neuro/ endo/ musculoskeletal/ mental health

Question 1

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

Answer 1

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

Question 2

• Suicide risk factors

Answer 2

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

Question 3

• Brain tumor symptoms

Answer 3

*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

Question 4

Brain tumor Differential dx:

Answer 4

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

Question 5

Brain tumor Treatment:

Answer 5

surgery, radiation, chemo, meds/steroids

Question 6

Seizure disorder cause

Answer 6

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

Question 7

Generalized seizures verses partial seizures

Answer 7

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

Question 8

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

Answer 8

Focal (affecting just one part of the brain):

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

Question 9

What are generalized seizures and what are the 5 kinds?

Answer 9

(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

Question 10

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?

Answer 10

*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)

Question 11

• Parkinson’s s/sx
  Who gets it?

Answer 11

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

Question 12

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

Answer 12

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)

Question 13

Parkinson’s tests

Answer 13

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

Question 14

Multiple sclerosis Symptoms

Answer 14

*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

Question 15

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

Answer 15

*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)

Question 16

Multiple sclerosis Treatment:

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

Answer 16

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)

Question 17

What is Myasthenia gravis?

Answer 17

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

Question 18

Myasthenia gravis s/sx

Answer 18

*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

Question 19

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

Answer 19

*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

Question 20

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

Answer 20

*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

Question 21

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

Answer 21

“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

Question 22

Carpel tunnel tests

Answer 22

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

Question 23

Carpel tunnel treatment

Answer 23

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

Question 24

• Rheumatoid arthritis

Question 25

* Rheumatoid arthritis tests What is the preferred test? What are other tests?

Answer 25

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

Question 26

* Rheumatoid arthritis s/sx

Answer 26

*Key physical finding: symmetric polyarthritis and morning stiffness > 1 hr *Symptoms are usually present for 9 months prior to diagnosis*s/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

Question 27

* What is the recommended screening age for DEXA scan?

Answer 27

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

Question 28

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

Answer 28

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 %

Question 29

* What is considered prediabetes?

Answer 29

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

Question 30

Normal fasting glucose for non-diabetic:

Answer 30

* <100 (ADA)

Question 31

What is considered diabetes?

Answer 31

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

Question 32

When and why should diabetic screening begin?

Answer 32

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

Question 33

risk factors for Type 2DM:

Answer 33

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

Question 34

Acanthosis Nigricans, symptoms and common areas

Answer 34

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

Question 35

* First line BP treatment for patient with diabetes

Answer 35

*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)

Question 36

symptoms of type 1 diabetes

Answer 36

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

Question 37

* Characteristics of type 2 diabetes

Answer 37

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

Question 38

* Metabolic syndrome characteristics (insulin resistance)

Answer 38

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

Question 39

* What diabetic medication will reduce a1c levels the most?

Answer 39

Biguanides (Metformin)?

Question 40

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

Answer 40

Thiazolidinedions (ex-Actos) Metformin (lactic acidosis)

Question 41

What side effects should you watch for with metformin?

Answer 41

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

Question 42

Which patients should avoid metformin?

Answer 42

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

Question 43

What are contraindications of metformin?

Answer 43

*pregnancy *alcoholics or binge drinkers

Question 44

Somogyi effect symptoms

Answer 44

“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)

Question 45

* What medication is the first-line therapy for a newly diagnosed diabetic patient?

Answer 45

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

Question 46

Normal range TSH =

Answer 46

0.5-5.0

Question 47

How often should TSH be assessed after medication adjustment?

Answer 47

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

Question 48

Hypothyroidism cause and symptoms

Answer 48

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

Question 49

clinical hypothyroid

Answer 49

TSH > 5.0 with low T4 =

Question 50

subclinical hypothyroid

Answer 50

TSH > 5.0 with normal T4

Question 51

hypothyroid Treatment:

Answer 51

* 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)

Question 52

Hyperthyroidism (“thyrotoxicosis”)-

Answer 52

*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

Question 53

Treatment hyperthyroidism

Answer 53

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

Question 54

* Physical findings and symptoms of graves’ disease

Answer 54

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

Question 55

* What labs would you perform with thyroid disease?

Answer 55

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

Question 56

How often should you perform a pap and HPV test?

Answer 56

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

Question 57

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

Answer 57

(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

Question 58

* Post-menopause hormone therapy Benefits

Answer 58

 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

Question 59

Post-menopause hormone therapy contraindications

Answer 59

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

Question 60

* What is the recommended screening age for DEXA scan?

Answer 60

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

Question 61

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

Answer 61

< 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

Question 62

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

Answer 62

Pap smear for all women >21 y/o

Question 63

Abnormal uterine bleeding

Answer 63

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

Question 64

Acute vs Chronic

Answer 64

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

Question 65

what test will you perform for AUB: 

Answer 65

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

Question 66

* What is the usual age of menopause?

Answer 66

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

Question 67

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

Answer 67

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 *

Question 68

When should screening for gestational diabetes begin?

Answer 68

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

Question 69

Symptoms of perimenopause (Hollier p 1010)

Answer 69

* 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

Question 70

Symptoms of menopause

Answer 70

* 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

Question 71

biploar treatment 1st line for mania

Answer 71

Anticonvulsants (Divalproex/Depakote/valproic acid) is o

Question 72

other treatments for bipolar

Answer 72

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

Question 73

first line generalized seizures treatment

Answer 73

Generalized * 1st line: valproic acid for all types

Question 74

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

Answer 74

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

Question 75

What is the Mcdonald criteria?

Answer 75

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.

Question 76

Difference between myasthenia gravis and MS

Answer 76

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.

Question 77

commonly used glucocorticoids?

Answer 77

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

Question 78

What does the thymus do?

Answer 78

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.

Question 79

Why is myasthenia gravis hard to diagnose?

Answer 79

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

Question 80

What is plasmapheresis ?

Answer 80

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.

Question 81

What medication would you give for abnormal uterine bleeding?

Answer 81

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.