Treatment of Otitis Media

For children ages 2 months to 12 yrs:

1. Treat pain
2. Observation vs. Abx
   • If severe illness (i.e. fever > 39 deg), treat with Abx

   • Observation for 48 hrs for mild disease if >6 months old

Antibiotic regimen: Amoxicillin 80-90mg/kg/d

Ref: 2004 AAP / AAFP Guidelines

Serotonin Syndrome

Triad of symptoms:

Cognitive effects: mental confusion, hypomania, hallucinations, agitation, headache, coma
Autonomic effects: shivering, sweating, hyperthermia, hypertension, tachycardia, nausea, diarrhea.
Somatic effects: myoclonus (muscle twitching), hyperreflexia (manifested by clonus), tremor.

Lithium Side Effects

• Tremor, ataxia
• Nephrogenic DI
• Hypothyroidism
• Teratogenicity

Antipsychotics

Typical: haloperidol, trifluoperazine, fluphenazine, thioridazine, chlorpromazine (haldol + the -azines)

• Mechanism: Dopamineric antagonist, blocks D2 receptor
• Indications: Schizophrenia, mania, Tourette
• Side effects: EPS*, galactorrhea, anti-muscarinic effects, alpha-blockade, antihistamine, NMS

Atypical: Clozapien, Olanzapine, risperidone, aripiprazole, quetiapine, ziprasidone

• Mechanism: Dopamine, 5-HT, alpha, and H1 antagonist
• Indications: Schizophrenia (will improve positive and negative symptoms due to 5-HT effect). Olanzapine for OCD< anxiety D/O, depression, mania, Tourette
• Fewer extrapyramidal and anticholinergic side effects. Agranulocytosis (w/ clozapine)

*Extra-Pyramidal Side Effects: dystonia, akinesia, akathisia, tardive dyskinesia

Personality Disorders

Cluster A (Sad)

1. Paranoid
2. Schizoid – social withdrawal
3. Schizotypal – eccentric, awkward, odd beliefs

Cluster B (Bad)

1. Antisocial – disregard for others, criminality, m > f, conduct disorder if age<18
2. Borderline – unstable mood and relationships, impulsive, f > m splitting
3. Histrionic -attention seeking, sexually provocative
4. Narcissistic – grandiose, lacks empathy

Cluster C (Mad)

1. Avoidant – socialy inhibited but desires relationships with others
2. Obsessive-Compulsive – perfectionist, egosyntonic (vs. OCD)
3. Dependent – submissive and clingy, low self-confidence

Borderline Personality D/O

I M P U L S I V E

I mpulsive
M oody
P aranoid under stress
U nstable self image
L abile intense relationships
S uicidal
I nappropriate anger
V ulnerable to abandonment
E mptiness

Wernicke-Korsakoff Syndrome

Lesion: mamillary bodies

Wernicke’s Encephalopathy: triad of confusion, ataxia, and ophthalmoplegia
Rx: thiamine 100mg PO OD x1-2wks

Korsakoff’s Syndrome: persistent (i.e. after withdrawal) anterograde amnesia and confabulation
Rx: thiamine 100mg PO BID-TID x3-12mo

EtOH Withdrawal

Hx: CAGE Questions
Ever felt like you need to Cut back?
Ever felt Annoyed by people criticizing your drinking?
Ever felt Guilty about your drinking?
Ever had an Eye opener?

Symptoms
Stage 1 (6-12 hrs): tremor, diaphoresis, agitation, anorexia, cramps, diarrhea, sleep disturbances
Stage 2 (1-7 d): hallucinations (visual, auditory, tactile, olfactory)
Stage 3 (12-72 hrs): seizures (usually grand mal)
Stage 4 (3-5 d): delerium tremens diaphoresis, tachycardia, tachypnea, tremor, insomnia, psychomotor agitation, anxiety, n/v, grand mal sz, hallucinations, persecutory delusions

Monitoring CIWA-A Scoring System -/67
mild <10
moderate 10-20
severe >20

Mgmt
1. Supportive therapy
2. Diazepam 20mg PO q2h until symptoms subside
3. thiamine 100mg IV, then thiamine 100mg PO OD x3d
if unable to take PO meds, give diazepam 2-5mg IV/min up to 20mg/h; or lorazepam SL
if liver failure or age>65, give short-acting benzo instead (lorazepam 1-4mg PO/SL/IM q1-2h)
if seizures persist, give Dilantin
if hallucinosis, give haldol 2-5mg PO/IM q1-4h up to 5 doses/d (can also use atypical anti-psychotics)
admission: withdrawal after >80mg diazepam, DT, recurrent arrhythmias, multiple sz, or otherwise unsafe to d/c home

Infectious Causes of Esophagitis

CMV, HSV, Candida

TTP/HUS

Pathophysiology: TTP is caused by a defect in ADAMTS13, a metalloproteinase responsible for the cleavage of vWF. This results in a hyper-coagulable state.

Clinical Presentation – Classic Pentad:

1. Thrombocytopenia
2. Renal Failure
3. MAHA
4. Fever
5. Change in MS

Etiology:
Primary TTP: Idiopathic, autoimmune Abs against ADAMTS13
Secondary TTP: Mechanism unknown. Triggered by cancer, pregnancy etc.

HUS:
Seen more commonly in children. Triad of symptoms (MAHA, renal failure, and thrombocytopenia). Triggered by E. coli 0157:H7 infection.