Usmle review 11

Danil HAMMOUDI.MD

sinoe medical association

 

 

The only test that would reveal proviral DNA is the polymerase chain reaction [pcr] .

 

phenoxybenzamine and phentolamine are alpha blockers used in the management of pheochromocytoma and associated with the devlpt of incontinence.

 

 

• Robinul =:Glycopyrrolate 

 

• What is glycopyrrolate?
• This drug acts on the muscle in the wall of the gut and also the urinary bladder. It relaxes the muscle and prevents spasms from occurring. It also can slightly reduce the production of stomach acid.
• In Anesthesia:Glycopyrrolate injectionis indicated for use as a preoperative antimuscarinicto reducesalivary, tracheobronchial, and pharyngealsecretions; to reducethe volumeand free acidity of gastric secretions; and, to blockcardiacvagalinhibitory reflexes during induction of anesthesiaand intubation. When indicated, glycopyrrolateinjection may be used intraoperatively to counteractdrug-induced or vagaltraction reflexes with the associated arrhythmias. Glycopyrrolate protects against the peripheralmuscariniceffects (e.g., bradycardiaand excessive secretions) of cholinergicagents such as neostigmineand pyridostigmine given to reverse the neuromuscularblockadedue to nondepolarizing musclerelaxants.
• In Peptic Ulcer:For use in adults as adjunctive therapy for the treatmentof pepticulcerwhen rapid anticholinergiceffectis desired or when oralmedicationis not tolerated.

 

SIDE EFFECTS

Anticholinergics produce certain effects, most of which are extensions of their pharmacologic actions. Adverse reactions to anticholinergics in general may include dry mouth: urinary hesitancy and retention; blurred vision due to mydriasis; increased oculartension; tachycardia; palpitation; decreased sweating; lossof taste; headache; nervousness; drowsiness; weakness; dizziness; insomnia; nausea; vomiting; impotence; suppressionof lactation; constipation; bloatedfeeling; severe allergicreactionor drugidiosyncrasies including anaphylaxis; urticariaand other dermal manifestations; some degree of mentalconfusionand/or excitement, especially in elderly persons.

Glycopyrrolate is chemically a quaternary ammoniumcompound; hence, its passageacross lipid membranes, such as the blood- brainbarrieris limited in contrastto atropine sulfateand scopolamine hydrobromide. For this reason the occurrence of CNSrelated sideeffects is lower, in comparison to their incidencefollowing administrationof anticholinergics which are chemically tertiary amines that can crossthis barrierreadily.

 

 

DRUG INTERACTIONS

The intravenousadministrationof any anticholinergicin the presence of cyclopropaneanesthesiacan result in ventriculararrhythmias; therefore, caution should be observed if glycopyrrolateinjectionis used during cyclopropane anethesia. If the drugis given in small incremental doses of 0.1 mg or less, the likelihood of producing ventriculararrhythmias is reduced.

 

An interaction generally means that one drug may increase or decrease the effect of another drug. Also, the more medications a person takes, the more likely there will be a drug interaction. Because this is a synthetic drug and falls into a class called quaternary ammonium compounds, it differs in some ways from the other anticholinergics such as hyoscyamine (Levsin) and dicyclomine (Bentyl). The manufacturer notes that there are no known drug interactions but it may be wise to note the interactions with other drugs in this class.

Interactions with this drug may occur with the following:

• monoamine oxidase (MAO) inhibitors (Nardil, Parnate)
• sedatives (Ambien, Dalmane, Restoril)
• antidepressants (Haldol, Elavil)
• antacids
• antihistamines (Benadryl)
• cimetidine (Tagamet)
• prednisone
• digoxin (Lanoxin)
• metoclopramide (Reglan)
• thiazide diuretics (Dyazide, hydrochlorothiazide)
• amantadine (Symmetrel)
• cardiac rhythm regulators (Pronestyl, quinidine)

 

 

 

Is there a problem if I have another disorder or disease?

At times, a drug may have a different or enhanced effect when other diseases are present. At other times, the drug may worsen or effect another disease.

With this drug, the following disorders may be a problem:

glaucoma

prostate enlargement - BPH

hypertension (high blood pressure)

congestive heart failure

severe ulcerative colitis where bowel movements have stopped

 

lipoprotein lipase is the enzyme complex in blood to binds to and utilizes circulating chylomicrons.

• FAMILIAL LIPOPROTEIN LIPASE DEFICIENCY =Type I hyperlipoproteinemia; Familial chylomicronemia
• - A rare inherited disorder where there is a deficiency of an enzyme(lipoprotein lipase) which breaks down fat molecules , causing the accumulation of fats or lipoproteinsin the blood. Symptoms in infancy include abdominal pain (appears as if its colic), failure to thrive, and skin lesions(xanthomas).

lipoprotein lipase (LPL) is a key enzyme in the regulation of lipid- and lipoprotein metabolism, changes in LPL activity may contribute to these effects of GH.

It is characterised by the presence of chylomicrons in fasting plasma. Characteristically there is a fasting hypertriglyceridaemia and chylomicronaemia.   Possible clinical features include: hepatosplenomegaly eruptive xanthomas lipaemia retinalis (turbid blood in the retinal vessels). pancreatitis   Note that there is an overlap between lipoprotein lipase deficiency and apolipoprotein C-II Deficiency (familial inhibitor to lipoprotein lipase is a rare autosomal recessive hereditary disorder) apolipoprotein C-II (apoC-II) is a necessary cofactor for the activation of lipoprotein lipase. this condition is characterized by a deficiency of apolipoprotein C-II, causing an accumulation of chylomicrons and very low density lipoproteins (VLDL) xanthomas and hepatosplenomegaly are less common in C-II anapolipoproteinemia than in lipoprotein lipase deficiency (1)

 

• physical examinationreveals xanthomas, an enlarged liver, an enlarged spleen, and jaundice may be evident. An eye examination reveals pale retinas and whitish retinal vessels.
• Tests that may indicate this disorder is present include: milky appearing serum/plasma from blood.
• a special test showing absent or decreased lipoprotein lipase activity in blood collected after treatment with intravenous heparin.
• markedly elevated triglyceridesin blood.
• elevation of cholesterol and total fat in blood.
• failure to remove chylomicrons from blood more than 12 hours after a meal.
• an overnight icebox test showing chylomicrons in fasting serum.
• an apolipoprotein CIIdeficiency may cause a rare subset of this disease in people with normal lipoprotein lipase activity.
• genetic testing may reveal a mutation(s) in the genes for lipoprotein lipase or apolipoprotein CII.

   

 

apo B-48 deficiency decresed production of chylomicron

the secretion of testosterone by interstitial [leydig] cells in the testes is stimulated by the secretions of cell pituitary basophils

leydig cells are stimulated by the secretion of LH , which is secreted by pituitary basophils.

 

Pituitary acidophils secrete growth hormone and prolactin.

 

• Sertoli cells secrete inhibin, androgen binding protein, and mullerian inhibiting substance.
• y including dimeric inhibin-Aas a fourth biochemical marker for Down syndrome screening, FBR makes it possible for prenatal care providers to screen for this disorder more accurately than ever before
• Maternal serum levels of DIA are twice as high in pregnancies affected by Down syndrome as in unaffected pregnancies. DIA is as effective a marker for Down syndrome as hCG, yet provides information that hCG and the other markers do not.
• Also: Tumour marker for granulosa cell tumours and mucinous ovarian tumours; monitoring levels after surgery to detect recurrence. The test should not be used to screen for the presence of these tumours.
• Activin and Inhibin are polypeptides that stimulate and inhibit FSH secretion, respectively. Their subunits were first discovered in the gonads. However, they are also found in gonadotropes themselves. This suggests self- or autocrine regulatory mechanisms. We would like to know if a particular subset of gonadotropes produces these polypeptides. We would also like to learn more about the interactions between activin, inhibin and their target cells.
• Activin increases numbers of LH or FSH cells.
• Male germ cell development, spermatogenesis, consists of three steps; proliferation of stem cells by mitosis, production of haploid round spermatids by meiosis, and differentiation of haploid cells to spermatozoa with dramatic morphological and biochemical changes. This is a very complex process regulated by gonadotropin such as leutenizing hormone (LH) and follicle stimulating hormone (FSH), and many local hormones and factors produced in the testis.  LH stimulates the Leydig cells to produce androgen that is absolutely necessary for normal spermatogenesis, and FSH modulates the function of Sertoli cells that physically and biochemically support male germ cells. Our lab are currently taking molecular and developmental genetic approaches to investigate how spermatogenesis is controlled at the molecular and cellular level in mouse system.

 

 Control of Testicular Function

 

 

1. ¨GnRH - secreted by hypothalmus
2. ¨LH - secreted by anterior pituitary
3. ¨FSH - secreted by anterior pituitary
4. ¨Testosterone - secreted by Leydig cells
5. ¨Inhibin - secreted by sertoli cells

1. GnRH

- secreted by hypothalmus

- stimulates secretion of LH and FSH

2. Luteinizing hormone (LH)

- acts on leydig cells

- stimulate synthesis of testosterone

 

3. Follicle stimulating hormone (FSH)- initiation of spermatogenesis

- seminiferous tubule development

- acts on sertoli cell to stimulate inhibin secretion

 

4. Testosterone- required for spermatogenesis

- secreted by Leydig cells

- synthesis stimulated by LH

- feedback to AP and HP to decrease LH

 

  5. Inhibin

  - secreted by sertoli cells

- inhibits FSH secretion

 

 

 

 

1. Regulation of spermatogenesis by testosterone

        Testosterone, a major androgen produced in Leydig cells, is essential for normal spermatogenesis. While there have been numerous studies of endocrine effects of testosterone in spermatogenesis, just beginning are the molecular studies of how the hormone supports male germ cell development.  

A number of studies reported so far imply that testosterone indirectly controls spermatogenesis by regulating gene expression and function of supporting cells, Sertoli and Myoid cells in the testis.  Our

 

 

2. Cloning and functional analysis of genes that regulate spermatogenesis

        Spermatogenesis is an extremely complex process of cellular differentiation that includes the dramatic morphological transformation of haploid spermatids.  This elaborately controlled process is regulated by many hormones and factors involved in cell-cell communications.  Many genes are speculated to be involved in this process and their expressions tightly regulated developmentally by external signals and internal programs in testicular cells.  Our lab has been looking for genes that have a role in the regulation of spermatogenesis and investigating their functions in male germ cell development.

spermatocyte

 123

1 This field shows three Sertoli cells(only one is labeled) at low magnification, to demonstrate their relationship to the wall of the tubule and to other cells in the seminiferous epithelium. Sertoli cells are really the only true resident cell of the seminiferous tubules.

·        The various stages of spermatozoan development (except perhaps the ancestral spermatogonia) all are destined to mature and be used up.

·        The Sertoli cell is present before puberty and remains in place until death.

·        The Sertoli cells are a permanent population; they don't normally divide and proliferate, unlike the various stages of the developing sperm around them.

·        They can occasionally become neoplastic, producing a Sertoli cell tumor.

 

 

 

2In this image the peculiar appearance of the Sertoli cell's nucleus, with its rhomboid inclusion and vesicular nucleoplasm, is clearly evident. So is its relationship to the various stages of developing sperm cells around it.

 

• The Sertoli cell's overall shape is somewhat like a tree. The early stages of sperm development, the spermatogoniaand early primary spermatocytesare located near the base of the "trunk" and as they develop into later stages, the spermatocytes are moved up into the "branches" of the tree.
•  By the time they get to the part close to the tubule lumen, they have completed their meiotic division and become spermatids, haploid cells undergoing the final morphological transformation into sperm.

 

 

 

 

 

3In this image you see two Sertoli cells with some early (ES) and late (LS) spermatids in their upper reaches.

• Dropletsof excess cytoplasm are being shed from the late spermatids.
•  There's a spermatogonium near the base, with a primary spermatocyte visible immediately above it.
• A major role of the Sertoli cell is to define two separate and physiologically different compartments in the seminiferous tubule.
• The basal compartment, near the periphery, is sealed off from the luminal compartment by processes of adjacent Sertoli cells that "reach out" and make contact. At the point of contact these fuse to form occluding junctions. Below the junction, in the basal compartment, are located the diploid spermatogonia.
•  Once these commence division, the cells send out new processes to "undermine" the forming spermatocytes, and seal off a new layer belowthem, then break the barrier above.
• This effectively transfers the haploid cells to the luminal side and prevents the diploid ones from being exposed to it.
• This elaborate mechanism for separating the two compartments is necessary because the haploid elements are immunologically distinguishable as "non-self."
•  The basal compartment has access to the blood stream and all the immune system components it carries.
•  Even though the haploid gametes are "non-self," they are very similar in composition and nature to the diploid cells; exposing the immune system to haploid gametes runs a risk of developing systemic autoimmune reactions.
• Furthermore, the haploid cells are physiologically "compromised" and the sperm especially lack the capacity to deal with harmful materials that might be borne in the blood. So for everyone's protection, the blood-testis barrieris created by the occluding junctions of adjacent Sertoli cells.

 

  Each spermatogonium lining the tubules divides so rapidly that each testicle can produce between 300 and 600 sperm per gram of testis per second.

• On average, sperm are produced at a rate of 1,500 per second per testicle.

• Sperm take 74 days to form and a further 26 days to mature and pass through the epididymis and vas deferens.

• Sperm swim at a rate of 3 mm (1/10 in) per hour.

• A sperm lashes its tail 800 times to swim one cm (1/3 in).

• Sperm must travel through 3040 cm (1013 in) of male and female 'plumbing' to reach the Fallopian tube this is equivalent to swimming more than 100,000 times their own length.

• Sperm reach the Fallopian tubes within 3060 minutes after ejaculation into the female tract, helped along by eddy currents.

• Sperm normally only survive in the vagina for up to six hours as the acid vaginal secretions are hostile once in the alkaline mucus of the cervix, however, they can survive for several days.

• The average survival time for a sperm in the female reproductive tract is 34 days live sperm have been found in the female tract 7 days after ejaculation, but whether or not they are capable of fertilization remains unknown.

 

 

ceftazidime + gentamycin =è pneumonia aquire institution treatment

 

ceftazidine = cephalosporin third generation against enteric gram negative rods and antipsudomonal activity

 

Ceftazidime (Fortaz, Ceptaz, Tazicef, Tazidime)

 

 

Category:

 

Antibiotic

 

 

 

Description:

 

Cephalosporin, Third Generation

 

 

 

Indications:

 

• Lower respiratory tract infections (P. aeruginosa  and other Pseudomanas species,H. influenzae, Klebsiella species,S. pneumoniae, S. aureus, E. coli, Serratia species, Enterobacter species,P. mirabilis, Citrobacter species)

 

• Urinary tract infections (E. coli, Klebsiella species, Proteus species, Enterobacter species, P. aeruginosa)

 

• Skin, bone and joint infections (P. aeruginosa, Enterobacter species, E. coli, Proteus species, Klebsiella species, Serratia species, E. coli, S. aureus, S. pyogenes)

 

• Intra-abdominal infections (E. coli, Klebsiella species,S. aureus, Bacteroides species, polymicrobial infections caused by aerobic and anaerobic organisms)

 

• Bacterial septicemia (P. aeruginosa, Klebsiella species, H. influenzae, E. coli, Serratia species, S. pneumoniae, S. aureus)

 

• Gynecological infections (E. coli)

 

 

• CNS infections (H. influenzae, N. meningitidis)

 

 

 

Contraindications:

 

Cross sensitivity with penicillin allergies

 

 

 

Precautions:

 

Pregnancy category B

 

 

Use with caution in patients with penicillin allergy (5-10% chance of cross-reactivity)

 

 

Dosage modifications are generally only required in patients with severe renal impairment

 

 

 

Adverse Reactions (Side Effects):

 

Hypersensitivity reactions

 

 

Gastrointestinal: nausea, vomiting, diarrhea

 

 

Vaginitis

 

Dosage:

 

Administered by injection (IM and IV)

 

 

Adults:

1 gram IV or IM every 8-12 hours

 

 

 

uncomplicated urinary tract infections: 

250mg IV or IM every 12 hours

 

 

 

complicated urinary tract infections: 

500mg IV or IM every 8-12 hours

 

 

 

meningitis: 

2 grams IV every 8 hours

 

 

 

uncomplicated pneumonia, mild skin infections: 

500mg – 1 gram IV or IM every 8 hours

 

 

 

bone and joint infections: 

2 grams IV every 12 hours

 

 

 

meningitis: 

2 grams IV every 8 hours

 

 

 

severe, life-threatening infections: 

2 grams IV every 8 hours

 

 

 

pseudomonal lung infections: 

30-50mg/kg IV every 8 hours (maximum 6 grams per day)

 

 

 

Infants and Children (1 month – 1 year)

30-50mg/kg IV every 8 hours (maximum 6 grams per day)

 

 

 

Neonates (0-4 weeks):

30mg/kg IV every 12 hours

 

Side Effects (Reactions) of Smallpox Vaccine

• For most people, the smallpox vaccine is safe and effective. Most people experience normal, typically mild reactions to the vaccine, which indicate that it is beginning to work. Some people may experience reactions that may require medical attention.
• Some people are at greater risk for serious side effects from the smallpox vaccine. Individuals who have any of the following conditions, or live with someone who does, should NOTget the smallpox vaccine unless they have been exposed to the smallpox virus:
• Eczema or atopic dermatitis. (This is true even if the condition is not currently active, mild or experienced as a child.)
• Skin conditions such as burns, chickenpox, shingles, impetigo, herpes, severe acne, or psoriasis. (People with any of these conditions should not get the vaccine until they have completely healed.)
• Weakened immune system. (Cancer treatment, an organ transplant, HIV, or medications to treat autoimmune disorders and other illnesses can weaken the immune system.)
• Pregnancy or plans to become pregnant within one month of vaccination.

 

• In addition, individuals should not get the smallpox vaccine if they:
• Are allergic to the vaccine or any of its ingredients.
• Are younger than 12 months of age. However, the Advisory Committee on Immunization Practices (ACIP) advises against non-emergency use of smallpox vaccine in children younger than 18 years of age.
• Have a moderate or severe short-term illness. (These people should wait until they are completely recovered to get the vaccine.)
• Are currently breastfeeding.

 

• Again, people who have been directly exposed to the smallpox virus should get the vaccine, regardless of their health status.
• Don't Hesitate!
• If offered the smallpox vaccine, individuals should tell their immunization provider if they have any of the above conditions, or even if they suspect they might.

 

Smallpox Overview

Smallpox is a serious, contagious, and sometimes fatal infectious disease. There is no specific treatment for smallpox disease, and the only prevention is vaccination. Smallpox outbreaks have occurred from time to time for thousands of years, but the disease is now eradicated after a successful worldwide vaccination program. The last case of smallpox in the United States was in 1949. The last naturally occurring case in the world was in Somalia in 1977.

 

 

	Arteries
Artery	Source	Branches	Supply	Notes
aorta, ascending	left ventricle of heart	left & right coronary aa., continues as aortic arch	heart, entire body	(Greek, aorta = to lift)
atrioventricular nodal	right coronary near the point where it becomes the posterior interventricular a.		atrioventricular node & surrounding myocardium	located at junction of coronary sulcus & posterior interventricular sulcus
circumflex	left coronary	marginal br., possibly posterior artery of left ventricle	posterior surface of left ventricle	(Latin, circum = around + flexs = to bend)
coronary, left	ascending aorta	anterior interventricular & circumflex brs.	left ventricle, left atrium, anterosuperior two-thirds of interventricular septum	(Latin, coronary = something that is "crown-like", i.e., goes around in a loop)
coronary, right	ascending aorta	sinuatrial nodal, right marginal, posterior interventricular, atrioventricular nodal brs.	right ventricle, right atrium, inferior third of interventricular septum	right coronary a. usually provides the posterior interventricular a. (Latin, coronary = something that is "crown-like", i.e., goes around in a loop)
septal	posterior interventricular		interventricular septum
sinuatrial nodal	right coronary		sinuatrial node & surrounding myocardium	important artery to locate during cardiac surgical procedures

 

Veins
Vein	Tributaries	Drains Into	Region Drained	Notes
cardiac, anterior		right atrium	anterior surface of right ventricle	bridge the right coronary a.
cardiac, great	ventricular vv., left marginal	unites with oblique v. of left atrium to form coronary sinus	heart near anterior interventricular sulcus
cardiac, middle	ventricular vv.	coronary sinus	heart near posterior interventricular sulcus
cardiac, small		coronary sinus	heart near inferior vena cava & right coronary sulcus
cardiac, smallest		directly into heart chambers	myocardium	also known as: Thebesian vv.; least cardiac vv.; venae cordis minimae
coronary sinus	formed by union of great cardiac v. & oblique v. of left atrium; tributaries: middle cardiac, small cardiac vv.	right atrium	heart except anterior cardiac vv. & venae cordis minimae	opening into right atrium is guarded by an imperfect valve, (Latin, coronary = something that is "crown-like", i.e., goes around in a loop)
pulmonary	segmental pulmonary vv.	left atrium	lungs	carries oxygenated blood to heart for distribution to body
left posterior ventricular	ventricular vv.	coronary sinus	heart near posterior interventricular sulcus
oblique, of left atrium		unites with great cardiac v. to form coronary sinus	left auricle & adjacent portion of left atrium

Viscera/Fascia
Organ	Location/Description	Notes
heart	located within middle mediastinum within pericardial sac, nearly surrounded by pericardial cavity
coronary sulcus	groove separating atria from ventricles	coronary sinus, circumflex a., & right coronary a. lie in coronary sulcus, (coronary = something that is "crown-like", i.e., goes around in a loop)
endocardium	a thin internal layer or lining membrane of the heart that also covers its valves
myocardium	a thick middle layer composed of cardiac muscle
epicardium	a thin external layer (mesothelium) formed by the visceral layer of serous pericardium
epicardial fat	loose connective tissue in the epicardial (outer) space
annulus fibrosus	thick collagenous rings surrounding the four orifices of the valves of the heart	(Latin, annulus = ring)
aortic vestibule	superoanterior part of the left ventricle	leads to the aortic orifice
apex	tip of left ventricle	located 3" left of midline at level of 5th intercostal space (Latin, apex = tip)
atrium, right	forms the right margin of the heart	receives blood from the superior vena cava, inferior vena cava & coronary sinus
atrium, left	located on the posterior aspect of the heart	receives blood from the pulmonary vv.
auricle	projects anteriorly from the atrium	one on each atrium, they lie beside aorta & pulmonary trunk (Latin, auricula = little ear; the auricle of the atrium is shaped like a little ear)
base	superior aspect of heart	where aorta, pulmonary trunk & superior vena cava enter the heart
interventricular septum	strong, obliquely placed partition between the left and right ventricles	has membranous and muscular parts
interventricular sulcus, anterior	groove between ventricles on anterior surface of heart	anterior interventricular a. & great cardiac v. lie within sulcus (Latin/Greek, holkos (sulcus) = furrow)
interventricular sulcus, posterior	groove between ventricles on diaphragmatic surface of heart	posterior interventricular a. & middle cardiac v. lie within sulcus (Latin/Greek, holkos (sulcus) = furrow)
ligamentum arteriosum	remnant of ductus arteriosus; connects left pulmonary a. near origin with undersurface of aortic arch	left recurrent laryngeal n. passes beneath it
pericardial sinus, oblique	recess of pericardial cavity located behind left atrium of heart	serous pericardium reflects on inferior vena cava & pulmonary vv. (Latin, sinus = fold, hollow)
pericardial sinus, transverse	recess of pericardial cavity located behind aorta & pulmonary trunk and anterior to superior vena cava	(Latin, sinus = fold, hollow)
pericardium, fibrous	forms pericardial sac attached to central tendon of diaphragm; fuses superiorly to adventitia of great vessels; contains pericardial cavity & heart; lined by parietal layer of serous pericardium	defines outermost boundary of middle mediastinum
pericardium, parietal serous	serous lining of pericardial cavity on inner surface of fibrous pericardium (pericardial sac)	reflects onto heart at great vessels
pericardium, visceral serous	serous lining of pericardial cavity on surface of heart; reflects at inferior vena cava & pulmonary vv. to form oblique pericardial sinus	also known as: epicardium
sulcus terminalis	groove on right atrium marking crista terminalis, which is seen within the atrium	(Latin/Greek, holkos (sulcus) = furrow)
ventricle, right		features moderator band and 3 papillary mm.; pumps blood into pulmonary trunk
ventricle, left		features only 2 papillary mm., pumps blood into ascending aorta
chordae tendineae	thin connective tissue cords that attach atrioventricular valve cusps to papillary mm.	(Latin, chordae = cord + tendere = to stretch)
crista terminalis	ridge of cardiac muscle separating smooth sinus venarum posteriorly from rough wall of primitive atrium anterioly	sinuatrial node lies within superior end of crista terminalis (Latin, crista = crest)
atrioventricular bundle	part of conduction system of heart; passes through right fibrous trigone, below membranous part of interventricular septum	divides into right & left branches to supply ventricles
atrioventricular node	part of conduction system of heart; located in wall of right atrium above ostium of coronary sinus & septal cusp of tricuspid valve
atrioventricular valve, left	between the left atrium and left ventricle	also known as: mitral or bicuspid valve
atrioventricular valve, right	between the right atrium and right ventricle	also known as: tricuspid valve
fossa ovalis	depression in left wall of right atrium	remnant of foramen ovale connecting right & left atria in the fetus (Latin, fossa = ditch + ovale = oval)
limbus fossa ovalis	ridge around the fossa ovalis in right atrium	its limbus is located on the interatrial septal wall (Latin, limbus = border + fossa = ditch + ovale = oval)
mitral valve	between left atrium and left ventricle	also known as: bicuspid or left atrioventricular valve; possesses anterior & posterior cusps (Latin, mitra = a a coif or turban, shaped like a bishope's miter, as are the two leaflets of the bicuspid or mitral valve of the heart)
moderator band		also known as: septomarginal trabecula
papillary muscles	attach to cusps of atrioventricular valves via chordae tendineae; right: anterior, posterior & septal; left: anterior & posterior	(Latin, papilla = nipple)
pectinate muscles	located near auricles in walls of both atria; more pronounced in right atrium	(Latin, pecten = comb)
pulmonary conus	smooth area of right ventricle below pulmonary trunk	pulmonary part of the conus arteriosus
semilunar valves	located in base of pulmonary trunk & ascending aorta; free margin of cusps called lunula, dense nodule located at midpoint of free margin	pulmonary valve has anterior, left & right cusps; aortic valve has right, left & posterior cusps (Latin, semis = half + luna = moon, the cusps of semilunar valves are shaped like a half moon)
septomarginal trabecula	ridge of cardiac muscle stretching from interventricular septum to anterior papillary m. in right ventricle; contains part of right branch of atrioventricular bundle	also known as: moderator band
sinuatrial node	located within crista terminalis near superior vena cava	"pacemaker" of heart
trabeculae carnae	ridges of cardiac muscle within both ventricles	(Latin, trabeculae = little beam, carnae = meaty)
tricuspid valve		also known as: right atrioventricular valve; possesses anterior, posterior & septal cusps
valve of the inferior vena cava	right atrium

 

Nerves
Nerve	Source	Branches	Motor	Sensory	Notes
cardiac	vagus, cervical sympathetic trunk		heart (parasympathetic: decrease rate & force of contraction; sympathetic: increase rate & force of contraction); bronchial tree & lungs via pulmonary pleuxs	heart, bronchial tree & lungs	vagus has 2 (superior & inferior) cervical cardiac brs. & 1 or more thoracic br.; cervical sympathetic trunk usually gives 3 (superior, middle & inferior) cardiac brs.
cardiac plexus	cardiac brs. of vagus & cervical sympathetic trunk; thoracic visceral nn.	continuous with coronary & pulmonary plexuses	moderate heart muscle (parasympathetic decreases rate & force of contraction; sympathetic increases rate & force of contraction); vascular smooth muscle of heart & lungs (sympathetic); smooth muscle & mucous glands of bronchial tree (parasympathetic)	pain from heart and lungs; thoracic visceral nn. carry pain from the heart to the upper thoracic spinal cord segments resulting in pain referred to the left upper limb in the T1 and T2 dermatomes	(Latin, plexus = to braid, a network of nerves, blood vessels, or lymphatic vessels)
pulmonary plexus	continuous with cardiac plexus, thoracic visceral nn., pulmonary brs. of vagus		smooth muscle & glands of bronchial tree (parasympathetic); vascular smooth muscle of lungs (sympathetic)		located along pulmonary vessels & primary bronchi in root of lung (Latin, plexus = to braid, a network of nerves, blood vessels, or lymphatic vessels)
vagus	medulla: dorsal motor nucleus (preganglionic parasympathetic) and nucleus ambiguus; superior and inferior ganglia	auricular br., pharyngeal br., superior laryngeal, superior & inferior cervical cardiac brs., recurrent laryngeal, thoracic cardiac brs., brs. to pulmonary plexus, esophageal plexus, anterior & posterior vagal trunks	intrinsic muscles of larynx, pharynx (except stylopharyngeus), & palate (except tensor veli palatini); preganglionic processes synapse in small ganglia within or near viscera of thorax and abdomen; postganglionic processes from these ganglia supply smooth muscles of respiratory tree & gut (proximal to splenic flexure), heart or are secretomotor to mucous glands of larynx, respiratory tree, pharynx & gut, digestive glands	skin of external auditory meatus; viscera of head, neck, thorax & abdomen proximal to splenic flexure; taste to epiglottis	also known as: CN X, 10th cranial nerve; passes through jugular foramen; (Latin, vagus = wanderer, so called because of its wide distribution to the body cavities)

 

Clinical Terms
Term	Definition
deltopectoral triangle	a triangle in the upper chest region that is bounded medially by the clavicle, superiorly by the deltoid m., and inferiorly by the pectoralis major m.; the deltopectoral triangle is pierced by the cephalic vein on its course from the upper limb to join the axillary vein in the axilla
precordium	a rectangular area of body wall over the heart and the lower part of the thorax
auscultation	the act of listening for sounds within the body, chiefly for ascertaining the condition of the lungs, heart, pleura, abdomen and other organs and for the detection of pregnancy
atherosclerosis	the progressive narrowing and hardening of the arteries over time; known to occur to some degree with aging, but other risk factors that accelerate this process have been identified, including: high cholesterol, high blood pressure, smoking, diabetes and family history for atherosclerotic disease
coronary bypass (CABG)	a surgical procedure which involves replacing diseased (narrowed) coronary arteries with veins obtained from the patient's lower extremities or the patient's internal thoracic arteries (which have longer periods of patency than veins). During this procedure the patient is placed on a heart bypass machine (heart-lung machine) to allow the surgeon adequate time to perform surgery on the resting (non-beating, ice-chilled) heart; this procedure has proven to extend the lives of individuals with coronary artery disease and improve the quality of life; recovery in the hospital is approximately 7-10 days
myocardial infarct (MI)	a term used to describe irreversible injury to heart muscle; common symptoms include substernal, crushing chest pain (which patients typically describe as a feeling of intense pressure) that may radiate to the jaw or arms; chest pains may be associated with nausea, vomiting, sweating, and shortness of breath; also known as a heart attack
ventricular hypertrophy	increase in the cellular size of ventricular myocardial cells resulting in gross enlargement. It should be noted that hypertrophy is the increase in cell size, whereas hyperplasia is the increase in cell number.
septal defects	a hole in the interatrial septum (the wall between the atria) is called an atrial septal defect (also known as an ASD); A ventricular septal defect (VSD) usually affects the upper, membranous portion of the interventricular septum (wall between the ventricles) and is the most common congenital cardiac defect (26% of all congenital cardiac lesions).
coarctation of aorta	a congenital heart defect that results in the narrowing of the lumen of the aorta; the narrowing occurs most often just distal to the origin of the left subclavian artery; coarctation occurs in approximately 7% of patients with congenital heart disease and is twice as common in males; surgical correction is most often required; symptoms include headaches, dizziness, fainting, nosebleeds, increased blood pressure in upper extremities, diminished pulses in lower extremities and muscle cramps in legs with activity; some individuals may be asymptomatic.
patent foramen ovale	an inherited condition where there is nonclosure of the foramen ovale at birth; usually asymptomatic until the third or fourth decades of life, symptoms include exertional shortness of breath, fatigue, and palpitations (Latin, patent = to lie open + foramen = an apperature + ovale = oval)
patent ductus arteriosus	a condition where the normal channel between the pulmonary artery and the aorta fails to close at birth; in normal fetal circulation, the blood bypasses the pulmonary circuit since oxygen and nutrients are acquired through the placenta; after birth, this channel normally closes in response to ventilation of the lungs; those who are affected may demonstrate poor growth, shortness of breath and rapid respiratory rate; diagnosis is via echocardiogram and treatment involves the use of indomethacin, a non-steroidal anti-inflammatory (NSAID) which decreases prostaglandin synthesis to stimulate ductus arteriosus closure; surgical ligation will be required in those cases unresponsive to medical management (Latin, patent = to lie open)
cardiac tamponade	interference with venous return of blood to the heart due to an extensive accumulation of fluid in the pericardium (pericardial effusion); tamponade may occur as a complication of dissecting thoracic aneurysm, pericarditis, renal failure, acute myocardial infarction, hypothyroidism, autoimmune disease (for example lupus), chest trauma or a malignancy; fluid in the pericardial sac is demonstrated by echocardiogram; treatment involves the emergent removal of the fluid; this may be accomplished by a needle aspiration technique or emergency surgery (pericardial window)
aortic stenosis	narrowing of the orifice of the aortic valve or of the supravalvular or subvalvular regions (Greek, stenosis = narrowing)
mitral stenosis	a congenital or acquired heart valve abnormality that involves the narrowing and ineffective opening of the mtiral valve (Greek, stenosis = narrowing)
mitral valve regurgitation	the backflow of blood from the left ventricle to the left atrium due to a defective mitral valve
cardiac angiography	radiographic technique that allows visualization of the heart vessels after injection of a radio-opaque contrast material
ischemia	a decrease in the oxygen delivery to a tissue, often due to an obstructed artery or decreased blood flow (Greek, ischo = to keep back + hemia = blood)
murmur	a finding on that can be indicative of heart disease. Murmurs can result from abnormalities in the heart or vessels that lead to turbulent flow
cardiac enzymes	when an area of the myocardium becomes infarcted and undergoes necrosis, cell lysis leads to the release of various cardiac enzymes whose levels can be used to diagnose a myocardial infarction
nitroglycerin	used as a vasodilator, especially in angina pectoris
defibrillation	to arrest the fibrillation of heart muscle by applying an electrical shock across the chest that results in restoration of a normal heart rhythm
heparin	an anticoagulant that works by inhibiting the action of thrombin on fibrinogen, two proteins of the clotting cascade

 

 

Infarction of cardiac muscle located near the posterior interventricular sulcus would most indicate a blockade of the left anterior descending artery branch of the right coronary artery.

 

Circumflex artery supplies most of the left atrium and a prtion of the ventricle

 

The left descending artery branch of the left coronary artery supplies the anterior part of the interventricular septum

 

Left coronary artery =è left ventricle and part of the left atrium.

 

Marginal artery =è right ventricle

 

 

 

Bipolar disorder involves cycles of mania and depression.

Signs and symptoms of mania include discrete periods of:

 

• Increased energy, activity, restlessness, racing thoughts, and rapid talking

 

• Excessive “high” or euphoric feelings

 

• Extreme irritability and distractibility

 

• Decreased need for sleep

 

• Unrealistic beliefs in one’s abilities and powers

 

• Uncharacteristically poor judgment

 

• A sustained period of behavior that is different than usual

 

• Increased sexual drive

 

• Abuse of drugs, particularly cocaine, alcohol, and sleeping medications

 

• Provocative, intrusive, or aggressive behavior

 

• Denial that anything is wrong

 

Signs and symptoms of depression include discrete periods of:

 

• Persistent sad, anxious, or empty mood

 

• Feelings of hopelessness or pessimism

 

• Feelings of guilt, worthlessness, or helplessness

 

• Loss of interest or pleasure in ordinary activities, including sex

 

• Decreased energy, a feeling of fatigue or of being “slowed down”

 

• Difficulty concentrating, remembering, making decisions

 

• Restlessness or irritability

 

• Sleep disturbances

 

• Loss of appetite and weight, or weight gain

 

• Chronic pain or other persistent bodily symptoms that are not caused by physical disease

 

• Thoughts of death or suicide; suicide attempts

 

Depression: I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless...[I am] haunt[ed]..with the total, the desperate hopelessness of it all... Others say, “It’s only temporary, it will pass, you will get over it,” but of course they haven’t any idea of how I feel, although they are certain they do. If I can’t feel, move, think or care, then what on earth is the point?

 

 

Hypomania: At first when I’m high, it’s tremendous...ideas are fast...like shooting stars you follow until brighter ones appear... All shyness disappears, the right words and gestures are suddenly there...uninteresting people, things become intensely interesting Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria... you can do anything...but, somewhere this changes.

 

 

 

Mania: The fast ideas become too fast and there are far too many...overwhelming confusion replaces clarity... you stop keeping up with it--memory goes. Infectious humor ceases to amuse. Your friends become frightened...everything is now against the grain..you are irritable, angry, frightened, uncontrollable, and trapped.

Recognition of the various mood states is essential so that the person who has manic-depressive illness can obtain effective treatment and avoid the harmful consequences of the disease, which include destruction of personal relationships, loss of employment, and suicide.

Manic-depressive illness is often not recognized by the patient, relatives, friends, or even physicians.

 

An early sign of manic-depressive illness may be hypomania--a state in which the person shows a high level of energy, excessive moodiness or irritability and impulsive or reckless behavior .

 

Hypomania may feel good to the person who experiences it. Thus even when family and friends learn to recognize the mood swings the individual often will deny that anything is wrong.

 

In its early stages bipolar disorder may masquerade as a problem other than mental illness. For example, it may first appear as alcohol or drug abuse, or poor school or work performance.

 

If left untreated, bipolar disorder tends to worsen and the person experiences episodes of full-fledged mania and clinical depression.

 

 

 

 

Treatment

• Most people with manic-depressive illness can be helped with treatment.

 

• Almost all people with bipolar disorder--even those with the most severe forms--can obtain substantial stabilization of their mood swings.

 

• One medication, lithium, is usually very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.

 

• More recently, the mood-stabilizing anticonvulsants carbamazepine and valproate have also been found useful especially in more refractory bipolar episodes. Often these medications are combined with lithium for maximum effect.

 

• Some scientists have theorized that the anticonvulsant medications work because they have an effect on kindling, a process in which the brain becomes increasingly sensitive to stress and eventually begins to show episodes of abnormal activity even in the absence of a stressor. It is thought that lithium acts to block the early stages of this kindling process and that carbamazepine and valproate act later.

 

• Children and adolescents with bipolar disorder are generally treated with lithium, but carbamazepine and valproate are also used.

 

• Valproate has recently been approved by the Food and Drug Administration for treatment of acute mania.

 

• The high potency benzodiazepines; clonazepam and lorazepam may be helpful adjuncts for insomnia.

 

• Thyroid augmentation may also be of value.

 

• For depression, several types of antidepressants can be useful when combined with lithium, carbamazepine or valproate.

 

• Electroconvulsive therapy (ECT) is often helpful in the treatment of severe depression and/or mixed mania that does not respond to medications.

 

• As an adjunct to medications, psychotherapy is often helpful in providing support, education, and guidance to the patient and his or her family.

 

• Constructing a life chart of mood symptoms, medications, and life events may help the health care professional to treat the illness optimally.

 

• Because manic-depressive illness is recurrent, long-term preventive (prophylactic) treatment is highly recommended and almost always indicated.

 

Obsessive-compulsive disorder (OCD), one of the anxiety disorders, is a potentially disabling condition that can persist throughout a person’s life. The individual who suffers from OCD becomes trapped in a pattern of repetitive thoughts and behaviors that are senseless and distressing but extremely difficult to overcome. OCD occurs in a spectrum from mild to severe, but if severe and left untreated, can destroy a person’s capacity to function at work, at school, or even in the home.

 

The following three case histories are typical for those who suffer from obsessive-compulsive disorder--a disorder that can be effectively treated.

 

 

• Isobel is intelligent, but she is failing her first period class in biology because she is either late to class or absent. She gets up at five o’clock, hoping to get to school on time. The next three hours are spent taking a long shower followed by changing clothes repeatedly until it “feels right.” She finally packs and repacks her books until they are just right, opens the front door and prepares to walk down the front steps. She goes through a ritual of pausing on each step for a particular length of time. Even though she recognizes her thoughts and behaviors are senseless, she feels compelled to complete her rituals. Once she has completed these rituals, she makes a mad dash for school and arrives when first period is almost over.

 

 

• Meredith’s pregnancy was a time of joyous anticipation. If she had moments of trepidation about taking care of a new baby, these times passed quickly. She and her husband proudly brought a beautiful, perfect baby boy home from the hospital. Meredith bathed and fed the baby, comforted him when he was restless, and became a competent young mother. Then the obsessional thoughts began; she feared that she might harm her child. Over and over again she imagined herself stabbing the baby. She busied herself around the house, tried to think of other things, but the distressing thought persisted. She became terrified to use the kitchen knives or her sewing scissors. She knew she did not want to harm her child. Why did she have these distressing, alien thoughts?

 

 

• During his last year at college, John became aware that he was spending more and more time preparing for classes, but he worked hard and graduated in the top ten percent of his class with a major in accounting. He accepted a position at a prestigious accounting firm in his hometown and began work with high hopes for the future. Within weeks, the firm was having second thoughts about John. Given work that should have taken two or three hours, he was going over and over the figures, checking and rechecking, spending a week or more on a task. He knew it was taking too long to get each job done, but he felt compelled to continue checking. When his probation period was over, the company let him go.

 

 

KEY FEATURES OF OCD

• Obsessions

These are unwanted ideas or impulses that repeatedly well up in the mind of the person with OCD. Persistent fears that harm may come to self or a loved one, an unreasonable belief that one has a terrible illness, or an excessive need to do things correctly or perfectly, are common. Again and again, the individual experiences a disturbing thought, such as, “My hands may be contaminated--I must wash them”; “I may have left the gas on”; or “I am going to injure my child.” These thoughts are intrusive, unpleasant, and produce a high degree of anxiety. Often the obsessions are of a violent or a sexual nature, or concern illness.

 

·        Compulsions

 

In response to their obsessions, most people with OCD resort to repetitive behaviors called compulsions. The most common of these are washing and checking. Other compulsive behaviors include counting (often while performing another compulsive action such as hand washing), repeating, hoarding, and endlessly rearranging objects in an effort to keep them in precise alignment with each other. These behaviors generally are intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals while others have rituals that are complex and changing. Performing rituals may give the person with OCD some relief from anxiety, but it is only temporary.

 

·        Insight

 

People with OCD usually have considerable insight into their own problems. Most of the time, they know that their obsessive thoughts are senseless or exaggerated, and that their compulsive behaviors are not really necessary. However, this knowledge is not sufficient to enable them to stop obsessing or the carrying out of rituals.

 

• Resistance

 

Most people with OCD struggle to banish their unwanted, obsessive thoughts and to prevent themselves from engaging in compulsive behaviors. Many are able to keep their obsessive-compulsive symptoms under control during the hours when they are at work or attending school. But over the months or years, resistance may weaken, and when this happens, OCD may become so severe that time-consuming rituals take over the sufferers’ lives, making it impossible for them to continue activities outside the home.

 

·        Shame and Secrecy

 

OCD sufferers often attempt to hide their disorder rather than seek help. Often they are successful in concealing their obsessive-compulsive symptoms from friends and coworkers. An unfortunate consequence of this secrecy is that people with OCD usually do not receive professional help until years after the onset of their disease. By that time, they may have learned to work their lives--and family members’ lives--around the rituals.

 

·        Long-lasting Symptoms

 

OCD tends to last for years, even decades. The symptoms may become less severe from time to time, and there may be long intervals when the symptoms are mild, but for most individuals with OCD, the symptoms are chronic.  

 

 

 

 

Panic Disorder occurs in one out of every 75 people and usually appears during the teens or early adulthood.  Many times Panic Attacks can be triggered by a stressful event along with a  physiological response. 

 

 There is a connection with  major life transitions which are potentially stressful: such as graduating from college, getting married, having a first child, and so on.

 

 There is more risk of it occurring if there is a genetic predisposition; or if a family member has suffered from panic disorder;  or when a person is experiencing a time in his/her life that is particularly stressful.

 

A panic attack is a sudden surge of overwhelming fear that comes without warning and without any obvious reason. It is far more intense than the feeling of being 'stressed out' that most people experience. Symptoms of a panic attack include:

• racing heartbeat
• difficulty breathing, feeling as though you 'can't get enough air'
• terror that is almost paralyzing
• dizziness, lightheadedness or nausea
• trembling, sweating, shaking
• choking, chest pains
• hot flashes, or sudden chills
• tingling in fingers or toes ('pins and needles')
• fear that you're going to go crazy or are about to die

Several classes of medication can reduce or prevent panic attacks and therefore substantially decrease patients' anticipatory anxiety about having attacks. The medications most often used are:

Antidepressants, including tricyclics, monoamine oxidase inhibitors, and serotonin reuptake inhibitors;

Certain high-potency benzodiazepines

 

Each of these classes of medications works differently and has different side effects. The latest information about the pharmacotherapy of panic and related disorders is available in clinical handbooks of psychotherapeutic medications. For most of these medications, treatment lasts 6 months to a year. With all of them, proper dosing and monitoring is essential.

The practitioner who administers medication for panic disorder should be well versed in the clinical use of the relevant psychotherapeutic medications. It is important to start with a low dose and increase it gradually. Build up to the recommended dosage for the particular medication you are prescribing, watching for troublesome side effects as well as for a decrease in panic attacks. The goal should be to stop the panic attacks. Make sure the patient is maintained on a dose that is in the therapeutic range. When withdrawing medication, reduce the dosage gradually, and watch for possible relapse. To improve compliance, it is important to educate the patient about the medication and its side effects.

 

 

trt: alprazolam = xanax = benzodiazepine

 

What are the different kinds of antidepressants?

There are many different kinds of antidepressants, including:

·         Selective serotonin reuptake inhibitors (SSRIs)

·         Tricyclic antidepressants (tricyclics)

·         Others

SSRIs

SSRIs are a group of antidepressants that includes drugs such as citalopram (brand name: Celexa), fluoxetine (brand name: Prozac), paroxetine (brand name: Paxil) and sertraline (brand name: Zoloft). These medicines tend to have fewer side effects than the tricyclics. Some of the side effects that can be caused by SSRIs include dry mouth, nausea, nervousness, insomnia, headache and sexual problems. People taking fluoxetine might also have a feeling of being unable to sit still. People taking paroxetine might feel tired. People taking sertraline might have runny stools and diarrhea.

Tricyclics

The tricyclics have been used to treat depression for a long time. They include amitriptyline (brand name: Elavil), desipramine (brand name: Norpramin), imipramine (brand name: Tofranil), nortriptyline (brand names: Aventyl,  Pamelor) and trimipramine (brand name: Surmentil). Common side effects caused by these medicines include dry mouth, blurred vision, constipation, difficulty urinating, worsening of glaucoma, impaired thinking and tiredness. These antidepressants can also affect a person's blood pressure and heart rate.

Other antidepressants

Other antidepressants exist that have different ways of working than the SSRIs and tricyclics. Commonly used ones are venlafaxine, nefazadone, bupropion, mirtazapine and trazodone. Less commonly used are the monoamine oxidase inhibitors (MAOIs).

Some of the most common side effects in people taking venlafaxine (brand name: Effexor) include nausea and loss of appetite, anxiety and nervousness, headache, insomnia and tiredness. Dry mouth, constipation, weight loss, sexual problems, increased blood pressure, increased heart rate and increased cholesterol levels can also occur.

Nefazodone (brand name: Serzone) can cause headaches, blurred vision, dizziness, nausea, constipation, dry mouth and tiredness. This drug may cause serious liver problems in some patients, although this is not common. Bupropion (brand name: Wellbutrin) can cause agitation, insomnia, headache and nausea. Mirtazapine (brand name: Remeron) can cause sedation, increased appetite, weight gain, dizziness, dry mouth and constipation. Some of the most common side effects of trazodone (brand name: Desyrel) are sedation, dry mouth and nausea.

MAOI antidepressants like phenelzine (brand name: Nardil) and tranylcypromine (brand name: Parnate) commonly cause weakness, dizziness, headaches and tremor.

 

Drug Class	Primary Effects/Approved Medicinal Uses	Examples
Opiates/Opioids/Narcotic Analgesics	analgesia, cough suppression, antidiarrhea, suppression of opiate withdrawal, sedation; currently used therapeutically for the first four effects	opium, morphine, codeine, heroin  (diacetyl morphine), fentanyl, methadone, meperidine, L-alpha-acetylmethadol (LAAM)
Narcotic/Opiate Antagonists	block the effects of narcotics; used to treat opiate overdose	naloxone, naltrexone
Psychomotor Stimulants	stimulate psychological and sensory-motor functioning; used therapeutically to treat ADHD and narcolepsy, sometimes as an appetite suppressant, occasionally antifatigue, formerly for asthma and for sinsus decongestion	amphetamine, methamphetamine, cocaine, methylphenidate
Other Stimulants	similar to psychomotor stimulants but with much less efficacy; various therapeutic effects including caffeine compounded with aspirin in some OTC pain relievers, ephedrine in OTC asthma medicines, pseudoephedrine in OTC sinus decongestants and OTC appetite suppressants	caffeine, nicotine, ephedrine, pseudoephedrine
Barbiturates	general decrease in CNS arousal/excitability level; used therapeutically for anesthetic, anticonvulsant, sedative, and hypnotic effects	thiopental, secobarbital, pentobarbital, phenobarbital
Minor Tranquilizers	general decrease in CNS arousal/excitability level, but low dose are somewhat selective for anxiety and much less sedative than barbiturates; used therapeutically as anxiolytics, benzodiazepines also as anesthetics and anticonvulsants	includes two subclasses: benzodiazepines (e.g.,. diazepam, chlordiazepoxide, flunitrazepam [Rohypnol]) and muscle relaxants (e.g., meprobamate)
Major Tranquilizers (antipsychotics/neuroleptics)	general sedation at high doses, with selective antipsychotic activity at lower doses; used therapeutically to treat schizophrenia and other major psychotic disorders	haloperidol, pimozide, flupenthixol, chlorpromazine, spiroperidol, clozapine
Antidepressants	no perceptible CNS effects in normals, but effectively alleviate depression in many depressives; used therapeutically to treat depression	includes three subclasses: ·        monoamine oxidase inhibitors (e.g., pargyline), ·         tricyclic antidepressants (e.g., amitriptyline, desmethylimipramine), ·        selective serotonin reuptake inhibitors (SSRIs: e.g., sertaline)
Antimanic	dampens extreme mood swings in some people; used to treat manic-depressive (bipolar) disorders	lithium
Alcohol	general decrease in CNS arousal/excitability level; no current therapeutic uses, but formerly used as an anesthetic and a sedative	ethyl alcohol (other alcohols have similar actions but are associated with very toxic effects, e.g., methanol)
Volatile Anesthetics	general decrease in CNS arousal/excitability level; used therapeutically for anesthesia	nitrous oxide, halothane, ether
Volatile Solvents	produce feelings of intoxication, can produce hallucinations at high doses; no therapeutics uses (all can cause marked brain damage in moderately low concentrations	toluene, benzene, naphtha
Psychogenics	produce altered states of consciousness; hallucinogenics produce hallucinations sometimes reported as "mystic" experiences; cannabinoids usually produce increased feelings of "well being" and "mellow" intoxication; the "pleasantness" of the states produced by both classes probably depends partially on expectancies; no approved therapeutic uses, but cannabinoids are being increasingly used for their antinausea, anxiolytic, and appetite-stimulating effects in severely ill patients (e.g., AIDS)	includes two subclasses: hallucinogenics (e.g., lysergic acid diethylaminde [LSD], mescaline, psilocybin) and cannabinoids (e.g., marijuana, hashish).
Stimulatory Hallucinogenics (cf. former psychotomimetics)	produce a mixture of psychomotor stimulant and hallucinogenic effects, depending on dose and other factors; no therapeutic uses, except phencyclidine as a veterinary anesthetic	MDMA (ecstasy), phencyclidine (PCP), ketamine (?)
Abbreviations: ADHD, attention deficit hyperactivity disorder; AIDS, acquired immune deficiency syndrome; CNS, central nervous system; OTC, over-the-counter (nonprescription) medicines.