describe

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48
Q

Disequilibrium

A

imbalance with standing and walking, expecially with turning

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49
Q

Presyncope

A
  • almost fainting or blacking out with either standing or sitting (not laying), possible assoc with sweating, a sensation of warming, visual blurriness, and nausea
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50
Q

Benign Positional vertigo

A
  • recurrent (lasts for weeks in spells), short lived (<1 minute) w episodes of vertigo w changes in position. N/V not uncommon.
  • see more in elderly and consider Giant cell arteritis
  • Dix Hallpike is + if nystagmus in supine/upright position
  • tx-Epley or semont maneuver
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51
Q

walking more than 4 hours a week

A

dramatically decreases cardiovasc hospitalizations in persons >65

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52
Q

Isolated systolic HTN in elderly

-common

A 
*meds 1/2 usual start dose:
thiazides- esp chlorthalidone over HCTZ
dihydropyridine CCBs
ACE/ARBs
**avoid BB for this as not as effective and incr mortality
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53
Q

CHF in the elderly

*#1 cause of hospitalization in the elderly

A

Tx: diet, diuretics and ACE inhibitors

  • *NSAIDS are impt precipitant of CHF in elderly
  • mortality benefit: ACE, BB, spironolactone
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54
Q

urinary incontinence in the elderly

  • common but is always considered a pathologic condition and is not a normal consequence of aging!
  • normal age related changes: decreased flow rate and bladder capacity, increased residual volume
A

Urge-leakage w the feeling of urgency
Stress- leak assoc w incr abd pressure-cough, sneeze
Mixed- leak w both above
Incomplete bladder emptying-leak after voiding

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55
Q

urge incontinence
-related to overactive bladder-caused by uncontrollable bladder contractions (detrusor Instability)-usually due to CNS problem-loss of communication frontal lobes and micturition center in the brainstem

A

*tx-bladder training, oxybutynin if needed, Kegels also help

**remember anticholinergics can precipitate acute angle glaucoma

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56
Q

Stress incontinence

*urethra cant maintain the pressure gradient when intra abd pressure is increased-cough…

A

*assoc w :mult vag births, pelvic surg, postmenopause, males post prostatectomy
*tx: behavioral-esp kegels, pelvic floor physical therapy
surgery high cure rate but high risk of complications
*No effective drug treatment

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57
Q

fecal incontinence

A

usually due to fecal impaction and secondary overflow incontinence in the elderly

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58
Q

BPH

  • does not increase risk of prostate cancer
  • s/s: frequency, hesitancy, difficult start and stop stream, urgency, nocturia, bladder CA, cystitis
A
  • 2 tests must be done: digital rectal exam, urinalysis
  • PSA levels increase as size of prostate increase, so less specific if has BPH
  • tx only if signif affects or outlet obstr, hydronephr. or AKI
  • alpha blockers or 5 alpha reductase inhibitors
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59
Q

ED - impotence

*ED that occurs in >75% of sexual encounters

A

Organic causes: neurogenic, vascular, hormonal, normal aging
Medications:SSRI, BB, thiazide diuretics, spironolactone
Psychogenic: acute onset, younger patient, continue to have nocturnal & morning erections, but libido is lost

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60
Q

ED due to neurogenic causes

A
  • Diabetes,MS,ALS, parkinsons
  • surgeries esp prostate surgery
  • cyclists who spend >3 hrs/week on bike - pudendal nerve pressure
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61
Q

vascular causes of ED

A
  • diabetes and/or cardiovasc dz

* pelvic frx, surgery, inflammatory conditions

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62
Q

Hormonal causes of ED

A
  • often has loss of libido
  • space occupying lesion- gradual onset frontal HA or vision change
  • decreased androgens-hot flash, decr need to shave
  • hypothyroid-fatigue, wt gain, dry skin, constipation
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63
Q

tx of ED

A
  • sildenafil (viagra) PDE5 inhibitors, also cialis, etc-all have vasodilator properties
  • cialis-one specific s/e is back pain
  • all PDE5 risk of hearing loss with any of these drugs
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64
Q

decreased hearing is age related

A
  • age related sensorineural hearing loss
  • bilateral
  • loss of higher frequencies
  • hearing aids can help
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65
Q

Physicians duty to the patient is based on 3 principals -basis for all ethical interactions

A
  • Beneficence-duty to act in best interest and welfare of pt &health of society
  • Nonmaleficence-duty to do no harm to the patient
  • Respect-for pt autonomy, make free, non-coerced choices
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66
Q

Patients right to accept or refuse health care is based on these 3 principles:

A
  • personal autonomy
  • personal liberty interest under the constitution
  • common law right of self-determination
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67
Q

Informed consent

A

*the willing acceptance of medical intervention-after adequate disclosure by the physician- of the nature of the intervention and all the risks and benefits

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68
Q

Medical records

A
  • physical chart belongs to hospital or physician

* information in the chart belongs to the patient

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69
Q

advanced directive

living will is more focused form of advanced directive

A

means by which patient have for stating which treatments they would accept or decline if they lost decision making capacity

  • they have the right to change their minds and make changes
  • fluids/nutrition are ethically the same as any other treatments
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70
Q

decision making capacity

A

the ability to comprehend, evaluate, and choose among realistic options

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71
Q

Surrogate (proxy)
*person authorized to make decisions on behalf of incapacitated person, can also be a power of attorney-if not a family member, this person would supersede the family members.

A
  • decisions must promote the patients wishes & welfare

* surrogates authority ends when the patient dies

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72
Q

emergency situations

A

patient unable to express their preferences, the doctor may perform life-sustaining emergency procedures under the presumption that the alternative would be death or severe disability

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73
Q

Physician error

A

must disclose to patient any errors in judgement and procedure when the information is deemed “material to the patients well-being”
*always disclose errors

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74
Q

CPR and DNR

*only time CPR in not done is when there is an order stating DNR

A

3 considerations

  • whether or not CPR would be futile
  • preference of the patient
  • expected quality of life
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75
Q

confidentiality & public welfare

  • if the condition or disease of a patient can endanger other persons, the physician is legally and ethically obligated to report the situation to the appropriate parties
  • STD,motor vehicle operation, seizure, severe cardiac arrhyth.
A
  • those w serious, highly infective disease (TB, meningitis) should not be allowed to infect others. can be held against there will if threat to others. some dz may need to inform employer
  • adolescent consent for birth control is acceptable in all states
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76
Q

Brain death

A

loss of entire brain function, including brain stem

  • EEG not required
  • organs can be donated without patients prior consent if next of kin or surrogate gives permission
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77
Q

Perioperative cardiac evaluation

  • does pt need emergency noncardiac surgery? if yes, go to surgery.
  • does patient have an active cardiac condition?
  • unstable angina, recent MI (more than 7 days but
A
  • decompensated heart failure, significant arrhyth. , severe valve dz **if yes to above, do evaluation & tx before non cardiac surg.
  • is surgery low risk? if yes, proceed to surgery
  • do they have good functional capacity? if yes, proceed to surg.
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78
Q

Who gets beta blockers perioperative?

  • vascular surgery pt with positive pre-op stress tests
  • pt already on them for HTN, angina, arrhythmia
A

**high dose BB in perioperative without hx of dose titration in pt not previously on BB: do reduce primary coronary events BUT carry increased risk of mortality and stroke so are NOT recommended

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79
Q

low risk procedures

A
  • endoscopies
  • local biopsies
  • breast bx
  • vasectomy
  • cataracts
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80
Q

intermediate risk surgeries

  • carotid endarterectomy
  • intraperitoneal, intrathoracic surgeries
A
  • orthopedic surg
  • prostate surg
  • head and neck surg
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81
Q

major risk surgeries

  • aortic & major vascular surgery
  • cardiothoracic surgery
  • emergent major surgery
A

-long procedures w large blood loss and/or fluid shifts

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82
Q

Pre op screening labs

  • hematocrit: >age 65 w major surg, all surg expect major bld loss
  • electrolytes: Not unless reason to need to check
  • creatinine: >age 50, major surg, hypotension likely, nephrotoxic drugs need to be used
A

*glucose, liver, PT/PTT, UA-only if clinical s/s warrant

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83
Q

Pre op EKG

  • all vascular procedures
  • non vascular procedures:
A
  • men >45, women >55 -major surgical procedure
  • known cardiac disease
  • clinical eval suggests possible cardiac dz
  • diuretic use
  • DM, HTN, renal insufficiency
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84
Q

Pre op CXR

A

> age 50 for major surgery

suspected cardiac or pulm disease

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85
Q

Stents and surgery

*hold off on elective Non cardiac surgery if:

A
  • within 4-6 wks of bare metal stent placement
  • within 12 months of drug eluding stent if pt must stop anticoags
  • within 4 weeks of balloon angioplasty
86
Q

breast self exams

A

teaching pt to do these does NOT reduce their mortality from breast cancer , so most no longer recommend it

87
Q

Know that smoking cessation can exacerbate

A

colitis

88
Q

AAA screening

A

one time screening in men age 65-75 if they have ever smoked or men >60 if they had sibling or parent with AAA

*repeat screening not recommended

89
Q

prostate screening

A

men >50 yearly PSA and digital rectal exam

90
Q

cervical cancer screening

  • start pap age 21
  • when have 3 negative annual paps, continue every 3 years until age 60-65
A
  • if paps have been negative and no new sex partners, patients >65 do not need further testing
  • women age 30 + with ASCUS and high risk HPV types=>colposcopy
91
Q

Overdose management-general mgmt obtunded/coma pt:

  • airway-intubation unstable vitals or inability to maint. airway
  • IV D50 if glucose low
  • Thiamine 100mg IM or IV
  • ABG +/- carboxyhemoglobin , tox screen, salic/acetam levels
A
  • chemistries,CBC, measure serum anion& osmolar gaps
  • CPK if immobilized long time
  • CXR & supplemental oxygen
  • Naloxone IV if suspect opiate OD
92
Q

exam in toxic ingestions-“excited”, aggitation, restless, HTN, tachycardia hyperventilation, hyperthermia, mydriasis (dilated pupils) think these categories of drugs:

A
  • anticholinergics
  • sympathomimetics
  • hallucinogens
93
Q

anticholinergics

  • antihistamines
  • neuroleptics
A
  • TCAs
  • antispasmotics
  • plants: nightshade (belladonna) & jimson weed
94
Q

sympathomimetics

  • ephedrine
  • dextromethorphan
  • cocaine
A
  • amphetamines, meth
  • MDMA-ecstasy
  • 2CB
  • blue mystic
95
Q

Hallucinogens

A

LSD
mescaline
PCP
psilocybin-mushrooms

96
Q

toxic ingestions showing “depressed” obtunded state, hypotension, bradycardia, hypoventilation, hypothermia, miosis (constricted pupils)

A
  • cholinergics: organophosphate, carbamate insecticides
  • sympatholytics: clonidine
  • opiates: oxycodone, hydrocodone
97
Q

presentation of anticholinergic intoxication

  • Red - cutaneous vasodilation
  • Dry - anhidrosis
  • Hot - hyperthermia
A
  • Blind - mydriasis (dilated pupils)
  • Mad - hallucinations
  • Full - urinary retention
  • Antidote - physostigmine
98
Q

Isopropyl alcohol ingestion (rubbing alcohol)

  • CNS depressant
  • metab to acetone-sweet odor on breath
A
  • osmolar gap >35
  • abd pain, vomiting, some cardiac depression
  • tx:supportive, lavage if <2 hrs post ingestion
  • severe cases-hemo/peritoneal dialysis
99
Q

Methanol ingestion (wood alcohol)

  • contaminated moonshine
  • many s/s delayed >24hrs ie visual blurr to blindness
A

*toxic metabolites: formaldehyde, formic acid
**incr anion & osmolar gap
*tx: fomepizole, folic acid, immediate dialysis
(folic acid to increase metabolism of the formic acid)

100
Q

ethylene glycol

  • antifreeze
  • metabolized to very toxic oxalate. oxalate is indicated by calcium oxalate crystals in urine and hypocalcemia (oxalate chelates calcium)
A
  • suspect in pt acts drunk but no alcohol smell
  • HAGMA and incr osmolar gap
  • tx: fomepizole, bicarb for acidosis, calcium prn, immediate dialysis
101
Q

Opiate overdose

  • think if see:
  • obtunded
  • hypoventilation
  • decreased bowel sounds
A
  • constricted pupils
  • all incl ultram are assoc w seizures in intoxicated & esp patients on dialysis
  • methadone can incr QT interval=> torsades
  • tx: naloxone IV 2mg up to max 10mg, titrate to normal resp rate!
102
Q

salicylate overdose

  • *classic ASA overdose presentation:
  • tachypnea
  • mixed acid base: HAGMA + respiratory alkalosis
  • some tinnitus
A

*tx: activated charcoal with cathartic
serum/urine alkalinization with sodium bicarb
*severe cases: hemodialysis & charcoal hemoperfusion (salicylate levels >100)

103
Q

acetaminophen overdose
*90% metabolized by liver w 5% goes thru P450 system to hepatotoxic NAPQI. with large ingestion, not enough glutathione to metabolize it all and toxic metabolites persists

A
  • severe OD presents w N/V/D , the liver toxicity takes 24-48hours
  • often see coingestions with this OD
  • Tx: activated charcoal is beneficial if present within 4 hr of taking
  • 4 hr post ingestion level of acetaminophen >250=give N acetylcysteine (NAC) loading dose then 17 more every 4 hr
104
Q

alcohol-acetaminophen syndrome

  • chronic moderate to heavy alcohol use 2 fold effect:
  • cytochrome P450 system is cranked up=more NAPQI produced
  • amount of glutathione is decreased (cant detox as much)
A
  • if drinker takes even normal doses of acetaminophen can get severe hepatotoxicity or liver failure
105
Q

theophylline toxicity

*suspect if see COPD pt that has s/s: tremulous, tachycardia/ventricular arrhy, vomiting, +/- seizures and theo level >20

A
  • usually due to another drug they started: macrolide, quinolone, zileuton
  • tx:supportive and mult doses activated charcoal w cathartic, treat hypoK+,if too much vomiting use zofran + zantac
106
Q

cont tx theo toxicity:

  • seizure-diazepam
  • SVT-adenosine
  • stable vent arrhy-amiodarone
A
  • hypotension-alpha agonists - phenylephrine or norepinephrine (if these dont reverse hypotension
  • dialysis if seizures or vent arrhythmias is recommended
107
Q 
Lithium toxicity
>90% have mental status changes
*CNS s/s: poor memory, incoherence, disorientation
*N/ V/D
*parkinsonian movement disorders
A
  • get level of lithium, but symptoms do NOT correlate with levels
  • tx; gastric lavage (act. charcoal no help), restore fluids & lytes. hemodialysis in severe (level >3.5 or levels dont come down as expected)
108
Q

TCA overdose

  • *lipophilic and protein bound so large volume of distribution and can NOT be removed by dialysis
  • s/s:sedation, confusion, arrhythmias
A

*tx: activated charcoal w cathartic if within 2 hr ingestion
*EKG; tachy, PR, QT, QRS prolongation. QRS prolongation most closely correlates w degree of toxicity- use IV bicarb to keep serum pH 7.5-7.55, also lidocaine for arrhythmias
*benzodiazepam for seizures
*

109
Q

digoxin toxicity

  • narrow therapeutic index. levels do NOT correlate with toxicity, so pay attention to symptoms.
  • s/s: anorexia, N/V, abd pain, confusion, weakness, change color vision, scotoma, bradycardia w hypotension
A
  • common drugs that increase dig levels: diltiazem, verapamil, amiodarone.
  • tx: activ charcoal if within 2 hr, serious arrhy-Fab fragment tx**but this will rapidly reverse the presenting hyperK+ so dont tx it aggressively before Fab given
110
Q

cocaine

  • cardiotoxicity can occur regardless of route used
  • causes rhythm disturb (VF/VT) , ischemia, myocarditis, systolic dysfunction
A
  • *suspect in young pt with MI
  • seizures & strokes also common
  • *DO NOT USE BB- use nitroglycerine, CCB, BZDs are first line tx
111
Q

methamphetamine

  • causes release of epi, norepi, serotonin, dopamine
  • s/s: sweaty, severe agitation, psychotic, tachycardia, HTN
A
  • acute tx: IV BZDs for agitation, then antipsychotics (haloperidol)
  • *watch for rhabdomyolysis- monitor their BMP, CPK, serum lactate, liver enzymes and clotting times
112
Q

PCP - phencyclidine

*acute psychotic agitation, seizure, dystonia (incl laryngospasm)and dystonia can cause rhabdomyolysis, hypertensive crisis

A

*tx: calm environment

IV BZDs prn and supportive care

113
Q

Heroin (opiate)

  • CNS depressant
  • also see constricted pupils and decreased bowel sounds
A

be careful w naloxone in chronic heroin users due to risk of causing withdrawl if overshoot the dose

114
Q

MDMA (Ecstasy)

  • euphoria, loss inhibitions, incr intimacy and sexual arousal
  • OD can cause death, not benign drug
A
  • s/s:bruxism, anxiety, sweating, HTN, tachycardia
  • *hyperthermia and rhabdomyolysis-esp when they dance all noc
  • tx: activated charcoal if w in 1 hr, then BZDs. CCB for arrhythmia. NO BB! hypoNa+- water restrict if sz-use hypertonic saline
115
Q

Carbon monoxide

  • CO has 250X affinity to hemoglobin than O2=> tissue hypoxia
  • fetal hemoglobin with even higher affinity so tx preg aggressively
  • think in FIRES, car exhaust, winter in homes, generator use…
  • do carboxyhemoglobin level-hand held can quickly tell to r/o
A
  • levels 15-30% mild-moderate, >30% mod-severe, >50%often fatal (cherry red is rare)
  • tx: 100% oxygen, hyperbaric in pregnant & if >25% or any level with LOC or neuro deficit, end organ damage-esp acidosis
116
Q

Cyanide poisoning

  • *almond odor to breath
  • *lab draw : bright red venous blood
  • it binds to ferric molecule and blocks aerobic metabolism
  • dx is clinical
A
  • think in those in fire, taking sodium nitroprusside or amygdalin (derived from apricot and peach pits used in some herbals)
  • often signif. lactic acidosis
  • s/s:HA, tachycardia, tachypenia, progress quick to coma, cardiac arrhyth,tx next card
117
Q

Tx cyanide poisoning

  1. amyl nitrate under nose for 30 seconds
  2. 3% sodium nitrite IV
A
  1. sodium thiosulfate IV
118
Q

Lead (inorganic)

  • 3 scenarios to test for lead exposure, depends on when exposure occurred
A
  • ongoing exposure: whole blood lead level
  • after exposure: RBC protoporphyrin & zinc protoporphyrin levels are elevated several months
  • exposure years ago- 24hour urine lead after giving 1 gm of EDTA
  • organic lead is rapidly excredet and prior exposure not detected
119
Q

Insecticides - organophosphate & carbamate poisonings
*absorption is dermal

*organophosphate more toxic-bind irreversibly to acetylcholinesterase

A

*s/s: salivation, miosis (pinpt pupils), N/V/D, abd cramps, chest tight and gen weakness in some
Tx: decontaminate -showering w soap
-mod-severe s/s-atropine 1-2mg Iv, repeat q 5” prn. for organoph also give 2-protopam IV (2-PAM) Not for carbamate

120
Q

Benzodiazepine withdrawal

  • can be fatal
  • s/s: anxiety, tremulous, melancholy, psychosis, sz
A
  • time to withdrawal from last dose depends on half life
  • *up to 3 weeks for diazepam!
  • taper over long period of time
  • withdrawal tx w long acting BZDs
121
Q

Glaucoma

*insidious dz, prolonged elevated intraocular pressure causes progressive visual field loss due to optic nerve damage

A

2 TYPES

  • primary open angle
  • closed angle
122
Q

Primary open angle glaucoma

  • most common
  • they have progressive gradual loss of peripheral vision
  • risk factors: advanced age, family hx, african americans, incr intraocular pressure
A
  • cupping on funduscopic exam >50% of optic disc
  • screening: eye exam after age 40, repeat 3-5 yr no risk factors, 1-2 yr if risk factors
  • diabetics need yearly
123
Q

Closed angle glaucoma

  • primary closed angle -occular emergency
  • risks: > age 40, female, hyperopia (farsighted) , asian , family hx
  • rapid increase in intraocular pressure=>redness, severe eye pain, nausea, halos around lights, HA.
A
  • low-light conditions that precipitate pupillary dilation is assoc w onset
  • exam: fixed, mid-dilated pupil, decr vision, corneal edema, conjunctival hyperemia
  • immed ophth. referral for laser iridotomy,if not within hr see tx
124
Q

Retinal detachment

*flashes/streaks of light, showers of black dots, shade coming down or waving curtain in portion of visual field

A

risk factor: myopia- nearsightedness

*emergent referral

125
Q

Retinal artery occlusion-true ocular emergency!!

  • occlusion of central retinal artery-usually embolic
  • sudden, painless, unilateral blindness
A
  • see “cherry red spot” in the macula
  • tx to dislodge embolus: ocular massage, paracentesis of anterior chamber and carbogen inhalation to dilate vessels
  • while wait eye doc, trendelenburg, rebreathe into paper bag, massage globe 5sec pressure, 5 sec no pressure…
126
Q

Retinal vein thrombosis

  • sudden painless, near total loss of vision
  • “blood and thunder” fundus with multiple hemorrhages
  • Not an emergency- no acute treatment
A
  • causes:
  • HTN
  • polycythemia
  • Waldenstrom
127
Q

Macular degeneration

A

age related-leading cause of irreversible acquired legal blindness

  • risk factors: smoking, low levels of zinc & antioxidants
  • atrophic type - gradual loss of central acuity down to 20/400- peripheral vision is spared
  • neovasc type-some tx with laser photocoagulation
128
Q

Optic neuritis

  • inflam of optic nerve
  • freq presentation of MS
A
  • s/s: ocular pain,esp with eye movement
  • exam- normal initially, later pallor
  • tx: ophth urgent, IV glucoccorticoids improve vision more quickly
  • MRI for MS eval
129
Q

Ischemic optic neuropathy

A

feared complication of giant cell (temporal) arteritis

  • malaise, fever, wt loss, muscle aches, jaw claudication, elevated ESR
  • start corticosteroids presumptive before dx-dont delay tx
130
Q

suspect CN involvement in patient presenting with

A

sudden onset of painless double vision

131
Q

CN 6 - abducens

A
  • supplies lateral rectus eye muscles

* paralysis: cant move eye laterally

132
Q

CN 4 -trochlear

A

paralysis: eye deviated up and the head tilted toward the uninvolved side (Bielschowsky sign)

133
Q

CN 3 - oculomotor

2 branches

A
  • superior branch- superior rectus & levator palpebrae superioris (eyelid muscle)
  • inferior branch-parasympathetic - tonic constriction of the pupil
  • complete paralysis-eye deviates down and out,ptotic eyelid, dilated pupil
134
Q

alkali eye injury

  • tx delay of minutes can devastate the eye
  • immed profuse irrigation with lid eversion
A

check pH of tears to confirm adequate irrigation

135
Q

conjunctivitis

  • most common cause of red eye
  • viral (most common), bacterial, allergic
A
  • diffuse conjunctival hyperemia is nonspecific
  • preauricular adenopathy is suggestive of adenoviral cause
  • purulent discharge suggests bacterial
136
Q

eye symptoms of concern

A
  • decreased visual acuity
  • photophobia
  • ciliary flush-red near corneal limbus only in sun ray like pattern
  • eye pain
137
Q

anterior uveitis

can be assoc w spondyloarthropathies, sarcoid, lupus, vasculitis

A
  • autoimmune inflam of anterior eye structures

* *ocular pain, photophobia, ciliary flush=emergent referral

138
Q

periorbital cellulitis

*rapidly progressive cellulitis of periorbital area and may become orbital if not tx

A
  • warm, red, edema around the eye-KEY: exam normal extraocular eye movement without diplopia or pain with eye movement
  • *if disconjugate gaze, diplopia, pain w eye movement -ORBITAL-get periorbital CT or MRI and IV abx w staph and strep coverage
139
Q

conductive hearing loss

A
  • something blocks sound from entering the inner ear

- OM, eustacian tube blockage, otosclerosis (autosomal dominant ), TM perforation, cerumen…

140
Q

Sensorineural hearing loss

*either cochlear damage or CN VIII damage

A

*causes: viral, ototoxic drugs, meningitis, cochlear otosclerosis, Meineres, acoustic neuroma, aging (presbycusis)

141
Q

Presbycusis

A

1/3 pts older than 65

bilateral symmetrical sensorihearing loss in freq >2000 Hz

142
Q

Meniere disease

  • recurrent severe attacks vertigo
  • lasts hours
A
  • s/s: vertigo, vomiting, tinnitus, fullness in ear, progressive hearing loss (often one side)until deaf-at which time symptoms stop
  • tx acute:BDZs & antiemetics
    chronic: avoid caffeine & salt, diuretics
143
Q

aoustic neuromas (vestibular schwannomas)

A

benign very slow growing tumors of CN VIII

  • tinnitus, unilateral hearing loss, gait imbalance
  • dx:MRI
  • tx: radiosurgery or surgical resectin
144
Q

acute sensorineural hearing loss

A

immed eval and treatment, if ENT cant see immediate, start prednisone 80mg/d and ASAP eval

145
Q

Rinne test

  • air conduted sound louder than bone.
  • vibrating tuning fork-mastoid (bone) & in front of ear.
A
  • no conductive hearing loss-louder in front of ear testing
  • conductive hearing loss- louder on bone
  • sensorineural hearing loss- both are decreased, but air is perceived as louder
146
Q

Weber test

tuning fork middle of forehead

A
  • if sound perceived as stay in middle=normal or symmetrical hearing loss
  • if sound lateralizes there is either a conductive hearing loss-hear decrease that side or sensorineural loss in opposite ear
147
Q

Neuroleptic malignant syndrome
*idiosyncratic response to potent neuoleptics=> autonomic dysfunction, extrapyramidal symptoms, and HIGH fever (up to 106)

A
  • most common w: haloperidol, piperazine, thiothixene
  • persists up to 10 days after drug stopped
  • tx: stop drug, cool patient, oral dopamine agonists-#1 bromocriptine, others amantadine, dantrolene - to counteract the depletion of dopamine
148
Q

Serotonin syndrome

  • think if pt on serotonin drug ie SSRI-esp if on 2 or more of these drugs. occurs within 6 hours of starting a new or additional drug
  • serotonin can cause derangement in thermoregulation
A
  • s/s: anxiety, disorient, sweating, tachycardia, HTN, vomiting, diarrhea, HYPERTHERMIA can be marked. exam: rigidity, tremors, hyperreflexia
  • tx, stop drug, supportive, heart monitor, BZD for anxiety & tachycardia, resolves 24hrs, may need intub/paralysis,cyproheptadine is serotonin antagonist in severe
149
Q

Philadelphia chromosome

A
  • first chromosomal abnormality found to be assoc w malignancy
  • CML
150
Q

Burkitt lymphoma and leukemic analog ALL

A

chromosome 8 to 14 translocation

151
Q

Most leukemia and lymphoma patients have a

A

chromosomal abnormality

152
Q

during pregnancy, GI procedure of choice for work up is

A

EGD

endoscopic ultrasound if pancreatic dz

153
Q

2nd trimester of pregnancy

A

best time for GB surgery if needed

154
Q

3rd trimester pregnancy

A
  • hep E can cause fulminant hepatitis 20% fatal
  • fatty liver of pregnancy- very serious: assoc encephalopathy, hypoglycemia, preeclampsia, pancreatitis, DIC, renal failure
  • intrahepatic cholesatsis of preg-itching w incr AST & ALT
155
Q

asthma tx in pregnancy

A

Budesonide is ok steroid in pregnancy, others are cat C

156
Q

TB tx in pregnancy

A

DO NOT use PZA - causes birth defects

157
Q

warfarin and pregnancy

A

absolute contraindication

158
Q

normal cardiac findings in pregnancy:

A
  • S3-common in children and pregnancy (high cardiac output) S3 always abnormal in nonpregnant and >age 40
  • some pedal edema
  • flow murmur (and S3 gallops) and increased jugular venous pressure
159
Q

Abnormal cardiac issues in pregnancy:

  • atrial fib of new onset and pulmonary edema indicates need to rule out both Mitral stenosis and Secundum ASD!
  • secundum ASD itself is not a huge risk in pregnancy unless they develop atrial fib
A
  • maternal rubella infection during pregnancy-common cause PDA, supravalvular aortic stenosis, branch pulmonic stenosis, other congenital cardiac defects
  • 3rd trimester aortic dissection
  • valve surgery-porcine so no anticoag needed
160
Q

Not used as primary or secondary prevention of cardiac disease in women

A
  • hormone therapy
  • antioxidants
  • folic acid
  • aspirin in healthy women (is used STROKE prevention age 65+)
161
Q

NOT contraindicated in pregnancy:

  • heparin, LMWH
  • digoxin, quinidine, propranolol, CCB, labatelol, clonidine
  • sulfasalazine, beta-lactams, emycin , azithromycin, amp B
A
  • gentamicin
  • PTU
  • chlorpheniramine (antihistamine)
162
Q

UTI tx in pregnancy
*asymptomatic bacteriuria treat in all pregnant, neutropenic patients, diabetics and transplant patients pregnant or not!

A

NO CIPRO

  • do tx w amp, keflex, macrobid-step agalactiae, E. coli
  • listeria-think UTI in preg w negative urine culture-
  • postpartum fever-think strep agalactiae (group B)-post partum endometritis and bacteremia
163
Q

approx 5%pregnant have chlamydia trachomatis in genital tract

A

antibiotic ointment in newborns eyes does NOT treat this!

164
Q

syphilis is often asymptomatic in

A

pregnant females

165
Q

Gonorrhea in pregnancy

A
  • more likely to disseminate in pregnant women

* NB at risk of GC conjunctivitis- tx w eye ointment at birth

166
Q

viral infections in pregnancy that pose the greatest teratogenic potential: (especially if acquired 1st trimester)

  • CMV
  • varicella zoster-chicken pox
  • herpes simplex
A
  • rubella
  • HIV mother to fetus transmission risk 30%, reduced to <1% with 3 drug antiretroviral therapy (ART) ALL pregnant HIV need TX!!
167
Q

Toxoplasma gondii (parasite) in pregnancy

*serious in immunocompetent only if acquired during pregnancy

A

*causes congenital toxoplasmosis=> mental retardation and chorioretinitis. worse px if in later pregnancy

168
Q

Gestational diabetes

  • strict bs control even before preg impt.
  • maintain FPG
A

and shoulder dystocia in NB

  • during preg, insulin requirements incr t/o preg and gone immed upon delivery so cut insulin to 50% at birth
  • all other than insulin contraind in pregnancy for diabetic control
169
Q

Migraines and pregnancy

A

risk of inducing ischemia with triptans, do not use in pregnancy

170
Q

seizures during pregnancy
*goal-control sz, as sz can cause placenta abruption and early labor and premature delivery. risk of seizure outweighs risk of meds!

A
  • use monotherapy at lowest level as possible
  • no “safe” but valproate is more risky so dont use
  • use folic acid 1-2 mg/ day to help decr teratogenic risk of med
  • vit K last month preg on sz meds which decrease bleeding risks assoc w sz meds
171
Q

carpal tunnel and pregnancy

A

pregnancy can cause acute carpal tunnel that usually improves after delivery
splints best tx

172
Q

pre existing renal or liver disease ie HBV, HCV, alcohol abuse and pregnancy

A

are definate contraindications to pregnancy

173
Q

Predisposing factors to disseminated gonorrhea

A
  • pregnancy

* menstruation

174
Q

SLE and pregnancy

  • SSA (Ro)/SSB (La) antibodies-assoc w neonatal lupus & congenital heart block **counsel lupus pt about risk of pregnancy!
  • higher risk failed preg, and preg complications esp if active dz or if woman has APS or anti ds DNA
A

*if lupus pt w recent flare and becomes preg-continue glucosteroids and flares during preg tx same

175
Q

women w APS (antiphospholipid antibodies) and recurrent miscarriages can be treated with

A

heparin or LMWH PLUS ASA low dose to help decrease risk of miscarriage

176
Q

causes of avascular necrosis of hip

  • pregnancy
  • sickle cell dz
  • HIV/AIDS
A
  • gaucher dz

- hypercoaguable states

177
Q

HPV testing for ASCUS

*NOT appropriate for adolescents as they have high rate of HPV but low rate of cervical cancer. for them do pap at 1 yr and if still ASCUS can observe another year, if at 2 yrs present=colpo

A

see above

178
Q

women should undergo endometrial assessment if has postmenopausal bleeding:

A
  • in absence of HRT therapy
  • after on combined HRT continuously for 1 year without bleeding
  • at an unexpected time during cyclic replacement
179
Q

DUB

  • menses may be too frequent, too long, or too heavy of flow
  • dx of exclusion
  • causes: hypothyroid, liver dz, renal dz, coagulopathies, pregnancy complications, anatomic lesions, drugs…
A

*tx young women - OCP - 4 tabs (35-50 of ethinyl estradiol OCP best) a day which increases bleeding for 1-2 days then stops bleeding in 3-4 days, then take only 2 pills/day for 20 days. withdrawal bleeding occurs in 2-5 days then give 2-3 months of OCP at usual dose and stop

180
Q

complications of cocaine addiction

  • vascular thrombosis -liver necrosis -nasal septum perf
  • HTN -seizures -resp depression
  • rhabdomyolysis -arrhythmias -sex dysfunction
  • sinusitis -myocarditis
A
  • crack smokers: cough, hemoptysis, pulmonary edema
  • pregnancy: abortion, premature, stillbirth, abrupto placentae
  • acute intox: hyperadrenergic ): Incr HR, Incr BP, incr temperature, blur vision, anxiety, sweating
181
Q

Metabolic syndrome

  • dx if 3 or more of the following risk factors are present
  • obesity waist male >102cm (40”),female >88cm (35”)
  • TG150 or more
  • HDL male <50
A
  • BP 130/85 or higher

- FBS 110 or higher or prior dx diabetes

182
Q

metabolic syndrome is associated with these risks:

A
  • 7 x incr cardiovascular event
  • 2 x incr diabetes
  • 1.5 x incr all causes of mortality
183
Q

treatment of metabolic syndrome:

  • weight control, exercise
  • low glycemic diet,
  • aspirin
A
  • BP control <130/80
  • ACE/ARBs
  • LDL control
184
Q

Factors that increase triglycerides

  • obesity
  • smoking
  • incr alcohol intake
  • incr carbohydrate intake
A
  • diabetes
  • CRF
  • nephrotic syndrome
  • familial combineed hyperlipidemia
  • drugs: steroids, estrogen, BB, retinoids
185
Q

statins in stroke prevention

A

lowering LDL in patients with CAD reduces stroke by about 30%

*not proven in primary prevention of strokes

186
Q

consider risk factors for hemorrhagic stroke before rx high dose (80mg) of atorvastatin in secondary prevention of stroke.

Risk factors

A
  • older age
  • prior hemorrhagic stroke
  • chronic HTN
  • male sex
  • use of anticoagulants
187
Q

aspirin for primary prevention of CAD

  • indications:
  • intermediate to high risk pt with 10 yr risk of CV vent >15%, probable use if 10-15% but up to patient risk/benefit
  • diabetics: >age 40,1or more CV risk factor, known vasc dz
A

**asa

188
Q

most important preventable cause of death in USA

A

smoking

189
Q

Smoking health risks:

  • cardiovasc disease
  • cancer: lung, head & neck, pancreas, stomach
  • pregnancy: low birth wt, premature delivery
A
  • effect on lipids: incr LDL & TG, decr HDL
  • increase risk of invasive pneumococcal disease
  • quit- risk death from CV dz by 50% in first year and cont to decr
  • decr risk lung ca by 30-50% by 10 years
190
Q

Heart Protection Study

in pt with high risk of coronary event due to existing CAD, DM, PAD, hx CVA, other cerebrovasc dz…

A

simvastatin reduces the risk of death, MI, CVA irrespective of cholesterol level

191
Q

JNC definitions of HTN

Normal BP <120/80
Pre HTN 120-139/80-89

A

stage I HTN 140-159/90-99
stage II HTN >160/>100

Isolated systolic HTN: SBP >/=140 and DBP <90

192
Q

lowering SBP by 10-12 and DBP by 5-6mmHg

A

lowers risk of CVA 40% and CAD by 15% within 5 years

risk of heart failure reduced by >50%

193
Q

lifestyle modifications for HTN

  • wt loss, BMI <25
  • aerobic exercise daily
  • limit alcohol intake
A
  • low sodium intake
  • adequate calcium, potassium and magnesium intake
  • stop smoking
  • diet fresh fruit/veg, low fat dairy, whole grain,fish, poultry
194
Q

Benefits of regular exercise

  • decr LDL, TG increase HDL
  • protect against CAD & exertion related MI
  • reduce body weight
  • improve glucose metabolism
A
  • reduce BP, stress, insulin resistance
  • reduces death rate from all causes
  • decreases risk of breast cancer
  • decreases risk of osteoporosis
  • increases stroke volume in CHF
195
Q

Obesity-BMI best estimate of obesity

A 
normal <25
over weight 25-30
class 1 30-35
class 2 35-40
class 3 40+
196
Q

complications of obesity

  • incr risk of CAD, BP and sudden death
  • incr LDL & TG, decr HDL
  • DM, insulin resistance
  • gallstones, osteoarthritis
A
  • sleep apnea

- increase risk of cancer: endometrial, breast, colon, prostate

197
Q

Pneumococcal vaccine

*age > 65 or any younger with signif health problems, incl adults who smoke, asplenia …

A
  • single dose over age 65, except if given for any reason < age 65, give 2nd dose after age 65 or later if at least 5 years since last dose
  • protects against invasive pneumococcal disease: bacteremia, meningitis
198
Q

Influenza vaccine

A
  • age 6 mo or olderr
  • pregnant in any trimester
  • intranasal : healthy, non pregnant age 2-49
199
Q

Indications hepatitis B vaccine

  • healthcare workers
  • NH or prison
  • sexually active homosexual/bisexual/hetero w multiple partners
  • IVDU
A
  • hemodialysis patients
  • household & sex contacts of HBV carriers
  • pt on long term use of plasma derivatives
  • infants born to HBsAg + mothers
200
Q

Exposure to HBsAg+ blood (needle stick or mucous membrane)

*unvaccinated: HGIB + HB vaccine

A

*vaccinated:
-known responder (anti HBs is adequate) no rx
-nonresponder- HGIB x 2 or HGIB + HB vaccine dose
-unknown : anti HBs adequate - no rx
inadequate HGIB + HB booster

201
Q

Malaria prophylaxis

-no chloroquin resistance: chloroquin 300mg weekly, 1 wk prior and 4 wk post travel

A 
-with resistance: Malarone (atovaquone + proguanil) 1po 1-2day prior and cont til 1 week post travel
or mefloquin ( not if hx of psych )
or doxycycline 100mg daily 1-2 day prior and to 4 wk post travel
202
Q

high altitude illness

  • rapid exposure to altitude >8000ft
  • s/s:HA, fatigue, nausea, anorexia,insomnia, dizziness
  • pulmonary edema and cerebral edema may occur
  • prevention; acclimate 2-4 days at 6000-8000feet and grad ascent
A
  • acetozolamide 250mg BID start 1-2 day prior and cont at high altitude for 48 hours
  • *tx: descent, O2, dexamethasone 4mg every 6 hours and acetazolamide (for AMS or HACE), nifedipine 20-30mg BID for HACE
203
Q

travel and DVT risk

A

give single dose LMWH to reduce risk in high risk: hx thrombosis, obesity, malignancy, high platelets

204
Q

ADD/ADHD

*dx requires evidence of inattentive or hyperactivity w impulsivity or both starting < age 7

A
  • must be some impairment of social, occupational or academic functioning.
  • tx: methylphenidate (best initial), detroamphetamine, atomoxetine (SNRI-Strattera)
205
Q

depression during pregnancy

  • untreated depression may adversely affect the woman, fetus, other children and partner
  • mild to moderate tx w cognitive behavioral therapy
A
  • severe: SSRI (best- but NOT paroxetine), or SNRI + cognitive
  • maternal complications are slight increase in: diabetes, preeclampsia, premature rupture of membranes, bleeding
206
Q

Chronic Fatigue syndrome

  • severe fatigue > 6 months plus 4 or more of the following:
  • impaired short term memory or concentration
  • sore throat
A
  • tender cervical or axillary nodes -headache
  • muscle pain -difficulty sleeping
  • arthralgias without red or swelling
  • postexertional malaise lasting >24hrs
207
Q

Pharyngitis criteria for strep

  • fever, no cough, tender ant. cerv nodes, tonsillar exudates
  • rapid strep antigen test, tx if +
A

*tx PCN or emycin

208
Q

sinusitis

  • most viral, suspect bacterial if symptoms last 7days or longer and assoc with any one of the following:
  • purulent nasal discharge
  • maxillary tooth or facial pain
A
  • unilateral maxillary sinus tenderness
  • worsening symptoms after initial improvement
  • tx: amox, sulfa, doxy
209
Q

External otitis=>tx w local antibiotic & steroid drops

*malignant otitis (diabetes + otitis externa + swollen canal & granulation)=>pseudomonas=>IV cipro and local debridement

A

*Ramsey Hunt-facial paralysis + sensorineural hearing loss + vesicular eruption of ear canal =>herpes zoster=>rx antivirals

210
Q

severe hyperthermia (heat stroke)

  • core temp >40.5 (105)
  • exercise/exertion in high heat or humidity, elderly or young in heat waves, elderly on anticholinergics, antiparkinson or diuretics most susceptible
A
  • s/s: hot dry skin, delirium, dilated pupils, muscle rigidity, tachypnea, rhabdo, DIC, ARDS, renal failure, hepatic dysfuncton
  • tx-rapid cooling, IV fluids, internal cooling by gastric or peritoneal lavage with iced saline
211
Q

Hypothermia

  • core temp 35 or less (severe <28C)
  • features: CNS, dehydration, bradycardia, AF ,hypotension, lactic acidosis
  • tx: rewarming, warm isotonic fluids as external warming can drop
A

BP , warmed O2, peritoneal lavage w saline warmed to 40-45C, hemodialysis/cardiopulmonary bypass
*CPR and active internal rewarming should continue until core temp is >32 C

212
Q

Adolescent medicine

  • most common death causes: MVA, homicide, suicide
  • parent concent for tx *routine vaccines
A
  • emancipated: live away from home, economically self supporting, married, in military service
  • tx severe depression=>fluoxetine & cognitive behavioral therapy

GI (10 decks)

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