A 53-year-old female presents with a fingernail infection. See picture:
This should be treated with:
Correct Answer B:
Onychomycosis (tinea unguium) is a fungal infection of the nail. In such infections you can see nail plate separation from nail bed and thickened, discolored (white, yellow, brown, black), broken, and dystrophic nails.
Terbinafine (Lamisil) is the first-line therapy for these infections 250 mg per day for 6 weeks to treat fingernails and for 12 weeks to treat toenails. Complete blood count and ALT and AST levels are obtained at baseline, then every 4 to 6 weeks during therapy.
Itraconazole (Sporanox) is alternative first-line therapy for nail infections. Given 200 mg per day for 6 weeks to treat fingernails and for 12 weeks to treat toenails. You need to monitor ALT and AST levels at baseline, then every 4 to 6 weeks during therapy.
A 69-year-old female sees you for an annual examination. She asks you to look at her toes, and you note a fungal infection in five toenails. She says the condition is painful and limits her ability to complete her morning walks. She asks for treatment that will allow her to resume her daily walks as soon as possible. Her only other medical problem is allergic rhinitis which is well controlled.
Which one of the following would be the most appropriate treatment for this patient?
Continuous therapy with oral terbinafine for 12 weeks has the highest cure rate and best long-term resolution rate of the therapies listed. Other agents and pulsed dosing regimens have lower cure rates. Topical creams are not appropriate for onychomycosis because the infection resides in the cell of the toenail. Antifungal nail lacquers have a lower cure rate than systemic therapy and should be used only when oral agents would not be safe. Toenail removal is reserved for patients with an isolated infected nail or in cases involving a dermatophytoma.
A 68-year-old patient comes to ED complaining of dyspnea. On exam his vitals show HR 160 bpm, BP 110/60 mmHg. His EKG shows supraventricular tachycardia (SVT).
What is the treatment of choice?
Correct Answer E:
In the treatment of SVT, adenosine, a short-acting medication is used to decrease the heart rate. This medication is given by IV to act quickly. Adenosine has some temporary side effects, including facial flushing, chest pain, shortness of breath, nausea and dizziness. If a single dose does not stop supraventricular tachycardia, then you can give higher doses. Adenosine successfully stops paroxysmal supraventricular tachycardia (PSVT) in more than 90% of cases.
If adenosine is unsuccessful, other medications can be used, such as calcium channel blockers, digoxin (Lanoxin), or beta-blockers.
A young female presents with supraventricular tachycardia. The patient does not experience symptoms of haemodynamic decompensation.
The best initial management is:
Correct Answer C:
Vagal maneuvers are the first-line treatment in hemodynamically stable patients. Vagal maneuvers, such as breath-holding and the Valsalva maneuver (ie, having the patient bear down as though having a bowel movement), all slow conduction in the AV node and can potentially interrupt the re-entrant circuit.
Carotid massage is another vagal maneuver that can slow AV nodal conduction. Massage the carotid sinus for several seconds on the nondominant cerebral hemisphere side. This maneuver is usually reserved for young patients. Due to the risk of stroke from emboli, auscultate for bruits before attempting this maneuver. Do not perform carotid massage on both sides. A Valsalva maneuver, if performed properly by the patient, can frequently avert an attack.
Synchronized cardioversion starting at 50 J can be used immediately in patients who are hypotensive, have pulmonary edema, have chest pain with ischemia, or are otherwise unstable.
When SVT is not terminated by vagal maneuvers, short-term management involves intravenous adenosine. Other alternatives for the acute treatment of SVT include calcium channel blockers like verapamil, diltiazem or beta-blockers like metoprolol or esmolol.
Which one of the following is true regarding supraventricular tachycardia (SVT)?
Correct Answer A:
The use of verapamil, propranolol, or digoxin reduces SVT episodes by 30%-50%. There is no evidence that one is superior to the others.
Hypokalemia and hyperthyroidism can cause SVT, but there is no association with hyperparathyroid disease or hyponatremia.
Carotid sinus massage and adenosine have been used for diagnosing atrial tachycardia. (Adenosine is an ultra-short-acting drug that is useful in SVTs of unknown origin both in making the diagnosis and in terminating those that are dependent on the AV junction and some focal atrial tachycardia).
Excessive alcohol use can precipitate SVT.
Click to expand