Mixed Flashcards
what are absolute contraindications to electroconvulsive therapy (ECT)
no absolute contraindications to ECT, but factors associated with reduced efficacy:
- prolonged episode
- lack of response to medication
- coexisting psych diag, ie personality disorder.
Persons at increased risk for complications: -unstable cardiac dx, ie ischemia/arrhythmias
-cerebrovascular dx, ie recent cerebral hemorrhage or stroke, increased ICP
ECT is safe in elderly patients, ppl with cardiac pacemakers or implantable cardioverter-defibrillators, during pregnancy,
community-acquired pneumonia
peds
diagnosis of community-acquired pneumonia is based on hx & PE. Pneumonia should be suspected in any child with fever, cyanosis, & any abnormal respiratory finding on exam. kids
initial screening test for late-onset male hypogonadism.
A serum total testosterone level is recommended as the initial screening test for late-onset male hypogonadism. Due to its high cost, a free testosterone level is recommended only if the total testosterone level is borderline and abnormalities in sex hormone–binding globulin are suspected. Follow-up LH and FSH levels help to distinguish primary from secondary hypogonadism
what does a low TSH mean In a patient receiving levothyroxine,
In a patient receiving levothyroxine, a low TSH level usually indicates overreplacement. If this occurs, the dosage should be reduced slightly and the TSH level repeated in 2–3 months’ time
herpetic gingivostomatitis
peds
gingivostomatitis due to a primary or initial infection with herpes simplex virus type 1 (HSV-1). After a primary HSV-1 infection with oral involvement, the virus invades the neurons and replicates in the trigeminal sensory ganglion, leading to recurrent herpes labialis and erythema multiforme, among other things. Antibiotics are not useful for the treatment of herpetic gingivostomatitis and could confuse the clinical picture should this child develop erythema multiforme, which occurs with HSV-1 infections. the only specific treatment listed is acyclovir suspension, which has been shown to lead to earlier resolution of fever, oral lesions, and difficulties with eating and drinking. It also reduces viral shedding from 5 days to 1 day (SOR B).
don’t confuse with coxsackie
Anterior cruciate ligament (ACL) tears
most accurate maneuver for detecting an ACL tear is the Lachman test, followed by the anterior drawer test and the pivot shift test. McMurray’s test is used to detect meniscal tears.
how can you determine if monoclonal gammopathy of undetermined significance (MGUS) has progressed to multiple myeloma?
the diagnosis of multiple myeloma is based on evidence of myeloma-related end-organ impairment in the presence of M protein, monoclonal plasma cells, or both. This evidence may include hypercalcemia, renal failure, anemia, or skeletal lesions. Monoclonal gammopathy of undetermined significance does not progress steadily to multiple myeloma.
femoral neuropathy
femoral neuropathy = mononeuropathy commonly associated with diabetes mellitus.
Diabetic polyneuropathy
Diabetic polyneuropathy is characterized by symmetric and distal limb sensory and motor deficits.
Meralgia paresthetica,
Meralgia paresthetica, or lateral femoral cutaneous neuropathy, may be secondary to diabetes mellitus, but is manifested by numbness and paresthesia over the anterolateral thigh with no motor dysfunction.
Women who use low-dose estrogen oral contraceptives have a 50% lower risk of cancer of the
Women who use low-dose estrogen oral contraceptives have at least a 50% lower risk of subsequent epithelial ovarian cancer than women who have never used them. Epidemiologic data also suggests other potential long-term benefits of oral contraceptives, including a reduced risk of postmenopausal fractures, as well as reductions in the risk of endometrial and colorectal cancers. Oral contraceptives do not reduce the risk of carcinoma of the breast, cervix, lung, or head and neck
Polymyalgia rheumatica
Polymyalgia rheumatica= inflammatory disorder in ppl> 50yrs, esp White women. clinical hallmarks of polymyalgia rheumatica are pain and stiffness in the shoulder and pelvic girdle. systemic symptoms of Polymyalgia rheumatica: Fever, night sweats, depression, fatigue, malaise, anorexia, and weight loss. treatment=Corticosteroids
Refeeding syndrome
Refeeding syndrome= potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding. hallmark biochemical feature of refeeding syndrome = hypophosphatemia.
when is laryngoscopy for hoarseness recommended
laryngoscopy is recommended when hoarseness does not resolve within 3 months or when a serious underlying cause is suspected (SOR C). The American Academy of Otolaryngology/Head and Neck Surgery Foundation guidelines state that antireflux medications should not be prescribed for patients with hoarseness without reflux symptoms
urine drug tests:
relationship between morphine & codeine
oxazepan & diazepam
morphine & methadone
Morphine is a metabolite of codeine that may be found in the urine of someone taking a codeine-containing medication; morphine is not a metabolite of methadone. Oxazepam is a metabolite of diazepam but the reverse is not true.
initial management of hypercalcemia of malignancy
initial management of hypercalcemia of malignancy includes fluid replacement with normal saline. The use of loop diuretics such as furosemide should be restricted to patients in danger of fluid overload. Although intravenous pamidronate has become the mainstay of treatment for the hypercalcemia of malignancy, it is considered only after the hypercalcemic patient has been rendered euvolemic by saline repletion.
myomectomy vs fibroid embolization for treatment of uterine fibroids
symptomatic patient with uterine fibroids unresponsive to medical therapy, myomectomy is recommended over fibroid embolization for patients who wish to become pregnant in the future.
what is associated with the use of percutaneous endoscopic gastrostomy (PEG) tubes
Increased use of restraints. Studies have shown that PEG tubes do not improve nutritional status or quality of life for residents with dementia, nor do they decrease the risk of aspiration pneumonia. Feeding tubes can also cause discomfort and agitation, leading to an increased use of restraints
COPD vs asthma
Patients with COPD are usually in their 60s. Symptoms of chronic cough (sometimes for months or years), dyspnea, or sputum production are often not reported because the patient may attribute them to smoking, aging, or poor physical condition.
Spirometry is the best test for the diagnosis of COPD. The pressure of outflow obstruction that is not fully reversible is demonstrated by postbronchodilator spirometry showing an FEV /FVC ratio of 70% or less.
screening colonoscopy guidelines
high risk group = pts w/ 1 first degree relative diagnosed with colorectal cancer or adenomatous polyps before 60yrs, or at least two 2nd degree relatives with colorectal cancer. They should start colon cancer screening at age 40, or 10 years before the earliest age at which an affected relative was diagnosed (whichever comes first) and be rescreened every 5 years.
Drug-induced pleuritis
hydralazine, procainamide, and quinidine, amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, minoxidil, and mitomycin.
how do Adenosine, digoxin, and calcium channel antagonists work and what condition should they be avoided in?
Adenosine, digoxin, and calcium channel antagonists act by blocking conduction through the atrioventricular (AV) node, which may increase the ventricular rate paradoxically, initiating ventricular fibrillation. These agents should be avoided in Wolff-Parkinson-White syndrome.
what should be used in WPW
Procainamide is usually the treatment of choice in these situations, although amiodarone may also be used.
what should you screen for before starting TNF inhibitors
Tumor necrosis factor inhibitors have been associated with an increased risk of infections, including tuberculosis. This class of agents includes monoclonal antibodies such as infliximab, adalimumab, certolizumab pegol, and golimumab. Patients should be screened for tuberculosis and hepatitis B and C before starting these drugs.
treatment for Nursing home–acquired pneumonia
empiric coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. guidelines recommend combo therapy consisting of: 1)antipseudomonal options:
- cephalosporin such as cefepime or ceftazidime - carbapenem such as imipenem or meropenem - extended-spectrum β-lactam/β-lactamase inhibitor such as piperacillin/tazobactam, 2) antipseudomonal fluoroquinolone such as levofloxacin or ciprofloxacin, or an aminoglycoside such as gentamicin, tobramycin, or amikacin 3) anti-MRSA agent (vancomycin or linezolid)
ex Ceftazidime, levofloxacin, and vancomycin
pregnancy: Li, benzos, SSRIs
Lithium is known to be teratogenic. Benzodiazepines such as alprazolam are controversial due to a possible link to cleft lip/palate. Studies have shown no significant risk of congenital anomalies from SSRI use in pregnancy, except for paroxetine.
Teriparatide
eriparatide
- treatment of severe osteoporosis, pts with multiple osteoporosis risk factors, or pts with failure of bisphosphonate therapy
- limited to 2 yrs of therapy on teriparatide, subQ, expensive
- contraindicated in patients with hx bone ca, Paget disease, hypercalcemia, or previous treatment with skeletal radiation
bacterial cystitis vs sexually transmitted urethritis
Correct.
Women who present with symptoms of acute dysuria, frequency, and pyuria do not always have bacterial cystitis. In fact, up to 30% will show either no growth or insignificant bacterial growth on a midstream urine culture. Most commonly these patients represent cases of sexually transmitted urethritis caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex virus.
STD suggeted when gradual onset, absence of hematuria, and week-long duration of symptoms A history of a new sexual partner or a finding of mucopurulent cervicitis would confirm the diagnosis. Empiric treatment with a tetracycline and a search for other sexually transmitted diseases would then be indicated.
UTIs with Escherichia coli or Staphylococcus species usually have abrupt onset, suprapubic pain or hematuria.
aspirin stroke prevention guidelines
The USPSTF recommends the use of aspirin for men 45–79 years of age when the potential benefit from a reduction in myocardial infarctions outweighs the potential harm from an increase in gastrointestinal hemorrhage (Grade A recommendation)
◾ The USPSTF recommends the use of aspirin for women 55–79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (Grade A recommendation)
◾ The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older (Grade I statement)
◾ The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 and for myocardial infarction prevention in men younger than 45 (Grade D recommendation)
what asthma medications should be used only as additive therapy and not as monotherapy because of safety concerns
Due to risk of asthma exacerbation or asthma-related death, the FDA warns against use of long-acting β2-agonists as monotherapy.
Inhaled corticosteroids, leukotriene-receptor antagonists, short-acting β2-agonists, and mast-cell stabilizers are approved for monotherapy and combination therapy in the mgmt of asthma
what medication should you avoid in CKD
NSAIDs induce renal injury by acutely reducing renal blood flow and, in some patients, by causing interstitial nephritis. High-dose aspirin should be avoided because it acts as an NSAID.
ACE-I/ARBs recommended in all diabetics b/c renoprotective. The use of low-dose aspirin and folic acid is recommended in all patients with diabetes, due to the vasculoprotective properties of these drugs.
best drug treatment for symptomatic mitral valve prolapse
primary treatment for symptomatic mitral valve prolapse is β-blockers. Asymptomatic patients require only routine monitoring, while those with significant mitral regurgitation may require surgery. Some patients with palpitations can be managed with lifestyle changes such as elimination of caffeine and alcohol. Orthostatic hypotension can often be managed with volume expansion, such as by increasing salt intake
Altitude illness
most common manifestation is acute mountain sickness, heralded by malaise and headache. Risk factors include young age, residence at a low altitude, rapid ascent, strenuous physical exertion, and a previous history of altitude illness.
- Ginkgo biloba -not recommended.
- Acetazolamide is an effective prophylactic agent, but contraindicated if sulfa allergy
- Dexamethasone =effective prophylactic & tx agent
what drugs commonly cause acute interstitial nephritis
Antibiotics, esp penicillins, cephalosporins & sulfonamides, are most common drug-related cause of acute interstitial nephritis. Corticosteroids useful for treating this condition.
NSAIDS, ACE-I, diuretics cause renal injury, but not acute interstitial nephritis.
what is Horse chestnut seed extract helpful for
Horse chestnut seed extract has been shown to have some effect when used orally for symptomatic treatment of chronic venous insufficiency, such as varicose veins. It may also be useful for relieving pain, tiredness, tension, and swelling in the legs. It contains a number of anti-inflammatory substances, including escin, which reduces edema and lowers fluid exudation by decreasing vascular permeability.
what is milk thistle helpful for
Milk thistle may be effective for hepatic cirrhosis
St Johns wort may be helpful for
St. John’s wort may be effective for treating mild to moderate depression
What is the most common cause of erythema multiforme
Herpes simplex virus (HSV) is the most commonly identified cause of this hypersensitivity reaction
pyogenic tenosynovitis
When early tenosynovitis (within 48 hours of onset) is suspected, treatment with antibiotics and splinting may prevent the spread of the infection. However, this patient’s infection is no longer in the early stages and is more severe, so it requires surgical drainage and antibiotics. A delay in treatment of these infections can lead to ischemia of the tendons and damage to the flexor tendon and sheath.
Scombroid poisoning
Scombroid poisoning is a pseudoallergic condition resulting from consumption of improperly stored scombroid fish such as tuna, mackerel, wahoo, and bonito. Nonscombroid varieties (mahi-mahi, amberjack, sardines, and herring) can also cause this problem. The poisoning is due to high levels of histamine and saurine resulting from bacterial catabolism of histidine. Symptoms occur within minutes to hours, and include flushing of the skin, oral paresthesias, pruritus, urticaria, nausea, vomiting, diarrhea, vertigo, headache, bronchospasm, dysphagia, tachycardia, and hypotension. Therapy should be the same as for allergic reactions and anaphylaxis, and will usually lead to resolution of symptoms within several hours.
what is greatest risk factor for abdominal aortic aneurysm
Cigarette smokers are five times more likely than nonsmokers to develop an abdominal aortic aneurysm (AAA). The risk is associated with the number of years the patient has smoked, and declines with cessation
Which tinea infections in children always requires systemic antifungal therapy?
Tinea capitis requires systemic therapy to penetrate the affected hair shafts.
What does elevated BNP mean
BNP lack the specificity necessary to function as absolute indicators of acute heart failure syndrome .
Elevated BNP levels associated with renal failure (because of reduced clearance), pulmonary embolism, pulmonary hypertension, and chronic hypoxia.
side effects of omeprazole (prilosec) ppi
Omeprazole is associated with an increased risk of community-acquired pneumonia and Clostridium difficile colitis. Omeprazole has also been shown to acutely decrease the absorption of vitamin B 12 , and it decreases calcium absorption, leading to an increased risk of hip fracture.
what is the most effective adjunctive therapy for pt with unipolar depression who fails single antidepressant treatment
Lithium, triiodothyronine (T3 ), and atypical antipsychotics can all provide clinical improvement when used in conjunction with the ineffective antidepressant. The American Psychiatric Association and the Institute for Clinical Systems Improvement both recommend a trial of lithium or low-dose T 3 for patients who have an incomplete response to antidepressant therapy.
Atypical antipsychotics can be used as add-on therapy, but are not as effective as lithium or T3. Anticonvulsant medications such as gabapentin have been shown to be effective in the management of bipolar affective disorder, but not as adjunctive therapy in the treatment of unipolar depression resistant to single-agent antidepressants.
first line treatment for acute cervical radiculopathy with normal radiographs
NSAIDs are the initial treatment of choice. Tricyclic antidepressants, as well as tramadol and venlafaxine, have been shown to help with chronic neuropathic pain.
Intertrigo
Intertrigo is inflammation of skinfolds caused by skin-on-skin friction and is common on opposing cutaneous or mucocutaneous surfaces. Secondary cutaneous bacterial and fungal infections are common complications. Cutaneous erythrasma may complicate intertrigo of interweb areas, intergluteal and crural folds, axillae, or inframammary regions. Erythrasma is caused by Corynebacterium minutissimum and presents as small reddish-brown macules that may coalesce into larger patches with sharp borders. Intertrigo complicated by erythrasma is treated with topical or oral erythromycin.
paronychia
often associated with chronic immersion in water, contact with soaps or detergents, use of certain systemic drugs (antiretrovirals, retinoids) and, as is most likely in a 6-year-old child, finger sucking.
findings include tenderness, erythema, swelling, and retraction of the proximal nail fold. Often the adjacent cuticle is absent.
basic treatment principles for the condition include avoidance of contact irritants, avoiding immersion of the hands in water, and use of an emollient. Topical corticosteroids is severe
patellofemoral pain syndrome
= common overuse injury observed in adolescent girls. characterized by anterior knee pain associated with activity. pain is exacerbated by going up/down stairs or running hills. associated with inadequate hip abductor and core strength
