PRACTICE QUESTIONS IN CLASS Flashcards
Neurodegnerative diseases include:
Alzheimer’s disease
Dementia with Lewy body
Parkinson’s disease with dementia
Frontotemporal dementia
Huntington disease
Chronic traumatic encephalopathy
Corticobasal degeneration (CBD)
Progressive supra nuclear palsy (PSP)
True or false dementia can be Alzheimers disease
True
True or false there are many forms of dementia
True
What are the types of non- neurodegenrative diseases?
vascular dementia
alcohol-related dementia
normal pressure hydrocephalus
chronic subdural hematoma
neurosyphilis
HIV associated dementia
Creutzfeldt-Jakob (CJD)
Neurodegenerative you cannot correct
You cannot correct the brain
Nonneurodegenerative disease
You can correct like vascular dementia- correct hypertension and high cholesterol
Most dementias are considered neurodegenerative caused by the progression of neuron loss over time
The most common type of dementia is?
Alzheimer’s disease (neurodegenerative disease)
Dementias invariably process over time
Nonneurodegenerative dementias may be reversible or their progression slowed if the underlying cause is identified
What is the most common non- neurodegenerative dementia?
vascular dementia- caused by a stroke or cerebral small vessel disease (think baba)
People with depression have a higher risk for developing headaches
Anyone with chronic pain is at higher risk for developing depression (think Stella)
If a patient has extrapyramidal symptoms (EPS) with bipolar I how do we fix it?
EPS can happen with any antipsychotic medication
If a patient has extrapyramidal symptoms (EPS) with bipolar I how do we fix it?
Treatment is either gradual dose reduction or D/C causative agent then trial anticholinergics, benzos, beta blockers, muscle relaxants based on the symptoms
What is a new drug that treats Tardive Dyskinesia
Ingrezza (valbenazine)
For bipolar I do we change medication depending on depression or mania?
We add on the regimen in a stepwise approach- drug of choice depends on symptoms
Bipolar I if the patient is manic we?
start the patient on a mood stabilizer
In bipolar I if the symptoms are no controlled?
add a antipsychotic
In bipolar I if the patient has depression?
start antipsychotic
What is the difference between bipolar I disorder versus bipolar 2 disorder
Many patients can be on a mood stabilizer or antipsychotic.
Type I- more severe form- true manic episodes
Type II- less severe hypomanic- not as much highs as in mania
A 27 year old patient c/o 3 year h/o depressed mood, loss of interest in hobbies, & low energy levels. The MD prescribes fluoxetine to help improve mood. After 2 weeks she returns saying does not feel better
A. add sertraline
B. Do nothing
C. Increase the dose
D. stop the drug
E. switch to another drug
B. do nothing - wait 2-4 weeks with SSRI medications
SEVERE SYMPTOMS- INCREASE SOONER
The patient is a 27-year-old woman with a 3-year history of depressive symptoms who was prescribed fluoxetine (an SSRI antidepressant). Key points to consider:
Antidepressant medications, including SSRIs like fluoxetine, typically require 4-6 weeks to achieve full therapeutic effect
2 weeks is too early to evaluate the efficacy of the medication
No side effects or adverse reactions were mentioned in the case
Evaluation of Options
(A) Add sertraline - Adding another SSRI would be inappropriate and potentially dangerous (serotonin syndrome risk)
(B) Do nothing - This is the correct approach as more time is needed to evaluate efficacy
(C) Increase the dose - Premature dose adjustment before allowing adequate time for the initial dose to work
(D) Stop the drug - Discontinuation is not warranted as the medication hasn’t had sufficient time to work
(E) Switch to another drug - Switching medications before allowing adequate trial period is not recommended
Correct Answer
(B) Do nothing
The physician should explain to the patient that antidepressants typically take 4-6 weeks to show full therapeutic effect, and encourage the patient to continue the current treatment while monitoring for improvement or side effects.
These medications take several weeks to reach maximum therapeutic effect. Continue to take it for two more weeks before you decide it isn’t helping.”
EPS
gradual dose reduction to see if it stops or d/c if they can tolerate.
EPS can also treat the symptoms- these symptoms can be mild to life threatening
mild symptoms:
-anticholinergics
-benzos
-beta blockers
-muscle relaxers
**this depends on what symptoms they are actually having!!!
serious symptoms- send them to the emergency department
Cyclothymic Disorder
Presence of hypomanic & depressive symptoms that do not meet the full criteria of hypomania episode or a depressive episode. They must occur over 2 years patients may not have symptom free periods for more than 2 months.
Watch patient for to see if they develop bipolar 2 and even bipolar I category
You diagnose a 31 year old patient with otitis externa and tympanic membrane perforation. Which of the following is appropriate for this patient and will offer analgesic effect?
a. ciprofloxacin/dexamethason
b. OTC swimmers ear drops - not safe to go in the middle ear
c. neomycin/polymixin - not safe to go in the middle ear
d. acetic acid/propylen glycol/hydrocortisone- not safe to go in the ear
ans. a. ciprofloxacin/dexamethasone
This is the only option that is both safe and effective for otitis externa with tympanic membrane perforation, as it provides antimicrobial coverage and anti-inflammatory effects without risking ototoxicity.
Ciprofloxacin/dexamethasone:
Ciprofloxacin is a fluoroquinolone antibiotic that is non-ototoxic
Dexamethasone is a corticosteroid that reduces inflammation
This combination is specifically formulated to be safe for use with tympanic membrane perforations
OTC swimmers ear drops:
Often contain alcohol or other potentially ototoxic ingredients
Not safe for use with tympanic membrane perforations as they can cause damage if they enter the middle ear
Neomycin/polymyxin:
Neomycin is an aminoglycoside antibiotic with known ototoxicity
Can cause permanent hearing loss if it enters the middle ear
Contraindicated in patients with tympanic membrane perforations
Acetic acid/propylene glycol/hydrocortisone:
Acetic acid can be irritating and potentially ototoxic
Not safe for use with tympanic membrane perforations
externa- infection
TM perforation- the med safe to go into the inner ear
A 30 year old patient presents to the office after starting sertraline for 2 weeks he reports his depression is severe what should you do?
- Keep the scheduled dose
- Increase the dose
- Change the medication
- What the fuck
Increase the dose- because the patient has severe symptoms
What medications are unsafe to go into the middle ear?
OTC swimmers ear drops:
Often contain alcohol or other potentially ototoxic ingredients
Not safe for use with tympanic membrane perforations as they can cause damage if they enter the middle ear
Neomycin/polymyxin:
Neomycin is an aminoglycoside antibiotic with known ototoxicity
Can cause permanent hearing loss if it enters the middle ear
Contraindicated in patients with tympanic membrane perforations
Acetic acid/propylene glycol/hydrocortisone:
Acetic acid can be irritating and potentially ototoxic
Not safe for use with tympanic membrane perforations
What medication would be safe to go into the middle ear?
ciprofloxacin/dexamethasone
This is the only option that is both safe and effective for otitis externa with tympanic membrane perforation, as it provides antimicrobial coverage and anti-inflammatory effects without risking ototoxicity.
You have an 80 year old female patient who complains of a headache. Which of the following is not included within the differential?
A. brain tumor
B. subarachnoid hemorrhage
C. ischemic stroke
D. all are within the differential
D. all are within the differential
You have a 30 year old patient with skin infections secondary to MRSA. The patient has no chronic medical conditions, denies smoking, or alcohol use. She does have allergies to sulfa and penicillin. Which of the following is most appropriate for this patient?
A. Dicloxacillin
B. Doxycycline
C. Ciprofloxacin
D. Trimethoprim/sulfamethoxazole
ans. B doxycycline
Treatment for MRSA some of the best choices would be for a patient who is allergic to sulfa and penicillin?
A. Dicloxacillin
B. Doxycyline
C. Ciprofloxacin
D. Trimethoprim/sulfamethozazole
Doxycycline
or Bactrim- TMP/SMX
BUT patients who are allergic to sulfa cannot take Bactrim!!!
For less severe MRSA skin infections
- Trimethoprim-sulfa- methoxazole (Bactrim)
- Clindamycin
- Doxycycline or minocycline
Decolonization protocols - To eliminate MRSA carriage:
Mupirocin nasal ointment
Chlorhexidine body washes
Sometimes oral antibiotics
Which of the following provides coverage against beta hemolytic strep & MRSA?
A. Amoxicillin
B. Trimethoprim/sulfamethoxazole
C. Nitrofurantoin
D. Cephalexin
answer- D. Cephalexin
A.- Amoxicillin-Effective against beta hemolytic streptococci.
Not effective against MRSA (MRSA is resistant to beta-lactam antibiotics)
B. Trimethoprim/sulfamethoxazole (TMP-SMX)
Limited activity against beta hemolytic streptococci (not reliable)
Effective against many MRSA strains (commonly used for community-acquired MRS
C. NitrofurantoinLimited activity against beta hemolytic streptococci
Not effective against MRSA
Primarily used for urinary tract infections only
D.Effective against beta hemolytic streptococci
Crying spells we want to assess the patients neuro and psychiatric history
What screening tools would we use for her psych?
Screening tools for this patient:
-Geriatric depression scale
-PHQ-9
-Check cognition
-MOCHA okay but you have to be certified to do MOCHA
- Mini- mental status exam
If we are concerned about anxiety symptoms what screening tool would we use?
GAD-2 versus GAD-7
The patient has post-nasal drip and congestion
allergic rhinitis
Anytime the patient is on medication- there needs to be a matching diagnosis.
How would you treat her allergic rhinitis?
Restart Flonase because it has been working for the patient
The loratadine is not helping what other antihistamine would we consider prescribing?
- Allegra- Dr. Clabo likes this drug - It does not cross the blood brain barrier so it does not make you sleepy
Zyrtec- not great to use because of drowsiness
Claritin (loratadine) is a non-drowsy antihistamine that treats allergy symptoms. It can relieve sneezing, runny nose, itchy and watery eyes, and itchy throat or nose. Claritin can be taken by adults and children ages 6 and up.
Fexofenadine (oral route) (Allegra) to treat allergic rhinitis
Fexofenadine is an antihistamine. It is used to relieve the symptoms of hay fever (seasonal allergic rhinitis) and hives of the skin (chronic idiopathic urticaria) .
This 1 is a great 1 because it does not cross the blood brain barrier
However, elderly patients are more likely to have age-related kidney problems, which may require an adjustment in the dose for patients receiving fexofenadine .
Montelokast
not same class as antihistamine- this can cause very bad nightmares + some psychiatric side effects
Nondrowsy antihistamine
GAD-7 what does a score of 12 mean? mild, moderate, severe
moderate anxiety
PH-9= + at 17 points- Is this mild, moderate, etc.
moderately severe
Remeron
Buspar
Buspirone is a non-benzodiazepine anxiolytic medication primarily used to treat anxiety disorders. It is a partial agonist of the serotonin 5-HT1A receptor, which means it can both stimulate and inhibit the activity of this receptor.
The 5-HT1A receptor is a type of serotonin receptor found throughout the central nervous system, including the hippocampus, amygdala, and septal nuclei. These areas are involved in emotion regulation, stress response, and anxiety. By partially activating the 5-HT1A receptor, buspirone helps to modulate the release of neurotransmitters such as serotonin, dopamine, and norepinephrine, thereby reducing anxiety symptoms.
Buspirone has several advantages over benzodiazepines, which are also used to treat anxiety disorders. Unlike benzodiazepines, buspirone is not associated with sedation, muscle relaxation, or amnesia. It also has a lower potential for abuse and dependence. However, buspirone has a slower onset of action compared to benzodiazepines and may take several weeks to achieve its full therapeutic effect.
Final answer: Buspirone is a non-benzodiazepine anxiolytic medication that acts as a partial agonist of the serotonin 5-HT1A receptor, reducing anxiety symptoms by modulating the release of neurotransmitters such as serotonin, dopamine, and norepinephrine. It has several advantages over benzodiazepines, including a lower potential for abuse and dependence, but has a slower onset of action and may take several weeks to achieve its full therapeutic effect.
Alprazolam
You are seeing a 42 year old female for the first time. She is not taking any medication at this time. She has a history of severe depression with past suicide attempts. Upon assessment and through shared decision making, you and the patient decide it is best to treat her depression with medication and therapy. Which of the following medications should be avoided?
Paroxetine (Paxil) - This is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. It is generally safe and effective, but like all medications, it can have side effects.
Duloxetine (Cymbalta) - This is a serotonin and norepinephrine reuptake inhibitor (SNRI) used to treat depression and anxiety. It is generally safe and effective, but like all medications, it can have side effects.
Desipramine (Norpramin) - This is a tricyclic antidepressant (TCA). TCAs are older medications that are not typically first-line treatments for depression due to their side effect profiles and potential for toxicity in overdose. They can be lethal in overdose, which could be a concern in a patient with a history of suicide attempts.
Sertraline (Zoloft) - This is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. It is generally safe and effective, but like all medications, it can have side effects.
Mirtazapine (Remeron) - This is an atypical antidepressant that is often used to treat depression. It is generally safe and effective, but like all medications, it can have side effects.
The medication that should be avoided in this case is Desipramine (Norpramin) due to its potential for toxicity in overdose, which could be a concern in a patient with a history of suicide attempts.
Which SSRI is considered the drug of choice for treating depression in elderlypatients due to its favorable side effect profile? Fluoxetine Sertraline Paroxetine Citalopram
Fluoxetine: This SSRI is effective for treating depression but is not typically the first choice for elderly patients due to its longer half-life and potential for drug interactions.
Sertraline: This SSRI is often preferred for elderly patients because it has a favorable side effect profile and fewer drug interactions.
Paroxetine: This SSRI is generally avoided in elderly patients due to its anticholinergic effects, which can cause confusion and other cognitive issues.
Citalopram: This SSRI is also considered a good option for elderly patients due to its relatively mild side effect profile, but it can cause QT prolongation at higher doses.
what drug would you give an older patient who has anxiety and depression with vascular dementia who is allergic to SSRIs
For an older patient with anxiety, depression, and vascular dementia who is allergic to SSRIs, mirtazapine would be an appropriate choice.
Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA)
that can address both depression and anxiety symptoms while having a favorable side effect profile for elderly patients. It may help with sleep disturbances and has minimal anticholinergic effects, which is important in vascular dementia where cognitive function is already compromised.
Other options might include SNRIs like duloxetine or venlafaxine,
but these should be used cautiously with close monitoring for cardiovascular effects and potential drug interactions.
Trazodone at lower doses could also be considered, particularly if sleep disturbances are prominent. Any medication choice should start at low doses with careful titration and regular monitoring for efficacy and adverse effects.
First-line therapy for uncomplicated MRSA skin infections is typically TMP-SMX or doxycycline, with clindamycin as alternative when susceptible.
Clindamycin: Lincosamide antibiotic that inhibits bacterial protein synthesis by binding to 50S ribosomal subunit
TMP-SMX (Trimethoprim-Sulfamethoxazole): Sulfonamide combination that inhibits bacterial folate synthesis
Doxycycline and Minocycline: Tetracycline antibiotics that inhibit protein synthesis by binding to 30S ribosomal subunit
Linezolid: Oxazolidinone antibiotic that inhibits protein synthesis by binding to 23S rRNA of 50S ribosomal subunit
Specific attributes of these MRSA antibiotics:
All are effective against MRSA through mechanisms that bypass β-lactam resistance
All are available in oral formulations, facilitating outpatient treatment
Resistance patterns vary geographically, requiring local susceptibility monitoring
Side effect profiles differ significantly (e.g., C. difficile risk with clindamycin, photosensitivity with tetracyclines)
Cephalexin, dicloxacillin, and clindamycin are antibiotics that work by different mechanisms to treat bacterial infections.
Cephalexin:
First-generation cephalosporin antibiotic
Mechanism: Inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins
Spectrum: Effective against many gram-positive bacteria and some gram-negative bacteria
MRSA effectiveness: Generally ineffective against MRSA (methicillin-resistant Staphylococcus aureus)
Beta-hemolytic strep effectiveness: Highly effective against beta-hemolytic streptococci
Notable attributes: Oral administration, relatively low cost, good tissue penetration
Dicloxacillin:
Penicillinase-resistant penicillin antibiotic
Mechanism: Inhibits bacterial cell wall synthesis similar to other beta-lactams
Spectrum: Narrow spectrum focused on gram-positive organisms
MRSA effectiveness: Generally ineffective against MRSA
Beta-hemolytic strep effectiveness: Effective against beta-hemolytic streptococci
Notable attributes: Resistant to beta-lactamase enzymes produced by some bacteria, good oral absorption
Clindamycin:
Lincosamide antibiotic
Mechanism: Inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit
Spectrum: Active against gram-positive aerobes and anaerobes, some gram-negative anaerobes
MRSA effectiveness: Often effective against community-acquired MRSA strains
Beta-hemolytic strep effectiveness: Highly effective against beta-hemolytic streptococci
Notable attributes: Good penetration into bone and abscesses, alternative for penicillin-allergic patients, risk of Clostridioides difficile infection
For MRSA infections, clindamycin may be effective against community-acquired strains but susceptibility testing is required. For beta-hemolytic streptococcal infections, all three can be effective, with penicillins typically being first-line therapy when the organism is susceptible.
Meds to help with anxiety in an older adult?
Buspar
Hydroxyzine
Avoid Benadryl in the older adult!!
Remeron can help with sleeping and eating
