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Preventive strategies for primary preventionAntihypertensive treatment: Lowering blood pressure in hypertensives reduces the relative risk (RR) of stroke - both ischemic and hemorrhagic - by 42%. In elderly patients with isolated systolic hypertension, the RR reduction is 30%. There is a therapeutic effectiveness-outcome relationship; the greater the reduction in blood pressure, the greater the risk reduction. All classes of antihypertensives are effective in this respect.

Treatment of hyperlipidemia: Statin therapy is associated with a RR reduction of stroke of 25%. Other lipid-lowering therapies - resins, fibrates, and diet - have not been shown to be effective in reducing the risk of stroke.

Antithrombotic therapy in atrial fibrillation: The risk of stroke in patients with non-rheumatic atrial fibrillation - paroxysmal or chronic - is about 5% per year. Warfarin is the most efficacious agent in preventing stroke; the associated slight risk of hemorrhage can be greatly reduced in almost every case by careful dosing and lab controls.

Antiplatelet therapy after myocardial infarction: Aspirin lowers the RR of stroke in post-MI subjects by 36%.

Treatment of diabetes: One small study has shown a 44% reduction in the RR of stroke in diabetics who had their blood pressure tightly controlled. Otherwise, level 1 or 2 evidence is lacking for possible valuable effects of tight blood sugar control in diabetics on the risk of stroke. The proven useful effects on microvascular renal disease suggest that such a benefit must exist, though the appropriate studies have not yet been reported.

Stopping smoking, antiplatelet therapy with aspirin, ACE inhibitors: The evidence for these measures is inadequate to be able state unequivocally that prevent stroke (except for the antihypertensive action of ACE inhibitors).

Carotid endarterectomy: In asymptomatic patients with over 50% stenosis, the risk of stroke or death in the immediate peri-operative period was quadrupled, but there was a 30% reduction in the RR of death or stroke in the next 3 years. Obviously more trials need to be done to identify those best suited for this type of intervention.

Strategies for secondary stroke prevention

Around 7% of all patients with a stroke or TIA will have a recurrence every year. Secondary prevention is therefore likely to be much more cost-effective than primary prevention attempts - the RR reductions for each measure remain largely the same, but the absolute RR reductions are clearly much higher. Thus the number needed to treat (NNT) to prevent one stroke a year is in the 1000's for primary prevention measures, and in the 100's for secondary prevention.

The RR reductions for effective antihypertensive treatment in preventing another stroke or TIA is 28%, for statin therapy it's 25%, for adjusted-dose warfarin in atrial fibrillation patients it's 62%, for aspirin it's 28%, and for thienopyridines (clopidrogel or ticlopidine) there is a 13% advantage over and above aspirin. Unlike primary prevention, stopping smoking as a secondary prevention measure carries a RR reduction of 33%. The results for carotid endarterectomy are rather variable from one study to the next, depending on the skill and experience of the surgery team, the age and sex of the patient, systolic blood pressure, and peripheral vascular disease

Primary prevention guidelines

For patients with no known heart or blood vessel disease: Follow the AHA's "Guide to Primary Prevention of Cardiovascular Diseases." Here is a brief summary:

Smoking cessation and smoke avoidance
Ask about smoking status and exposure to second hand smoke. Reinforce patients who are nonsmokers. Strongly encourage smokers and their families to stop smoking and to avoid other people's tobacco smoke. Provide counseling, nicotine replacement or adjunctive therapy and formal cessation programs as appropriate.

Blood pressure control
Measure blood pressure in all adults every routine visit. Promote lifestyle modification – weight control, physical activity, moderation of alcohol consumption, and dietary sodium reduction. If blood pressure is 140/90 mm Hg or greater after lifestyle modification, consider adding blood pressure medication. In patients with hypertension and diabetes or renal disease, the blood pressure goal is less than 130/80 mm Hg.

Cholesterol management
Ask about dietary habits in routine exams. Measure fasting lipoproteins including LDL and HDL cholesterol and triglycerides in all adults 20 years and older and assess risk factors at least every five years. More frequent measurements are required for persons with multiple risk factors.

The primary treatment goal is LDL-C less than 160 mg/dL if the patient has no more than one risk factor, or LDL-C less than 130 mg/dL if the person has two or more risk factors, but an LDL-C goal <100 mg/dL is a therapeutic option on the basis of recent trial evidence. For very high risk patients, treatment goal is LDL-C less than 100 mg/dL with a therapeutic option of <70 mg/dL. Secondary goals for the general population are HDL-C more than 40 mg/dL and triglycerides less than 150 mg/dL. HDL-C more than 50 mg/dL is more appropriate for women.

In patients whose LDL-C exceeds these goals, start the Therapeutic Lifestyle Changes (TLC) diet -- less than 30 percent of calories as fat, less than 7 percent of calories as saturated fat, and less than 200 mg of dietary cholesterol -- as well as weight control. Consider adding drug therapy in patients with high LDL-C levels that persist despite the TLC.

Physical activity
Ask about exercise habits in routine exams. Encourage at least 30 minutes of moderate-intensity activity on most days of the week (brisk walking, jogging, cycling or other aerobic activity) as well as increased daily lifestyle activities for inactive persons. Regular physical activity improves conditioning and promotes optimum fitness. Advise medically supervised programs for those with low functional capacity and/or other health problems.

Weight management
Measure your patients' weight and height, body mass index (BMI), and waist circumference as part of routine exams. The goal is to achieve and maintain desirable weight, defined as a BMI range of 18.5-24.9 kg/m2 (BMI of 25 kg/m2 corresponds to 110 percent of desirable body weight). A desirable waist circumference for men is no more than 102 cm or 40 inches and for women is no more than 88 cm or 35 inches. Start weight management and physical activity as appropriate.

 

 

 

 

 

 

 

 

Botulism - Food poisoning usually caused by ingesting the neurotoxin produced by the bacterium Clostridium botulinum; characterized by paralysis; can be fatal

  • Blepharospasm - Involuntary spasmodic contraction of certain eye muscles
  • Cervical dystonia - Dystonia of the neck area
  • Dystonia - State of abnormal tension in any of the tissues resulting in the impairment of a person's voluntary movement
  • Neurotoxin - Any toxin that acts specifically on nervous tissue
  • Strabismus - A manifest lack of parallelism of the visual axes of the eyes (crossed eyes)

 Botox® (botulinum toxin type A) is successfully used to treat blepharospasm, strabismus, and cervical dystonia -- these are all conditions that in some way involve spasms, involuntary muscle contractions

Apgar rate:

Heart rate
0 - No heart rate
1 - Fewer than 100 beats per minute — The baby is not very responsive
2 - More than 100 beats per minute — The baby is obviously vigorous


Respiration
0 - Not breathing
1 - Weak cry; may sound like wimpering or grunting
2 - Good, strong cry


Muscle tone
0 - Limp
1 - Some flexing (bending) of arms and legs
2 - Active motion


Reflex response
0 - No response to airways being suctioned
1 - Grimace during suctioning
2 - Grimace and cough or sneeze during suctioning


Color
0 - The baby's whole body is completely blue or pale
1 - Good color in body with blue hands or feet
2 - Completely pink or good color

 

The seven warning signs of Alzheimer's disease are:

1. Asking the same question over and over again.

2. Repeating the same story, word for word, again and again.

3. Forgetting how to cook, or how to make repairs, or how to play cards — activities that were previously done with ease and regularity.

4. Losing one's ability to pay bills or balance one's checkbook.

5. Getting lost in familiar surroundings, or misplacing household objects.

6. Neglecting to bathe, or wearing the same clothes over and over again, while insisting that they have taken a bath or that their clothes are still clean.

7. Relying on someone else, such as a spouse, to make decisions or answer questions they previously would have handled themselves

SJOGREN'S SYNDROME (Mikulicz's disease, "autoimmune exocrinopathy", "autoimmune epithelitis", etc. Review Br. J. Rheum. 35: 204, 1996.

A common, usually mild illness characterized by autoimmune damage to the salivary and lacrimal glands, plus arthritis.

Sometimes the vulvar and other glands are affected, and occasionally the renal tubules are ruined.

Most patients are middle-aged women. Sjogren's affects perhaps 2 million people in the US.

The terminology is a little loose. This seems to be the common usage:

* "Mikulicz's syndrome" is large salivary and lacrimal glands infiltrated with lymphocytes, from any cause (Sjogren's, sarcoid, leukemia, lymphoma, AIDS, GVH-disease). Any of these diseases can cause dryness, and so can many common drugs, notably antihistamines, antipsychotic drugs, and antidepressants. "Sicca syndrome" is unexplained dry eyes ("keratoconjunctivitis sicca") and dry mouth ("xerostomia") together.

* "Mikulicz's disease" or "autoimmune exocrinopathy" (neither in common use now) describe "sicca syndrome" due to autoimmune destruction. "Primary Sjogren's syndrome" is autoimmune exocrinopathy by itself, or with mild arthritis. Biopsy of a minor salivary gland (usually from normal-appearing lower lip) is now required for research subjects.

"Secondary Sjogren's syndrome" is diagnosed when there is associated autoimmune disease: "Sjogren's with lupus", "Sjogren's with scleroderma", "Sjogren's with polymyositis", or "Sjogren's with rheumatoid arthritis". Very common -- perhaps a majority of these patients have it: Ann. Rheum. Dis. 46: 286, 1987.

* "The benign lymphoepithelial lesion" is an anatomic pathologist's description of the glandular enlargement due to Sjogren's; it may present as a mass.

Paroxysmal nocturnal hemoglobinuria

The distinct and rather peculiar characteristics of paroxysmal nocturnal hemoglobinuria (PNH) have puzzled hematologists for more than a century. PNH is characterized by a decreased number of red blood cells (anemia), and the presence of blood in the urine (hemoglobinuria) and plasma (hemoglobinemia), which is evident after sleeping. PNH is associated with a high risk of major thrombotic events, most commonly thrombosis of large intra-abdominal veins. Most patients who die of their disease die of thrombosis.

PNH blood cells are deficient in an enzyme known as PIG-A, which is required for the biosynthesis of cellular anchors. Proteins that are partly on the outside of cells are often attached to the cell membrane by a glycosylphosphatidylinositol (GPI) anchor, and PIG-A is required for the synthesis of a key anchor component. If PIG-A is defective, surface proteins that protect the cell from destructive components in the blood (complement) are not anchored and therefore absent, so the blood cells are broken down.

The PIG-A gene is found on the X chromosome. Although not an inherited disease, PNH is a genetic disorder, known as an acquired genetic disorder. The affected blood cell clone passes the altered PIG-A to all its descendants ---red cells, leukocytes (including lymphocytes), and platelets. The proportion of abnormal red blood cells in the blood determines the severity of the disease

 

MYDRIASIS

topical mydriatics, eg. atropine, homatropine, tropicamide, cyclopentolate

sympathomimetic drugs,eg. amphetamines

anti-cholinergic drugs, eg. tricyclic antidepressants

3rd nerve lesion (pupil may not be dilated with an incomplete lesion)

Holmes-Aide syndrome ['myotonic pupil'; dilated pupil responding sluggishly to light; absent tendon reflexes]

phaeochromocytoma

retrobulbar neuritis / optic atrophy

congenital

IN UNCONSCIOUS PATIENT:
  • temporal lobe herniation due to raised ICP (3rd nerve palsy)
  • intra-cranial bleeding, tumour or abscess (3rd nerve palsy)
  • tricyclic anti-depressant overdose
  • cocaine
  • ecstasy and other amphetamines

Parameters measured be evaluation of the supernatant: specific gravity, pH, glucose,ketones, bilirubin, nitrites, leukocyte esterase, and protein

A. Specific gravity

1. Used as an index of urine concentration

2. Specific gravity is a comparison between the mass of a certain volume of

supernatant and the mass of an equal volume of distilled water

3. Specific gravity is used as an indicator of urine osmolality to evaluate how

concentrated the urine is, i.e., it tells us what the kidney is doing with water and

solutes.

4. There is a direct correlation between specific gravity and urine osmolality

a. Maximally dilute urine has a specific gravity = 1.002, which correlates with an

osmolality = 50-100 mosmol/kg

b. Maximally concentrated urine has a specific gravity = 1.030-1.040, which

correlates with an osmolality = 1000-1200 mosmol/kg

c. Urine which is isotonic to plasma (isosthenuric) has specific gravity = 1.010

which correlates to an osmolality = 300 mosmol/kg

i. Isosthenia indicates renal tubular damage,so this is a good number to

remember: specific gravity = 1.010 when tubular damage has occurred.

ii. If the renal tubules are damaged, they cannot concentrate nor dilute the

urine so the urine remains isotonic to the plasma

Ham's test Also known as:
Ham-Dacie acidified serum test
Ham-Dacie test

Synonyms:
Acid serum test, acified serum test.
The definitive test for diagnosing paroxysmal nocturnal heamoglobinuria (PNH). The red cells are tested for resistance to lysis during incubation with acidified fresh serum. Lowering of pH results in complement lysis of red cells with the PNH defect.

See also Crosby's test, under William Holmes Crosby, American physician, born 1914.

 

Anticholinergic Toxicity
Anticholinergic Poisoning
Anticholinergic Symptoms

  1. Causes
    1. Anticholinergic Medications
    2. Antihistamines
    3. Tricyclic Antidepressants
    4. Incapacitating Agents: BZ
    5. Ingested items
    6. Jimsonweed
    7. Amanita muscaria mushrooms
      1. Parasympatholytic medications
        1. Atropine
        2. Scopolamine
        3. Hyoscyamine

  2. Symptoms: Mnemonic (antimuscarinic)
    1. Hot as a hare (Hyperthermia)
    2. Dry as a bone (Dry Skin)
    3. Red as a beet (Flushed)
    4. Blind as bat (Mydriasis)
    5. Mad as a hatter (Delirium)

  3. Symptoms: Complete List (antimuscarinic)
    1. Altered Level of Consciousness
      1. Hallucinations
      2. Delirium
      3. Coma
    2. Seizures
    3. Tachycardia
    4. Hypertension
    5. Hyperthermia (hot, Dry Skin)
    6. Dry Mouth
    7. Mydriasiswith blurred vision
    8. Decreased bowel sounds
    9. Constipation
    10. Urinary retention

    1. Control hyperthermia
    2. Antidote: Physostigmine (Usually contraindicated

     

Management

 

Protein in the urine

1. Suggests that something might be wrong at the glomerular level

2. Normal urine has< 150 mg/day of protein

a. Most of the normal protein in the urine is Tamm-Horsfall mucoprotein, which

is produced by the thick ascending limb of the loop of Henle; its function is

unknown and it is often found as a component of casts.

b. Low molecular weight proteins (LMWPs) are normally found in the urine

c. Only micro amounts (<20mg/dL) of albumin are normally found in the

urine

3. To determine protein concentration in the urine:

a. Measure the amount of protein excreted over a 24 hour period

i. =3-3.5 g/day is the nephrotic range

ii. The nephrotic range is the amount of protein loss that is usually required to

give the nephrotic symptoms of edema and hypoalbuminemia

b. Determine the ratio of urine protein concentration to urine creatine

concentration

i. This is a simpler way to estimate total protein excretion per day

ii. The lab measures both protein and creatinine in mg/dL

iii. The advantage is that you don't have to do a timed urine collection

iv. Closely parallels the g/day measurement of protein in a 24-hour urine

sample

v. A ratio of 5 means that the urine protein concentration is about 5 g/day

 

  • Healthy heart:
    • Total volume is 100 mL.
    • 60 mL of blood are pumped to the aorta.
    • Ejection fraction is 60%.
  • Heart with enlarged left ventricle:
    • Total volume is 140 mL.
    • 60 mL of blood are pumped to the aorta.
    • Ejection fraction is 43%.

    The left ventricle pumps only a fraction of the blood it contains. The ejection fraction is the amount of blood pumped divided by the amount of blood the ventricle contains. A normal ejection fraction is more than 55% of the blood volume. If the heart becomes enlarged, even if the amount of blood being pumped by the left ventricle remains the same, the relative fraction of blood being ejected decreases.

    •  
    10. MC side effect of cancer chemotherapy is vomiting.
    51effect of alcohol excess on the anion gap (AG) increases the AG [This is due to an increase in the production of lactate (see above) and l3-hydroxybutyrate (13-*HB). Acetyl CoA, the end-product of alcohol metabolism, is in- creased in the blood and is converted in the liver into ketone bodies (AcAc and 13-*HB). Excess amounts of NADH (see above) favor the conversion of AcAc into 13-*HB. *wing to the increase in lactate and 13-*HB anions, there is an increased AG metabolic acidosis in alcoholics. See Table 6-2.]
    52 effect of alcohol on uric acid levels hyperuricemia [The increase in lactate and 13- *HB anions leads to hyperuricemia, since all acids compete for secretion in the same loca- tion in the proximal renal tubules. Hyperuri- cemia may precipitate acute gouty arthritis.]
    53 effect of alcohol on TG levels hypertriglyceridemia [The metabolic products of alcohol (NADH, acetate, acetyl CoA) are used by the liver to synthesize TG. The TG is packaged into VLDL (cause of a fatty liver) and released into the blood (type IV hyperli- poproteinemia).]
    54 effect of cigarette smoking on ABGs . chronic respiratory acidosis, . hypoxemia; an increase in Paco2 always causes a decrease in Pao2' . increase in the A-a gradient: refers to the oxygen gradient between the alveoli and arterial blood [Smoking also increases C* levels in the blood. See Table 6-2.]
    55 effect of cigarette smoking on the WBC and REC count increases total neutrophil and RBG count [The neutrophil count is increased owing to the release of catecholamines, which interfere with the synthesis of adhesion molecules. This causes the marginating pool (normally 5*% of the peripheral blood neutrophils) to enter the circulating pool of neutrophils. RECs increase owing to a hypoxemic stimu- lus for erythropoietin release, which pro- duces a secondary polycythemia.]
    56 effect of volume depletion on serum BUN and albumin, Hb and Hct, and urine specific gravity . serum BUN, Hb, Hct, and albumin are all increased: due to hemoconcentration of blood from a reduction in plasma volume, . urine specific gravity is increased: ADH is released in response to volume depletion, leading to the reabsorption of free water in the collect- ing tubule and concentration of urine
    57 cause of an FP syphilis serology presence of anti-cardiolipin antibodies [The test antigen in the RPR and VDRL is beef cardiolipin to which non-treponemal anti- bodies normally react in the test. Anti-cardio- lipin antibodies in patients with SLE and other disorders cross-react with the cardio- lipin in the test system, leading to an FP syphilis serology. The FTA-ABS is negative, since it measures specific treponemal anti- bodies.]
    58 cause of neutropenia in African Americans normal increase in the marginating neutro- phil pool [Normally, the circulating and mar-ginating (adherent to the endothelium) pool of neutrophils is equally distributed. An in- crease in the marginating pool in African Americans is a normal variation and does not hinder neutrophil response to infection.]
    59 lab test alterations in children that differ from those in adults
    increased serum alkaline phosphatase: 3-5 times higher in children than in adults and due to increased osteoblast activity from ac- tive bone growth, . increased serum phos- phate: phosphate is the driving force for de- positing calcium in bone, . lower Hb: 11-12 g/dL
    60 ab test results in women that significantly differ from those in men lower serum levels: * serum iron, * percent transferrin saturation, * ferritin [The above differences are secondary to menses (- 3 5-4* mL of blood loss per period), lower serum mL of blood loss per period), lower serum
    61 lab test alterations in pregnancy that differ from those in non-pregnant women . two times greater increase in plasma volume than RBG mass: this results in * decrease in Hb and Hct-dilutional effect, * increase in creatinine clearance-increased plasma vol- ume, * low serum BUN-increased urine clearance, * low serum uric acid-increased urine clearance, * low serum creatinine- increased urine clearance, . increased serum alkaline phosphatase: * placental origin, * heat stable, . respiratory alkalosis: progester- one overstimulates the central respiratory center, . increased total T4 and cortisol: estro- gen increases synthesis of their binding pro- teins without altering the free hormone lev- els, . mild glucose intolerance: anti-insulin effect of hPL, . glucosuria: * lower renal threshold for glucose, * normal blood glucose
    62 lab test alterations in the elderly decreased creatinine clearance: due to a * decrease in the GFR, * decrease in renal excretion of drugs (potential for nephrotoxic- ity), * decreased ability to concentrate urine, . lower Hb concentration in men: * drop in testosterone reduces erythropoiesis, * elderly men and women have the same Hb concentra- tion, . increase in serum autoantibodies: de- crease in CD8. T suppressor cells allows CD4 T helper cells to stimulate antibody produc- tion, . decreased response to skin testing with common antigens: * diminished DRH re- sponse, * cellular immunity slightly im- paired, . slight elevation in serum glucose: due to down-regulation of insulin receptors as adipose increases, . "obstructive" type of PFTs: * lower Paoz, * increased TLC and RV, * lower VC, TV, and FEVlsec, . slight increase in serum alkaline phosphatase: due to osteo- phyte formation in osteoarthritis
    1. Clonidin - reduces withdrawal symptoms of smoking
    2. Plasma homocysteine - independent factor for CAD (Coronary artery disease).
    3. Aspirin - useful for primary and secondary prevention of acute MI & stroke.
    4. CAGE screening test for alcohol abuse.
    5. Doc for mild to moderate pain is Aspirin.
    6. Brufen increases the serum lithium levels.
    7. Tramadol - has beoth opoid and non opoid effects.
    8. Side effect of Codeine - constipation
    9. A test with high specificity is useful to confirm a diagnosis.
    10. a) Immunisation - primary prevention b) Cervical pap smear - secondary prevention c) Partial mastectomy or radiation therapy for localized ca breast - tertiary prevention
    11. Best means of preventing many infectious disease immunization.
    12. Rx of hyper homocysteinemia - folate and B6 vitamins.
    13. Systolic blood pressure better predictor of morbidity than diastolic BP.
    14. Drug used for chemoprophylaxis of ca breast is tamoxifen.
    15. The most important preventable cause of cancer smoking.
    16. Aspirin and other NSAIDS reduce the risk of colon cancer.[2]
    17. AUDIT (Alcohol Use Disorder identification Test).
    18. Action of NSAIDS cyclo oxygenase I inhibitors.
    19. NSAIDS with cyclo oxygenase 2 inhibitor action - celecoxib (celebrex) and roxecoxib
    20. Acetamiophen is not a NSAID because it lacks peripheral anti inflammatory effects
    21. Misoprostol, synthetic PGL E1 analogae used in Rx of peptic ulcer.
    22. Opioids: a) Full opioid agonists - Morphince, codeine, methadone and fentanyl b) Partial agonist - Buprenorphine c) Mixed agonist and antagonist - Pentazocine, butorphenol, nalbuphine d) Rx of opioid addiction methadone e) Opioid with powerful cough suppressant action codeine f) Opioid in toxic doses predisposes to seizure meperidine g) Tramadol atypical analgesic with tricyclic antidepressant action h) Tramadol should not be given with MAO l i) DOC for breakthrough pain in chronic pain syndrome fentanyl lozenges j) Rx of adverse effects of opioid is naloxone
    23. Antiepileptics used for chronic neuropathic pain and post herpetic neuralgia gabapentine, carbamazepine and phenytoin
    24. Normal rectal (or) vaginal temperature 0.50 C higher than and normal axillary temperature 0.50 C lower than oral temperature.
    25. Rectal temperature more reliable than oral temperature
    26. Normal diurnal temperature variation 10 C
    27. a) Body temperature in IL 1 induced fever seldom exceeds 41.10 C b) In hyperthermia due to heart stroke temperature exceeds 41.10 C with no diurnal variation
    28. High temperature during 1st trimester of pregnancy may cause anencephaly
    29. Temperature over 410 C is a medical emergency
    [3]
    1. Post operatively
    • Epinephrine and nor epinephrine levels elevated for 1 - 2 days
    • Serum cortisol levels elevated for 1 - 3 days
    • Serum ADH levels elevated for 1 week
    2. Preoperative ECG is must for
    • Men over 40 years age
    • women over 50 years age
    3. Canadian cardiovascular society (CCS) angina class - used to assess the severity of anginal symptoms
    4. Non invasive testing for myocardial ischaemia
    • Exercise treadmill testing
    • Dipyridamole thallium scintigraphy
    • Dobutaminie stress echo cardiography
    5. Clinical criteria associated with cardiac complications in patients undergoing vascular surgery
    • H/O MI
    • Q waves in ECG
    • H/O angina
    • H/O ventricular arrhythmias
    • Diabetes mellitus
    6. Incidence of perioperative myocardial infarction reduced by prophylactic betablockers in immediate preoperative period.
    7. Surgery is to be delayed for 3-6 months for patient with a recent M.I.
    8. Hb level below or 9g/dl is associated with significant more perioperative complication.
    9. Hb levels below 10 g/dl in IHD patient associated with increased perioperative mortality rate.
    [4]
    10. Hyperglycemia in diabetic patients during surgery due to
    • Insulin resistance
    • Increased secretion of cortisol, epinephrine, glucagon and growth hormone.
    11. Ideal blood glucose level during surgery is between 100-250mg/dl.
    12. Indications for intraoperative insulin
    • Type I DM
    • Type II DM on insulin
    • Type II DM on oral agents undergoing major surgical procedures.
    13. Methods of administration of intraoperative insulin
    • Subcutaneous insulin (most often used)
    • Continuous IV infusion in 5-10% dextrose
    • Separate IV insulin and dextrose infusions
    [5]
    1. Watson and Crick base pairing of nucleic acids in DNA
    Purines - Adenine and Guanine
    Pyramidines- cytosine and thymine
    Adenine pairs with thymine
    Guanine pairs with cytosine
    (in RNA, thymine is replaced by uracil)
    2. Unwindins of DNA is by Helicase enzyme defects in genes encoding helicase Eg. Werner's syndromes.
    3. DNA
    1. Noncoding regions introns
    2. Coding regions Exons
    4. Transcription-Syntheses of RNA and DNA
    1. Enzyme involved-RNA polymerase II
    2. Translation-Syntheses of proteins form mRNA
    5. Initiating codons AUG, GUG, - code for methionine.
    1. Stop codons/nonsense codons - UAA, UAG, UGA.
    6. DNA replication occurs by semiconservative method.
    7. Stability of chromosomes conferred by Telomeres, (the ends of chromosomes).
    8. Peroxisomal diseases Eg.
    1. 1. Zellweger's syndrome
    2. Rhizomelic dwarfism
    9. Programmed cell death is called apoptosis.
    10. Eosinophil specific chemotaxins - IL - 5, chemokines Rantes and Eotoxin.
    11. Eosinophil peroxidase (EPO) and major basic protein (MBP) are specific to eosinophils.
    [6]
    12. IL - 8 is chemotactic specifically for neutrophils.
    13. Tertiary lymphoid organs present in skin, mucosa of pulmonary, genitourinary and gastrointestinal tracts.
    [7]
    1. Geriatric unit-
    1. Acute confusion
    2. Urinary incontinence
    3. Immobility
    4. falls
    2. Biswanger's disedase - Dementia in elders due to subcortical arteriosclerotic encephalopathy.
    3. Earliest manifestation of dementia is forgetfulness.
    4. Homeostenosis - human aging
    5. Diagnostic "Law of parsimony" often does not apply in geriatric medicine.
    6. Frontal release sings (snout, glabellal (or) palmomental reflexes) and absent ankle jerk and vibratory sense in elderly normally.
    7. Modified Hachinski ischaemic score making clinical diagnosis of vascular dementia.
    8. Acetyl cholinesterase inhibitors used in Rx of early stages of alzheimer's disease donepezil and tacrine.
    9. Vitamin used in Rx of alzheimer's disease high dose vitamin E.
    10. MC cause of stiffness in the elderly in osteoarthritis
    11. Transient causes of geriatric incontinence "DIAPERS"
    • D - Deleriums
    • I - Infection
    • A - Atrophic urethritis/vaginitis
    • P - Pharmaceuticals and psychological
    • E - Excess urine output
    • R - Restricted mobility
    • S - Stool impaction
    [8]
    12. MC cause of established geriatric incontinence in detrusor over activity.
    13. Second MC cause of established incontinence in
    • Older women is stress incontinence (rare in men)
    • Older men is urethral obstruction
    14. Least common cause of incontinence is detrusor over activity.
    15. Post voiding residual (PVR) volume > 450ml detrusor underactivity.
    16. The corner stone of Rx of detrusor over activity incontinence is behavioral therapy.
    17. Rx of choice for stress incontinence in surgery.
    18. NSAID with highest risk of causing confusion and GI bleeding is indomethacin.
    19. First choice of antihypertensive in older people is low dose thiazides.
    20. DOC for isolated systolic hypertension in older patients is nitrendipine.
    [9] 76
    1. Macrophages -
    • Lungs - alveolar macrophages
    • Liver - Kupffer cells
    • Lymph - circulating macrophages
    • Brain - microglial cells
    • Kidney - mesangial cells
    2. Natural killer cells - Antibody dependent cell mediated cytotoxicity.
    3. Immunoglobulin -
    • IgG - crosses placenta
    • IM - primary Response
    • Jchain - igM and igA
    • ID - excessively found on surface of immature B cells.
    4. Cytokines -
    • IL - 1AND TNF - alpha secreted by activated macrophages
    • IL2, 3,4,5,6 and IFN - r - by activated T cells.
    • IL - 4 - by Mast cells
    • IL - 8 is Neutrophilic chemotactic agent
    5. Autoimmunity Theories
    1. Aberrant immunity eg. IDDM [by virus]
    2. Antigen recognition
    • - eg. sequestrated Ag - sperms -
    • sharing of Ag - Rhematic fever -
    • Auto Ab development - drugs - m- dopa.
    6. IgM deficiency - susceptible to blood born infections
    • Eg. Meningococi.
    • IgA deficiency - GIT and RT infection common
    • IgA deficiency caused by phenytoin and penicillamine.
    7. Quinke's disease/Angioedema - C1 inhibition deficiency Rx - Danazol or EACA
    [10]
    8. T ½ of injected gamma globulins - 4 weeks.
    9. Cyclosporin A - direct suppressive effect of B and T helper cells.
    10. BRCA 1 gene associated with Ca. Breast and ovaries, BRCA 2 gene associated with Ca. Male Breast.
    11. Lifraumeni syndrome - mutation of p53 tumor suppressor gene.
    12. Anticancer drug used commonly in GIT malignancies - 5 fluorourail.
    13. High fat diet associated with increased risk of Ca. Breast, colon, prostate and lung.
    14. Procarbazine - anticancer drug with disulfiram like effect.
    15. Cisplatinum causes sever nausea and vomiting and Nephrotoxicity.
    16. Mitomycin causes - hemolytic uremic syndrome.
    17. Hydroxy urea causes - hyperpigmentation.
    18. Allopurinol causes - steven Johnson syndrome and enhances toxicity of 6 mercaptapurine.
    19. Duxorubicin - cardiomyopathy.
    20. Rx. of hypercalcaemia - 1. hydration 2. Biphosphonates 3. Calcitones.
    21. Stiffman syndrome - associated with Ca. Breast.
    22. Most common cancer associated with paraneoplastic syndrome is small cell Ca of lung.
    23. Nepelometry - quantitative determination of serum immunoglobulins. (IgG, IdgA and IgM)
    24. RAST - for IgE.
    25. Multicolony stimulating factor - IL - 3
    • Mast cell growth factor - IL - 4
    • B-cell growth factor - IL - 5
    • B-cell differentiation factor - IL - 6
    [11]
    Very early B cell and T cell growth factor - IL -7, Chemotactic factor for neutrophils - IL - 8
    26. MC primary immunodeficiency disorder - selective IgA deficiency.
    27. Immunodeficiency in sarcoidosis
    1. Partial deficit in T cell function
    2. Intact or increase B-cell function
    28. SLE-
    • Sensitive test - Antinuclear Antibody (ANA)
    • Specific test - Anti - Smith Ab and Anti - ds DNA
    29. Recipients for Liver transplantation are selected on basis of
    1. ABO matching
    2. Organ size.
    30. Tacrolimus (FK506) - 100 times more patent immunosuppressant drug than cyclosporine.
    31. HLA and associated diseases.
    1. Ankylosing spondylytis B27, Reiter's disease B27, Salmonella arthritis B27
    2. Psoriasis vulgaris - CW6
    3. Grave's disease - DW3, DW12
    4. Diabetes mellitus - DR3, DR4
    5. ALL - A2 6. SLE - DR4
    6. Narcolepsy - DR2
    32. Drug causing hypersensitivity pneumonitis - Minocycline.
    33. Most effective Rx. of any allergic conditions is Avoidance.
    34. Major Histocompatibility complex (MHC) chromosome 6
    1. Class I - HLA - A, B and C Class II - HLA D
    35. Hypersensitivity reactions:
    1. Type I/Anaphylaxis - IgE mediated Eg. Urticaria, atopy
    2. Type II/cytotoxic - IgG/IgM mediated Eg. ITP, Myasthenia, Autoimmune hemolytic anaemia.
    3. Type III/Immune complex - IgG/IgM mediated Eg. Extrinsic allergic alveolitis, Arthus reactions, serum sickness
    4. 4. Type IV / cel mediated - T cell mediated Eg. contact hypersensitivity, Tuberculin test.
    36. Transplantation
    1. Autograft - one part of the body to the other.
    2. Isograft - among twins.
    3. Allograft - same species
    4. Xenogaft - different species
    37. Transplant rejection
    1. Hyperacute - immediately after revascularization
    2. Acute - within days and weeks
    3. Chronic - with in months and years.
    38. Pseudo allergic reaction
    1. Not mediated by allergen - IgE reaction
    2. Direct mast cell activation occurs
    3. c) Eg: i) Redman syndrome in rapid infusion of vancomycin ii) Radiocontrast media reactions.
    [13] 114
    6 - Cancer
    1. Serum tumour Markers:
    1. HCG - Testicular (Germ cells) carcinoma, choriocarcinoma
    2. Alphafetoprotein - Hepatocellular CA, Testicular Ca.
    3. CEA - Colorectal Ca.
    4. Neuron specific enolase ? Neuroblastoma, Ca.lung
    5. CA -125 -Ca. ovary ,CA -19-9 -Ca. colon. pancreas, CA -15-3 -Ca. Breast.
    2. Erythropoeitin secreting tumors
    1. Uterine fibromyoma
    2. Cerebellar hemangioblastoma.
    3. Branchogenic ca
    4. Hepatocellur ca
    5. Renal cell ca
    3. Hypercalcaemia - squamous cell type of Bronchogenic Ca.
    4. Prolactin secretion (Galactorrhoea) - by Hypernephroma.
    5. Acanthosis migricans by Ca.stomach, thyrotoxicosis.
    6. 60 Cobalt machines, Linear accelerators - used in Teletherapy.
    7. Examples of brachytherapy Caesium 137 in Ca.cervix
    8. Radiomimetic drugs - nitrogen mustards
    9. Spindle, poisons - plant alkaloids

      Here are the famous HLA linkages for diseases.

    A3 familial hemochromatosis (gene is in this and some other alleles

    B8 & DR3

    		 autoimmune Addisonism
    myasthenia gravis
    Sjogren's

    B27

    		 ankylosing spondylitis
    Reiter's syndrome
    enteropathic arthropathy
    autoimmune uveitis

    B35

    		 DeQuervain's

    B38

    		 psoriatic arthritis

    B51

    		 Beçet's

    B47

    		 21-hydroxylase deficiency (gene is in the allele)

    Cw6

    		 common psoriasis

    DR2

    		 Goodpasture's
    multiple sclerosis

    DR3

    		 celiac sprue / dermatitis herpetiformis
    lupoid hepatitis
    lupus (weak)

    DR3, DR4

    		 autoimmune diabetes

    DR4

    		 pemphigus
    rheumatoid arthritis

    DR5

    		 autoimmune pernicious anemia
    Hashimoto's autoimmune thyroiditis
    Sedimentation rate

    Males younger than 50:

     

    0–15 millimeters per hour (mm/hr)

    Males 50 and older:

    0–20 mm/hr

    Females younger than 50:

    0–25 mm/hr

    Females 50 and older:

    0–30 mm/hr

     

    THYROID

    Test / Name
    Normal Range
    Interpretation
    "TSH" Test -- Thyroid Stimulating Hormone / Serum thyrotropin 0.4 to 6

    0.3 to 3.0 (as of 2003)    		 Under .4 can indicate possible hyperthyroidism. Over 6 is considered indicative of hypothyroidism. Note: the American Association of Clinical Endocrinologists has revised these guidelines as of early 2003, narrowing the range to .3 to 3.0. Many labs and practitioners are not, however, aware of these revised guidelines.
    Total T4 / Serum thyroxine 4.5 to 12.5 Less than 4.5 can be indicative of an underfunctioning thyroid when TSH is also elevated. Over 12.5 can indicate hyperthyroidism. Low T4 with low TSH can sometimes indicate a pituitary problem.
    Free T4 / Free Thyroxine - FT4 0.7 to 2.0 Less than 0.7 is considered indicative of possible hypothyroidism.
    T3 / Serum triiodothyronine 80 to 220 Less than 80 can indicate hypothyroidism.

    From good and close friend Ed Friedlander.MD

      When you order an "ANA" ("anti-nuclear antibodies") screen, the patient's serum will be placed on some mammalian cells and counterstained to stain green any patient antibodies that may have stuck.

      The pattern may give you a hint of which antibody is present!

    RIM PATTERN Probably anti-dsDNA. Your patient probably has systemic lupus.
    HOMOGENEOUS PATTERN Probably anti-histones. Your patient probably has drug-induced lupus.
    SPECKLED PATTERN Could be anti-Sm and/or anti-Ro/SSA and/or anti-La/SSB and/or anti-U1RNP and/or any of several others. You'll certainly want to continue your workup!
    CENTROMERE PATTERN An especially fine speckling with little background staining. This is anti-centromere, the marker for CREST / pulmonary hypertension.
    NUCLEOLAR PATTERN anti-Th or anti-fibrillarin / anti-U3RNP or anti-U17RNP. Think of scleroderma, though most scleroderma patients don't show the nucleolar pattern.
      Notice the titer. If it's 1:40 or less, it probably means nothing. If it's 1:160 or more, your patient probably has something going on.

      You can also order these tests for individual autoantibodies.

    anti-dsDNA Anti-double stranded DNA. A misnomer, of course. Your patient has systemic lupus. About half of lupus patients have these antibodies.  
    anti-ssDNA Anti-single stranded DNA. Think of drug-induced lupus.  
    anti-histone Think of drug-induced lupus.  
    anti-Sm Anti-Smith. Your patient has systemic lupus. About a third of lupus patients have these antibodies.  
    anti-Ro/SSA Lupus, Sjogren's, neonatal lupus, or some mix of these.  
    anti-La/SSB Lupus, Sjogren's, or some mix of these  
    anti-U1RNP Anti-ribonucleoprotein. When this is the main autoantibody, your patient has mixed connective tissue disease.  
    Anti-Scl70 Anti-topoisomerase. Your patient has the bad kind of scleroderma. A large minority of people with the bad kind of scleroderma have this autoantibody.  
    Anti-centromere Very sensitive and very specific for CREST, the limited scleroderma variant.
    Anti-Jo Antibody against transfer-RNA synthetase. Your patient probably has polymyositis / dermatomyositis. About half of PMDM patients have this autoantibody.  

    SYSTEMIC LUPUS ERYTHEMATOSUS (SLE, "the red wolf"; Ann. Int. Med. 115: 548, 1991, NIH review Ann. Int. Med. 123: 42, 1995; Med. Clin. N.A. 81: 113, 1997).

     

     

    These are the common investigations that you should keep in mind while writing Pt notes.

    HEENT

    X-ray, CT, MRI of head

    Eye- Snellen’s chart, Visual acuity

    Ear- Complete audiometry and tympanometry, Culture/Sensitivity for any discharge

    Routine CBC with diff, ESR

    CNS

    Routine CBC with diff, ESR     X-ray, CT, MRI

    Lumbar puncture

    Carotid Doppler study

    EEG

    Electromyography and Nerve conduction studies.   

    Echocardiogram for suspected embolic phenomena.  

    from tommy hy tommy hy

    Patient, young, with obesity, hypotonia, mental retardation, short stature, hypogonadotropic hypogonadism, strabismus, and small hands and feet. What disease and what is tx?
    A. Prader Willi Syndrome. Treat with GH

    Q. Pt w/ symptoms include tall stature, ectopia lentis, mitral valve prolapse, aortic root dilatation, and aortic dissection? What gene is missing and what is treatment of choice? Don't peek below w/o guessing.
    A. Marfan's Syndrome . Defect in fibrillin gene. Treat the aortic dissection with B-Blockers. Warn them about pneumothorax and strenous exercise. Tell patients that they are AD inheritance. Warn them about weird things like an elevator that travel up too fast or an airplane without decompression.


    You have to know that many test takers said it really "helped" to do the NBME Step 2 questions and the NBME Step 3 questions that they have on the website. Please do not neglect them. Just ignore the "next step" questions, and do the diagnosis problems

    Q. IF you are given a diagram with an LDL receptor molecule, and ...
    Then if you are asked what ion binds to it, what would you guess?

    Choices: Na, Ca, Fe?
    A. The answer is Ca. You should look at the concept of diagrams of receptors. Remember, many of the writers of the questions are MD-PhDs and they specialize in their own receptor research

    Q. A patient who had her gall bladder removed for stones STILL feels colicky pain, what could be the reason? This is a very HY concept....

    A. loss of inhibitory enteric innervation (motor

    value MD.COM

    1. Direct hernia: leaves abdominal cavity medial to inferior epigastric vessels
    Indirect hernia: leaves abdominal cavity lateral to inferior epigastric vessels
    Femoral hernia: protrusion of abdominal viscera through femoral ring into femoral canal
    Lumbar puncture: needle into lumbar cistern between spinous processes L3/L4 or L4/L5 Pericardiocentesis: 
    wide bore needle inserted through 5th or 6th intercostal space near sternum.
     Careful not to puncture internal thoracic artery
    - 2. Thyroid C5 Duodenum T12-L1
    Sternal notch T2 Kidneys T12-L3
    Bifurcation of trachea T4-T5 Conus medularis L1-L2 adult, L3 newborn
    Heart: Base T6-T9 Umbilicus L4
    Apex 5th left intercostal space  
    - 3. Knee: 1. Patellar ligament- damage to femoral nerve or spinal cord L2-L4. Loss of patellar reflex 2.
     MCL- tear also tears medial meniscus. Passive abduction of extended leg at knee joint. 3.
     LCL- passive adduction of extended leg at knee joint. 4. ACL- anterior drawer sign.
     5. PCL- posterior drawer sign. 6. Terrible triad- MCL, medial meniscus and ACL tears.
    - Hip: 1. Posterior dislocation- head of femur moves posterior to the iliofemoral ligament. 
    Presents with lower limb that is flexed at hip joint, adducted, medial rotated and shorter than opposite limb.
     2. Fracture of neck of femur presents laterally rotated and shortened.
    - Shoulder: 1. Dislocation- may be anterior or posterior. If anterior then axillary nerve may be damaged. 
    2. Separation- results in a downward displacement of clavicle.
    - Clavicle: 1. Fracture- most common at medial 1/3. Results in upward displacement of proximal fraagment and 
    downward displacement of distal fragment
    - 4. Brachial Plexus: 1. Axillary n- dislocation of shoulder, abduction (deltoid) and lateral rotation (teres minor) 
    are compromised. 2. Long thoracic n- winging of scapula (serratus anterior). 3. Radial n- wrist drop
     (extensors of forearm). 
    4. Median n- ape hand (thumb muscles) and flexors of forearm if damage is at elbow or above. 
    5. Ulnar n- claw hand and radial deviation of hand, loss of some flexors if at elbow or above.
    - 5. Peripheral nerves: 1. Common peroneal n- foot drop (tibialis anterior m) and inversion  
    (peroneus muscles). 2. Deep peroneal n. entrapment-  
    Compression of anterior compartment muscles of the lower leg by ski  
    boot or athletic shoes that are too tight. Causes pain in the dorsum
     of the foot that radiates to the space between the first two toes.

     

    A varicocele is a collection of venous varicosities of the spermatic veins in the scrotum caused by incomplete drainage of the pampiniform plexus.  A varicocele is present in up to 20% of all males and is often asymptomatic (1).

    Left-sided varicoceles account for 85%-95% of cases; however bilateral varicoceles may be present in up to  22% of patients (2). Most varicoceles occur on the left side, largely because of the differences in the venous drainage patterns of the right and left testicular veins. The left spermatic vein empties directly into the renal vein, whereas the right spermatic vein drains into the inferior vena cava (IVC) and then into the right renal vein. 

    Intrabdominal pathology should be suspected in cases of right-sided varicoceles because these are usually caused by IVC thrombosis or compression of the IVC by tumors.

    What is the treatment of a popliteal (Baker's) cyst?

    Although a popliteal cyst can be treated by aspiration or even surgical excision, spontaneous disappearance is common and no treatment is usually required (Rosen's Emergency Medicine, 5th. Ed., pg. 697).

     

    METHAMPHETAMINE ABUSE

    Methamphetamine abuse is once again emerging as a serious problem in the US. Since methamphetamine is highly lipophilic, it easily crosses the blood-brain barrier. It can be smoked, snorted, ingested or injected. The drug begins to act about 5 minutes after snorting, about 20 minutes after ingestion, and almost immediately when smoked or injected intravenously.

    Acute toxicity is similar to that of cocaine, but longer in duration, lasting up to several hours as the half-life of methamphetamine is about 12 hours, much longer than that of cocaine. The acute physiologic effects of the drug include anorexia, insomnia, tachycardia, tachypnea, hypertension, hyperthermia and seizures. Hemorrhagic and ischemic strokes and renal failure have occurred; rhabdomyolysis has been reported. CNS effects include anxiety, agitation, paranoia, delirium and psychosis, all similar to the effects of cocaine. When the drug effect wears off, there is usually prolonged sleep and some mild dysphoria. A more severe withdrawal syndrome, typically beginning 24 hours after the last dose, is characterized by profound sleep, followed by hunger and moderate to severe depression.

    As methamphetamine is metabolized in the liver by CYP2D6, drugs that are metabolized by or inhibit CYP2D6 potentially could increase serum concentrations of methamphetamine. Severe reactions can occur if methamphetamine is used by patients being treated with an MAO inhibitor.

    Short-term treatment of intoxication is similar to that for cocaine. It usually includes a benzodiazepine such as lorazepam to control agitation or irritability and an antipsychotic to treat psychotic symptoms, but haloperidol (Haldol) is a CYP2D6 inhibitor and might increase serum concentrations of methamphetamine

     

     

     

    Web master : Danil Hammoudi. MD

     

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