Supplement and Answer Key - Northwestern Medical Review · 2015-09-29 · NBI 100 Supplement and...

NBI 100 Supplement and Answer Key

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Supplement: NBI 100, Northwestern Medical Review, 2003 1

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Supplement To NBI 100 Review Book Page Page Location/Question Notes/Added Comments

19 Bugs and Drugs • H. Flu: Cephalosporins, Ampicillin/Amoxicillin, TMP/SMX • Bacillus anthracis: Penicillin G, Cipro • Candida: Fluconazole • Proteus: Quinolones • Salmonella: Cipro, 3rd generation, TMP/SMX • Rickettsia: Doxycycline, Chloramphenicol • Staph aureus: Methicillin • Streptococcus pyogenes: Penicillin G or V • Legionella: Erythromycin • Gardenerella: Metronidazole • Chlamydia: Doxycycline or tetracycline • Toxoplasmosis: Sulfadiazine and pyremethamine • MRSA: Vancomycin • Klebsiella: Cephalosporin • TB: INH • Herpes: Acyclovir • Influenza A and Rubella: Amantidine • RSV: Ribavarin • HIV: AZT • CMV: Ganciclovir

20 Non-anticancer drugs that cause aplastic anemia

Carbamazepine, Chloramphenicol, Phenylbutazone

24 Mitral infection: If, then • Streptococcus mutans • Staphylococcus aureus • Streptococcus pyogenes • Streptococcus epidermidis

25 What is the most common cause of. … • Streptococcus pneumoniae 27 What disease has a more? • Cholera 30 An occlusion of the left… • Loss of strength and weakness in the right side of the body 30 An occlusion of the middle cerebral… • Loss of strength and sensation in the upper part of the body 30 An occlusion of the anterior cerebral… • Loss of strength and sensation in the lower part of the body 32 The most common primary… • Glioblastoma multiforme 32 The third most… • Schwannomas


32 Top Panel • Bitemporal heteronymous hemianopia • Pituitary adenomas, Meningiomas

32 Lower Panel • Right Nasal heteronymous hemianopia • Compression of chiasm and calcified right carotid arteries

32 Lower RT Panel • Right Superior Quadrantanopia • Pie in the Sky

32 Lower: What lesions… • Lesions anywhere behind the chiasm 33 Right filling blanks • Paradoxical

• Sympathetic • Argyll Robertson Pupil

34 A 75-year-old • Normal aging 34 A 25-year-old • Heroin (opiate) overdose 35 Make Corrections • Inferior Oblique: Up and Away 35 Multiple Choice • [B] is correct 38 Make Corrections: On all the drawing on the

lower left of panels in page 38-39 the label for L and R eye needs to be corrected as it is shown in the adjacent box here. Practically, Just change the “R” to “L” and the “L” to “R” in your book

LLRRAddAdd AbdAbdAbdAbd

40 Left blanks: What deduction can you make.. • Left Cortex must have some anomaly 40 Which side of cortex… • Left side 40 …The nystagmus would be… • Slow drift to the right and fast to the left 40 Lower RT panel: Multiple-Choice • Left CN V 41 Multiple Choice: Top Left • Right CN VII 41 Multiple Choice: Left Middle Panel • Right parotidectomy 41 Multiple Choice: Right Top • Bell’s 42 Multiple Choice: Top Left • Right Horner’s 43 Matching • A = RT CN III palsy; B = Right Horner’s; C = RT CN VII lesion 44 Lower Left Blank Stroke affects UMN of CN7 (I.e. area below the eye). Hence, closure of the upper eyelid is

not affected. Bell’s affects an entire facial side-- including the eyes. 44 Lower RT Blank Patients will lacrimate instead of salivating…the so called “crocodile tear” 45 Produces wakefulness Dopamine (Day break!) 45 Negatively affected by sleep deprivation Cortex 45 Right side Alcohol and Benzodiazepine decrease REM 45 2-3 hours after sleep.. Prolactin 45 Initiates sleep Serotonin (Sleep)


45 Increases during REM Acetylcholine 46 Not the in the books: Stages of Sleep

Delta wave Lowest Frequency & Highest Amplitude

Theta wave

Alpha with Sleep Spindles

Alpha wave

Beta wave Highest Frequency & Lowest Amplitude

Cannot feel the earthquake. You are deep into sleep!

Deep Sleep

The show is going on. Your spouse turns off the TV and you do not even notice!

Moderate Sleep

You are almost falling asleep but you don’t want to miss the best part of the show!

Light Sleep

Now, you are watching a TV movie in supine position!

Quiet/Relaxed

You are awake, you take a bath, and then go to your bed!

Awake

BATheD!Awake (Takes a ath) Deep SleepB

47 A patient with bilateral… Quadriplegia 47 ..Caudal to arms.. Paralysis of both legs 48 What lesion causes bilateral dorsal… Tabes dorsalis 49 What spinal lesion causes lower motor? Amyotropic lateral sclerosis 50 Why hemi section of …. Pain and temperature fibers do not cross over immediately. They ascend one or two levels

before crossing to the opposite side. 50 Why hemisection of the chord at the.. Spinothalamic fibers 50 Right: Patient with infarction of… Nucleus gracilis and cuneatus-- sensory proprioception and stereognosis. 50 Right blank.. Ventral spinal artery occlusion (lesion) 51 A patient with infarction of anterior.. Nucleus gracilis and cuneatus-- sensory proprioception and stereognosis 51 …Paralysis and atrophy C7C8… Syryngomyelia 51 Blank on the right Guillain-Barre-Syndrome 56 Added Plate: Sensitivity vs. Specificity

Sensitivity = [A]/[A+C] Specificity =

-+

-+

Negative Disease

Negative Test

Positive Disease

Negative Test

Negative Disease

Positive Test

[D][C]

[B]Positive Disease

Positive Test [A]Test

Disease

Sensitivity = [A]/[A+C] Specificity = [D]/[B+D]


57 Added: List of Twelve Organs and Anatomical Relationships

• Location of Cervix in uterus • Relationship of left bronchus to esophagus • Location of Sphenoid bone in cranial fossa • Location of Subdural hematoma • Location of Foramen ovale in the embryo • The origin of RT gastro-epiploic artery • The origin of axillary artery • Location of Direct inguinal hernia • Location of Thoracic duct in thorax • Location of Spinalis muscle • Location of Maxillary sinus ostium • Location of Primary visual cortex

64 For blanks See the test strategy chapter (book) 68 Added: Treatment of cyanide poisoning • GI decontamination (lavage)

• Amyl nitrite (inhale) • Sodium nitrite (IV) • Sodium thiosulfate (IV) • Pure oxygen

68 Role of nitrites in cyanide poisoning • Nitrites (Amyl nitrite & Sodium nitrite) produce methemoglobin • Methemoglobin has a higher affinity for cyanide than cytochrome oxidase • Hence, displaces cyanide

68 Antidotes • Digitalis: Lidocaine or Phenytoin or K+ • Cyanide: Amylnitrate • Iron: Deferoxamine • Arsenic: BAL • Opioids: Naloxone • Benzodiazepine: Flumazenil • Acetaminophen: Acetyl-cysteine • Methanol: Ethanol • Warfarin: Vitamin K • Heparin: Protamine Sulfate • TCA’s (Imipramine): Sodium bicarbonate • Atropine: Physostigmine

68 Garlic odor in arsenic poisoning: mnemonic

GGararsenicsenicliclic


68 Inhibit P450 • Chloramphenicol • Cimetidine • Phenylbutazone • Metronidazole

68 Induce P450 • Alcohol • Phenytoin • Barbiturate • Rifampin • Griseofulvin

71 Multiple-choice [A]74 Matching A (2); B (1); C (4); D (3); E (5) 76 Make Corrections (table) In Paget’s calcium is Normal to High 80 Added Plate: Food Poisoning Bugs • Vibrio Parahaemolyticus, Seafood

• Staph Aureus, Meats, Toxic Shock Syndrome • Clostridium Perfringens, Re-Heated Meat, Gas Gangrene, And Myonecrosis • Clostridium Botulism, Canned Food, Honey; Botulism • Bacillus Cereus, Re-Heated Rice

80 Added Plate: Mnemonic for Food Poisoning Bugs Vomiting Big

Smelly Chunks!

VBSC

ibrio parahaemolyticus

acillus Cereus

taph aureus

lostridium perfringens!

80 Added Plate: Two forms of C. Perfringens 1. Necrotizing: a-toxin of C. perfringens A forms lecithinase (which splits membrane lecithin) and DNAse and hyaluronidase (digests collagen and subcutaneous tissue). Enters by trauma & contaminated soil.

2. Food Poisoning Strains: Produce enterotoxin--causing marked hypersecretion in the small intestine.

80 Added Plate: Endospore producing bugs • Bacillus (cereus & anthracis): Aerobic • Clostridium: anaerobic • Endospores are dormant, tough and resistant to heat and drying


82 Added Plate: Must Know List of Odds and Ends in Microbiology

(1) Cholecystectomy in S. typhi source removal (2) Infectious form of human schistosomes (3) Liver as the target organ for Echinococcus granulosis hydatid cyst (4) Gram-positive Seagull appearance in Campylobacter jejuni (5) Substance of transmission in Leptospira interrogans (6) Association of hepatitis B with hepatic carcinoma (7) Strep component in rash of scarlet fever (8) Example of prozone phenomena (9) Transmission and infection site of Babesia. Microti (10) Acanthameba. Castellani induced keratitis with contact lens

82 Added Plate (notes) About Babesia microti…. Tick bite (Ixodes); Infests RBCs like malaria but no hepatic stage

About Leptospira Interrogans…. Weil’s Dz (Infectious jaundice); Urine of dog, rat and cow. Penetrate through abraded skin; Associates with hot weather and contaminated water.

82 Multiple-Choice: During her third month.. [E] 83 Multiple-Choice: During her third… [A] 83 Multiple-Choice: During her third… [B] Jarisch-Herxheimer 84 The most Common … 6 mo – 6yr... Strep pneumoniae 84 The most Common … HIV +... Cryptococcus neoformans 84 Supplemental Plate Carbohydrate Use of N. Meningitides and gonorrhea: Meningitidis (ferMents) Maltose! 84 Supplemental Plate: Thayer-Martin VCN • Classic Medium for Culturing N. meningitides and gonorrhea: Thayer-Martin VCN

• Chocolate Agar with antibiotics to kill competing germs: Vancomycin, Colistin (Polymyxin) and Nystatin.

84 Supplemental Plate: DOC of H. Flu DOC of H. Flu

1) 3rd generation Cephalosporins

mpicillin and mox

3) TMP/SMX

2) A A

C TS for H. Feline!A 84 Added Plate: Three important causes of

meningitis treatable by Chloramphenicol • H. Flu, Neisseria meningitides and Strep pneumoniae • Chloramphenicol is not DOC for all however can be used if identity of the causative

agent is not identified and the patient is allergic to cephalosporins and penicillin.


84 List of 10 Must know Virology Concepts (1) Characteristics of Retrovirus (2) Routes of transmission & symptoms of cytomegalovirus infection (3) Causative agent of heterophil positive infectious mononucleosis (4) Papovavirus characteristics (5) Togavirus: Mode of transmission (6) Know viruses with latent infections (7) Characteristic of adenovirus outbreak (8) Mode of transmission of paramyxovirus (9) Viruses with double stranded genome (10) Parainfluenza and croup

84 Added Case: During an excavation expedition in a cave, a strange palisade of inscription with club-shaped characters was discovered. What is the inscribed message?

Gram staining of Diphtheria lesions reveals characteristic club-shaped, gram-positive rods in palisades or Chinese character configuration!

85 Supplemental Plate

• Trichomonas viginalis• 25% of sexually active females• Persistent virginities; Odiferous discharge• Metronidazole

TRICHOMONIASIS

• Third leading worldwide parasitic cause of death• Entamoeba histolytica• Diarrhea & heme-positive stool; Amebic liver abscess• Metronidazole

AMEBIASIS

• Toxoplasma gondii; Cats• Transplacental transmission• Lymphadeopathy, encephalitis, ocular infection• AIDS• Pyrimethamine & Sulfadiazine

TOXOPLASMOSIS

• Plasmodium falciparum & vivax • Anopheles mosquitoes• Periodic bouts of fever• Chloroquine & Quinine

MA RIA

• Drinking untreated water. • Persistent non

LA

-bloody diarrhea & no fever• Poor fecal hygiene: day-cares; homosexuals• Associated with selective IgA deficiency• Metronidazole

GIARDIASIS (G. lamblia)

PROTOZOANS

rdia; gIA IgA



85 Helminthology Check-list “DATES”

Diphyllobothrium Ascariasis Trichinosis, Taenia, Toxocariasis Echinococcosis/ Entrobiasis Schistosomiasis, Strongyloides

86 Multiple-Choice [D] 87 Worms (nematodes) acquired by EATing

helminthes eggs… Entrobiasis, Ascaris & Trichuris

87 Three nematodes acquired via larval penetration through skin

Necator, Strongyloides and Schistosoma

87 Only infect humans Strongyloides and Pinworm 87 Emigrate to lung Necator, Strongyloides & Ascaris 87 Worms that crawl out of Children’s anal sphincter Pinworm 87 Amphotericin B Indication: C3HAB Coccidioides, Candida, Cryptococcus, Histoplasmosis, Aspergillosis, Blastomycosis 87 Topical antifungals Nystatin, Clotrimazole, Miconazole

Gastritis Due to NSAID Use • NSAIDS inhibit prostaglandin synthesis • Remove inhibition over acid secretion in stomach (via cAMP) • At low stomach pH, aspirin is uncharged. Readily enters mucosal cells (ionizes there, becomes negatively charged)

and trapped. Hence, directly damages cells. Cardiac Slowing Mechanism of Digoxin

• Digitalis increases force of contraction via increased intracellular calcium • Increased force decreases end diastolic volume (i.e. increases ejection fraction) • Improved circulation reduces sympathetic activity & enhances parasympathetic tone • Reduction in peripheral resistance reduces heart rate. • Increased vagal tone decreases HR and oxygen demand.

Acute Pulmonary Edema: Role of Mannitol • Life-threatening alveolar edema is due to elevation of hydrostatic pressure in pulmonary capillaries (left failure or

Mitral stenosis) or increased permeability of alveolar membrane. • Immediate aggressive therapy is mandated • Up-right seating reduces venous return • IV use for mannitol only (not absorbed orally) induces osmotic diuresis

Thiazide & loop diuretics are also helpful Potency vs. Efficacy

• Potency: Amount of drug to produce desired biologic effect. • Efficacy: Ability to produce a biologic effect

If only 1 mg of drug A is needed to reduce stomach acid, whereas 5 mg of drug B is needed, then it can be inferred that drug A is more potent.

88 Several High-Yield Pharmacology Facts

Ganciclovir Side-effects • Bone-Marrow Suppression; Renal Dysfunction, Seizures, GI Disturbances

Lidocaine in Dysrrhythmia • Drug of choice (Ib) for acute ventricular arrhythmias—e.g. infarction • Unlike Quinidine suppresses arrhythmias caused by abnormal automaticity. • Like quinidine abolishes re-entry • Preferentially works at higher frequencies of myocardial function • Indications: Ventricular tachycardia, premature complexes, ventricular fibrillation, digitalis-induced fibrillation

Open Angle Glaucoma: Timolol vs. Pilocarpine vs. Epinephrine • Pilocarpine: Muscarinic (cholinergic) agonist Increases outflow; Duration of Action: 1 Day; Used for emergency

treatment • Timolol: b-blocker. Used for chronic cases; Reduces fluid production • •Epinephrine (2% topical, Increases outflow and, Reduces fluid production (vasoconstricts ciliary body)•

Prolonged Use of Sodium Bicarbonate Metabolic alkalosis, Hypernatremia, Fluid retention, Acid rebound due to high gastric pH Chemical antagonism

• Chemical Antagonism: Direct binding of a drug by another drug without involvement of receptors (e.g. Chelators) • Competitive Surmountable (Reversible): Induce parallel shift of agonist dose response curve to the right with no

change in intrinsic activity. The effect of antagonist can be surmounted (overcome) by higher dose of agonist. • Competitive Insurmountable (Irreversible): Binds, often covalently to the receptor. • Non-competitive: Acts at a site other than the receptor • Functional (physiological Antagonist): Opposing action of 2 agonists at different receptors—e.g. ACh and NE on SA

node.

Drug Concentration

Chemical Antagonism

Competitive antagonistEfficacy Same/Potency decreases

Bio

logi

cal E

fect Non-Competitive antagonist

Efficacy decreases

Drug alone

Role of Propranolol in Hyperthyroidism: Manages tachycardia and hypertension


Nifedipine and Verapamil in Angina Pectoris • Both reduce smooth and cardiac muscle contractility • Both are drug of choice for Prinzmetal angina • Both can also be used for chronic stable angina • Nifedipine acts mainly on arterioles (best decrease in TPR) • Verapamil has the best inhibitory effect on the AV node

Amoxicillin and Clavulanate Spectrum • All organisms affected by natural Pens • Gram-positive bacilli: Listeria monocytogenes • Gram-negative enteric rods: E. coli, Proteus & Salmonella, Shigella • Other gram negative bacilli: H. flu

A few More Other Must Know Pharmacology Concepts

• Mechanism Of Sucralafate Function • Effect Of Propranolol On The Heart • Treatment Of Acne Vulgaris • Disorders Exacerbated By High-Doses Of Prednisolon

87 Side Effects of Cisplatin Therapy Nephro and Ototoxicity 87 Three drugs causing both Ototoxicity and

Nephrotoxicity Aminoglycosides, Cisplatin, Loop diuretics

87 Unique Side Effects of Anticancer Medications

Hemorrhagic Cyctitis!CyclophospHamide

Fotosensitivity! Foot & Hand!5-FlurouracilNephro & OtotoxicityCisplatin

Neurotoxicity (Neural Crest!)Peripheral Neuropathy, Foot Drop, Ataxia

Vincristine

Pulmonary Toxicity From Rales and Cough to Fatal Fibrosis

BleomycinMethotrexate

CardiotoxicityDoxorubicin (adriamycin)Daunorubicin

Unique Organ Toxicity of Anti-Cancer Medication

87 Three medications causing pulmonary fibrosis: Amiodarone, Bleomycin, Methotrexate 87 Treatment of Insulinoma Streptozocin 87 Commonly tested anticancer drug? Cisplatin! 87 Three Must-Know Hormone-related Anticancer

Drugs Leuprolide, Tamoxifen, Flutamide


87 Side-Effects of Methotrexate

Right atrium

Breaking bones!

Ripping Brains!

What does T REX Do to people?

Wrecking Liver!

Raking lungs!

Expelling fetus!

METHOTREXATE

Tearing kidneys!

90 Hereditary anemias are … G6PD Deficiency 90 The two facultative Brucella and Listeria 91 Top Right: Title is missing for the first line Title is: Acute Lymphoblastic Leukemia 91 Leukemias by Age • The most common leukemia at age 60 or more is chronic lymphocytic leukemia

(CLL) • The most common leukemia at the age 40-60 is chronic myeloid leukemia (CML) • The most common leukemia at the age 15-40 is acute myeloblastic leukemia (AML) • The most common leukemia at the age 14 or less is acute lymphoblastic leukemia

(ALL) 92 What is most common… • Lipoma

• Odontoma • Na+ deficiency • ACL • Neck • Commonly missed carpal Fracture: Scaphoid • Infra-orbital • Lingual Nerve injury • Porphyria Cutanea Tarda • Acute Intermittent Porphyria • Congenital Erythropoietic • Thyroid Surgery

• Hurler • Hyperprolactinoma • Neuroblastoma • Meduloblastoma • Squamous Cell Carcinoma • Chlamydia trachomatis • Diabetes or Glaucoma • Q-fever • RMSF • Rhino virus • Corona virus

93 Blank: Left Lower… Homogenous 93 Right blanks • Trichinosis

• Appendix

94 Early death except… • Gaucher’s and Fabry’s 94 Autosomal recessive except… • Fabry’s (x-linked) 96 Lethal… • Pompe’s and Anderson’s


96 Most common glycogen storage.. • Von Gierke 97 Top Panel Blanks • Similar

• Equal

97 Which Arbo…highest mortality • Eastern Equine 97 Rate • Eastern (50%); St. Louis (7%); Western (3%); California (2%) 97 Control of Encephalitis epidemics from

Togavirus • Bunyaviridae, Togavirus and Flaviviridae are arboviruses • Western equine, Eastern equine, and Venezuelan encephalitis are togaviruses. All transmitted

by mosquito. • Control by mosquito control and control of disease among horses. • St. Louis encephalitis is a Flaviviridae.

87 Who Am I? • This virus is a close relative of Western and Eastern Equine Encephalitis. • In contrast to Equine encephalitis, it is only confined to human population. • In all human population but one, it causes a mild flu-like symptom. • It causes a rash that covers face and extremities and lasts for 3 days. • There is a live attenuated vaccine available for it. • Major problem with this virus is due to congenital defects that it causes--especially if

the mother contracts it within the first trimester. • It causes microencephaly, mental retardation, PDA, VSD, pulmonary stenosis and

other cardiac anomalies in the newborns. • This bug is: • R_______

99 LT: All adult…. Eisenmenger & Infantile coarctation of aorta 99 RT: The most common adult.. VSD 99 RT: The second… ASD 99 LT: The 3rd…. PDA99 21-year-old…. VSD

100 Maternal Rubella102 Which heart valve… Pulmonic 102 A 20-year-old… Eisenmenger113 Tested anticoagulants and antiplatelet Warfarin, Naproxen, Aspirin, Heparin 113 Aspirin and. … Hence, aspirin must be stopped 2-10 days before, and NSAIDs 24 hours before surgery


ABOUT GI

Triple Treatment For Helicobacter Pylori

1. Pepto-Bismol 2. Metronidazole 3. Erythromycin or Amox

STOMACH SECRETIONS

HCl: Antibacterial. Parietal Cells. Maintains pH at about 1.3 for conversion of pepsinogen to pepsin. INTRINSIC FACTOR: Parietal Cells PEPSINOGEN: Chief Cells. An inactive precursor of pepsin. MUCUS: Glycoprotein. Prevents gastric self-digestion GASTRIN: Stimulates Parietal and Chief cell’s secretions. Increase gastric and intestinal motility, and exocrine pancreas secretions.

PEPTIC ULCERS 1. Duodenal Ulcers 2. Gastric Ulcers 3. Zollinger-Ellison

Cl-

K+

Na+

K+

K+ Cl-

Cl-

pH=1-3

pH= 7.0

BLO

OD

BLO

OD

pH

=7.4

HCO3-

Stomach Stomach LumenLumen

H+

H+ + HCO3-H2CO3CO2 + H2O

H+

Cl-

CO2

Parietal Cell Acid Secretion

Duodenal Ulcers • Pyloric-duodenal junction. Peak age 40-50; Helicobacter pylori in

mucous-gel layer • CHARACTERISTICS: Elevated acid secretion rate Normal fasting

serum gastrin, with excessive response to meal. • TREATMENT: Antacids: Combination of Al-OH and Mg-OH • H2-receptor antagonists: Cimetidine; Proton-pump inhibitors:

Omeprazol; Diet and Stress management

K+

H+H2

cAMP

Ca++

CIMETIDINECIMETIDINE

PirenzepinePirenzepine

ASPIRINASPIRIN

xx

Decreases PGE2 synthesis, removes inhibition, and increases acid secretion

H2 receptor antagonist

Muscarinicantagonist

cAMP

M1

Gs

PGE2

Gi

CONTROL OF ACID SECRETION

Acetylcholinexx

HISTAMINExx

Peptic Ulcer Drugs

• Coats mucosa, Binds pepsin• Don’t use with antacids

SUCRALFATE

• PirenzepineANTIMUSCARINICS

• Salicylic poisoning• Black stool• Effective against Helicobacter pylori

BISMUTH SALICYLATE

H2 AntagonistRANITIDINE NIZATIDINE FAMOTIDINE

• Al-OH and Mg-OH; Neutralize Acid• Constipation • Inhibit absorption of tetracyclines, ketoconazole, isoniazid, and aspirin

ANTACIDS

• Inhibits H+/K+ ATPaseOMEPRAZOLEM LANSOPRAZOLE

• H2 Antagonist• Inhibit P-450

CIMETIDINE


Gastric Ulcers • CAUSES: Defective mucous-gel layer, injury to the mucosal

layer, overuse of Aspirin and NSAIDs, and H. pylori. • Peak incidence between 50-60; slightly more in men • CHARACTERISTICS: Normal or depressed HCl secretion.

High gastrin levels. • Less common than duodenal type. • Usually in the Antrum. • Treatment: • Antacids: Al-OH, Mg-OH • H2-receptor Antagonists: Less common due to less HCl • Diet and Stress management

Zollinger-Ellison • CAUSE: Gastrin secreting tumor of pancreas or duodenum. Excessive

gastrin causes excessive stomach acid secretion • Any age. Often 30-60 • CHARACTERISTICS: Elevated acid secretion. Very high gastrin level. • DIAGNOSIS: Measure gastrin level by radio-immune assay. Secretin

infusion test greatly increase serum gastrin level in ZE patients, but no effect in normal or duodenal ulcer patients.

Treatment: • H2-receptor antagonists • Proton pump inhibitors • Antimuscarinics • Surgery

DUODENAL ULCERS

GASTRIC ULCERS

ZOLLINGER

ELLISON

GASTRIN HCl

After Meal OnlyAfter Meal OnlyDepressed Depressed or Normalor Normal

HH++

Ach

Ca++

ANTIMUSCARINICSANTIMUSCARINICS•• PirenzepinePirenzepine

HH++M1uscarinic

• Drugs activate Chemoreceptors Trigger Zone (caudal aspect of 4th ventricle, outside blood barrier) and Medullary Vomiting Center. MVC coordinates vomiting; receives input from higher brain, vestibular center and upper GI.

• Neuroreceptor: Dopamine Type 2 (D2), and Serotonin Type 3 (5-HT3)

DRUG INDUCED EMESIS

Emetic Response

VOMITING CENTER

D2 5HT3

STIMULUS Cock-roach!

What are the Two main medications for gastroesophageal reflux?

• Metoclopramide: 5-HT3 and D2 antagonist. Increases ES tone. Also, antiemetic. Drug of choice for cisplatin.

• Cisapride: Stimulates ACh from myenteric plexus. Increases ES tone.

HH ++/K/K ++--ATPaseATPase

Pump Inhibitors

Pump Inhibitors

KK++

•• OmepraOmeprazolzolee•• LansopraLansoprazolzolee

“ZOL”“ZOL” drugs fordrugs for ZolZollingerlinger--Ellison Ellison Syndrome!Syndrome!

• Central anticholinergic• Helps with motion sickness emesis

SCOPOLAMINE

•D2 Dopamine AntagonistPROCHLORPERAZINE

• D2 Dopamine AntagonistMETOCLOPRAMIDE

•D2 Dopamine and H1 AntagonistPROMETHAZINE

• Selective serotonin 5-HT3 antagonist• Used prior to chemotherapy with

emetogenic drugs

ONDANSETRON &GRANISETRON

Cock-roach!ANTIEMETICS

* -SETRON for SEROTON!


A 36-year-old man with the history of burning epigastric pain that is decreased with meals and Mg-OH is being evaluated for the complaint of gynecomastia and Galactorrhea. The patient has been on a medication for his peptic ulcer within the past 8 months. Which of the following is the most likely medication? (A) Ranitidine (B) Famotidine (C) Cimetidine (D) Pirenzepine

(E) Lanzoprazole If the medication has been successful in controlling the epigastric pain of the patient. Which of the following would be an appropriate alternative for him? (A) Ranitidine (B) Al-OH (C) Cimetidine (D) Pirenzepine (E) Lanzoprazole

What is the mechanism of action of Bismuth? • Selectively binds to ulcers • Coating and protection • Also, has anti-bacterial effect against H. pylori

What is the main side effect of metoclopramide? • 5-HT3 (serotonin) antagonism: Sedation • D2 Antagonism: Extrapyramidal signs—parkinsonism.

A Zollinger-Ellison patient is receiving omeprazole. Can you also add sucralfate to his drug regimen to minimize irritation to his gastric mucosa?

• Sucralfate requires acidic pH for activation • Cannot be administered with pump inhibitors or histamine blockers!

Note: The answer to ZE question above is No!

116 Pathological Condition Vs. Neurotransmitters • Alzheimer’s, Low ACh • Depression, Low Nepi and/or Low Serotonin • Parkinson’s, Low Dopamine • Huntington, Low ACh and Low GABA • Bipolar Disorder, Low Serotonin • Schizophrenia, High Dopamine

121 Matching antagonist and appropriate receptor • Atropine (E) • Phenoxybenzamine and Phentolamine (B) • Hexamethonium (A and D) • Tubocurarine (C)

123 Beta stimulation…. Except in the Heart where it causes contraction, and kidneys, where it stimulates renin secretion (b1 effect). 123 Blank #2 . Increases blood pressure through: increased contractility and increased rennin secretion

(beta-1 effect) 130 There is no parasympathetic.. • There are cholinergic receptors on the vessels

• Systemic (injected) ACh through phosphatidyl-inositol increases intracellular Ca++ • Nitric oxide (NO) is formed • NO relaxes vessels.

. 131 In emergency Physostigmine


132 Causes of Blindness Glaucoma, diabetes & trachoma 132 ...Closed or open? Closed 133 What is? …… Pilocarpine 134 Rapid______ Miosis 134 Dilation of iris… Antimuscarinics (atropine) 134 ..What is the main advantage of.. Near vision and pupil size is not affected 136 What if pH & bicarbonate are low… Mixed metabolic and respiratory acidosis 136 What if pH & bicarbonate are high… Mixed metabolic and respiratory alkalosis 136 What measure…. Anion Gap 137 What type of acid.. Non-carbonic (e.g. lactic acid) 137 All metabolic… Hyperchloremic types 137 In respiratory acidosis… Acidity is from carbonic pool 150 HBsAg (Live virus, infection and disease); Anti-HBsAg (No active sickness, immune, cured); Anti-HBcAg –IgM(New infection); Anti-

HBcAg –IgG (Old infection); HBeAg (High infectivity); Anti-HBeAg (Low infectivity) 154 5 Must know Psychiatric Conditions Schizophrenia, Alzheimer’s, Panic Disorder, Major Depressive Disorder, and Bipolar

Disorder 155 This drug is: Caffeine 155 Anti-psychotics treat schizophrenia because Block D2 receptors 155 Schizophrenia is due to… High dopamine…problems associated with D2 function

Addendum to Psychiatric Medications • Thioridazine causes Pigmentary retinopathy • Halo is associated with severe extra-pyramidal side-effects

Genetic Movement Disorders 1. Tourette’s (Gilles de la Tourette’s) syndrome: Childhood onset; simple or

complex vocal, facial and motor tics; coprolalia (compulsive utterance of obscenities); more in males; sex-influenced autosomal dominant

2. Huntington’s Adz: Progressive dementia; choreiform movement; 3rd to 4th decade onset; autosomal dominant single defect on chromosome 4.

3. Parkinson’s Dz: 5th to 6th decade onset; No major genetic association except in twins.

4. Wilson’s Dz: Hepatolenticular degeneration; Disorder of copper metabolism; copper deposits in liver, basal ganglia, and eye; hypokinesia and progressive dementia. Autosomal recessive. Treatment= Penicillamine (Copper chelator)

Tic Douloureaux: Trigeminal neuralgia; paroxysm of pain in lips, gums, cheek or chin; Middle or old age; rarely associated with herpes. Treatment: carbamazepine &/or trigeminal surgical decompression.

Characteristic of Adrenergic Blockade • Orthostatic hypotension • Light-headedness • Failure to ejaculate

Extra pyramidal Side-Effects • Akathisia (motor restlessness); can’t seat quietly! • Parkinsonian syndrome (bradykinisia, tremor) • Dystonia (slow prolonged spasm of tongue, face and neck muscles) • Neuraleptic Malignant Syndrome

Tardive Dyskinesia: Involuntary movement of facial buccal, oral and cervical musculature (Tardive: may appear and/or persist long after withdrawal of Antipsychotic therapy)

Uses of Traditional Antipsychotics: • Bipolar Disorder & Schizophrenia (positive symptoms of schizophrenia) • Antiemesis (block dopamine receptors of chemoreceptor zone) • Intractable hiccups (Chlorpromazine) • Antipruritus (Promethazine) • Tourette’s (Haloperidol)



156 Antipsychotic side effects exaggerated with Haloperidol:

Extra-pyramidal effects

156 Similarly sounding tic besides Tourette’s Tic Douloureaux: Trigeminal neuralgia 156 Low potency Antipsychotics: Top 3 Characteristics

Of Adrenergic Blockade: (1) Orthostatic hypotension; (2) Light-headedness; (3) Failure to ejaculate

156 Chlorpromazine and Thioridazine are low potency…because of low affinity for

D2 receptors

156 Galactorrhea & Antipsychotics • Inhibition of pituitary dopamine removes inhibition on prolactin release • Prolactin Inhibitory Factor

156 4 (non-anticancer) causes of agranulocytosis Clozapine, Carbamazepine, Cholchicine, Chloramphenicol 156 Another must know (non-anticancer) causes of

agranulocytosis Phenylbutazone

158 Treatment of bed-wetting Imipramine 158 Children Cardiac Arrest Desipramine 158 Least Sedative TCA Desipramine 158 Causes aggressive behavior Clomipramine 158 Causes painful erection Trazodone 158 Fatal if prescribed with the other two

antidepressants MAOI’s

158 Antidepressant Associated with Insomnia

SSRI’s

158 Widely Used antidepressant Fluoxetine 158 Common overdose side-effect Anticholinergic 158 TCA Antidote Physostigmine 158 Life-threatening side-effect of

neuraleptics • Neuraleptic Malignant Syndrome • Drug of choice: Dantrolene and bromocriptine

158 Number One Choice for panic attack Alprazolam 158 Number One Choice for alcohol

withdrawal and status epilepticus Diazepam

158 Benzodiazepines mostly used for insomnia

Intermediate acting: Lorazepam and Temazepam

158 Earliest sign of phenobarbital……… Nystagmus & Ataxia 158 Exacerbates porphyric symptoms Barbiturates 159 Benzodiazepines antidote Flumazenil159 Barbiturates Duration of Action TAP!

Thiopental (extra-short) Amobarbital and pentobarbital (Short) Phenobarbital (Long)

159 Drugs that Induce P450 Phenytoin, Carbamazepine, Rifampin & Quinidine

159 Anticonvulsant answer key 1.Absence (B); 2.Simple partial (A); 3.Myoclonic (C); 4.Complex partial (E); 5.Tonic-Clonic (D); 6.Atonic (G) 7.Tonic (F); 8.Grand-mal (D); 9.Petit mal (B)

161 Drugs Causing Gingival hyperplasia Phenytoin, Nifedipine, Cyclosporine (immune suppressant) 161 Used for tonic-clonic & absence

seizures Valproic acid Don’t administer in pregnancy

161 Top drugs causing hepatic necrosis Acetaminophen, Halothane, Valproic acid 161 Drugs Causing Aplastic anemia Carbamazepine, phenylbutazone, Chloramphenicol 161 Who am I? This Febrile condition…. Steven-Johnson 161 Drugs causing Steven Johnson

Syndrome Sulfonamide & Penicillin

161 Infection Causing Steven Johnson Mycoplasma pneumoniae 161 Drugs causing lupus Phenytoin, Hydralazine, Isoniazid, Procainamide 161 Who Am I: Drug in prophylaxis of

manic depression… Lithium

162 Antiviral & Anti-Parkinson’s Amantidine 162 Causes of Drug induced Parkinson’s Haloperidol & Chlorpromazine

SHORT ACTING BENZODIAZEPINES

• Average= 5-hr duration

• Triazolam, Oxazepam, Midazolam, & Clonazepam

TOM Thumb Clones!TOM is Thumb size!

TOMTOM & his CLONE are short! & his CLONE are short!

Six Commonly tested facts about Psychiatric Drugs

Thioridazine causes iridopathy and pigmentary retinopathy.

Thioridazine

Induce porphyric attacksBarbituratesTreated with Dantrolene (an skeletal muscle relaxant)

Neuroleptic Malignant Syndrome

Treats Parkinson’s and hyperprolactinoma

Bromocriptine

Causes tardive dyskinesia & Neuroleptic Malignant Syndrome

Chlorpromazine

Causes agranulocytosis & seizuresClozapine

About HIV Virus • RNA virus. Reverse transcriptase. • The only diploid virus. It has surface proteins--gp120 and gp41 envelops, plus a core p24 protein. • gp120 binds to CD4 and initiates infection • HIV infects helper T-cells, CD4+ cells such as macrophages and monocytes • Helper T less than 200/mm3 • 2-4 weeks post infection a mono-like syndrome appears • Drugs: Zidovudine (Azidothymidine) [AZT] a thymidine analog • HIV Tests: ELISA and PCR detect coding for p24 GAG. \

SEROTONIN (5-HT) RECEPTORS

• Ondansetron & Granisetron• Selective serotonin 5HT3

antagonist• Central acting antiemetics• Used prior to chemotherapy

with emetogenic drugs

EmesisSerotonin Type 3(5-HT3)

• Risperidone, Olanzapine &Clozapine block 5HT2 and cause antipsychosis

PsychosisSerotonin Type 2(5-HT2)

•Sumatriptan (migraine drug) activates 5HT1 (agonist) and vasoconstricts

VasoconstrictionSerotonin Type 1(5-HT1)

NOTESFUNCTIONRECEPTOR

5 = S = Serotonin!-setron for Serotonin!


MEMBRANE PHOSPHOLIPID

Phospholipase A2

Lipoxygenase Cyclooxygenase

Thromboxanes• Increase

Bronchial Tone

• Decrease vascular & bronchial tone

• Increase Uterine Tone

Prostaglandins

Leukotrienes

ARACHIDONIC ACID

Corticosteroids

NSAIDS

• PGI2• Decrease Platelet

aggregation• Decrease vascular,

uterine, & bronchial tone

• Increase Platelet aggregation

• Increase vascular, & bronchial tone

Prostacyclin

ANALGESICS/ANTIPYRETICS (Non-opiate)

• Ibuprofen, Naproxen, Ketoprofen• Analgesic, anti-pyretic and anti-inflammatory• Lower toxicity than above two

Phenylpropionic Acid

• Absorption orally; • Elimination renally via glucurination• Analgesic and antipyretic; Inhibit PG synthesis in the CNS• Hepatotoxicity (necrosis); Antidote: N-acetylcysteine • No anti-inflammatory action. Less effect on peripheral COX• No or less bleeding

Acetaminophen(and Phenacetin)

• Absorption via stomach and Duodenum• Elimination by conjugation via renal• Antipyretic effect • Non-selective inhibition of COX 1 and 2 enzymes (by

acetylation); hence decreasing PG production. Inhibition is irreversible—new COX’s synthesis needed to recover effects.

• Decreases TXA-2; Decreases aggregation• Side-effects: Acidosis, Uricosemia, Keratolysis, gastric

bleeding• Toxicity: Hypersensitivity; tinnitus, Ryes (in children with influenza)

Salicylates


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