Quiz 12 Flashcards
pharmacokinetics. Which is increased in old people
Correct.
The physiologic changes that accompany aging result in altered pharmacokinetics. In older persons there
is a relative increase in body fat and a relative decrease in lean body mass, which causes increased
distribution of fat-soluble drugs such as diazepam. This also increases the elimination half-life of such
medications. The volume of distribution of water-soluble compounds such as digoxin is decreased in older
patients, which means a smaller dose is required to reach a given target plasma concentration. There is also
a predictable reduction in glomerular filtration rate and tubular secretion with aging, which causes
decreased clearance of medications in the geriatric population. The absorption of drugs changes little with
advancing age. All of these changes are important to consider when choosing dosages of medications for
the older patient.
Based on current evidence, which one of the following NSAIDs would you recommend as being
LEAST likely to be associated with an increased risk of myocardial infarction
NSAIDs cause an elevation of blood pressure due to their salt and water retention properties. This effect
can also lead to edema and worsen underlying heart failure. In addition, all NSAIDs can have a deleterious
effect on kidney function and can worsen underlying chronic kidney disease, in addition to precipitating
acute kidney injury. Celecoxib, ibuprofen, meloxicam, and diclofenac are associated with an increased risk
of cardiovascular adverse effects and myocardial infarction, compared with placebo. However, naproxen
has not been associated with an increased risk of myocardial infarction and is therefore preferred over
other NSAIDs in patients with underlying coronary artery disease risk factors
A 32-year-old male smoker presents with a 4-day history of progressive hoarseness. He is almost
unable to speak, and associated symptoms include a cough slightly productive of yellow sputum,
as well as tenderness over the ethmoid sinuses.
Acute laryngitis most often has a viral etiology and symptomatic treatment is therefore most appropriate.
A Cochrane review concluded that antibiotics appear to have no benefit in treating acute laryngitis.
A 26-year-old female presents with acute low back pain. She says it started a week ago after she
lifted a sofa when helping a friend move. The patient’s medical history is otherwise negative.
The patient says the pain is limited to the lower back. The physical examination is normal,
including the neurologic examination.
Low back pain is one of the most common reasons for visits to physicians. The workup should start with
a thorough history and physical examination to determine whether the patient has nonspecific back pain,
back pain possibly related to radiculopathy or spinal stenosis, or back pain due to some other specific
cause. Nonspecific back pain does not require imaging (SOR B). An initial plain film would be appropriate
if there were a history of recent significant trauma, or even a history of minor trauma in an elderly patient.
Immediate MRI would be appropriate in the presence of other red flags such as bladder dysfunction,
areflexia, saddle anesthesia, progressive motor weakness, a history of cancer, or the presence of fever,
unexplained weight loss, or night sweats.
blood
pressure measurements average >175/105 mm Hg
potassium levels <3.5 mEq/L (N 3.5–5.0) despite increasing dosages of
oral potassium supplements,
Hyperaldosteronism, usually caused by a hyperaldosterone-secreting adrenal mass, has to be considered
in a middle-aged patient with resistant hypertension and hypokalemia. Peripheral aldosterone concentration
(PAC) and peripheral renin activity (PRA), preferably after being upright for 2 hours, are the preferred
screening tests for hyperaldosteronism. A PAC >15 ng/dL and a PAC/PRA ratio >20 suggest an adrenal
cause. Abdominal CT may miss adrenal hyperplasia or a microadenoma. Renal CT angiography is useful
for detecting renal artery stenosis. If the PAC/PRA is abnormal, an aldosterone suppression test should
be ordered.
Henoch-Schönlein purpura (HSP),
This patient meets the clinical criteria for Henoch-Schönlein purpura (HSP), an immune-mediated vasculitis
found commonly in children under the age of 10. The clinical triad of purpura, abdominal pain, and
arthritis is classic
Almost 95% of children with HSP spontaneously improve, so supportive therapy is the main intervention.
Acetaminophen or ibuprofen can be used for the arthritic pain. However, ibuprofen should be avoided in
those with abdominal pain or known renal involvement.
elective
cholecystectomy. He is also being treated for panhypopituitarism
A patient with known adrenal insufficiency secondary to hypopituitarism who is undergoing a period of
stress such as illness or surgery should be given intravenous corticosteroids. For moderate-risk procedures
such as vascular or orthopedic operations, 50 mg of hydrocortisone is recommended. For major surgery,
such as open heart surgery or an esophagectomy, 100 mg of hydrocortisone would be needed. These doses
can be repeated every 8 hours until the patient is stable and is able to take his usual oral maintenance dose.
In which one of the following patients should a creatine kinase level be obtained to detect
Duchenne muscular dystrophy?
15 month-old male who is walking but is unable to stand up from a supine position without support
Infants should roll from prone to supine by 4 months of age and supine to prone by 6 months of age. They
should be able to get themselves into a sitting position by 9 months of age. While low muscular tone in an
infant suggests muscular dystrophy, high muscle tone is concerning for an upper motor neuron condition
and should be evaluated with MRI.
Kawasaki disease
also known as mucocutaneous lymph node syndrome.
It is an acute type of vasculitis that predominantly affects small and medium-size vessels and is the most
common cause of acquired coronary artery disease in childhood.
Diagnostic criteria include fever for at least 5 days and at least 4 of the 5 principal clinical features:
• changes of the oral cavity and lips
• polymorphous rash
• bilateral nonpurulent conjunctivitis
• changes in the extremities (erythema followed by desquamation)
• cervical lymphadenopathy
Coronary abnormalities, including coronary aneurysms, are the most concerning sequelae of Kawasaki
disease and may occur in the first week. For this reason early cardiac evaluation is recommended, with
transthoracic echocardiography being the preferred initial imaging. Radionuclide imaging can be useful
in assessing cardiac perfusion in patients found to have persisting echocardiographic findings. MR
coronary angiography can be used to assess response to treatment over time. Intravenous immunoglobulin
and corticosteroids reduce the risk of coronary abnormalities and should be administered as soon as the
disease is suspected.
Which one of the following is true regarding electronic cigarettes?
Electronic cigarettes (e-cigarettes) are not currently regulated by the FDA. The amount of particulate
matter released into the air by low-nicotine e-cigarettes is comparable to that released by tobacco
cigarettes, while higher-nicotine e-cigarettes release more particulate matter. E-cigarettes have various
concentrations of nicotine in solution. While the number of tobacco cigarettes smoked per day is decreased
in e-cigarette users, this has not yet been shown to lead to smoking cessation. There are no studies of
e-cigarettes in pregnant women, and nicotine is contraindicated during pregnancy.
