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primary 3 chronic conditions final exam > neuro/ endo/ musculoskeletal/ mental health > Flashcards

neuro/ endo/ musculoskeletal/ mental health Flashcards

1
Q
  • Bipolar first-line treatment, what are the risks and how often check labs?
A

Lithium is the GOLD standard
*Risk of neurotoxicity (alters the normal activity of the nervous system) with serum levels > 2.0
* Draw levels 2 x week until levels are stable, then every 1-3 months
* adversely affects kidneys in 20 % of patients

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2
Q
  • Suicide risk factors
A

o Ages 15-24 and > 60 y/o
o Older people who have recently lost a spouse (death or divorce)
o Plan involving a gun or other lethal weapon/firearms in the house
o Hx of attempted suicide and/or family hx of suicide
o Mental illnesses (depression or bipolar)
o Hx of sexual, emotional and/or physical abuse
o Terminal illness, chronic illness/chronic pain
o Alcohol/substance abuse
o Stressful life issues (financial or relationship problems)
o Medical professionals/public service
o American Indian and Alaskan native youth/middle age have the highest risk
o Blacks have the lowest risk

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3
Q
  • Brain tumor symptoms
A

*New onset HA (mild-severe), throbbing, progressively worse,
*unexplained n/v,
*blurred/double vision,
*gradual loss of sensation of movement in extremities, off-balance,
*slurred speech

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4
Q

Brain tumor Differential dx:

A

o CVA, MS, SAH, meningitis, optic neuritis, AVF, brain abscess, neurosyphilis

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5
Q

Brain tumor Treatment:

A

surgery, radiation, chemo, meds/steroids

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6
Q

Seizure disorder cause

A

Caused by a sudden burst of electrical activity from a collection of cerebral cortex neurons which affect motor, sensory, and cognition

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7
Q

Generalized seizures verses partial seizures

A

Generalized seizures are associated with a complete loss of consciousness, whereas partial seizures preserve wakefulness; involuntary twitching or stiffness in the body

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8
Q

What are the 2 types of focal seizures and what are focal seizures?

A

Focal (affecting just one part of the brain):

  1. Complex partial- impairs LOC
  2. Simple partial- LOC not impaired (motor-sensory is affected)
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9
Q

What are generalized seizures and what are the 5 kinds?

A

(affecting the entire brain)
1. tonic-clonic/”grand mal”-sudden stiffening of muscles/contractions
2. absence sz-“blank stare” or brief interruption in activity
3. myoclonic-sudden, brief, shock-like contractions, usually during sleep
4. tonic-sudden muscle stiffening, sudden without warning and can lead to injury
5. atonic-sudden loss of muscle control , sudden without warning and can lead to injury

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10
Q

Treatment of seizures:
Do you treat seizures first time?
How do you choose a medication?
What is preferred in treatment?
First-line focal seizure treatment?

A

*No medication recommended for 1st time seizure
*Choice of med depends on type of sz, comorbities, etc
*Monotherapy is preferred (achieve best control of sz with least meds possible)
Focal Seizures
* 1st line: Carbamazepine (Tegretol) or lamotrigine (Lamictal)

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11
Q
  • Parkinson’s s/sx
    Who gets it?
A

TRIAD (rest tremors, muscular rigidity, bradykinesia)
> 50 y/o
more common in men

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12
Q

What is Parkinson’s 1st line Treatment?
What is the treatment for essential tremors?

A

Treatment
*1st line: Sinemet TID 25/100mg PO TID with meal or snack to avoid nausea
* Start low and titrate slowly
*For essential tremors: propranolol 60-320mg daily or long-acting (Inderal LA)

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13
Q

Parkinson’s tests

A

There are no specific tests
*Get a good H&P
*look for s/s and red flags

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14
Q

Multiple sclerosis Symptoms

A

*Fatigue (95% of patients)
* visual loss, diplopia, nystagmus and optic neuritis
* Vertigo
* Walking/balance problems/Ataxic gait
* Weakness of the legs/Foot drop
* Paresthesias of extremities
* Bowel or urinary dysfunction
* Electric shock like sensation runs down the back when bending neck forward
*Muscle spasms, stiffness/weakness

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15
Q

Multiple sclerosis tests
How can a diagnosis be made?
What criteria is used?
What two other tests can be orderd?

A

*The key is to get a good H&P.
For the dx to be made, 2 or more areas of the CNS must be involved at 2 different periods of time (Vision, speech, strength, coordination, balance, position)
* MRI of brain, spine may show lesions
* LP-eval for lymphocytes and IgG bands)
* McDonald criteria (H&P, lesions or lab tests, MRI)

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16
Q

Multiple sclerosis Treatment:

What are the goals?
What treats acute exacerbations (mainstay of treatment)?
What else can you use?
Should you refer?

A

3 major goals:
1. delay progression
2. manage symptoms
3. treat acute flares
*Glucocorticoids are the mainstay of treatment for acute exacerbations
*Can also use IV Depomedrol and/or oral prednisone
*Refer to neurology
*Disease-modifying therapies (B-Interferon which are substances which help immune system fight disease)

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17
Q

What is Myasthenia gravis?

A

Autoimmune dx caused by an error in the transmission of nerve impulses to muscles

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18
Q

Myasthenia gravis s/sx

A

*muscle fatigue,
* weakness with use,
*eye movements and speech are affected
*weakness of the eye muscles, drooping of the eyelid, blurred vision, changes in facial expressions, dysphagia, dyspnea, dysarthria
 s/s are usually worse later in the day, may subside with rest

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19
Q

Myasthenia gravis Test?
What is a positive test?
What else could they do?

A

*Tensilon test: Tensilon drug is injected into the muscles which prevents the breakdown of Ach (neurotransmitter that nerve cells release to stimulate your muscles)
* A positive test for MG if their muscles get stronger after the injection
*EMG (electrymyography)-electrodes used to assess the health of muscles and nerve cells)
*Serum antibodies (IgG) as a rescue med but not long term while you’re waiting for meds to take effect

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20
Q

Myasthenia gravis Treatment
Drug of choice?
Other drugs?
Other treatment?
What should patients be screened for?

A

*Symptomatic and supportive treatment
-Meds
* Mestinon/pyridostigmine is the drug of choice
* Steroids
* Immunosuppressants
* IVIG
* Plasmapheresis
 All pts should be screened for thymoma; thymectomy can be curative

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21
Q

Carpel tunnel :
What else is it called?
What causes it?
What are the s/sx?
Hallmark symptom?

A

“wake and shake syndrome”
*Caused by entrapment neuropathy of the median nerve at the wrist
s/s: gradual onset (wks to months); paresthesia on the thumb, index finger, and middle finger areas; weak grip; hx occupation/hobby with repetitive hand movements
*aching sensation that radiates into the thenar area (base of the thumb)
Hallmark symptom-nighttime awakening with pain and numbness

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22
Q

Carpel tunnel tests

A

tests:
 Most useful dx test is a median nerve conduction velocity study ($$$)
 Tinel’s sign: tapping the anterior wrist briskly causes pins and needles sensation along the median nerve
 Phalen’s sign: flex both hands against each other for 1 min; positive if tingling down median nerve

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23
Q

Carpel tunnel treatment

A

Treatment
*NSAIDs or steroid injections
*Splints
*Avoid aggravating factors
*Ortho referral
*Surgery for decompression of the carpal tunnel with release

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24
Q
  • Rheumatoid arthritis
A
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25
Q
  • Rheumatoid arthritis tests
    What is the preferred test?
    What are other tests?
A

Tests:
RA classification criteria Scale
Preferred test: Rheumatoid factor (RF)-an IgM autoantibody
* positive in 70-80% of patients (20% may be negative despite other RA s/s)
*Serology/antibodies: ANTI-CCP (anti-cyclic citrullinated peptide protein) only for people with RA
*Sed rate, CRP, (both show infllmation in the blood) and PLTS may be elevated in acute phases
*ANA may be helpful; usually negative, but can be positive in 20-30% of patients
*Radiographs: bony erosions, joint space narrowing, subluxations or dislocations

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26
Q
  • Rheumatoid arthritis s/sx
A

*Key physical finding: symmetric polyarthritis and morning stiffness > 1 hr
Symptoms are usually present for 9 months prior to diagnosiss/s can be acute over 24 hours or gradual over months
*middle-aged adult (women>men)
*s/s: weakness, daily fatigue; depression low-grade fever; weight loss/decreased appetite; body aches/joint pains-bilateral; myalgias; lymphadenopathy; joint pains start on the fingers/hands; early morning stiffness; pain, warm, tender, and swollen fingers (“sausage joints”) PIP/MCP; eventually involve the majority of joints bilaterally

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27
Q
  • What is the recommended screening age for DEXA scan?
A

Women: >= 65 y/o or younger If high risk for fractures
o Men: >70= y/o or at high risk for thinning bones

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28
Q

A1C, how often tested if it’s not normal? Normal A1C? prediabetic? diabetic?

A

Test every 3 months, until BG is controlled (or if changing therapy), then 2x year
What is a normal a1c? < 5.7%
What is an abnormal a1c? 5.7-6.4% = prediabetic
What does the a1c have to be to be considered diabetic? > =6.5 %

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29
Q
  • What is considered prediabetes?
A

Impaired Fasting glucose 100-125 OR
OGTT 140-199 OR
A1C: 5.7-6.4

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30
Q

Normal fasting glucose for non-diabetic:

A
  • <100 (ADA)
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31
Q

What is considered diabetes?

A

Diagnosis requires 2 abnormal test results
 Fasting plasma glucose > =126
 A1C > =6.5
 Non-fasting glucose > =200

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32
Q

When and why should diabetic screening begin?

A

o Type 1:
 For children at age 10 or onset of puberty, if overweight (>85 percentile) with 1 or more risk factors
* Maternal hx of DM or GDM
* Family hx of T2DM in 1st or 2nd degree relative
* Insulin resistance (obesity, acanthosis nigricans, etc)
* If they display s/s (weight loss, excessive hunger, fruity breath, ketones in urine, viral-like illnesses)
 Goal for A1C
* < 7.5 for children/teens
* <7.0 for aduts

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33
Q

risk factors for Type 2DM:

A

Adults > 45 y/o who:
 Are overweight/sedentary
 Have 1st-degree relative with DM
 HX of CVD, HTN, hyperlipidemia
 Have PCOS
 Are insulin resistant
 Women with hx of GDM require lifelong testing at least every 3 years
o Test lipid profiles every year with 9-12 hours fasting labs
o Test urine for microalbuminuria annually

34
Q

Acanthosis Nigricans, symptoms and common areas

A

o Diffuse velvety thickening of the skin (dark pigmentation)
o Common behind the neck and on the axilla
o Associated with DM, obesity, metabolic syndrome/insulin resistance and GI tract CA

35
Q
  • First line BP treatment for patient with diabetes
A

*ACEI (prils) and ARBs (sartans) may delay complications from DM (AAFP)
*Thiazides and CCB (pine and Cardizem) are 1st line in African Americans (unless albuminuria)

36
Q

symptoms of type 1 diabetes

A

s/s: polyuria, polydipsia, polyphagia
o fatigue
o confusion
o fruity breath
o FTT (in infants)
o A1C > =6.5%
o Fasting glucose > =126
o Random glucose > =200

37
Q
  • Characteristics of type 2 diabetes
A

Abnormal CMP and UA (glycosuria, proteinuria, hyperglycemia)
o BMI > 25 or 30 (overweight – obese)
o Abdominal obesity, sedentary lifestyle
o Acanthosis nigricans
o 3 Ps
o Fatigue, blurred vision
o Balanitis in men > 65 (pain and inflammation of the penile head)
o Hx of gestational diabetes or infant weighing > 9 lbs at birth
o Impaired fasting glucose

38
Q
  • Metabolic syndrome characteristics (insulin resistance)
A

Obesity (abdominal) > 35-40 in waist size
o Acanthosis nigricans
o HTN > 130/85
o Dyslipidemia
o Fasting plasma glucose >=100, or Type 2 DM
high weight, high BP, high chol, high sugar

39
Q
  • What diabetic medication will reduce a1c levels the most?
A

Biguanides (Metformin)?

40
Q

What diabetic medications should not be given to patients with CHF?

A

Thiazolidinedions (ex-Actos)

Metformin (lactic acidosis)

41
Q

What side effects should you watch for with metformin?

A

GI upset (usually resolves in 2 wks), may use XR

42
Q

Which patients should avoid metformin?

A

Careful in pts with HF, renal or hepatic dysfunction (d/c if GFR < 30)

43
Q

What are contraindications of metformin?

A

*pregnancy
*alcoholics or binge drinkers

44
Q

Somogyi effect symptoms

A

“rebound hyperglycemia”
*Night sweats, tachycardia, HA, blurred vision, confusion, dizziness, dry mouth, fatigue
*More common with type 1 DM
*High fasting BG in the morning d/t overtreatment with evening insulin (rebound high)

45
Q
  • What medication is the first-line therapy for a newly diagnosed diabetic patient?
A

Metformin (Glucophage)-Biguanides
 Side effects: GI such as diarrhea and nausea
 Avoid in pts with renal or hepatic disease, acidosis, alcoholics, hypoxia
 IV contrast dye testing: hold metformin on the day of the procedure and 48 hours after, d/t primary kidney excretion

46
Q

Normal range TSH =

A

0.5-5.0

47
Q

How often should TSH be assessed after medication adjustment?

A

Recheck TSH every 6-8 wks; once stable, recheck every 6-12 months (or annually)

48
Q

Hypothyroidism cause and symptoms

A

cause: When the thyroid gland does not make enough thyroid hormone, therefore the TSH is increased as part of a negative feedback system

 T4 is most commonly decreased, occasionally T3
 Symptoms:
* Fatigue/lethargy
* Weight gain even with anorexia
* Dry, coarse skin
* Cold intolerance
* Hair loss/brittle nails
* Swelling of face, hands and legs
* Constipation
* Weakness, muscle cramps, arthralgias, paresthesias, impaired memory and hearing

49
Q

clinical hypothyroid

A

TSH > 5.0 with low T4 =

50
Q

subclinical hypothyroid

A

TSH > 5.0 with normal T4

51
Q

hypothyroid Treatment:

A
  • Synthroid (levothyroxine/L-thyroxine)
    o Adults: 50-200 mcg/day
    o Elderly: 12.5-25mcg/day then gradually increase to avoid cardiac issues
     “Start low and slow”
    Pts can chew before swallowing with water for better absorption; take on an empty stomach
  • Do not treat subclinical hypothyroid, and recheck in 6 months
  • At initiation of treatment and with every change in doses, check every 6-8 wks until normalized, then 6-8 months (or annually per Hollier)
  • Monitor periodically for thyrotoxicity (tremors or tachycardia)
52
Q

Hyperthyroidism (“thyrotoxicosis”)-

A

*TSH < 0.05 with high T4 and T3 = clinical hyperthyroid
*TSH < 0.05 with normal T4 and T3= subclinical hyperthyroid

Symptoms
* Unintentional weight loss with increased appetite
* Tachycardia, arrhythmias (AFIB most common), palpitations
* Nervousness, anxiety and irritability
* Thyroid enlargement (2-6x) may have vascular thrill/bruit

53
Q

Treatment hyperthyroidism

A

Goal is to attain euthyroid state in 3-8 wks
* Thionamides
o Ex-Tapazole (methimazole) or PTU (propylthiouracil)
 Check CBC with plts and LFTs
 Methimazole is preferred in children
* Do not use PTU in children d/t liver failure risk
 PTU preferred with pregnancy (does not cross placenta)
o May use Betablockers for symptom management
o Supplement with calcium and vitamin D (1200mg)
o Engage in weight-bearing exercises
* May also use RAI (radioactive iodine ablation)
o Radiation therapy to eradicate remaining thyroid tissue after thyroidectomy
o DO NOT use in pregnancy

54
Q
  • Physical findings and symptoms of graves’ disease
A

o An autoimmune disorder with genetic component
o Weight loss, anxiety, insomnia, palpitations, HTN, arrhythmias, warm/moist skin, increased perspiration, ophthalmopathy and lid lag, frequent/loose stools, pretibial myedema (thickening of the skin around the shins, “orange peel” appearance)
o Require f/u with opthalmology

55
Q
  • What labs would you perform with thyroid disease?
A

o TSH, T3, and T4, free T4
o TSI-thyroid stimulating immunoglobulin (to r/o Graves)
o CBC and LFTS (with hyperthyroid)
o Thyroid US
o Refer to endocrinologist if needed
o FNA or thyroid scan if needed

56
Q

How often should you perform a pap and HPV test?

A

Begin pap screening at age 21
o Ages 21-29: Pap every 3 years
o Ages 30-65, there are 3 options:
 Pap every 3 years
 Pap/HPV co-test every 5 years
 HPV alone every 5 years

57
Q

With abnormal PAP results, how often will you perform tests?

A

(Hollier p 1016 and 986-7)-(REREAD p 987)
o Abnormal: 21-29 y/o, every 2-4 mths until normal results, then repeat in 2 yrs
o Abnormal: 30-65 y/o, yearly until 3 normal pap smears, repeat in 3 yrs
o Abnormal: > 65 y/o, every 3 years, for at least 25
 >65 y/o adequate negative screening = 3 negative Pap OR 2 negative Pap and HPV in previous 10 years AND no abnormal results

58
Q
  • Post-menopause hormone therapy
    Benefits
A

 For women with a uterus: Estrogen + Progestin = less risk of endometrial CA
* Only use for < 5 years as risk of breast CA increases
* Use younger than 60 y/o
 For women s/p hysterectomy: Estrogen can alleviate dyspareunia (painful sex) and vaginal/urethral atrophy

59
Q

Post-menopause hormone therapy contraindications

A

 Estrogen only: increases the risk of developing/exacerbating SLE (lupus?)
 Estrogen + Progestin: increase risk of breast CA, CVA, CAD and PE

60
Q
  • What is the recommended screening age for DEXA scan?
A

Women: >=65 y/o or younger If high risk for fractures
Men: >70= y/o or at high risk for thinning bones

61
Q

What screening test will you perform for a sexually active female and how often?

A

< 25 y/o: test for Chlamydia and gonorrhea annually
> 25 y/o with risk factors such as new or multiple sex partners, or positive partner, should test annually

62
Q

What screening test will you perform for a non-sexually active female and how often?

A

Pap smear for all women >21 y/o

63
Q

Abnormal uterine bleeding

A

Blacks>whites
o Causes:
 PALM: polyps, adenomyosis, leiomyoma, malignancy
* Adenomyosis: when the tissue that normally lines the uterus grows into the muscular wall of the uterus
* Leiomyoma: “uterine fibroids”, growths that appear in the uterus (benign and common up to 75-80% of people will have)
 COEIN: coagulopathy, ovulatory disorders/hormone changes, endometrial, iatrogenic, not classified

64
Q

Acute vs Chronic

A

Acute: episodes requiring intervention; Chronic episodes lasting > 6 months

65
Q

what test will you perform for AUB:

A

pregnancy test (r/o miscarriage)
 CBC (evaluate hemodynamic stability)
 Coags
 STD tests/Wet prep (r/o STIs and vaginitis)
 Pap smear
 hormone levels, prolactin/estrogen/testosterone levels
 hysteroscopic exam of uterine lining (r/o fibroid, polyps and CA)
 1st line imaging: Pelvic/transvag US (r/o tumors, PID)
 Endometrial Biopsy (r/o CA)
 MRI

66
Q
  • What is the usual age of menopause?
A

Avg age = 51 y/o (Hollier p 1010)
*

67
Q

When should post-hysterectomy pts be screened for cervical cancer?

A

Cervix intact: continue regular screenings (pap every 3 years, HPV or Cotest every 5 years)
o Total hysterectomy: may stop screening
o CIN3 or AIS (adenocarcinoma in situ) requires HPV based testing at 3-year intervals for 25 years
*

68
Q

When should screening for gestational diabetes begin?

A

Screen at the first visit if HX of GDM or presence of risk factors (known impaired glucose metabolism or BMI > 30)
o Otherwise, screen all women at 24-28 weeks

69
Q

Symptoms of perimenopause (Hollier p 1010)

A
  • o Shorter/irregular periods, VMS: Hot flashes, night sweats; dry skin, brittle hair, insomnia, GSM: vaginal dryness, bladder changes; mood swings (depression/anxiety), joint pains
    o Generally lasts many years
70
Q

Symptoms of menopause

A
  • o Menopause occurs in 100% of women
    o Not all women experience s/s with menopause
    o Symptoms Same as above
    o Hormone therapy is the most effective treatment for VMS and GSM and prevents bone loss/fractures
    o Paroxetine (Brisdelle) is the only non-hormonal med FDA-approved for VMS
71
Q

biploar treatment 1st line for mania

A

Anticonvulsants (Divalproex/Depakote/valproic acid) is
o

72
Q

other treatments for bipolar

A

Others include: Lamictal/lamotrigine and tegretol
o 2nd generation antipsychotics (Risperdal/risperidone, Seroquel/quetiapine, Zyprexa/olanzepine)

73
Q

first line generalized seizures treatment

A

Generalized
* 1st line: valproic acid for all types

74
Q

first line status epilepticus treatment and
2nd line status epilepticus treatment

A

Status epilepticus
* Be sure to secure airway and assess cardiac/resp function 1st and check BG levels
* 1stline: Buccal midazolam
* 2nd line: rectal diazepam

75
Q

What is the Mcdonald criteria?

A

In order to make a diagnosis of MS, the physician must: Find evidence of damage in at least two separate areas of the central nervous system (CNS), which includes the brain, spinal cord and optic nerves AND. Find evidence that the damage occurred at different points in time AND. Rule out all other possible diagnoses.

76
Q

Difference between myasthenia gravis and MS

A

Myasthenia gravis is an autoimmune condition of the neuromuscular system that’s characterized by impaired communication between the nerves and muscles. This condition leads to weakness in the skeletal muscles. Multiple sclerosis (MS) is a chronic neurological condition that’s characterized by progressive nerve damage.

77
Q

commonly used glucocorticoids?

A

The commonly used glucocorticoids are prednisone, prednisolone, triamcinolone, methylprednisolone, dexamethasone

78
Q

What does the thymus do?

A

The primary function of the thymus gland is to train special white blood cells called T-lymphocytes or T-cells. White blood cells (lymphocytes) travel from your bone marrow to your thymus. The lymphocytes mature and become specialized T-cells in your thymus.

79
Q

Why is myasthenia gravis hard to diagnose?

A

The symptoms fluctuate throughout the day- difficulty swallowing, breathing, visual problems… might go away the same day.

80
Q

What is plasmapheresis ?

A

a method of removing blood plasma from the body by withdrawing blood, separating it into plasma and cells, and transfusing the cells back into the bloodstream. It is performed especially to remove antibodies in treating autoimmune conditions.

81
Q

What medication would you give for abnormal uterine bleeding?

A

Hormonal management is considered the first line of medical therapy for patients with acute AUB without known or suspected bleeding disorders. Treatment options include IV conjugated equine estrogen, combined oral contraceptives (OCs), and oral progestins.

primary 3 chronic conditions final exam (16 decks)

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