FM 2

- Broca's Area - Expressive/motor aphasia

A patient understands what you are saying and what they want to say, but can't say it. The area of their brain affected is the ___________ area, and this is considered ___________/___________ aphasia.

- pyoderma gangrenosum - not a clear cause - autoimmune issue - oral prednisone + ciclosporin + biologic agent (-mab)

A patient with rheumatoid arthritis presents with this. What do you think is going on? What causes that? How do you treat?

D. Poverty of content

A person is speaking to you but very little information is conveyed. This is called: A. Glossolalia B. Circumstantiality C. Thought disorder D. Poverty of content

A. Folstein

Which of the following is the most commonly used dementia screen? A. Folstein B. Beck C. GDS D. GAD-7 E. PHQ-9

B. Catatonia

A patient is unresponsive, not moving and not speaking. Which of the following describes this presentation? A. Cataplexy B. Catatonia C. Clanging D. Agnosia

E. PHQ-9

Which of the following is the most commonly used depression screen? A. Folstein B. Beck C. GDS D. GAD-7 E. PHQ-9

- dependent personality disorder - Pervasive and excessive need to be taken care of leading to submissive and clingy behavior - History - *SSRI or tricyclic antidepressant* - group therapy, assertiveness training - Often good - some anxiety and depression

"I know I won't actually die, but it often feels like it." - says Mona and nervously pats her auburn hair - "I can't live without him, that's for sure. When he is gone, it's like life switching from Technicolor to black and white. There is no excitement, this electricity in the air that seems to constantly surround him." She misses him so much that it physically hurts. Sometimes she feels like throwing up at the mere thought of separating or being abandoned by him. She is helpless without him: "He is so masterful and knows how to fix things around the house." He is gorgeous and a great lover. She is supporting him financially. "He is studying". In the last seven years he had switched from psychology to political science to physical therapy. How long will she underwrite his quest for self-realization? "As long as it takes. I love him". What do you think is going on here? What is that? How do you diagnose? How do you treat? Prognosis? case source: Myles_Rizvi quizlet

C. Perserveration

"Is your name Mary?" "Yes." "Are you in the hospital?" "Yes." "Is your name Joan?" "Yes." This is called: A. Tangentiality B. Derailment C. Perserveration D. Circumstantiality

C. Pressured speech

A patient speaks rapidly and loudly - like they have limited time. This is called: A. Sensory aphasia B. Motor aphasia C. Pressured speech D. Erotomania

C. Flight of ideas

"The sky is blue. I love blue eyes. My eyes are watering. There's water everywhere." This is called: A. Loose associations B. Derailment C. Flight of ideas D. Circumstantiality

A. Word salad

"Why do people comb their hair?" elicits a response like "Because it makes a twirl in life, my box is broken help me blue elephant. Isn't lettuce brave? I like electrons, hello please!" - this is called: A. Word salad B. Derailment C. Tangentiality D. Circumstantiality

Crohn disease

"skip lesions" - suspected diagnosis?

ADHD meds a. Stimulants i. dexedrine, dextroamphetamine (Adderall) ii. methylphenidate (Concerta, Ritalin) b. Non-stimulants i. atomoxetine (Strattera)

** review pharm from BB 4 **

Alcohol detox a. naltrexone (Revia) b. acamprosate (Campral) c. disulfuram (Antabuse)

** review pharm from BB 4 **

Review antipsychotic agents a. Typical (traditional) antipsychotic agents: phenothiazines - chlorpromazine (Thorazine) piperadines - thioridazine (Mellaril) piperazines - fluphenazine (Prolixin), trifluoperazine (Stelazine) thioxanthenes - thiothixene (Navane) butyrophenones - haloperidol (Haldol) b. Atypical antipsychotic agents - risperidone (Risperdal), olanzapine (Zyprexa)

** review pharm from BB 4 **

Review depression agents a. Tricyclic antidepressants (TCAs) b. Lithium (Lithobid) c. Anticonvulsants d. Serotonin specific reuptake inhibitors (SSRIs) e. Serotonin-norepinephrine reuptake inhibitors f. Monoamine oxidase inhibitors (MAOIs) g. Other - bupropion (Wellbutrin), mirtazapine (Remeron), trazodone (Desyrel)

** review pharm from BB 4 **

a. Benzodiazepines - alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium) b. Barbiturates - pentobarbital (Nembutol), secobarbital (Seconal), phenobarbital

** review pharm from BB 4 **

a. methadone (Dolophine) b. naltrexone (Revia) c. buprenorphine/naloxone (Suboxone)

** review pharm from BB 4 **

allergic disease workup

***

- Scleroderma

- Suspected diagnosis?

C. GDS (geriatric depression screen)

Which of the following is used to screen for depression in the elderly population? A. Folstein B. Beck C. GDS D. GAD-7 E. PHQ-9

- mass lesion - No, it is typically diffuse - Increase in pressure - sneezing, coughing - Middle/late life new type of HA

1/3 of all patients with a __________________ present with primary complaint of worsening headache. Is the pain localized? What things increase the pain? What is the key feature that will prompt imaging?

- cluster HA - Posterior ipsilateral hypothalamic region - No - prevalence close to 0.1% - Oxygen therapy, SQ verapamil - intranasal are also options- prednisone at beginning can also help - Lots of medications - Verapamil is first line treatment, melatonin also an option - 2-3 days (suicide headache)

33 M who presented with severe disabling headaches for 2 months. He recalls similar bouts every 2 years, lasting 3 weeks to 3 months. The pain is on the left, behind the eye, radiating to the top of his head. He reports sweating, tearing and nasal drainage. The pain last 1-3 hours, happen multiple times a day. He is unable to work (mail carrier). He is just miserable. What is the diagnosis? What area of the brain is likely being affected? Is this common? How do you treat now? How do you prevent? When do you follow up with them?

- central/branch retinal artery occlusion - obstruction or blockage of the retinal vascular lumen - thrombus (OCPs) - EMERGENT - lay pt down, ocular masage, IV diamox, if giant cell arteritis, high dose steroids

34 year old woman presents to ED with sudden vision loss in left eye. She denies any pain, redness, or swelling. No injury. Only medication is OCP. Fundoscopy shows "cherry-red spot" What do you think is going on? What is that? What do you think caused it? What is treatment?

- tension HA - unknown - associated with central sensitization and chronic tension/pain - First line is NSAIDs or acetaminophen - followed by TCA (amitriptyline), or SNRI (venlafaxine) - Gabapentin for elderly - Trigger points + exercise

47 yo M with pmh significant for HTN, OSA ( on CPAP machine), bipolar type I (on Tegretol and Seroquel) who presented with frequent headaches, which he calls sinus headache. He describes his headaches as pressure-like pain "over his sinuses". Episodes last 30 min- 1 hour. The intensity varies between 2-4/10. They occur 5-7 times per week on average for the last 3 years. He did not see any difference since starting his CPAP. His headaches are not associated with nausea, vomiting, sensitivity to light, sound or smell. Routine physical activity does not aggravate his headache. What is the diagnosis? What causes it? How do you treat? What if he was 70 yo? Any procedures?

- cataracts - dilated slit lamp exam - cataract surgery - vision loss leading to blindness

68 y/o woman complains of difficulty driving at night. Has glare in right eye when oncoming headlights come toward her. Has limited herself to daytime driving. Difficult to see road signs in the distance. PMH of chronic COPD with intermittent oral steroid use for COPD exacerbation. What do you think is going on? How do you diagnose? How do you treat? What if you don't?

- type 2 diabetes mellitus

A 30 year old male presents to you with polyuria, polydipsia and fatigue. Fasting glucose 250 (high). Because he is overweight, but relatively young, you check a c-peptide which is 4 (high). What do you think is going on? (treatment and diagnosis discussed elsewhere)

- Wernicke's Area - Receptive/sensory aphasia

A patient is saying words you understand, but collectively they don't mean anything. He does not seem to understand you. The area of their brain affected is the ___________ area, and this is considered ___________/___________ aphasia.

- bipolar disorder - I and II - I is a one week manic episode, two is depression + hypomania (4 days of elevated/irritable mood + 3 symptoms of mania) - I would say type I because length of episode and no history of depression - First treat acute presentation with antipsychotics, then maintain with lithium or valporic acid

A 20-year-old man presents to the hospital emergency department accompanied by his parents, due to a change in mental status and behavior, marked by uncharacteristic argumentativeness, eruptions of laughter, excessive talking, and unusual thoughts. He is being treated for insomnia, and has recently been drinking more alcohol. For the past 2 weeks he has missed college classes, while staying up most nights until 4 or 5 a.m., writing feverishly in several notebooks. When asked, he reports that he is writing 2 novels at the same time and also documenting his accomplishments in an autobiography. He denies any illicit substance use while admitting to increasing alcohol consumption "like all the great novelists do". Efforts by his family to understand his recent change in thinking and behavior have been met with loud and rambling discourses, and he angrily accuses them of wanting him to stay "subjugated by the tyranny of depression". What is the suspected diagnosis? What are the two types and how do they differ? What type is this case? How do you treat?

- conversion disorder - When a patient shows psychological stress in physical ways - DO NOT tell them the diagnosis at the first encounter, slowly and gently explain - CBT, psych support, social support - Early intervention is key - if >6 months, prognosis for change is not good

A 23-year-old white female nutrition assistant was brought to the emergency department by her family after "suddenly passing out for a couple of seconds while on the elevator." She stated that she woke up with blurred vision that developed into loss of vision in both eyes. She also reported an inability to stand due to weakness in her left leg. No pertinent family or personal medical history. No drug use, no current medications. The patient's mother reported that her daughter was experiencing significant situational stressors from working 2 jobs, attending school, being a single parent to a 4-year-old child, experiencing significant financial difficulties, and having a difficult relationship with her child's father. PE was completely unremarkable. Lab work and imaging were normal. Consultation with ophthalmology was unremarkable. What do you think is going on? What is that? How do you treat? Prognosis?

- erythema nodosum - Unknown - possibly strept throat or other infections - Bed rest, leg elevation, analgesia +/- potassium iodide

A 25-year-old otherwise healthy woman awakens with a mild sore throat, fatigue, pain in both ankles, and red lesions on her legs. She reports weakness and fatigue for the past 2 days, but denies fever, chills, nausea, or night sweats. There is no history of using recreational drugs, oral contraceptives, or other medications. She lives in Chicago and has not traveled abroad for 3 years. Physical examination reveals red, tender, fixed, deep-seated nodules on both shins. Her ankles are mildly swollen and tender and she reports difficulty bearing weight. Chest, cardiovascular, and ophthalmologic examinations are normal. A chest x-ray shows left lower lobe infiltration. Her tuberculin skin test is negative. She is diagnosed with pneumococcal pneumonia. What do you think is going on? What causes it? How do you treat?

- schizophrenia - Must be six months, if not it is schizophreniform - *Positive* (delusions, disorganized speech, hallucinations) and *negative* (diminished sociability, restricted affect, and lack of speech) - Clinical: Symptoms for *>6 months* of the above listed symptoms or "other markedly abnormal behavior" - Anti-psychotics - first generation or second generation

A 26 year old female is brought to the ED by her two friends. The friends tell you they all met in the library to study for finals. While studying, she started speaking in ways that didn't make any sense "Plant cells have walls. The walls are grey. They are around us and moving inward. Have you killed anyone?" When they asked her what she was talking about. She responded: "Whose what, what's who, let's go out on the roof where it's safe." The patient tells you she has fear the government was reading her thoughts and she had killed thousands with her thoughts. She continues to mumble incoherently. What do you think is going on? What is the required timeline? What if it is shorter than that? What are the two types? How do you diagnose? How do you treat?

- Deep vein thrombosis - Pulmonary embolism - OCP - Acute - LMWH/heparin bridge to warfarin for 3 mos. Each treatment individualized to patient.

A 28 year old woman presents to urgent care with posterior right knee pain. She doesn't recall any injuries and she went for a run yesterday but that is her typical exercise. She is worried she tore her ACL. Upon physical exam her knee joint is completely unremarkable, but she has swelling and warmth in the popliteal fossa. The patient does not have any pertinent medical history and her only medication is birth control. What do you think could be going on? What is the biggest complication of this? What likely caused it? How do you treat?

- Behcet's syndrome - Systemic vasculitis - Steroids + symptom relief + referral to rheum

A 28-year-old Turkish man presents with a 2-month history of eye pain and blurring of vision that has been getting worse over the last several weeks. Both of his eyes are involved. He also complains of recurrent oral and genital ulcers that have been bothering him for the last 5 months. He has had facial acne for some time, but now is getting acne on his back, upper arms, and legs. What do you think is going on? What is that? How do you treat?

- brief reactive psychosis/brief psychotic disorder - Psychosis lasting less than 1 week/month - History - Eliminate triggers, benzos for acute attacks and long term treatment focused on improving coping skills/"Rat Park"

A 33 year old man is brought to the ED by his family. He presents with restlessness, visual and hearing hallucinations ("I saw and I heard my parents in my room", "I saw the cameras in my room, they were fallowing me"), delusions - exterior influence ideas ("they took my parents' and my friends' identities") and bizarre behavior (he stayed locked in his room and let nobody to enter, because he was afraid they would occupy his beautiful room) for the last two hours. No FH of psych disorders, no significant PMH. His parents tell you it is his fourth year applying for PA school, he had his interview one day ago and is expecting to hear from the program in the coming days. What do you think is going on? What is that? How do you diagnose? How do you treat?

- scleroderma - Hand moisturizers, physical therapy, immunosuppressive drugs - consult rheum

A 38-year-old woman presents with Raynaud phenomenon for the past 5 years. She also has a history of digital ulcers and GERD. Physical exam reveals telangiectasias on the hands. She has sclerodactyly. Digital pits are present with no active ulcers. Serology tests reveal a high-titer ANA by indirect immunofluorescence, at a titer of >1:640 in a centromere pattern. The patient is diagnosed with limited cutaneous systemic sclerosis. What do you think is going on? How do you treat?

- Bell's palsy - Age, timeline and eyebrow involvement - Borrelia burgdorferi - lyme - Eye protection from dryness and prednisone dose pack

A 40-year-old woman awakens with left-sided facial fullness and a subjective feeling of facial and tongue "numbness" without objective hypoesthesia. Left-sided facial palsy ensues, with associated oral incompetence, facial weakness, and asymmetry progressing to complete flaccid paralysis by the next morning. On physical exam, there is complete absence of brow movement, incomplete eye closure with full effort, and loss of smile, snarl, and lip pucker on the affected side. The remainder of the history and physical exam are unremarkable. What is going on? How do you know it isn't a stroke? What bug can be associated? How do you treat?

- OSA - sleep study - ≥15 episodes/hour. However, 5 episodes per hour is considered sufficient for diagnosis if additional symptoms or comorbidities are present. - CPAP or sleep device recommended by specialist

A 41-year-old obese man presents with loud chronic snoring and gasping episodes during sleep. His wife has witnessed episodic apnea. He reports unrefreshing sleep, multiple awakenings from sleep, and morning headaches. He has excessive daytime sleepiness, which is interfering with his daily activities, and he narrowly avoided being involved in a motor vehicle accident. His memory is also affected. He has been treated for hypertension, gastroesophageal reflux, and type 2 diabetes. What do you think is going on? How do you diagnose? How do you treat?

- sialadenitis/parotitis - swelling of the parotid, submandibular, sublingual, or minor salivary glands - Mups - Sjogren syndrome

A 42-year-old woman presents to her dentist with acute swelling and pain under the tongue on the left side. She states these symptoms have lasted for 3 days and that the pain increases while eating. Medical history is unremarkable. Examination reveals erythema and edema of the left anterior floor of the mouth. No neurologic deficits are noted. A discrete yellow waxy object is seen through the mucosa in the vicinity of Wharton duct. The pain decreases during the postprandial period. What do you think is going on? What is that? What should be a concern if it is unilateral parotitis in a child? What about chronic diffuse sialadenitis in an adult?

A Per Brianna: Naltrexone requires patients to be opioid-free for 7-10 days prior to initiation so this is not a good option right away for this patient. Buprenorphine may be used after the initial withdrawal. Methadone maintenance may be a good option for this patient considering his 20 years of use and multiple failed treatment attempts.

A 45 year old man seeks treatment for opioid dependence. He has been using heroin for 20 years intravenously and has previously attended 3 long term treatment programs. Which of the following approaches would offer this patient the best possibility of success? A. Long term inpatient treatment B. Long term outpatient treatment C. Methadone maintenance D. Naltrexone E. Buprenorphine

- angioedema - airway, supply oxygen - Epinephrine, H1 blockers +/- H2 blockers - if still no response, fresh frozen plasma

A 45‐year‐old woman is brought to the emergency department (ED) by ambulance after collapsing at home. She had been seen by her regular doctor earlier in the day and prescribed amoxicillin for sinusitis. Paramedics report field vital signs remarkable for a blood pressure of 70/30 mm Hg, heart rate of 140 beats per minute, respiratory rate of 40 breaths per minute, and an oxygen saturation of 76%. What do you think is going on? What is your biggest concern? How do you treat if severe?

- seasonal affective disorder - Clinical: two episodes in last two years with full remission in between - Light therapy. If needed SSRI or bupropion. And might as well sprinkle on some vitamin D.

A 48-year-old PA program director reports a 3-year history of hypersomnia, lethargy, amotivation, concentration difficulties, and depressed mood since moving to Portland. The symptoms start acutely in mid-October, gradually worsen during the winter months, and eventually remit in early April. He denies any significant stressors that may precipitate these episodes - because when you run a PA program, the stressors are constant. In addition, he denies any history of depressive episodes during the spring and summer months. He has never experienced any manic symptoms. What do you think is going on? How do you diagnose? How do you treat?

B. Delusion of persecution

A patient believes that "the FBI has put a chip in her brain because she ran a stop sign" - this is called: A. Thought broadcasting B. Delusion of persecution C. Delusion of graneur D. Paranoid delusion

C. Thought withdrawal

A patient believes their thoughts have been "taken" by aliens. This is called: A. Thought broadcasting B. Delusion of persecution C. Thought withdrawal D. Paranoid delusion

C. Delusion of graneur

A patient believes they have super human strength - this is called: A. Thought broadcasting B. Delusion of persecution C. Delusion of graneur D. Paranoid delusion

A. Cataplexy

A patient has a sudden loss of muscle control after an emotional response, but is fully conscious. When you move their arm up, it stays. Which of the following describes this presentation? A. Cataplexy B. Catatonia C. Clanging D. Agnosia

- *Trauma*, depression/anxiety, or learning disability - History - family environment, early childhood, depression, etc. Send home with assessments for parent and teacher. (the DSM criteria is a mile long... but includes inattention and/or hyperactivity/impulsivity before age 12, in multiple settings, interfering with life, and no other possible psych cause) - Red food dye.... JK JK, we have no idea, possibly genetics + enviro - Parent education, behavioral therapist, medications (start with stimulants - MPH or amphetamine aka Ritalin) - If suspected comorbidities/complicated unclear diagnosis

A 5 year‐old boy is brought in by his mother, she complains he is "bouncing off the walls." At home he "can't sit still" is "constantly fidgeting." In preschool, his teachers sometimes have him run laps around the classroom when the other kids are doing focused activities. She is worried he won't be ready to start kindergarten in the fall. The only way she can get him to sit still is to put him in front of a video game, which he will focus on for "hours at a time." However when she tells him it is time to stop he has terrible tantrums. He is also her naughtiest child: constantly doing things "he knows he's not allowed to do." She is at her wits' end and wants to know if this is just a normal boy with a lot of energy or if he has something wrong with him like ADHD or bipolar disorder. What should be on your differential for ADHD?How do you diagnose ADHD? What causes it? How do you treat? When do you refer?

- Varicocele - LT>BL and RARELY right alone - Not if asymptomatic - but can affect fertility - Scrotal support

A 52 year old male comes to see you and tells you he has seen changes in his left testicle. He tells you it feels heavy, but doesn't hurt and feels like a "bag of worms." It started a couple months ago. What is this? Where does it occur? Does it require treatment? How do you treat?

- Diverticulitis - Either colonoscopy or CT colonography - If mild = conservative (*low* fiber, abx used selectively!) - If severe = acute hospitalization, IV fluids, IV abx x 5-7 days

A 54 year old male presents to your ED with left lower abdominal pain, diarrhea, nausea and vomiting. He states that he has a decreased appetite along with a low grade fever and chills. His past medical history includes a diagnosis of hypertension and obesity. He is a smoker. On exam you note the patient is visibly uncomfortable. When you examine his abdomen, you note tenderness and guarding to the left lower quadrant. What do you think is going on? How do you confirm Dx? How do you treat?

- Mesenteric insufficiency - Yes, 50% mortality rate - Diagnosis timeline - Immediate exploration to determine bowel viability then bypass/bowel resection surgery. - A fib

A 62 year old female patient with a history of diabetes and HTN comes to your clinic with the complaint of stomach pain. She describes the pain as right around her belly button, and that is has been steady and severe pain. PE reveals no findings of the abdomen, and hypotension. She has a irregularly irregular heart beat. What are you concerned she has? Is this serious? What is the most important indicator of survival? How do you treat? What else do you need to manage?

- Acute arterial occlusion - YES - medical emergency - Doppler imaging - Immediate revascularization *within 3 hours* and heparin IV - Statins, aspirin, plavix - treating underlying cause

A 62 year old male patient with a history of claudication comes to your clinic with sudden pain and numbness in his foot. He is afraid he did something to his back. The savvy PA you are, you first check his lower extremity pulses and see he has pallor, coolness, and absent pulses in his foot. What do you think he has? Is this serious? What is the gold standard diagnostic tool? How do you treat? What do you do after treating?

- Occlusive disease of the lower extremities caused by atherosclerosis - Calf pain = any vascular level or superficial femoral artery - Foot gangrene, or ulceration leading to amputation - Conservative care (stop smoking, exercise treatment) and endovascular surgery (used for superficial femoral). If severe - revascularization or amputation.

A 62 year old male smoker comes to your clinic with complaint of cramping pain when he walks his dog. When it started 6 months ago it didn't bother him, but now he just walks down the street and the symptoms start. Upon PE, you see changes in hair distribution on the lower extremities and reduced popliteal arteries. What do you think he has? Which artery? What complications are you concerned about? Treatment?

C. Depersonalisation

A detachment of oneself from the present experience, as if one is the observer instead of participant. A. Dissociative fugue B. Delusion of persecution C. Depersonalisation D. Paranoid delusion

A. Fetishism

A form of sexual behavior in which gratification is linked to an abnormal degree to a particular object, activity, part of the body, etc. A. Fetishism B. Exhibitionism C. Pedophilia D. Voyeurism

- Spermatocele - Ultrasound - If asymptomatic, no treatment needed - if symptoms, surgical excision

A male patient comes to clinic very concerned because he thinks he has cancer. While doing his monthly self exam, he found a small painless smooth bump in the upper middle portion of his testicle. With transillumination you see an opaque, fluid filled mass. His only medical history is DES exposure while his mother was pregnant with him. Because of this history, what do you think could be going on? How do you better diagnose? How do you treat?

B. Exhibitionism

A mental condition characterized by the compulsion to display one's genitals in public. A. Fetishism B. Exhibitionism C. Pedophilia D. Voyeurism

D. Erotomania

A patient believes Ryan Reynolds is in love with her. This is called: A. Euthymic B. Expansive C. Euphoric D. Erotomania

A. Thought broadcasting

A patient believes everyone can hear her thoughts. This is called: A. Thought broadcasting B. Delusion of persecution C. Thought withdrawal D. Paranoid delusion

D. Paranoid delusion

A patient believes that "everyone is out to get me" - this is called: A. Thought broadcasting B. Delusion of persecution C. Delusion of graneur D. Paranoid delusion

- Yes, benign prostatic hyperplasia (BPH) (90% of men >80 yo have it) - Urinary hesitancy, decreased stream, post void dribble - DRE and UA (to exclude infection or blood) - other tests like PSA, US, and cystoscopy can be used if symptoms are severe or tests are needed - If symptoms are minor, watch and wait - First line is alpha adrenergic blockers (Flomax). Other options are 5-alpha reductase inhibitors (cause sexual dysfunction) and phosphodiesterase 5 inhibitors (Cialis - expensive)

As women age, they eventually hit menopause. Is there something like this practically all men will eventually develop the older they get (typically older than menopause, though)? What are the symptoms? How do you examine? How do you treat if symptoms are minor? What are the first line medication options?

- Testicular torsion - Yes - Absent - Urgent surgery - manual manipulation only in rural areas

Adolescent with sudden onset pain in scrotum and bump in scrotum associated with vomiting - what are you worried about? Is this a medical emergency? Cremasteric reflex is ___________. How do you treat?

Mood is a state of feeling (emotional), usually temporary, resulting from a specific stimulus. Affect may either mean changing someone's feelings or altering someone's mental state.

Affect vs mood related to emotion

D. Blocking

An abrupt stop in the middle of a train of thought; the individual may or may not be able to continue the idea. This is called: A. Tangentiality B. Clanging C. Derailment D. Blocking

- Varicose veins - Family history and pregnancy - Compression stockings to reduce pressure and prevent progression. Sclerotherapy to fibrose and obliterate target veins. Other options: chemical irritants, hypertonic saline, or ablation.

An otherwise healthy 45 year old woman presents to clinic with "these ugly veins" on the back of her leg. She started to notice them after giving birth to her second child a year ago. She came to see you because they have started to ache when she stands for prolonged periods. What do you call these? What possibly caused them? How do you treat?

Short acting

Any medication that is ______________ has the risk of causing MOH.

X-linked trait that causes low levels of clotting factors resulting in spontaneous and excessive post traumatic bleeding in the joints and muscles.

BRIEFLY describe hemophilia.

C. Akathisia

Can't sit still. Fidgeting, restlessness. Which of the following describes this presentation? A. Automatisms B. Alogia C. Akathisia D. Agnosia

A. Neologism

Coming up with new words is called: A. Neologism B. Clanging C. Delusion D. Glossolalia

- 200 - 126 - 6.5%

Diagnosis of diabetes is a random glucose of > _______, a fasting glucose of > _______, or a hemoglobin A1c of at least ______.

- hypochondriasis - Clinical diagnosis (no specific requirements or timeline) - Build an alliance with patient and offer reassurance to cope. CBT is best - antidepressants can also be used - 30-50% achieve recovery

Every week, we learn about a new disorder that we maybeeee could have. Our 43rd classmate, Chad, tends to worry about the presumed (but not present) illness. During AII he refused to touch door knobs, during SMB he complained of constant knee pain, and during BCP he was just a mess. What do you think is going on with Chad? How do you diagnose? How do you treat? Prognosis?

- antisocial personality disorder - Patterns of recurrent antisocial, delinquent and criminal behavior - exploiting others with lack of any remorse. *Must be 18 years old for diagnosis* - *No meds* - group based therapy is ideal

Doing a rotation at Salem hospital, you see a 37 year old man referred to therapy by the court, as part of a rehabilitation program. He is serving time in prison, having been convicted of grand fraud. The scam perpetrated by him involved hundreds of retired men and women in a dozen states over a period of three years. All his victims lost their life savings and suffered grievous and life-threatening stress symptoms. He seems peeved at having to attend the sessions but tries to hide his displeasure by claiming to be eager to "heal, reform himself and get reintegrated into normative society". When asked how does he feel about the fact that three of his victims died of heart attacks as a direct result of his misdeeds, he barely suppresses an urge to laugh out loud and then denies any responsibility: his "clients" were adults who knew what they were doing and had the deal he was working on gone well, they would all have become "filthy rich." He then goes on the attack: aren't psychiatrists supposed to be impartial? He complains that I sound exactly like the "vicious and self-promoting low-brow" prosecutor at his trial. What do you think is going on? How do you diagnose that? How do you treat? case source: Myles_Rizvi quizlet

- Peritonsillar abscess - deep neck infection - Polymicrobial - usually bacterial (strep or staph) - Drainage - augmentin or clindamycin and hydration

I have the worst sore throat of my life and I'm talking funny, like I have something hot in my mouth. On PE you see medial deviation of the soft palate. What do I have? What bug caused it? How do you treat it?

- schizotypal personality disorder - Schizoid is more indifference to relationships, this is a discomfort with relationships paired with perceptional distortions and eccentric behavior (paranoid, magical thinking) - Psychotherapy and *low dose antipsychotic* - Anxiety and depression

El-Or's real name is George. He changed it as a result of an epiphany he experienced at the tender age of 9 when he encountered an alien spaceship in his back yard and "in all probability" was abducted by its crew. Can't he remember for sure? It's all kind of fuzzy, but ever since then he has had numerous out of body experiences and has developed psychic capabilities such as clairvoyance and remote viewing. "I can see that you don't believe a word of it." - he declaims bitterly - "You probably can't wait to tell the other therapists here about me and have a good laugh at my expense." I remind him that therapy sessions are strictly confidential but he nods his head sagely: "Yeah, sure, whatever you say, Doc." What do you think is going on? How is that different from schizoid? How do you treat? What are they at a high risk of? case source: Myles_Rizvi quizlet

1972 - 10, 9, 7, 2 Warfarin

Factors that need vitamin K? Med that stops vitamin K?

Crohn disease

Granulomas on pathology - suspected diagnosis?

Factor 8

Hemophilia A factor?

Factor 9

Hemophilia B factor?

The pharmacologic action of donepezil, rivastigmine, and galantamine is inhibition of the cholinesterases, primarily acetylcholinesterase, with a resulting increase in cerebral acetylcholine levels

How do Alzheimer's drugs work?

- Rule out UTI, medications causing the symptoms (diuretics, etc) - first line: bladder training associated (Kegel exercises) and biofeedback - Antimuscarinic (tolterodine, darifenacin, and fesoterodine) are modestly effective for mixed-etiology incontinence - monitor cognitive status. - In some cases, surgical treatment should be considered, avoid chronic catheterization

How do you treat urinary incontinence?

- Eye exams yearly - Foot exams yearly - Dental exams yearly - Smoking counseling every visit (if smoking) - HbA1c every 3-6 mos - Yearly

How often should patients with diabetes get ..... - Eye exams? - Foot exams? - Dental exams? - Smoking cessation counseling? - HbA1c? - Urinary albumin to creatinine ratio?

B. Group therapy

Which therapy encourages a social experience to decrease anxiety? A. Family therapy B. Group therapy C. Supportive psychotherapy D. Psychoanalysis

This difference in RDW is helpful when you're trying to differentiate IDA and thalassemia; if you have a microcytic, hypochromic anemia, the next thing you'd do is look at the RDW (or just look at the blood smear). If the RDW is low (the cells are mostly the same size), then it's probably thalassemia. If the RDW is high (the cells vary a lot in size), then it's probably iron deficiency anemia.

How thalassemia is differentiated from iron deficiency anemia?

- von Willebrand disease - VWF acts as a carrier protein for factor 8 and helps with platelet aggregation/adhesion - Type I: deficiency of VWF, Type II: your VWF doesn't work, Type III: you can't make VWF - Desmopressin (DDVAP) - stimulates release of VWF, the other two types need to be treated with factor VII - Anemia

I am a 14 year old and I have bruising all over my legs. I also go through 12 tampons every day when I am on my period. I thought it was normal because my sister is the same way, but I learned in health class it is more than normal so I thought I should see my doctor. Also, when I got one of my teeth pulled, I had to keep gauze in my mouth for 3 days. Labs indicate normal PT and elevated PTT. What do you think she has? What is going on? What are the different types and their differences? If she has type I, how would you treat it? Complication?

- Ulcerative colitiis (inflammatory bowel disease) - Rule out infection (stool), then referral for endoscopic eval - if acutely ill, CT - Oral steroids, aminosalicylates, immunomodulators, biologics - Technically proctocolectomy (removal of colon) will "cure" - but major surgery with major QOL implications

I am a 22 year old woman and I keep having GI "flares." I use the bathroom (using both-ends....) 15-20 times a day, my weight fluctuates drastically with each flare-up and I would often lose 20-25 pounds within a 4 week period. I have also noticed hair-loss, and joint pain. My diarrhea *is* bloody. What do you think is going on? What is the next step? What are the types of medications used to treat? Will surgery help?

- Crohn disease (inflammatory bowel disease) - Rule out infection (stool), then referral for endoscopic eval - if acutely ill, CT - Oral steroids, immunomodulators, biologics (limited support for aminosalicylates) - Surgery is generally palliative (obstruction, abscess, etc) - If abscess/fistula

I am a 22 year old woman and I keep having GI "flares." I use the bathroom (using both-ends....) 15-20 times a day, my weight fluctuates drastically with each flare-up and I would often lose 20-25 pounds within a 4 week period. I have also noticed hair-loss, and joint pain. My diarrhea is not bloody. What do you think is going on? What is the next step? What are the types of medications used to treat? When are antibiotics indicated? Will surgery help?

- SLE - ANA must be positive (sensitive), but positive does not mean SLE, and four of the SOAP BRAIN MD symptoms - NSAIDs for minor joint pain, antimalarials (hydroxchloroquine) for rashes and joints, corticosteroids if systemic involvement, immunosuppressives or methotrexate if steroid resistant.

I am a 30 year old woman and my wrists have really been hurting. I have also noticed I'm really sensitive to the sun, my hands are always freezing cold and I have felt like my mood is off. What do I have? How do you check it? How do you treat it?

- Dermatomyositis - NOT PM due to rash - HANDS: Gottron's sign, EYES: heliotrope rash. - Corticosteroids (daily prednisone) Patterns: same as PM but with rash

I am a 43 year old female. Over the last few weeks, I have had difficulty with everyday tasks like climbing stairs, stepping onto a curb, lifting objects and combing my hair. I can still feel everything. I also have a rash on my eyelids, my anterior chest, my back and shoulders and my hands look like this. What do I have? What do you call these rashes? How do you treat it?

- Autoimmune hemolytic anemia - IgG - Type II - Prednisone - refer to hemotologist

I am a 50 year old woman with SLE. I have been having fatigue, dyspnea and angina for the last month. Upon physical exam, she has jaundice and splenomegaly. Blood smear demonstrates spherocytes and reticulocytosis. What does she likely have? What type of immunoglobulin is involved? Hypersensitivity type? How do you treat it?

- Hemochromatosis - HFE genetic test, EKG and liver biopsy - Therapeutic phlebotomy, avoid iron rich foods

I am a 56 year old man from Portland with fatigue and joint pain. I think I'm just getting old but my wife wanted me to come in for a check up. My blood work shows elevated liver function tests, and elevated ferritin. What do you think I have? What additional tests would you like to run? How do you treat?

- Bullous pemphigoid - Autoimmune disorder effecting sub-dermal tissue - Mild: ultrapotent topical steroids. - Widespread disease: immunosuppressants. If not treated, sepsis.

I am a 65 year old male patient. I started having this itchy hive like bumps, but now they are tender, tense blisters. What do I have? What is going on? How do you treat it? What if it gets worse?

- Giant cell (temporal) arteritis - maybe - Biopsy is definitive - 60 mg prednisone for 1 month then taper

I am a 68 year old woman. I have a headache, and every time I pull my hair back my scalp hurts. I came in because my vision has changed a bit. What is going on? Do we need to test it? How do we treat it?

- Poor is 20/60 - 20/400, blind is 20/>400, legal20/>200 - Basic eye exam, urgent if sudden onset

I can't see well. What do you consider poor vision vs blindness vs LEGAL blindness. What causes that? What is your workup?

- Oral hairy leukoplakia - Most are benign but some are early signs of cancer

I have a white plaque on the side of my tongue - what do I have? What is that?

- Bitemporal hemianopia - Pituitary tumor pressing on optic chiasm - Visual field assessment, MRI brain to r/o tumor or lesions

I have lost my peripheral vision. What do you call that? What causes that? What is your workup?

- Mononucleosis - Epstein Barr virus -NOT abx (only if secondary pharyngitis), ampicillin and amoxicillin cause rash

I have serious fatigue, fever, a sore throat, exudative pharyngitis and tender lymph nodes. What do I have? How do you treat it?

D. Psychoanalysis

Which therapy encourages spontaneous expression of thoughts and emotion? A. Family therapy B. Group therapy C. Supportive psychotherapy D. Psychoanalysis

- Pemphigus vulgaris - Rare autoimmune disorder in epidermis - more severe than bullous pemphigoid - Biopsy - take the edge of the bistered skin - Refer to derm - prednisone, immunosuppressants

I have these sores in my mouth I thought were canker sores, but it isn't healing. And my back has a loose, fluid filled blister. They don't itch, but they are burning and painful. What do I have? What is going on? How do you test it? How do you treat it? What if it gets worse?

- borderline personality disorder - Long list of confusing symptoms - but there is a pervasive pattern of *instability* in relationships, self image, mood and marked impulsivity - Psychotherapeutic and *medications (lithium, antipsychotics, antidepressants)* - Not great because many of the self-destructive behaviors are dangerous

I never really feel 'happy and content' inside. I can feel excited, temporarily happy, seriously angry, aggressive, loving, depressed and empty, extremely sad, charitable, obsessive, jealous, hopeless, worthless and confused. I can feel any of these emotions at any time, and often they are temporary (a few hours up to a day or so). The main emotion that stays with me most of the time is anxiety. I can switch from one good emotion to another in a flash, and no-one can understand why - even though I have reasons of my own at the time. I don't really trust anyone so I don't have any stable relationships. I have threatened to commit suicide multiple times, and tried twice. What is the likely diagnosis? How do you diagnose? How do you treat? Prognosis? case source: Myles_Rizvi quizlet

- Acute laryngitis - Mostly viral - ABX don't change course and avoid using voice

I was sick a week ago but I am still hoarse! What do I have? What bug caused it? How do you treat it?

- Acute bacterial prostatitis - Gram negatives - E coli, pseudom. - Quinolones x 4-6 weeks - if acutely ill, admit for IV antibiotics - YES, STI checks

I'm a 40 year old male with sudden painful urination, fever, sacral pain and supra pubic pain. On PE, my prostate is very tender. What do I have? What causes it? How do you treat it? Do you need to do any other tests?

- Chronic prostatitis - "Four Glass Test" with prostatic massage - not typically done - Usually the same pathogen - abx do not easily penetrate prostate - Refer to urologist for at least 6 weeks antibiotics - Yes, check their blood sugar

I'm a 45 year old male with recurrent urinary tract infections. It doesn't hurt to pee, my prostate isn't tender, but there is pus in my urine. What do I have? What is the gold standard diagnostic? Is this commonly done? What causes it? How do you treat it? Do you need to do any other tests?

- Don't start with sleep study - start with *history* - Sleep journal - Sleep hygiene - have some sleepy time tea, light a candle and turn off those screens for some time before bed - Cognitive behavioral therapy, try melatonin - Then, maybeee drugs (benzos)

I'm stressed and I can't sleep and now the fact I'm not sleeping is making me more stressed. I heard a radio ad about a sleep center. Do I need a sleep study to figure out what is wrong? What is a good way to evaluate sleep without a sleep study? How do you treat initially? That's not working, then what? Then what?

- aorta and iliac - iliac or common femoral - any vascular level or superficial femoral artery - at or below the popliteal artery

Identify the vessel affected by occlusive disease based on these locations of pain... - Low back/buttock = - Thigh = - Calf = - Foot =

B. Derailment

If I ask, what are you doing tomorrow? "The next day when I'd be going out you know, I took control, like uh, I put bleach on my hair in California." This is called: A. Tangentiality B. Derailment C. Preservation D. Circumstantiality

A. Loose associations

If I ask, what did you have for breakfast? "I want some ice cream. Her skin is so soft and creamy. Have you had the cheesecake at the restaurant?" This is called: A. Loose associations B. Derailment C. Preservation D. Circumstantiality

Atypical

In schizoaffective disorder, do you use typical or atypical antipsychotics?

- pain disorder - Clinical diagnosis - no specific timeline or requirements - Focus on behavioral, social, medical and psychological therapy - really difficult to manage (try to remove opioids as best as possible)

In the 2014 file "Cake" Jennifer Aniston plays Claire, who, having survived a car crash that killed her child, now lives in near isolation in with chronic pain and depression. The film depicts the pain and struggle she faces to get out of bed, attend aquatic physical therapy and have intimate relationships. All the while she is popping pain pills like candy. When she runs out, she goes to Mexico to get more. Although she has minor anatomical changes from the crash, she has completely changed her lifestyle. What do you think is going on? How do you diagnose? How do you treat?

A. Astereognisis

Inability to identify a ballpoint pen by feeling it is called: A. Astereognisis B. Alogia C. Anhedonia D. Agnosia

D. Agnosia

Inability to identify a ballpoint pen is called: A. Astereognisis B. Alogia C. Anhedonia D. Agnosia

- major depression - 5 or more of SIG E CAPS + either depressed mood or decreased interest/pleasure - Rule out things like hypothyroidism or sleep disorder - SSRI

Jessica is a 28 year-old second year medical resident in a large hospital. She has very high standards for herself and can be very self-critical when she fails to meet them. For the last month, she has continued feelings of worthlessness and shame due to her inability to perform as well as she always has in the past. For the past few weeks Jessica has felt unusually fatigued and found it increasingly difficult to be interact with her patients. Her husband has noticed she has shown little interest in sex and has had difficulties falling asleep at night. What is the diagnosis? How do you diagnose? What labs can you run? What is your first line medication?

C. Supportive psychotherapy

Which therapy is based on a collection of techniques without distinctive theoretic basis? A. Family therapy B. Group therapy C. Supportive psychotherapy D. Psychoanalysis

- generalized anxiety disorder (GAD) - Having the symptoms more days than not for >6 months - SSRIs, venlafaxine and buspirone - Yes - most face recurrence of symptoms even with treatment

Kristen is a 38 year-old divorced mother of two teenagers. She has had a successful, well-paying career for the past several years in upper-level management. Even though she has worked for the same, thriving company for over 6 years, she's found herself worrying constantly about losing her job and being unable to provide for her children. This worry has been troubling her for the past 8 months. She associates the thoughts with feeling restless, tired, and tense. When she goes to bed at night, it's as if her brain won't shut off. What is the diagnosis? Those symptoms seem kind of common, how do you know it's that? What are some medication options? Is remission common?

- schizoid personality disorder - pervasive pattern of detachment from social relationships in a variety of contexts - No drugs - try group therapy, but they don't place value in relationships so that's tough - Depression is less likely than other personality disorders

Mark sits where instructed, erect but listless. He rarely twitches or flexes his muscles or in any way deviates from the posture he has assumed early on. He reacts with invariable, almost robotic equanimity to the most intrusive queries on my part. He shows no feelings when we discuss his uneventful childhood, his parents ("of course I love them"), and sad and happy moments he recollects at my request. Mark veers between being bored with our encounter and being annoyed by it. How would he describe his relationships with other people? He has none that he can think of. In whom does he confide? He eyes me quizzically: "confide?" Who are his friends? Does he have a girlfriend? No. He shares pressing problems with his mother and sister, he finally remembers. When was the last time he spoke to them? More than two years ago, he thinks. What do you think is going on? What is that? How do you treat? Is depression present? case source: Myles_Rizvi quizlet

- histrionic personality disorder - Excessive and superficial emotionality and sexuality to draw *attention* - relationships are very important, the patient is extraverted - No meds, group therapy (putting a bunch of these people in a room would be interesting...) - Most tend to improve but high levels of anxiety and depression

Marsha visibly resents the fact that I have had to pay attention to another patient (an emergency) "at her expense" as she puts it. She pouts and bats suspiciously long eyelashes at me: "Has any of your female patients fallen in love with you?" - she suddenly changes tack. I explain to her what is transference and countertransference in therapy. She laughs throatily and shakes loose an acid blond mane: "You may call it what you want, doctor, but the simple truth is that you are irresistibly cute." I steer away by asking her about her marriage. She sighs and her face contort, on the verge of tears: "I hate what's been happening to Doug and me. He has had such a stretch of bad luck - my heart goes out to him. I really love him you know. I miss what we used to be. But his rage attacks and jealousy are driving me away. I feel that I am suffocating." What do you think is going on? What is that? How do you diagnose? How do you treat? Prognosis? case source: Myles_Rizvi quizlet

Recurrent laryngeal?

Nerve that causes vocal cord paralysis?

A. Automatisms

Movement or behavior without realizing they are doing it - lip smacking, gesturing, tics. Which of the following describes this presentation? A. Automatisms B. Alogia C. Anhedonia D. Agnosia

- alcohol use disorder - >4 drinks/day or >14/week for men *or* >3 drinks/day or 7 drinks/week for women - Clinical and labs - >2 symptoms of dependence within a 12 month period + carbohydrate deficient transferrin is a marker - Must use caution because of seizure risk with immedient discontinuation - naltrexone if using meds

Mr. A is a 50 year old man who presents primary care to establish care. He reports a 30 year history of binge drinking. He drinks 1 pint of vodka 2- 3 times per week. He has been hiding his use from his family and wife for many years. Medical problems include cirrhosis of the liver, atrial fibrillation and hypertension. Family history is notable for both parents having alcohol substance use disorders. He reports a history of depression and is taking sertraline 100mg per day (when he remembers). He received his first DUI last week. What is his diagnosis? What is the drink quantity requirement? How do you diagnose? How do you treat?

- opioid drug dependency - Very similar to alcohol dependence signs - Best treated in inpatient or outpatient therapy - Naltrexone or methadone

Mr. A is a 50 year old man who presents primary care to establish care. He reports a10 year history of misuse of prescription opioids. He takes ~160mg of Oxycontin or the equivalent per day. He obtains opioids through from multiple specialist he sees and buys them from friends when he runs out. He has been hiding his use from his family and wife for many years. He has tried many times to stop taking opioids but he couldn't tolerate how sick he felt. Medical problems include chronic pain, atrial fibrillation and hypertension. He fears losing his marriage, family, health and business if "something does not change." What do you think is going on? How do you diagnose? How do you treat? What meds can be used?

- Raynaud phenomenon - Typically self limited - calcium channel blockers if severe

My fingers are always freezing cold... what is this called? What kind is it? How do you treat it?

- diplopia - if one eye: primary issue of the eye like cataracts or refractive error. if both eyes: brain issue - If new onset, opthalmology referral, if associated with giant cell or isolated CN III palsy, URGENT REFERRAL

My see two of everything! What do you call that? What causes that? What is your workup?

- body dysmorphic disorder - Clinical - basically impairing preoccupation with perceived defects, with repetitive behaviors all in the absence of delusional beliefs - SSRIs and CBT - About half have partial remission

On Oprah (I remember this episode...) a 28-year-old female was interviewed after undergoing 26 plastic surgeries. After the show aired, she'd watch herself with TiVo over and over. "I try to occupy my time in other ways and stay really busy doing important things. I try to stay away from the mirror when I'm not feeling good about myself. I try not to obsess about it so much" What is the likely diagnosis? How do you diagnose? How do you treat? Is remission common?

- Factor VIII or IX deficiency (hemophillia A or B) - Hemophilia A is more common, but both are rare - Bethesda assay - Factor VIII or IX (plasma derived or recombinant) - Total joint replacement

Our 5 year old adopted son constantly bruises and when he cuts his knee he bleeds for hours. What is going on? Which is more likely? How do you test it? How do you treat it? Complications?

- Polyarteritis nodosa (necrotizing arteritis) - Medium vessel vasculitis - Prednisone up to 60 mg per day

Over the last few months, I have felt exhausted, I have been losing weight, and my foot kind of drops down when I walk. Upon angiogram, you see a "string of beads" appearance. What do I have? What caused it? How do we treat it?

Sudden flaccid paralysis warrants immediate admission with close monitoring for respiratory compromise in a step-down unit or intensive care unit. Patients who present with the acute asymmetric onset of weakness have vasculitis, which is potentially life-threatening until proven otherwise. Hospitalization for chronic polyneuropathy is unusual. Admission is reasonable for complications of chronic polyneuropathy, such as infection, fracture, or threatened amputation, or for treatment of intractable pain. Patients with inflammatory, or demyelinating, chronic polyneuropathies may require hospital admission for IV immunoglobulin or plasmapheresis.

Peripheral neuropathy requiring hospitalization?

- agitation - retardation

Physical restlessness is called psychomotor ________________, physical or mental slowing is called psychomotor ________________.

Autoimmune hemolytic anemia

Positive Coombs test - suspected diagnosis?

- types of insulin

Review

types of hypersensitivity immune responses

Review :)

*S*leep disturbance *I*nterest decreased *G*uilty feelings *E*nergy decreased *C*oncentration (up or down) *A*ppetite (up or down) *P*sychomotor function (agitation) *S*uicidal ideation Used for depression

SIG E CAPS - what is this and what is it used for?

C. Global aphasias

Severe form of nonfluent aphasia, caused by damage to the left side of the brain, that affects receptive and expressive language skills (needed for both written and oral language) as well as auditory and visual comprehension. A. Sensory aphasia B. Motor aphasia C. Global aphasias D. Erotomania

A. Glossolalia

Speaking in tongues is called: A. Glossolalia B. Circumstantiality C. Thought disorder D. Delusion

- Medium vessel vasculitis - polyarteritis nod. - Livedo reticularis

Suspected diagnosis? What is it called?

Hemoglobinopathies = structural abnormalities in the globin proteins themselves. Thalassemias = underproduction of normal globin proteins, often through mutations in regulatory genes. The two conditions may overlap, however, since some conditions which cause abnormalities in globin proteins (hemoglobinopathy) also affect their production (thalassemia). Thus, some hemoglobinopathies are also thalassemias, but most are not.

Thalassemia vs hemoglobinopathies?

- homonymous hemianopia - Lesions *posterior* to the optic chiasm - Test visual fields and neuro imaging for lesions

The left side of my vision is out. What do you call that? What causes that? What is your workup?

D. Voyeurism

The practice of gaining sexual pleasure from watching others when they are naked or engaged in sexual activity. A. Fetishism B. Exhibitionism C. Pedophilia D. Voyeurism

- migraine without aura (common) - At least two of: UL pain, throbbing pain, aggravated by movement, moderate/severe intensity *+* one of the following: N/V. photo or phonophobia - Preventative if 2-3x/month with topiramate, valproic acid, propranolol, etc. Symptomatic: analgesics, triptans, ergotamines

This is a 22 yo F who presents with daily headache for 2 weeks. Her headaches are constant, stabbing in quality, moderate to severe in intensity. They are most often located on the left side, behind the eye and temple and last 4 hours. She reports nausea, light and sound sensitivity in addition to dizziness, difficulty concentrating and word finding difficulty associated with her headaches. She is worried she will lose her job due to poor productivity. What is her diagnosis? What are the diagnostic criteria? How do you treat?

1. Experimentation 2. Regular use 3. Risky use 4. Dependence 5. Addiction

What are the 5 stages of addiction?

A - Hb*A*1c - aim for <7% B - *b*lood pressure - aim for <140/90 C - *c*holesterol - aim for LDL below 100 Aim for 7% weight loss

What are the ABCs of diabetes? What are the general goals for each? How much weight should I try to lose?

- Beau's lines - uncontrolled diabetes and peripheral vascular disease, as well as illnesses associated with a high fever, such as scarlet fever, measles, mumps and pneumonia. Beau's lines can also be a sign of zinc deficiency.

What are these called? Differential?

in no order: hypocalcemia, hypoparathyroidism, hypothyroidism

What are your top three differentials for muscle cramping?

Serositis Oral ulcers Arthritis Photosensitivity Blood dyscrasis Renal ANA Immunologic Neurologic Macular rash Discoid rash SLE!!

What does SOAP BRAIN MD stand for? What disease is it a diagnostic criteria for?

Codependency refers to psychological behavioral problems that cause people with addictions and those in their lives to engage in mutually destructive habits and maladaptive coping strategies.

What is codependency?

- an alcoholic going cold turkey - 48-72 hours after last drink

What is delirium tremens a serious AE of? When is it seen?

- Face droop, arm weakness, slurred speech, TIME - Occlusive cerebrovascular disease - strokes and TIAs - Most caused by atherosclerosis leading to thrombus or emboli traveling to brain

What is the acronym F.A.S.T stand for? What is it used for (there is one big name, and two types)? What are the two types? What are most caused by?

1. Difficulty learning and recalling 2. Visuospatial problems 3. Language impairment

What is the classic triad of Alzheimer disease?

- Osteoporosis is the decrease in bone matrix and mineral. - Osteomalacia is defective mineralization of the skeleton during childhood it's Rickett's but can occur throughout life - only decrease in bone mineral (matrix is intact) - Osteomalacia causes more bone pain - Osteomalacia treatment is more straight forward - you treat the *mineral* deficiency with supplements - osteoporosis is a more complex and multifactorial diagnosis, so treating is more complex as well (supplements, stop steroids, hormones, exercise, etc.)

What is the difference between osteoporosis and osteomalacia? Which one can cause bone pain? Which treatment is more straight forward and why?

When personality traits are inflexible or maladaptive enough to cause distress or impairment of functioning.

What is the difference between personality disorder vs trait

Schizoaffective disorder= schizophrenia + either depression or bipolar disorder. That's why it has two subtypes (depression type, bipolar type). Schizophreniform = schizophrenia for less than six months (usually one month) Schizophrenia = >6 mos of symptoms

What is the difference between schizoaffective, schizophreniform and schizophrenia?

Von Willebrand Disease

What is the most commonly inherited bleeding disorder?

people with hypochondriasis believe that they are ill whereas people with factitious disorders do not.

What is the one key difference between factitious disorders and hypochondriasis?

wrist --> hip --> spine

What is the typical progression of bone density loss due to hyperparathyroidism?

- Splinter hemorrhages - differential: endocarditis - can also be caused by vasculitis, diabetes

What is this called? What can cause it?

- Spooned nails - differential: iron deficiency - can also be from trauma, chemotherapy, malnutrition, psoriasis

What is this called? What causes it?

- Pitting - differential: psoriasis

What is this called? What is your differential?

- Terry's nails - differential: Terry's nails can sometimes be attributed to aging. In other cases, Terry's nails can be a sign of a serious underlying condition, such as liver disease, congestive heart failure, kidney failure or diabetes.

What is this called? What is your differential?

- acanthosis nigricans - Insulin resistance

What is this? What is it associated with?

- *High* fiber diet - No - no symptoms = no scan

What kind of diet do you recommend for a patient with diverticulosis? Do you do a CT scan to confirm diagnosis if they are asymptomatic?

Diverticulitis is macroscopic inflammation that has a wide spectrum Diverticulosis is a herniation (either of part or all of the bowel wall) that are either asymptomatic or nonspecific symptoms (constipation, abdominal pain, etc.) BOTH: LLQ pain

What the heck is the difference between diverticulitis and diverticulosis?

C. Thought disorder

What word is the umbrella term for disterbances in thought evidenced by disorganized speech (examples are word salad, derailment, etc.) A. Glossolalia B. Circumstantiality C. Thought disorder D. Delusion

- usually benign vitreous opacities - if sudden onset + flashing lights = urgent referral. If gradual and vision is fine, no workup.

When I do my clin apps reading, I see this spot kind of floating with my vision. What causes that? What is your workup?

A. Dissociative fugue

When a patient suddenly journeys away from home without reason is called: A. Dissociative fugue B. Delusion of persecution C. Thought withdrawal D. Paranoid delusion

A. Tangentiality

When asked about the age of a person's mother at death, the speaker responds by talking at length about accidents and how too many people die in accidents and never answers what the mother's age was at death. This is called: A. Tangentiality B. Derailment C. Flight of ideas D. Circumstantiality

D. Circumstantiality

When asked about the age of a person's mother at death, the speaker responds by talking at length about accidents and how too many people die in accidents, then eventually says what the mother's age was at death. This is called: A. Tangentiality B. Derailment C. Flight of ideas D. Circumstantiality

C. Clanging

When asked, did you hear that? They respond: "I heard the bell. Well, hell, then I fell." This is called: A. Cataplexy B. Catatonia C. Clanging D. Circumstantiality

- More than 95% of laryngeal tumors are squamous cell carcinomas (SCC) - CT

Which is more common: benign tumor of the larynx or squamous cell cancer? How do you diagnose?

B. Beck

Which of the following is a 21 item test for depression that requires a 6th grade reading level? A. Folstein B. Beck C. GDS D. GAD-7 E. PHQ-9

D. GAD-7

Which of the following is is a brief screening tool for anxiety? A. Folstein B. Beck C. GDS D. GAD-7 E. PHQ-9

- ADA = age 45, USPSTF = age 40 - Every 3 years pending initial results (prediabetes = yearly)

Without any risk factors, when do you screen for diabetes (ADA vs USPSTF)? When do you repeat?

B, D, E

You are called to the emergency room to evaluate a patient in opioid withdrawal. This patient would be expected to present with which of the following symptoms - pick all that apply A. Miosis B. Piloerection C. Seizures D. Nausea and vomiting E. Tachycardia

- panic disorder - Clinical - recurrent unexpected attacks followed by one month of worry or maladaptive change behavior - CBT, SSRIs, benzos for break through, decrease caffeine intake

You are doing a psych rotation. Reviewing your next patient's chart, you see she is a 27 year old female who was referred to you four weeks ago by the ED. Their note reads: "27 yo female presents after experiencing an episode of extreme chest pain, difficulty breathing, and numbness in her arms. She states the following to the admitting physician: 'I was walking my dog earlier when I started sweating. Since it isn't hot outside, I couldn't quite understand why...then I started having trouble breathing and really got scared. My heart was pounding so hard I thought it might explode out of my chest. My knees felt weak - it seemed like my whole body was shaking, then my arms went numb. Apparently the whole thing only lasted a few minutes, but it felt like each second was an hour. Did I have a heart attack? Am I going crazy? I felt like I was going to die.'" EKG was normal. The MA who roomed the patient tells you she has had four additional "attacks" and has avoided walking almost entirely with the fear this will happen again. What do you think is going on? How do you diagnose? How do you treat? What can it lead to?

- adjustment disorder - diagnose with depression - TSH and CBC - CBT and possibly SSRI - Usually self-limited - monitor for suicide attempt

You are doing a rotation on a college campus. You see a 19 year-old first year engineering student. She moved to Portland from Omaha one month ago and was nervous about the change, but set her fears aside to be able to study here. In the first few weeks, she never connected with her roommates. She sometimes looked nervous and sad. She told one roommate she was homesick but was afraid of telling this to her parents as she feared that they may worry and ask her to give up her college and come back home. What do you think is going on? What if she also falls under the diagnosis of depression? What labs should you run? Treatment? Prognosis?

- factitious disorder - No, Munchausen is when a parent creates an illness in their child, factitious disorder is when someone does it to themselves - Can dx if there is 1. intentional production of symptoms 2. motivation to assume a sick role 3. No secondary gain or incentives such as money or avoiding legal prosecution - Malingering - Therapy if patient sticks around after confrontation

You are doing your ED rotation. You see a woman for the fourth time for seizures. The staff at the hospital tell you she is constantly coming in for these presentations but there is no physical manifestation of her complaints. They tell you at one visit she even bit her own tongue when the provider left the room to try to prove her diagnosis. What do you think is going on? Is that the same as Munchausen Syndrome? How do you diagnose? What do you call it if they are doing it to get something like pain meds? How do you treat?

- Autism spectrum disorder - See DSM for specifics - *Persistent deficits in social interactions, and two or more restricted and repetitive patterns of behavior/interests*. Symptoms must be present in early development, cause significant impairment, and not better explained otherwise. - You don't - they are all the same diagnosis in DSM - 18 months and 24-30 mos - use ASD screening tools - Refer for behavioral intervention and possible pharm (stimulants, antipsych, SSRIs)

You are doing your family medicine rotation and a 3 year old girl is brought in by her parents due to language delay. She has said a handful of individual words, but no phrases. Does not make effort to communicate non-verbally. As a baby she was very well behaved and quiet. She was interested in stuffed animals and blocks, but avoids engaging with other kids. Mom is worried how she will do in preschool What do you think is going on? How do you diagnose? How do you diagnose this vs Aspergers? When do you screen? How do you treat?

- somatic symptom disorder - when a person feels extreme anxiety about physical symptoms (pain, fatigue, gut issues, etc). - Must have either disproportionate thoughts re: symptoms, high levels of anxiety re: healthy or excessive time and energy spent on health - Behavior modification - really difficult - Early intervention, better the prognosis

You are establishing care with a 32 year old woman in your office. She says she is "falling apart." When you ask her to tell you more about that, she lists off her symptoms including headache, fatigue, IBS, anxiety, constipation, food intolerances, menstrual irregularities, muscle aches, fibromyalgia, and weight gain. She tells you no provider has ever been able to solve what is wrong with her after "hundreds" of blood draws, MRIs and tests. She tells you she is very anxious because she recently had to quit her job to maintain all of her healthcare appointments. What do you think is going on? What is that? How do you diagnose? How do you treat? Prognosis?

- attachment disorder - Irregular support system - DSM 5 - emotional withdrawal + social disturbance + history of insufficient care + >9 mos and <5 yo old - Continue providing a caring and supportive environment - symptoms may persist for several years but should improve

You are meeting with a 3 year old foster child and his caregiver of 6 months. The caregiver tells you he sits in his room and cries constantly, but when she tries to comfort him he runs away. During the visit, he is sitting in the chair across the room from his caregiver and doesn't answer questions and has a stern affect. What is this? What can cause it? How do you diagnose? How do you treat?

- Superficial thrombophlebitis - Common inflammatory-thrombotic disorder in which a thrombus develops in a vein located near the surface of the skin (as opposed to a DVT) - Local heat and NSAIDs is typical treatment - LMWH is recommended if thrombophlebitis is >5 cm

You are on your inpatient rotation and check on a patient who had a PICC line placed 3 days ago. She tells you she has a new dull pain in her left leg. Upon physical exam, you see a region of induration, redness and tenderness on her leg. What do you think she has? What is going on? How do you treat?

- Hypercalcemia - Malignancy or primary hyperparathyroidism - Ionized calcium - ID cause - hydrate and calciuresis until identified

You are on your inpatient rotations and speak with a patient who has been bed bound for the last 2 weeks. She is on HCTZ and spironolactone to manage her blood pressure. She tells you she has had a headache, nausea, constipation and she had a kidney stone for the first time in her life. Because she is bed-bound and her medications (thiazide and K-sparing)... What are you worried is causing her symptoms? What else can cause this? How do you test it? How do you treat?

- Chronic veinous insufficiency - Severe manifestation of venous HTN - DVT - Compression stockings, avoid prolonged sitting/standing, elevate legs - Avoid surgical stripping

You are riding the MAX on one of the first 60 degree days in Portland - so everyone is in shorts and t shirts. You notice the woman sitting across from you has swollen ankles and what looks like bruising with thickened skin around her ankles. She is wearing sandals and her feet look normal, but she has an ulcer on her ankle as well. What do you think she has? What is this a manifestation of? What does she likely have a history of? How do you treat? What treatment do you avoid?

- Anorexia nervosa - Teased as kid, new life experience (college), food not monitored (college), new vegan diet and symptoms - Distorted body image, deniel, intense fear of gaining weight, restriction of energy intake relative to energy requirements (<85% normal or BMI <17.5 in DSM IV) - Refer to psych - admit if hypothermia, unstable vitals, major electrolyte d/o - Cardiac arrhythmia, depression/suicide

You are seeing a 19 year old male patient in clinic the summer after his first year of college. You haven't seen him for a few years and you comment on his height and that he looks slimmer since you last saw him. He tells you it was just his baby fat and he was sick of always being teased so he started watching what he ate and routinely exercising. You ask him to describe his typical breakfasts, lunches and dinners and he says "mostly raw veggies" because he is trying a vegan diet. When you ask about how he monitors his body, he tells you he measures his arms and legs on a regular basis. He came in to see you because he is experiencing fatigue, headaches, and joints aches. What should be on your radar for a possible issue with this patient? Why? What is required for the diagnosis? How do you manage it? What complications are you concerned about?

- Bronchogenic carcinoma (lung cancer) - TNM - tumor size/location, nodal location, metastases - Not great - as symptoms increase, chance of survival decreases - NO MEAT NO TREAT - you want to diagnose and stage in one swoop (fine needle aspiration, thoracentesis, CT)

You are seeing a 79 y/o retired truck driver in your clinic. He has had 6 weeks of hoarseness, and 1 week of hemoptysis. His PMH includes 80 pak-years of cigarette smoking, but no fever, or chest pain. PE reveals a clear chest and digital clubbing. What are you concerned he has? What three things determine staging? What is the prognosis? How do you screen/image?

- conduct disorder - Overlap with ADHD, substance abuse, learning disabilities, family dysfunction, etc. Many present with exposure to domestic violence. - DSM 5 - repetitive pattern manifested by the presence of 3 red flags (from the categories of aggression, destruction, deceitfulness, or serious rule violation) in the last 12 months, one of which has to be in the last 6 months - Optimize school and home environments (multi-systemic therapy), inpatient tx if severe, increase involvement in scouts, team sports, etc.

You see a 12 year old boy with a history of ADHD with is mother. She is bringing him in after she received a call from the school principal that he was pinching classmates hard enough to leave a bruise. When you talk about this he rolls his eyes and says "yeah but they deserved it." At home, he has thrown a controller at the TV while playing video games due to anger, which subsequently broke the TV screen. When asked about these the TV incidence, he denies it. His mom tells you this has gotten much worse after she left her husband, the patient's father, due to domestic violence directed toward her, but not their children. What is this? What causes it? How do you diagnose? How do you treat?

- Bulimia nervosa - DSM IV: recurrent episodes of binge eating, recurrent inappropriate compensation (purging or non purging), all occuring 2x/week for 3 mos, self-eval highly influenced by body shape - Supprotive care, psych referral (CBT) - Long term psych prognosis worse in bulimia than anorexia

You see a 16 year old girl who is brought in by her mother who is a dentist. She is concerned because at her daughter's most recent cleaning, there was a significant increase in tooth erosion and she had 3 new cavities. The daughter denies any issues and says her mom is being dramatic. All vitals, weight and blood work are healthy. When speaking to the daughter alone, she tells you she loves sweets, and sometimes over indulges and she "feels like crap" after she does it. To make up for it, she will go on a 2 hour run. What should be on your radar for a possible issue with this patient? How would you diagnose? How would you treat? Complications?

- post-concussive/traumatic - persistent post-traumatic migraine or tension headache - treatment focused on type of headache - NSAIDs or acetaminophen

You see a 16 year old male football player. After getting his "bell rung" at practice 3 days ago he has had a persistent headache. He describes it as throbbing and constant, all over his head. What is the diagnosis? What if his injury was three months ago and his HA was still present? How do you treat?

- Orchitis secondary to EBV (mono) - Torsion - Depends on cause - if due to virus, supportive care. If bacterial is suspected, antibiotics.

You see a 19 year old man who is very concerned because he thinks he has cancer. His right testicle is swollen and very tender. He has also been very fatigued, has had a fever and his lymph nodes are all swollen. He started college 6 months ago. What could be going on? What testicular pathology do you need to rule out?

- obsessive compulsive disorder - Clinical - obsessions *and/or* compulsions interfering with life - Cognitive behavioral therapy and rule out other symptoms such as anxiety

You see a 24 year old male patient for recurrent "habits." He tells you he has to eat the same thing every day at the exact same time. He also exercises every day at the same time, which is 12 am to avoid other people being there to "get in his way." He rolls his eyes and says "I know it's weird... it's just my routine I guess." PMH of tics as child, which have resolved. What do you think is going on? How do you diagnose? How do you treat?

- hirsutism and virilization - Excessive androgen secretion (from ovaries or adrenals), or excessive conversion of weak androgens into testosterone - PCOS - Check testosterone levels and perform pelvic exam - Depends on cause - spironolactone, remove tumor, and all the hair removal things

You see a 26 year old female patient in clinic. She tells you she is just SICK of all of the hair removal she has to do and knows it is more than her peers. Upon PE, you see diffuse acne, and an increase in hair growth in an androgenic pattern. How do you describe this hair growth? What would be a more severe presentation of these symptoms? What two hormone inbalances can cause this? What is the most common cause? How do you test? How do you treat?

- posttraumatic stress disorder - symptoms of hyperarousal, illusions, dreams, etc for > 1 month - Psychotherapy *immediately* after event + SSRIs - The sooner the therapy, the better the prognosis

You see a 27 year-old male who recently moved back in with his parents after his fiancée was killed by a drunk driver 3 months ago. His fiancée, a beautiful young woman he'd been dating for the past 4 years, was walking across a busy intersection to meet him for lunch one day. He witnessed the entire crash and she died at the scene. No matter how hard he tries to forget, he frequently finds himself reliving the entire incident as if it was happening all over. Since the accident, he has been plagued with nightmares about the accident almost every night. Normally an outgoing, fun-loving guy, Josh has become increasingly withdrawn, "jumpy", and irritable since his fiancé's death. He's stopped working out, playing his guitar, or playing basketball with his friends. What do you think is going on? How do you diagnose? Prognosis?

- Epididymitis - Sexually transmitted infection - chlamydia or gonorrhea - Yes, I would suspect non-sexually transmitted infection associated or BPH - Empiric if >14 yo (<35 yo = ceftriaxone IM + azythromycin for gonorrhea, >35 yo = "-floxacins") - Safe sex - Yes!

You see a 31 year old male patient with pain in his scrotum that radiates to his side. He also has a fever, swelling in his scrotum and his prostate is very tender on exam. What does he have? What causes it? If he was 60, would you consider something different? How do you treat it? How do you prevent it? Do you treat his partner?

- narcissistic personality disorder - Pervasive pattern of grandiosity, need for admiration, lack of empathy in a variety of contexts - No drugs. Psychotherapy - little is proven effective

You see a 32 year old male patient with CC of "depression." He complains of inability to tolerate people's stupidity and selfishness in a variety of settings. He admits that as a result of his "intellectual superiority" he is not well placed to interact with others or even to understand them and what they are going through. He is a recluse and fears that he is being mocked and ridiculed behind his back as a misfit and a freak. He is consistently and repeatedly victimized by his clients, for instance. They take credit for his ideas and leverage them to promote themselves, but then fail to re-hire him as a consultant. He reports he is never obnoxious or gratuitously offensive. What do you think is going on? How do you diagnose? How do you treat? case source: Myles_Rizvi quizlet

- phobic disorder - >6 mos - exposure therapy - generally good!

You see a 34 year old male patient with an irrational and debilitating fear of flying since a teenager. A traumatic experience on the metro resulted in feelings of being trapped extended to flying, lifts and being in crowds. He has found very ingenious (and expensive) ways of getting around without having to use the Metro, and would use medication, lack of sleep and avoidance tactics to cope with the fear of flying. With a long-haul US trip required in Sam's business role, Sam decided that it was time to confront this phobia and find a way to overcome it once and for all. What do you call this fear? How long do you have to have symptoms before the diagnosis is made? What is the best treatment? Prognosis?

- Sarcoidosis - Autoimmune - Bilateral hilar lymphadenopathy - No cure - oral corticosteroids or methotrexate

You see a 45 year old African American woman in your clinic for shortness of breath on exertion, joint pain, mild fever and fatigue. Upon physical exam eye redness, hepatosplenomegaly, and no wheezing. Her CXR shows: What do you think she has? What type of disorder is this? How would you describe these findings? How do you treat?

- paranoid - clinical diagnosis of a pervasive distrust and suspiciousness of others - Little proven effective - focus on gradual recognition of the origins and negative consequences of paranoid thoughts - possibly consider low dose anti-psychotic medications

You see a 45 year old male patient. His first enquiry is whether you are in any way associated either with the government or with his former employer. He doesn't seem reassured by your negative response. He eyes you skeptically and insists that you must inform him if things change and you do become entangled with his persecutors. Why do you treat him pro bono? He suspects some ulterior motives behind your altruism and inexplicable generosity. You explain to him that you donate 25 hours a month to the community. "It's good for your image, gives you access to local bigwigs, I bet." - he retorts, accusingly. He refuses to allow you to tape record your conversation. What do you think is going on? How do you diagnose? How do you treat? case source: Myles_Rizvi quizlet

- persistent depressive disorder (dysthymia) - "disordered mood" - basically persistent major depression - Consistent therapy and consider electrical therapy

You see a 45 year old woman with the chief complaint of fatigue. She tells you she just can't get out of bed, is constantly tired, doesn't like to eat and feels worthless. She tells you this has been going on for three years now. She has tried some different "depression drugs" but quit them when they didn't work. What is the likely diagnosis? What is that? How do you treat?

- medication overuse (rebound) headache - Anything fast acting - simple analgesics >15 d/month, combo analgesics >10d/month - Stop offending agent (only taper opiods), start appropriate preventative agent, bridge therapy (long acting NSAID with tizanidine) and close follow up - If triptans, 4 days, if mixed medications, 2 weeks - Preventative medications - B-blocker (propranolol), anti-seizure medication

You see a 46 year old woman with two years of daily headaches. After taking a thorough personal and family history you are stumped. Then you specifically ask how *much* of her sumatriptan she takes, and she tells you she takes it nightly after ordering it from India. What is her diagnosis? What meds cause it? How do you know? First step of treatment? Medication? How long do the withdrawal symptoms last? Then how do I treat?

- vit D resistance and pseudohypoparathyroidism (OTHERS: renal failure, drugs [calcium chelator, bisphosphonates], pancreatitis, hyperventilation) - Look for signs of osteomalacia, monitor response to vitamin D and calcium therapy - Vit. D def is more common - pseudohypoparathyroidism is a congenital disorder

You see a 46- year-old woman who lives in Portland was with a 2-week history of facial twitching and hand spasms. She denied abdominal pain, GI changes or urinary symptoms. She does not take any supplements and works inside. On examination, she demonstrated positive Chvostek's and Trousseau's signs. Labs reveal marked hypocalcaemia, low vitamin D and markedly elevated PTH. What are your top two differentials for low calcium and elevated PTH? How do you differentiate the two? Which one is more common and how do you get the rare one?

- erythema multiforme - it's on the same spectrum as SJS/TEN but lacks any mucous membrane involvement - associated with HSV or M. pneumonia - *reassurance,* treatment is only supportive and sx improve after 1-3 weeks

You see a 62 year old patient with a strange "target looking" rash. His mother is afraid it is Lyme Disease after hearing about target shaped rashes it on tv. The lesions are painful, on the extensor acral surfaces and face - there are multiple of them. She denies he has any other PMH. What do you think is going on? Why is this an emergency? What bugs are associated with this? How do you treat?

- retinal *vein* occlusion - branch (not central) - thrombophilias and glaucoma - REFER - laser, VEGF

You see a 65 year old man with a history of HTN, and hyperlipidemia. He was brought in by his wife due to sudden loss of vision in his left eye. He denies any pain. Fundoscopy shows: What do you think the diagnosis is? What type? What else should you screen him for? How do you treat?

- Yes - Age (>65), gender (F>M), race (caucasian, African Americans have lower risk), chronic corticosteroid steroid use, no vitamin D - If T score is less than lower than -2.5 - -1 to -2.5 - The matrix would be weak - leading to instability - Fragility fracture

You see a 67 year old caucasian woman who has rheumatoid arthritis managed with corticosteroids, but is otherwise healthy. She does not take any supplements or any other medications. She is meeting with you for the first time and you notice she has not had a bone density scan. Does she qualify to have one? What are her risk factors of having bone density loss? Her DEXA comes back, at what point is a T score considered osteoporosis? Osteopenia? What part of her bones would be affected? What is she at a high risk for if she has osteoporosis?

- primary degenerative dementia (Alzheimer) - symptomatic - Cholinesterase inhibitors - No known strategy to prevent - Smoking and depression

You see a 74 years old who has lived alone for the past several years, doing her own cooking and caring for herself. Her daughter, who lives in another city, calls once each week although she has not seen her mother for about 6 months. During the last phone call, her mother repeatedly said that she was "so worried." She repeatedly asked the same question. Alarmed, she drove to her mother's home and was shocked to see how thin her mother had become. There was little in the house to eat and her mother had broken her dentures and was having difficulty chewing. As the evening progressed her mother repeated more questions and became agitated. PE reveals: orientation to self but not location or date, sluggish skin turgor, and repeatedly answering questions with "I know but I don't want to answer." What do you think is going on? What is the focus of treatment? What is the mainstay medication type? How do you prevent? What is linked to an increased risk?

- ask about scar and surgical history - thyroid removal? - hypoparathyroidism (20% is caused by prior thyroidectomy) - Low calcium, high phosphate, low/low normal PTH - Monitor for hypocalcemia - start with calcium and vit. D supplements. Consider PTH analogs if supplements not helping.

You see a patient with the chief complaint of "my lips and hands are all tingly." She is a 56 year old woman who is otherwise healthy. She reports occasional "charlie horse" cramps at night which have become more frequent. While doing a physical exam, you notice a scar on her neck. What do you do next? What do you think is going on? What do you expect to see on her bloodwork? How do you treat it?

- oppositional defiant disorder - Caregiver dysfunction and history of multiple care givers - DSM 5 - four sxs of anger, irritability, defiance or vidictiveness + associated distress in loved ones + no psychosis, depression, substance use or bipolar - Support parenting skills, screen for comorbid dx

You see a six year old girl brought in by her adoptive mother. She tells you she is worried be she has been out of control for the last 6 months. She is constantly throwing temper tantrums, arguing, and breaking rules. Even when she is caught, she blames others on it - even the dog! In the visit, the child is angry, constantly disagreeing with her mother and say "UGH!" about 15 times. She has not hurt anything or anyone. Her adoptive mother tells you her biological mother (she was adopted at age 4) has a history of drug abuse and schizophrenia. What do you think is going on? What causes this? How do you diagnose? What if it's unclear? How do you treat?

- Type 1 diabetes

You see an 18 yo after mother calls with report that he has weight loss, excess urination and has not been performing well on his baseball team. Random glucose is over 500. CO2 is 18 and urine ketones are 1+. What do you think is going on? (treatment and diagnosis discussed elsewhere)

- macular degeneration - degeneration of the retinal pigment epithelium secondary to oxidative stress and chornic deterioration - Drusen - Refer - they will recommend certain vitamins (C/E/zinc/copper), inject inhibitors of vascular endothelial growth factors and perform autofluorescence imaging

You see an 82 year old woman with a history of smoking with bilateral vision distortion. Fundoscopy shows: What is this? What is going on? What are those yellow spots called? How do you treat?

Magical thinking

________________ is defined as the belief that an object, action or circumstance not logically related to a course of events can influence its outcome A. Neologism B. Clanging C. Delusion D. Magical thinking

- adolescent girls - boys - firearm

_______________ make up 3-4x as many suicide attempts, but _______________ make up 3-4x as many completed suicides. What is the most common form of completed suicide?

reserved for treatment-resistant cases and delusional depressions. Transcranial magnetic stimulation (TMS) is approved for treatment-resistant depression and has been shown to have efficacy in several controlled trials. Vagus nerve stimulation (VNS) has also recently been approved for treatment-resistant depression, but its degree of efficacy is controversial. Deep brain stimulation and ketamine, a glutamatergic antagonist, are experimental approaches for treatment-resistant cases.

electroconvulsive therapy?

sarcoidosis

shortness of breath + this finding - suspected diagnosis?

Crohn

transmural thickness of inflammation - UC or Crohn?