3 Question Warm-Up
1. W h a t are the 5 main lacunar syndromes that may arise from a lacunar infarct?
2. W h a t is the typical complaint o f a patient w ith retinal detachment?
3. W h a t is the treatment o f choice o f m ania w ith psychosis?
When is observation without antibiotics appropriate for a child with acute otitis media?
According to 2013 A A P/A A FP guidelines, you may refrain from antibiotics and simply observe if:
° Age 6 months to 2 years + unilateral AOM without otorrhea + mild illness + appropriate follow-up available + antibiotics can be started promptly if symptoms worsen
° Age > 2 years + unilateral or bilateral AOM without otorrhea + mild illness + appropriate follow-up available + antibiotics can be started promptly if symptoms worsen
° In either case, the decision to observe without antibiotics should be made jointly between provider and parent/caregiver(s)
° Antibiotics should be started if improvement is not noted in 48-72 hours
W hat are the classic signs and symptoms of bullous myringitis?
Bullous myringitis is a bullous/vesicular inflammation of the tympanic membrane that may occur in association with acute otitis media. It typically manifests as follows:
» More painful than; usual acute otitis media
° Otoscopy: large, reddish vesicles on the TM
W hat is the treatment for bullous myringitis?
° ____________________ is a common organism —> treat with oral___________________
° Topical analgesics
7. W hat are the diagnostic features of mastoiditis?
° Symptoms occur days-weeks after developing acute otitis media
° Erythema, edema, tenderness behind the ear
° External ear displaced
° Diagnosis made from C T scan of the mastoid process
8. W h at are the distinguishing characteristics of acute labyrinthitis?
° Acute onset of vertigo, nausea, vomiting and nystagmus - Auditory function preserved = vestibular neuritis
Hearing loss + above symptoms = labyrinthitis
° Single episode that lasts days to weeks (usually not longer than 2 weeks)
° Preceded by a viral URI
° Nystagmus: horizontal, suppressed with visual fixation and has a fast phase away from the affected side
0 Abnormal head thrust test: W hen examiner rapidly turns the patient’s head to the affected side, the patient is unable to maintain visual fixation
° Gait instability, but preserved ambulation
° Absence of focal neurologic defects
9. W h at is the treatm ent for acute labyrinthitis (vestibular neuritis)?
° Typically subsides spontaneously within weeks
° Corticosteroid taper shown to improve recovery
° Symptomatic treatment only indicated for the first 48 hours of illness E.g., scopolamine patch, meclizine, metodopramide or promethazine Long-term recovery is theoretically delayed if used long-term
° Vestibular rehabilitation exercises
° M R I if > 60 years of age, headache, focal neuro signs, vascular risk factors or sustained vertigo inconsistent with acute labyrinthitis (vestibular neuritis)
10. W h at is the m ost com m on cause of conductive hearing loss in adults? W hat is the m ost com m on cause of sensorineural hearing loss in adults?
° Conductive — otosclerosis
° Sensorineural — presbycusis
11. Cholesteatom a:
° Overgrowth of desquamated keratin debris within the middle ear space that may eventually erode the ossicular chain and external auditory canal
° Causes: negative middle ear pressure (chronic retraction pocket) from eustachian tube dysfunction or direct growth of epithelium through a T M perforation
° Commonly associated with chronic middle ear infection
° PE: grayish-white “pearly” lesion behind or involving the T M , conductive hearing loss, vertigo
° Treatment: surgical removal usually involving tympanomastoidectomy and reconstruction of the ossicular chain
AUDIOVESTIBULARDISORDERS 12. W hat is the treatment for Ramsay Hunt syndrome?
Ramsay H unt syndrome is herpes zoster oticus and is treated as follows:
° Narcotic analgesia for pain relief
° Oral steroids to decrease inflammation
° Antiviral therapy with valacyclovir (highest efficacy), famciclovir or acyclovir
End of Session Quiz
13. W h a t are the important characteristics seen on otoscopic exam o f a patient with otitis media?
14. W h a t is the underlying cause o f benign paroxysmal positional vertigo (BPPV)?
15. Explain how the W eber test can help distinguish conductive hearing loss from sensorineural hearing loss.
16. W h a t are the major characteristics o f M eniere’s disease?
P sychiatry
1 D epression 2 A ntidepressants
3 O th e r M o o d D isorders
4 A n x ie ty D isorders
5 P sychotic D isorders
6 P ersonality D isorders
7 Substance A buse p a rt 1
8 Substance A buse p a rt 2
9 O th e r Psych D isorders
10 D eliriu m and D em en tia
11 P edi Psych
DEPRESSION
3 Question Warm-Up
1. W h a t is the empiric treatm ent for a brain abscess?
2. W h a t is the treatm ent for an epidural hem atom a or subdural hematoma?
3. W h a t is the typical pseudotum or cerebri patient?
4. A t what point does grief/bereavement become pathological?
G rief becomes pathological when any o f the following are found:
° Depression criteria met for at least 2 weeks after the first 2 months following the loss
° Generalized feelings o f______________________________________________
O
° Distressing feelings do not diminish in intensity b y ___________________
° Inability to move on, trust others and reengage in life b y___________________
5. W h at medical conditions can cause severe depression?
6, W h at medications are known for causing symptoms of depression?
° Sedatives: alcohol, benzos, antihistamines
° Stimulant withdrawal
o _______________________ (antihypertensive often used for hypertension in pregnancy)
° First-generation antipsychotics (such as haloperidol)
° Anti-nausea drugs including metoclopramide and prochlorperazine O
° Insufficient thyroid replacement -» hypothyroidism
o ________________________(used in viral hepatitis treatment)
DEPRESSION 7. W h at are the sym ptom s of m ajor depression with atypical features? W h at medications w ork well for this?
8. W hat is the first-line treatment for major depression with seasonal pattern?
E nd o f Session Q uiz
9. A 36-year-old male smoker says he has been thinking a lot about quitting, and wants to talk to you about ways to go about it. A t what stage o f change in overcoming his smoking habit is this man?
10. W h a t neurotransmitter derangements are seen in patients w ith depression?
II. List the symptoms o f depression using the mnemonic SIG E CAPS:
12. Diagnosis of major depressive disorder (M DD) requires five o f the above symptoms, including depressed mood or anhedonia, that must last how long?
ANTIDEPRESSANTS
1. A patient presents w ith hyperphagia, hyperorality and hypersexuality. W h a t is the diagnosis, and w hat brain lesion causes this?
3 Question Warm-Up
2. W h a t are the m ost com m on causes o f seizures in young adults (18-35 years)?
3. W h a t is the treatm ent for cluster headaches?
4. Categorize each of the following antidepressants:
nortriptyline, bupropion, mirtazapine,fluvoxamine, doxepin,phenelzine, fluoxetine,
imipramine, amitriptyline, milnacipran, sertraline, venlafaxine, paroxetine, tranylcypromine, duloxetine, citalopram, trazodone, escitalopram, desvenlafaxine, nefazodone
SSRI -
TC A -
MAOI -
NDRI -
SNR.I
Tetracyclic
-W h at are the sym ptom s of m ajor depression with atypical features? -W h at medications w ork well for this?
W hat is the first-line treatment for major depression with seasonal pattern?