Medicine 3 Flashcards
Pt has Parkinsons: cogwheel rigidity, resting tremor, small writing, orthostasis, intact congnition.
He’s 55 yo, what is 1st line treatment?
Over 60?
Anticholinergics: benztropine or hydroxyzine
>60: Amantadine = increase dopamine release (too many SE with old people on anticholinergics)*
Pt with severe parkinsons starting to have symptoms of pyschosis. Why is this? What should you do?
meds that increase dopamine can cause pyschosis.
Remove LEAST potent medications first, then reduce stronger meds.
Last start antipyschotic like quetiapine or clozapine
Medications for parkinsons
Goal is to increase dopamine
- Anticholinergic if <60; benztropine/hydroxyzine
OR Amantidine >60 - Severe symptoms;
Levo or Cardiodopa (more efficacious, can see on-off phenomenon)
or
Dopamine antagonist (pramipexole, ropinerole, cabergoline)
Next
COMT inhibitors: tolcapone/entacapone to prevent metabolism of dopamine
MAO inhibitors: Selegiline or rasagiline
Patients with primary, secondary or early latent syphyillis need what for tx?
x1 dose of IM Pen G
Primary: chancre w/ + RPR or VDRL confirmed with Darkfield or FTA
Secondary: rash/alopecia/conydlomata, dx with RPR or VDRL
Early latent = <12 months
*Start SSRI like sertraline for depressive symptoms
What pts with syphillis need 3 weeks of IM penicillin?
Pt with Late lenent syphillis (no active symptoms with exposure >12 months ago)
Unknown duration of illness
Gummatous or CV syphillis
Baby born with congenital syphillis, tx?
IV Pen G x 10 days
PT comes in 2 weeks after hiking trip to Maine. Has a erythematous rash with pale center and target shaped on his shin, did have a tick bite.
Next step?
TREAT! you don’t have to confirm if high suspicion, tx with Doxycycline
For CNS involvement or cardiac: then CTX
Tx for joint/Bells palsy: doxy, amoxicillin or cefuroximine
What are long term complications of Lymes disease?
JOint pain; common late manifestation
Cardiac: AV conduction block
Neuro: 7th CN palsy or Bells
Dx: IgM, IgG ELISA, Western blot or PCR
Pt comes in with SOB with activity and headache. Recently traveled to Northwest on hiking trip, recalls a rash on leg with tick exposure. CBC shows anemia.
What further test do you want?
What co-morbidity makes this worse?
Tx?
C/f Babesiosis; transmitted by deer tick, get Hemolytic anemia
Get smear; shows tetrads of intraerythrocytic rings or can get PCR
Asplenic pt get more sick bc spleen removes damages RBC
TX: Azithromycin + atovaquone
Pt comes in with rash, fever, HA. Had tick bite four days ago, Rash is maculopaular blanching over wrists and ankles. Dark spot at tick bite
How do you Dx?
Expected lab findings?
Tx
RMSP: rickettsia via tick peak in summer
Dx rickettsia serology or Bx
see LOW plts, LOW Na and elevated LFT
Tx: DOXYCYCLINE
Side effects of Metformin
Works by blocking gluconeogenesis; no risk of hypoglycemia but DONT use if renal insufficiency.
diarrhea and lactic acidosis
Side effects of Sulfonylureas (glyburide, glimepiride, glipizide) or Meglitinides (natelginide, repaglinide) used to tx T2DM
Act by increasing insulin secreation and blocks B-ell Katp channels
SE: Hypoglycemia (confusion), weight gain
PT diagnosed with childhood absence seizures. Which medication should be started
What is seen on EEG
Ethosuximide
3 hz spike/wave discharges
Can see agranulocytosis; monitor CBC, but liver is fine
What lab should you monitor when starting pt on valproic acid?
LFTs
Boy comes in with mild BL flank pain. UA shows +2 protein, no blood, normal Na, BUN and Cr with normal BP,
Most likely dx, next step?
Probably orthostatic proteinuria
Get a 24hr UA; if elevated, get a split 24 hr collection; you can see if day vs night is higher, on feet with high protein diagnostic for orthostatic
IF proteinuria is persistent and NOT orthostatic, get renal Bx
Good initial drug for Rheumatoid arthritis?
Failure of this drug… start this class
Methotrexate; folate antimetabolite; can cause hepatotoxicity and cytopenia
If fail, start Biologics such as TNF inhibitors
= adalimumab, etanercept, infliximab
SE of TNF inhibitors (adalibumab, etanercept infliximab)
Infection, demyelination, CHF, malignancy
check interferon gamma release assay (TB reactivation can occur)
Patient passed out and brought to ED, fine now. Felt lightheaded w/ pounding in chest prior to passing out
ECG with short PR interval, delta wave and wide QRS. Dx
Tx?
WPW–> lead to tachyarrythmia and atrial fibrillation
If pt is having symptomatic tachyarrtyhmia it’s automatic indication to tx with catheter ablation
PT with HIV comes in, not taking HARRT therapy, CD4 count is 10. HA, n/v and lethargy with oral yeast infection. LP done:
increased protein, low glucose, very VERY elevated OP of 300 with low white count, lymphocytic predominance.
Dx
Tx?
Cryptococcal meningococcal encephalitis
seen in HIV when <50 or immunocompromised
Tx with Ampho and Flucytosine
will have LOTS Of head aches and elevated IP symptoms, tx serial LPs, steroids don’t help
Dont start ART therapy until 2-4 weeks in d/t immune reconstitution inflammatory syndrome
Pt comes in for routine exam with 3/6 holosystolic murmur, with a palpable thrill at LUSB
Most likely cause?
VSD
Pt with wide and fixed splitting of the second heart sound. Mid systolic ejection murmur.
ASD
Pt comes in with three months of itchy and twitchy legs, worse when laying still, relieved by moving and pacing. No other PMHx, she is in her 50s with HTN controlled on amlodipine. Neuro and rest of PE normal.
Most likely dx?
Additional testing?
Tx?
dx restless leg syndrome
get iron stores or ferritin; can be associated with RLS
Tx pramipexerole (dopamine agonist) or gabapentin
What affects does amiodarone have on thyroid?
decresease conversion of T3 to T4 so have higher T4
high iodine in amiodarone can inhibit thryoid hormone synthesis
Can induce thyroxicosis (will need tx w/ glucocorticoids)
Pt in ED on cardiac monitor, is in afib and becomes unresponsive. No pulses present, not breathing. Next step?
Per ACLS… start Chest Compressions for pulseless electrical alternans
Pt in ED has palpitations and chest pain, monitor shows narrow complex tachycardia. He is alert. Next step?
SVT– give IV adenosine
IF unstable.. cardiovert!
When do patients undergo defibrillation?
ventricular tachycardia
pulseless ventricular tachycardia
What are red flags for patient presenting with scoliosis?
dull or achy pain, pain that wakes at night
neurologic signs; paresthesias, B/B dysfunction
Rapidly progressing
Initially to spinal Xray
Gold standard is MRI
Pt comes in with chest pain and HTN with UDS + for cocaine. She is aggitated but CTAB, tachy but no murmurs.
Tx?
Benzos; will reduce sympathetic outflow to alleviate tachycardia and HTN
Next step is nitro for those symptoms
If refractory… you can use phenotolamine
DON”T use B-blockers; you get unopposed alpha 1 vasoconstriction
Pt is in 70s, having fluctuating memory issues; good days and bad days for past several months. Last year daughter felt her mom was more unsteady on her feet, she now takes very short steps and will find her dad talking to someone who isn’t there on occasion.
On PE, rigid upper extremities
Dx?
Dementia with Lewy Body
Pt with reduced dopamine transporter uptake in basal ganglia on PET adn sleep study with REM w/o atonia.
preserved medial temporal lobe on CT or MRI
Pt is in 70s, having difficulty with memory and recall, loss of bladder control. Now has abnormal gait is very stiff.
Likely dx
Normal pressure hydrocephalus
Pt in 80s brought in with son, noticed his dad has been acting bizarre, he says whatever is on his mind and used to be a very conservative person so is surprised. What is most likely cause of dementia?
Frontotemporal dementia
In pt with newly diagnosed frontotemporal dementia, what medication do you need to be careful of 2/2 to side effects?
Often go on anti-parkinson drugs and anti psychotics.. they are EXTREMELY sensitive to anti-psychotics and can actually make confusion, Parkinsonism and autonomic dysfnx worse
One week old baby born at home comes to hospital, severely dehydrated, labs notable for low Na, elevated K. VItals notable for tachycardia and hypotension. On PE ambiguous genitals.
ML diagnosis?
Congenital adreanal hypoplasia
D/T 21- hydroxylase enZ deficiency
See hypoNa, hyperK, hypoT, hypoglycemia
ELEVATED 17-hydroxyprogesterone leads to elevated andgrogens and amb genitals; low cortisol, low aldosterone
What is the Tx for CAH due to 21-hydroxylase deficiency
Glucocorticoids, mineralocorticoids, high salt diet, genital reconstruction for girls, pyschotherapy
Pt presents to acute care, he has rapidly growing mass on anterior neck for past month, now difficulty swallowing. Has history of small goiter and family hx of hypothyroidism in several relatives. TSH is very elevated with low T3/4. +antithyroid peroxidase antiB.
ML diagnosis?
Thyroid lymphoma
Pts +antithryoid peroxidase and high TSH w/ low T3/4 suggestive of Hashimotos
This increases risk for thyroid lymphoma
____ is acceptable alternative to colonoscopy. When do you need to get colonscopy?
sigmoidoscopy
Need to visualize proximal colon if large >1.0 cm adenomatous polyp,l mult adenomatous polyps, villous or tubovillous morphology
Pt is teen, comes in with episode of witnessed GTC at home, now at baseline. Normal PE, labs and normal. Parents state he’s has complained thepast few months he was jerking his arms more when he was falling asleep making it hard to sleep and was more anxious.
EEG with bilateral polyspike and slow waves
Dx and tx??
Juvenile myoclonic epilepsy
First line is valproic acid
can also have absence seizure
Side effects and required monitoring for valproic acid?
Get CBC; monitor for thrombocytopenia and other cell line depression
LFTS for hepatotoxicity and pancreatitis
Teratogenic; off while preggers
Screening 50yo M during routine exam, some weight loss over the past 6 months and constipation but otherwise no changes. Has 20 yr smoking hx, no drinking, no c/p.
Labs show elevated Ca level and otherwise WNL.
Next steps?
Order serum PTH
If elevated likely primary hyperparathydrisms
If not… higher suspicion for malignancy
Others: thyrotoxicosis,Vit A toxicity, immobilization, Vit D Toxicity, granulomatosis
Pt comes in with unknown ingestion. She is n/v, has dry mucous membraneson exam and is aggitated. Tachy with normotenisive BP, and tachypneic, astas are 98% on RA with temp of 100. pupils are 4+ and equally reactive.
Likely ingestion?
Salicylate
causes n/v and tachypnea w/ resiratory alkalosis and lactic acidosis as well as hypertherma with AMS all from stim of the medullary respiratory center and chemorectpor trigger zone
Lab abnormalties seen in patient with salicylate OD?
Tx?
Mixed acid-base disorder;
primary respiratory alkalosis d/t activation of medullary respiratory center; see elevated pH with low PaCo2
AG metabolic acidosis due to inhibition of cellular metabolism (normal 8-14)
**Tx is sodium bicarb drip, supplemental glucose and monitor ABG
IF w/in 2 hrs ingestion.. activated charcoal
At what point do you screen for lung cancer in pt with smoking history?
Get low dose CT for pt btwn 55-80 who have a >30 pack year smoking history OR are current smokers or quit w/i last 15 years
What antiBx are indicated/safe in pregnancy for UTI?
Cephlexin Amox-clavulanate Nitrofurantion NOT bactrim (NT defect 1st trimester) NOT FlouroQ (cartiledge defects)
Lesions c/f melanoma should be ____
excised w/ 1-3mm margins
Tx for BRAF mutations: Nivolumab or pembrolizumab
Tx for Bipolar; baseline
Depression
Mania
Lithium (goal 0.6 to 1.2 level)= mood stabalizer
Depressive symptoms; Add lamotrigine (can use as maintenance)
Mania: may need to add antipsychotic
Incidental pituitary adenoma discovered on CT when pt came in for head trauma. All hormone levels are normal and otherwise asymptomatic.
Recommended steps if
<5mm?
5-10mm?
Less then that, nothing
5-10 mm get yearly MRI for 2 years
_____ has a nonejection click followed by systolic murmur like MR; often occur in late systole as LV end diastolic volume increaes and may disappear in setting of large volume venous return
Mitral valve prolapse
A harsh holosystolic murmur at lower sternum increasing with inspiration
Tricuspid regurg
An ejection click followed by a crescendo-decrescendo systolic murmur that increases with increased venous return
Hypertrophic cardiomyopathy
Harsh holosystolic murmur with maximal intensity over left third and fourth intercostal space w/ palpable thrill
VSD