Clinical questions - Various IM Topics

Question 1

Management of angioedema associated with ACE-i

Answer 1

caused by accumulation of bradykinin

Stop the ACE and switch to ARB when stable
Monitor for airway compromise, intubate if needed

Antihistamines for quicker resolution - H1 (benadryl) + H2 (ranitidine)

Epi and glucocorticoids are NOT helpful, they do not lower bradykinin levels

Question 2

Causes of pharyngitis

Answer 2

Viral: flu, EBV, common cold

Noninfectious: allergic rhinitis, post nasal drip

Bacterial: 
GAS, GCS, GGS
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Corynebacterium diphtheriae

Question 3

Centor Criteria and treatment of Strep pharyngitis

Answer 3

Centor criteria:

• tonsillar exudates
• tender anterior cervical adenopathy
• fever by history
• absence of cough

3-4 of these test for strep

Abx:
PO amor or PCN V for 10 days
IM PCN G X1 dose

2nd line - cephalosporins - cephalexin
PCN all: macrolide - azithro or clarithro
If Macrolide resistant and PCN allg - Clinda

Question 4

Contraindications to and side effects of phosphodiesterase -5 inhibitors

Answer 4

sildenafil, tadalafil (longest acting)

Contra:
Nitrates (NG, imdur) risk of severe hypotension
Caution in alpha blockers - terazosin or parazosyn for BPH due to risk of hypotension

Side effects:
Flushing
Headache
nasal congestion
Blue vision (sildenafil - blue pill)

Question 5

Management of anaphylaxis

Answer 5

IM epi
O2 +/- intubation
IVF
Antihistamine for itching/hives
Albuterol if not fully responding to episode
Monitor 8-10 hrs following tx

Question 6

Vitamin deficiency associated with macrocytic anemia with hypersegmentated neutrophils

Answer 6

Folate (B9) or B12

Question 7

Vitamin deficiency associated with swollen gums, poor wound healing, bleeding mucous membranes, spots on skin

Answer 7

Vit C

Question 8

Vitamin deficiency associated with dermatitis, diarrhea, dementia

Answer 8

-Pellagra

Niacin B3

Question 9

Vitamin deficiency associated with hemorrhagic disease

Answer 9

Vit K

Question 10

Vitamin deficiency associated with neural tube defects

Answer 10

Folate B9

Question 11

Vitamin deficiency associated with pernicious anemia

Answer 11

B12

Question 12

Vitamin deficiency associated with kidney disease

Answer 12

Vit D

Question 13

Vitamin deficiency associated with bitot spots, keratomalacia, xerophthalmia

Answer 13

vit A

Question 14

Vitamin deficiency associated with cheilosis and glossitis

Answer 14

B vitamins - 2, 3, 9, 12

Question 15

Vitamin deficiency associated with dilated cardiomyopathy, edema, polyneuropathy

Answer 15

Wet beriberi - Thiamin def B1

Question 16

Vitamin deficiency associated with osteomalacia and rickets

Answer 16

Vit D

Question 17

Epistaxis management

Answer 17

Direct pressure continuously for 10-15 min
Oxymetazoline (afrin) nasal spray - alpha 1 agonist
Cautery - silver nitrate or electrical
Nasal packing - nasal tampon, gauze

Question 18

Presentation and treatment of otitis externa

Answer 18

Hx of swimming, muffled hearing
Pain with manipulation of pinna
External ear canal edematous and erythematous
Scant purulent debris in canal
Normal TM

Tx: 
clean ear canal - irrigate with H2O2
Topical Abx gtt:
-Ofloxacin, ciproflox
-Polymixin B + neomycin
-Tobramycin, gentamicin
Topical steroids:
-Hydrocortisone
-Dexamethasone
Analgesics - NSAIDs, tylenol

Question 19

Allergic Rhinitis

Answer 19

Presentation: sneezing, nasal congestion, watery nasal discharge, itching eyes
PE: no cervical LAD, nasal congestion with non-purulent nasal discharge

Tx:
Glucocorticoid nasal spray
-Fluticasone (Flomax), mometasone, triamcinolone, budesonide
Nasal decongestant spray
-Oxymetazoline (afrin) no more than 2-3 days as mono therapy - risk rebound congestion
Antihistamines
-benadryl, loratadine (claritin), fexofenadine (allegra), cetirizine (zyrtec)
Montelukast (singulair)
second line: cromolyn (stabilize mast cells), ipratropium spray - anticholinergic

Nasal spray/saline rinse
SQ immunotherapy

Question 20

BPH - presentation, exam, treatment

Answer 20

urinary hesitancy, frequency, and weak urine stream gradually worsening over 3 months

PE: symmetrically enlarged, smooth, nontender
Labs: normal UA

Tx:
Alpha blockers: relaxation of sm.m. in capsule of prostate and urethra/bladder neck -> less compression of urethra
Nonselective: vasodilation -> BP effects
-doxazosin, terazosin, alfuzosin
Selective: tamsulosin, silodosin

5 alpha reductase inhibitors: block T conversion to DHT, leads to shrinkage of prostate

• Side effects: decreased libido, ED
• Finasteride, dutasteride

Question 21

Indication for antibiotics in rhinosinusitis

Answer 21

Majority caused by virus

Indications:
Sxs 7 or more days PLUS
-purulent nasal discharge
-Maxillary tooth or facial pain - esp unilateral
-unilateral maxillary sinus tenderness on exam
-Worsening sxs after initial improvement

Abx: 5-7 day course

• Augmentin
• Doxy
• Levaquin or moxifloxicin

Clarithro, azithro, 2nd or 3rd gen celphalosporins not recommended given s. pneumonia resistance

Consider nasal steroid spray in addition to abx