NBI 100 Supplement and Answer Key
P.O. Box 22174, Lansing, Michigan 48909 www.northwesternmedicalreview.com
Supplement: NBI 100, Northwestern Medical Review, 2003 1
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
Supplement: NBI 100, Northwestern Medical Review, 2003 2
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)
Supplement: NBI 100, Northwestern Medical Review, 2003 3
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]
Supplement: NBI 100, Northwestern Medical Review, 2003 4
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
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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
Supplement: NBI 100, Northwestern Medical Review, 2003 6
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.
Supplement: NBI 100, Northwestern Medical Review, 2003 7
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
Supplement: NBI 100, Northwestern Medical Review, 2003 8
Supplement: NBI 100, Northwestern Medical Review, 2003 9
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
Supplement: NBI 100, Northwestern Medical Review, 2003 10
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
Supplement: NBI 100, Northwestern Medical Review, 2003 11
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
Supplement: NBI 100, Northwestern Medical Review, 2003 12
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
Supplement: NBI 100, Northwestern Medical Review, 2003 13
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
Supplement: NBI 100, Northwestern Medical Review, 2003 14
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!
Supplement: NBI 100, Northwestern Medical Review, 2003 15
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
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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)
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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!
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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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