Two years later Mr. Hunter reports progression of his urinary symptoms and desires “a pill to make this better.” His current IPSS is 17, with a bother score of 3 indicating moderate voiding symptoms with moderate impact on his quality of life. On review of systems he notes that his vision has worsened, especially in his left eye. His ophthalmologist has recommended cataract surgery. For which of the following medications would initiation of therapy be delayed until after cataract surgery?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Tamsulosin. Tamsulosin is an alpha-1 adrenergic antagonist commonly used to treat symptoms of benign prostatic hyperplasia (BPH) by relaxing smooth muscle in the bladder neck and prostate, improving urine flow. The reason initiation of Tamsulosin therapy should be delayed until after cataract surgery is due to its potential to induce intraoperative floppy iris syndrome (IFIS), a complication that can complicate cataract surgery. Finasteride (Option A) is a 5-alpha reductase inhibitor that reduces prostate size and can be used in BPH. Tadalafil (Option C) is a phosphodiesterase-5 inhibitor primarily used for erectile dysfunction but can also improve lower urinary tract symptoms. Oxybutynin (Option D) is an anticholinergic medication used to manage overactive bladder symptoms. These medications do not pose the same risk of IFIS during cataract surgery as Tamsulosin. In an educational context, this question highlights the importance of considering a patient's entire medication regimen when planning surgeries or procedures to prevent potential drug interactions or adverse effects. It also emphasizes the need for healthcare providers to be aware of the specific side effects and considerations associated with different pharmacological treatments to ensure optimal patient outcomes.

Correct Answer: A

Rationale: Donepezil is a cholinesterase inhibitor commonly used to treat Alzheimer's disease. The correct answer, A) Thrombocytopenia, is NOT a common side effect of donepezil. Thrombocytopenia is a decrease in platelet count, and it is not typically associated with the use of donepezil. Option B) Bradycardia is a potential side effect of donepezil due to its cholinergic effects on the heart, leading to a decrease in heart rate. Option C) Vivid dreams may occur as a side effect of donepezil due to its impact on cholinergic neurotransmission in the brain. Option D) Gastrointestinal distress, such as nausea, vomiting, or diarrhea, is a common side effect of donepezil, as it affects cholinergic receptors in the GI tract. In an educational context, it is important for healthcare providers to be familiar with the common side effects of medications used to treat Alzheimer's disease, like donepezil, to monitor patients for adverse reactions and provide appropriate care. Understanding the side effect profile of medications helps in assessing and managing the patient's overall well-being and treatment outcomes.

Correct Answer: A

Rationale: In this case, the most likely cause of Randall Johnson's dizziness is orthostatic hypotension (Option A). Orthostatic hypotension is a common issue in the elderly, especially in those with a history of high blood pressure. When an individual stands up from a sitting or lying position, a sudden drop in blood pressure can occur, leading to symptoms like dizziness. Option B, benign positional paroxysmal vertigo, is less likely in this scenario as the patient's symptoms are ongoing and not triggered by specific head movements, which is characteristic of vertigo. Option C, overcontrol of thyroid, is also unlikely as hypothyroidism typically leads to symptoms like fatigue and weight gain rather than dizziness. Option D, Ménière disease, is less likely without symptoms like hearing loss or ringing in the ears, which are common in Ménière disease. In an educational context, understanding the common causes of dizziness in the elderly is crucial for healthcare providers to provide appropriate care and management. Recognizing orthostatic hypotension in patients with a history of conditions like high blood pressure is essential for timely intervention to prevent falls and other complications associated with low blood pressure.

Correct Answer: C

Rationale: The correct answer is C) All patients should receive referral to both psychiatry and neurology, neuroimaging, and screening polysomnography to identify underlying sleep disorder. This option is correct because patients receiving atypical antipsychotics are at increased risk for developing sleep disorders due to the pharmacological effects of these medications. Referral to psychiatry and neurology allows for a comprehensive evaluation of the patients' mental health and neurological status, which can uncover any underlying conditions contributing to their sleep disturbances. Neuroimaging can help identify any structural abnormalities in the brain that may be impacting their sleep, while polysomnography is essential for assessing their sleep patterns and identifying specific sleep disorders. Option A is incorrect because actigraphy monitoring alone may not provide sufficient information to diagnose underlying sleep disorders in these patients. Option B is incorrect because while cognitive behavioral therapy for insomnia may be beneficial for some patients, it does not address the need for a comprehensive evaluation of potential underlying causes of sleep disturbances in patients on atypical antipsychotics. Option D is incorrect because assuming all patients have irregular sleep-wake phase disorder without further evaluation can lead to missed diagnoses of other sleep disorders that may require different management strategies. In an educational context, understanding the importance of thorough evaluation and multidisciplinary approach in patients receiving atypical antipsychotics can help healthcare providers provide optimal care and address the complex interplay between psychiatric medications and sleep disorders.

Correct Answer: B

Rationale: In this scenario, the correct diagnostic test to be done first for the 82-year-old woman who collapsed at home is a STAT noncontrast head computed tomography (CT) (Option B). This test is crucial in ruling out any acute intracranial pathology such as hemorrhage or stroke, which could have contributed to her collapse. Option A, a complete blood count and basic metabolic panel, would provide information about her general health status but would not be the first priority in this acute situation where a neurological issue needs to be urgently assessed. Option C, a two-dimensional echocardiogram, is more focused on assessing cardiac function and would not be the initial test of choice when a neurological cause is suspected. Option D, a urinalysis, is important for assessing renal function and urinary tract issues but is not the primary test needed in this acute setting of a collapsed elderly patient with a potential neurological cause. Educationally, it is important to prioritize diagnostic tests based on the clinical presentation and urgency of the situation. Understanding the rationale behind choosing specific tests in different clinical scenarios is crucial for healthcare providers to make informed decisions and provide timely and appropriate care to patients.