TO Notes Flashcards
How long can a limb tolerate acute occlusion of a peripheral artery before irreversible damage?
6 hours
Exception is only acute on chronic occlusion where collaterals provide SOME perfusion
Is abnormal pulse in the unaffected limb a sign of emboli or thrombus?
Thrombus
Also look for prior history of claudication, vascular intervention, bypass
Gold standard test for diagnosis and grading of aortic dissection
CTA
Tear in intima allowing blood to go into media
MRA if CTA contraindicated
What are conditions that predispose to priapism where PDE inhibitors should not be used?
Leukemia, myelofibrosis, polycythemia, sickle cell disease
Contraindicated in patients on nitrates due to severe hypotension
Medications for benign prostatic hyperplasia
- Alpha blockers (terazosin or doxazosin, tamsulosin, afluzosin, silodosin) - watch for headache, leg edema, presyncope
- 5 alpha reductase inhibitors (finasteride, dutasteride) - blockers conversion of test to DHT and reduces prostatic volume - watch for sexual dysfunction
Medications for prostate carcinoma
- GnRH agonist (leuprolide, goserelin, degarelix) - watch for hot flashes, headaches, decreased libido
- Non steroidal antiandrogen (flutamide, bicalutamide, abiraterone, enzalutamide) - watch for hepatotoxicty, high triglycerides, periheral edema
What medications can you give for an overactive bladder?
- Oxybutynin (antispasmodic and anticholinergic)
- Tolterodine, trospium, solifenacin, darifenacin, fesoterodine, proiverine (anticholingerics)
- Mitabegron (beta3 agonist)
- Imipramine (TCA) better for stress incontinence
- Botulinum injection (neurotoxin)
What should all patients with suspected uretehral injury undergo?
Retrograde urethrogram or cystoscopy
Blood at meatus, high riding prostate on DRE, penile/scroal hematoma, distended bladder
What meds are NSAIDs and what are their contraindications?
Ibuprofen Advil, diclofenac Voltaren (+- misoprostol Arthrotec), naproxen Aleve, meloxicam
Contraindicared in GI bleeds, renal problems, pregnancy or if pt is anticoagulated
What is tylenol (acetaminophen) contraindicated in?
Severe liver disease
It is first line for osteoarthritis though
What needs to be done if you are starting a patient on a newer DMARD biologic (ie etanercept, infliximad, adalimumab, golimumab abatacept, rituximab)?
Patients require negative TB skin test, CXR, & negative hepatitis B serology
Be mindful that there is increased risk of: infections, worsened heart failure, multiple sclerosis and positive autoantibodies
Do pneumonia, shingles and hepatitis B vaccines 2 weeks prior ideally
Bronchodilator in acute reversible airway obstruction
SABA (short acting beta2 agonist)
Salbutamol or albuterol
Maintenance treatment and prevention of bronchospasm in COPD or asthma
LABA
Salmeterol, formoterol, indacterol
Short and long acting anticholinergics used in asthma and COPD
Short = ipratropium bromide
Long = tiotropium bromide
Watch for palpations, anxiety, dizziness, fatigue
Medication for status asthmaticus
Prednisone or methylprednisolone oral
Can also be used for acuter exacerbation of COPD, bad asthma, PCP pneumo
Medications for community acquired pneumonia
Amoxicillin
Macrolide - erythromycin, azithromycin, clarithromycin
Tetracycline - Doxycycline
Fluoroquinolone - levofloxacin, moxifloxacin
Pressor medications
Use for hypotension or intropic support
Norepinephrine
Phenylephrine
Dobutamine
Who is dialectical behavioral therapy used in?
People with borderline personality disorder
Combined CBT and Buddhist Zen mindfullness practices
What dopamine pathways are affected in schizophrenia?
Mesolimbic = high dopamine causes positive symptoms
Mesocortical = low dopamine causes negative symptoms
Medications for the treatment of acute psychosis in the emergency setting
Haloperidol IM
Loxapine PO or IM
Olanzapine PO or IM
Risperidone Liqui
Typical antipsychotics
Haloperidol, fluphenazine, zuclopenthixol, perphenazine, loxapine, chlorpromazine
Chlorpromazine and haloperidol highest risk of QT prolongation
Atypical antipsychotics
Risperidone, paliperidone, olanzapine, asenapine, ziprasidone, aripiprazole, quetiapine, clozapine
Ziprasidone and clozapine highest risk of QT prolongation
Neuroleptic malignant syndrome features
FARM (think of going crazy on the farm)
Fever
Autonomic changes (high HR/BP, sweating)
Rigidity
Mental status changes
IF THERE IS SHIVERING, RESTLESSNESS, TWITCHINESS, VOMITING, DIARRHEA OR STOMACH PAIN THINK MORE OF SEROTONIN SYNDROME
More due to antipsychotics causing dopamine disturbances
Young pt with mental health changes, fever, ridigity, autonomic instability over 2-3 days with increased creatine phosphokinase, leukocytosis, myoglobinuria
RX: STOP MED, COOL, DANTROLENE, AMANTADINE OR BROMOCRIPTINE
What meds block the affects of dopamine and what are generalised side effects?
Antipsychotics
EPS, galactorrhea, amenorrhea, erectile dysfunction, weight gain
Name the extrapyramidal symptoms
DYSTONIA sustained abnormal posture, muscle spasms, oculogyric crisis
AKATHISIA crawling sensation relieved by walking
PARKINSONISM tremor, rigid, absent arm swing, stooped posture, shuffling gait
DYSKINESIA purposelessness, involuntary facial and mouth movements, can sometimes show up as hiccups
RX BENZTROPINE, DIPHENHYDRAMINE (anticholergics but DO NOT GIVE FOR TD AS THESE WORSEN SYMPTOMS - can try clozapine for TD)
How long does it take antidepressants to work?
1-3 weeks for neuro vegetative and physical symptoms
2-6 weeks for emotional and cognitive symptoms
MONITOR FOR SUICIDAL BEHAVIOR FOR FIRST TWO WEEKS
SSRI medications and what they are useful for
Fluxoetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram
Good for typical and atypical depression, seasonal, anxiety, OCD and other eating disorders
Which SSRI is best in pregnancy and breast feeding
Sertraline
SNRI medications and what conditions they are useful for?
Venlafaxine, desvenlafaxine, duloxetine
Good for depression, anxiety, neuropathic pain
sad, scared, suffering
What type of medication is bupropion?
NDRI
Increases risk of seizures
Contraindicated in strokes or head injury
Bad for anxiety as it has stimulating effects
Which TCA is good in OCD?
Clomipramine gold standard
Required ECG monitoring, highly lethal in overdose
What kind of medications are nortriptyline and desipramine?
TCAs (secondary amines)
Prefered because less anticholinergic effects
What medication class good for refractory depression?
Hint: cheese
MAO inhibitors such as phenelzine and tranylcypromine
What medications are mood stabilizers are what is their main indication?
Divaloproex, lamotrigine, carbamazepine, lithium
Use for long term stabilization of bipolar disorder or monotherapy/conjunction with atypical for acute bipolar disorder
What mood stabilizer do you need to order LFTs before initiating?
Divalproex and carbamazepine
Of note they both riase the seizure threshold
What drugs increase risk of lithium toxicity?
NSAIDs, thiazides, ACEi, metronidazole
Which mood stabilizer is associated with Steven Johnson Syndrome?
Lamotrigine
Who are benzos contraindicated in?
Myasthenia gravis, major depression (unless it is an adjunct), drug/alcohol misuse history, caution in pregnancy/breastfeeding
Cause GABA to bind it receptors to decrease neuronal activity
Benzos that are safe in impaired liver function
LOT
Lorazepam
Oxazepam
Temazepam
LIVER OK THINGS
What is the preferred med for generalized anxiety disorder?
Buspirone
Non sedating
Does not react with alcohol
Does not alter seizure threshold
Not prone to abuse
What are the short acting benzos?
LOAT
Lorazepam - high dependency
Oxazepam - use for alcohol withdrawl or GAD
Alprazolam - As above
Temazepam - dont use
Triazolam - overnight plane travel but risk of rebound insomnia
What is WHO’s Pain Relief Ladder steps
Non opioid + adjuvant
Then add opioid
Then add stronger opioid
Pediatric otitis media treatment
Amoxicillin
Colic definition
Paroxysms of unexplained irritability and crying for more than 3 hours per day for more than 3 days per week for more than 3 months in an otherwise healthy baby
Rx: Relief and reassurance and rest, maybe try changing feeding technique, try eliminating allergens
When to initiate treatment in primary enuresis?
Not until 7 years old because there is a high rate of spontaneous cure
Bladder control has never been attained
Leading cause of death of 1-12 month old babies
SIDS
Risks: prematurity, alcohol use, soft bed, low birthweight, Indigneous, no prenatal care, smoking in household, prone sleep position, poverty, bed sharing, drugs
MC congenital heart defect in children
VSD
Baby who throws up (non bilious) very soon after birth and is drooling, choking, in resp distress, cannot feed and cyanotic
Excessive secretions SOON AFTER BIRTH
Think TE fistula
On exam you wont be able to advance the NG tube
Do upper GI series with contrast
Baby who projectile vomits (non bilious) within 30 minutes of feeding, is fatigued and dehydrated and has palpable olive mass in RUQ
Think pyloric stenosis
Look for hypokalemic, hypochloremic metabolic acidosis on ABG
What is the most common cause of pediatric hearing loss?
Otitis media with effusion
90% resolve in 3 months
Surgical rx: myringotomy with tempanostomy
What are vesiscles/erosions on the pharynx/tongue caused by vs buccal mucosa/tongue?
Pharynx = posterior = Coxsackie A (Hand foot and mouth)
Buccal = anterior = herpes simplex
Medical treatment for GAS
Penicillin V or amoxicillin or erythromycin (if penicillin allergy)
PEA
Pharyngitis, sclarlet fever, rheumatic fever, PSGN
What is piperacillin with tazobactam used to treat?
Pseudomonas coverage
Gram +
Gram - aerobes
What nasal sprays are bad in pts with preexisting HTN?
Decongestants like xylometazoline, oxymetazoline, phenylephrine
What medications are used for migraine prophylaxis vs acute migraine
Prophylaxis = topiramate or propanolol
Acute = sumatriptan or dihydroergotamine
Which medications are loops and what electrolyte changes do they cause?
Furosemide, bumetanide, ethacrynate, torsemide
Hypokalemia
Hyponatremia
Hypocalcemia but hypercalciuria (stones)
Precipitate gout
Which medication class increases calcium excretion? Which decreases it?
Loops LOSE calcium (increased excretion)
Thiazides TIGHTLY hold calcium
(decreased excretion - used for hypercalciuria and stones)
Features of malignant lymphadenopathy
Firm
Non tender
Enlarging
Immobile
Worrisome location like supraclavicular or generalized
Abnormal imaging or bloodwork
Constitutional symptoms
Fluctuance, warmth, or tenderness are more suggestive of benign nodes
How many doses of MMR are required?
2 doses of MMR after 12 months and at least 28 days apart
Drugs that prolong QT
Normal QTc 350-450
Antiarrhythmics
Antipsychotics (hal/zip)
Antibiotics (macrolides ery/azi)
Antidepressants (cital)
Things that decrease QT
Digoxin
Hypothyroid
Increased calcium
Signs of adrenal insufficiency
Fatigue
Weight loss
GI issues
Hypotension
Electrolyte disturbance
Do ACTH stimulation test
Guillain Barre cause and presentation
MC a/w Campylobacter
Acute rapidly evolving demyelinating inflammatory polyradiculoneuropaty that starts in the lower limbs and moves up
Look for a child with paresthesias, weird walk, poor propioception and vibration, weakness, areflexia, BP dysregulation and bladder dysfunction
Consider CSF to look for HIGH PROTEIN AND NORMAL WBC (albumocytologic dissociation)
Treat with IVIG and pain management
First line treatment for severe hypercalcemia
FLUIDS
THEN furosemide to prevent heart failure from high volume saline
THEN Alendronate and/or calcitonin (take 24-48 hours to work)
Most common cutaneous malignancy in immunocompromised patients such as organ transplant recipients
Squamous cell carcinoma
HTN and hypokalemia
Consider primary hyperaldosteronism
Underdiagnosed cause of HTN
K could be normal
TEST WITH PLASMA ALDOSTERONE TO PLASMA RENIN ACTIVITY RATIO (should be more than 20 in normal)
