• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/217

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

217 Cards in this Set

  • Front
  • Back
What are some drugs that undergo first-pass effect?
opiates, CCB's, TCA's, benzo's, anticonvulsants, NSAIDs, coumadin
Which drugs should not be used with PPI's?
azole antifungals (except diflucan and vori), thyroid hormone, calcium supplements
Cations (iron, calcium, mag, etc) should not be ingested with which drugs?
thyroid hormone and quinolones
What is the volume of distribution?
The volume of distribution is the effective volume for determining the total amt of drug and for determining the loading dose.

V = D(amt of drug)/C(concenration)
If drug is dosed at each half-life, rule of thumb for what is total amt of drug? Loading dose?
Total amount of drug is double the maintenance dose. Loading dose does not depend on excretion capacity.
What is the metabolism of meperidine?
Metabolized by liver to active metabolite causing CNS stimulation including seizures. Metabolite is cleared by kidney -- so both.
What is the relationship between rate of drug clearance and drug concentration in first-order kinetics?
None. T1/2 is the same.
How long does it take to get to steady state (if drug follows first-order kinetics)?
5 half-lives = 97%
what are the most important drugs that result in increased INR?
bactrim, erythromycin, amio, propafenone, azole antifungals, flagyl. (esp bactrim). any abx can dec vitamin K producing bacteria though.

also quinolones, exium, clarithro, azithro, prednisone, and >1.5g/day tylenol
What electrolyte disturbance can heparin cause? What situation puts it at higher risk for this? What electrolyte disturbance can bactrim cause?
Heparin can cause hyperkalemia. Especially higher risk when used w/other drugs that cause hyperkalemia.

Bactrim can also cause hyperkalemia by blocking amiloride-sensitive channels in renal tubule.
What does grapefruit do to statin levels? Except which one?
It will increase it - least of all pravachol though bc it is metabolized by the kidney.
What are side effects of topiramate?
Side effects are non-anion gap acidosis and kidney stones.
What are side effects of St. John's Wort?
Increases metabolism of statins, cyclosporin, some HAART, OCP's (can lead to Rx failure)
What are side effects of bisphosphonates?
Muscle and bone pain
What is the relationship between sensitivity/specificity and prevalence? PPV and NPV?
None- sens/specificity only look at D+ and D- individually. (vs PPV and NPV - PPV is higher in diseases with higher prevalences.
How is alcohol specifically related to osteopeoosis? Weight specifically?
EtOH >2 drinks/day. BMI < 21 or wt less than 127 lbs
What disorders and medications require screening for osteoporosis?
GI diseases (malabsorption, IBD, etc), Endo (hyperPTH, Cushing syndrome, hypogonadism, hyperthyroidism), meds (steroids, synthroid, lithium, phenobarbital, dilantin, cyclosporine), lupus, RA, anorexia, bed rest
How do vertebral fx's usually present?
2/3's are painless
What is the most accurate form of screening for osteoporosis? What are the other options.
The most accurate is DXA scan. Quantitative CT and dual photon absorptimotery (DPT) are other options.
What is the T-score cutoff of osteoporosis? Why is a z-score helpful?
T-score-- < 2.5; osteopenia if between -1 and -2.5

Z-score helpful for detecting accelerated osteoporosis (ie 2/2 factors)
Who in the general population should be screened for osteoporosis? When? What about in the risk factor population?
All women greater than 65 and all men greater than 70. If RF's, then should screen > 50yo.
Is a fracture alone in elderly enough to start drug therapy for osteoporosis?
Yes- hip or vertebral fracture
What osteoporotic agent stimulates osteoblasts? What are its limitations and side effects?
Teriparatide- it stimulates both bone buildup and bone resorption but net effect is buildup. can only be used for 2 years bc of cumulative increased risk of osteosarcoma. And after it is discontinued, patient needs to use a bisphosphonate.
What is the net effect of bisphosphonates and HRT together in the treatment of osteoperosis? additive or synergistic?
They have an additive effect.
What form of bisphosphonate is especially associated with osteonecrosis of the jaw? What are other side effects that are important?
1) IV form is more associated with osteonecrosis.

2) Severe myalgias and arthralgias and
3) atypical fractures (femur) are other side effects.

4) Also alendronate can cause severe esophagitis but less likely with weekly dosing. Avoid it by taking it with full glass of water on an empty stomach, and don't recline 30 min afterwards.
What are the benefits of calcitonin?
Nasal spray, decreases risk of vertebral fractures - but not hip fractures
What is an example of hormone modifier Rx for osteoporosis?
Raloxifene- similar to estrogen on bone and lipids (although anti-estrogen on breast and uterus)
What are the rates of DVT in hip fx with and without a/c?
With a/c, risk is 48%

Without a/c, risk is 25%
What is frailty defined as?
At least 3 of the following:
1) wt loss > 10 lbs in 1 year
2) exhaustion bc no endurance
3) decreased hand strength
4) walking slowly
5) reduced activity
What is the mini-cog?
3 word recall with clock draw (2 points). 0-2 points = dementia.
What is the confusion assessment method for delirium? (CAM)
Need both acute onset/fluctuating and inattention, with either
1)disorganized thinking or
2)altered level of consciousness
What is a positive whisper test?

What is a positive get-up-and-go test?
Patient answers 3 or more questions out of 6 incorrectly.

10 seconds to do the routine (stand, walk, turn, sit) = moderate risk. 20 seconds = high risk.
What is the definition of malnutrition?
Any of the following:
1)wt loss of 10 lbs over 6 months
2)BMI<22
3)albumin<3.8
4)cholesterol<160
5)any vitamin deficiency
Can aging explain orthostatic hypotension and swaying?
Yes- aging is associated with decreased proprioception and baroreceptor reflexes.

Also postprandial - can get hypoglycemic from ingestion of carbs
How does physical restraint affect risk of serious falls?

What are some office tests that can be done to assess risk for fall in elderly?
It iincreases the risk of serious falls and injuries

Timed get-up-and-go test, gait speed, tandem walk (heel to toe), calf circumference, and vision
How do sacral decubs affect mortality in NH patients?
Increases mortality in nursing home patients
What do you do if eschar is on top of an ulcer?

How do you treat an infected ulcer?
Remove it for proper staging

Rx infected ulcer with debridement, saline cleansing (not peroxides/iodines - kills tissues after too much). Not wet-to-dry for same reason
What is the effect of age on the immune system specifically?
Decreased immunity with age. Total T and B cell numbers stay the same, but number of CD4 T cells increases with age, while the number of CD8 T cells decreases.

Also only half of the T cells remain competent (more susceptible to herpes zoster and reactivation TB)
What happens to volume of distribution of a drug with age?
It increases because there is a proportional increase of body fat compared to muscle.
What is the most common cause of falls in nursing home?

How many medications does it take to dramatically increase errors in self-administration?
Atypical antipsychotic causing delirium is the most common cause of falls in NH's.

3 or more meds greatly increases risk of errors
If you come across an elderly patient on benzo's, how do you take them off it?
Switch to an equivalent dosage of a water-soluble benzo (such as oxazepam) with slower onset, less addictive potential and taper over several months.
What does TSH do with age? Treat it?
TSH normally increases with age, but if T4 is still OK it does not merit treatment (ie sublicinal hypothyroidism).
What are complications of Paget Disease?
1) Arthritis (more brittle bones)
2) high-output heart failure (more vascular bones)
3) nerve compression (larger bones).. includes hearing loss
What is the etiology and prevalence of Paget disease? How do you diagnose it and what is management of it?
Etiology is viral trigger with genetic predisposition (1% of population > 40yo).

Diagnose with bone scan (focal areas of marked increased uptake) after seeing isolated elevated alkaline phosphatase.

Treatment only if symptomatic - bisphosphonates or calcitonin
What is the average age of menopause?
51yo
How does hypoglycemia more commonly present in the elderly (vs in younger people)?
More often in elderly as mental status change - not tremors/sweats.
Who needs to have a creatinine clearance measured before starting metformin, and at what value for any age should you not give metformin to?
Measure creatinine clearance in anyone over 80 in whom you're starting it in.

Do not give it to any age patient with a CrCl < 60.
What is the evidence for estrogen only in preventing coronary disease? Other risks of estrogen only?

How about combination HRT? Other risks of combination HRT?
estrogen only is ineffective long term for preventing heart disease, and increased risk of gall bladder disease. Also endometrial hyperplasia with increased risk of cancer.

combination HRT has an increased risk for all CV disease (in older women only), breast cancer, DVT, and GB disease.
How do you treat premature ovarian failure safely with HRT?
If patient has premature ovarian failure (menopause before age 40), give combination HRT until the woman is 50 years old, then stop and discuss the risks.
Is there a relationship between bladder catheters and delirium? How about pain?

What drugs are high risk for deliirum?

What is withdrawal delirium?
Both catheters and post-op pain are causes of delirium.

Demerol, NSAIDs, new abx, benadryl, all CV drugs, antidepressants, antiemetics, baclofen, H2 receptor blockers, St. John's Wort.

Also acute discontinuation of EtOH, benzo's, SSRI's, pain meds can cause withdrawal delirium.
What is sundowning?
It is not delirium. No precipitating illness. It occurs predictably in the evening.
Is Vitamin E recommended as a supplement for dementia treatment?

Is there any data supporting ginkgo or vitamins A and D?
No because it may increase CV disease and death.

Studies are negative.
What are 3 side effects of SSRI's to watch out for?
hyponatremia, sexual dysfunction, and tremor
Is insomnia associated with any other illnesses?
Yes, it is associated with worsening of chronic CV disease, lung dz, depression, pain, incontinence.
What medications are associated with insomnia?
steroids, beta blockers, beta-agonists. stopping sedatives and pain meds.
What is ramelteon? How is it for the elderly?
Melatonin agonist. No known side effects- good choice for elderly but variable in efficacy.
What are specific side effects of fluoxetine (prozac)?
Paroxetine (paxil)?
Sertraline (zoloft)?
Fluvoxamine (Luvox), but who is it good for?
Citalopram?
Nefazodone, but who is it good for?
Venlafaxine (effexor)?
Bupropion?
Mirtazapine (remeron)?
Fluoxetine- causes insomnia.

Paxil- most anticholinergic, insomnia

Sertraline- GI discomfort (don't give if hx of IBS), insomnia

Fluvoxamine- most sedating. good for agitation, insomnia, OCD patients

Citalopram- anxiety, insomnia, n/v

Nafazodone- good for insomnia and maintains sexual activity

Venlafaxine- insomnia, htn

Bupropion- less sexual dysfunction. can cause insomnia, htn

Mirtazappine- most anticholinergic . may cause htn.
In addition to primary RLS, what are secondary causes of restless leg syndrome? Workup? What to make sure it's not before giving diagnosis of RLS?
Primary or 2/2 to iron deficiency (even without anemia), dialysis, diabetic neuropathy, MS, Parkinson's, pregnancy.

Workup- always check a ferritin level, even if no anemia.

Also make sure it's not akathisias from SSRI's/antipsychotics.
What is management of RLS?
behavioral (avoiding caffeine, EtOH, nicotine) and iron replacement if not severe.

if needed use dopamine agonists (ropinrole and pramipexole).

if refractory, try gabapentin, ultram, opioids.
What does the 'benign disequilibrium of aging' refer to?
Multisensory deficits as a cause for disequilibrium (mix of visual, hearing, ortho, neuropathic deficits).
What disorder is a RF for BPV?

What is on the ddx for BPV (also giving positive Dix-Hallpike but uncertain history)? How to work this up if needed?
Geriatric patients who have giant cell arteritis.

Also on ddx is central causes of vertigo including cerebellar lesions. Work this up with imaging and water calorics, called electronystagmography.
How do you treat BPV?
Epley and Semont maneuvers. No drugs recommendd (eg antivert) officially
What is the age distribution for incidence of asthma? What is criteria for diagnosis of asthma in elderly population? Bronchodilator study? Bronchoprovocation?

Management of geriatric asthma- any drugs that should not be used?
Childhood or as aging adult (less common than COPD but happens even > 65yo).
Do not use 70% FEV1/FVC ratio bc it will overdiagnose asthma - instead, use >90% as the cutoff.

Use GOLD criteria of >12% predicted or >200cc increase in FEV1 for bronchodilator response.

Bronchoprovocation can be used if normal PFT's, in the same way as it is for younger poeple.

Theophylline should not be used.
Can urinary incontinence be expected with aging?
No - it is always pathologic.
What are the types of urinary incontinence? Which is most common?
1)urge
2)stress (with coughing, sneezing)
3)mixed
4)incomplete bladder emptying (leaking after voiding)

Urge incontinence is most common.
What is urge incontinence caused by? How do you manage it?

Important side effect of meds? Important cross-reaction?
Detrusor instability (hyperactive) usually caused by CNS problems vs cystitis.

Treatment of urge incontinence is bladder training with antimuscarinics as an adjuct.

Watch for acute angle glaucoma. Do not use fthem for incontinence in pts taking cholinesterase inhibitors for dementia - can accelerate cognitive decline togehter.
How do you treat stress incontinece?
Treat with kegel exercise. Surgery has high cure rates, but also high risk of complications. Also periurethral collagen injections.
What is incomplete bladder emptying? Who gets it?

What other type of incontinence might it present as?
overactive bladder with outlet obstruction or by under-active bladder that has trouble contracting

Males get it 2/2 BPH, also patients on anticholinergics; diabetics, Parkinson's.

Can present as urge incontinence.
What are drugs used for urge and mixed incontinence?
oxybutynin, tolterodine, trospium, solifenacin (vesicare), darifenacin
What are 2 tests that should be done before making diagnosis of BPH?
DRE and urinalysis to look for hematuria (cystitis).
Which alpha blocker should not be used in BPH and wh
Prazosin, because it has shorter t1/2 and more side effects.
How long dose it take for 5-alpha reductase inhibitors to work?

Do any BPH drugs affect PSA?
Takes at least 6 months

5-alpha reductase inhibitors decrease serum PSA even in cancer- adjust by multiplying measured PSA by 2.
What can bicycling do to erections?
Avid bikers can get ED 2/2 pressure on pudendal nerves
What can aging do to erections?
Decreased potency does decrease with age.
What are side effects of sildenafil? Tadalafil (cialis)?
Sildenafil- vasodilatory (flushing, h/a, dyspepsia), bluish vision

Tadalafil- back pain

All PDE5 inhibitors have a risk of hearing loss.
What is yohimbine?
Alpha blocker with very few side effects, mostly for psychogenic. Doesn't work great.
Which meds most commonly cause sexual dysfunction?
clonidine, beta-blockers, SSRI's, spironolactone and thiazide diuretics
What are examples of intermediate risk surgeries?
Endovascular AAA repair and carotid endartercetomy, ortho, head and neck, intrathoracic
Who gets beta blockers started on them perioperatively?
Vascular surgeries with a positive pre-op stress test
If patient gets balloon angioplasty, how long should you wait before elective procedure?
4 weeks - same as BMS
Is it beneficial to teach male patients testes self exam?
Yes
What's the relationship between smoking and ulcerative colitis?
Smoking cessation can exacerbate UC.
What are pre-op screening labs/tests for specific indications?
Hematocrit if old for major surgery/if potential for major blood loss.

Creatinine in >50yo or other RF's

ECG for all vascular procedures an all others if any RF's at all including age

CXR if >50 and major surgery or suspected cardiopulm dz
What are side effects of varencicline (chantix)?
Serious psych effects including suicidality.
What does high intake of red meat increase risk for? Alcohol? Obesity? Low fluid intake?
Red meat- colon cancer
Alcohol- whole GI tract and breast
Obesity- pretty much all cancers
Low fluid intake- strong risk for bladder
What does tomatoes do for cancer? Fiber for anything? Vitamin D?
Tomatoes- decreases prostate cancer
Fiber- reduced CV disease and DM
Vitamin D- CRC and prostate ca (supplementation does not help if adequate diet)
What do 5-alpha reductase inhibitors do in prostate ca?
Dutasteride and finasteride decrease prostate ca risk.
Who should get screened for hyperlipidemia? How often?
Men 35-65 every 5 years
Women 45-65 every 5 years
Who should get screened for DM 2, how, and how often?
Venous fasting plasma glucose if older than 45 if no RF's, and 30 if any RF's
AAA screening?
Men who have hx of tobacco 65-75, or if 60yo M and have 1st degree relative with AAA
Between what ages should PSA be discussed and how often should it be drawn if it is? DRE?
Between 50-69yo (or 40yo if AA, FH) - and every 4 years.

DRE no longer recommended by ACP.
What does a total hysterectomy imply in terms of cervical ca screening?
If total (ie cervix removed) and for a benign indication, then can stop pap smears.
How often should FOBT's be done?
Annually until colonoscopy is done.
At what age should pap smears be started?
age 21
What drugs even hours after ingestion may still be in the stomach in terms of poisoning? What do you do after lavage (unless in what situation)?
ASA, anticholinergics, or narcotics (cause decreased gastric motility)

Gastric lavage (done rarely bc it is usually ineffective). should be followed by activated charcoal and a cathartic (sorbitol or Mg citrate) (activated charcoal is no effective if o/d is with the metals lithium and iron)
What is gut dialysis? What are examples of drugs that this is good for?
Continued dosing with oral charcoal -> causes absorption via enteric recirculation.

Examples - dig, theophylline, TCA's, salicylates, phenobarbital
With TCA, ASA, phenobarb o/d, what do you want to do to the urine?

What about with amphetamine and PCP?
Alkalinize to pH > 7

Acidify using ammonium chloride for pH , 5.0
What drugs is HD not effective for? Effective for?
Benzo's, opiates, TCA's (large molecules)

good for lithium, EtOH's, ASA
What is charcoal hemoperfusion?
Blood pumped thru charcoal filter.

Good for lipid soluble, protein bound molecules: dig, theophylline, ASA
Someone who ingests 5x therapeutic dose of dextromethorphan - excited or depressed presentation?
Excited (sympathomimetic)
What is the antidote for anticholinergic o/d?
Physostigmine
Contaminated moonshine usually leads to what toxicity? How to treat?
Methanol; fomepizole, folic acid (increases metabolism of formic acid), and immediate HD
What ingestion to suspect with calcium oxalate crystals in urine and hypocalcemia? How to treat it?
Ethylene glycol - it gets broken down into oxalate. Treat with fomepizole, bicarb, calcium prn, and HD.
ESRD patient who is intoxicated and takes ultram, demerol - what are they at risk for?
seizure
What's a specific side effect of methadone?
It prolongs QT
When giving naloxone what do you titrate the dose to?
Ventilation (not consciousness or for dx purposes bc of worry of withdrawal)
If patient is on high flow O2, unconscious, and then was reversed quickly on naloxone, what are they at risk for?
Acute lung injury
What is the common acid-base disturbance seen in aspirin o/d? How does that happen? How to treat aspirin o/d?
Common disturbance is mixed met acidosis and respiratory alkalosis (hyperventilating in order to bring up blood pH to prevent ASA from crossing bbb).

Treat asa overdose wtih activated charcoal and bicarb
How does a patient respond in first 48 hours after a severe tylenol overdose?
First mild nausea/vomiting and diarrhea, then in 1-2 days gets liver toxicity
Do you use activated charcoal in tylenol o/d?
Only in the first 4 hours
What does theophylline toxicity present as? What drugs can raise levels?
Patient w/hx of obstructive lung disease and tachyarrhythmia, tremors, vomiting, seizures (like cocaine or methamphetamine). Theophylline level elevated.

Drugs that increase levels are macrolides, quinolones.
How do you manage theophylline toxicity?
Look for hypokalemia, and treat with a lotof activated charcoal, otherwise symptomatic care.
What are symptoms of lithium overdose and are levels helpful?
Altered MS encephalopathy, seizures, parkinsonian sxs, n/v/diarrhea.

Levels do not correlate with symptoms.
What are complications of chronic lithium use?
RTA, nephrogenic DI, sicca symptoms
How do you manage lithium overdose?
Hemodialysis
How does TCA overdose present and how do you manage it? What correlates with degree of overdose?
Presents with arrhythmias, sedation/confusion. Also QRS prolongation correlates most closely with degree of intoxication. Can also see vtach/vfib.

Do not use HD bc molecules are protein-bound and large. Treat cardiac problems by hyperventilating or using IV bicarb. Lidocaine for arrhythmias.
How does potassium derangement vary with dig toxicity?
Hypokalemia in acute injury but hyperkalemia in chronic toxicity.
What leads should you look for ST depressions with dig toxicity?
Lateral leads
What should you be cautious about when you use Fab antibody?
Overcorrecting hyperkalemia to hypokalemia rapidly. Should not give calcium if giving Fab ab's
In a very agitated psychotic patient who is sweaty, what overdose did the patient have? How do you treat it? What to watch for both acutely and in long-term users?
Methamphetamine. IV benzo's and then haldol.

Acutely- rhabdomyolysis. Long term- severe tooth decay.
What does PCP present with and what to watch out for? How to manage it?
Seizures, dystonia including laryngospasm, hypertensive crisis, psychosis.

Watch out for rhabdomyolysis with dystonia.

Treat with IV benzo's.
What is MDMA? What are side effects?

How to manage it?
Ecstasy. Side effects are jaw gridning (bruxism), anxeity, sweating. Dangerous complications are severe hyponatremia, malignant htn, CV events, aortic dissection, serotonin syndrome. Also hyperthermia and rhabdo.

Give activated charcoal if 1 hour ago Benzo's. Avoid haldol. Do not give beta blockers bc of unopposed alpha adrenergic (like in cocaine). Can use CCB instead of BB for arrhythmias.
What are some typical real-life scenarios of acquiring CO poisoning?
Car exhaust inhalation, exhaust from gas-powered generators, poor heating hookup, smoke inhalation
What are longer term effects of CO poisoning?

How do you assess severity of the poisoning?
CNS long-term to permanent damage, including personality/movement/memory.

CO level > 15% is moderate, > 30% is severe, >50% is fatal
Who gets hyperbaric oxygen in CO poisoning?
End-organ damage, any focal neuro defect, CoHb level greater than 25% and in pregnant women with level greater than 20%.
What are clues to cyanide poisoning by history, physical exam and labs?
Almond odor to breath
Bright red venous blood
Hx of being in a fire or sodium nitroprusside or amygdalin (apricot, peach pits). If severe can see Parkinsonian features.

Labs show significant lactic acidosis.
How do you treat cyanide poisoning?
3 step cyanide antidote package- induce methemogobinemia bc cyanide preferentially binds methemoglobin (and this is less toxic).

Give amyl nitrate under patient's nose, then sodium nitrite IV (converts hemoglobin to methemoglobin ie the ferric form), and sodium thiosulfate which converts cyanide to inactivef orm --> renally excreted.
When do you check for inorganic lead exposure and what do you check in these situations?
Whole blood lead level for ongoing exposure.

RBC protoporphyrin and zinc protoporphyrin levels months after exposure.

Urine lead after EDTA administration, for years since exposure.

note: organic lead is rapidly excreted- prior exposure undetectable.
What are 2 types of insecticides? Difference? How do you treat insecticide poisoning?
AChesterase inhibitor- 1)organophosphates (long lasting) and 2)carbamates (reversible binding)

Treat by removing clothes and showering, then atropine prn and 2PAM if organophosphate (but not if carbamate)
What to think about in the tearful patient who is yawning?
Heroin withdrawal
In heroin withdrawal what are pupils?
constricted- stays constricted even in withdrawal
How to manage acute heroin withdrawal?
methadone; if refuses, can use clonidine and diazepam (valium)
How to treat hallucinosis / delirium in DT of EtOH withdrawal? what should you not give?

How to prevent alcohol withdrawal if they want to quit drinking?
long-acting benzodiazepines (not haldol bc it can precipitate seizures)

Give chlordiazepoxide (first discovered benzo)
What is the normal flow of aqueous humor in the eye?
It's made by ciliary body --> flows through pupil into anterior chamber --> trabecular network --> into Schlemm's canal
What are risk factors for open-angle glaucoma?
age, family history, African American
What on fundoscopic exam should make you suspicious for glaucoma?
cupping (cup occupies > 50% of the optic disc)
What is screening for open angle glaucoma?
AAO: optho after 40yo and then every 3-5 years without risk factors, every 1-2 years if risk factors. after 60, every 1-2 years

(USPSTF found insufficient evidence for this)
What is used to treat open angle glaucoma first line? how do they work?
prostaglandins are first line (latanoprost, etc) bc of once daily dosing and few side effects.

They work by increasing aqueous flow.
What are 3 other classes of drugs for treatment of open angle glaucoma?
beta-blockers- decrease production of aqueous humor. (eg timolol), can cause systemic side effects.

alpha (nonsel or alpha2) agonists- increase aqueous outflow (epi, brimonidine)

cholinergic agonists (incr aqueous outflow)- open trabeculae by relaxing ciliary body muscle. cause pupil constriction (pilocarpine)

carbonic anhydrase inhibitors (PO acetazolamide)- inhibits CO2-->Bicarb which then prevents Na (and water) from accumulating in eye
What are risk factors for closed-angle glaucoma? What is it due to?
Age > 40, female, hyperopia, Asian, and family history.

Due to anomalous iris configuration causing trabecular network obstruction.
How does closed angle glaucoma present? What does their pupil look like?

What can precipitate this?
Rapid severe eye redness, pain, nausea, and halos around lights. Pupil is fixed and mid-dilated.

Low-light conditions (like night time, movie theater) precipitate it.
What is treatment for closed angle glaucoma?
Laser iridotomy immediately - if delayed, give pilocarpine, beta-blocker, alpha agonist, and acetazolamide.
What does retinal detachment present as? What is biggest risk factor?

What can sometimes be seen on exam?
Flashes, streaks of lights (photopsias), showers of black dots (hemorrhage), waving curtain.

Myopia is biggest risk factor.

Portion of retina appears elevated/folded.
What is retinal artery occlusion usually 2/2 to? How does it present and what is its management?
Usually embolic. Presents with sudden, painless unilateral blindness. Retinal edema creates pallor and see cherry red spot in macula.

Emergent treatment- ocular massage and paracentesis and carbogen inhalation (to dislodge embolus, lower pressure and dilate retinal vessels). While waiting for optho, have patient get into Trendelenburg position and hyperventilate and do ocular massage.
What is retinal vein occlusion 2/2 to? How does it present and what is its management?
Secondary to htn, PV, Waldenstrom. Sudden, painless, near-total loss (not total) of vision. See retinal edema with hemorrhage (but no cherry red spot). There is no effective acute Rx and not emergency.
What are risk factors for ARMD?
smoking, low zinc/antioxidants are risk factors
What is ARMD due to? Types? Management?
Macula (fovea+surrounding retina) is very small but has many cones. ARMD can be atrophic ARMD (dry) or neovascular ARMD (wet).

Treat wet ARMD with laser photocoagulation and photodynamic Rx.
What is the treatment of retinal detachment?
Tack down the retina if small; if large, requires vitrectomy/scleral buckling.
What is optic neuritis associated with? What is seen on exam? What should be done next?
MS. Initially optic disc is normal, later on develops pallor.

MRI +/- IV steroids (MRI to look for MS)
What is vitreous degeneration? Who gets it and what are symptoms? What to watch out for with this?
Occurs in all elderly people. Get bothersome floaters, brief flashing lights, vitreous detachment (sudden shower of floaters/flashing lights).

Not dangerous unless it damages the retina - vitreous hemorrhage.
What is vitreous hemorrhage?
Sudden, painless los of vision caused by viterous detachment tearing a retinal vessel or breaking BV's in proliferative DM retinopathy.
What should you suspect in someone who presents with sudden onset painless double vision?
CN dysfunction - 3 (oculomotor)- dilated and down and out; 4 (trochlear)- eye is up and head tilted towards uninvolved side; 6- can't deviate laterally
In severe alkali injury what may the eye look like?
White and quiet - the alkali solutin can blanch the vesels (parardoxically)
Preaurical adenopathy with red eye -what does this suggest? What about white, stringy exudate? Clear? Purulent?
Adenoviral conjunctivitis. Allergic, Viral, Bacterial.
What to suspect with ocular pain, photophobia, and a ciliary flush with normal cornea and normal intraocular pressure? What is seen on slit lamp? Management?
Anterior uveitis. Slit lam shows inflammation in aqueous humor. Emergent referral and treat with steroids and cycloplegics to prevent synechiae
What is keratoconjunictivitis sicca (keratitis)? Who gets it?
Elderly and middle aged owmen - dry eyes. may be sign of systemic inflammation.
What is a risk factor for viral conjunctivitis?
Adenovirus in summer around swimming pools.
What is the natural course of bacterial conjunctivitis? Standard treatment?
Most cases will resolve within 5 days even without Rx but treat and follow bc it can result in vision loss.

Topical erythro, sulfa - if complicated/serious use quinololne and refer.
What organism can cause conjunctivitis resulting in hyperacute sxs? What can lead to possible corneal perforation? management?
Neisseria (either gonococcal or meningococcal).

Neisseria or Pseudomonas can lead to corneal perforation.

Treat aggressively (topical quinololone) and also with systemic therapy.
What is the relationship between bacterial conjunctivitis and contact lens wearers? Progression of disease?
If wearing contacts for a long time, they have an impaired ability to fight conjunctivitis and can result in vision loss.

Acanthamoeba can be seen in this population, especially if they use tap water. Will progress to keratitis.
Who gets infectious keratitis? Exam?
Bacterial keratitis- contacts, immunosuppressed. Exam shows red eye with mucoid discharge and a visible white spot (corneal opacity).

Viral keratitis- reactivation of latent HSV- see fluorescein staining showing a dendritic branching pattern. RF's are laser eye treatments and immunosuppression. Rx with topical or oral antivirals. Do not give steroids - can exacerbate.
What types of organisms cause endophthalmitis? And what are the 2 sources? What specific organisms are seen with these 2 sources most commonly?

What is the biggest RF and organism associated with it?

What do patients present with?
Bacterial or fungal. Either traumatic or systemic source. With trauma to orbit, suspect Bacillus cereus. With bloodstream, think candida.

Biggest RF is right after cataract surgery, get CONS.

Present with decreased vision, hazy cornea, pain, and hypopyon (layering of white cells visible in anterior chamber).
What is management of endophthalmitis?

Besides immunosuppressed/abx users, who else is at risk for candida endophthalmitis? Management of candida endophthalmitis specifically?
Vitrectomy, cx, and intraocular abx that cross BBB to get to vitreous fluid.

Heroin IV drug users, using contaminated lemon juice to dilute drugs. Rx candida with systemic azoles (not ampho B bc poor eye penetration)
What is chalazion? Stye?
Caused by obstruction of one of the tarsal glands. NTD.

Stye is an abscess at base of eyelid- first try warm compresses and topical abx.
What does toxoplasmosis look like on funduscopy? CMV retinitis (and who gets it)? Arcus senilis (and who gets it)? Papilledema? Synechiae (and who gets it)?
Toxo- Pigmented macula.

CMV retinits- Retinal hemorrhage and vasculitis (AIDS)

arcus senilis- Older people, but if young suspect lipid disorder.

papilledema- Swollen optic disc (similar to optic neuritis but it is bilateral)

synechiae- grossly see connections btwn iris and pupil, as a complication of iritis (usually idiopathic but also CTD and viral infection)
What is ddx for white on iris?
Bacterial keratitis vs corneal ulcer
What is conduction hearing loss 2/2 to?
Blockage (otitis media, otosclerosis, TM perforation) of sound to inner ear.

Otosclerosis is incomplete AD inheritance, much more common in whites.
What causes sensorineural hearing loss?
Presbycusis, Meniere disease, acoustic neuroma, drugs, virus.
How do you treat Meniere disease? Acoustic neuroma (presentation as well)?

How do you manage acute sensorineural hearing loss presentation?
Meniere disease- avoid caffeine and salt, +/- diuretics. benzo's and antiemetics but not meclizine.

Acoustic neuromas- present with gait imbalance, unilateral hearing loss, tinnitus. get MRI, Rx with surgery.

Eval immediately- if cannot be seen immediately, start prednisone 60mg/day right away.
What principal is the Rinne test based on?
Air conduction is louder than bone conduction of sound in normal hearing. (mastoid vs air)
What is the Weber test?
middle of forehead- does the sound lateralize? if so- either conductive hearing loss in ipsilateral ear, or sensorineural loss in opposite ear.
What is a good case to think about bulimia?
Young woman presenting with a mallory-weis tear or severe GERD.
How to manage generalized anxiety disorder? Panic disorder?
GAD- behavioral therapy, then SSRI's +/- Benzo's or Buspirone if needed

Panic disorders- SSRI and benzo's/buspirone, maybe psychotherapy
How to manage bipolar disorder? What if it's refractory?
Lithium, depakote, carbamazepine. Can use antipsychotics if psychotic features.

If refractory, use ECT.
What are side effects of atypical antipsychotics? Of antiepileptics?

What drugs increase lithium level?
Atypical antipsychotics can have weight gain, DM, HL.

Entiepileptics- assoc with increased risk of suicide (beware of giving depakote or carbamazepine to bipolar patient).

Thiazide diuretics, ACE-i, and NSAIDs increase lithium levels.
Anorexia nervosa- how low is their weight under ideal?
< 85% of ideal weight
What is neuroleptic malignant syndrome? What drugs typically cause it? And what is thought to be the etiology?
Response to potent neuroleptics (haldol and others), thought to be 2/2 depletion of dopamine. It results in ANS dysfunction, extrapyramidal sxs, high fever
How long does it last for and how do you treat?
It can last for up to 10 days after the drug is stopped. Stop drug, cool down the patient, and give bromocriptine or dantrolene or amantadine (dopamine agonists).
What is serotinin syndrome due to? When does it happen? What is presentation?
Serotinin drugs can cause a derangement in thermoregulation. It happens usually w/in 6 hours of starting a new/additional serotinin drug.

Presentation is like NMS/anticholinergic toxicity/cocaine overdose.
How do you manage serotonin syndrome, and how long does it last for?
Manage it with benzo's. For the hyperthermia, it is often 2/2 muscle rigidity and so you may need to paralyze the patient. Cyproheptadine given for severe cases.

Resolves in 24 hours.
What chromosome are the HLA genes on? What is HLA?
Chromosome 6. HLA is human set of genes for antigens involved in graft rejection.

Class I (all cells except RBCs), II, and III HLA
Why do pregnant women get more reflux?
Progesterone decreases LES tone
What should you use to treat Crohn's in pregnancy?
Flagyl (although generally contraindicated in 1st trimester), prednisone, sulfasalazine
When in pregnancy is hepatitis E very high risk in pregancy for fulminant hepatiti?
3rd trimester
When is the best time for surgery for severely symptomatic gall stone patients?
2nd trimester
What is fatty liver of pregnancy? When does it happen? What are complications and what is treatment?
Modest elevation of LFT's bc microvesicular fat deposition. 3rd trimester and is associated with encephalopathy, hypoglycemia (like Reye syndrome), preeclampsia, pancreatitis, DIC and renal failure.

Need to do early delivery.
What to do for treating asthma in pregnancy?
Budesonide is OK in pregnancy, the other steroids are category C.
What are cardiac conditions that are absolute contraindications to pregnancy?
PAH and Eisenmenger syndrome.
If a pregnant patient is found to have mitral stenosis or secundum ASD, what is a medication worth considering?
digoxin, to prevent afib bc they can decompensate with this.
What infection is a common cause of PDA, pulm stenosis, supravalvular AS?
maternal rubella infection
What are recommendations for healthy women and asa?
Not recommended for MI prevention, but once 65 should be on it for stroke prevention.
What to use for htn in pregnancy?
clonidine, labetalol, CCB, dig, procainamide
What can you use if you need an aminoglycoside in pregnancy? Antihistamine?
gentamicin (most other ones- no).

antihistamine- chlorpheniramine
What bacteria cause UTI's in pregnant women? How to treat? What to suspect in pt with clinical UTI but negative urine culture?
Strep agalactiae and E coli. Treat with ampicillin, cephalexin, or nitrofurantoin.

Suspect Listeria in this patient.
What is a cause of postpartum endometritis and bacteremia? (postpartum fever).

What does abx ointment in neonates protect them from? What does it not protect them from?
Strep agalactiae

Protects them from gonorrhea but not chlamydia.
Who gets treated for asymptomatic bacteriuria?
pregnant women, neutropenic, diabetics, and transplant patients
What is the most common congenital viral infection? Symptoms?

What about rubella? If pt is exposed to it while pregnant, what to do?
CMV - most are symptom free but can have microcephaly

Rubella is german measles. severe congenital defects in baby. Test for ab and then repeat in 3 weeks. Immune globulin may give some fetal protection if therapeutic abortion is declined.
What does VZV do in pregnancy? What to do with HIV women who are pregnant?
There is a slight risk of congenital defects and the pregnant woman with chicken pox has a 10% chance of developing severe PNA.

Give ART.
Is pregnancy a RF for renal stones?
No, even though Vit D level is 2x normal and ca absorption and excretion is increased.
If htn in pregnant woman, what is one thing that needs to be checked for and when?
Proteinuria after 20th week
How does management of elevated BP help in preeclampsia?

What are the goals for BP in preeclampsia and why?
It does not help outcome of preeclampsia but helps with stroke prevention only.

Low BP has significant IUGR risk. Therefore Rx for goal SBP 130-150
How do you manage a pregnant woman who has controlled, chronic htn hx (BP <120/80)?
Take off BP meds and frequently monitor - and same goals for BP as preeclampsia.
What is the diagnosis in a woman who presents with elevated BP and seizures up to 3 months postpartum?
Eclampsia
What is the outcome of pregnancy in a stable renal transplant patient? dialysis patient?
Great.

dialysis patient- rarely able to become pregnant
What happens to dose of synthroid in pregnancy?
Usually goes up by 50%
Should statins be discontinued for pregnancy?
yes
Are triptans ok in pregnancy?
no- risk of inducing ischemia.
When weighing balances of uncontrolled seizure to risk of teratogenicity, which is more important?

What is general management of seizures in pregnant women?
Controlling seizures is more important because they can also cause placental abruption, premature delivery.

In general, maintain on monotherapy and at lowest dose possible. Also make sure they are taking folic acid. Women should take prophylactic vitamin K in last month of pregnancy bc they have a higher risk of bleeding.
What happens to carpal tunnel that presented during pregancy?
It resolves with delivery - so treat with splints for these patients.
Pregnant women who have not had prenatal care are at risk for what deficiency?
Iron deficiency
Can methotrexate be used in pregnancy? What are contraindications for MTX?
No it cannot. Also don't use in renal, liver, hepatitis B or C, and alcohol abuse.
What is the association between gonorrhea and pregnancy?
Pregnancy (and menstruation) are predisposing factors to disseminated gonorrhea.
What should you look for in a pt with lupus thinking to get pregnant re risks to fetus?
SSA(Ro)/SSB(La) ab's - associated with neonatal lupus and congenital heart block.

Also risk of complications is greater if active disease (esp renal manifestations) or if APS. If there was a recent flare, continue steroids as needed.
How do you manage pregnant women with APS and hx of recurrent miscarriages?
Treat with heparin plus low-dose aspirin.
What causes AVN of hip besides Hgb SS?
Pregnancy, HIV, Gaucher disease, hypercoaguable states
Who should not get reflex HPV testing in ASCUS? What should happen instead?
Teenagers bc they have a high rate of HPV but low rate of cervical ca. They should get a 1 year follow-up pap - if ASCUS 2 more times after the first time, then colposcopy.
What is dysfunctional uterine bleeding? How to diagnose? What can cause it? Rx for DUB?
XS bleeding 2/2 anovulation in a reproductive age woman producing estrogen.

DUB is a diagnosis of exclusion.

DUB can be caused by many things including thyroid, liver, kidney, anatomy, drugs.

Rx with oral OCP combo for a few months