Miscellaneous

Question 0

What drug used for nausea, when given to patients with diarrhea predominant bowel syndrome, resulted in significant reduction in symptoms of diarrhea?

Answer 0

Zofran(ondansetron) 4mg : 1-2 tablets TID

Question 1

For patients with anxiety and or depression what is the result of quitting smoking?

Answer 1

One recent study showed a significant reduction in anxiety and or depression when patients quit smoking.

Question 2

What exercise for plantar fasciitis was found to be more effective than simple stretching?

Answer 2

But the new study, published in August in the Scandinavian Journal of Medicine & Science in Sports, finds that a single exercise could be even more effective. It requires standing barefoot on the affected leg on a stair or box, with a rolled-up towel resting beneath the toes of the sore foot and the heel extending over the edge of the stair or box. The unaffected leg should hang free, bent slightly at the knee.
Then slowly raise and lower the affected heel to a count of three seconds up, two seconds at the top and three seconds down. In the study, once participants could complete 12 repetitions fairly easily, volunteers donned a backpack stuffed with books to add weight. The volunteers performed eight to 12 repetitions of the exercise every other day.

Question 3

What is the association between Developmental Veinous

Anomalies (Veinous angiomas) and Seizures?

Answer 3

They don’t cause seizures directly. But there is an increased incidence of seizures in patients with DVA’s

Question 4

Do DVA’s(veinous angiomas) cause intra cerebral hemorrhage?

Answer 4

No. Patients with DVA’s often have in addition cavernous

angioma which can bleed.

Question 5

Do DVA’s(veinous angioma) become symptomatic?

Answer 5

No. DVA can be considered a benign
cerebral anomaly which is very unlikely to
become symptomatic. To our knowledge no
cases of enlarging DVAs have been described in
the literature; DVA can be considered a
variation of venous drainage of otherwise
normal brain tissue, as the region of the
malformation is characterized by a complete
absence of normal draining veins.

Question 6

What organism, besides chlamydia, is an important cause of non-gonococcal urethritis and possibly PID and cervicitis?

Answer 6

Mycoplasma Genitalium. It is now a significant cause of NGU

Question 7

What Rx for non-Gonococcal urethritis?

What would the Rx be if symptoms persist?

Answer 7

-Empiric Rx with azithromycin or doxycycline
-For persistent symptoms can consider Nucleic Acid Amplification Test(NAAT) on urine specimen (expensive).
If the patient was Rx’s with Doxy> try azithromycin( more effective)…..but some M. genitalium are now resistant to azithromycin> try moxifloxacin

Question 8

Explain the treatment recommendations for Epididymitis and Urethritis.

Answer 8

If patient has non gonococcal urethritis(NGU) or epididymitis Cipro is not likely to be effective according to UpToDate. They recommend Doxycycline or Azithromycin for NGU.
Epididymitis should be treated with Ceftriaxone I.M. + Doxycycline in men < 35 y/o. Men over 35 y/o should also receive Ceftriaxone(unless no possibility of GC)
+ Ofloxacin or Levofloxacin to cover enteric organisms.*Men < 35 y/o who have sex with men should also receive Ofloxin or Levofloxacin, in addition to Ceftriaxone, if they engage in anal sex.

Question 9

How NSAIDS affect the stomach?

Answer 9

The drugs cause ulcers by interfering with the stomach’s ability to protect itself from stomach acids, according to the National Digestive Diseases Information Clearinghouse. “Normally the stomach has three defenses against digestive juices: mucus that coats the stomach lining and shields it from stomach acid, the chemical bicarbonate that neutralizes stomach acid, and blood circulation to the stomach lining that aids in cell renewal and repair,” the clearinghouse explains. “NSAIDs hinder all of these protective mechanisms, and with the stomach’s defenses down, digestive juices can damage the sensitive stomach lining and cause ulcers.”

How do NSAIDS undermine the stomach’s defenses? All block an enzyme called cyclooxygenase 1, or COX-1. This enzyme helps prevent ulcers by enhancing blood flow to the stomach and increasing the production of protective mucous. If there’s a shortage of COX-1, your stomach may not develop its usual protective lining, making it more vulnerable to attack by stomach acid.

Question 10

What is the difference between plasma glucose and blood glucose?

Answer 10

• Plasma glucose is 10 to 12% higher than blood glucose
• Most new glucometers measure plasma glucose.
• The definition of diabetes is expressed in plasma glucose: FBS =/> 126 or 2HPP =/> 200

Question 11

What medications cause interstitial nephritis?

Answer 11

Antibiotics, PPIs, and NSAIDs appear to be the most common culprits in drug-induced acute interstitial nephritis; the PPI association probably is the least well-known among clinicians. Although absolute risk is very low, this association is worth keeping in mind when PPI-treated patients have otherwise unexplained acute declines in renal function.

Question 12

Describe the excess relative risk of GI bleed with mixing meds. Also interaction risk.

Answer 12

The researchers found that monotherapy with nsNSAIDs correlated with increased risk of UGIB (incidence rate ratio [IRR] during exposure vs. nonexposure, 4.3) to a greater extent than COX-2 inhibitors or low-dose aspirin monotherapy (IRRs, 2.9 and 3.1, respectively). In general, increased risk was seen with concomitant therapy, with the relative risk increased to the greatest extent for nsNSAID and corticosteroid therapies (IRR, 12.8); the greatest excess risk was also seen for this combination (relative excess risk due to interaction [RERI], 5.5). The IRR and RERI for concomitant use of nsNSAIDs and aldosterone antagonists were 11.0 and 4.5, respectively. The excess risk for nsNSAIDs, COX-2 inhibitors, and low-dose aspirin with selective serotonin reuptake inhibitors (SSRIs) was 1.6, 1.9, and 0.5, respectively. Excess risk of concomitant anticoagulant use was 2.4 for nsNSAIDs, 0.1 for COX-2 inhibitors, and 1.9 for low-dose aspirin.

Question 13

What is the period of contagiousness for influenza?

Answer 13

Most symptoms typically last for 3-5 days but cough, tiredness and malaise may last for 1-2 weeks. Infectivity continues for five days from onset, although children can remain infectious for two weeks, and the severely immunocompromised can shed virus for weeks.

Question 14

What is an important fact regarding the presentation of pneumonia in elderly patients?

Answer 14

Some patients with pneumonia (especially those who are elderly) do not cough, produce sputum, or have an elevated white-cell count, and about 30% are afebrile.

Question 15

NEJM article 11/14 on community acquired pneumonia Rx outpatient

Answer 15

Outpatients with CAP are generally treated empirically. A cause of infection is usually not sought because of the substantial cost of diagnostic testing. For outpatients without coexisting illnesses or recent use of antimicrobial agents, IDSA/ATS guidelines recommend the administration of a macrolide (provided that <25% of pneumococci in the community have high-level macrolide resistance) or doxycycline. For outpatients with coexisting illnesses or recent use of antimicrobial agents, the guidelines recommend the use of levofloxacin or moxifloxacin alone or a beta-lactam (e.g., amoxicillin–clavulanate) plus a macrolide.
By contrast, guidelines from the United Kingdom and Sweden recommend amoxicillin or penicillin as empirical therapy for CAP in outpatients.53,54 Several factors favor the use of a beta-lactam as empirical therapy for CAP in outpatients. First, most clinicians do not know the level of pneumococcal resistance in their communities, and Str. pneumoniae is more susceptible to penicillins than to macrolides or doxycycline. Second, even though the prevalence of Str. pneumoniae as a cause of CAP has decreased, it seems inappropriate to treat a patient with a macrolide or doxycycline to which 15 to 30% of strains of Str. pneumoniae are resistant. 59 In some parts of the world, rates of pneumococcal resistance to macrolides are far higher.60 Third, if a patient does not have a prompt response to a beta-lactam, a macrolide or doxycycline can be substituted to treat a possible atypical bacterial infection, such as that caused by Myc. pneumoniae. In the United States, because one third of H. influenzae isolates and a majority of Mor. catarrhalis isolates produce beta-lactamase, amoxicillin–clavulanate may be preferable to amoxicillin or penicillin, especially in patients with underlying lung disease.

Question 16

●Head pain that spreads into the lower neck and between the shoulders may indicate?

Answer 16

meningeal irritation due to either infection or subarachnoid blood; it is not typical of a benign process.

Question 17

Which drugs classes are more likely to cause orthostatic hypotension, especially in the elderly?

Answer 17

Alcohol
Alpha blockers: Terazosin (eg)
Antidepressant drugs: Selective serotonin receptor reuptake inhibitors, trazodone, monoamine oxidase inhibitors, tricyclic antidepressants
Antihypertensive drugs: Sympathetic blockers (eg)
Antiparkinsonism drugs: Levodopa, pramipexole, ropinirole (egs)
Antipsychotic drugs: Olanzapine, risperidone (egs)
Beta-blocker drugs: Propranolol (eg)
Diuretic drugs: Hydrochlorothiazide, furosemide (egs)
Muscle relaxant drugs: Tizanidine (eg)
Narcotic analgesic drugs: Morphine (eg)
Phosphodiesterase inhibitors: Sildenafil, tadalafil (egs)
Sedatives/hypnotic drugs: Temazepam (eg)
Vasodilator drugs: Hydralazine, nitroglycerin, calcium channel blockers (egs)

Question 18

What are the cautions regarding use of Beta-2 adrenergic agonists?

Which drug interactions are particularly important to be aware of.

Answer 18

MONITOR: Beta-2 adrenergic agonists can cause dose-related prolongation of the QT interval and potassium loss. Theoretically, coadministration with other agents that can prolong the QT interval may result in additive effects and increased risk of ventricular arrhythmias including torsade de pointes and sudden death. In general, the risk of an individual agent or a combination of agents causing ventricular arrhythmia in association with QT prolongation is largely unpredictable but may be increased by certain underlying risk factors such as congenital long QT syndrome, cardiac disease, and electrolyte disturbances (e.g., hypokalemia, hypomagnesemia). In addition, the extent of drug-induced QT prolongation is dependent on the particular drug(s) involved and dosage(s) of the drug(s). Clinically significant prolongation of QT interval and hypokalemia occur infrequently when beta-2 adrenergic agonists are inhaled at normally recommended dosages. However, these effects may be more common when the drugs are administered systemically or when recommended dosages are exceeded.

MANAGEMENT: Caution is advised if beta-2 adrenergic agonists are used in combination with other drugs that prolong the QT interval, including class IA and III antiarrhythmic agents, certain neuroleptic agents, phenothiazines, tricyclic antidepressants, quinolones, ketolide and macrolide antibiotics, and cisapride. Patients should be advised to seek medical attention if they experience symptoms that could indicate the occurrence of torsades de pointes such as dizziness, palpitations, or syncope.

Question 19

Onset of seizures in older individuals is not unusual. An acute provoked(secondary) seizure often has a reversible cause.
What are the most common causes of provoked seizures in an older patient?

Answer 19

Stoke is most common cause. Causes more than half of secondary seizures. Other causes:

• head injury from fall
• fever
• brain tumor
• metabolic( hypoglycemia, hypocalcemia, liver or kidney failure)
• drug interactions and adverse effects

Question 20

What are the causes of new onset epilepsy in older patients(recurrent, unprovoked)?

Answer 20

• TIA
• cerebrovascular atherosclerosis
• dementia
• *in 50% of patients there is no apparent underlying cause

Question 21

-Tylenol poisoning(Acetaminophen) can be acute or chronic
-For adults what is max recommended dose?
-Acute single dose overdose: Toxicity is unlikely at doses
less than______GMS_ or ______mg/kg toxicity IS likely to occur at acute single dose>____mg/kg or > ___GMS total dose over a 24 hour period.
-Name risk factors for Acetaminophen Toxicity:
-

Answer 21

Max recommended is 4 GM/24 hours. Recommend 250 mg/kg or >12 gms/24

Risk factors: underlying liver disease (to some extent), chronic ETOH, malnourishment, smoker, on medications that interact to increase toxicity

Question 22

What are the major Side effects proton pump inhibitors

Answer 22

• long-term dependence due to rebound hyper acidity
• diarrhea including C. diff.
• osteoporosis
• ** dangerously low magnesium levels

Question 23

Why does best pills worst does not like Lyrica

and recommend to not be used for any indication.

Answer 23

The original FDA medical officer advised not to approve Lyrica for use because of significant side effects. These included a fourfold increase in blurred vision and a sevenfold increase in double vision compare to placebos.Accidental injuries occurred nine times more frequently in patients who used Lyrica(Pregabalin).
Other side effects included dizziness drowsiness dry mouth difficulty with concentration and attention confusion and other cognitive abnormalities. Also loss of libido, sexual problems in women and erectile function and men, decreased platelets fever memory problems and unsteady gait.

Question 24

HIV Testing:
-How soon will 4th generation combined antigen/antibody
test become (+) with acute HIV?
-How soon will PCR RNA detect HIV?

Answer 24

-4th generation combined antigen(p 24)/antibody test
will detect HIV at 15-20 days
-3rd generation IgG/IgM antibody test >20-30 days
-RNA PCR Viral Load (+) 10-15 days
-Ultra Sensitive Viral Load (+) 5 days

Question 25

What common group of drugs can exacerbate

chronic spontaneous urticaria(CSU)

Answer 25

NSAIDS

Question 26

Does the evidence support the use of Biphosphonates in women with high Frax score showing 3% or more risk of hip fracture over next 10 years.

Answer 26

No. For women who have not had a fracture the evidence is less clear. There is evidence that they do prevent some tiny asymptotic fractures in the spine **but there is NO EVIDENCE THEY PREVENT HIP FRACTURES!

ALSO: Even for high risk patients who have had a prior fracture the benefit is not huge. FOR EVERY 100 WOMEN WHO TAKE BIPHOSPHONATES FOR 3 YEARS about 1 hip fracture will be prevented.

Question 27

What are the presenting signs and symptoms of cervical(carotid and vertebral)artery dissection?

Answer 27

-Headache and neck pain: headache is usually gradual but can be a severe sudden Thunderclap headache.
-Horner’s Syndrome in 25% patients
-Other signs sometimes seen:
Audible bruit, Tinnitus, cranial neuropathys’s,
occasionally isolated monocular pain

Question 28

ADHD

Answer 28

see Pediatrics

Question 29

What is the difference between labyrinthitis and vestibular neuronitis?

Answer 29

Both have vertigo or disequilibrium but only labyrinthitis has hearing loss

Question 30

Mycoplasma pneumoniae infection in children
>Clinical presentation?
>Complications?
>Dx?
>Rx?

Answer 30

M. pneumoniae accounts for approximately 20 percent of acute pneumonias in middle and high school students and up to 50 percent of cases in college students and military recruits [11]. The cumulative attack rate in families approaches 90 percent, and immunity is not long lasting [12
>Usually presents as a URI indistinguishable from viralURI. Also causes pneumonia. Can give protracted cough.
>Complications: meningitis, cerebritis, transverse myelitis, hemolytic anemia cold agglutinin (+), arthritis (complications may be immune related
>Dx: Culture difficult, takes 3 wks, serologies
not best. Best test is PCR
>Treat pneumonia and complications, not the URI syndrome. No definite evidence Rx effective, but may be. Macrolide’s, Doxycycline

Question 31

Asthma is the second most common cause for chronic cough , especially in children.
>What is best way to make Dx if patient not wheezing?

Answer 31

> Spirometry and provocative testing not helpful due to false positives.
Hx: Be suspicious if (+)Hx allergies or if (+)fam Hx asthma
Best test is a 4-6 wk trial of inhaled corticosteroids

Question 32

GERD is the 3rd most common cause for chronic cough. Upwards of 40% of patients have no associated heart burn.
>Mechanism of cough with GERD?
>Diagnostic test?

Answer 32

> Direct aspiration, stimulation of upper airway (laryngeal) receptors and An esophageal-tracheobronchial cough reflex induced by reflux of acid into the distal esophagus
24 hour esophageal ph monitoring along with diary

Question 34

> Where are bodies cough receptors located?

>

Answer 34

> In upper and lower respiratory tract, stomach, esophagus, intestines, pericardial
Each cough occurs through the stimulation of a complex reflex arc. This is initiated by the irritation of cough receptors that exist not only in the epithelium of the upper and lower respiratory tracts, but also in the pericardium, esophagus, diaphragm, and stomach. Chemical receptors sensitive to acid, cold, heat, capsaicin-like compounds, and other chemical irritants trigger the cough reflex

Question 35

> what is the most common cause of chronic cough?

>What is post nasal drip due to? and how does it cause a cough?

Answer 35

> upper airway cough syndrome related to postnasal drip
Underlying reasons for postnasal drip include allergic, perennial nonallergic, and vasomotor rhinitis; acute nasopharyngitis; and sinusitis . Once secretions are present in the upper airway, cough is probably induced by stimulation of cough receptors within the laryngeal mucosa. (See “An overview of rhinitis”.)

Question 36

> What are the symptoms of Laryngopharyngeal reflux (LPR) ?

> What’s the mechanism of LPR? Is it more apt to happen upright or supine?

> Will pH monitoring help Dx LPR?

Answer 36

> Most patients are relatively unaware of LPR with only 35 percent reporting heartburn. Typical LPR symptoms include dysphonia/hoarseness, chronic cough, mild dysphagia and nonproductive throat clearing
LPR is seen as primarily an upper esophageal sphincter (UES) problem that mainly occurs in the upright position during periods of physical exertion (eg, bending over, Valsalva, exercise). In contrast, GERD is felt to be a problem of the lower esophageal sphincter and mainly occurs in a recumbent position

> Not necessarily: Among 49 patients with unexplained chronic cough who underwent MII, 73 percent had nonacid proximal esophageal events. Furthermore, in the nearly half of these who went on to anti-reflux surgery, 100 percent had either total or significant resolution of cough

Question 37

> What is the most likely cause of a chronic cough in patient with Obstructive Sleep Apnea?

Answer 37

The incidence of chronic cough in patients with obstructive sleep apnea (OSA) can exceed 30 percent [48], which may be related to GERD [49]. Continuous positive airway pressure (CPAP) treatment significantly improves cough in such OSA patients, and this benefit may be via an effect on GERD

Question 38

> Whats the relationship of chronic cough and bacterial infection?

Answer 38

Some patients appear to have unsuspected bacterial suppurative disease of the large airways, in the absence of bronchiectasis, as a cause of chronic cough. Bronchoscopic evaluation and microbiologic sampling of the airways led to this diagnosis in a series of 15 patients undergoing evaluation at a single center for cough that remained unexplained after extensive evaluation [64]. While four of these patients had underlying systemic disease, the remainder had no evidence of immune compromise. Aggressive antibiotic therapy, based upon the results of bronchoscopic culture, led to improvement or elimination of the cough in all patients.

Question 39

> What is Non Asthmatic Eosinophilic Bronchitis?

Answer 39

Nonasthmatic eosinophilic bronchitis is an increasingly recognized cause of chronic nonproductive cough, particularly in patients who lack any of the risk factors described above Patients with this disorder demonstrate atopic tendencies, with elevated sputum eosinophils and active airway inflammation in the absence of airway hyper-responsiveness These same findings with evidence of hyperresponsiveness are consistent with the diagnosis of cough-variant asthma (See ‘Asthma’ above.) In one series of 20 patients with chronic isolated (nonspecific) cough, no apparent cause, and no airway hyperresponsiveness, bronchial biopsy revealed eosinophilic bronchitis in 16

Although bronchial mucosal biopsies are required to definitively diagnose eosinophilic bronchitis, a trial of therapy is usually performed without biopsy, since most patients respond well to inhaled glucocorticoid

Question 40

Definition of Hypotension in children

Answer 40

Low systolic blood pressure for children is defined as:
Less than 70 mmHg from 1 month to 1 year
Less than (70 mmHg + [2 x age]) from 1 to 10 years
Less than 90 mmHg from 11 to 17 years

Question 41

Regards Bee,Wasp, Hornet sting:

> how to recognize anaphylaxis?

Answer 41

> anaphylaxis suggested by: Either A,B or C
A-)acute (minutes to hours) onset of skin and/or mucosal changes: urticaria, pruritis, flushing and/or edema of tongue, lips, uvula AND: respiratory difficulty(wheeze, stridor, hypoxia,dyspnea) OR:
hypotension/or syncope, collapse

B)Two or more of the following after exposure to a *likely allergen, occurring within minutes to hours:

• generalized urticaria, pruitis, swelling of lips, tongue etc
• respiratory difficulty
• hypotension
• persistent crampy abdominal pain, vomiting

C)Reduced BP after exposure to a *known allergen for that patient or greater than a 30%decline from that patients baseline

Question 42

Eosinophilic esophagitis:
>What is sometimes seen on BA swallow?
>What is clinical presentation?
>Clinical presentation in children?
>role of allergy?

NEXT CARD

Answer 42

> multiple esophageal rings
Dysphagia
●Food impaction is present in 50% of pts.
●Chest pain that is often centrally located and does not respond to antacids
●Gastroesophageal reflux disease-like symptoms/refractory heartburn
●Upper abdominal pain
Esophageal stricture noted in 30% of pts
reports of spontaneous esophageal perforation (Boerhaave’s syndrome), esophageal perforation following endoscopy, and mucosal tears associated with endoscopy have been reported

>Clinical presentation in children:Feeding dysfunction (median age 2.0 years)
●Vomiting (median age 8.1 years)
●Abdominal pain (median age 12.0 years)
●Dysphagia (median age 13.4 years)
●Food impaction (median age 16.8 years)

> There is a strong association of eosinophilic esophagitis with allergic conditions such as food allergies, environmental allergies, asthma, and atopic dermatitis.

Question 43

How to Diagnose Eosinophilic Esophagitis?

Answer 43

> esophageal biopsy AFTER 2 MONTHS OF
proton pump inhibitor : because GERD can cause eosinophilia ●Symptoms related to esophageal dysfunction
●Eosinophil-predominant inflammation on esophageal biopsy, characteristically consisting of a peak value of ≥15 eosinophils per high power field
●Mucosal eosinophilia is isolated to the esophagus and persists after two months of treatment with a proton pump inhibitor (PPI) trial
●Secondary causes of esophageal eosinophilia have been excluded (table 1)
●A response to treatment (dietary elimination; topical glucocorticoids) supports the diagnosis but is not requiredPatients with clinical and

PPI RESPONSIVE EoE : histologic features compatible with eosinophilic esophagitis but who respond histologically to a PPI have been described as having PPI-responsive esophageal eosinophilia [88-96]. The pathogenesis of esophageal eosinophilia in such patients is not well understood. It is also unclear if PPI-responsive esophageal eosinophilia and eosinophilic esophagitis are distinct diseases

Question 44

What are some of the features differentiating Crons Disease and Ulcerative Colitis?

Answer 44

Differential diagnosis of ulcerative colitis and Crohn disease
Ulcerative colitis vs Crohn disease
Clinical features
Haematochezia Common Less common
Passage of mucus or pus Common Rare
Small-bowel disease No (except backwash ileitis) Yes
Can affect upper-gastrointestinal tract No Yes
Abdominal mass Rare Sometimes in right lower quadrant
Extraintestinal manifestations Common Common
Small-bowel obstruction Rarely Common
Colonic obstruction Rarely Common
Fistulas and perianal disease No* Common
Biochemical features
Antineutrophil cytoplasmic antibodies Common Less common
Anti-saccharomyces cerevisiae antibodies Rarely Common
Pathological features
Transmural mucosal inflammation No Yes
Distorted crypt architecture Yes Yes
Cryptitis and crypt abscesses Yes Yes
Granulomas No¶ Yes (seen in 25 to 40 percent of mucosal biopsies)
Fissures and skip lesions Rarely Common

Question 45

> What are pseudonyms for Lower rib pain syndromes ?

> What is a test for the above syndrome>

Answer 45

> rib-tip syndrome, slipping rib, twelfth rib, and clicking rib

> the “hooking maneuver,” in which the examiner’s curled fingers are hooked under the ribs at the costal margin and the ribs are gently pulled forward, reproducing the patient’s symptoms.

Question 46

Discuss Mycoplasma pneumonia infection

Answer 46

Being a smoker increases the risk of Mycoplasma pneumonia by 500%

The incubation period after exposure averages two to three weeks [18]. Infection occurs most frequently during the fall and winter but may develop year round [16]. Overall, it is estimated that nearly one percent of the population is infected annually in the United States [19]. The cumulative attack rate in families approaches 90 percent, and immunity is not long lasting [

Mycoplasma infection can occur at any age, but infection rates are highest among school-aged children, military recruits, and college students
M. pneumoniae infection may worsen asthma symptoms and can produce wheezing in children who do not have asthma. A separate question, for which there has been some experimental and clinical evidence, is whether M. pneumoniae might have a pathogenic role in asthma.

Most patients with respiratory infection due to M. pneumoniae do not develop pneumonia. But in those that do: There may be no findings on chest auscultation even if pneumonia is present early in the course of disease. However, scattered rales, wheezes, or both may be present later
1-2 week incubation period»Fever, headache, malaise, sore throat and ** intractable, nonproductive cough,…..non-productive at first»mildly productive and lightly discolored

*Other clinical signs may include wheezing, rhinorrhea, ear pain,sinus tenderness, mild erythema of the posterior pharynx, erythema of the tympanic membrane, and nonprominent cervical adenopathy.

90% attack rate within a family. Community epidemics are not unusual

Some of the pathogenicity may be due to M. pneumoniae stimulating an auto immune response.

• Mild hemolysis due to stimulation of Cold Agglutinins in 60 % of patients
• Dermatologic manifestations may range from a mild erythematous maculopapular or vesicular rash (which is most commonly seen accompanying respiratory tract infections) to the Stevens-Johnson syndrome

*Central nervous system (CNS) manifestations occur in approximately 0.1 percent of all patients with M. pneumoniae infections and in up to 7 percent of those patients requiring hospitalization [46]. CNS involvement occurs most frequently in children, with encephalitis as the most common manifestation
Other manifestations include aseptic meningitis, peripheral neuropathy, transverse myelitis, cranial nerve palsies, and cerebellar ataxia [48,49]. Acute transverse myelitis (ATM) and acute disseminated encephalomyelitis (ADEM)
59 percent of patients presenting with spinal cord involvement suffered permanent neurologic sequela
Cardiac involvement is one of the more commonly reported extrapulmonary manifestations of M. pneumoniae infection [15]. Cardiac syndromes include rhythm disturbances, congestive heart failure, chest pain, and conduction abnormalities on the electrocardiogram. Myocarditis has been described in rare autopsy reports since the disease is usually not fatal. There are several case reports of mycoplasma associated thrombosis involving the heart and other vessels; the suggested pathophysiology is the formation of anticardiolipin antibodies [52]. A single report of M. pneumoniae endocarditis is, for the first time, quite convincing [53]. The incidence and severity of most forms of cardiac involvement increase with patient age.

Subclinical evidence of hemolytic anemia is present in the majority of patients with pneumonia as suggested by a positive Coombs’ test and an elevated reticulocyte count. Cold agglutinin titers are elevated in greater than 50 percent of patients with mycoplasma disease, and the titer usually exceeds 1:128 in patients with pneumonia [16]. With overt hemolysis, titers may be as high as 1:50,000. Elevated cold agglutinin titers can also be seen in a number of other disorders including mononucleosis secondary to Epstein-Barr virus or cytomegalovirus, adenovirus pneumonia, other viral illnesses, and in some patients with lymphoma and collagen vascular disorders.

The white blood cell count is normal in 75 to 90 percent of cases. Thrombocytosis can occur and probably represents an acute phase response, while thrombocytopenia is unusual

None of the radiographic patterns seen with mycoplasma pneumonia is pathognomonic of this etiology as compared with interstitial pneumonia caused by any other agent. The most common radiographic findings are a reticulonodular pattern and/or patchy areas of consolidation;

*When available, polymerase chain reaction (PCR), which can be done rapidly and has a high specificity, is the diagnostic test of choice. A multiplex assay has been cleared by the US Food and Drug Administration for the diagnosis of M. pneumoniae infection using nasopharyngeal samples
The mainstays of therapy for possible M. pneumoniae infection are macrolides such as erythromycin and azithromycin, doxycycline, or a fluoroquinolone such as levofloxacin or moxifloxacin. In several in vitro studies, azithromycin was the most active drug, and resistance to this agent did not develop despite multiple passages in the presence of the drug [88,89]. Trials that evaluated the treatment of community-acquired pneumonia in which cases caused by M. pneumoniae were identified have shown excellent efficacy of azithromycin [90], levofloxacin [91], and moxifloxacin [92], although the numbers of patients with a diagnosis of M. pneumoniae were small.

We favor azithromycin for five days (500 mg for the first dose, then 250 mg daily for the next four days) for most patients with pneumonia

Macrolide resistance has also been reported in 5 to 10 percent of isolates studied in France and the United States [94-96]. In a report from China, 95 percent of M. pneumoniae isolates from adult patients with respiratory tract infections were resistant to macrolides [97]. Although the majority of isolates worldwide remain susceptible to macrolides, alternative therapy should be considered in patients with severe or refractory disease, particularly in those who reside in areas where there is a substantial rate of macrolide resistance. by M. pneumoniae. Patients treated with other agents (eg, doxycycline or a fluoroquinolone) should receive 7 to 14 days

Question 47

Key points in differentiating between acute bronchitis and pneumonia?

Answer 47

Fever is an unusual sign in patients with acute bronchitis and suggests the presence of either influenza or pneumonia. Patients with the combination of cough, fever, sputum production, and constitutional symptoms are more likely to have influenza or pneumonia. Patients with acute bronchitis have few systemic symptoms.

Question 48

What are some pearls regards appendicitis as to presentation?

Answer 48

Abdominal pain is the main presenting complaint. Pain typically starts at midabdominal region and later (1 to 12 hours) shifts to the right lower quadrant. Pain is usually constant in nature and with intermittent abdominal cramps and is usually worse on movement and coughing.

Location of the pain may vary depending upon the location of the appendix:

Retrocecal appendix may cause flank or back pain

Retroileal appendix may cause testicular pain due to irritation of the spermatic artery or ureter

Pelvic appendix may cause suprapubic pain

A long appendix with tip inflammation in the left lower quadrant may cause pain to that region.

*Anorexia is another important symptom almost always associated with acute appendicitis. [21] Without anorexia the diagnosis of acute appendicitis is in question. Nausea and vomiting are also present in 75% of patients. [21] Vomiting usually occurs only once or twice. Severe constipation is a late feature.

The sequence of presentation in 95% of the patients with acute appendicitis usually starts with anorexia, followed by abdominal pain and then vomiting (seen only in 75% of patients).

Question 49

> What are some pearls regarding the significance of proteinuria in healthy individuals?

> Significance of microscopic hematuria in
young vs older patients ?

Answer 49

Proteinuria screening is not recommended in any healthy, asymptomatic adult population, since four population-based studies have found that fewer than 1.5% of those with positive dipsticks have serious and treatable urinary tract disorders.

In young adults, evidence from five population-based studies indicates that fewer than 2% of those with a positive heme dipstick have a serious and treatable urinary tract disease, too few to justify screening and the risks of subsequent workup. For older populations, evidence is contradictory

Question 50

> The dipstick detects primarily which protein?

Answer 50

> Albumin.It is less sensitive to globulins or parts of globulins (heavy or light chains or Bence Jones proteins

Question 51

> What percent of depressed people commit suicide?

> What are the risk factors for suicide?

Answer 51

> 15%

· one or more diagnosable mental health conditions
· impulsivity
· adverse life events
· family history of mental health or substance use disorders
· family history of suicide
· family violence
· prior suicide attempt
· firearm in the home
· incarceration
· exposure to suicidal behaviors of others

Question 52

How do benzodiazepines work in the brain?

Answer 52

All benzodiazepines work by increasing the activity of the neurotransmitter GABA. Since GABA is an inhibitory transmitter, which slows or stops the firing of other neurotransmitters, by increasing GABA activity you quiet the brain’s overall activity level. GABA is the brain’s natural sedative, and benzodiazepines simply enhance its functioning.

Question 53

What are some of the typical withdrawal symptoms from benzodiazepines?

Answer 53

Typical withdrawal symptoms include:1

Sleeping problems
Feeling anxious or tense
Panic
Depression
Confusion
Paranoia – thinking other people want to do you harm
Feelings of disassociation
Abnormal sensory perception (noises sound loud, colors seem odd, etc.)
Shaking, or more rarely, convulsions
Muscle aches, pains and spasms
Irritability
Symptoms that mimic flu

Question 54

How soon do withdrawal symptoms from Klonopin begin and how long do they last?

Answer 54

Klonopin withdrawals are different for everyone, though it will likely be intense at the beginning and then they will gradually lessen. Symptoms typically develop within 24 -72 hours and become their worst after about 5-7 days. The average length of Klonopin withdrawal is about six weeks, though in some people certain symptoms can persist for months. The symptoms often run a two-phase course where they seem to get better after a week, but then they intensify the next week. The physical symptoms are usually present at the beginning of the withdrawal, while the more psychological symptoms appear later. Klonopin withdrawal symptoms can include the following problems:

Question 55

What are the indications for anticoagulation for people with AF?

Answer 55

-age 75 or older
-prior history of TIA or stroke
For the following risk factors two or more points is a definite indication for anticoagulation. One point is a possible indication-uncertain. No points means no indication for anticoagulation:
-Female sex
-Diabetes
-Hypertension
-Congestive heart failure
-Vascular disease: coronary artery disease, peripheral artery disease or aortic plaque buildup.

Question 56

What are the most common causes of subacute/chronic coughs?

Answer 56

The most common etiologies of chronic cough are upper airway cough syndrome (due to postnasal drip), asthma, and gastroesophageal reflux However, a number of other important etiologies must also be considered in patients presenting with persistent cough. As an example, a post-infectious etiology is a particularly common cause of subacute cough, with the cough often lingering long after the other acute symptoms of the infection have dissipated. One study showed that in nearly half of patients, subacute cough was post infectious and resolved without specific therapy

Question 57

What are the less common causes of chronic cough?

Answer 57

less common causes of chronic cough include a number of disorders affecting the airways (non-asthmatic eosinophilic bronchitis, chronic bronchitis, bronchiectasis, neoplasm, foreign body) or the pulmonary parenchyma (interstitial lung disease, lung abscess) . A cause is identified in 75 to 90 percent of patients with chronic cough However, some patients may experience chronic cough of unclear etiology for years, despite extensive evaluation. The etiology of so-called “chronic idiopathic cough” is unknown; exaggerated cough reflex sensitivity has been suggested