A 60 year old presents with vertigo, tinnitus and hearing loss he states that this has happened to him before and the last time the sensation lasted 3 hours what should be on the differential diagnosis?
A: Acoustic neruoma
B: Vestibular neuritis
C: Meniere's disease
D: all of the above
D: all of the above
An hearing loss that is gradual and continuous, associated with vertigo and possibly tinnitus
A hearing loss that lasts severl days usually following an URI with vertigo and tinnitus
What non-ear specific problem would you be worried about in an older patient with ringing in the ear, vertigo and falling?
Idiopathic diagnosis of the inner ear that is characterized by recurrent spontaneous attacks of vertigo, tinnitus, fluctuating hearing impairment and aural fullness
What Medications do you use to treat Meniere's disease?
Diazapem, Meclizine (antivert), Phenergan (to treat the vertigo)
Triamterene/hydrochlorothiazide- diuretics to decrease fluid in the ear
True of False you can treat Meniere's disease surgically
What medication would you use to treat vertigo in a Meniere's patient
What class of medications would you use to treat the underlying eitiology of meniere's?
A patient brings in their one year old child and states that the patient has been irritable and fussy. Pt's temperature is 38.5 C (101.3) there is redness around the TM but the TM is still mobile how would you treat?
B. amoxicillin + clavulunate
C. watchful waiting
D. topical antibiotics
C. Watchful Waiting
What are 3 things needed for the diagnosis of acute otitis media?
1. a history of acute onset of signs and symptoms
2. The presense of middle ear effusion
3. signs and symptoms of middle ear inflammation
What 4 things indicate the pressence of a middle ear effusion?
Bulging of the tympanic membrane
limited or absent mobility of the tympanic membrane
air fluid level behind the tympanic membrane
Give 2 signs or symptoms of middle ear inflammation
1. distinct erythema of the tympanic membrane
2. distinct otalgia (discomfort clearly referable to the ears that results in interference with or precludes activity or sleep)
For a child with suspected AOM less than 6 months old will you treat with antibiotics for an uncertain diagnosis?
With a patient age 6 months to 2 years whom you suspect has an AOM how will you treat?
It depends!!!!! Antibacterial therapy for severe illness (to modify sever otalgia or fever = to or above 39 degrees C) Otherwise Observation for non severe illness (fever less than 39 degrees C and mild otalgia)
A 10 year old presents to you with acute onset of left ear pain febrile at 39 degrees C and bulging TM that does not move with pneumatoscope the patient has no known drug allergies what would you perscribe?
A 10 year old patient that presented to you with a 39 degree C fever red bulging TM comes back to you after 2 days of being on Amoxicillin what are your next steps?
Confirm the original diagnosis, change the antibiotic, start a different antibiotic, tell the parent to bring the child back soon to check the progress
What is the first line treatment for acute otitis media?
When treating AOM if amoxicillin fails or the infection is sever what would you perscribe?
You diagnose a 10 year old with severe acute otitis media. The child is allergic to penicilin, but did not have hives or anaphylaxis with the penicillin what would you perscribe?
Cefuroxime, cefproxoime or cefdinir
You diagnose a 5 year old with severe acute otitis media and the child is allergic to penicillin with a history of uticaria and anaphylaxis with the drug. What would you perscribe this patient?
azithromycin of clarithromycin
Is it appropriot to give a patient with AOM pain medication?
Yes ibuprofen or acetaminophen but not asprin
What common OTC drug can cause tinnitus at higher or prolonged doses?
A 22 year old presents complaining of left ear pain the patient is afebrile on physical exam and you see an erythematous TM that has limited movement the patient has no known drug allergies what would you give this patient?
If ear pain not bad watchful waiting or if ear pain is bad amoxicillin there is no difference in treating kids and adults with AOM
A 28 year old presents with pain to his right ear, he denies trauma and is afebrile, physical examination is unremarkable (non erythematous TM with movement with valsalva) what do you diagnose?
A 16 year old presents with itchy minimal painful right ear he swims for his high school, on physical exam you note minimal tenderness on pushing on the tragus and you notice some debri with no edema in the canal what would you do to treat?
Gently clean and dry the ear canal
Pt presents with painful right ear. On PE the canal of the ear is swollen, TM can not be visualized because of the swelling. What would you treat this patient with?
Topical antibiotics, systemic antibiotics and a wick
How would you treat a mild OE?
gentle cleaning of the canal and topical drying agents
How would you treat moderate OE with a visible TM?
How would you treat severe OE with no visible TM?
Topical antibiotics and systemic` antibiotics and a wick
Non-antibiotic treatment for OE
Acidifying agents: acetic acid with aluminum acetate (domeboro otic) or acetic acid with hydrocortisone (vosol HC)
What otic` antibiotic should you NEVER use if you cannot visualize the TM?
Neomycin containing meds (cortisporin otic)
What are some Topical antibiotics that you can use for OE?
polymyxin B + neomycin + hydrocortisone
What is the number one risk factor for the development of COPD?
What are the characteristic symptoms of COPD?
chronic and progressive dsypnea cough and sputum production
as disease progresses can develop reduced exercise capacity, fatigue, dyspnea on exertion and cor pulmonale
What are some physical exam findings that are characteristic of COPD?
wheezing, hyperresonance (from air trapping), diminished breath sounds, use of accessory muscles, pursed lip breating, elevated JVP, hepatomegaly, peripheral edema
COPD findings on chest CXR
hyperlucency in severe emphysema
What is the recommended treatment for all patients with COPD?
SABA prn, influenza and pnumococcal vaccinations, smoking cessation
True or False inhailed corticosteroids don't work ask well for COPD patients as they do for asthmatics
What treatment plan would you choose for mild COPD FEV1 > or =80% predicted?
Short acting bronchodilator
What treatment plan would you choose for a moderate COPD patient FEV1 50% < FEV1 < 80% perdicted with or without symptoms?
Add regular treatment with LABA, add rehab
What treatment plan would you choose for a severe COPD patient 30% < FEV1 < 50% ?
Add ICS to albuterol, LABA and rehab with exacerbations
What treatment plan would you choose for a VERY Severe COPD patient with an FEV1/FVC of less than 30% or chronic respiratory failure?>
Albuterol, ICS, Rehab, LABA, LTOT and possible surgery
What are the general treatment options for COPD?
Name a short acting beta 2 agonist ( bronchodilator)
Name a long acting B2 agonist (bronchodilator)
salmeterol, formeterol, arformeterol
What are the side effects of long acting beta 2 agonists?
binds to antithromin and accelerates its activty thus preventing extension of thromus, short half life if pt has to undergoe surgery, contraindicated in active hemorrhage and/or recent brain hemorrahage
Low molecular weight heparins
Used to Treat PE
greater bioavalibility, more predictable response than unfractionated, longer half life
enoxaparin and dalteparin
used for PE tx
contraindications: intracranial neoplasm, previous hemorrhagic stroke, ishemic CVA in past year, active internal bleeding or suspected aortic dissection
__ occurs when air enters the potential space between the visceral and parietal pleura
What are the symptoms of pneumothorax?
chest pain, dyspnea, often tachycardia
what are some physical exam findings that are sugestive of pneumothorax?
How do antileukotrienes modify the course of disease in asthma?
work on leukotriene receptors in the respiratory tract producing: bronchodialation, decrease microvascular leakage, increase eosinophilc inflammation
Name an antileukotriene
Name an immunomodulator druge used to treat asthma
immunomodulator used to treat asthma
block antibody that neutralizes circulating IgE and inhibits IgE mediated reactions
decreases number of exacerbations in those patients with severe asthma
treatment is suitable for highly selective patiens who are not controlled with maximal doses of inhailer therapy, very expensive
have an IgE within a specified range
Pt has been on SABA prn however she has been using her inhailer several times per week what would you do first?
A: Check environment
B: Put her on high dose ICS
C: put her on LABA
D: start her on theophylline
A: Check environment
Your patient with mild asthma has been using her SABA multiple time per week and denies any environmental changes recently or any new exacerbating factors, you decide that she is poorly controlled what do you do next?
A: add low dose ICS
B. Add high dose ICS
C. add LABA
D. Add albuterol
A. Add low dose ICS
Pt is on albuterol prn and low dose ICS having night time symptoms greater than one time per week, using inhailer daily what would your next step after checking environment, adherence and co-morbidities?
A: Add a LABA
B: Increase ICS to medium dose
C. add oral steroids
D. A or B
D. A or B
Your patient is having an acute asthma exacerbation, they come into the ER with wheezing and shortness of breath. You do a PEF, pulse ox and CXR, What will you give them via nebulizer?
Albuterol and possibly oxygen
What are the steps for treating mild, moderate and severe asthma exacerbations?
Mild- albuterol, PEF before and after treatment, pulse ox and possibly CXR
Moderate- all of the above plus albuterol or combivent via nebulizer, and prednisone d/c home after normal pulse ox with walk tests
Severe- albuterol or combivent nebulizer, magnesium, solumedrol, reevaluate, and/or admit (usually admit with severe wheezing, inability to talk in full sentances, inability to walk)
What are the 4 types of pneumonia (classified by setting)?
CAP, HAP, VAP, HCAP
You have a patient with pneumonia who you are treating outpatient who is mildly ill, has no cardiopulmonary disese or other modifying factors what do you choose to treat with?
Azithromycin or clarithromycin
You have an patient with pneumonia who you are treating outpatietn who is stable with comorbidities what would you treat with?
Floroquinolone (moxifloxacin, levofloxacin) or a beta lactam (amoxicillin clavulanate with a macrolide)
Floroquinolones (moxifloxacin and levovloxacin) are contraindicated with what?
You have a patient with pneumonia who you are treating as an outpatient who has had a course of antibiotics in the past three months how do you treat this person?
Floroquinolones (moxifloxacin, levofloxacin) or a beta lactam (amoxicillin clavulanate with a macrolide)
What are the criteria for curb 65?
Confusion, BUN > 19 mg/dL, Systolic pressure of <90 or diastolic <60, Respiratory rate 30 or greater, age 65 or older
each of these factors earns you one point
1 or 2 points on a CURB 65 how would you manage?
Short in patient hospitalization or closely supervised outpatient care
0 points on CURB 65 how would you manage?
Low risk consider outpatient treatment
3 or 4 or 5 on Curb65 how would you manage?
hospitalization and consider ICU admission
A 62 year old male presents with fever, cough, chillls x3 days. He has well controlled DM and HTN but otherwise healthy. RR 24 BP 130/70, HR76 no signs of confusion WBC 23,000 BUN 14 where should the patient be treated? Bonus what should the patient be treated with?
Out patient therapy (according to CURB65) and with Levofloxacin or moxifloxacin because he has comorbidities
First line treatment of a patient that has no comorbidities that has CAP and is going to be treated outpatient is ?
Note: you can also use erythromycin but it has a worse side effect profile and can cause C.diff
16 year old male presents with fever, cough, and 15 pounds of weight loss in 3 months. He recently returned from Ghanna doing missionary work. On chest X-ray he has a consolidated apical mass in his right upper lung apical region what is the most likely Dx?
A PPD test induration of 5 or more millimeters is considered positive in...
HIV in fected persons
a recent contact of a person with TB disease
persons with fibrotic changes on chest radiograph consistent with prior TB
Pts with organ transplants
persons who are immunosurppressed
A PPD test induration of 10 or more millimeters is considered positive in
Injection drug users
Residents and employees of high-risk congregate settings
mycobacteiology laboratory personel
persons with clinical conditions that place them at high risk
children under 4yo
infants, children, and adolescents exposed to adults in high risk categories
A PPD test with induration of 15 or more mm is considered positive in
any person, including people with no known risk factors for TB, however targeted skin testing programs should only be conducted among high-risk groups
What are some symptoms of TB?
many cases are asymptomatic, fever, shortness of breath, cough,
post primary TB- productive cough, night sweats, anorexia
Other signs and symptoms of disese depend on location such as abdominal pain
What is the preferred Tx for treatment of latent TB (for both HIV positive and HIV negative)?
Isoniazide for 9 months taken either daily or twice weekly
What should all suspected latent TB patients get before starting treatment?
For patients who in whom active TB is proved or strongly suspected what is your choice for initial treatment?
Isoniazid, rifampin, pyazinamide and ethambutol (initial phase) Then a continuation phase of 4 months on just two
What must all patients baseline tests should you get on all patients before starting initial TB therapy?
LFTs, CBCs, HIV, etc
After initial TB treatment what are subsequent treatments based on?
initial chest x ray, smear results, CD4 count
Adverse effects of Isoniazide (INH)
asymptomatic elevation of aminotransferases discontinue if they become 5x the upper limit or symptomatic
Peripheral neuropathy- recommend pyridoxine supplementation in pts that have increased for this secondary to other conditions
What monitoring do you need if you have a patient on Isoniazide?
routine monitoring not necessary. however pts who have preexisting liver disesae or had abnormal liver function baseline lfts should be monitored monthly monitor serum concentratiosn of drugs that have interactions (phenytoin)
first line treatment for all forms of TB caused by organisms known or presurmed to be susceptible to the drug. inhibits cytrochrome p450 system therefore significant drug interations
First line agent for treatmetn of all forms of TB caused by organisms with known or presumed sensitivity to the drug
Inducer of cytochrome P450 system; interferes with NRT and PI (rifambutin is used as a substitute for RIF patietns recieveing any drug having unacceptable interactions with RIF)
If a patient is on a drug that is not compatable with Rifampin what do you use instead?
What are the adverse effects of Rifampin?
Cutaneous reactions with or without rash
Orange discolorations of bodily fluids
Which TB drug causes Red urine?
first line agent for the treatment of all forms of TB caused by organisms with known or presumed susceptibility to the drug
What do you have to monitor on a patient who is on pyrazinamide and rifampin for the treatment of latent TB?
What are the adverse effects of Pyrazinamide?
Hepatotoxicity, GI symptoms, polyarthralgias, asymptomatic hyperuricemia, photodermatitis
first line agent for the treatment of all forms of TB caused by organisms with known or presumed susceptibility to the drug
Not recommended in children whose visual actuity can not be monitored
Which TB drug is contraindicated for children whose visual acuity cannot be monitored?
What are the side effects of Ethambutol?
Retrobulbar neuritis- manifested as decreased visual acuity or decreased red-green color discrimination
What monitoring do you have to have with the use of Ethambutol?
baseline visual acuity test and testing of color discrimination. Pts asked montly about vision and instructed to contact a physician if they experience any change in their vision. Montly testing of vision and color vision discrimination for patients taking doses of 15-25mg/kg or recieving the drug more than twice a month or a patient with renal insufficency
An induration of 10 or more mm on TST would be positive for
A. pts with no risk factors
C. children under 4
D. male over 65
Pt is on a TB treatment regimin, you did a color discrimination test before treatment what drug is he on?
You are going to start a patient on Rifampin in addition to telling them about skin rx, GI upset you would tell them about what?
A. Possible visual changes
B. Productive cough
C. Orange discoloration of body fluids
C. Orange discoloration of body fluids
What is the preferred drug for LTBI?
What are the symptoms of Influenza?
Fever, chills, malaise, headache, myalgias
What is the treatment for influenza?
Supportive treatment, Zanamivir (shortens by 2 days and can be taken prophylactically), Oseltamivir
You have a patient with flu like symptoms fever, chills malaise, headache and myalgias, as a good PA you ask them if they have nuchal ridgidity. what are you ruling out by asking them this?
What are the most common pathogens of Epiglottitis?
Haemophillis influenza, group A strep, S. pneumo
Who presents more acutely with epiglottitis kids or adults?
What are the symptoms of Epiglottitis?
Abrupt onset of fever, drooling, muffled voice, inspiratory retractions, stridor, pts present sitting up and leaning forward
How do adult patients with epiglottitis present?>
1-2 day history of worsening dysphagia, odynophagia and dyspnea especially in the supine position
You inspect the larynx of a patient with worsening dysphagia and see a cherry red swolen eppiglottis what do you Dx
True or false the incidence of epiglottitis is increasing
False the incidence of epiglottitis is actually decreasing secondary to immunizations
What is the primary clinical concern in Epiglottitis?
protection of the airway
what would you perscribe a patient with Epiglottitis?
Cefuroxime, cefotaxime, ceftriaxone
Rifampin to PCN allergic patients
Epiglottitis will show what important sign on X-ray
"Thumb Sign" on X ray
Infectious process that is characterized by a bark like or brassy like cough
In addition to cough croup may be associated with what other respiratory symptoms?
What is the most common cause of stridor after neonatal period? (6mo to 3yr)
Viral croup (laryngotracheobronchitis)
What is the most common cause of viral croup?
1-5 day prodrome consisting of cough coryza and rhinorrhea followed by a 3-4 day barking type cough that is worse at night
Is stridor from croup greater on inspiration or expiration?
Inspiration (it is also not affected by position or with increased crying or agitation)
True or false increased costal retractions and tachypnea are some symptoms of Croup
How would you treat moderate to severe croup?
Nebulized racemic epinephrine and dexamethasone
How would you treat severe croup for whom intubation is being considered?
What is the most common respiratory infection in children under 2 y.o.?
What is the most common pathogen of Bronchiolitis
Inflammation, edema and necrosis of epithelial cells lining small airways increased mucous production and bronchospasm with a nasal wash positive for RSV would indicate what?
What are some symptoms of bronchiolitis?
presentation can be minimal to respiratory distress, usually begins with a prodrome of upper respiratory infection first sign is rhinorrhea, followed by increaseing respiratory effort and wheezing, fever inconsistent
What would be the next step to take with a hyperlipidemia patient after you rule out all the secondary causes?
Determine lipoprotein levels, ID prescence of clinical atherosclerotic dz, determine presence of major risk factors for CHD other than LDL, assess the 10 year CHD risk factor, determine the risk category
Name 5 vascular diseases that you should look for in a hyperlipidemia patient
Symptomatic carotid artery disease
What are the 5 ATP risk factors?
HTN or on HTN meds
Low HDL less than 40
Family Hx of premature CHD (CHD in male first degree relatives under 55yrs, CHD in female first degree relatives under 65)
Age (men 45 or older, women 55 or older)
Patients with a 10 year CHD risk factor of >___ % are considered CHD equivalents
Patients with CHD equivalents should be treated as agressively as...
patients with CHD
CHD and CHD risk equivalents have an LDL goal of what?
less than 100
Multiple (2+) risk factor patients have an LDL goal of what?
Patients with 0-1 risk factors have an LDL goal of what?
less than 160
If the patient has a TG of greater than 150 and an HDL of less than 40 then the diagnosis is ____
atherogenic dyslipidemia (look for metabolic syndrome in these patients)
What is a normal triglyceride level?
less than 150
what is a borderline high triglyceride level?
what is a high triglyceride level?
what is a very high triglyceride level?
What is non HDL equal to?
VLDL + LDL
If a patient has CHD or CHD risk equivalents then their LDL goal is ___ and their non HDL goal is ___
less than 100, less than 130
if a patient has multiple (2 or more) risk factors and a 10 yr risk of 20% then their LDL goal is ___ and their HDL goal is ___
less than 130 and less than 160
If a patient has 0-1 risk factors then their LDL goal is __ and their non HDL goal is __
Which cholesterol is always first priority in treatment?
If goal LDL is achieved but non HDL remains high what should you add?
high dose of statin or statin + niacin or fibrate
If triglycerides are greater than 500 then your first piority is to prevent what? what would you perscribe?
prevent pancreatitis, perscribe fibrate or niacin
What is metabolic syndrome?
Abdominal obesity men waist circumf. (greater than 102 cm or greater than 40 inches) for women (greater than 88 cm or 35 inches)
Triglycerides of 150 or more
HDL in men of less than 40 and in women of less than 50
Blood pressure of 130 or >/85 or >
Fasting glucose of 110 or more
What are some causes of low HDL?
increase in serum triglycerides, overweight obesity, physical inactivity, high carbohydrate intake, DM II, genetic factors, certain drugs
A low ___ as in less than 40 is associated with an indcrease in the risk of ___
What are 3 lifestyle changes you can suggest to your patient to help them lower their cholesterol?
Increased physical activity
Dietary changes - decreased intake of saturated fats and cholesterol and increased intake of plant sterols and fiber
How long do you give the patient to make life style changes?
What are the 4 major classes of drugs used to control cholesterol?
Statins (HMG CoA reductase inhibitors)
Bile acid sequestrants
Nicotinic acid (Niacin)
fibrinic acid derivatives (Fibrates)
What is the most effective set of drugs for lowering cholesterol?
What is the first line drugs used to lower LDL?
What drugs would you want to use for children with heterozygous familial hypercholesterolemia?
What drug do you use for children under 8 with heterozygous familial hypercholesterolemia?
What do you use for children 11 and older who have heterozygous familial hypercholesterolemia?
Atorvastatin, lovastatin, simvastatin
What are some contraindications to statin use?
active or chronic liver disease and pregnancy
What drugs can you not take with statins?
cyclosporine, macrolides, antifungals, and cytochrome p450 inhibitors
What are some side effects of Statins?
Increase LFTs by 3X, myopathy, increased CK, non specific aches or joint pains, good to get a baseline LFT before starting therapy, possible rhabdomyolysis
What is the MOA of statins?
inhibit HMG CoA reductase which is the rate limiting step in cholesterol biosynthesis
Name a bile acid sequestrant (resin)
Cholestyramin, colestipol, colesevelam
True or False Bile acid sequestrants work to lower all types of cholesterol
False they have no effect on triglycerides
What is the primary side effect with Bile acid sequestrants?
GI upset; bloating, cramping, fullness, nausea, flatulance
Which class of Cholesterol drugs is perscribed mainly to add to the effects of other drugs particularly the statins?
Bile acid sequestrants
What is the MOA of bile acid sequestrants?
binds to intestinal bile acids
What is the drug of choice for lowering cholesterol in patients planning to get pregnant?
Bile acid sequestrants
What affect doe bile acid resins have on other drugs?
they decrease the other drugs absorbtion, so you must take other drugs 1 hour prior or 4 hours after (except for colesevelam)
Are bile acid sequestrants salf for use in younger patients?
What is the most effective lipid lowering drug for raising HDL levels???
Niacin (Nicotinic acid)
What are the contraindications for Niacin?
liver disease, peptic ulcer disease, pregnancy
What are the side effects of niacin?
flushing, hyperglycemia, hyperuricemia, GI distress, hepatotoxicity
What should you monitor for a patient on niacin?
LFTs at baseline, fsting glucose, uric acid
When do you use Niacin?
In patients with atherogenic dyslipidemia who do not have a substancial increase in LDL and in combination with other medications
What are 3 recommendations for the use of Fibric Acid derivatives
1. to decrease the risk of pancreatitis in patients with very high triglycerides
2. in patients with low levels of LDL and atherogenic dyslipidemia
3. Combination with statins who have elevated LDL and atherogenic dyslipidemia
MOA of fibric acid derivatives
unclear mechanism but inhibit tryglyceride synthesis and stimulate catabolism of triglyceride rich lipoproteins
What are the side effects of Fibric acid derivatives
GI distress, rash, increase LFT
What are the drug interactions with Fibric acid derivatives?
Will affect levels of coumadin, monitor INR for increased risk of bleeding
Ezetimibe should not be used in patients with ____