INTERNAL MEDICINE BOARDS - PART 9 ppt

PSYCHIATRY 586 S YMPTOMS ■ Obsessions: Recurrent or persistent thoughts that cause anxiety. ■ Compulsions: Behaviors or rituals that temporarily relieve anxiety. ■ Patients must recognize that their symptoms are unreasonable and that their obsessions are their own thoughts. DIFFERENTIAL ■ Delusional disorder: Patients do not find the thoughts unreasonable. ■ Schizophrenia: Patients have psychotic symptoms along with affective flat- tening, asociality, and avolition. ■ Generalized anxiety disorder: Patients have anxiety in several different ar- eas of their lives that are generally not relieved by compulsive acts. TREATMENT ■ Behavioral: Exposure-response prevention therapy; cognitive-behavioral therapy (teaches patients how to diminish their cognitive distortions of the stressor and how to change their behavioral response). ■ Medication: Clomipramine, SSRIs (e.g., paroxetine, sertraline, fluvoxam- ine). Higher doses than those used for depression are usually required. COMPLICATIONS Often leads to depression if left untreated. Post-traumatic Stress Disorder (PTSD) Reaction to a traumatic event characterized by reexperiencing, avoidance, and ↑ arousal. Age of onset is variable; the male-to-female ratio is 1:2. Preva- lence is up to 3%, but 30% of Vietnam veterans are affected. SYMPTOMS Patients must have a perceived life-threatening trauma and all three of the fol- lowing: 1. Reexperiencing (flashbacks, nightmares, etc.). 2. Avoidance (places, thoughts, feelings, people related to the trauma). 3. ↑ arousal (insomnia, hyperstartle, poor concentration, anger outbursts). Patients must have all symptoms for a minimum of one month. DIFFERENTIAL ■ Depression: Patients do not have flashbacks to a traumatic event. ■ Generalized anxiety disorder: Patients do not have a history of a trau- matic event or flashbacks. ■ Adjustment disorder: Patients have stress, anxiety, depression, or behav- ioral changes that are related to a specific trigger but do not have all three 1° symptoms: reexperiencing, avoidance, and ↑ arousal. TREATMENT ■ Behavioral: Various forms of individual and group psychotherapy. ■ Medication: SSRIs, sleep agents (e.g., trazodone), long-acting benzodi- azepines (e.g., clonazepam). Prazosin is sometimes given for nightmares. Obsessions cause ↑ anxiety that is temporarily relieved by compulsions. PSYCHIATRY 587 P REVENTION Some research suggests that reducing autonomic activation (with β-blockers) shortly after the trauma may ↓ the likelihood of developing PTSD. COMPLICATIONS ■ Long-term use of benzodiazepines can lead to psychological dependence. Prescribe with caution/selectivity. ■ Avoidance of stimuli associated with the trauma can generalize to avoid- ance of wide-ranging things (which become secondarily associated with the trauma in the patient’s mind). This leads to a far greater negative im- pact on the patient’s life. MOOD DISORDERS Major Depressive Disorder Age of onset is variable; the male-to-female ratio is 1:2. Lifetime prevalence in men is 10% and in women 20%. Risk is higher if there is a family history. Un- treated episodes usually last four or more months. SYMPTOMS ■ Patients must have depressed mood or loss of interest/pleasure (anhedo- nia) and five of the SIG E CAPS symptoms (see mnemonic). ■ Symptoms must represent a change from baseline; cause functional im- pairment (e.g., work, school, or social activities); and last at least two weeks continuously. DIFFERENTIAL ■ Adjustment disorder: Patients have a known stressor that causes a reaction similar to a depressive episode, but the reaction is less severe and is trig- gered specifically by that stressor. ■ Dysthymic disorder: Patients have “low-level depression” (i.e., depression involving fewer than five SIG E CAPS symptoms) that lasts at least two years. ■ Anxiety disorders: Generalized anxiety disorder, PTSD, OCD. ■ Medical “masqueraders”: Hypothyroidism, anemia, pancreatic cancer, Parkinson’s disease. ■ Substance-induced mood disorder: Illicit drugs, thiazide diuretics, digoxin, glucocorticoids, benzodiazepines, cimetidine, ranitidine, cy- closporine, sulfonamides, metoclopramide. DIAGNOSIS Eliminate potential medical etiologies (e.g., check TSH and CBC). TREATMENT ■ Behavioral: Various forms of individual and group psychotherapies. ■ Medication: SSRIs; other classes of antidepressants. Choose medication on the basis of the symptom profile and anticipated side effect tolerability. ■ Electroconvulsive therapy (ECT): Often reserved for medication-resistant depression; especially useful in the elderly. Symptoms of major depressive disor- der— SIG E CAPS Sleep (hypersomnia or insomnia) Interest (loss of interest or pleasure in activities) Guilt (feelings of worthlessness or inappropriate guilt) Energy (↓) Concentration (↓) Appetite (↑ or ↓) Psychomotor agitation or retardation Suicidal ideation In acute stress disorder, symptoms last < 1 month. In PTSD, symptoms last > 1 month. Depression is the fourth largest cause of morbidity worldwide. PSYCHIATRY 588 C OMPLICATIONS ■ Severely depressed patients can develop psychotic symptoms (e.g., audi- tory hallucinations, paranoid ideations, ideas of reference). These symp- toms can be treated with a low dose of an antipsychotic agent. ■ Suicidality: One of the major comorbidities of untreated depression is sui- cidality. ■ Women generally have more attempts, but those of men are usually more lethal. ■ Clinicians must assess the degree of risk (e.g., consider the number of prior attempts, degree of premeditation, lethality of method, and access to the proposed method) and hospitalize if necessary to ensure patient safety. Bipolar Affective Disorder Extreme mood swings between mania and depression. Age of onset is most commonly in the 20s and the 30s; the male-to-female ratio is 1:1. Prevalence is 1%. Risk is higher if there is a family history. There are two types: type I, which alternates between mania and depression, and type II, which alternates between depression and hypomania (i.e., fewer symptoms for a shorter dura- tion). SYMPTOMS ■ The symptoms of bipolar affective disorder are described by the mnemonic DIG FAST. ■ Manic episodes must last at least four days or lead to hospitalization in order to be called mania. Anything less is considered hypomania. ■ See the entry on depression for symptoms of the depressive episodes of bipolar disorder; remember the mnemonic SIG E CAPS. DIFFERENTIAL ■ Major depressive disorder: Patients have no history of a manic episode. ■ Schizoaffective disorder: Patients have both psychotic symptoms and mood symptoms. Psychotic symptoms occur in the absence of mood symptoms. ■ Schizophrenia: Patients do not have mood symptoms. TREATMENT ■ Acute manic episode: Hospitalize; consider antipsychotic agents (e.g., haloperidol, olanzapine, risperidone). ↑ doses of mood stabilizers (lithium carbonate, valproic acid, carbamazepine). ■ Maintenance treatment: Give mood stabilizers such as those listed above. Titrate to the lowest effective dose to maintain mood stability. ■ Depressive episodes: Antidepressants alone may trigger mania, so use care- fully; consider individual and group psychotherapies. PREVENTION ■ ↑ the mood stabilizer dose in the presence of imminent symptoms of ma- nia. ■ Educate patients to recognize the earliest signs of mania/depression (sleep changes are often the first sign), and encourage them to seek additional help early. Symptoms of manic episodes— DIG FAST Distractibility Insomnia (↓ need for sleep) Grandiosity (↑ self- esteem) Flight of ideas (or racing thoughts) ↑ Activities/psychomotor Agitation Pressured Speech Thoughtlessness (poor judgment—e.g., spending sprees, unsafe sex) Treating a bipolar patient with antidepressant monotherapy can lead to a manic episode. Psychotherapy and antidepressants together are more effective for depression than either treatment alone. PSYCHIATRY 589 C OMPLICATIONS ■ In severe phases of mania or depression, patients can have psychotic symp- toms. ■ Left untreated, many patients have progressively more rapid cycling (more frequent and shorter-duration episodes). PSYCHOTIC DISORDERS Schizophrenia A history of severe and persistent psychotic symptoms (≥ 1 month) in the con- text of chronic impairment in function (> 6 months). There are several sub- types. Age of onset is mostly in the late teens or 20s for men and in the 20s–30s for women; the male-to-female ratio is 1:1. Prevalence is 0.5–1.0%; risk is higher if there is a family history. SYMPTOMS Patients must have two or more of the following: ■ Delusions: Fixed false beliefs. ■ Hallucinations: Most often auditory, but can be visual, olfactory, gusta- tory, or tactile. ■ Disorganized speech or thoughts. ■ Grossly disorganized or catatonic behavior. ■ Negative symptoms: Affective flattening, avolition, alogia (poverty of speech), asociality. DIFFERENTIAL ■ Bipolar affective disorder: Patients have psychotic symptoms only during extreme manic or depressive episodes. ■ Schizoaffective disorder: Patients have psychotic symptoms but also have prominent mood symptoms (either depression or mania). ■ Delusional disorder: Patients have one fixed false belief that is nonbizarre and that does not necessarily have a broad impact on functioning. ■ Developmental delay (mental retardation): Patients do not have overtly psychotic symptoms and have not deteriorated from a higher-function- ing baseline. ■ OCD: Patients are aware that their obsessions (recurring repetitive thoughts) are their own thoughts. ■ Depression with psychotic features: Patients have psychotic symptoms that occur only during depressive episodes, and the depressive symptoms can occur without psychotic symptoms. ■ Generalized anxiety disorder: Patients have severe and chronic anxiety but no psychotic symptoms. ■ Substance-induced psychosis: Especially associated with amphetamine or cocaine, both of which can cause paranoia and hallucinations. Patients have other signs/symptoms of substance use. ■ Medical “masqueraders”: Examples include neurosyphilis, herpes en- cephalitis, dementia, and delirium. ■ Neurologic “masqueraders”: Include complex partial seizures and Hunt- ington’s disease. Psychotic = “break with reality.” The 4 A’s of schizo- phrenia: Affective flattening Asociality Alogia (paucity of speech) Auditory hallucinations Olanzapine and several other atypical antipsychotics can cause significant weight gain and the risk of type 2 DM. PSYCHIATRY 590 D IAGNOSIS Diagnose by history. Neuropsychological testing can be helpful in clarifying the diagnosis but often is not indicated. TREATMENT ■ Choose an antipsychotic agent that minimizes both symptoms and side ef- fect profile. ■ First-line agents are now the atypical antipsychotics (e.g., olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole) because they have fewer motor side effects than do typical antipsychotics (e.g., haloperidol). How- ever, atypicals are much more expensive and can cause significant weight gain. ■ Acute psychotic episodes: Hospitalize; ↑ the dose of antipsychotic agent and consider the use of anxiolytic agents (e.g., alprazolam, clonazepam). Group therapy can provide a forum for reality checks if patients can toler- ate them. ■ Maintenance treatment: Titrate to the lowest effective dose of antipsy- chotic agent to maintain stability. Group therapy and structured day pro- grams provide safety, socialization skills, and reality checks. COMPLICATIONS ■ Left untreated, will lead to a “downward drift” in socioeconomic class. ■ Long-term use of typical antipsychotics (e.g., haloperidol) can lead to tar- dive dyskinesias—i.e., involuntary choreoathetoid movements of the face, lips, tongue, and trunk. ■ Tardive dyskinesias should be treated by minimizing doses of neurolep- tics or by switching to an atypical neuroleptic (e.g., olanzapine, risperi- done, quetiapine). ■ Can also be treated with a benzodiazepine (e.g., alprazolam, clon- azepam) or a β-blocker (e.g., propranolol). Delusional Disorder Patients have a fixed false belief (delusion) that is nonbizarre. Prevalence is 0.025%. Age of onset is from the mid-20s to the 90s; the male-to-female ratio is roughly 1:1. SYMPTOMS ■ The delusion is often highly specific and organized into a system (i.e., pa- tients can describe wide and varying evidence to support the delusion). This leads to hypervigilance and hypersensitivity. ■ There is usually a relative lack of other symptoms, and patients often re- main high functioning otherwise. DIFFERENTIAL ■ Schizophrenia: Patients often have a history of auditory hallucinations or other psychotic symptoms, such as prominent negative symptoms (affec- tive flattening, avolition, alogia, asociality). Frequently, there is greater functional impairment. ■ Substance-induced delusions: Particularly associated with amphetamine and cannabis. There is often a prodromal phase of schizophrenia involving negative symptoms without the positive symptoms (delusions or hallucinations). Patients newly diagnosed with schizophrenia (“first break”) are at high risk for suicide attempts. PSYCHIATRY 591 ■ Medical conditions: Hyper-/hypothyroidism, Parkinson’s, Huntington’s, Alzheimer’s, CVAs, metabolic causes (hypercalcemia, uremia, hepatic en- cephalopathy), other causes of delirium. TREATMENT ■ Patients are often likely to refuse treatment and/or medications. Low-dose atypical antipsychotics may be helpful, ■ Do not pretend that the delusion is true, but do not argue with patients to prove it false. Instead, gently remind them of your goal of maximizing functionality. COMPLICATIONS Many patients do not seek treatment, leading to progressive isolation and a ↓ in productivity and/or functional status. SUBSTANCE ABUSE DISORDERS Chronic Abuse/Dependence Substance abuse is a maladaptive pattern of use that occurs despite adverse consequences. Dependence is abuse and physiologic tolerance. TREATMENT All the dependencies are characterized by relapsing and remitting patterns. Optimal treatment varies from patient to patient but usually involves combi- nations of the following: ■ Pharmacologic substitutes: Replace the substance of abuse with a longer- acting and less addictive pharmacologic equivalent. Examples include methadone for heroin, chlordiazepoxide (Librium) for alcohol, and clon- azepam for short-acting benzodiazepines. Can be used either in a detoxifi- cation program (e.g., 21 days) or as maintenance therapy (e.g., methadone maintenance). ■ Pharmacologic antagonists: ↓ the pleasurable response associated with the substance of abuse. Examples include the following: ■ Antabuse (disulfiram) for alcohol: Blocks the efficacy of alcohol dehy- drogenase, causing buildup of acetaldehyde. ■ Naltrexone: Thought to ↓ alcohol craving. ■ Therapeutic communities: Provide a safe, structured environment in which to boost attempts at maintaining early sobriety. Can be inpatient (residential) or outpatient, brief or long-term. ■ Self-help organizations: Provide a regular and ongoing community of peers to maintain ongoing sobriety. Examples include Alcoholics Anony- mous (AA) and Narcotics Anonymous (NA). ■ Family support/education: Provide support to family members; offer an environment in which to learn from and commiserate with others. An ex- ample is Al-Anon. ■ Individual counseling/therapy: Various techniques focus on the following: ■ Understanding and eliminating triggers for relapse. ■ Harm reduction approach: Minimizing use of the substance, which minimizes its functional impact on patients’ lives. ■ Abstinence model: Getting patients to accept that they cannot mini- mize use but must abstain in order to improve their functional quality of life. Delusional disorder is far less common than schizophrenia and is less responsive to medications. PSYCHIATRY 592 ■ Psychoeducation: Educating patients regarding issues such as the cy- cle of relapses and remissions; the chronic nature of the illness; and available resources. For information on the treatment of acute intoxication or withdrawal syn- dromes, see the Hospital Medicine chapter. COMPLICATIONS Chronic substance dependence leads to significant loss of productivity, func- tionality, and quality of life. OTHER DISORDERS Somatoform Disorders A group of disorders in which patients complain of physical symptoms that have no clear medical etiologies. Affect 15% of all psychiatric patients and 20% of medical inpatients. Certain subtypes are more common in women (e.g., conversion disorder, pain disorder); others are more common in men (e.g., factitious disorder, malingering). All generally occur more often in those with lower socioeconomic status and education. SYMPTOMS ■ Vary across the specific disorders, but all are insufficiently explained by medical causes alone. ■ Demonstrate inconsistent findings and often lead to many unnecessary hospitalizations, procedures, and workups. Specific subtypes include the following: ■ Somatization disorder: Complaints are in at least two organ systems. ■ Conversion disorder: Complaints are in the neurologic system. ■ Pain disorder: Complaints are of pain (predominantly). ■ Hypochondriasis: Complaints and fear are of serious diseases. ■ Body dysmorphic disorder: Complaints are about a perceived defective body or body part. ■ Factitious disorder: Complaints are consciously simulated by the patient (vs. somatization disorder). ■ Malingering: Complaints are consciously simulated by the patient with specific 2° goals as a 1° motivator (vs. factitious disorder). DIAGNOSIS ■ Eliminate likely medical etiologies through standard medical workups. A balance must be struck between sufficient workup to rule out realistic causes and exhaustive workup to rule out extremely rare causes. ■ Psychiatric consultation can help clarify specific diagnoses and therefore potential treatment options that could be most helpful. TREATMENT ■ Minimize the number of different providers involved in the care of the pa- tient. ■ Establish and maintain a long-term, trusting doctor-patient relationship; schedule regular outpatient visits and routinely inquire about psychosocial stressors. PSYCHIATRY 593 ■ On each visit, perform at least a partial physical exam directed at the organ system of complaint, and gradually change the agenda to inquire about psychosocial issues in an empathic manner. ■ Refer patients to a mental health professional to help them express their feelings, thereby minimizing physical symptoms as a proxy for those feel- ings. ■ Treat any 2° depression (i.e., depression 2° to the sense of hopelessness as- sociated with having the somatoform disorder). ■ Some patients may benefit from the use of an anxiolytic agent (e.g., alpra- zolam). ■ Be aware that some patients will develop psychological dependence on medications, so prescribe selectively. Attention-Deficit Hyperactivity Disorder (ADHD) Persistent (> 6 months) problems with inattention and/or hyperactivity and impulsivity. Prevalence is 3–5%; the male-to-female ratio is 3–5:1. DIAGNOSIS ■ Inattention, including at least six of the following: 1. Poor attention to tasks, play activities, or schoolwork. 2. Poor listening skills. 3. Poor follow-through on instructions. 4. Poor organizational skills. 5. Avoidance of tasks requiring sustained mental effort. 6. Frequent loss of things. 7. Easy distractibility and forgetfulness. 8. Frequent careless mistakes. ■ Hyperactivity-impulsivity, including at least six of the following: 1. Fidgetiness. 2. Leaves rooms where sitting is expected. 3. Excessive running/climbing. 4. Subjective thoughts of restlessness. 5. Difficulties with leisure activities. 6. Acts as if “driven by a motor.” 7. Talks excessively. 8. Interrupts others often. DIFFERENTIAL ■ Med-seeking behavior: Patients often present with a history of substance abuse (especially amphetamine abuse). ■ Bipolar affective disorder: Inattention/racing thoughts occur only during manic episodes; are accompanied by a lack of need for sleep and by grandiosity/euphoria; and are cyclical in nature. ■ Substance-induced symptoms: Especially amphetamine intoxication. Look for associated signs/symptoms of substance abuse. TREATMENT ■ Stimulants (methylphenidate, others): ↑ the dose as needed. ■ Antidepressants: If there is a risk of abuse/dependence, bupropion (Well- butrin) is a nonaddictive and reasonable first-line agent. ■ Behavioral therapy: Focus on changing maladaptive behaviors and on learning more effective ones. Informal “curbside” consults of colleagues can be quite helpful and are preferable to the formal introduction of yet another medical provider. In order for an adult to be diagnosed with ADHD, symptoms must have been present in childhood and must cause functional impairment. Adults tend to have less hyperactivity than do children. Patients with ADHD describe stimulants as slowing them down rather than making them “high.” PSYCHIATRY 594 Eating Disorders Marked disturbances in eating behavior. There are two major types: ■ Anorexia nervosa: Patients have misperceptions of body weight, generally weigh < 85% of their ideal body weight, and self-impose severe dietary lim- itations. Affects 0.5–1.0% of adolescent girls; the male-to-female ratio is 1:10–20. More common in developed/Western societies and in more afflu- ent socioeconomic strata. ■ Bulimia nervosa: Episodic uncontrolled binges of food consumption fol- lowed by compensatory weight loss strategies (e.g., self-imposed vomiting, laxative and diuretic abuse, excessive exercise). Affects 1–3% of young women; the male-to-female ratio is 1:10. SYMPTOMS ■ Both anorexia and bulimia involve a marked misperception of body image and poor self-esteem. ■ Anorexia only: Actual body weight must be < 85% of ideal body weight (for height and age). Also presents with lanugo, dry skin, lethargy, brady- cardia, hypotension, cold intolerance, hypothermia, and hypocarotenemia. ■ Bulimia only: Patients must have at least three months of binge-purging activity that occur at least twice a week. They must also have a sense of loss of control during food consumption binges. Patients often have signs of frequent vomiting (e.g., low chloride levels, pharyngeal lesions, tooth enamel decay, scratches on the dorsal surfaces of the fingers) and en- larged parotid glands. DIFFERENTIAL Medical causes of weight loss and amenorrhea; failure to thrive. DIAGNOSIS Diagnose by history. A collateral history obtained from other family members is often helpful. TREATMENT ■ Correct electrolyte abnormalities. ■ Psychotherapy. ■ Antidepressants: SSRIs. Personality Disorders Persistent maladaptive characteristic patterns of behavior that have been pre- sent since childhood and cause significant impairment in patients’ func- tioning in society. All are coded on Axis II. SYMPTOMS There are several types, most often subdivided into clusters: ■ Cluster A (aka the “weird” personality disorders): ■ Schizoid ■ Schizotypal ■ Paranoid ■ Cluster B (aka the “wild” personality disorders): ■ Borderline 2° amenorrhea may be a sign of an eating disorder in a young woman. [...]... subacute cutaneous lupus erythematosus Anti-SSB (La) 0–2 5–20 60–70 Associated with neonatal lupus Anticentromere 50 Anti-SCL-70 33 20 25 25 Non-ANA tests: RF 70–80 CCP 47–76 ANCA Anti-Jo-1 a 20 75 33 1–5 50 93 96 20–30 SS = Sjögren’s syndrome; DS = diffuse scleroderma; LS = limited scleroderma; P/DM = polymyositis/dermatomyositis Usually present in patients with extra-articular disease Extremely high titers... DS LS P/DM WEGENER’S 30–60 95 –100 95 80 95 80 95 80 95 0–15 COMMENTS ANA tests: ANA Often used as a screening test; a ᮎ test virtually excludes SLE Anti-dsDNA 0–5 60 Titer generally correlates with disease activity Anti-Smith Anti-RNP 10–25 0–10 Specific for SLE 30 20–30 20–30 Antibody must be present to make the diagnosis of mixed connective tissue disease Anti-SSA (Ro) 0–5 15–20 60–70 Associated with... pulmonary fibrosis, hepatotoxicity, cirrhosis Sulfasalazine First- or Daily CBC GI intolerance, deficiency (can neutropenia, thrombo- hemolysis) (if suspected) DMARD G6PD cause second-line CBC, G6PD cytopenia First- or Daily, but t1/2 is Hepatitis CBC, LFTs, Myelosup- second-line Leflunomide > 2 weeks serologies, creatinine pression, DMARD Second-line inhibitors DMARDs; usually added after 3–6 months if there... Normal serum complement levels (anti-myeloperoxidase) ■ ᮍ p-ANCA (anti-myeloperoxidase) Imaging: CXR shows fleeting pulmonary infiltrates Biopsy of affected tissue demonstrates extravascular eosinophils TREATMENT ■ ■ High-dose corticosteroids, Immunosuppressants for renal or nerve/CNS involvement or for steroidunresponsive disease 654 Medium- or, more commonly, small-vessel vasculitis and capillaritis... Rheumatoid Arthritis 632 Systemic Lupus Erythematosus and Drug-Induced Lupus 634 SYSTEMIC LUPUS ERYTHEMATOSUS 634 DRUG-INDUCED LUPUS 638 NEONATAL LUPUS 6 39 Sjögren’s Syndrome 6 39 Seronegative Spondyloarthropathies 640 ANKYLOSING SPONDYLITIS 640 PSORIATIC ARTHRITIS 642 REACTIVE ARTHRITIS 643 INFLAMMATORY BOWEL DISEASE–ASSOCIATED ARTHRITIS 644 Crystalline-Induced Arthropathies 644 HYPERURICEMIA 644 GOUT 644... CHONDROCALCINOSIS 6 49 Inflammatory Myopathies 6 49 POLYMYOSITIS 6 49 DERMATOMYOSITIS 650 INCLUSION BODY MYOSITIS 651 Systemic Sclerosis (Scleroderma) 651 LIMITED SCLERODERMA 651 PROGRESSIVE (DIFFUSE) SYSTEMIC SCLEROSIS 652 Vasculitis 653 APPROACH TO VASCULITIS 653 1° VASCULITIS SYNDROMES 653 OTHER VASCULITIDES 658 6 29 Copyright © 2008 by Tao Le Click here for terms of use Infectious Arthritis 6 59 NONGONOCOCCAL... Cystic Fibrosis 613 Interstitial Lung Disease 614 Pleural Effusion 616 Pneumothorax 617 Pulmonary Complications of HIV 6 19 Pulmonary Embolism 620 Pulmonary Hypertension 621 Solitary Pulmonary Nodule 623 599 Copyright © 2008 by Tao Le Click here for terms of use Sarcoidosis 624 Sleep-Disordered Breathing 625 Lung Transplantation 626 CANDIDATE SELECTION 626 SURGICAL PROCEDURES 626 TREATMENT COURSE AND... Supplemental O2 accelerates the reabsorption of gas from the pleural space to about 8 9% per day ■ Larger, more symptomatic 1° spontaneous pneumothoraces: May be drained either with simple aspiration or with placement of a small-bore chest tube 2° spontaneous pneumothorax: Treat with a larger-bore chest tube attached to a water-seal device ■ Persistent air leaks and recurrences are more common with 2° than... infections (e.g., HCV) Anti–cyclic citrullinated peptide (anti-CCP): ■ Present in 47–76% of patients with RA ■ ■ ■ 633 RH E U MATOLOGY TA B L E 1 7 3 Comparison of Antirheumatic Drugs INITIAL DRUG Methotrexate INDICATION First-line DOSAGE Weekly DMARD ROUTINE CONTRA- SIDE MONITORING MONITORING INDICATIONS EFFECTS CXR, hepatitis CBC, LFTs Hepatic Myelosup- disease serologies, CBC, pression, LFTs, creatinine... dulling, Lithium toxicity, hypothyroidism (in long- tremor, sedation, term use), nephrogenic diabetes insipidus nausea, diarrhea, T-wave flattening Mood stabilizers/ Valproic acid (Depakote) Weight gain, sedation, Carbamazepine (Tegretol) Same as above anticonvulsants Thrombocytopenia cognitive dulling SIADH, agranulocytosis, Stevens-Johnson rash Typical high-potency Haloperidol (Haldol), antipsychotics . the male-to-female ratio is 1:2. Preva- lence is up to 3%, but 30% of Vietnam veterans are affected. SYMPTOMS Patients must have a perceived life-threatening trauma and all three of the fol- lowing: 1 of onset is from the mid-20s to the 90 s; the male-to-female ratio is roughly 1:1. SYMPTOMS ■ The delusion is often highly specific and organized into a system (i.e., pa- tients can describe wide. weight, and self-impose severe dietary lim- itations. Affects 0.5–1.0% of adolescent girls; the male-to-female ratio is 1:10–20. More common in developed/Western societies and in more afflu- ent socioeconomic