Mixed Flashcards
1
Q
what are absolute contraindications to electroconvulsive therapy (ECT)
A
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,
2
Q
community-acquired pneumonia
peds
A
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
3
Q
initial screening test for late-onset male hypogonadism.
A
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
4
Q
what does a low TSH mean In a patient receiving levothyroxine,
A
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
5
Q
herpetic gingivostomatitis
peds
A
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
6
Q
Anterior cruciate ligament (ACL) tears
A
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.
7
Q
how can you determine if monoclonal gammopathy of undetermined significance (MGUS) has progressed to multiple myeloma?
A
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.
8
Q
femoral neuropathy
A
femoral neuropathy = mononeuropathy commonly associated with diabetes mellitus.
9
Q
Diabetic polyneuropathy
A
Diabetic polyneuropathy is characterized by symmetric and distal limb sensory and motor deficits.
10
Q
Meralgia paresthetica,
A
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.
11
Q
Women who use low-dose estrogen oral contraceptives have a 50% lower risk of cancer of the
A
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
12
Q
Polymyalgia rheumatica
A
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
13
Q
Refeeding syndrome
A
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.
14
Q
when is laryngoscopy for hoarseness recommended
A
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
15
Q
urine drug tests:
relationship between morphine & codeine
oxazepan & diazepam
morphine & methadone
A
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.
16
Q
initial management of hypercalcemia of malignancy
A
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.
17
Q
myomectomy vs fibroid embolization for treatment of uterine fibroids
A
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.
18
Q
what is associated with the use of percutaneous endoscopic gastrostomy (PEG) tubes
A
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
19
Q
COPD vs asthma
A
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.
20
Q
screening colonoscopy guidelines
A
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.
21
Q
Drug-induced pleuritis
A
hydralazine, procainamide, and quinidine, amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, minoxidil, and mitomycin.
22
Q
how do Adenosine, digoxin, and calcium channel antagonists work and what condition should they be avoided in?
A
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.
23
Q
what should be used in WPW
A
Procainamide is usually the treatment of choice in these situations, although amiodarone may also be used.
24
Q
what should you screen for before starting TNF inhibitors
A
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.
25
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
26
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.
27
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
28
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.
29
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)
30
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
31
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.
32
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
33
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
34
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.
35
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.
36
what is milk thistle helpful for
Milk thistle may be effective for hepatic cirrhosis
37
St Johns wort may be helpful for
St. John’s wort may be effective for treating mild to moderate depression
38
What is the most common cause of erythema multiforme
Herpes simplex virus (HSV) is the most commonly identified cause of this hypersensitivity reaction
39
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.
40
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.
41
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
42
Which tinea infections in children always requires systemic antifungal therapy?
Tinea capitis requires systemic therapy to penetrate the affected hair shafts.
43
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.
44
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.
45
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.
46
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.
47
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.
48
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
49
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
50
mechanism & class
1) Repaglinide and nateglinide
2) Pioglitazone
3) Acarbose
4) Sitagliptin
5) Exenatide
Repaglinide, nateglinide = nonsulfonylureas that act on a portion of the sulfonylurea receptor to stimulate insulin secretion.
Pioglitazone is a thiazolidinedione, which reduces insulin resistance through activation of PPAR-Y, a receptor that affects several insulin-responsive genes.
Acarbose =competitive inhibitor of α-glucosidases, enzymes that break down complex carbs into monosaccharides. This delays absorption of carbs; doesn't affect glucose absorption.
Sitagliptin= DPP-IV inhibitor that inhibits the enzyme responsible for the breakdown of the incretins GLP-1 and GIP.
Exenatide= incretin mimetic that stim.insulin secretion in glucose-dependent fashion, slows gastric emptying, promotes satiety.
51
which has higher rate of neonatal cephalhematoma and retinal hemorrhage: vacuum-assisted vs forceps delivery
Vacuum-assisted delivery assoc'd with higher rates of neonatal cephalhematoma and retinal hemorrhage compared with forceps delivery.
assisted delivery with episiotomy.
52
which class of drugs are known to increase uric acid levels? decrease uric acid levels?
Diuretics such as hydrochlorothiazide are known to increase serum uric acid levels, but losartan has been shown to decrease uric acid.
53
Vocal cord dysfunction
Vocal cord dysfunction is an idiopathic disorder commonly seen in pts in their 20/30s in which the vocal cords partially collapse or close on inspiration. It mimics asthma. Symptoms include episodic tightness of the throat, a choking sensation, shortness of breath, and coughing.
54
Keratoacanthoma
Keratoacanthoma= common lesion in the elderly, but is difficult to distinguish from squamous cell carcinoma. Most keratoacanthomas undergo a benign self-healing course but may leave a large, unsightly scar.
55
initial emergency department treatment of acute asthma exacerbations
initial emergency department treatment for acute asthma exacerbations = Repeated doses of a short-acting β2-agonist and correction of hypoxia. Nebulizer no better than a metered-dose inhaler w/ a spacer. In children already receiving standard treatment with albuterol and corticosteroids the addition of intravenous magnesium sulfate has been shown to improve lung function and reduce the need for hospitalization. Oral administration of corticosteroids is as effective as IV route
56
Sudden infant death syndrome (SIDS)
Sudden infant death syndrome (SIDS) is the most common cause of death during the first 6 months of life in the United States, with a peak incidence at 2–4 months of age and a quick dropoff by the age of 6 months
57
treatment for Ethylene glycol poisoning
Ethylene glycol poisoning should be suspected in patients with metabolic acidosis of unknown cause and subsequent renal failure. treat with fomepizole (Antizol) has this specific indication, however, and should be initiated immediately when ethylene glycol poisoning is suspected. If ethylene glycol poisoning is treated early, hemodialysis may be avoided, but once severe acidosis and renal failure have occurred hemodialysis is necessary. E
58
chronic kidney disease and diabetes
| what med do you begin initially
- metformin should be avoided in CKD -Glyburide has an active metabolite that is eliminated renally. This metabolite can accumulate in patients with chronic kidney disease, resulting in prolonged hypoglycemia.
- Acarbose should be avoided in CKD b/c hasn't been evaluated in these patients.
- Glipizide doesn't have an active metabolite, and is safe in patients with chronic renal disease.
59
treatment of Essential tremor
Essential tremor =action tremor, EtOH intake will temp. cause marked reduction in tremor. β-Adrenergic blockers have been the mainstay of treatment for these tremors, but if pt is intolerant to these drugs then use primidone
60
How can you improve voiding trial, ie decrease urinary retention, in post-op hospitalized pts
Urinary retention is a common problem in hospitalized patients, especially following certain types of surgery. Starting an a-blocker, ie tamsulosin, during urethral catheter insertion increases success of a voiding trial
61
diagnosis of giardiasis
diagnosis of giardiasis is suggested by its most characteristic symptoms: foul-smelling, soft, or loose stools; foul-smelling flatus; belching; marked abdominal distention; and the virtual absence of mucus or blood in the stool
62
latex allergy and crossreactive proteins
Foods that have the highest association with latex allergy include avocados, bananas, chestnuts, and kiwi.
63
cardiac toxicity of methadone
cardiac toxicity of methadone is primarily related to QT prolongation and torsades de pointes.
64
mgmt Atrial fibrillation
major risk with atrial fibrillation is stroke, and a patient’s risk can be determined by the CHADS 2 score --Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and previous Stroke or transient ischemic attack. Each of these is worth 1 point except for stroke, which is worth 2 points. A patient with 4 or more points is at high risk, and 2–3 points indicates moderate risk. Having ≤1 point indicates low risk, and this patient has 0 points.
Low-risk patients should be treated with aspirin, 81–325 mg daily (SOR B). Moderate-or high-risk patients should be treated with warfarin.
65
best initial therapy for rheumatoid arthritis
disease-modifying drugs, ex MTX = best choice for initial therapy
66
what has been shown to help with IBS symptoms in controlled trials
daily use of peppermint oil
67
workup & treatment for urethritis in men
According to CDC guidelines, the initial workup for urethritis in men includes gonorrhea and Chlamydia testing of the penile discharge or urine, urinalysis with microscopy if no discharge is present, VDRL or RPR testing for syphilis, and HIV and hepatitis B testing. Empiric treatment for men with a purulent urethral discharge or a positive urine test (positive leukocyte esterase or ≥10 WBCs/hpf in the first-void urine sediment) includes:
1) azithromycin, 1 g orally as a single dose, OR doxycycline, 100 mg orally twice a day for 7 days
PLUS
2) ceftriaxone, 125 mg intramuscularly, OR cefixime, 400 mg orally as a single dose.
If the patient presents with the same complaint within 3 months, and does not have a new sexual partner, the tests obtained at his first visit should be repeated, and consideration should be given to obtaining cultures for Mycoplasma or Ureaplasma and Trichomonas from the urethra or urine. Treatment should include:
1)azithromycin, 500 mg orally once daily for 5 days, or doxycycline, 100 mg orally twice daily for 7 days,
PLUS
2)metronidazole, 2 g orally as a single dose.
68
FDA has imposed a black box warning on all thiazolidinediones, such as pioglitazone (Actos).
black box warning for thiazolidinediones specifically addresses heart failure. also contraindicated in patients with type 1 diabetes mellitus or hepatic disease, and in premenopausal anovulatory women.
69
Recommendations by the American Academy of Family Physicians and the American Academy of Pediatrics treatment of otitis media
AAFP & AAP advocate a 10-day course of antibiotics for children under 2 years if the diagnosis is certain. If the diagnosis is not certain and the illness is not severe, there is an option of observation with follow-up. For children over the age of 2 years, the recommendation is still to treat if the diagnosis is certain, but there is an option of observation and follow-up if the illness is not severe and follow-up can be guaranteed.
Amoxicillin is the first-line therapy; the recommended dosage is 80–90 mg/kg/day in two divided doses, which increases the concentration of amoxicillin in the middle ear fluid to help with resistant Pneumococcus.
70
antibiotics is most appropriate for treatment of Bartonella henselae infection
Azithromycin has been shown to reduce the duration of lymphadenopathy in cat-scratch disease.
71
threshold for prophylactic platelet transfusion
threshold for prophylactic PLT transfusion is 10,000/μL. A count below 50,000/μL = indication for PLT transfusion in pts undergoing invasive procedure.
72
what medications has the best evidence for preventing hip fracture
zoledronic acid, risedronate & alendronate prevent hip fracture (anti-osteoporosis drugs)
Ibandronate (Boniva), raloxifene (Evista), denosumab (Prolia), & etidronate (Didronel) reduce new vertebral fractures
73
```
Sensitivity
Specificity
Pretest probability
posttest probability
positive predictive value
negative predictive value
```
Sensitivity = %pts with a dx who have a (+) test result.
Specificity = %pts without the dx who have a (-) test result.
Pretest probability = probability of dx before a test is performed.
Posttest probability = probability of dx after a test is performed.
Positive predictive value = % pts with (+) test result who are confirmed to have the dx
74
agents for ovulation induction and treatment of infertility in patients with polycystic ovary syndrome (PCOS)
metformin and clomiphene, alone or in combination, as well as rosiglitazone
75
FDA issued a boxed warning describing an increased risk of tendinopathy and tendon rupture associated with the use of which class of antibiotics
Fluoroquinolones are associated with an increased risk of tendinopathy and tendon rupture
76
venous ulcers
Pentoxifylline is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy in patients unable to tolerate compression therapy
77
Prevention traditionally has been divided into three categories: primary, secondary, and tertiary.
Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex).
Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (e.g., routine Papanicolaou tests; screening for hypertension, diabetes, or hyperlipidemia).
Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications (e.g., screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post–myocardial infarction prophylaxis with β-blockers and aspirin).
78
American College of Chest Physicians guidelines for mgmt of pulmonary embolus
initial treatment with low molecular weight heparin, unfractionated heparin, or fondaparinux for at least 5 days, and then can be stopped if the INR has been ≥2.0 for at least 24hrs
79
Headaches in children and adolescents, prophylaxis
propranolol is the best choice for peds pt. Sumatriptan is not approved for children under the age of 12 years. Carbamazepine has significant side effects and requires monitoring. Amitriptyline is commonly agent, but causes constipation
80
Henoch-Schönlein purpura
associated with a palpable purpuric rash, without thrombocytopenia. Other diagnostic criteria include bowel angina (diffuse abdominal pain or bowel ischemia), age ≤20, renal involvement, and a biopsy showing predominant immunoglobulin A deposition. The long-term prognosis depends on the severity of renal involvement.
81
According to the Beers criteria, which NSAID should be avoided in older patients due to its higher rate of adverse central nervous system effects
Indomethacin due to propensity to produce more CNS adverse effects than other NSAIDs.
82
what treatment for type 2 diabetes mellitus often produces significant weight loss
metformin and incretin mimetics such as exenatide have the additional benefit of helping with wgt loss
83
pes anserine bursitis
pes anserine bursa is associated with the tendinous insertion of the sartorius, gracilis, and semitendinosus muscles into the medial aspect of the proximal tibia. associated with early osteoarthritis in the medial knee compartment, pes anserine bursitis can also result from overuse of the involved muscles or from direct trauma to the area. Pt will generally complain of pain in the area of insertion when flexing and extending the knee and tenderness of the area. Tx may include oral anti-inflammatory agents, PT, and corticosteroid injection.
84
what has been shown to help with IBS symptoms in controlled trials
daily use of peppermint oil has been shown to relieve symptoms.
85
criteria for diabetes mellitus
- hemoglobin A1c level ≥6.5% be used to diagnose diabetes mellitus.
- Other criteria include a fasting plasma glucose level ≥126 mg/dL, a random glucose leve l≥200 mg/dL in a patient with symptoms of diabetes, or a 2-hour oral glucose tolerance test value ≥200 mg/dL.
86
osteoporosis screening
All women ≥65 and all men ≥70 should be screened for osteoporosis. For men and women age 50–69, the presence of factors associated with low bone density would merit screening (low body weight, previous fracture, a family history of osteoporosis with fracture, a history of falls, physical inactivity, low vitamin D or calcium intake, and the use of certain medications or the presence of certain medical conditions)
87
Treatment of alcoholic ketoacidosis
vigorous vol. repletion with normal saline + administration of thiamine and glucose.
88
treatment of ascites
grade 2 ascites (visible clinically by abdominal distention, not just with ultrasonography), the initial treatment of choice is diuretics along with salt restriction. Aldosterone antagonists such as spironolactone are more effective than loop diuretics such as furosemide (SOR A). Chlorthalidone, a thiazide diuretic, is not recommended.
Large-volume paracentesis is the recommended treatment of grade 3 ascites (gross ascites with marked abdominal distention), and is followed by salt restriction and diuretics.
89
glucose targets in critically ill hospitalized pts
target glucose level of 140–180 mg/dL in critically ill patients.
90
rationale for antibiotic tx for pertussis
ntibiotic treatment for pertussis is effective for eradicating bacterial infection but not for reducing the duration or severity of the disease. The eradication of infection is important for disease control because it reduces infectivity. macrolides for primary treatment of pertussis. The preferred antimicrobial regimen is azithromycin for 3–5 days or clarithromycin for 7 days
91
Tarsal coalition
= fusion of two or more tarsal bones. occurs in mid/late adolescence and is bilateral in 50% of ppl. Pain occurs around the ankle, with decreased range of motion of the hindfoot & pain on foot inversion
92
Rosacea
cond'n seen mostly in wmn 30-60yrs. Central facial erythema & telangiectasias that may progress to a chronic infiltrate with papules, sterile pustules, facial edema or rhinophyma due to hypertrophy of the subcutaneous glands on nose. Mgmt= avoidance of precipitating factors and use of sunscreen. Also, oral metronidazole, doxycycline, or tetracycline. Low-dose clonidine or a nonselective β-blocker for flushing. if mild, topical metronidazole and benzoyl peroxide
93
In vitro interferon-gamma release assays (IGRAs) vs traditional targeted tuberculin skin test (TST)
In vitro interferon-gamma release assays = new screening for latent Tb infection. advantage of IGRA is that it targets antigens specific to Mycobacterium Tb. These proteins are absent from the BCG vaccine strains and from commonly encountered nontuberculous mycobacteria. Unlike skin testing, the results of IGRA are objective.
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Amiodarone
antiarrhythmic med used for acute mgmt of sustained ventricular tachyarrhythmias, regardless of hemodynamic stability. Amiodarone = 1st line for tx of atrial fibrillation only in symptomatic patients with left ventricular dysfunction and heart failure.
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vocal cord dysfunction vs asthma
The diagnosis of vocal cord dysfunction should be considered in patients diagnosed with exercise-induced asthma who do not have a good response to β-agonists before exercise. PFTs normal expiratory portion but a flattened inspiratory phase.
asthma: decreased FEV1 and normal FVC
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Three different cutoff levels for tuberculin skin test
high risk and/or immunocompromised, including HIV+, transplant patients, & household contacts of a Tb patient, an induration ≥5 mm is considered positive.
increased probability of exposure or risk, an induration ≥10 mm is positive. This group includes children; employees or residents of nursing homes, correctional facilities, or homeless shelters; recent immigrants; intravenous drug users; hospital workers; and those with chronic illnesses.
For those at low risk of exposure, induration ≥15 mm is considered positive.
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Framingham Heart Study.
study defined major risk factors: elevated blood pressure, cigarette smoking, cholesterol levels, diabetes mellitus, and advancing age. determines risk in ppl 30–74 yrs without overt coronary heart disease. most accurate for white patients.
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elevation of serum methylmalonic acid is both sensitive and specific for a cellular deficiency of which vitamin
sensitive & specific for vit B 12 deficiency.
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gadolinium-associated nephrogenic systemic fibrosis
associated with use of gadolinium-based contrast material in patients with severe renal dysfunction, often on dialysis. Associated proinflammatory states, such as recent surgery, malignancy, and ischemia, are often present as well. Dermatologic manifestations common(deep biopsy of affected skin is diagnostic), but can affect multiple organ systems. no treatment
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Resistant or refractory hypertension
BP≥140/90 mm Hg, or ≥130/80 mm Hg in patients with diabetes mellitus or renal disease (i.e., with Cr level >1.5 mg/dL or urinary protein excretion >300 mg over 24 hours), despite adherence to treatment with full doses of at least 3 antihypertensive medications, including a diuretic. JNC 7 guidelines suggest adding a loop diuretic if serum Cr is >1.5 mg/dL in pts with resistant HTN
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Dupuytren’s contracture
characterized by changes in the palmar fascia, with progressive thickening & nodule formation that can progress to a contracture of the associated finger; 4th finger commonly affected. Pitting/dimpling can occur over the nodule because of the connection with the skin. not terrible painful
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first-line treatment for head lice
permethrin = first-line treatment b/c safe
| Lindane is 2nd line b/c it's inconsistently ovicidal & carries a black box warning b/c neurotoxic.
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Venous thromboembolism prophylaxis
Prophylaxis recommended for pts >40yrs with limited mobility for 3 days or more and have at least 1 of the following risk factors: acute infectious disease, New York Heart Association class III or IV heart failure, acute myocardial infarction, acute respiratory disease, stroke, rheumatic disease, inflammatory bowel disease, previous venous thromboembolism, older age (especially >75 years), recent surgery or trauma, immobility or paresis, obesity (BMI >30 kg/m2), central venouscatheterization, inherited or acquired thrombophilic disorders, varicose veins, or estrogen therapy
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According to JNC 7, the risk of CVD increases when the systolic & diastolic BP exceeds a threshold of
According to JNC 7, the risk of both ischemic heart disease and stroke increases progressively when systolic blood pressure exceeds 115 mm Hg and diastolic blood pressure exceeds 75 mm Hg
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treatment of acute dystonic reaction
Dystonia caused by dopamine blockers, including prochlorperazine, metoclopramide, and typical neuroleptic agents such as haloperidol. The acute treatment of choice is diphenhydramine or benztropine.
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Effective treatments for chronic orthostatic hypotension
fludrocortisone, midodrine, and physostigmine (SOR B). Clonidine, pseudoephedrine, terbutaline, and theophylline are not appropriate therapies.
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Marfan syndrome
associated with arachnodactly, arm span greater than height, a high arched palate, kyphosis, lenticular dislocation, mitral valve prolapse, myopia, and pectus excavatum. Cardiac examination may reveal an aortic insufficiency murmur, or a murmur associated with mitral valve prolapse.
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primary, secondary, tertiary prevention
Primary prevention:
targets at risk individuals and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex).
Secondary prevention:
targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (e.g., routine Papanicolaou smears, and screening for hypertension, diabetes, or hyperlipidemia).
Tertiary prevention:
targets individuals with a known disease, with the goal of limiting or preventing future complications (e.g., screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial infarction prophylaxis with β-blockers and aspirin).
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What is associated with testosterone supplementation in men with hypogonadism
Testosterone increases hematocrit and can cause polycythemia. In patients receiving testosterone supplementation, hematocrit should be monitored every 6 months for the first 18 months, then annually. Testosterone also causes an increase in lean body mass, and may increase bone density
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DRESS
"Drug Reaction with Eosinophilia & Systemic Symptoms" hallmark= erythroderma, fever, lymphadenopathy, elevation of liver enzymes, eosinophilia. Should dc offending med and give corticosteroids. Seizure meds (carbamazepine, phenytoin, lamotrigine, phenobarbital) commonly cause DRESS. Allopurinol-associated DRESS syndrome has the highest mortality rate
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contraind to combined hormonal contraceptives
combined hormonal contraceptives, migraine headaches with aura at any age are classified as category 4 because of the increased risk of ischemic stroke
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JNC-7 BP guidelines
JNC-7 guidelines recommend the adoption of healthy lifestyles for all patients, especially those with hypertension, and the addition of pharmacologic treatment as necessary to reach a goal blood pressure
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Jarisch-Herxheimer reaction
acute, transient, febrile rxn that occurs within the first few hours after treatment for syphilis. peaks at 6–8 hrs and disappears within 12–24 hours after therapy. low grade temp, myalgia, headache, and malaise. pathogenesis unclear (liberation of antigens from spirochetes), reassure and give antipyretics.
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guidelines of the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, this patient’s cervical cytology and HPV testing
In women 30–65 years old, screening for cervical cancer with cervical cytology and HPV testing is recommended every 5 years. An alternative screening recommendation is to perform cervical cytology only, at 3-year intervals.
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antiepileptic drugs and contraception
Certain antiepileptic drugs induce hepatic metabolism of estrogen and progestin (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, and topiramate). This can potentially lead to failure of any contraceptive that contains estrogen and progestin.
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sepsis criteria
criteria for sepsis are satisfied by a temperature >38.3°C, a WBC count >12,000/mm3, a respiratory rate >20/min, and a source of probable infection.
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American Heart Association guidelines for treating: -hypertension in patients with stable heart failure
-uncomplicated HTN
American Heart Association guidelines recommend treating hypertension in patients with stable heart failure with ACE inhibitors and/or β-blockers. Other agents, such as thiazide diuretics or calcium channel blockers, can be added if needed to achieve blood pressure goals
While thiazide diuretics are often a first choice for uncomplicated hypertension, this is not the case for patients with coronary artery disease.
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Meniere’s disease
characterized by multiple episodes of vertigo lasting for 20–120 minutes, accompanied by a fluctuating hearing loss, tinnitus, and a sense of aural fullness. Audiograms will reveal a low-frequency hearing loss with an upsloping curve, which can become flattened over the years.
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pneumovax guidelines
For a healthy nonsmoker with no chronic disease who is not in a high-risk group, pneumococcal vaccine is recommended once at age 65. Persons that should be immunized before age 65 include patients with chronic lung disease, cardiovascular disease, diabetes mellitus, chronic liver disease, cerebrospinal fluid leaks, cochlear implants, immunocompromising conditions, or asplenia, and residents of nursing homes and long-term care facilities.
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ARDs
Patients with ARDS should be started at lower tidal volumes (6 mL/kg) instead of (10–15 mL/kg). These patients also often require higher positive end-expiratory pressure settings. Fluid management should be conservative to allow for optimal cardiorespiratory and renal function and to avoid fluid overload.
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prophylactic cholecystectomy for asymptomatic gallstones
Patients with hemoglobinopathies are at increased risk for developing pigmented stones. Gallstones have been reported in up to 70% of sickle cell patients, up to 85% of hereditary spherocytosis patients, and up to 24% of thalassemia patients. In sickle cell patients, complications from asymptomatic gallstones have been reported to be as high as 50% within 3–5 years of diagnosis. This has been attributed largely to the diagnostic challenge associated with symptomatic cholelithiasis versus abdominal sickling crisis. In the past these patients were managed expectantly because of the significant morbidity and mortality associated with open operations. The operative risk for these patients (especially sickle cell patients) has been lowered by laparoscopic cholecystectomy, along with improved understanding of preoperative hydration and transfusion, improved anesthetic technique, and better postoperative care. Prophylactic laparoscopic cholecystectomy prevents future diagnostic confusion, as well as the mortality and morbidity risk associated with emergency surgery.
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drug induced lupus
most common offenders are antiarrhythmics such as procainamide and hydralazine. symptoms: polyarthritis, pleuropericarditis, +antinuclear antibody titers, histone antibodies BUT usually NO antibodies to dsDNA or low complement levels. The best initial management for drug-induced lupus is to withdraw the drug, if severe symptoms, a short course of corticosteroids is indicated.
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recommended prophylactic antibiotic for most patients undergoing orthopedic procedures
Cefazolin is the recommended prophylactic antibiotic for most patients undergoing orthopedic procedures such as total joint replacement, unless the patient has a β-lactam allergy
