Brain 101 Info (Merged) PDF

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info 1
BEHAVIORAL SCIENCE
Bipolar I is characterized by manic and depressive episodes but could be by a manic
episode alone.
Bipolar II is hypomania and depression .. never manic
Id says: "I want it!"
Superego says: "you know you can't have it!"
Ego is the mediator between the two and deals with the conflict.
- the ego id and superego operates on an unconscious level.
the id is all your instincts ,the things that you would do if you did not have a super
ego who will say stop so the super ego is ALL THE MORAL VALUES THAT A
PERSON WILL HAVE LIKE IF YOU WANT TO STEAL SOMETHING
(ID)THE SUPEREGO WILL SAY NO IT IS BAD (IT IS NOT MORAL)
The ego links both of them. The ego controls the expression of the id so it can
adapt to the external world.
Hardy-Weinberg Law
--------------------
Developed in 1908, the Hardy-Weinberg law is an algebraic formula to estimate the
frequency of a dominant or recessive gene in a population based on the frequency with
which the trait or condition is found in that population.
The derivation takes several steps, but the final formula is...
p2 + 2pq + q2
...in which...
p = frequency of the dominant allele in a population
q = frequency of the recessive allele in the population, and
p + q = 1
Using the frequency for a condition known to be inherited in either an autosomal-
recessive or autosomal-dominant manner, the frequency of the genes involved can be
assessed. This can be important information in designing and delivering programs to
screen for specific mutant genes in targeted populations.
An Example: Cystic Fibrosis
Cystic fibrosis is a recessive condition that affects 1 in 2,500 Caucasian babies. What is
the frequency of the gene responsible for cystic fibrosis in the Caucasian population?
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If...
we say that affected individuals have the aa genotype, and
the frequency of the aa genotype is indicated by q2 in the Hardy-Weinberg equation
...then...
q2 = 1/2,500 and q equals the square root of 1/2,500, or
q = 1/50 = 0.02
The frequency of the cystic fibrosis allele in the Caucasian population is therefore 2%
(0.02).
Since...
p + q = 1
...then...
p = 1 0.02 = 0.98
The frequency of the "normal" allele in the Caucasian population is therefore 98% (0.98).
Lastly, since...
2pq = frequency of heterozygotes or carriers
...then in this example...
2pq = 2 _ 0.98 _ 0.02 = 0.04
That is, 1 in 25 Caucasians (0.04) are carriers of the cystic fibrosis gene.
These numbers differ in other subpopulations (such as racial or ethnic groups) of the
world.
It is important to note that with random mating, no selection or mutation there will be no change
in gene frequencies. The recessive trait does not die out, and it is possible that in fact the
recessive trait may be very much more common than the dominant trait!
SAMPLE PROBLEMS
Hardy-Weinberg Problem
1) If 9% of an African population is born with a severe form of sickle-cell anemia (ss), what percentage of
the population will be more resistant to malaria because they are heterozygous(Ss) for the sickle-cell
gene?
- Ans. 9% =.09 = ss = q
2
()s = q = Square root of .09 = .3
p = 1 - .3 = .7
2pq = 2 (.7 x .3) = .42 = 42% of the population are heterozyotes (carriers)
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2) After graduation, you and 19 friends build a raft, sail to a deserted island, and start a new population,
totally isolated from the world. Two of your friends carry (that is, are heterozygous for) the recessive cf allele,
which in homozygotes causes cystic fibrosis.
A. Assuming that the frequency of this allele does not change as the population grows, what will be the
instance of cystic fibrosis on your island?
B. Cystic fibrous births on the island is how many times greater than the original mainland. The frequency of
births on the mainland is .059%.
- Ans.
A. There are 40 total alleles of the 20 people of which 2 alleles are cystic fibrous causing.
2/40 = .05 the of the cystic fibrous allele
thus cc or q
2
= (.05)
2
=.0025 or .25% of the population will be born with cystic fibrous.
B. 0.25/.059 = about 4 times greater occurrence
Hardy-Weinberg Problem 3
This is a classic data set on wing coloration in the scarlet tiger moth (Panaxia dominula).
Coloration in this species had been previously shown to behave as a single-locus, two-allele
system with incomplete dominance. Data for 1612 individuals are given below:
White-spotted (AA) =1469 Intermediate (Aa) = 138 Little spotting (aa) =5
Calculate the following frequencies:
(_)A =
(_)a =
(_)AA =
(_)Aa =
(_)aa =
Solution to Problem 3
(_)A = (2 * (1469) + (138))/(2 * (1469 + 138 + 5)) = .954 or 95.4% Q: How did we arrive at this
data?
(_)a = 1 - .954 = .046 or 4.6%
(_)AA = (.954) 2 = .910 or 91%
(_)Aa = 2 (.954)(.046) = .087 or 8.7%
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(_)aa = (.046) 2 = .002 or .2%
Ans. genotype___Number______A__________a_________Total
AA_________1469____2*1469(2938)___0__________2938
Aa__________138_______138________138__________276
aa____________5_________0_______2*5(10)________10
Totals_____1612______3076________148_________3224
now let's count frequency
Frequency of A = 3076/3224 =95.4%
Frequency of a = 148/3224(or 1-A= 1-95.4%)= 4.5%
> Another good sample problem on H-W Equation:
In a certain place in Europe, it was found out that the prevalence of a newly discovered autosomal
recessive disorder is 1/100. What is the carrier frequency of this disease?
Ans. 0.18 using Hardy-Weinberg
Explanation: Prevalence is = q^2=1/100=0.01
so q= 1/10=0.1
carrier frequency = 2pq
p= 1-q = 1-0.1=0.9
carrier= 2*0.1*0.9= 0.18
So the carrier frequency is 0.18
TYPE 1 vs. TYPE 2 ERROR
In Type 1 error, null hypothesis is rejected when it is actually true. Is it the same as false
negative error??? In one note it was given as false positive.
Pl clarify
thanks
- Ans. It's not the same.
The sensitivity of a test is a measure of its ability to detect the presence of a
disease in those who
truly have the disease (true positive)
- The specificity of a test is a measure of its ability to detect the absence of a
disease in those who
truly have no disease (true negative)
- I find a simple explanation of type I vs type II here:
> I just want to share - - I asked this from my review class: what's the difference between type I (alpha) and type II
(beta) error ?
Our mentor answered us with a question from qbank:
A group of researchers mistakenly conclude from a poorly designed experiment that acetaminophen cures the common
cold. They have committed what error?
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Answer: Type I error
Explanation: First we know that..
null hypothesis (Ho): no difference
alternative hypothesis (H1): there is difference
Type I error is rejecting the null hypothesis, when in fact it should not be rejected. Therefore, the study has really no
difference or the study is really not significant. But since he made the type I error, the researcher thought that it has
difference or it is significant.
In type II error, null hypothesis is not rejected, when in fact it should be rejected. Therefore, the study really has
difference or the study is really significant. But since he made the type II error, the researcher thought that it has
no difference or it is not significant.
-> To change the question above to make a type II error:
A group of researchers mistakenly conclude from a poorly designed experiment that acetaminophen has no effect on
the common cold. They have committed what error?
Answer: Type II error
Part I (ETHICS)
RULES OF ETHICS (Posted by SMART DOC from IP 202.141.238.2 on August 13,
2002 at 08:40:490).
HOW TO DEAL WITH A DYING PATIENT:
1) Tell the patient EVERYTHING. There is no excuse for not doing so. If you know,
the patient knows.
2) DO NOT GIVE FALSE HOPE
3) Allow the person to talk about his feelings
4) Kept he patient involved in social activities
5) Avoid social isolation
GENERAL RULES:
1) Substituted judgment: when a patient cannot make a decision, the decision is
made based on what is thought WOULD BE that persons choice. The decision is
finally made by who is most likely to represent the patients own wishes (not
necessarily who is closest next of kin).
2) Best interest standard: trying to determine what a never-competent patient
would have wanted is practically impossible.
When you are not clear about the patients wishes, you should make the decision as a
dispassionate, rational observer: do what a rational person would do. It is not your
personal preference is. DO WHAT MOST PEOPLE WOULD WANT in this
circumstance. What would a jury of 12 people do if they knew what I know?
Who makes the decision is not really important: anybody using the best interest
standard should arrive to the same decision.
You must set aside your personal preferences: like strong religious beliefs (that is
considered irrelevant)
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As a general rule, parents cannot withhold treatment from their children. Yet, in
Infant Does case, they did. In this case, the best interest standard rule was applied.
3) Patients decide over their own bodies: The patient ALWAYS MAKES THE
DECISION.
This was decided over the ROE vs WADE case in 1973, the case that made abortion
legal. The issue will never be over abortion in the USMLE, but it illustrates the
principle that governs medicine in the US: the patient always decides, and the only
thing a doctor can do is lay out the possibilities.
SPECIFIC RULES:
Rule #1: Competent patients have the right to refuse medical treatment, no matter
what.
Rule #2: Assume that the patient is competent unless clear behavioral evidence
indicates otherwise.
-Drunk, schizophrenia, Alzheimers: these are all medical dg. DIAGNOSIS SAYS
NOTHING ABOUT THE LEGAL COMPETENCE OF A PERSON!!!
Competency can ONLY be decided by a COURT OF LAW: it is not a medical dg, it
is not a blood alcohol level!
Clear behavioral evidence of incompetence:
Attempted suicide
Patient is grossly and evidently psychotic and dysfunctional
Patients physical or mental state prevents communication
However, when in doubt, assume competency!
Rule #3: Decision-making should occur in clinical setting if possible, without going
to court. Normally, the USMLE will want YOU to make the decision: try to avoid the
answer that says go to court, unless it is clearly stated that the guardian (ex: parent
of a sick child) is NOT acting in the patients best interest. And that is only if the case
is not an emergency: if it can wait going to court.
Rule #4: When surrogates make decisions for a patient, they should use the following
criteria and in this order:
1) Patient expressing wishes in the past: what historically did the patient say in the
past? (wish for organ donation expressed to relative, for example)
2) What would the patient want? : Substituted judgment
3) Best interest standard: what would most people want
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Rule #5: If patient is incompetent, physician may rely on advance directives
Directives that a patient can leave for his doctor before becoming incompetent:
- Can be oral directive from patient to his doctor: does NOT necessarily have to be
a written document.
- Can be living will: expression in writing, notarized, by the patient.
- Health powered attorney: person that was named by the patient to represent him.
TREAT THIS PERSON AS THE PATIENT HIMSELF, IN TERMS OF
DECISIONS: this person is the VOICE of the patient: a health powered attorney
BEATS ALL OTHER CHOICES ON THE USMLE (it is the patient talking to
you).
Rule #6: Feeding tube is a medical treatment and can be withdrawn at the patient's
request. A competent patient has the right to refuse hydration and nutrition. Period.
In the case of anorexia nervosa: if the patient is a minor: not legally competent. If
NOT a minor: go to court.
Refusing food and water: may seem close to euthanasia, but on the exam this is
accepted.
Rule #7: Do nothing to actively assist the patient to die sooner. Do not ACTIVELY
do anything (as opposed to number 6)
Rule #8: the physician decides when the patient is dead.
Futile treatment: means a treatment that is not AND WILL NOT improve anything.
Still, if the patient or the family want the treatment to continue: it is not YOUR
decision, it is the patients or the patients family.
In case of clear cortical death: even if the family is hoping for a special doctor to
arrive, for a special treatment to come: CALL THE DEATH.
Rule #9: Never abandon a patient: even if they cant pay you, even if you dont like
the patient. If you simply CANNOT continue to be the doctor to this patient: you
need to arrange that he will have care and make sure that they are getting it.
Never, ever threat to abandon your patient (not even if you are doing it to make sure
they follow treatment).
Rule #10: Always obtain informed consent: before you do ANYTHING!!!
Informed consent can be oral.
The patient can revoke written consent orally, at any moment
Of the patient signs consent without reading it: it is NOT INFORMED CONSENT
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Informed consent: means that the patient understands:
1) Nature of the procedure
2) Purpose or rationale
3) Benefits of treatment or procedure
4) Risks
5) Availability of other alternatives
GAG CLAUSES: you work for an institution that tells you not to discuss certain
procedures or possibilities. THEY ARE ILLEGAL.
Exceptions to informed consent:
1) Emergency situation
2) Waiver by the patient: the patient says its OK not to know what is going to happen
(exploratory surgery, drug undergoing trial to know side effects)
DO NOT ASSUME YOU HAVE A WAIVER UNLESS THE USMLE TELLS YOU.
3) Patient is incompetent
4) Therapeutic privilege: doctors have the right and obligation to deprive the patient
of their autonomy in the interest of the patient and other people. Ex: patient on PCP,
violent and dangerous: put him on restraints!
Rule #11: Special rules apply with children
Rule #12: Parents cannot withhold life- or limb-saving treatment from their children
Rule #13: For the purposes of the USMLE, issues governed by laws that vary widely
across states cannot be tested
Rule #14: Good Samaritan Laws limit liability when physicians help at accidents
Rule #15: Confidentiality is absolute
Rule #16: Patients should be given the chance to state DNR (Do Not Resuscitate)
orders, and physicians should follow them
Rule #17: Committed mentally ill patients retain their rights
Rule #18: Detain patients to protect them or others.
Rule #19: Remove from patient contact health care professionals who pose risk to
patients
Rule #20: Focus on what is the best ethical conduct, not simply the letter of the law
I looked it up:
Rule # 8 says this:
- if there are no more treatment options (if the patient is cortically dead), and the
family insists in treatment?: if there are no options and there is nothing the
physician can do, it is his duty to stop the treatment. (The USMLE wants you to
be able to make decisions when the patient is DEAD)
- - if the physician thinks tratment is futile and the patient won't improve, but the
patient (or surrogate) insists on continued treatment: then treatment must
continue.
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Rule # 17:
Commited mentally ill adults legally are entitled to the following:
- they must have treatment available
- they can refuse treatment
- they can command a jury trial to determine sanity
They lose only the civil liberty to come and go
they retain their competence for everything UNLESS A COURT OF LAW DECIDES
they are incompetent.
The underlying rule here is that no matter what the psychiatric diagnosis is, treat the
patient as you would any other competent person (unless they show signs of clear
incompetence, stated on #2)
rule #20: Focus on what is most ethical. USMLE wants you to pick the answer where
there are no doubts that it is the most ethical thing to do. In other words, don't worry
about being fired, sued or that your hospital may go to shreds if you do the "right
thing". ACT NOT AS A LAWYER WOULD, BUT AS MOTHER THERESA
WOULD.
There is also something interesting that they pointed out: what do you do if you find
out a collegue or fellow resident is having a substance abuse problem? Who do you
talk to?
RULES:
- talk to the collegue and REMOVE him from patient care
- if there is a direct employer or supervisor (like your residency program director) :
TELL THE SUPERVISOR. Failure to do so will endanger patients, and will
ALWAYS be the worong answer on the USMLE.
What they meant was: the best way to get someone to treatment is if their employer
forces them to: if they are afraid to lose their job. So don;t waste time talking to the
person or the family or anyone: go to the supervisor.
Part 2 (ETHICS)
Ethical Terms
Autonomy
The principle of autonomy, or self-determination, entails respecting the choices and wishes of
persons who have the capacity to decide and protecting those who lack this capacity. This
principle would be used when a physician who has discussed preferences about life-sustaining
treatment with a woman who has just been diagnosed with metastatic breast cancer is then
guided by those wishes.
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Beneficence
The principle of beneficence advises physicians to benefit patients and protect their interests,
whereas the principle of nonmaleficence encompasses the oft-quoted phrase, "Above all, do no
harm." Physicians must balance the risks and benefits of any proposed treatment. An example of
beneficence would include a physician who refuses to provide a prophylactic mastectomy for a
patient who fears cancer but does not have any unusual risk factor for the disease.
Justice
The principle of justice entails providing persons with that to which they are entitled and treating
similar cases similarly. Together, the principles comprise the foundation of ethical principalism,
the dominant approach in bioethics today.
Informed Consent
The ethical foundation on informed consent can be traced to the promotion of two values:
personal well-being and self-determination. To ensure that these values are respected and
enhanced, patients who have the capacity to decide their care must be permitted to do so
voluntarily and must be provided all relevant information regarding their condition and
alternative treatments, including possible benefits, risks, costs, other consequences and
significant uncertainties surrounding any of this information.
Informed consent is a two-art process involving disclosure by the health care professional and a
decision by the patient. If health care professionals support a patient's right to make informed
choices, they must respect the patient's decision regarding whether to accept or decline treatment.
The consent form provides written documentation of the patient's decision but it is not a
substitute for a thorough discussion between their physician and the patient.
Three elements of informed consent must be considered. These elements include (1) the
information to be discussed, including the nature of the intervention described in sufficient
detail, (2) the patient's comprehension, (3) the patient's decisional capacity and (4) the voluntary
nature of the decision. The physician should carefully discuss the proposed purpose of the
intervention, including how any knowledge gained from the procedure will change the treatment
course or outcome. The likely risks of the proposed intervention must be fully disclosed together
with a discussion of their severity and likelihood. The likely benefits of the proposed
intervention should be explained.
Life-Sustaining Treatment
Life-sustaining treatment may include but is not limited to a mechanical ventilator, renal dialysis,
chemotherapy, antibiotic thereapy and artificial nutrition or hydration. Physicians, ethicists and
lawyers widely agree that withdrawing or withholding life-sustaining treatment is legally and
ethically permissible under appropriate circumstances. In fact, ethical and legal principles require
that physicians respect the decision to forego life-sustaining treatment by a patient who has
decisional capacity. However, if a physician is morally opposed to the patient's treatment
preferences, the physician may transfer care to another physician who is more comfortable with
the patient's wishes.
In addition, a competent patient may make his wishes known in advance of losing the ability to
make health care decisions, such as a living will. In such cases, physicians are morally and
legally required to follow these health care preferences to the extent permissible by law.
Medical Futility
Situations in which a patients underlying diagnosis or diagnoses impart a terminal or poor
prognosis thus rendering specific medical interventions unhelpful and possibly detrimental.
Medical Treatment Options
Cardiopulmonary Resuscitation (CPR) in Older Persons
The indications for CPR have changed considerably since its inception in 1960. Initially a
treatment for sudden death in the setting of an acute myocardial infarction, CPR has become a
procedure utilized in death from any cause. In the absence of a Do Not Resuscitate (DNR) order,
CPR is often done by default, despite a growing body of literature that indicates CPR is often
ineffective, particularly in persons dying of non-cardiac, multi-system diseases.
Several studies have evaluated the efficacy of CPR in older persons. In frail older persons who
are dependent in their activities of daily living, CPR is usually not effective. Less than 2% of
patients living in nursing facilities who receive resuscitation survive. Those who do survive are
often more debilitated than before the cardiac arrest. The outcomes of older adults in the
community who have a cardiac arrest are equally poor.
Functionally, active older persons with primarily cardiac disease, who suffer a witnessed arrest
in the hospital, may fare better. Hospitalized older patients suffering cardiac arrest have a
survival rate of 26%. Some patients are more functionally dependent after the arrest. When
people begin to develop functional disability and accrue chronic illnesses, their survival drops
precipitously, regardless of age.
Artificial Feeding Near the End of Life
Food is an essential requirement of life and without it death is certain. The symbolic nature of
food is very powerful and firmly rooted in our culture and religious beliefs. As such, the decision
to not provide food is often a difficult one.
The delivery of food through artificial means is a medical therapy. It may be instituted,
withdrawn or refused like any other medical treatment. However, a person must declare clearly
that they do not want artificial feedings. This statement can be as simple as: "If I were to become
so ill that I could not talk meaningfully with my family and the hope of me regaining that ability
was small, I would not want artificial feeding." It is useful to have statements like this included
in the Health Care Proxy form (HCP), or to state in the form that your health care agent knows
your wishes regarding artificial feeding. If a person feels strongly that they would always want to
have artificial feeding, they should make sure their health care agent knows their wishes (and if
they have a HCP they should note this on the form).
Much of the information about what happens to people when they decide to forego artificial
feeding comes from the hospice and oncology literature. People working in hospice have noted
that their patients suffer very little because of not eating. Dying patients who choose not to have
foods delivered by artificial means, do not suffer from hunger and thirst. Patients that do
experience hunger and thirst, can have their symptoms relieved with mouth care, and small
amounts of food and fluids that they chose to eat.
Studies in the oncology literature have shown that cancer patients have a higher mortality and
morbidity who when they receive aggressive artificial feeding, in comparison to those that do
not. In patients with strokes who are fed with gastrostomy tubes, the median time of survival is
only 53 days (range 2 - 528 days), with only 12% of the patients surviving for more than three
months. No study has shown that dying patients live longer or are more comfortable as a result of
artificial feeding. Enteral tube feedings are not without side effects. One of these side effects is
aspiration pneumonia, which occurs in 50% of patients. When feeding tubes are used in patients
with confusion or dementia, self extubation is common and often results in the use of restraints.
Some rules of thumb to consider:
Dying patients should choose what they want to eat, when they want to eat and the amounts of
food that they want to eat.
For some patients, the act of eating is still important even though they may eat only very small
amounts of the food presented to them.
Almost all dietary restrictions should be lifted in older adults especially for dying persons.
Food should be fed but never forced.
Education of family and caregivers concerning artificial feeding is very important.
Food should never be withheld from a dying patient who desires it.
Artificial feeding has substantial risks, especially aspiration and self-extubation, that often results
in the use of restraints.
To date, no studies have demonstrated that artificial feeding improves morbidity or mortality in
dying patients.
None of the predominant religions in the USA demand that artificial feeding be administered to
dying patients. All are firm however, that food never be withheld from a patient who wants it, or
with the intent to cause pain or death.
Severe anorexia and loss of thirst is often part of the dying process, no matter what the cause.
Organ function slows and metabolic processes shut down.
Re: DNR
Do Not Resuscitate (DNR), without any qualification means no cardiopulmonary
resuscitation. It does not mean terminate treatment, or refrain from simple health-supporting
or even life-saving procedures. With DNR orders in place, a patient would still be given
medication and might even undergo surgery. What if the patient is choking, and in need of a
simple intervention to save his life. Nothing is implied by DNR that says we should not
perform the Heimlich maneuver. Do it.
Recall:
- 1. Two nominal - Chi square
2. Two interval - Pearson correlation
3. One nominal and one interval - T-test
4. mathematical based literature review- Meta analysis
NEUROTRAMSMITTER DISTURBANCE IN DIFFERENT DISEASES (Ref. P 130 FA) -
- Schizophrenia increase in dopamine and serotonin
- Depression decrease in dopamine ,serotonin (5HT) and norepinephrine
- Anxiety decrease in GABA (remember antianxiety drgudssuch benzodiazepins acts
onGABA receptors) and serotonin and increase in norepinephrine
- Mania increase in dopamine
- Alzheimer decrease in ACH
- Parkinsons Disease decrease dopamine
- Huntingtons Disease decreased GABA, decreased Ach
> US-PREVENTIVE SERVICE TASK FORCE
PRE-SERVICE-----SEX----AGE
physical-exam:-
---------------
BP-----------M/F------18 +----q 2YRS
CL- BREAST EXAM--F---50-69---q 1-2YRS
LABS-TESTS:-
PAP-SMEAR-------F---18-65 YRS----q 3 YRS
STOOL FOR OCCULT BLOOD---M/F--50+ YRS---ANNUALLY.
SIGMOIDDOSCOPY---M/F--50+YRS q ? YRS
MAMMOGRAPHY---F----50-69 YRS--q 1-2 YRS
CHOLESTROL---M----35-65 YRS---q ? YRS
---F----45-65 YRS
IMMUNIZATIONS:----
TETENUS-DIPTHERIA BOOSTER
M/F---18+ YRS---q15-30YRS
INFLUENZA-VAC---M/F--65+ YRS--ANNUALLY
PNEUMOCOCCAL VAC--M/F---65+YRS--ANNUALLY.
COUNSELLING----M/F----18+YRS----AT ROUTINE VISIT
(SOURCE- CMD 2003)
Note: PNEUMOCOCCAL VACCINE SHOULD BE GIVEN ONCE AFTER 65 YRS, NOT
ANNUALLY. (CDMT 2003)
RE: COMPETENCY
- Assume the patient is competent unless clear behavioral evidence indicates otherwise.
-Drunk, Schizophrenia, Alzheimers = all COMPETENT
-INCOMPETANT:
1. ATTEMPTED SUICIDE
2. PATIENT IS GROSSLY AND EVIDENTLY PSYCHOTIC AND DYSFUNCTIONAL
3. PATIENT'S PHYSICAL OR MENTAL STATE PREVENTS COMMUNICATION...
CAN EVERYONE TRY TO THINK OF EXAPMPLES OF 1, 2, AND 3!
are the following competant or not?
minor with anorexia nervosa?
Adult with anorexia?
Mentally retarded?
Autistic?
Personality disorder?
Murderer?
Drug addict (presently under influence of drug?)
- minor with anorexia , is still a minor, parents decide
adults with anorexia, competent
MR, not competent
autistic , not competent
personality disorder, if gross enough, incompetent, also if has history of suicide , then
definatLy not competenT
murderer, competent to make decisions for himself, unless, gross abnormal behaiour
observed
addict, under the inflence not competent.
- Hey guys ,I have seen a q about MR that u shouldNOT consider all of them
noncompetent!It depends on situation and some legal documents r needed(from court)that
shows he/she is incompetent.
- I think that mental retardation is Competant- they live by themselves, and can function in
society.
But what about Autimsm- i think Incompetant because they cannot communicate.
==============================================================
BEHAVIORAL SCIENCE QUESTIONS
1) A 60-year-old man with a 5-year history of stable angina pectoris sustains a head injury
in an automobile accident and dies. The family is contacted and consents to an autopsy.
Microscopic examination of a section of heart muscle would most likely reveal which of
the following pathologic findings?
A. Coagulative necrosis of the subendocardial muscle
B. Dense scar localized to the distribution of one coronary artery
C. Focal fibrosis and subendocardial myocardial vacuolization
D. Heavy neutrophilic infiltrate adjacent to a large area of coagulative necrosis
E. Transmural coagulative necrosis
- Ans. B.
Necrosis require 8-12 hours to form (reject A and E)
Neutrophils will be there in 4-6 hours (reject D).
C doesn't connect with stable angine at all. But may be a cause of arrhytmia.
2) A 72-year-old man is admitted to the hospital after suffering a stroke. His family comes
to visit him the next day only to discover that he does not recognize them. When visited
by the team of doctors, the patient seems to be able to recognize voices and sounds, but
claims that he has never seen his wife and son before. He seems confused because when
they talk to him their voices are just like the ones of his family members. Which of the
following is the most likely diagnosis?
A. Anosagnosia
B. Confabulation
C. Conversion disorder
D. Ganser syndrome
E. Prosopagnosia
- Ans. E, prosopagnosia....inability to recognise faces,due to destruction of part of
occipital lobe adjucent to area 21,22 of temporal lobe.
3) A 49-year-old patient is evaluated for suicidal ideation after he is found laying on train
tracks by police. The man is disheveled and malodorous and states that he has "reached
the end" and would rather die. He admits to depressed mood, anhedonia, poor energy and
appetite; he feels miserable and regrets what he has done with his life and wants to put an
end to it. He states he has felt this way since age 26, after he was discharged from the
military. The man indicates that his life was "great" until he increased his drinking, which
caused a divorce at age 30. He has had two arrests for driving under the influence. He
was in jail for 6 months after he had an accident while drunk that resulted in public
property damage. He remembers that he initially felt sick in jail, with sweating, vomiting,
shaking, and he experienced a seizure. He then improved after a few days and felt better
during the rest of his imprisonment without any depression. Which of the following
criteria most strongly suggests alcohol abuse?
A. Desire to cut down
B. Recurrent drunk driving
C. Seizure after withdrawal
D. Suicidal ideation
E. Tolerance
- Ans. C?
4) A 10y/old boy was noted for his extreme fear of water during his first day of swimming
lessons. The teacher helps the child sit on the edge of the pool and splash the water with
his feet. She then goes one step further and shows him how to wet his knees. It takes her
an hour to have him float on the water while holding his hand. What technique has the
teacher used to help the child conquer his fear of water?
A. Classical conditioning
B. Desensitization
C. Extinction
D. Flooding
E. Operant conditioning
- Ans. B?
5) The mother of a 6-year-old boy brings him to see the local pediatrician complaining that
the boy is enuretic from 4 to 5 times a week. She reports that the problem began in the
past few months after she gave birth to a baby girl. Breast-feeding for the new baby has
been difficult and has consumed a great deal of her time each day. She says that the boy
is very embarrassed about his enuresis and is afraid that the other children where he goes
to school will find out and make fun of him. She asks the physician help and advice. The
physicians best course of action would be to do which of the following?
A. Arrange to interview the boy about his condition
B. Direct her to have a serious discussion with her son about whether anything is
bothering him
C. Prescribe a course of imipramine for the boy
D. Refer the mother to a seminar on breast feeding
E. Send the boy to a child psychologist for counseling
F. Suggest that the mother block out some special time each day and give exclusive
attention to her son
G. Tell the mother that the boys problem is normal and temporary, and will soon pass if
left alone
- Ans. F?
6) A nurse on an inpatient internal medicine ward comes to see the attending physician.
While drawing blood for routine laboratory tests ordered by the medical staff, the nurse
inadvertently stuck herself with a hypodermic needle, in which were several drops of the
patient's blood. The nurse is anxious, and wants the physician to order that the patient's
existing blood sample be tested for HIV. The physician is aware that the patient has a
history of homosexual encounters, although neither the physician nor the nurse are aware
of the patient's HIV status. At this point, the physician should do which of the following?
A. Assure the nurse that the probability of contracting HIV by this method is relatively
low, but that she should be more careful in the future
B. Convene a meeting of the nursing staff and ask if anyone on the ward is aware of the
patient's HIV status
C. Order the test, as the nurse requests
D. Review the patient's chart and medical history for clinical signs consistent with HIV
infection
E. Talk to the patient and order the test only if the patient gives his permission
F. Tell the nurse that you will order the test if she can obtain the patient's permission.
- Ans. C or E?
7) A 36-year-old married woman complains to her physician that she is having trouble
sleeping. A detailed history shows that her insomnia is sporadic and seems to be
connected to cyclical stressors related to her working environment. The physician
prescribes alprazolam to be taken as needed. The next day, the physician receives a
distressed call from the patient. With anger in her voice, she tells the physician that the
pharmacist said that taking this medication might cancel out the effects of my birth
control pills. At this point the physicians next response should be which of the
following?
A. Im sorry. This is my fault. The problem is not very likely given the dose level I
prescribed and your only occasional use, but I should have discussed this issue with you
before.
B. Its not the pharmacists job to be tinkering with your medications. I suggest you
have the prescription filled somewhere else.
C. Its really such a small chance that it is not worth worrying about.
D. Really, its nothing to worry about. Ill call the pharmacist and work it out.
E. Really, there is no problem here. Pharmacists just like to show what they know.
F. The pharmacist is being overly cautious. As long as you take both medications as I
prescribed them for you, you will have no problem.
G. Well, if you dont like the drug I prescribed, what would you rather have?
H. You seem angry about this. Tell me more about what you are feeling right now
- Ans. A?
8) A 41-year-old married woman of Asian decent becomes pregnant with her first child.
During the course of routine prenatal care, the women undergoes a series of tests
checking on her health and the health of the fetus. The results of the tests suggest the
woman is in good health, but strongly indicate that her child will be born with Down
syndrome. When informed of this result the woman becomes visibly upset and begins to
cry. How could this happen to me? she says, God must be punishing me! At this
point the physicians best reply would be which of the following?
A. I dont think God has anything to do with this. This sort of thing just happens some
of the time.
B. I know it is hard to heard this kind of news, but let me assure you that you are still
young enough to have other children.
C. Lets take a moment to reflect and pray together for guidance.
D. Sometimes God works in mysterious ways that we can not understand. We just have
to try to keep our faith.
E. Take some deep breaths and try to relax. When you collect yourself, we can talk
about how you want to proceed.
F. Tell me a bit more about why you think God is punishing you.
G. The chances for Down syndrome are simply higher when a woman your age becomes
pregnant. Thats why we run these tests.
H. The real issue before us is, how do you want to proceed? Do you want to carry the
child to term or explore other options?
- Ans. E or H?
9) A 24 year old woman comes to see her male physician complaining of pain and stiffness
in the left lower quadrant of her back. During the physical examination to locate the
extent and severity of the pain she says, Wow, youve got great hands, Doc. Just having
you touch me helps me feel better. As the patient is getting dressed, she asks the
physician if he is married, and then asks if he ever dates his patients. The physician is
unmarried, is attracted to the woman, and would like to see her socially. At this point his
best action would be to do which of the following?
A. Begin to see the patient socially as long as she understands that it must be kept
separate from the medical relationship
B. Explain that as long as she is his patient, no social relationship is possible
C. Have the patient sign a liability waiver and begin to see her socially
D. Refer the patient to a colleague and begin to see her socially
E. Refer the patient to a colleague and refuse to see her socially
F. Refer the patient to a colleague, wait six months, and then begin to see her socially
G. Tell the patient that he will not pursue any social relationship with her, but that he
would like to continue to be her physician
- Ans. B?
10) A 64-year-old married man is admitted to the hospital complaining of abdominal pain.
Symptoms are consistent with cancer of the colon, and an MRI reveals a large abdominal
mass. The patient consents to surgery, and the mass is removed along with 1/3 of the
patient's colon. The report from the pathologist confirms that the mass was cancerous
and, further, that the tumor had extended though the colon wall, and metastasis is likely.
Under the circumstances, the physician estimates life expectancy at less than one year.
The patient has not yet been informed of either the extent of the cancer's spread or his
projected life expectancy. As the physician enters the patient's room to inform the patient
of the negative prognosis, the patient is sitting with his wife and teenage daughter. After
introducing himself, the best thing for the physician to say would be which of the
following?
A. "I have some bad news. Would you like to discuss it in private or would you like to
have your family present?"
B. "I have some things to discuss with you in private. Would you mind having your
family wait outside?"
C. "I'm glad that your family is here. Can any of you recall whether any of your close
relatives have ever had cancer?"
D. "I'm glad that your family is here with you. I have some things to discuss with you."
E. "This is the part of my job that I hate the most. I came here today to tell you that the
cancer has very likely spread."
F. "Well, lets get right to it. I'm afraid that I have some bad news."
G. "We need to talk about your condition. Would you like your family to be present?
- Ans. B or G?
11) A 34-year-old man comes to see his physician complaining of sore throat, stuffy nose,
and difficulty sleeping at night. The physician diagnoses him with a sinus infection and
writes him a prescription for a course of a common antibiotic. On the last day of the
prescribed course of antibiotics, the man calls his physician and leaves a message saying
that he is feeling better, but does not feel fully recovered. He asks, in his message, that
the physician calls the local pharmacy with a refill of his prescription for an additional 7
days so that I can really kick this thing. After he receives the message, the physicians
best course of action would be to do which of the following?
A. Call the local pharmacy and ask to have the prescription refilled
B. Call the patient and tell him that he will be fine and does not need any further
medication
C. Call the patient back and explain that antibiotics cannot be extended beyond the
normal course without the risk of side effects
D. Call the patient back and talk with him about his condition, and, if all seems well, call
the pharmacy to order that the prescription be refilled
E. Call the patient, schedule a follow-up appointment and reevaluate the patients
condition
F. Have the office nurse call the patient to schedule a follow-up appointment
- Ans. E
12) Which of the following diseases should be reported to the Department of Public Health?
A.Candida albicans infection
B. Condyloma acuminatum
C. Gonorrhea
D. HIV infection
E. Streptococcal pharyngitis
- Ans. C?
13) A 22-year-old, married woman presents with pain in her lower right abdomen. Her
abdomen is tender to palpation and there is rebound tenderness. The patient reports
nausea, and has a temperature of 38.3 C (101 F). A diagnosis of acute appendicitis is
made, and the patient consents to, and is scheduled for immediate surgery. Prior to the
surgery, the woman tells the surgeon that she is a practicing Catholic, and says that she
will pray for the successful completion of the surgery. Surgical examination of the
appendix reveals that it is normal and without inflammation. Examination of the
abdominal cavity reveals that the true underlying cause of the patients pain is an ectopic
pregnancy on the right side. At this point, what action should the surgeon take next?
A. Close the incision, wait until the patient recovers from anesthesia, and seek full
informed consent before proceeding
B. Consult the chief of surgery
C. Consult with the local Catholic chaplain about how to proceed based on the womans
expressed religious beliefs.
D. Seek permission to operate on the ectopic pregnancy from the womans spouse
E. Surgical intervention to deal with the cause of the pain
- Ans. I think it should be D. In nonemergency, answer is A.?
14) A primary care physician (Dr. Green) in a community of 100,000 people enters an
examination room to find a new patient sitting on a chair just inside the door. Although
the patient had been instructed by the nurse to remove her clothes and have a seat on the
examination table, the patient remains fully clothed, including her shoes. The patient
glances up briefly when the physician enters the room and closes the door, and then
returns her gaze to stare at the floor. She says nothing. At this point, the best thing for the
physician to say next would be which of the following?
A. "Didn't the nurse ask you to remove your clothes?"
B. "Hello, I'm Dr. Green. How are you feeling today?"
C. "I see that you are still dressed. Is there something you want to talk with me about?"
D. "OK. Hop up on the table and let's have a look at you."
E. "So, what brings you to see me today?"
F. "You seem a little depressed. Why don't you tell me about it?"
G. "You seem very quiet. I'll just sit here for a moment while you collect your thoughts."
- Ans. B?
15) A 16-year-old girl comes to see her physician for a standard physical examination prior to
attending summer camp. The examination is unremarkable. The girl falls within the
normal range for height and weight. The physician notes that she has had menses for the
past 4 years. As the girl is getting dressed, the physician sits and completes the required
forms for the camp. When handed the completed forms, the girl thanks the physician and
says, Just one more thing. Could you also give me a prescription for birth control pills?
Im going to camp with my boyfriend and want to be prepared. And please, please, dont
tell my parents! The physicians most appropriate reply would be which of the
following?
A. Before I write you that type of prescription, Id like to examine your boyfriend first.
B. How long have you been having sexual relations with your boyfriend?
C. I can only give you a prescription like that if I have your parents permission. Lets
set up a time to talk with them.
D. I wish you would reconsider. Sex before marriage can be very complicated.
E. Ill be glad to give you the prescription, but I want you to discuss things with your
parents first.
F. Ill be happy to give you a prescription, but lets talk about some important issues
first.
G. Ill make a decision about the prescription after I have a discussion with you and
your boyfriend. When should we schedule that?
H. Im pleased that you are responsible enough to be prepared. Ill be happy to give you
the prescription and see no reason to tell your parents.
- Ans. C or F?
16) A 76-year-old man of Korean descent goes to see his primary care physician complaining
of chest pains, difficulty breathing, and general fatigue. When interviewed, he answers
the physicians questions respectfully in a soft voice with little eye contact. When
questioned about any pain, he indicates that it is always with him. Subsequent
examination and testing leads the physician to suspect that the patient might have lung
cancer. When the possibility is mentioned to the patient, he becomes very quiet, stares at
the floor and says softly, but distinctly, I do not think I want to know this if it is true.
At this point the physicians best reply would be which of the following?
A. I know cancer can seem a bit frightening, but modern advances in treatment give us
some options you may not be aware of.
B. I understand the custom of your culture is not to discuss these things, but Ill need
you to work with me so we can beat this.
C. I understand your hesitation, respected Grandfather. I will work with your family if
that is what you direct.
D. Im sorry, but I will need your cooperation as we arrange treatment. I will need to tell
you and you will have some decisions to make.
E. If it is your wish, I will not tell you. Whom in your family should I talk to in your
place?
F. In this country, patients have to be told everything. Ill let you know when we have
more definitive information.
G. Lets wait until we know something definitive and then we can talk about things
further.
H. OK, Ill respect your wishes and not tell you.
I. Tell me a bit more about why you do not want to know.
- Ans. H or A?
17) A 25-year-old HIV-positive woman gives birth to a 6-pound baby boy at a local health
clinic. The woman has received no prenatal care. She is ecstatic about the birth, holds the
child closely, and talks softly to the child every chance she gets. Tests performed to
assess the childs HIV status return positive results. When told of these results, the new
mother appears unfazed, and says that she will just have to be an even better mother to
help the child through this. She requests a consultation with a breast-feeding counselor
because she says, I want to make sure I do this right. The physician tells her that breast-
feeding is not advisable, to which she replies, I know that breast-feeding is best, and I
want the best for my baby. The physicians best reply would be which of the following?
A. Im pleased that you are taking your responsibilities so seriously. Ill arrange an
appointment with the breast-feeding counselor for you myself.
B. If you insist on breast-feeding your child, the courts will remove the child from your
custody.
C. If you really love your child, you will do what is best and not breast-feed.
D. It is important that you listen to me carefully. Breast-feeding increases the risk to
your child. You must not do it.
E. Its wonderful to see how happy you are. We can talk a bit more about these things
after youve has some rest and have recovered from the birth.
F. Let me explain. A positive test when the child is this young is not definitive. But if
you breast-feed your child, you greatly increase the chances of your child contracting
HIV.
G. Yes, breast-feeding is best in most circumstances, but given your HIV status, I
strongly advise against it.
- Ans. F?
18) A 55-year-old male begins group therapy. After the first session, he befriends one of the
other clients, and begins telling her how extraordinarily intelligent and talented the
facilitator is. At the next session, he and the facilitator disagree. After the session, he tells
his fellow group member that the facilitator is utterly incompetent and that they should
sue for malpractice. This is an example of
A. displacement
B. fixation
C. reaction formation
D. regression
E. splitting
- Ans. E?
==============================================================
EPIDEMIOLOGY
Glossary
Accuracy: the extent to which a measurement or study result correctly represents the
characteristic or relationship that is being assessed.
Acquired immunodeficiency syndrome (AIDS): a disease characterized by a marked reduction
in CD4+ T lymphocytes and associated defects in immune response caused by the human
immunodeficiency virus (HIV).
Acute: a disease of short duration.
Acute myelogenous leukemia (AML): a heterogeneous group of disorders, also known as acute
nonlymphocytic leukemia, each of which involves the uncontrolled proliferation of primitive
blood-forming cells.
Adjustment: a procedure for overall comparison of two or more populations in which
background differences in the distribution of covariables are removed. (See also Standardization.
)
Age adjustment: a procedure used to calculate summary rates for different populations in which
underlying differences in the age distributions are removed. (See also Age standardization. )
Age-specific rate: a rate (usually incidence or mortality) for a particular age group.
Age standardization (direct): a procedure for obtaining a weighted average of age-specific
rates in which the weights are selected on the basis of a standard age distribution (eg, the
population of the United States in 1940).
Allele: an alternate form of a gene or a genetic locus that differs from other forms in its specific
sequence of nucleotides; certain alleles may affect the structure and function of the
corresponding protein coded for by that gene, in turn affecting the susceptibility to a particular
condition.
Alpha error: see Type I error.
Alzheimer's disease: the most common form of dementia in many populations, first described in
1907 by Alois Alzheimer; affected individuals have characteristic abnormalities in their brains,
including neurofibrillary tangles and plaques with a protein fragment, -amyloid, at their core.
Analytic epidemiology: activities related to the identification of possible determinants of
disease occurrence.
Analytic study: a research investigation designed to test a hypothesis, often used in reference to
a study of an exposure-disease association.
Antibody: a protein, often produced in response to exposure to an antigen, that binds to the
antigen and thereby stimulates its inactivation by the immune system.
Antigen: a protein, usually foreign in origin, that is capable of generating an immune response in
a host animal.
Antigenic drift: mutation of a pathogen (eg, influenza A), such that the surface antigens differ
from those of previously existing strains.
Apgar score: a system of evaluating the health status of a newborn using five indicators, each
assigned a maximum of two points; the score is named after its originator, Dr. Virginia Apgar.
Arithmetic mean: see Mean.
Arteriosclerosis: hardening of the arteries.
Association: the extent to which the occurrence of two or more characteristics is linked either
through a causal or noncausal relationship.
Asymptomatic persons: individuals who have a particular disease but do not manifest
abnormalities of function, appearance, or sensation typically associated with that disease.
Atrophy: abnormal wasting of tissues, organs, or the entire body.
Attack rate: the proportion of persons within a population who develop a particular outcome
within a specified period of time.
Attributable risk percent: the percentage of the overall risk of a disease outcome within
exposed persons, related to the exposure of interest.
Autoimmune disorder: a disease state in which affected individuals produce antibodies against
their own cells or tissues.
Benign: a mild illness; when applied to an abnormal growth of cells (viz, neoplasm), it connotes
a slowly progressing defect that is not invading adjacent tissues (in contrast to the rapid growth
and invasive behavior of a malignant neoplasm).
Beta error: see Type II error.
Bias: a nonrandom error in a study that leads to a distorted result.
Biological marker: a measurable characteristic that helps to classify either level of exposure to a
risk factor or susceptibility to (or presence of) a disease.
Birth cohort effect: an unusual age-specific rate (either incidence or mortality) within cross-
sectional data that reflects the shared experience of persons born in specific years (birth cohort).
Blinding: assignment of treatment to individual subjects in a way such that subjects only (single
blinding ) or both subjects and treating physicians (double blinding ) do not know the actual
treatment allocation.
Borrelia burgdorferi: a spirochete that is borne by a particular deer tick and when transmitted
to humans can cause Lyme disease (a systemic illness characterized by a skin rash, joint pains,
and, in advanced cases, cardiac and neurologic manifestations).
Bronchoscopic examination: the insertion of an instrument (viz, bronchoscope) to help
visualize the trachea and bronchi and to facilitate the collection of specimens from these tissues.
Cancer: a heterogeneous group of diseases characterized by the abnormal, uncontrolled growth
of cells, which are capable of crossing normal anatomic boundaries to invade other tissues and
even spread to remote anatomic sites.
Candidate region: a physical location on a chromosome believed to contain a potential disease
susceptibility gene and identified by a genomewide scan and subsequent linkage analysis.
Case: a person who has a disease of interest. (See also Incident case and Prevalent case. )
Case-control study: an observational study in which subjects are sampled based on the presence
(cases) or absence (controls) of the disease of interest. Information is collected about earlier
exposure to risk factors of interest.
Case fatality: the proportion of persons with a particular disease who die from that disease
within a specified period of time.
Causality: the extent to which the occurrence of a risk factor is responsible for the subsequent
occurrence of a disease outcome.
Cerebral palsy: a disorder manifested by speech disturbances and lack of muscular coordination
that arises from damage to the brain of a newborn before, during, or shortly after birth.
Cerebrovascular accident: a deficit in the delivery of oxygenated blood to the brain that may
occur because of a blood clot or a hemorrhage; a synonym for a stroke.
Chance node: an element in a decision analysis that represents a point at which specified
outcomes are determined on the basis of probability.
Cholesterol: a steroid that is abundant in animal tissues and is necessary for normal function;
elevated levels of total cholesterol circulating in the blood of a host are associated with increased
risks of cardiovascular disease.
Chronic: a disease of long duration.
Chronic obstructive pulmonary disease (COPD): an abnormal and long-standing reduction in
airflow in and out of the lungs, typically caused either by chronic bronchitis or emphysema.
Clinical scenario: one of two or more alternative paths of management available in a decision
analysis.
Clinical trial: an experimental study that is designed to compare the therapeutic benefits of two
or more treatments.
Cluster: a group of cases of a disease closely linked in time, place of occurrence, or both.
Cochrane Collaboration: an international organization dedicated to promoting well-informed
health care decisions by preparing, maintaining, and ensuring accessibility to current, rigorous,
systematic reviews of the benefits and risks of health care interventions. The organization is
named in memory of Archie Cochrane, a physician epidemiologist who advocated using the best
available evidence to guide health care decisions.
Coefficient of determination: the square of the correlation coefficient; it represents the
proportion of total variability in an outcome that can be explained by the predictors in a
regression model.
Cohort: a group of persons that shares a common attribute, such as birth in a particular year or
residence in a particular town, and is followed over time.
Cohort study: an observational study in which subjects are sampled based on the presence
(exposed) or absence (unexposed) of a risk factor of interest. These subjects are followed over
time for the development of a disease outcome of interest. (See also Prospective cohort study and
Retrospective cohort study. )
Common-source exposure: contact with a risk factor that originates in the shared environment
of multiple persons.
Concordant results: the same outcome status for two or more individuals, as in a pair-matched
case-control study in which both the case and the control are exposed (or unexposed).
Confidence interval: a range of values for a measure that is believed to contain the true value
within a specified level (eg, 95%) of certainty.
Confounder: a variable that distorts the apparent relationship between an exposure and a disease
of interest.
Confounding: a systematic error in a study that arises from mixing of the effect of the exposure
of interest with other associated correlates of the disease outcome.
Control: in a case-control study, a subject without the disease of interest. (See also Adjustment.
)
Control group: a population of comparison subjects in an analytic investigation.
Coronary artery disease: complete or partial blockage of the blood vessels that bring
oxygenated blood to the heart muscle (myocardium), usually arising from atherosclerosis; if the
reduction in blood flow is severe, a myocardial infarction may result.
Correlation coefficient: a statistical measure of the relatedness of two variables; it can range
from -1 (perfectly related inversely to each other) to +1 (perfectly related in the same direction to
each other). When the variables are unrelated to each other, the correlation coefficient has a
value of zero.
Correlation study: a hypothesis-generating investigation in which the values of two or more
summary characteristics are associated across different population groups.
Cosegregation: the tendency of alleles on the same chromosome to be inherited together.
Cross-sectional study: an analytic investigation in which subjects are sampled at a fixed point
or period of time, and the associations between the concurrent presence or absence of risk factors
and diseases are then investigated.
Crude mortality rate: the rapidity with which persons within a given population die from a
particular disease, without adjustment for the underlying age distribution of the population.
Cumulative incidence: the risk of developing a particular disease within a specified period of
time.
Cutoff point: a value on an ordinal or a continuous scale of measurement used to distinguish
categories. For example, values above this threshold may be classified as "abnormal" and values
below this point may be classified as "normal."
Death rate: see Mortality rate.
Decision analysis: a formal probabilistic process for making clinical decisions that incorporates
information on medical options, anticipated likelihoods of various outcomes, and the uncertainty
associated with clinical information.
Decision diagram: a flow chart used in decision analysis that identifies the clinical management
choices, probabilities of events, and likelihoods of outcomes.
Decision node: an element of a decision tree that represents a choice between two or more
competing alternative management approaches.
Decision tree: see Decision diagram.
Dementia: a condition characterized by impaired short- and long-term memory, along with
disturbances of other cognitive functions, such as speech and the perception of spatial
relationships.
Dependent variable: see Outcome variable.
Descriptive epidemiology: activities related to characterizing patterns of disease occurrence.
Diabetes mellitus: a disorder of carbohydrate regulation caused by either a markedly reduced or
absent production of insulin by the pancreas (Type I ) or a decreased sensitivity to the effects of
insulin in the peripheral tissues (Type II ).
Differential misclassification: incorrect categorization of the status of subjects with regard to
one variable (eg, exposure) that is influenced by other characteristics of interest (eg, disease
status).
Discordant results: different outcome status for two or more individuals, as in a pair-matched
case-control study, when one subject in a pair is exposed and the other individual is unexposed to
the risk factor of interest.
Disease outbreak: a sudden, unexpected increase in the occurrence of a disease within a
relatively limited geographic area.
Diuresis: an abnormally elevated volume of urine production.
Dizygotic twin: fraternal twins resulting from the fertilization of two separate ova by two
separate spermatozoa; the members of this pair are no more similar genetically than are two
nontwin siblings.
Dose-response relationship: an exposure-disease association in which the risk of developing a
disease varies with respect to the intensity or duration of exposure.
Eclampsia: the occurrence of one or more seizures that cannot be attributed to an underlying
neurologic condition (such as epilepsy or a cerebral hemorrhage) in a patient with preeclampsia.
Ecologic fallacy: an association between summary characteristics across populations without
actual linkage of the characteristics within individual persons.
Ecologic study: see Correlation study.
enzyme-linked immunosorbent assay (ELISA); it can be used to test for antibodies to an
infectious agent.
Emerging infectious disease: an infection that has newly appeared within a population or has
existed but is rapidly increasing in incidence or geographic range.
Empiric treatment: in the context of infectious illness, the initiation of an antibiotic treatment
against a spectrum of suspected potential pathogens, in the absence of a documented specific
pathogen(s).
Endemic rate: the usual rate of occurrence of particular events within a population.
Eosinophilia-myalgia syndrome: a condition characterized by muscle pains and, in some
patients, joint pains, skin thickening, hair loss, or intestinal disease, accompanied by an
abnormally elevated level of eosinophil cells in the blood.
Epidemic: a dramatic increase above the usual or expected rate of occurrence of particular
events within a population.
Epidemiology: the study of the distribution and determinants of disease within human
populations.
Escherichia coli O157:H7: a strain of bacteria that is a cause of the hemolytic uremic syndrome,
which occurs in humans who consume food products contaminated with this pathogen.
Etiology: the cause(s) of a disease or the study of disease causation.
Evidence-based medicine: the integration of current best evidence from research with clinical
expertise, pathophysiologic knowledge, and patient preferences, used to make health care
decisions.
Excess risk: the extra risk of the occurrence of a particular disease among persons exposed to a
risk factor of interest. (See also Risk difference. )
Exclusions: persons who are eliminated from an analytic study because they do not satisfy the
eligibility (inclusion) criteria.
Expected utility: a numerical value that represents the average result if the decision maker
follows a particular path in a decision analysis.
Exposure: contact with or possession of a characteristic that is suspected to influence the risk of
developing a particular disease.
External validity: the extent to which the conclusions of a study can be correctly applied to
persons beyond those who were investigated. (See also Generalize. )
False negative: a test result that is normal (negative) despite the true presence of the disease of
interest or a study result that incorrectly fails to identify a true effect. (See also Type II error. )
False positive: a test result that is abnormal (positive) despite the true absence of the disease of
interest or a study result that incorrectly suggests an effect, when, in truth, the purported effect
does not exist. (See also Type I error. )
Familial aggregation: the extent to which the occurrence of a particular disease tends to cluster
within families.
Fixed effects model: a statistical approach to combining information from multiple sources in
which it is assumed that the investigated relationship is constant across sources and any
differences in individual results are attributable entirely to random variation.
Follow-up study: see Cohort study.
Food-borne disease: an illness that is caused by the ingestion of food or food products, often
arising from contamination of the food with microbes or other toxic materials.
Framingham Heart Study: a landmark prospective cohort study of risk factors for
cardiovascular disease initiated in 1950 among residents of Framingham, Massachusetts.
Generalize: the ability to extrapolate study results from the study subjects to other persons who
were not investigated.
Genetic epidemiology: the use of epidemiologic techniques to study hereditary determinants of
disease in human populations.
Genetic (linkage) map: a type of map of the genome in which markers are identified on the
chromosomes and the relative distances between these markers are estimated by the frequency
with which the markers are inherited together.
Genome: the full complement of genes on all chromosomes.
Genomewide scan: an approach to localizing candidate regions for genes contributing to the
susceptibility for a specific disease by analyzing the extent to which the disease occurs in
members of affected families in association with markers at known locations throughout the
genome.
Genotype: the genetic constitution of an individual; may be used in reference to the particular
allele(s) present at one or more gene loci.
Glucosuria: an abnormally elevated level of glucose in the urine, as my occur in diabetes
mellitus.
Granulocyte: a mature granular white blood cell, which includes neutrophils as well as other
types of cells.
Granulocytopenia: a condition marked by an abnormally low number of granulocytes in the
blood, and which may predispose the host to infection.
Hantavirus: a virus named for a river in South Korea, where human infection was first
recognized; this pathogen is capable of causing a hemorrhagic fever and a separate pulmonary
syndrome in infected human hosts.
Hematologic: of or relating to the blood or blood-forming tissues.
Heterogeneity: the statistical property of variation in an investigated relationship across
individual studies or across subgroups within a particular study.
Historical cohort study: see Retrospective cohort study.
Historical controls: subjects in a clinical study who were previously treated with the standard
therapy before the new experimental treatment was introduced.
HIV: see Human immunodeficiency virus.
Homogeneity: the statistical property of lack of variation of an investigated relationship across
individual studies or across individual subgroups within a particular study.
Human immunodeficiency virus: the cause of the acquired immunodeficiency syndrome
(AIDS) and other HIV-related disorders.
Hyperglycemia: an abnormally high level of glucose in the blood, as may occur in untreated
patients with diabetes mellitus.
Hypertension: an abnormal elevation in blood pressure.
Hypoglycemia: an abnormally low level of glucose in the blood, as may result from an overly
aggressive administration of insulin in patients with diabetes mellitus.
Hypothesis-generating study: an exploratory investigation designed to formulate questions that
are evaluated in subsequent analytic studies.
Hypothesis-testing study: an analytic investigation in which one or more specific refutable
suppositions are evaluated.
Hypoxia: an abnormally low level of oxygen in the arterial blood.
Immunity: a state in which a host is not susceptible to a particular infection or disease.
Inbreeding study: a study in which the degree of selective breeding among members of a
particular group is assessed with respect to risk of developing a particular disease.
Incidence density: see Incidence rate.
Incidence rate: the rapidity with which new cases of a particular disease arise within a given
population.
Incident case: a person who is newly diagnosed with a disease of interest.
Incubation period: the time interval between contact with a risk factor (often an infectious agent)
and the first clinical evidence of the resulting illness.
Independent variable: a factor that is suspected to influence the outcome of an analytic study.
Index case: in a disease outbreak, the first affected individual to be identified; in genetics, see
Proband.
Information (or observation) bias: a systematic error in a study that arises from the manner in
which data are collected from participants.
Informed consent: the process of providing a patient with information about the risks and
benefits of a proposed treatment plan and then securing the patient's (or if the patient is a child,
the guardian's) agreement to undergo the planned intervention recognizing the risks and benefits.
Insulin: a peptide hormone produced in the pancreas and secreted into the blood, which delivers
it to target organs to help regulate glucose utilization, protein synthesis, and formation and
storage of lipids.
Intention to treat: analysis of the results of a clinical trial based on initial treatment assignment
regardless of whether the subjects completed the full course of treatment.
Internal validity: the extent to which the conclusions of a study are correct for the subjects
under investigation.
Ketosis: a condition characterized by the enhanced production of ketone bodies, as may occur in
the metabolic abnormalities associated with diabetes mellitus.
Latent period: time between exposure to a risk factor and subsequent development of clinical
manifestations of a particular disease.
Lead-time bias: apparent increase in the length of survival of patients with a disease as a result
of earlier detection of the disease through the use of a screening procedure.
Length-biased sampling: preferential detection of less aggressive forms of a disease through the
use of a screening procedure.
Life expectancy: the expected, or average, duration of life for persons in a particular population,
under the assumption that current age-specific mortality patterns continue to apply.
Likelihood: the probability of the occurrence of a specified event.
Likelihood ratio: the probability of a particular test result for a person with the disease of
interest divided by the probability of that test result for a person without the disease of interest.
Likelihood ratio for a negative test result: the probability of a negative test result for a person
with the disease of interest divided by the probability of a negative test result for a person
without the disease of interest.
Likelihood ratio for a positive test result: the probability of a positive test result for a person
with the disease of interest divided by the probability of a positive test result for a person without
the disease of interest.
Linkage: the proximity of multiple genes or genetic markers on the same chromosome, which is
related to the probability that a certain combination of alleles at these sites will be inherited as a
linkage group or haplotype.
Linkage analysis: a statistical technique used to identify candidate regions for genes based on
the examination of the closeness of association between the inheritance within affected families
of the condition of interest and markers at known locations throughout the genome.
Linkage disequilibrium: an excess or deficiency of certain combinations of alleles from genes
or markers that are located on the same chromosome; alleles at tightly linked sites often are
inherited together, and, therefore, linkage disequilibrium may help to identify the location of a
particular susceptibility gene that is inherited as part of a linkage group with genes or markers at
known locations within the genome.
Longitudinal study: see Cohort study.
Malignancy: the property of being malignant, often used interchangeably with the term cancer.
Malignant: a severe disease that is resistant to treatment (eg, severe hypertension); the term
often is used in relation to the behavior of cancers.
Marker: in genetics, an identifiable physical location on a chromosome or deoxyribonucleic
acid (DNA) segment useful in mapping genes and in performing linkage analysis.
Matching: a procedure for sampling comparison subjects based on whether key attributes (ie,
matching factors ) are similar to those of subjects in the index group.
Mean: the arithmetic average of a distribution of values; calculated as the sum of the individual
values divided by the number of observations.
Meconium: the first intestinal discharges of a newborn; if passed prior to delivery, it may serve
as a sign of fetal distress, and if aspirated by the newborn, may give rise to acute pulmonary
distress.
Median: a measure of central tendency of a distribution; calculated as the mid-point of the
distribution when individual values are ordered from the smallest to the largest.
Median survival time: the duration of time from diagnosis to death that is exceeded by exactly
50% of subjects with a particular disease.
Medical outcome: See Outcome.
Meta-analysis: a statistical combination or integration of the results of several independent
research studies that are considered to be combinable.
Metabolic acidosis: an abnormally high level of acid and low level of bicarbonate in the blood
and other tissues resulting either from an accumulation of acids from metabolic processes (as in
diabetes mellitus) or from an abnormally high loss of bases from the body (as in diarrhea or renal
disease).
Misclassification bias: incorrect characterization of the status of subjects with regard to a study
variable, leading to a distorted conclusion. (See also Information bias. )
Mode: a measure of central tendency of a distribution; it is the value that occurs most frequently
within the distribution.
Monozygotic twin: genetically identical individuals arising from the division of a single
fertilized ovum.
Morbidity: a state of illness produced by a disease.
Mortality: death, usually in reference to death caused by a particular disease (viz, cause-specific
mortality ).
Mortality rate: the rapidity with which persons within a given population die from a particular
disease.
Mycobacterium: a genus of bacteria, a member of which is M tuberculosis, also known as
tubercle bacillus, the pathogen responsible for tuberculosis in humans.
Myocardial infarction: a sudden diminution in the delivery of oxygenated blood to the heart
muscle (viz, myocardium ), most commonly caused by partial or complete blockage of one or
more of the coronary arteries.
Natural history: the progression of a disease through successive stages, often used to describe
the course of an illness for which no effective treatment is available.
Negative predictive value: the probability that a person with a negative (normal) test result
actually does not have the disease of interest.
Neoplasm: a new growth that arises from the abnormal proliferation of cells; the proliferation
may be benign or malignant (viz, cancer ).
Nephropathy: a disorder of the kidney; among diabetics, the disorder arises because of damage
to the small blood vessels of the kidney, which can lead to failure of the kidneys in an advanced
stage.
Neutropenia: the presence of an abnormally low level of neutrophils in the blood, placing the
host at increased susceptibility to infection.
Neutrophil: a mature white blood cell in the granulocyte series necessary for normal host
defense responses.
Nondifferential misclassification: incorrect categorization of the status of subjects with regard
to one variable (eg, exposure) that is unrelated to another characteristic of interest (eg, disease
status).
Nosocomial infection: an illness caused by exposure to a pathogen during hospitalization of the
host.
Notifiable disease: a disease for which regular, frequent, and timely information on individual
cases is considered necessary for the prevention and control of the disease.
Null value: the point on the scale of a measure of association that corresponds to no association
(eg, 1 for the risk ratio and the odds ratio and 0 for the risk difference and the attributable risk
percent).
Observation bias: see Information bias.
Observational study: a nonexperimental analytic study in which the investigator monitors, but
does not influence, the exposure status of individual subjects and their subsequent disease status.
Odds: the probability that a particular event will occur divided by the probability that the event
will not occur.
Odds ratio: the odds of a particular exposure among persons with a specific disease divided by
the corresponding odds of exposure among persons without the disease of interest.
Opportunistic infection: an illness caused by a microorganism that is capable of causing
disease only in a host whose resistance is lowered below normal levels.
Outbreak: see Disease outbreak.
Outcome: clinical events that result from patient management decisions (eg, morbidity,
complications, quality of life, or mortality).
Outcome variable: in an analytic study, the response of interest (eg, development of disease).
Pandemic: an elevated occurrence of a disease across a wide geographic area, affecting a
substantial proportion of the population.
Pathogen: an agent responsible for the development of a particular disease.
Pathophysiology: derangement of function associated with a disease process.
Pedigree: the family members of a proband, identified with respect to their biological
relationship to the proband and whether they are known to have the disease of interest.
Penetrance: the proportion of individuals with a particular genotype that exhibits the same
phenotype under similar environmental conditions.
Perinatal asphyxia: an abnormally reduced level of oxygenation of a fetus during labor and
delivery, or shortly thereafter.
Person-time: a unit of measurement used in the estimation of rates that reflects the amount of
time observed for persons at risk of a particular event.
Person-to-person spread: propagation of a disease within a population by transfer from an
affected person to susceptible persons.
Person-years: a common unit for measuring person-time; one person-year corresponds to one
person being followed for one year, or, alternatively, two persons each followed for one-half
year, and so forth.
Person-years of life lost: a measure of total life expectancy lost within a particular population
because of premature death.
Phenotype: a category or group to which an individual may be assigned on the basis of one or
more characteristics observable clinically or by laboratory assessment that reflect genetic
variation or gene-environment interactions.
Placebo: an inert substance.
Placebo effect: occurs when persons affected with a specific illness demonstrate clinical
improvement when treated with an inert substance.
Polymerase chain reaction: a laboratory technique for rapidly synthesizing large quantities of a
particular portion of genetic material.
Population at risk: persons who are susceptible to a particular disease but who are not yet
affected.
Population-based study: an analytic study in which subjects are sampled from the general
population.
Positive predictive value: the probability that a person with a positive (abnormal) test result
actually has the disease of interest.
Posttest odds of disease: the estimated probability, after the administration of a diagnostic test,
that a patient has the disease of interest divided by the probability that the patient does not have
the disease of interest.
Posttest probability of disease: the estimated likelihood, after the administration of a diagnostic
test, that a patient has the disease of interest.
Power: see Statistical power.
Precision: the extent to which a measurement is narrowly characterized. Statistical precision is
inversely related to the variance of the measurement.
Predictor variable: see Independent variable.
Preeclampsia: the abnormal occurrence of hypertension accompanied by either an abnormal
collection of fluid in body tissues or abnormally increased levels of protein in the urine, or both,
due to pregnancy.
Premature death: a death that occurs earlier than would be expected in the absence of a
particular disease.
Pretest odds of disease: the estimated probability, prior to the administration of a diagnostic
test, that a patient has the disease of interest divided by the probability that the patient does not
have the disease of interest.
Pretest probability of disease: the estimated likelihood, prior to the administration of a
diagnostic test, that a patient has the disease of interest.
Prevalence: the proportion of persons in a given population that has a particular disease at a
point or interval of time.
Prevalent case: a person who has a disease of interest that was diagnosed in the past.
Proband: the first affected individual who brings his or her family to the attention of a
researcher or clinician for the purposes of medical care or investigation.
Prognosis: the predicted rate of progression of a disease process and its likely outcome(s).
Prognostic factor: an attribute anticipated to be related to the progression and outcome of a
disease process.
Proportion: one quantity divided by another quantity in which the population in the numerator
is a subset of the population in the denominator. The possible values of a proportion range from
zero to one.
Prospective cohort study: a cohort study in which exposure status and subsequent occurrence
of disease both occur after the onset of the investigation.
Publication bias: a distortion in conclusions derived from published studies because of the
selective factors associated with the likelihood of publication, including whether the findings
were positive and statistically significant, and the potential proprietary interests of sponsors.
Random effects model: a statistical approach to combining information from multiple sources
in which it is assumed that the investigated relationship varies across individual sources, in
addition to the influences of random variation in estimates.
Randomization: procedure for assigning treatments to patients by chance.
Rate: the rapidity with which health events such as new diagnoses or deaths occur. (See also
Incidence rate and Mortality rate. )
Rate ratio: the rate of occurrence of a specified health event among persons exposed to a
particular risk factor divided by the corresponding rate among unexposed persons.
Ratio: one quantity divided by another quantity, in which the population in the numerator is not
a part of the population in the denominator. The possible values of a ratio range from zero to
positive infinity.
Recurrence risk: in genetic epidemiology, the risk of developing a particular disease
experienced by relatives of a subject with that disease.
Relapse: the return of the manifestations of a disease after a period of diminished
manifestations.
Relative risk: see Risk ratio.
Reliability: the extent to which multiple measurements of a characteristic are in agreement.
Remission: elimination or reduction in the number or severity of the manifestations of a disease,
which may be transient or permanent.
Response variable: see Outcome variable.
Retinopathy: a disorder of the retina of the eye; among diabetics the disorder arises from
damage to the small blood vessels of the retina and can lead to blindness.
Retrospective cohort study: a cohort study in which exposure status and subsequent
development of disease both occur prior to the onset of the investigation.
Risk: the probability that an event (eg, development of disease) will occur within a specific
period of time.
Risk difference: the risk of the occurrence of a particular disease among persons exposed to a
given risk factor minus the corresponding risk among unexposed persons.
Risk factor: an attribute or agent suspected to be related to the occurrence of a particular
disease.
Risk ratio: the likelihood of the occurrence of a particular disease among persons exposed to a
given risk factor divided by the corresponding likelihood among unexposed persons.
Sample: a subset of a target population that is chosen for investigation.
Screening: the use of tests to detect the presence of a particular disease among asymptomatic
persons prior to the time that the disease would be recognized through routine clinical methods.
The Surveillance, Epidemiology and End Results (SEER) Program of the National Cancer
Institute; it consists of 11 population-based cancer registries in various locations within the
United States.
Segregation analysis: a complex statistical technique used to assess whether a particular disease
has, at least in part, a genetic origin, and, if so, the most likely mode of inheritance.
Selection bias: a systematic error in a study that arises from the manner in which subjects are
sampled.
Sensitivity: the probability that a person who actually has the disease of interest will have a
positive (abnormal) test result.
Sensitivity analysis: (1) in systematic reviews, including meta-analyses, the evaluation of the
pattern of results across subgroups of studies to characterize possible sources of heterogeneity
and their respective influences on the overall summary effect; (2) in decision analysis, use of
different values for an uncertain likelihood to determine whether the preferred course of action
remains unchanged.
Sentinel case(s): the initial person(s) affected by a particular illness during an outbreak.
Seroconversion: change in a person's status from not having evidence of infection (such as
antibodies) in the serum to having such evidence.
Seronegative: absence of evidence of infection in a person's serum (synonym: antibody
negative).
Seropositive: presence of evidence of infection in a person's serum (synonym: antibody
positive).
Sib-pair analysis: statistical analysis for many genetic linkage studies attempting to locate
susceptibility genes for a particular disease in which the fundamental unit of analysis is a pair of
siblings.
Specificity: the probability that a person who actually does not have the disease of interest will
have a negative (normal) test result.
Squamous cell carcinoma: a malignant neoplasm (cancer) arising from stratified squamous
epithelium, but that may also occur in sites in which glandular or columnar epithelium normally
occur.
Standardization: an analytic procedure for obtaining a summary measure for a population by
applying standard weights to the measures within subgroups of the population.
Statistical power: the ability of a study to detect a true effect of a specified magnitude. The
statistical power corresponds to 1 - Type II error.
Statistical significance: the likelihood that a difference as large as or larger than that observed
between study groups could have occurred by chance alone in a sample of the size investigated.
Usually, the level of statistical significance is stated as a P -value (eg, P < 0.05).
Stroke: a sudden derangement in function, as in sunstroke or heat stroke; often used in relation
to a sudden neurologic deficit that occurs because of insufficient delivery of oxygenated blood to
the brain, as may occur following a blood clot or hemorrhage.
Subacute: a rate of progression of a condition that is intermediate between acute and chronic.
Surveillance: ongoing observation of a population for rapid and accurate detection of changes in
the occurrence of particular diseases.
Survival: the likelihood of remaining alive for a specified period of time after the diagnosis of a
particular disease.
Systematic error: see Bias.
Systematic review: a synthesis of medical evidence on a topic, in which the synthesis has been
prepared using strategies to minimize errors.
Terminal node: in a decision tree, an element that represents the outcome for a particular
clinical scenario.
T lymphocyte: a white blood cell that is responsible for cell-mediated immunity in the host.
Transmission: the process by which a pathogen passes from one source of infection to a new
host.
True negative: a test result that is normal (negative) when the disease of interest is actually
absent.
True positive: a test result that is abnormal (positive) when the disease of interest is actually
present.
Tuberculosis: an infectious illness caused by Mycobacterium tuberculosis, characterized by a
brief initial illness; in a minority of cases, a chronic active illness, primarily affecting the lungs,
will occur months to years following infection.
Tumor: a swelling that may occur from an inflammatory process or a benign or malignant
neoplasm.
Twin study: a study of genetic susceptibility in which concordance for occurrence of a particular
disease is compared between dizygotic (fraternal) twins and monozygotic (identical) twins, or
between twins reared together versus apart.
Type I error: rejection of the null hypothesis when it is actually correct.
Type II error: failure to reject the null hypothesis when it is actually incorrect.
Underlying cause of death: (1) the disease or injury that initiated the train of morbid events
leading directly to death, or (2) the circumstances of the accident or violence that resulted in fatal
injury.
Utility: in decision analysis, a patient's preference for one outcome over another, usually graded
on a scale of zero, representing death, to one, representing perfect health.
Validity: the extent to which a measurement or a study result correctly represents the
characteristics or relationship of interest.
Variability: the property of having a spread of values, which may arise from random sources
(viz, the operation of chance) or from systematic influences (viz, bias).
Viremia: the presence of virus particles in the blood of a host.
Vital statistics: information concerning patterns of registered life events, such as births,
marriages, divorces, and deaths.
Weighted average: a summary measure in which some of the component data values are
assigned greater influence than others. For example, precision-based weighting is the calculation
of a summary measure in which the relative influence of individual results is based on statistical
confidence in the respective results.
Withdrawals: subjects who are initially included in a study but later voluntarily or involuntarily
terminate participation.
Years of potential life lost (YPLL): a measure of total life lost to a particular age (eg, 75 years)
within a population because of premature deaths.
Questions 1-3:
For each numbered situation below, select the most appropriate term from the following lettered
options. Each option can be used once, more than once, or not at all.
A. Birth cohort effect
B. Ecologic fallacy
C. Latent period
D. Endemic occurrence
E. Epidemic occurrence
1. Populations in which infection from Helicobacter pylori is common have a persistent, steady
elevation in gastric cancer when compared with other communities in which this infection is
uncommon.
2. H pylori infection increases the risk of gastric cancer, but the time from initial infection to
cancer occurrence is more than a decade.
3. A correlation is shown between national consumption of coffee and gastric cancer mortality,
but individual coffee drinkers do not have an elevated risk of developing gastric cancer.
Questions 4-7:
For each measure discussed in the numbered statements below, select the most appropriate value
from the following lettered options. Each option can be used once, more than once, or not at all.
A. 0.30
B. 0.50
C. 0.90
D. 6.5
E. 11.0
F. Cannot be determined from the information provided
4. In a correlational study, the average annual per capita consumption of alcohol (in gallons) is
used to predict annual mortality rates (per 100,000 persons) from cirrhosis of the liver across
states in the United States. The resulting regression equation is
The correlation coefficient is 0.55 and the coefficient of determination is 0.30. What is the
predicted increase in the liver cirrhosis annual mortality rate (per 100,000 persons) for 1 gallon
per capita annual alcohol consumption?
5. Given the equation in question 4, what is the predicted annual mortality rate (per 100,000
persons) for cirrhosis of the liver in the absence of alcohol consumption?
6. Given the equation in question 4, what is the predicted annual mortality rate (per 100,000
persons) for cirrhosis of the liver in a state with an average annual per capita alcohol
consumption of 5 gallons?
7. Given the equation in question 4, what proportion of the variability in average annual
mortality rates (per 100,000 persons) for cirrhosis of the liver can be accounted for by knowing
the corresponding per capita annual consumption of alcohol?
Questions 8-11:
For each migration discussed in the numbered statements below, select the lettered option that
describes the most likely effect on the incidence rate of disease among offspring. Each option
can be used once, more than once, or not at all.
A. Greater
B. Smaller
C. About the same
D. Cannot be determined from the information provided
8. When compared with the corresponding rate for nonmigrants in a high-risk country, the
incidence rate for an environmentally determined disease among offspring of migrants to a low-
risk country is
9. When compared with the corresponding rate for nonmigrants in a low-risk country, the
incidence rate for an environmentally determined disease among offspring of migrants to a high-
risk country is
10. When compared to the corresponding rate for nonmigrants in a high-risk country, the
incidence rate for a genetically determined disease among offspring of migrants to a low-risk
country is
11. When compared to the corresponding rate for nonmigrants in a low-risk country, the
incidence rate for a genetically determined disease among offspring in a high-risk country is
1. D
2. C
3. B
4. C
5. D
6. E
7. A
8. B
9. A
10. C
11. C
For each question, select the single best answer.
Questions 1-5:
A cohort study is conducted to evaluate the relationship between dietary fat intake and the
development of prostate cancer in men. In the study, 100 men with a high fat diet are compared
with 100 men who are on a low fat diet. Both groups start at age 65 and are followed for 10
years. During the follow-up period, 10 men in the high fat intake group are diagnosed with
prostate cancer and 5 men in the low fat intake group develop prostate cancer.
1. What is the risk of developing prostate cancer in the high fat group?
A. 0.05
B. 0.10
C. 0.15
D. 0.20
E. 0.25
2. What is the risk of developing prostate cancer in the low fat group?
A. 0.05
B. 0.10
C. 0.15
D. 0.20
E. 0.25
3. What is the risk ratio (high fat consumers compared to low fat consumers) for the occurrence
of prostate cancer?
A. 0.05
B. 0.75
C. 1.0
D. 1.5
E. 2.0
4. The point estimate for the risk ratio in question 3 suggests that the risk of prostate cancer
associated with consumption of a high fat diet is
A. Decreased
B. Increased
C. Not affected
5. The 95% confidence interval is 0.95 to 3.5. For statistical significance at an alpha level of
0.05, the correct interpretation of these results is that
A. A statistically significant association exists between high dietary fat intake and an increased
risk for prostate cancer.
B. A statistically significant association exists between high dietary fat intake and a decreased
risk for prostate cancer.
C. It can be concluded with 95% confidence that high dietary fat intake protects against prostate
cancer.
D. It can be concluded with 95% confidence that high dietary fat intake increases the risk of
prostate cancer.
E. The risk of prostate cancer is not statistically significantly different between men with high fat
intake and men with low fat intake.
Questions 6-10:
A cohort study is conducted to evaluate the relationship between serum cholesterol level and the
occurrence of myocardial infarction in women. In the study, 500 women with high serum
cholesterol levels and 500 women without high serum cholesterol levels are followed over a 10-
year period. During the study, 40 of the women with high serum cholesterol levels and 15 of the
women with normal serum cholesterol levels develop a newly diagnosed myocardial infarction.
6. The incidence rate (per 10,000 person-years) for a myocardial infarction among women with
high serum cholesterol is
A. 30
B. 50
C. 60
D. 80
E. 100
7. The incidence rate (per 10,000 person-years) for a myocardial infarction for women with
normal serum cholesterol is
A. 30
B. 50
C. 60
D. 80
E. 100
8. The (incidence) rate ratio for myocardial infarction is
A. 0.37
B. 1.33
C. 2.67
D. 3.15
E. 3.75
9. The risk difference is
A. 0.002
B. 0.005
C. 0.006
D. 0.01
E. 0.05
The attributable risk percent is
A. 25.5%
B. 35.0%
C. 47.5%
D. 55.5%
E. 62.5%
1. B
2. A
3. E
4. B
5. E
6. D
7. A
8. C
9. E
10. E
Questions 1-4:
For each numbered situation below, select the best descriptor from the following lettered options.
Each option can be used once, more than once, or not at all.
A. Ecologic fallacy
B. Confounding
C. Random error
D. Misclassification
E. Cohort effect
F. Selection bias
1. In a case-control study of environmental exposure to tobacco smoke and risk of sudden infant
death syndrome (SIDS) in children, low socioeconomic status is associated with exposure to
environmental tobacco smoke and is a risk factor for SIDS.
2. In the study cited in question 1, cases are sampled from death certificates and controls are
sampled from registrants in a managed care health insurance plan.
3. In the study cited in question 1, parents of children who have died from SIDS are more likely
to overestimate their child's exposure to environmental tobacco smoke than are parents of
controls.
4. A correlation analysis across 15 states reveals an association between mortality rates from
SIDS and smoking prevalence among young adults, but parents of children who die from SIDS
are not more likely than other parents to be smokers.
Questions 5-7:
For each numbered situation below, select the most appropriate advantage of the case-control
design from the following lettered options. Each option can be used once, more than once, or not
at all.
A. Confounding is unlikely because of randomization
B. Efficient for the study of rare diseases
C. Efficient for the study of diseases that develop slowly
D. The risk among exposed persons can be estimated directly
E. The temporal relationship between exposure and disease is clearly defined
F. The ability to conduct an assessment quickly allows rapid intervention
5. Assessing risk factors for infection in a community-wide outbreak of cryptosporidiosis.
6. Assessing risk factors for congenital defects of the neural tube.
7. Assessing the role of antioxidants in reducing the risk of atherosclerotic coronary artery
disease.
Questions 8-10:
For each numbered measure below, select the most appropriate calculation from the following
lettered options. Each option can be used once, more than once, or not at all.
A. 80/150
B. 20/280
C. 20/300
D. (80 280)/(20 70)
E. 80/70
F. (20 70)/(80 280)
G. (80/100)/(70/350)
8. The odds of exposure among cases in an unmatched case-control study of risk factors for
adenocarcinoma of the esophagus, in which chronic heartburn was found in 80 of 150 cases and
20 of 300 controls.
9. The odds of exposure among controls in the study described in question 8.
10. The odds ratio for exposure in the unmatched case-control study described in question 8.
Questions 11-13:
For each numbered situation below, select the best descriptor from the following lettered options.
Each option can be used once, more than once, or not at all.
A. Concordant pair
B. Discordant pair
C. Not applicable
11. In a pair-matched case-control study of traumatic head injury as a risk factor for Alzheimer's
disease, a patient with Alzheimer's disease had a prior history of head trauma and the
corresponding control did not have prior head trauma.
12. In a pair-matched case-control study of cognitive impairment as a risk factor for hip fracture
in the elderly, a patient with a hip fracture has cognitive impairment as does the corresponding
control.
13. In an unmatched case-control study of infection from Helicobacter pylori as a risk factor for
stomach cancer, a patient with stomach cancer has serum antibody to H pylori and a control also
is antibody seropositive for H pylori.
1. B
2. F
3. D
4. A
5. F
6. B
7. C
8. E
9. B
10. D
11. B
12. A
13. C
Accuracy vs. Precision
- Accuracy and validity are the same. (hitting the target)
Precision and reliability are the same. (hitting the target in the same place every
time)
- if you have both: accuracy/validity AND precision/reliability then you hit the
target in the middle (bull's eye) everytime...
- use this analogy for analyzing tests in biostats.
so accuracy/validity would mean you get the same answer most of the time, not
necessarily the right one
and precision/reliability means you get the right answer most of the time.
- CORRECTION:see the FA part of BS... they have a picture and explain it well.
Correction: accuracy and validity (hitting the target- but all over the target)
Precision and reliability (hitting one area of the target all the time- not necessarily
the bulls eye)
if you have both: accuracy/validity AND precision/reliability then you hit the
target in the middle (bull's eye) everytime...
- Validity: whether the test truly measures what it purports to measure
Reliability: Reproducibility of a test. (getting around the same ans./results every
time)
Achild begins to copy:
A Circle at 3yr
A Cross at 4yr
A Square at 5yr
A triangle at 6yr
Stranger Anexiety:7-11mo
Separation Anexiety:12-15mo
aging decrease both REM&stages 3,4,wake early in the morning
MDD:short REM latency,long first REM,total REM%INCREASE(>25%)BUT REM
decrease toward morning leads to waking early in the morning,decrease stages3,4,normal
sleep oneset
elderly and depressed people awake more than 3times during the night
bipolar and anxious people have difficulty with sleep begining
alcohol,benzo and barbiturates decrease REM&delta sleep(stage3,4)
Recall:TOTAL REM INCREASE IN MDD!
In what group age is illness percieved as a punishment??????? Ans. 0-5 yrs.
EMANCIPATION: Under 18 years is legally incompetent and considered minor.But the boy is
emancipated minor as he is serving military.Other facts that make minors emancipated are-1)living and
supporting on their own 2)Marriage.Please note being pregnant or having child does not make child
emancipated.
Partial emancipation is considered for substance abuse,STD treatment,birth control and prenatal care as
these issues have impact on public health.
1]diff bet schizotypal and schizoaffective?
2]diff bet autistic and asperger disorder?
Ans. schizotypal disorder:in DSMIV:a personality disorder:with odd behavioral and magical
thinking
but!schizoaffective disorder:in DSMIV:psychotic disorder that characterized by psychosis+mood
symptoms
Autistic disorder:problems with communication and social relationship,also MR,repeating
behavioral
some of them have unusual abilities in one field like math!asperger the same but no delay in
language development,infact it's mild form of autistic disorder
schizophreniform- - symptoms less than 6 months
schizophrenia-symptoms more than 6 months
schizoid--avoidant,socially isolated,very few friends
schizotypal- - magical thinking
in addition: schizoid--"voluntary",not a psychosis(what's that guy's name in "Angel
eyes"??)
schizotypal--thinks weird but looks weird too!! (Robbin Williams in "Fisher King" will
be a good example)
schizoaffective--schizophrenia + mood disorder(that will be me..:)
neurotransmitter of REM sleep? Ans. acetylcholine..
and what's the role of serotonin in sleep cycle? Ans. I think it initiates sleep!
yes,serotonin regulates sleep pattern,increase level of serotonin associated with increase
in total sleep and delta sleep,do u know the location of REM sleep system? Ans. Pons
Anaclitic Depression: when a baby between the age of 6 and 15 months is separated from
its primary care giver, it can suffer from anaclitic depression characterised by depression
and episodes of screaming and loud protests
ON HARDY-WEINBERG:
That's used to calculate the prevalence of each genotype(AA, Aa, or aa), given the
prevalence of each gene(A or a). If A accounts for 70% and a for the rest, AA will account for
49%(0.7x0.7), Aa for 42%(0.3x0.7x2), and aa for 9%(0.3x0.3). Just draw a 2x2 table, and that'll
make it very clear.
> Basically you have to calculate the positive predictive value (PPV), for which prevalance is
required which in this case is 10%. Assuming the population to 100 construct a 2x2 table using
the sensitivity and specificity for the test which is this problem is 80% and 90% respectively.
--- Disease No Disease Total
pos 8 -----------9 ----------17
neg 2 ----------81 ---------83
tot 10 ---------90 ---------100
So the PPV will be true positive divided by total positive ie 8 divided by 17 which is 47%
Emphasized Topics:
- STATISTICS
Lots of computations on odds ratio, relative risk, Hardy-Weinberg, values for sensitivity
and specificity of two studies and you will be asked to compare. May questions also
about biases. The study will be described and you have to determine what is the bias of
study. Questions on alpha and beta errors. Same thing as before, the study will be
described and you'll be asked what error is it. Questions on what is the best thing to say to
a patient given a particular situation. For this you have to study ethics. Kaplan is OK
- BEHAVIORAL SCIENCE
- ELDERLY
What are the cognitive changes?
Physiologic changes
Alzheimers, Dementia, Delirium etc. Know the common Differential Diagnosis like
Picks etc.
- PERSONALITY DISORDERS
- COMMON PSYCHIATRIC ILLNESS (Depression, Schizophrenia etc.)
- DRUG ADDICTION/DEPENDENCY
- DEFENSE MECHANISMS
- NEUROTRANSMITTERS
--------------------------------------------------------------------
MISCELLANEOUS TOPICS
PROGNOSTIC FACTORS IN SCHIZOPHRENIA.
Mark each one of the following choices with "g" for good prognisis and "p" for poor
prognosis for a patient with Schizophrenia.
1. onset of psychotic symptoms within a month of the first change in behavior.
2. withdrawn autistic behavior
3. flat affect
4. positive family history of schizophrenia.
5. confusion or perplexity at the height of the psychotic episode.
6. good premorbid social and occupational functioning.
Ans. 1, 5, 6 G : 2, 3, 4 -P
> 1.17 YR old male visits the physician bcos his parents are worried about his behaviour.he is
always in the shower taking hours in the morning.he spends lot of time washing his hands which
he says is to get rid of the germs.which of the foll neuro transmitter abnormalities is the cause for
the disease
a.dopaminergic
b.cholinergic
c.noradrenergic
d.serotonergic
2.A 30 yr old man is brought to the ER by a friend bcos he was turning blue.On exam he is
pale,perioral cyanosis,shallow resp of 3-5/min.he is unresponsive .his friend reports he must have
taken something to "relax".no track marks are seen.the drug most likely the patient has taken is
a.benzodiazepine
b.alcohol
c.cocaine
d.ketamine
e.opiate
Ans. 1.d ....diag is OCD ......NT is serotonin
2.e opiate........this is the one that causes respiratory depression
confidence interval
The formula is
CI= X +- Z( S/under root N)
where CI is conf interval
+- is plus minus
Z= z score which is 2 for 95% confidence and 2.5 for 99% (this will be mentioned in the
question)
S= Standard deviatin
N= sample size
Case 1
A 16-year-old female presents to a family physician to obtain a referral for family
therapy. She is estranged from her mother and stepfather, who see the same physician.
For many years, this patient responsibly cared for her four younger siblings while their
single mother worked. Since her mother's marriage, the family has become involved in a
fundamentalist church. The patient moved out when she felt the social and moral
restrictions of the family's religion were too burdensome for her. The patient seemed
quite mature; she maintained a 3.5 GPA, along with a part-time job. She demonstrated a
genuine desire for reconciliation, and the therapy referral was provided. She also
requested and obtained a prescription for contraceptives during the visit, with the
assurance that her sexual activity would be kept confidential. In follow-up, she reported
that the therapist had informed her that if she mentioned anything about being sexually
active with her adult partner, he would be obliged to report her to the state. The patient
was very concerned about the conflict between this statement and the family physician's
prior assurance of confidentiality. Should this patient's confidentiality be broken?
While the physician has a moral obligation to obey the law, he must balance this against
his responsibility to the patient. In researching the Criminal Code of Washington, the
physician learned that sexual intercourse with a minor, at least 16, but under 18, is a class
C felony, and a reportable offense, if the offender is at least 90 months older than the
victim. This patient's relationship did not actually meet the criteria for mandatory
reporting. Had this not been the case however, the physician could be justified in
weighing the balance of harms arising from the filing of such a report.
There is little justification for informing the family of the young woman's sexual activity.
Due to the family's strong fundamentalist beliefs, significant damage would have
occurred in the family reconciliation process with this discovery. Although they would
clearly disapprove of the patient's actions, her choices carry no risk of harm to them.
Case 2: A 55-year-old man has a 3-month history of chest pain and fainting spells. You
feel his symptoms merit cardiac catheterization. You explain the risks and potential
benefits to him, and include your assessment of his likely prognosis without the
intervention. He is able to demonstrate that he understands all of this, but refuses the
intervention.
Can he do that, legally? Should you leave it at that?
This patient understands what is at stake with his treatment refusal. As he is competent to
make this decision, you have a duty to respect his choice. However, you should also be
sure to explore his reasons for refusing treatment and continue to discuss your
recommendations. A treatment refusal should be honored, but it should also not be
treated as the end of a discussion.
Real Case: Feb. 01, 2002 - Two physicians are faced with their worst fear their own nine-
month old baby presents in the ED with a severe drug overdose. Instead of following his
colleagues' recommendations, the father refuses to intubate the child until it is clear that
she won't last much longer without the procedure. The mother pushes away the on-call
critical care pediatrician, demanding another doctor, even if it means wasting precious
minutes. Meanwhile, the baby is screaming, struggling for life on a trauma table. This
week's episode of ER presents a puzzling, but not uncommon, paradox of the medical
profession. If the physician's moral obligation is to always act in the best interests of his
patient by providing the most appropriate treatment, why will he sometimes deviate from
the standard of care when treating a family member or close friend? Just as Drs. Mark
Greene and Elizabeth Corday were reluctant to pursue the traditional and effective
method of treatment when their baby fell ill, many physicians provide treatments for their
family members that they might not consider for the typical patient. It has been argued
that physicians always have their patients' best interests in mind when caring for family
members, but may lose sight of this "best interests" standard when treating patients with
whom they have no personal connection. While the human urge to protect one's own is
admittedly strong, applying this view to the doctor-patient relationship seems to
undermine physician integrity. It seems far more likely that physicians, whose careers are
founded on the Hippocratic Oath, diligently look to the best interests of all their patients
whenever possible. However, when personal interests cloud the lens of objectivity (as
when treating family members), a physician may fail to act in the best interests of the
patient. Indeed, evidence suggests that physicians treating family members sometimes
lose their sense of impartiality and do not act in the patient's best interests. One study
reported that 33% of physicians have observed another physician "inappropriately
involved" in a family member's care. (1) Such inappropriate involvement may lead to
overtreatment or undertreatment, strained professional relations between colleagues with
differing views on treatment, improper allocation of hospital resources, and, most
significantly, severe emotional strain on the treating physician. Understanding the reasons
why physicians sometimes act inappropriately when treating family members is essential
when faced with the sort of situation presented in this week's episode. Not only does such
understanding help Dr. Greene's and Dr. Corday's colleagues in negotiating the proper
course of treatment, but it also may have helped Mark and Elizabeth themselves
understand their own biases and take a slightly more objective view towards the care of
their child.
There are three common situations in which physicians are often unable to maintain their
objectivity when treating family members or children - when the situation is too emotionally
charged, when the physician's personal knowledge of the patient makes objectivity impossible,
or when the situation is too personal for the physician to feel comfortable as a primary caregiver.
(2) Of these, the first situation is by far the most common, and is the one faced by Drs. Greene
and Corday this week. When their baby accidentally overdoses on their teenaged daughter's stash
of illegal drugs, Mark and Elizabeth's emotions are running high. These parents respond in an
understandable fashion - with fear, panic, and a desperate desire to do everything possible to get
their child through this emergency. However, unlike most parents, these two are in a position to
direct their baby's treatment based on their own medical expertise. Many physicians have a
psychological need to feel omnipotent, and any setback in treating a family member may result
in "doubts, guilt, or an exaggerated sense of responsibility that may become pathological." (3)
For this reason, physicians caring for their own children may be tempted to bypass traditional
means of treatment in an effort to avoid exposing the patient to further stress or trauma. While
many physician-parents tend to overtreat by taking all possible measures to improve their child's
health, Mark and Elizabeth err on the side of undertreatment. Like most clinicians, they
recognize how unpleasant and stressful intubation can be on a patient. In an effort to spare their
baby this ordeal, and possibly because they are in denial about the severity of her condition, they
delay the procedure for far longer than is medically indicated. When the two finally step aside,
Dr. Kerry Weaver tells Mark that the course of treatment would have been different had it not
been for his and Elizabeth's involvement. "If this wasn't your baby, we would have intubated a
long time ago," she emphasizes. Dr. Weaver's statement makes it clear that the baby's best
interests were not necessarily served by involving the emotionally-strained parents in her care.
When physician-parents are too emotionally involved in their child's care, treatment may not
only be rendered less effective, but other related problems may result. Interpersonal relations
between physician-parents and colleagues may become strained when colleagues are asked to
deviate from the typical standard of care when treating physicians' children. Physician-parents
may invoke the hostility of administrators and caregivers by bypassing what seem to them like
exasperating administrative procedures - everyday delays in treatment and test results, visitors'
hours, insurance paperwork, etc. At the request of the parent, resources may be directed towards
the ill child even if they would be better utilized elsewhere, and the care of other patients on the
unit may consequently be delayed. Finally, the emotional strain on the parent himself is
evidenced by conflicting responsibilities - to the child, to the medical profession, to colleagues or
family members, and to his own conscience - which make it impossible for him to look at his
child's care objectively. When your own child is in danger, it is often impossible to separate the
role of "parent" from that of "physician." Understanding and accepting this struggle of identity
helps some physician-parents to step back and leave their child's care in the hands of a trusted
colleague, who may be better able to serve both the child's and parent's best interests.
High Yield Re: Inform Consent
What is informed consent?
Informed consent is the process by which a fully informed patient can participate in choices
about her health care. It originates from the legal and ethical right the patient has to direct what
happens to her body and from the ethical duty of the physician to involve the patient in her health
care.
What are the elements of full informed consent?
The most important goal of informed consent is that the patient have an opportunity to be an
informed participant in his health care decisions. It is generally accepted that complete informed
consent includes a discussion of the following elements:
the nature of the decision/procedure
reasonable alternatives to the proposed intervention
the relevant risks, benefits, and uncertainties related to each alternative
assessment of patient understanding
the acceptance of the intervention by the patient
In order for the patient's consent to be valid, he must be considered competent to make the
decision at hand and his consent must be voluntary. It is easy for coercive situations to arise in
medicine. Patients often feel powerless and vulnerable. To encourage voluntariness, the
physician can make clear to the patient that he is participating in a decision, not merely signing a
form. With this understanding, the informed consent process should be seen as an invitation to
him to participate in his health care decisions. The physician is also generally obligated to
provide a recommendation and share her reasoning process with the patient. Comprehension on
the part of the patient is equally as important as the information provided. Consequently, the
discussion should be carried on in layperson's terms and the patient's understanding should be
assessed along the way.
Basic consent entails letting the patient know what you would like to do and asking them if that
will be all right. Basic consent is appropriate, for example, when drawing blood. Decisions that
merit this sort of basic informed consent process require a low-level of patient involvement
because there is a high-level of community consensus.
How much information is considered "adequate"?
How do you know when you have said enough about a certain decision? Most of the literature
and law in this area suggest one of three approaches:
reasonable physician standard: what would a typical physician say about this intervention? This
standard allows the physician to determine what information is appropriate to disclose. However,
it is probably not enough, since most research in this area shows that the typical physician tells
the patient very little. This standard is also generally considered inconsistent with the goals of
informed consent as the focus is on the physician rather than on what the patient needs to know.
reasonable patient standard: what would the average patient need to know in order to be an
informed participant in the decision? This standard focuses on considering what a patient would
need to know in order to understand the decision at hand.
subjective standard: what would this patient need to know and understand in order to make an
informed decision? This standard is the most challenging to incorporate into practice, since it
requires tailoring information to each patient.
Most states have legislation or legal cases that determine the required standard for informed
consent. In the state of Washington, we use the "reasonable patient standard." The best approach
to the question of how much information is enough is one that meets both your professional
obligation to provide the best care and respects the patient as a person with the right to a voice in
health care decisions. (See also Truth-Telling and Law and Medicine.)
What sorts of interventions require informed consent?
Most health care institutions, including UWMC, Harborview, and VAMC have policies that state
which health interventions require a signed consent form. For example, surgery, anesthesia, and
other invasive procedures are usually in this category. These signed forms are really the
culmination of a dialogue required to foster the patient's informed participation in the clinical
decision.
For a wide range of decisions, written consent is neither required or needed, but some
meaningful discussion is needed. For instance, a man contemplating having a prostate-specific
antigen screen for prostate cancer should know the relevant arguments for and against this
screening test, discussed in layman's terms. (See also Research Ethics.)
When is it appropriate to question a patient's ability to participate in decision making?
In most cases, it is clear whether or not patients are competent to make their own decisions.
Occasionally, it is not so clear. Patients are under an unusual amount of stress during illness and
can experience anxiety, fear, and depression. The stress associated with illness should not
necessarily preclude one from participating in one's own care. However, precautions should be
taken to ensure the patient does have the capacity to make good decisions. There are several
different standards of decision making capacity. Generally you should assess the patient's ability
to:
understand his or her situation,
understand the risks associated with the decision at hand, and
communicate a decision based on that understanding.
When this is unclear, a psychiatric consultation can be helpful. Of course, just because a patient
refuses a treatment does not in itself mean the patient is incompetent. Competent patients have
the right to refuse treatment, even those treatments that may be life-saving. Treatment refusal
may, however, be a flag to pursue further the patient's beliefs and understanding about the
decision, as well as your own.
What about the patient whose decision making capacity varies from day to day?
Patients can move in and out of a coherent state as their medications or underlying disease
processes ebb and flow. You should do what you can to catch a patient in a lucid state - even
lightening up on the medications if necessary - in order to include him in the decision making
process.
What should occur if the patient cannot give informed consent?
If the patient is determined to be incapacitated/incompetent to make health care decisions, a
surrogate decision maker must speak for her. There is a specific hierarchy of appropriate
decision makers defined by state law (also see the DNR topic page). If no appropriate surrogate
decision maker is available, the physicians are expected to act in the best interest of the patient
until a surrogate is found or appointed.
Is there such a thing as presumed/implied consent?
The patient's consent should only be "presumed", rather than obtained, in emergency situations
when the patient is unconscious or incompetent and no surrogate decision maker is available. In
general, the patient's presence in the hospital ward, ICU or clinic does not represent implied
consent to all treatment and procedures. The patient's wishes and values may be quite different
than the values of the physician's. While the principle of respect for person obligates you to do
your best to include the patient in the health care decisions that affect his life and body, the
principle of beneficence may require you to act on the patient's behalf when his life is at stake.
A 64-year-old woman with MS is hospitalized. The team feels she may need to be placed on a
feeding tube soon to assure adequate nourishment. They ask the patient about this in the morning
and she agrees. However, in the evening (before the tube has been placed), the patient becomes
disoriented and seems confused about her decision to have the feeding tube placed. She tells the
team she doesn't want it in. They revisit the question in the morning, when the patient is again
lucid. Unable to recall her state of mind from the previous evening, the patient again agrees to
the procedure.
Is this patient competent to decide? Which preference should be honored?
A 64-year-old woman with MS is hospitalized. The team feels she may need to be placed on a
feeding tube soon to assure adequate nourishment. They ask the patient about this in the morning
and she agrees. However, in the evening (before the tube has been placed), the patient becomes
disoriented and seems confused about her decision to have the feeding tube placed. She tells the
team she doesn't want it in. They revisit the question in the morning, when the patient is again
lucid. Unable to recall her state of mind from the previous evening, the patient again agrees to
the procedure.
Is this patient competent to decide? Which preference should be honored?
This patient's underlying disease is impairing her decision making capacity. If her wishes are
consistent during her lucid periods, this choice may be considered her real preference and
followed accordingly. However, as her decision making capacity is questionable, getting a
surrogate decision maker involved can help determine what her real wishes are.
---------------------------------------------------------------------------------------------------
please clarify my doubt
what happen s to the levels of Ach in alzeheimers and what is the role of Acetyl choline
esterase inhibitors in this.
- Ans. in Alzheimer:Ach decreased coz of cholinergic neurons degeneration
Achesterase:breaks down Ach to choline&acetate,so blocking the action of this
enzyme by tacrine,donepezil provides more Ach&can delay the progression of
Alzheimer dementia
The incidence of cystic fibrosis in caucasian population is 1 in 1600.the expected
frequecy of heterozygote carriers in this population is
a)1 in 10
b)1 in 20
c)1 in 40
d)1 in 80
e)1 in 160
Ans. B?
In kaplan page 7 behavioral science says "Question: what is the effect of increased
prevalence on sensitivity? On Positive Predictive Value"? Answer : Sensitivity stays the
same but positive value increases"
But WHY? Would you explain to me?And also would you explain in a very simple way
what is the relation between Sensitivity, specificity, PPV and NPP and accuracy?
- Ans. sensitivity measures how well A TEST identifies truely ill people(so test
feature!),it's not correlated to prevalence(number of individuals with disease/total
population)but PPV is a probability that someone with+test actually has
disease,and it increased when number of affected people increased in population
or in other words prevalence increased.
- If a test more sensitive=e.g Elsia=very sensivtive ...it include all case hiv+ve.+but
not SPECIFIC.it means if sensitive test it has some cases whoare not HIV +ve
only confirm by WESTRON BLOT.THATS why it goes with NPP>
IF SPECIFIC....e.g WESTREN BLOT...if positive...it mean all are +ve.no
chances that in those ppl one donot have disease...so it goes wih PPV.
- I will like to illustrate this question with the case of diabetes diagnosis using FBS.
Let us assume that the sensitivity of FBS to detect diabetes is 90%. Therefore if
the test is applied to a population with a prevalence of diabetes of 20% then we
will expect to identify 9/10 of the 20%.If the total population of of such a
community is 200 we well get 36 diabetic based on FBS. This leaves 4 diabetic
unidentified. If prevalence of diabetes were to increase due to poor eating habits
to about 30% our test will then identify 90% of the 30% of the diabetics which
will be 54.
Now positive predictive value tells us if you are identified as being diabetic from
the test what is the probability that you are diabetic. Every test except for one with
a 100% sensitivity and 100% specificity is bound to pick up some false positives.
In a highly prevalent community the number of false positives is reduced by
virtue of the fact that there are fewer negatives in the population. Thus the
positive predictive value which is the number of
true positives/(true positives+false positives) will be increased.
tell me the association between sensitivity or specificity to PPV or NPV...i got mixed up
sensitivity usually measures all those who truely have disease.then it should be ass. with
PPV ..right! but the books say the other way round..plz clarify my concept..any one?
- Ans. seN for N
sPe for P
- sensitivity goes with NPV.Cos if test is more sensitive and you have a +
result,you may still be normal(FP).But if u get a - then you sure dont have the
disease.
Specificity goes with PPV.Ie if u get a + result then you sure are +.But if u get a -
you might still have the disease(FN).
- PPV probability that someone with+test actually has disease,as it calculated by
true+s/sum of true+s&false+s,so it's correlated to specificity
(specificity measures how well a test identifies people without disease)and
false+:normal patients that incorrectly identified as being ill
NPV probability that a person with a -test is actually well,as it calculated by true-
s/sum of true-s&false-s,it correlated to sensitivity(sensitivity measures how well a
test identifies truely ill people)and false-:ill people that test shows they're normal
in summery:
sensitivity........false negative.........NPV
specificity........false positive.........PPV
this is what i know,hope it helps,if not i can explain more
- Mnemonic: +PV=true+s/sum of true+s & FALSE+s
specificity=true-s/sum of true-s & FALSE+s
- -PV=true-s/true-s & FALSE-s
sensitivity=true+s/sum of true+s & FALSE-s
-
BQ: which test is used for IQ testing in 2 yrold?
- Ans. Stanford Binet scale, coz verbal skill not component of a test, for children <4
yr
also:
4-6yr WPPSI
6-17yr WISC-R
>=17yr WAIS-R
- i meant Stanford Binet <4 yr old, after 4-6yr:WPPSI
What do objective and projective tests mean in beh?
Ans. objective test based on Qs easily scored: like MMPI, projective test requires subject to
interpret the Qs: like Rorschach test, TAT.
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in operant conditioning the rate of extinction is most effectively slowed wen the
response has been maintained on a reinforcement scedule of
1]fixed ratio
2]variable ratio
3]fixed interval reinforcement
4]continuous reinforcement
5]peicework reinforcement
B] extinction is easiest with?
Ans. 2]variable ratio
forb:4]continuous reinforcement
a behaviour pattern that increases in frequency wen followed by a reward is an
exampl of
1]classical conditioning
2]shaping
3]respondent conditionig
4]operant conditionig
5]generalization
ans. 4 ]operant conditioning
in a programme aimed at cessation of smoking, a 45yr old woman is required to
smoke as many cigarettes in a small booth i short period of time, the mech used
here is?
1] habituation
2]aversive conditionig
3]stimulus control
4]variable ratio reinforcement
5]systematic desensitization
Ans. 2
an obese women on a wt loss programme is not losing wieght n confesses not to
have followed the schedule for the first few weeks n then gone on a crash diet
during the week prior to the check up, it is.
1]stimulus control
2]variable ratio reinforcement
3]fixed interval reinforcement
4]variable interval reinforcement
Ans. 3, fixed interval ratio , i.e she follows the schedule everytime just befor the
planned check up
the best self management procedure in a weight loss intervention programme is?
1]inforamtion control
2]self monitoring
3]self punishment
4]self reward
5]enlisiting social support
Ans. 4
An old lady is brought to the hospital in coma by her daughter with whom she
lives. The old lady is in coma and is diagnosed to be brain dead. When the
daughter is spoken to, she says, knowing mom, I feel that should something
happen to her, shed prefer to be withdrawn from life support. Just then , the old
ladys estranged son comes there after hearing the news and he looks at the doc
and says why havent u done anything yet, I want the best treatment for my
mother? if I were the doctor, I would have been in a fix, what would you do?
Ans. follow daughter's advise (as the caregiver in this case), son is in state of denial!
A pt comes to ur office and tells u doc, I just want to tell someone this, but Im
going to go home and kill my wife and then walks out your door what do you
do?
Ans. this is tarasoff decision: stop harm
so, you need to go after the patient
in case if patient gets away - call911, then you call wife and ask her to come to your
office /here you need to remember tarasoff 2
A 16 yr old girl comes to you and tells you she is planning to have sex with her
boyfriend and does not want to get pregnant. She asks you to write a prescription
for birth control pills. What will you do as a physician ?
- Ans. parental consent not reqd for contraceptive prescription.Also treatment in
emergency,drugor alcohol addict,STD treatment.
So i guess you could give OC but counsel them.
- Hey I just verified the contraceptive usage thing. These are the 4 categories where a
minor living with his parents does not need parental consent -->
STD treatment, contraceptives, substance abuse treatment, prenatal care.
A 15 yr old mother of one, comes with genitourinary complaints. Whose consent
will the doctor have to take to examine her ?
- the 15 year old again.
theses are two fields.....Pregnant girl <18, mother less than 18, and an independant minor
who can give consent solely.
and Correct me if I am wrong..is it the same rule for a boy or a girl,<18 who ask for the
advise in contraception with out telling their parents!
- a married minor too...
- One more thing is a pregnant lady or a teenaged mom under 18 yrs of age does NOT
automatically become emancipated(not sure of the spelling!) ie doesn't become
independent to give consent unless she is ACTIVELY TAKING CARE OF THE CHILD
Well, heres a 17 yr old boy in the army and he comes with a bullet wound in his
thigh. U need to remove it surgically. Who do you have to take consent from?
Ans. the boy himself because he is independant minor.
TRUE OR FALSE? Feeding tube is a medical treatment and can be withdrawn at
the patient's request
- Ans. True
- How about in anorexia nervosa?
- Ans. false in case of anorexia nervosa. anorexia nervosa usually seen in girls teens e.g.
15y.o., in this case doesn't matter what she said
if this pt >18 - go to the cort /this is an exeption when on the test answer is go to the cort.
TRUE OR FALSE ? a competent patient has the right to refuse even life saving
hydration (oral or I.V fluids)
Ans. True if >18
An 8 yr old child with IDDM needs to undergo treatment with insulin but the
parents refuse surgery and say they will take the child home and pray for its
welfare what should the doctor do?
(a) Dont start treatment
(b) decide to go ahead against the parents wishes and start Rx
( c) try to convince them to agree threatening them with the childs death
(d) go to court with the dispute.
- Ans. Could have been b,But patient is not serious enough immediately.(like DKA).
So now could have been c but you cant threaten them.Only convince.
So D is best i guess.
- we have to go to court with the dispute. This is the only reason to go to court , other
decisions should be taken outside the court
If a patient, a 52 yr old male with no other illnesses, comes with signs of ischemic
heart disease and you, as a doctor know he needs an emergency coronary artery
bypass graft surgery but he REFUSES surgery. What next?
(a) ignore him and perform surgery
(b) take consent from his spouse
(c) dont do surgery
(d) threaten him that he will die if he doesnt undergo surgery
Ans. C, and mention in the notes that you have explained to the patients the need of
surgery and he refuses,
how do you assess for visual retention of presented objects?
how do you differentiate from Bendervisualmotor Gestalt test
ans. The Bender test is a brief, nonverbal assessment consisting of nine stimulus cards, each
showing a figure. The client is asked to reproduce the figures, a task requiring visual association,
motor coordination, and the ability to integrate perceptual and motor skills to achieve accurate
reproductions.
AND
Dynamic Visual Retention Test (W.H. Gaddes, 1988 Revision) has been shown to be sensitive to
left frontal lobe damage/dysfunction and to discriminate dyslexic readers
BQ: by decreasing the upper limit of normal of a test,what changes are seen in:
1)sensitivity?
2)PPV?
3)false negative rate?
Ans. sensitivity:increased
PPV:decreased
false negative rate:decreased
what are alpha and beta errors in stat? Ans. Alpha error is we reject(fail to accept) the
null hypothesis when the null is true. Beta error is when we accept the null hypothesis
though it is false. To have an anology, alpha error occurs when you convict an innocent
person and beta error occurs when you free a guilty person. Both these errors have to be
kept very low. The value 1-beta should be very high because that indicates the power of
the test.
Why is Stanford binet is best for young children? Ans. it's the ratio of mental age to
chronological age multiplied by 100 as it's not completey based on language performance
best for children 2-4yr
Mnemonic on Alzheimers disease:
- RONALD (Ronald Reagan, a famous victim):
R Reduction of Ach
O Old age
N Neurofibrillary tangles
A Atrophy of cerebral cortex (diffuse)
L Language impairment
D Dementia (MC in elderly)/ Downs syndrome
- very important... and what congenital anomaly is it associated with in those over
the age of 40?....ans. Downs syndrome
- so what do you see in the brain?...ans. amyloid deposits..and neurofibrillary
tangles
- we see plaques due to amyloid deposition.
in down syndrome patient beta amyloid protein production increses which causes
development of plaqes.
most likely method used by both males and females to commit suicide is? Ans. Pills to
try to kill themselves...
Gun to complete the act...
most admissions in the hospitalisation r due to? Ans. psych reasons including drug abuse
in which subspeciality of physicians highest suicide rate is seen? Ans. Psychiatrists
this disease diagnosis involves more malpractice suits than any other? Ans. Breast cancer
diagnosis.
highest suicide rates are seen in which profession?
- Ans. Dentists #1
Psychiatrists #2
which neurotransmitter is most imp for sleep serotonin or acytlcholine? Ans. Both.
In causing sleep its Seratonin and Ach.
In Waking up its Norepi, and Dopamine.
Which is the most common form (Nicotine, Caffine, Alcohol) of drug use in US? Ans.
ALCOHOL!
Alcohol is the most abused drug.
Therefore FAS is the most common cause of MR.
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CARDIAC TESTS
Chest X-ray
o X-rays are a form of electromagnetic radiation (like light); they are of higher energy,
however, and can penetrate the body to form an image on film. There is low radiation
exposure. X-rays are monitored and regulated to provide the minimum amount of radiation
exposure needed to produce the image.
o A chest X-ray may be ordered when an person's symptoms include a persistent cough,
coughing up blood, chest pain, a chest injury, or difficulty in breathing. The test is also used
when tuberculosis, lung cancer, or other chest or lung disease is suspected.
o A serial chest X-ray (repeated or sequential) may be used to evaluate changes over time if
an abnormality found on a chest X-ray (for example, an increase in the size of an
abnormality over a period of weeks).
EKG
o What is it?
An electrocardiogram often abbreviated, as EKG or ECG is a test that measures the
electrical activity of the heartbeat. With each beat, an electrical impulse (or wave) travels
through the heart. This wave causes the muscle to squeeze and pump blood from the
heart.
o Why is it done?
An EKG gives two major kinds of information.
1
st
, find out how long a wave takes to travel from one part of the heart to the next
shows if the electrical activity is normal or slow, fast or irregular.
Second, by measuring the amount of electrical activity passing through the heart
muscle, a pediatric cardiologist may be able to find out if parts of the heart are too
large or are overworked.
HDP
o Swan catheter
Exercise Stress Test
o Definition
An exercise stress test is a general screening tool to test the effect of exercise on
your heart. The test gives a general sense of how healthy your heart is.
During the test, the electrical activity of the heart is measured while you walk on a
treadmill or pedal a stationary bicycle. This measures the heart's reaction to your
body's increased demand for oxygen. (See also sestimibi and thallium stress tests.)
o How the test is performed
You will be asked to walk or pedal on an exercise machine. An electrocardiogram
(ECG) is used to record the activity of your heart and blood pressure readings are
taken. The response of the heart to this increased workload is monitored.
The test continues until you reach a target heart rate, unless complications such as
chest pain or an exaggerated rise in blood pressure develop with activity. Monitoring
continues after exercise for 10 to 15 minutes or until the heart rate returns to
baseline.
Thallium Stress Testing
o Nuclear imaging methods that provide a view of the blood flow into the heart muscle. The
thallium and sestamibi tests are also called MIBI stress test and myocardial perfusion
scintigraphy, and are used to evaluate how well your heart is perfused (supplied with
blood) at rest as compared with activity.
o During these tests, heart images can be obtained because the patient receives an injection
of a substance that is labeled with a radioactive marker or radiotracer to make it visible in
the bloodstream. These substances are also called radiopharmaceuticals, and include
thallium-201 and technetium-99m MIBI or sestamibi.
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o In comparison to the standard treadmill stress test, thallium and sestamibi stress tests are
more accurate and provide additional information.
o How the test is performed
Exercise as hard as you can on a treadmill or bicycle
When you reach your maximum level of exercise, a nurse will inject in your vein a
small amount of a radioactive substance (radiotracer), either thallium or sestamibi
The radiotracer will travel in the bloodstream and, through the coronary arteries, will
enter into the heart muscle as you complete your exercise session.
After you finish exercising, you will lie down on a special table under a bulky camera
called a gamma camera. The gamma camera can scan your heart and detect the
radiotracer in it.
The distribution of the radiotracer in your heart will be processed by a computer to
create pictures of your heart. The first pictures are made shortly after the exercise
test, to show the circulation of blood to your heart during exercise. This is the part
considered "a stress test" and is the most challenging for your heart.
Then you will need to lie quietly for 2-3 hours, and at that point the scanner will
make another series of pictures of your heart. These images will show the
circulation of blood through your heart muscle at rest.
Myoview or Cardiolite Stress Testing; Sestamibi
o Advantage
Technetium instead of Thallium which is brighter and better
Used for women w/ large breasts or men with big guts
Fewer false positive than Thallium, better for screening
Specificity is 96% (Thallium is 85%)
Good screening tool
o Disadvantage
Not as good for viability as Thallium
Not as good for people who have had an infarct
Persantine Stress Test
o What is an IV Persantine-Thallium Stress Test?
This test is an alternative procedure for patients with coronary artery disease who
can not exercise on a treadmill.
An IV line is started to administer the persantine and the thallium.
Persantine helps to expand the coronary arteries increasing the blood flow to the
area. This effect is similar to what happens during vigorous exercise.
Thallium (a radioactive isotope) is detected by X-rays and shows which parts of the
heart muscle are receiving enough oxygen.
EKG used to moniter.
A special camera takes pictures of the heart.
2 phases, with each phase lasting 30-60 minutes
o Why is a Persantine Stress Done?
This test will help the doctor to evaluate the patient's cardiac condition related to:
Irregular heart rhythms
Which areas of the heart are not getting enough blood and oxygen.
How quickly the heart recovers after exercise.
o Good area dilates more to Persantine and shows up as bright, bad area is dull.
o Steal can be created, but only occurs w/ very high grade stenosis, pt will become
symptomatic w/ chest pain
Multigated Acquisition Wall Motion Scan (MUGA)
o During the MUGA test, a radioactive isotope (Technetium) is injected into the vein
o Radioactive isotopes attach to red blood cells and pass through the heart in the circulation
o The isotopes can be traced through the heart using special cameras or scanners. Ejection
fraction (normal=55%, 30% after one MI, <30% major risk) can be measured by observing
volumes during systole and diastole.
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o The test is often given at rest, then repeated with exercise, or after administering certain
medications. The test is performed to detect certain heart conditions.
o Easily done and reproducible
First-pass radionuclide angiocardiography
o Nuclear imaging, same information as MUGA, but harder to do
o Injection of a bolus of a technetium-99m-labelled RBCs
o Nuclear scan images acquired in rapid sequence during the injection
o Images recorded allow the calculation of the ventricular ejection fraction (EF), the
determination of shunt volumes and wall motion abnormalities
o First-pass radionuclide angiocardiography is less frequently used nowadays, as gated
blood pool scanning yields much better results. Gating of the data to the cardiac cycle
permits addition of the five or so cardiac cycles observed during the first pass of the
radionuclide, thereby improving the statistical accuracy of the EF determination.
Spect
o Single photon emission computed tomography (SPECT) is a noninvasive technique for
creating very clear, three-dimensional pictures of a major organ (e.g., the heart)
o Uses radionuclide imaging a technique that involves the injection of very small amount of
a radionuclide substance called a tracer. Energy from the tracer in the body is detected by a
gamma ray camera, which then takes the pictures. A tracer is not a dye (contrast medium)
Gated Spect
o In addition to aquiring images, you play them back like a movie??
o You get wall motion
Echo Doppler
o You get ejection fraction, wall motion
o An instrument that transmits high-frequency sound waves called a transducer is placed on
your ribs near the breast bone and directed toward the heart. The transducer picks up the
echoes of the sound waves and transmits them as electrical impulses. The
echocardiography machine converts these impulses into moving pictures of the heart.
o Best test to test DYASTOLIC DYSFUNCTION
o This test is performed to evaluate the valves and chambers of the heart in a noninvasive
manner for
heart murmurs
check the pumping function of the heart
evaluate patients who have had heart attacks
o It is a very good screening test for heart disease in certain groups of patients.
TEE
o Swallow a probe
o Sedate patient, use Lidocaine
o You get a better view of the heart
o Sometimes you cant see the Left Atrium too well
o Use on pts:
Suspected descending aortic dissection
Endocarditis
Need a closer look
Non-Invasive Vascular Testing
o Plethysmography (Pulse Volume Recording w/ Segmental blood pressures)
A test is performed by placing blood pressure cuffs on the extremities to measure
the systolic pressure
The cuffs are then attached to a pulse volume recorder (plethysmograph) that
displays each pulse wave.
Compares the systolic blood pressure of the lower extremity to the upper extremity,
to help rule out disease that blocks the arteries in the extremities.
Use for diabetic pts over 70, non-healing ulcers, cellulitis, claudication Sx, reduced
pulses
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o Venous Duplex
Use when there is a venous problem
Vericous veins
Edema
Venous stasis
Stasis ulcers
Carotid Doppler
o Carotid duplex is an ultrasound procedure performed to assess blood flow through the
carotid artery to the brain. High-frequency sound waves are directed from a hand-held
transducer probe to the area. These waves "echo" off the arterial structures and produce a
2-dimensional image on a monitor, which will make obstructions or narrowing of the arteries
visible.
o Carotid duplex is a procedure that uses ultrasound to look for
Plaques (Intimal thickness)
Blood clots
Aneurisms
Other problems with blood flow
o Predict TIAs and strokes (CVAs) and if pt would benefit from stent
Holter
o Definition: 24 hours of ECG recordings
o Used to check for
Arrythmias (tachy, brady, V-tach)
Post MI
Palpataions, dizziness
Sudden death risk
Signal Average ECG
o Non-invasive
o Identifying risks for potentially fatal heart rhythm problems
o The procedure involves obtaining electrocardiograph signals from the heart, amplifying
them, and then filtering and averaging them by computer
o The procedure may detect "late potentials," low amplitude signals associated with serious
rhythm abnormalities, which can lead to sudden cardiac death.
o Useful in same pts as holter
HRV (Heart Rate Variability) Test
o High variability is good (HR quickens as you run up stairs, for instance, and slows as you
nap)
T Wave Alterans
o Low level stress test (bring hear to 110)
o Look at T wave
If they are stable good
If they invert, change bad
o Helps predict risk of sudden death
o Used in same pts as holter
Transtelephonic monitering
o Holter through the telephone
o Loop recorder records heart beat for 30 days
o Used in same pts as holter
Pacemaker Testing
o Monitor function of pacemaker over the phone
Ambulatory Blood Pressure and HR
o Monitor blood pressure for white coat syndrome pts
EPS
o Intracardiac electrophysiology study (EPS) involves placing wire electrodes within the heart
to find the location of a known arrhythmia and determine the best therapy
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o Abnormal electrical activity can occur anywhere along the conduction system, including in
the muscle cells of either the atria or ventricles. The electrodes inserted during EPS will
map the type of arrhythmia you have and where the problem arises in your heart.
o Allows for determination of the severity of the problem (including whether you are at risk for
sudden cardiac death) as well as appropriate treatment.
o Good for pts w/ syncope, posts MI, arrhythmias
Ablation
o Nonsurgical method
o Insert a thin tube (catheter) through a blood vessel (in the upper thigh, wrist or arm) and all
the way up to the heart
o At the tip of the tube is a small wire, which can deliver radiofrequency energy to burn away
the abnormal areas of the heart
o Success rate over 90 percent
o Treats
Tachycardia
Wolff-Parkinson-White syndrome: episodes of tachycardia caused by abnormal
electrical pathways (circuits) in the heart
V-tach w/ normal ventricle (Not good for people post MI)
A-fib
Most you cant burn b/c its due to stretch fibers
Some you can burn b/c its from one irritable focus
Pacemakers
o Biventricular pacemaker
New type of artificial pacemaker designed to treat heart failure
In many heart failure patients, the walls of the left ventricle are no longer
synchronized, these pacemakers resynchronize
Standard pacemakers pace either the lower-right chamber of the heart (single
chamber pacemaker) or both the lower-right and the upper-right chambers (dual
chamber pacemaker). In contrast, biventricular pacemakers pace both of the lower
chambers of the heart (the ventricles).This enables the device to stimulate the left
and right ventricles simultaneously, which can enable the left ventricle to pump
blood more efficiently
Used to treat heart failure
Used for pts w/
Stage 3 / 4 heart failure (sx w/ rest or minimal activity)
Ejection fractions <30%
Have an IVCD?
QRS interval >130 msec
Buy stock in Guidance?
ICDs
o An implantable cardioverter defibrillator (ICD) is a device that is implanted in the chest to
monitor for and, if necessary, correct episodes of rapid heartbeat.
o If the heartbeat gets too fast (ventricular tachycardia), the ICD will stimulate the heart to
restore a normal rhythm (anti-tachycardia pacing).
o In cases where the heartbeat is so rapid that the person may die (ventricular fibrillation), the
ICD will also give an electric shock (defibrillation) to reset the heartbeat.
o Similar to an artifical pacemaker, which is another type of device that corrects an abnormal
heart rhythm. However, pacemakers are usually chosen to correct a heart rhythm that is too
slow (bradycardia), whereas ICDs are used to correct a heart rhythm that is too fast
(tachycardia). And there are patients who need both bradycardia pacing and anti-
tachycardia pacing. In these patients, an ICD will be used to pace the heart.
o Minor surgical procedure (not open-heart surgery)
AEDs
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o A defibrillator is a device that attempts to restore a normal heart rhythm by delivering an
electrical shock to the heart. A defibrillator is used when the heartbeat is dangerously fast
due to ventricular tachycardia or ventricular fibrillation. Either of these conditions can be life-
threatening, because the heart may abruptly stop pumping blood to the body (cardiac
arrest). Some defibrillators are external (e.g., defibrillator paddles in an emergency room),
and some are surgically implanted in the patients chest (e.g., an implantable cardioverter
defibrillator).
o Recent advances in technology have allowed people with little training to use automatic
external defibrillators (AEDs) in an emergency when medical professionals are not present.
o The American Heart Association estimates that 20,000 lives would be saved every year in
the United States if AEDs were more widely available. The chance of surviving cardiac
arrest decreases by 10 percent with every minute that ticks by without defibrillation.
Cardiac Catheterization
o Used to study the various functions of the heart or to obtain diagnostic information about
the heart or its vessels
o A small incision is made in an artery or vein in the arm, neck, or groin. The catheter is
threaded through the artery or vein into the heart. X-ray images called fluoroscopy are used
to guide the insertion.
o When the catheter is in place, dye is injected to visualize the structures and vessels within
the heart.
o Using different techniques, the coronary arteries can be viewed by injecting dye or opened
using balloon angioplasty. The oxygen concentration can be measured across the valves
and walls (septa) of the heart and pressures within each chamber of the heart and across
the valves can be measured. The technique can even be performed in small, newborn
infants.
PTCA (POBA)
o Balloon angioplasty is one of three standard treatments for coronary artery disease (CAD)
a disease in which the blood flow to the heart and the body is restricted due to hardened
arteries (atherosclerosis). The other standard treatments for CAD are medication and
bypass surgery.
o The goal of balloon angioplasty is to push the fatty plaque back against the artery wall to
make more room for blood to flow through the artery. This improved blood flow reduces the
risk of heart attack and sudden cardiac death.
o Physician uses an artery into which a thin tube with an uninflated balloon at the tip (balloon-
tipped catheter) will be inserted. He inserts the balloon-tipped catheter through the femoral
artery all the way up to the heart
o Once the balloon-tipped catheter is at the site of the blockage, the balloon at the tip of the
catheter is inflated, pushing the plaque in the artery back against the wall of the artery
o The balloon-tipped catheter is then removed or replaced with a stent (a wire mesh tube
used to hold the artery open). The patient is then given time to recover
o Most patients are free to go home after about 24 hours.
Stents
o w/ PTCA
o everybody gets them
o The artery must be <2 mm
Heart Surgery
o Off pump, better to do surgery this way (let the heart beat naturally)
o Annuloplasty: Reconstruction of the ring (or annulus) of an incompetent cardiac valve.
INDICATIONS for doing an ECG
o Class I You have to do the tests
o Class 2A You should do the tests
o Class 2B You dont have to
o Class 3 You cannot do the tests
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BIOCHEMISTRY
Proteins and Enzymes
Electrolytes and Acid-Base Balance
Case Studies
PROTEINS and ENZYMES
Erythrocyte Sedimentation Rate (ESR): A high ESR occurs when the body is infected or under stress, and the
liver is releasing acute-phase proteins into the blood.
ACUTE-PHASE PROTEINS: Proteins released by the liver when the body is under stress.
alpha
1
-Antitrypsin: Protease inhibitor. When there is tissue damage, the dead tissue releases proteases, so
the anti-proteases help to prevent further damage.
alpha
2
-Macroglobulin: Indirect anti-protease that fixes proteases and allows macrophages to engulf them.
C-Reactive Protein (CRP): Opsonin, help to fix antibodies to antigen to facilitate phagocytosis.
Ceruloplasmin: Copper-carrying protein, and anti-oxidant.
Complement Proteins: Inflammatory mediators.
Ferritin: Iron protein-carrier.
Fibrinogen: Clotting factor.
Haptoglobin: Binds to hemoglobin in blood.
Serum Amyloid A Protein: Apolipoprotein.
PROTEIN ELECTROPHORESIS: alpha
1
, alpha
2
, beta, and gamma zones all have distinct proteins.
alpha
1
Zone: Closest to the anode (right).
o Albumin: Albumin is the tall peak closest to the anode.
Normal properties:
50% of liver protein production; primary determinant of oncotic pressure.
20-day lifespan in circulation. If albumin decreases, it won't show up until 20
days later.
MW = 68 kDa, which is right at the margin for glomerular filtration. That's why
even mild glomerular disease leads to albuminuria.
Albumin is decreased under a lot of circumstances:
Renal disease, proteinuria.
Times of stress or disease.
Malnutrition, Kwarshiorkor.
Albumin binds to bilirubin and Ca
+2
.
A decreased albumin levels can significantly alter the laboratory values for
bilirubin and calcium. If albumin is low, then these lab-values will be falsely
low, and you must adjust them upward to get the real value.
o Pre-Albumin: Fetal albumin is called pre-albumin. It consists of two proteins.
alpha-Fetoprotein (AFP):
Anencephaly, Spina Bifida: AFP leaks out of the fetus and into the maternal
circulation, thus AFP is increased in maternal blood.
Liver Cancer, Endodermal Sinus (Yolk-Sac) Tumor: The tumors contain
immature tissue thxat releases pre-albumin, thus AFP is increased.
Transtherytin: Fetal form of TBG that carries T
3
and T
4
in fetal blood.
alpha
2
Zone:
o alpha
2
-Macroglobulin: Huge molecule that binds to proteases and thus allows macrophages to
engulf them, getting rid of the proteases.
o Haptoglobin: Binds to free hemoglobin in the plasma. Its maximum binding-capacity is about
10% of all hemoglobin in blood.
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If free haptoglobin is decreased (all bound up) and free hemoglobin is increased, then
that indicates intravascular hemolysis, such as that caused by blood-type incompatibility
or artifical heart valves.
o Ceruloplasmin
o GC Globulin
beta Zone:
o LDL Lipoprotein
o Transferrin: Iron transporting protein.
o C3 Complement Factor
o beta
2
-Microglobulin: Part of the Major Histocompatibility Complex.
o Hemopexin: Binds free heme (hemoglobin degradation product) -- not hemoglobin itself, as in
Haptoglobin.
gamma Zone: Closest to cathode (left).
o Immunoglobulins (Ig):
o C-Reactive Protein (CRP): Good marker during wound-healing. If it increases during wound-
healing, then the wound is probably getting infected.
Originally discovered as a protein that binds to Streptococcus Pneumoniae.
o Fibrinogen:
o Lysozyme:
GAMMOPATHIES:
Polyclonal Gammopathy: Broad gamma peak, indicating infection.
Monoclonal Gammopathy: Narrow gamma peak. Differential:
o Multiple Myeloma, 60%. Malignancy of IgG-secreting plasma cells.
o Waldenstrom Macroglobulinemia, 10%. Hypersecretion of IgM.
o Lymphomas, Leukemias, 10%
o Monoclonal Gammopathy of Unknown Significance (MGUS), 10%
o Rare causes: Heavy chain disease, primary amyloidosis, solitary plasmacytoma.
Hypogammaglobulinemia: No peak or shallow peak in gamma range.
o Due to inherited immune deficiency:
X-Linked IgA Deficiency: Common, 1/750 births.
Agammaglobulinemia: Rare.
o Acquired causes: Malignancies, immunosuppressive drugs, HIV, measles, malnutrition.
PLASMA ENZYMES:
Alkaline Phosphatase (Alk.Phos.): Increased Alk.Phos. indicates:
o Cholestasis
o Increased bone growth or reformatuion. Osteoblasts secrete Alk.Phos.
Alanine Aminotransferase (ALT): Increased ALT indicates liver damage. It is released into circulation
from damaged or necrotic liver cells.
Aspartate Aminotransferase (AST): AST is released from a variety of damaged cells. Increased ALT
indicates:
o Liver damage
o Post-MI
o General cellular injury.
Myocardial Infarct (MI): CAL is a mnemonic to remember the order in which enzymes increase:
o Creatinine Kinase (CK): 4-8 hrs. post-MI
o Aspartate Aminotransferase (AST): Goes up next.
o Lactate Dehydrogenase (LDH): Last one to go up.
Creatinine Kinase (CK): Isozymes
o CK-MM: 99% of skeletal muscle, and about 77% of myocardium.
o CK-MB: About 22% of myocardium, but it is not found in any other tissues, so CK-MB is a
significant marker for myocardial infarct.
o CK-BB: Forms greater than 90% of CK in other tissues, such as CNS, colon, and ileum.
Lactate Dehydrogenase (LDH): Isozymes
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o LDH-1: The predominant isozyme in myocardial tissue. High LDH-1 indicates MI.
LDH-Flip: LDH-5 is normally highest, but in cases of MI LDH-1 may be higher. This is called an LDH-
flip and is suggestive of MI.
o LDH-2 thru LDH-4: Minor isozymes.
o LDH-5: The predominant isozyme in liver and skeletal muscle. It is normally the highest, except
in cases of MI LDH-1 may be higher.
PROTEINURIA: Can be caused by three mechanisms:
OVERFLOW:
o Normal proteins in blood: hemoglobinuria, myoglobinuria.
o Abnormal proteins in blood: Bence-Jones protein (IgG light-chains found in Mutiple Myeloma).
GLOMERULAR: Primarily albuminuria.
o Fever, glomerulonephritis cause higher renal permeability.
o Altered hemodynamics (such as exercise) can transiently cause proteinuria.
TUBULAR:
o Tubular damage due to heavy-metal poisoning, drug toxicities.
o Interstitial nephritis, pyelonephritis.
o beta
2
and alpha
1
Microglobulin will be found in urine. They are normally filtered and
reabsorbed, but with tubular disease they won't be reabsorbed.
ELECTROLYTES and ACID-BASE
TOTAL BODY WATER:
TBW is normally 60% of body weight. 60% of 70 kg = 42L
o INTRACELLULAR: Intracellular fluid is normally two thirds of TBW. 67% of 42L = 28L
o EXTRACELLULAR: Extracellular fluid is normally one third of TBW. 33% of 42L = 14L
PLASMA VOLUME: Plasma is normally about 5% of TBW. 5% of 42L = 2-3L
INTERSTITIAL VOLUME: ISF is the rest of the volume. 14L - 3L = 10-11L.
POTASSIUM: Reference range 3.5 - 5.0 mEq / L
HYPOKALEMIA: Decreased K
+
in plasma
o Hypokalemia is usually accompanied by metabolic alkalosis.
HYPERKALEMIA: Increased K
+
in plasma
o Hyperkalemia is usually accompanied by metabolic acidosis.
SODIUM: Reference range 135 - 146 mEq / L
HYPONATREMIA:
o Pitting Edema: Fluid has moved from vascular space into interstitial space. The intracellular
spaces are not affected.
It occurs because of an off-balance of Starlnig's Forces:
Too much hydrostatic pressure: CHF
Too little oncotic pressure: Nephrotic Syndrome, Liver Cirrhosis
One usually finds hyponatremia with these conditions, because the patient has
gained more water than sodium, so the sodium levels are diluted.
o Cerebral Edema: In hyponatremia, water enters into neuron cells in brain ------> cerebral edema.
Potential for herniation if it is not corrected.
Idiogenic Molecules are osmotically active molecules created by the cerebrum, to try to
compensate for the cerebral edema. They are excreted into the ISF to try to suck the
water out of the cells.
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4
o Syndrome of Inappropriate ADH (SIADH): It is the most common cause of hyponatremia with
a normal physical exam (no edema, no lost skin turgor).
CAUSES: Ectopic production by a tumor, such as small-cell carcinoma of the lung.
TREATMENT: Restrict intake of water. Electrolyte balance remains normal; no
electrolyte adjustments are needed. Treat with ADH antagonists.
HYPERNATREMIA:
o Dehydration: Pure water loss, infantile diarrhea.
TREATMENT: Don't give the calculated amount of fluid back to the patient. Always
give less, to prevent cerebral herniation. The brain will make osmotically active idiogenic
molecules to try to compensate for the dehydration. Then if you give too much fluid, the
brain can herniate.
o Diabetic Ketoacidosis (DKA):
Due to increased osmotic force of hyperglycemia, fluid will move from the intracellular
space into the plasma.
Sodium Concentration must be adjusted for the presence of hyperglycemia (which isn't
normally taken into account). The sodium concentration will be actually higher than what
is reported. This is true with blood sugar > 500.
TOTAL BODY SODIUM (TBNa):
o Decreased TBNa ------> decreased fluid in interstitial space ------> decreased skin turgor. You
can pull on skin and it isn't as elastic or tight.
o Increased TBNa ------> increased fluid in interstitial space ------> pitting edema. Fluid
accumulated in interstitial space.
Patient may still have Hyponatremia, because the sodium concentration in blood is
decreased. But, the total body sodium will be increased.
DEHYDRATION:
Adult Diarrhea is isotonic, thus adult dehydration will show normal sodium levels.
o To rehydrate, give them what they lost -- an isotonic saline solution.
Infantile Diarrhea is hypotonic, thus infantile diarrhea will show hypernatremia.
o To rehydrate, give them what they lost -- a pedialyte, or hypotonic saline solution.
EDEMA:
Cellular Edema: Tissue Hypoxia leads to cellular edema. Hypoxia ------> Na
+
/K
+
-ATPase Pump failure --
----> Na
+
collects inside cells and brings water with it ------> hydropic swelling of cells and cellular
edema.
Pitting Edema: CHF, Nephrosis, Cirrhosis lead to pitting edema. Transudate collects in interstitial space,
either due to increased hydrostatic pressure (CHF) or decreased oncotic pressure (Nephrosis, cirrhosis,
malnutrition).
Cerebral Edema: In hyponatremia, water enters into neuron cells in brain ------> cerebral edema. Potential
for herniation if it is not corrected.
o Idiogenic Molecules are osmotically active molecules created by the cerebrum, to try to
compensate for the cerebral edema. They are excreted into the ISF to try to suck the water out of
the cells.
OSMOLALITY: Normal value is about 289 mOsm.
ACID-BASE:
METABOLIC ACIDOSIS: Decrease the HCO
3
-
------> the pH goes down. Compensation: Respiratory
Alkalosis will bring the pH back near normal.
METABOLIC ALKALOSIS: Increase the HCO
3
-
------> the pH goes up. Compensation: Respiratory
Acidosis (hypoventilation) can help to bring the pH back near normal.
o CAUSES:
Vomiting: Lose enough stomach acid to produce alkalosis.
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Diuretics: Loop diuretics and thiazides can lead to hypokalemia ------> secondary
metabolic alkalosis.
RESPIRATORY ACIDOSIS: Increase the PCO
2
------> the pH goes down. Hypoventilation.
Compensation: Metabolic Alkalosis can help bring the pH back near normal.
RESPIRATORY ALKALOSIS: Decrease the PCO
2
------> the pH goes up. Hyperventilation.
Compensation: Metabolic Acidosis can help bring the pH back near normal.
ANION GAP: Essentially, the difference between between the concentrations of cations (Na
+
primarily) and anions
(Cl
-
, HCO
3
-
) in the blood.
High Anion Gap: Metabolic Acidosis. It indicates that you have added acids to the blood: salicylic acid,
formic acid, lactic acid, oxalic acid, sulfuric acid.
Normal Anion Gap: Respiratory Acidosis. It occurs when you ultimately become acidotic because of
losing HCO
3
-
.
NORMAL VALUES of ARTERIAL BLOOD-GASES:
Item Value
pH 7.4
[HCO
3
-
] 22 - 28 mEq / L
PaCO
2
33 - 44 mEq / L
PaO
2
90 - 100 mEq / L
CASE STUDIES
ACID-BASE CASE STUDIES:
Case # pCO
2
PO
2
HCO
3
-
pH Explanation
Case 1 70 low 27 7.2 Acute Barbiturate Overdose. PCO
2
is high ------> respiratory acidosis from
hypoventilation. It is uncompensated because the HCO
3
-
is normal and the
pH is low.
Case 2 70 100 12 7.0 Code Arrest. High PCO
2
------> respiratory acidosis. Also, low HCO
3
-
------
> metabolic acidosis. It's a mixed disorder.
Case 3 59 50 31 7.34 COPD. Partially compensated respiratory acidosis. High PCO
2
, high HCO
3
-
(metabolic alkalosis) in compensation, near normal but slightly low pH.
Case 4 29 100 22 7.50 Hyperventilation. Uncompensated respiratory alkalosis.
Case 5 50 80 12 7.27 Chronic Renal Failure. Patient shows partially compensated metabolic
acidosis with high anion gap. Patient can't excrete all the acid he is creating.
Case 6 50 80 42 7.52 Diuretics in a non-smoking female. Metabolic Alkalosis (high HCO
3
-
) with
partially compensated respiratory acidosis (low PCO
2
).
Case 7 62 50 36 7.37 COPD, loop diuretic. Mixed disorder. Respiratory acidosis from COPD, and
metabolic alkalosis from loop diuretic. The pH is near normal but it should
notbe called compensated, because full compensation never occurs, and the
pH is the result of two unrelated processes.
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CLINICAL BIOCHEMISTRY CASE STUDIES:
Case Pertinent Lab Values Explanation
1 Potassium Lab Error, Addison's
Disease
High K
+
High Urea
Low Na
+
K
+
was high becuase of partial hemolysis of blood,
because blood was aged. Labs could indicate
Addison's Disease, but they need to be retaken.
2 Potassium Lab Error High K
+
K
+
of 45 is incompatible with life.
3 IDDM Glucose tolerance test: young kid most likely has a
transitory hyperglycemia, because he just ate. Next
day glucose is normal
4 Starvation, Dehydration ICF and ECF will shrink to the same extent.
Drink seawater: death due to hypernatremia,
diarrhea from magnesium in the sea-water.
5 Dehydration High Na
+
, high Cl
-
High urea (pre-renal
failure)
Low HCO
3
-
(acidosis)
Man lost pure water ------> dehydration with
hypernatremia. He had hypotension, high pulse.
Pre-renal failure: Due to inadequate perfusion of
kidneys; uremia (high urea) is more prominent
than high creatinine.
6 Paraneoplastic SIADH Low serum osmolality,
low urine osmolality.
Low Na
+
, low Cl
-
High K
+
(aldosterone is
not being secreted at
all)
Differential should include Diabetic Ketoacidosis.
7 Dehydration High urea
All electrolytes are low.
Low HCO
3
-
, acidosis.
Uremia: pre-renal failure due to hypotension.
These labs would not be found in end-stage kidney
failure.
8 Injury with Lactic Acidosis High Na
+
High K
+
Low HCO
3
-
, metabolic
acidosis
Hyperkalemia is often associated with metabolic
acidosis.
Give calcium chloride immediately to prevent
arrhythmias associated with the hyperkalemia.
9 Volume depletion after surgery Low Na
+
Her sodium was depleted from surgery. Her
responses to the low sodium included all things
except reduced GFR.
10 Creatinine Clearance Erroneous collection of urine is most common
mistake in measuring creatinine.
11 Diabetes Insipidus Normal electrolytes
(more or less).
Lack of ADH. ADH effects osmolality and plasma
volume, but not electrolyte balance.
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(more or less).
High serum osmolality.
Low urine osmolality.
volume, but not electrolyte balance.
12 Septicemia with acidosis, pre-
renal failure
High K
+
High urea
High serum osmolality
High K
+
is associated with acidosis. Renal
disturbance is due to pre-renal failure. Serum urea
is also increased because patient is in a state of
excessive catabolism.
13 Renal Osteodystrophy High urea, high
creatinine
Chronic renal failure ------> low, calcium and
Vitamin-D ------> high PTH.
14 Compensated Metabolic
Alkalosis
High HCO
3
-
(alkalosis),
low PCO
2
(compensatory
acidosis).
pH is high, but variable.
Low K
+
Patient had severe vomiting, and later had shallow
respirations.
Low K
+
is associated with alkalosis.
15 Respiratory Acidosis High PCO
2
(respiratory
acidosis).
High HCO
3
-
(compensatory
alkalosis)
16 Compensated Respiratory
Acidosis
High PCO
2
(respiratory
acidosis).
High HCO
3
-
(compensatory
alkalosis)
pH is closer to normal, hence compensated.
17 Diuretic-induced hypokalemia
with Metabolic Alkalosis
Low K
+
High HCO
3
-
18 Membranous Nephropathy,
Albuminuria
Albuminuria
19 Multiple Myeloma Hypercalcemia
20 Myocardial Infarct Increased CK, AST,
LDH.
Creatinine Kinase MB (CK-MB) is most useful
isoenzyme for diagnosis.
21 Metastatic Breast Cancer High Alk.Phos, AST,
ALT.
Normal albumin
Cancer metastases to bone.
22 Obstructive Jaundice, caused by
Carcinoma of Head of Pancreas
Very high alk.phos,
indicated of cholestasis.
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High AST and ALT
High Bilirubin
23 Acute Viral Hepatitis Very high AST and
ALT
Moderate Alk.Phos.
High gamma-GT
Dark color of urine is due to conjugated bilirubin.
Patient should recover from the hepatitis without
consequences.
24 NIDDM glucose tolerance test
25 Diabetic Ketacidosis Odor on breath
26 Nocturnal Hypoglycemia in a
Diabetic
Low blood sugar at
night after taking
insulin.
Measuring blood sugar during a hypoglycemia
attack isn't practical. Can measure catecholamines
in the blood to estabolish diagnosis.
Treatment: adjust insulin levels.
27 Osteomalacia Low Ca
+2
Low adjusted Ca
+2
High alk.phos. would be found if ordered, to
establish diagnosis.
28 Paraneoplastic Hypercalcemia High Ca
+2
Low phosphate
Normal PTH
Normal PTH was found on further investigation,
so they took X-rays looking for metastases.
29 Hypomagnesemia with
scondary Hypoparathyroidism.
Low Mg
+2
Low PTH secondarily
Mg
+2
is required for PTH secretion!
30 Paget's Disease of Bone High alk.phos.
31 Lactotrope Adenoma with Pan-
hypopituitarism
High Prolactin
The rest of the pituitary
hormones are low
Compression atrophy of the rest of the pituitary.
32 Possible Growth Deficiency Repeat test. GH levels can fluctuate, and erroneous
results can happen after a single random
measurement.
33 Cystic Cold Thyroid Nodule in
woman on ERT.
High T
4
Low TSH
Taking estrogen ------> TBG is higher ------> T
4
baseline must be higher to compensate for the
increased TBG.
Perform fine-needle aspiration biopsy to evaluate
the nodule.
34 Hypothyroidism
35 Thyrotoxicosis Order free T
3
and T
4
tests to evaluate status.
36 Acute Adrenal Cortical Failure Low Na
+
, High K
+
Low Na
+
and high K
+
result from no aldosterone.
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9
Hypotension
Acidosis
Acidosis is secondary to the hyperkalemia.
Give ACTH (Synachten) test to confirm diagnosis.
37 Auto-immune Adrenalitis
(Addison's Disease)
Low Na
+
, High K
+
Hypotension
Acidosis
38 ACTH-Secreting Carcinoma of
Lung, Cushing's Disease
Carcinoid tumor.
39 Polycystic Ovary Syndrome High testosterone, High
LH, low FSH
40 Chronic Malnutrition Vitamin-K malabsorption
41 Pernicious Anemia with
Hypothyroidism
42 Total Parenteral Nutrition,
secondary hyperglycemia
High blood sugar Can see hyperglycemia in patients who are on
TPN, due to poor or no stimulation of insulin
release.
43 MVA with tissue injury High K
+
High K
+
is released from tissues, from tissue
injury.
Measure creatinine kinase to document muscle cell
necrosis (rhabdomyolsysis).
44 Osteomalacia High alk.phos.
Low Ca
+2
, low Vit-D
Most likely caused y malnutrition, or
malabsorption of Vitamin-D.
45 Iron-Deficiency Anemia Low Fe
+2
Low transferrin
saturation (high binding
capacity)
Low ferritin.
46 Wilson's Disease Liver failure.
47 Digoxin Toxicity, Renal Failure Patient had elevated serum urea due to pre-renal
failure, secondary to heart failure.
48 Salicylate Poisoning Low HCO
3
-
High anion gap
Metabolic Acidosis with Respiratory Alkalosis.
Anion gap is increased because it is metabolic
acidosis.
49 Lead Poisoning Measure protoporphyrin in blood cells to confirm
diagnosis.
50 Alcoholism There is no lab test that is specific for alcoholism.
gamma-GT comes close but is not diagnostic.
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10
51 Diabetic Hypoglycemia after
drinking alcohol
Patient was hypoglycemia, due to mixing alcohol
with insulin. Treat with IV glucose.
52 Hyperlipidemia Low electrolytes
High amylase
High triglycerides
Pseudohyponatremia: Low Na
+
due to abnormally
low water-content of plasma (i.e. plasma had way
too much lipid in it).
Genetic disorder involves Apolipoprotein-B
Patient is at risking of forming a volvulus.
53 Obesity, hyperlipidemia,
NIDDM, Alcohol
High cholesterol, lipids
High glucose
High gamma-GT
Treat with dietary measures. Man is at increased
risk for coronary artery disease.
54 Heterozygous Familial
Hypercholesterolemia
High fasting
cholesterol, Normal
lipids, Low HDL
Hypercholesterolemia is also found in patients
with Hypothyroidism.
55 Pheochromocytoma VMA in urine.
HTN
56 ACTH-secreting tumor,
Cushing's Disease
High HCO
3
-
Low K
+
, High Na
+
High creatinine
Metabolic Alkalosis secondary to hypokalemia,
from increased aldosterone activity.
Probably comes from oat-cell carcinoma of lung.
57 Alcoholic Liver Disease,
Hepatoma
High liver enzymes
High gamma-GT
alpha-Fetoprotein was normal in this case (it's
usually elevated)
Can also measure Carcinoembryonic Antigen
(CEA)
58 Thyroid Carcinoma Severe headache
High Ca
+2
59 Septic Arthritis posing as Gout Uric acid came back normal.
Give antibiotics to treat septic arthritis.
60 Hemolysis, Tissue Damage High LDH, high CK
Low haptoglobin
LDH, CK = damage to: muscle, liver, or
erythrocytes.
61 Cystic Fibrosis High Cl
-
in sweat
62 Rh-Incompatibility Disease Measure bilirubin in amniotic fluid to diagnose
erythroblastosis fetalis. High bilirubin would
indicate hemolysis in the fetal blood.
63 Pre-Eclampsia Progressive
albuminuria, HTN
64 Cretinism Baby came back normal. TSH must be above 100
before follow-up test is required.
65 IRDS in premature infant
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1
Cranial Nerves
Nerve CN Source Branches Motor Sensory Notes
Olfactory I
Filaments of the
bipolar olfactory
epithelial cells
constitute the
Olfactory n.
Second order
Olfactory nerve
cell bodies
located in the
olfactory bulb
None Smell (SVA)
Multiple olfactory
filaments pass
through the
cribriform plate to
exit the anterior
cranial fossa and
synapse in the
olfactory bulb; the
olfactory tract
carries the signal
from the bulb to
olfactory cortex of
the forebrain.
Optic II
Ganglion layer of
the retina to the
forebrain.
None None Vision (SSA)
The course of the
optic nerve is:
through the optic
canal to the optic
chiasma, then the
optic tract to the
lateral geniculate
body and optic
radiation
Oculomotor III
Oculomotor
nuclei of the
midbrain
(extraocular
muscles);
accessory
oculomotor
nucleus (nucleus
of Edinger-
Westphal -
preganglionic
parasympathetic)
Superior br.,
Inferior br.
GSE:
* Superior br.:
levator palpebrae,
superioris m.,
superior rectus m.
* Inferior br:
medial rectus m.,
inferior rectus m.,
inferior oblique m.;
GVE: ciliary m. &
sphincter pupillae
m. (preganglionic
parasympathetic
axons go to the
ciliary ganglion via
the parasympathetic
root, postganglionic
parasympathetic go
from the ciliary
ganglion to the
eyeball via short
ciliary nn.)
None
Passes through the
superior orbital
fissure to exit the
middle cranial fossa
Trochlear IV
Trochlear nucleus
of the midbrain
None
Superior oblique m.
of the eye (GSE)
None
Passes through the
superior orbital
fissure to exit the
middle cranial fossa;
it is the smallest
cranial nerve and the
only cranial nerve to
arise from dorsum
of brainstem
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it is the smallest
cranial nerve and the
only cranial nerve to
arise from dorsum
of brainstem
Trigeminal V
Motor root arises
from the
trigeminal motor
nucleus in the
pons (SVE);
sensory part
arises from the
trigeminal
ganglion (GSA)
and projects into
the pons to the
primary sensory
nucleus of V or
more inferiorly to
the nucleus of the
spinal root of V
(medulla and
upper spinal
cord)
Ophthalmic,
Maxillary &
Mandibular
divisions
SVE: anterior belly
of the digastric m.,
mylohyoid m.,
tensor veli palatini
m., tensor tympani
m.; muscles of
mastication:
temporalis m.,
masseter m., lateral
pterygoid m.,
medial pterygoid
m.
Skin of the face;
mucous membranes of
the nasal and oral
cavities; general
sensation (GSA) to the
anterior 2/3 of the
tongue
Some brs. carry pre-
or postganglionic
parasympathetic
fibers; the trigeminal
n. divides into three
divisions at the
trigeminal ganglion;
SVE supplies
muscles of 1st
pharyngeal arch
origin
Ophthalmic
division of the
trigeminal n.
V1
Trigeminal
ganglion
Meningeal br.,
lacrimal n.,
frontal n.,
nasociliary n.
None
(GSA) skin of the
forehead, upper eyelid
and nose; mucous
membrane of the
upper nasal cavity,
frontal sinus, ethmoid
air cells and sphenoid
sinuses
Passes through the
superior orbital
fissure to exit the
the lacrimal n.
Receives
postganglionic
parasympathetic
axons to the lacrimal
gland from the
zygomaticotemporal
br. of zygomatic n.
Maxillary
division of the
trigeminal n.
V2
Trigeminal
ganglion
Meningeal br.,
posterior
superior alveolar
n., pharyngeal,
posterior
superior medial
and lateral nasal
brs.,
nasopalatine n.,
greater and
lesser palatine
nn., zygomatic
n., infraorbital n.
None
GSA: skin of the
upper lip, cheek, lower
eyelid; mucous
membrane of the
palate; teeth and
gingiva of the
maxillary alveolar
arch; the mucous
membrane lining most
of the nasal cavity; the
mucous membrane
lining the maxillary
sinus
Passes through the
foramen rotundum
to enter the
pterygopalatine
fossa; the
pterygopalatine
ganglion is
associated with it in
the pterygopalatine
fossa;
postganglionic
parasympathetic
fibers distribute with
branches of the
maxillary division to
mucous glands of
the nasal cavity and
palate; the
zygomatic n. & its
brs. carry
postganglionic
parasympathetic
axons to the orbit to
reach the lacrimal n.
and lacrimal gland
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mucous glands of
the nasal cavity and
palate; the
zygomatic n. & its
brs. carry
postganglionic
parasympathetic
axons to the orbit to
reach the lacrimal n.
and lacrimal gland
Mandibular
division of the
trigeminal n.
V3
Trigeminal
ganglion; motor
root arises from
the pons
Meningeal br.,
medial pterygoid
and lateral
pterygoid nn.,
masseteric n.,
anterior and
posterior deep
temporal nn.,
buccal n.,
auriculotemporal
n., lingual n.,
inferior alveolar
n.
SVE: mylohyoid
m., anterior belly of
the digastric m.;
tensor tympani m.,
tensor veli palatini
m.; muscles of
mastication
(temporalis,
masseter, medial
pterygoid and
lateral pterygoid)
GSA: skin of the
lower lip and jaw
extending superiorly
above level of the ear;
mucous membrane of
the tongue and floor of
the mouth; lower teeth
and gingiva of the
mandibular alveolar
arch
Passes through the
foramen ovale to
exit the middle
cranial fossa; the
otic ganglion is
associated with the
medial side of V3
below the foramen
ovale; the
auriculotemporal n.
carries
postganglionic
parasympathetic
axons to the parotid
gland; the
submandibular
ganglion is
associated withe the
lingual n. near the
submandibular
gland;
postganglionic
parasympathetics
from the
submandibular
ganglion supply the
submandibular
gland and the
sublingual gland
Abducens VI
Pons: abducens
nucleus
None
GSE: lateral rectus
m.
None
Passes through the
superior orbital
fissure
Facial VII Pons and
medulla: nucleus
solitarius of
medulla via
nervus
intermedius
(SVA sensory
root) from
geniculate
ganglion;
superior
salivatory nucleus
(GVE
preganglionic
parasympathetic)
of pons via
nervus
intermedius;
facial motor
nucleus of pons
Greater petrosal
n. (preganglionic
parasympathetic
to
pterygopalatine
ganglion,
postganglionic
parasympathetic
travels with brs.
of maxillary
division of V),
chorda tympani
(SVA taste from
anterior 2/3 of
the tongue;
preganglionic
parasympathetic
to the
submandibular
ganglion,
Stapedius m.,
stylohyoid m.,
posterior belly of
digastric m.,
muscles of facial
expression;
secretomotor to
lacrimal,
submandibular,
sublingual, and
mucous glands of
the nasal and oral
cavities
Taste (SVA) from the
anterior 2/3 of the
tongue; part of the
skin of the external
auditory meatus
Exits the posterior
cranial fossa by
passing into the
internal acoustic
meatus, goes
through the facial
canal; motor to
muscles of facial
expression exits the
skull at the
stylomastoid
foramen
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superior
salivatory nucleus
(GVE
preganglionic
parasympathetic)
of pons via
nervus
intermedius;
facial motor
nucleus of pons
via motor root
division of V),
chorda tympani
(SVA taste from
anterior 2/3 of
the tongue;
preganglionic
parasympathetic
to the
submandibular
ganglion,
postganglionic
parasympathetic
to the
submandibular
and sublingual
glands), n. to
stapedius,
posterior
auricular n.,
intraparotid
plexus with
temporal,
zygomatic,
buccal, marginal
mandibular &
cervical brs.
mucous glands of
the nasal and oral
cavities
stylomastoid
foramen
Vestibulocochlear VIII
Pons & medulla:
vestibular nuclei
from the
vestibular
ganglion of the
semicircular
ducts; cochlear
nuclei in the
inferior cerebellar
peduncle
Divides within
the temporal
bone into
vestibular and
cochlear parts
None
Vestibular:
balance/proprioception
(SSA); cochlear:
hearing (SSA)
Auditory nerve;
passes into the
internal auditory
meatus
Glossopharyngeal IX
Medulla: spinal
trigeminal
nucleus from the
superior ganglion
(GVA); nucleus
solitarius from
the inferior
ganglion (SVA);
nucleus ambiguus
(GVA); inferior
salivatory nucleus
(GVE -
preganglionic
parasympathetic)
Tympanic nerve
to the tympanic
plexus and lesser
petrosal n.,
carotid sinus n.,
stylopharyngeus
brs., pharyngeal
brs.
GSE:
stylopharyngeus;
GVE: secretomotor
to the parotid gland
(preganglionic
parasympathetic via
the tympanic n. to
the lesser petrosal
n. to the otic
ganglion;
postganglionic
parasympathetic via
the
auriculotemporal
n.)
GVA: carotid body,
carotid sinus, pharynx,
middle ear; GSA: skin
of the external ear;
SVA: taste from the
posterior 1/3 of the
tongue
Exits the posterior
cranial fossa by
passing through the
jugular foramen;it
may penetrate the
stylopharyngeus m.
Vagus X Medulla: dorsal
motor nucleus
(GVE
preganglionic
parasympathetic);
inferior ganglion
(GVA); nucleus
ambiguus (SVE);
superior ganglion
(GSA); inferior
ganglion(SVA)
Auricular br.,
pharyngeal br.,
superior
laryngeal,
superior and
inferior cervical
cardiac brs.,
recurrent
laryngeal n.,
thoracic cardiac
brs., brs. to the
SVE: intrinsic
muscles of the
larynx, pharynx
(except
stylopharyngeus),
and palate (except
tensor veli palatini);
GVE: smooth
muscle of the
respiratory tree &
gut (proximal to the
GSA: skin of the
external auditory
meatus; GVA: viscera
of head, neck, thorax
& abdomen proximal
to the left colic
flexure; SVA: taste
from the epiglottis
Passes through the
jugular foramen to
exit the posterior
cranial fossa; vagus
means "wanderer" in
reference to its
extensive
distribution to the
body cavities
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5
motor nucleus
(GVE
preganglionic
parasympathetic);
inferior ganglion
(GVA); nucleus
ambiguus (SVE);
superior ganglion
(GSA); inferior
ganglion(SVA)
pharyngeal br.,
superior
laryngeal,
superior and
inferior cervical
cardiac brs.,
recurrent
laryngeal n.,
thoracic cardiac
brs., brs. to the
pulmonary
plexus, brs. to
the esophageal
plexus, anterior
and posterior
vagal trunks
muscles of the
larynx, pharynx
(except
stylopharyngeus),
and palate (except
tensor veli palatini);
GVE: smooth
muscle of the
respiratory tree &
gut (proximal to the
left colic flexure),
heart; secretomotor:
mucous glands of
the larynx,
respiratory tree,
pharynx and gut;
secretomotor to
digestive glands
external auditory
meatus; GVA: viscera
of head, neck, thorax
& abdomen proximal
to the left colic
flexure; SVA: taste
from the epiglottis
jugular foramen to
exit the posterior
cranial fossa; vagus
means "wanderer" in
reference to its
extensive
distribution to the
body cavities
Accessory XI
Cranial root:
medulla - nucleus
ambiguous.
Spinal root:
spinal nucleus of
the upper cervical
spinal cord
None
GSE:
sternocleidomastoid
and trapezius mm.
None
Spinal root enters
cranial cavity by
passing through the
foramen magnum.
Exits skull by
passing through the
jugular foramen.
Accessory n. is
motor only; the
subtrapezial plexus
of nerves receives
proprioceptive
fibers: for the
sternocleido-mastoid
m. from the ventral
primary rami of
spinal nn. C2 and
C3 - for trapezius
via ventral primary
rami of C3 and C4
Hypoglossal XII Medulla:
hypoglossal
nucleus
No named
branches.
Branches of the
ventral primary
ramus of spinal
nerve C1 are
carried by this
nerve and are
not considered
to be branches
of the
hypoglossal
nerve
Intrinsic and
extrinsic muscles of
the tongue (except
the palatoglossus
m.)
None Exits the posterior
cranial fossa by
passing through the
hypoglossal canal;
the superior root of
the ansa cervicalis
travels with the
hypoglossal n. for a
short distance
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1
Medical Students Amnesia A transient selective loss of memory during an exam
that prevents one from remembering the eponymically-named diseases discovered by old, dead doctors.
Addisons Disease 1. Primary adrenocortical deficiency
Addisonian Anemia 2. Pernicious anemia (antibodies to intrinsic factor or parietal cells IF Vit B12 megaloblastic anemia)
Albrights Syndrome 3. Polyostotic fibrous dysplasia, precocious puberty, caf au lait spots, short stature, young girls
Alports Syndrome 4. Hereditary nephritis with nerve deafness
Alzheimers 5. Progressive dementia
Argyll-Robertson Pupil 6. Loss of light reflex constriction (contralateral or bilateral)
7. Prostitutes Eye accommodates but does not react
8. Pathognomonic for 3Syphilis
9. Lesion pretectal region of superior colliculus
Arnold-Chiari Malformation 10. Cerebellar tonsil herniation through foramen magnum = see thoracolumbar meningomyelocele
Barretts 11. Columnar metaplasia of lower esophagus ( risk of adenocarcinoma)- constant gastroesophageal reflux
Bartters Syndrome 12. Hyperreninemia
Beckers Muscular Dystrophy 13. Similar to Duchenne, but less severe (mutation, not a deficiency, in dystrophin protein)
Bells Palsy 14. CNVII palsy (entire face; recall that UMN lesion only affects lower face)
Bergers Disease 15. IgA nephropathy causing hematuria in kids, usually following infection
Bernard-Soulier Disease 16. Defect in platelet adhesion (abnormally large platelets & lack of platelet-surface glycoprotein)
Berry Aneurysm 17. Circle of Willis (subarachnoid bleed) Anterior Communicating artery
18. Often associated with ADPKD
Bowens Disease 19. Carcinoma in situ on shaft of penis ( risk of visceral ca) [compare w/ Queyrat]
Brill-Zinsser Disease 20. Recurrences of rickettsia prowazaki up to 50 yrs later
Briquets Syndrome 21. Somatization disorder
22. Psychological: multiple physical complaints without physical pathology
Brocas Aphasia 23. Motor Aphasia (area 44 & 45) intact comprehension
Brown-Sequard 24. Hemisection of cord (contralateral loss of pain & temp / ipsilateral loss of fine touch, UMN / ipsi loss of consc.
Proprio)
Brutons Disease 25. X-linked agammaglobinemia ( B cells)
Budd-Chiari 26. Post-hepatic venous thrombosis = ab pain; hepatomegaly; ascites; portal HTN; liver failure
Buergers Disease 27. Acute inflammation of medium and small arteries of extremities painful ischemia gangrene
28. Seen almost exclusively in young and middle-aged men who smoke.
Burkitts Lymphoma 29. Small noncleaved cell lymphoma EBV
30. 8:14 translocation
31. Seen commonly in jaws, abdomen, retroperitoneal soft tissues
32. Starry sky appearance
Caisson Disease 33. Nitric gas emboli
Chagas Disease 34. Trypansoma infection - cardiomegaly with apical atrophy, achlasia
Chediak-Higashi Disease 35. (AR) Phagocyte Deficiency = defect in microtubule polymerization
36. Neutropenia, albinism, cranial & peripheral neuropathy & repeated infections w/ strep & staph
Conns Syndrome 37. Primary Aldosteronism: HTN; retain Na
+
& H2O; hypokalemia (causing alkalosis); renin
Coris Disease 38. Type III Glycogenosis Glycogen storage disease (debranching enz: amylo 1,6 glucosidase def. Glycogen)
Creutzfeldt-Jakob 39. Prion infection cerebellar & cerebral degeneration
Crigler-Najjar Syndrome 40. Congenital hyperbilirubinemia (unconjugated)
41. Glucuronyl transferase deficiency. Can progress to Kernicterus
42. Less severe form will respond to Phenobarbital therapy
Crohns 43. IBD; ileocecum, transmural, skip lesions, cobblestones, lymphocytic infiltrate, granulomas
44. (contrast to UC: limited to colon, mucosa & submucosa, crypt abscesses, pseudopolyps, colon cancer risk)
45. Clinically: ab pain & diarrhea; fever; malabsorption; fistulae b/t intestinal loops & abd structures
Curlings Ulcer 46. Acute gastric ulcer associated with severe burns
Cushings 47. Disease: Hypercorticism 2 to ACTH from pituitary (basophilic adenoma)
48. Syndrome: hypercorticism of all other causes (1 adrenal or ectopic)
49. - moon face; buffalo hump; purple striae; hirsutism; HTN; hyperglycemia
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Cushings Ulcer 50. Acute gastric ulcer associated with CNS trauma
de Quervains Thyroiditis 51. Self-limiting focal destruction (subacute thyroiditis)
DiGeorges Syndrome 52. Failure of 3
rd
& 4
th
pharyngeal pouches formation: Thymus & Parathyroid
53. Thymic hypoplasia T-cell deficiency
54. Hypoparathyroidism Tetany
Downs Syndrome 55. Trisomy 21 or translocation Simian Crease
Dresslers Syndrome 56. Post-MI Fibrinous Pericarditis autoimmune
Dubin-Johnson Syndrome 57. Congenital hyperbilirubinemia (conjugated) = bilirubin transposrt is defective not conjugation
58. Striking brown-to-black discoloration of the liver
Duchenne Muscular Dystrophy 59. Deficiency of dystrophin protein MD X-linked recessive
Edwards Syndrome 60. Trisomy 18
61. Rocker-bottom feet, low ears, small lower jaw, heart disease
Ehlers-Danlos 62. Defective collagen
Eisenmengers Complex 63. Late cyanotic shunt (RL) pulmonary HTN & RVH 2 to long-standing VSD, ASD, or PDA
Erb-Duchenne Palsy 64. Trauma to superior trunk of brachial plexus Waiters Tip
Ewing Sarcoma 65. Malignant undifferentiated round cell tumor of bone in boys <15yoa - t11;22
Eyrthroplasia of Queyrat 66. Carcinoma in situ on glans penis
Fanconis Syndrome 67. Impaired proximal tubular reabsorption 2 to lead poisoning or Tetracycline (glycosuria,
hyperphosphaturia, aminoaciduria, systemic acidosis)
Feltys Syndrome 68. Rheumatoid arthritis, neutropenia, splenomegaly
Gardners Syndrome 69. AD = adenomatous polyps of colon, osteomas & soft tissue tumors
Gauchers Disease 70. Lysosomal Storage Disease glucocerebrosidase deficiency glucocerebroside accumulation
71. Hepatosplenomegaly, femoral head & long bone erosion, anemia
Gilberts Syndrome 72. Benign congenital hyperbilirubinemia (unconjugated) = d glucuronyl transferase activity
Glanzmanns Thrombasthenia 73. Defective glycoproteins on platelets = deficient platelet aggregation
Goodpastures 74. Autoimmune: abs to glomerular & alveolar basement membranes. Seen in men in their 20s
Graves Disease 75. Autoimmune hyperthyroidism (TSI): IgG Ab reactive w/ TSH receptors. Low TSH & TRH High T3 /
T4
Guillain-Barre 76. Polyneuritis following viral infection/ autoimmune (ascending muscle weakness & paralysis; usually self-limiting)
Hamman-Rich Syndrome 77. Idiopathic pulmonary fibrosis. Can see honey comb lung.
Hand-Schuller-Christian 78. Chronic progressive histiocytosis
Hashimotos Thyroiditis 79. Autoimmune hypothyroidism. May have transient hyperthyroidism. Low T3 /T4 & High TSH
Hashitoxicosis 80. Initial hyperthyroidism in Hashimotos Thyroiditis that precedes hypothyroidism
Henoch-Schonlein purpura 81. Hypersensivity vasculitis = allergic purpura. Lesions have the same age.
82. Hemmorhagic urticaria (with fever, arthralgias, GI & renal involvement)
83. Associated with upper respiratory infections
Hirschprungs Disease 84. Aganglionic megacolon
Horners Syndrome 85. Ptosis, miosis, anhidrosis (lesion of cervical sympathetic nerves often 2 to a Pancoast tumor)
Huntingtons (Chromosome 4) 86. AD: Progressive degeneration of caudate nucleus, putamen (striatum) & frontal cortex GABA
Jacksonian Seizures 87. Epileptic events originating in the primary motor cortex (area 4)
Jobs Syndrome 1. Immune deficiency: neutrophils fail to respond to chemotactic stimuli
2. Defective neutrophilic chemotactic response = repeated infections
3. Commonly seen in light-skinned, red-haired girls
88. d IgE levels
Kaposi Sarcoma 89. Malignant vascular tumor (HHV8 in homosexual men)
Kartageners Syndrome 90. Immotile cilia 2 to defective dynein arms infection, situs inversus, sterility
Kawasaki Disease 91. Mucocutaneous lymph node syndrome in kids (acute necrotizing vasculitis of lips, oral mucosa)
Klinefelters Syndrome 92. 47, XXY: Long arms, Sterile, Hypogonadism
Kluver-Bucy 93. Bilateral lesions of amygdala (hypersexuality; oral behavior)
Krukenberg Tumor 94. Adenocarcinoma with signet-ring cells (typically originating from the stomach) metastases to
95. the ovaries
Laennecs Cirrhosis 96. Alcoholic cirrhosis
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Lesch-Nyhan 97. HGPRT deficiency
98. Gout, retardation, self-mutilation
Letterer-Siwe 99. Acute disseminated Langerhans cell histiocytosis
Libman-Sacks 100. Endocarditis with small vegetations on valve leaflets
101. Associated with SLE
Lou Gehrigs 102. Amyotrophic Lateral Sclerosis degeneration of upper & lower motor neurons
Mallory-Weis Syndrome 103. Bleeding from esophagogastric lacerations 2 to wretching (alcoholics)
Marfans 104. Connective tissue defect: defective Fibrillin gene Dissecting aortic aneurysm, subluxation of lenses
McArdles Disease 105. Type V Glycogenosis - Glycogen storage disease (muscle phosphorylase deficiency = Glycogen)
Meckels Diverticulum 106. Rule of 2s: 2 inches long, 2 feet from the ileocecum, in 2% of the population
107. Embryonic duct origin; may have ectopic tissue: gastric/pancreatic remnant of vitteline duct/yolk stalk
Meigs Syndrome 108. Triad: ovarian fibroma, ascites, hydrothorax associated w/ fibroma of ovaries
Menetriers Disease 109. Giant hypertrophic gastritis (enlarged rugae; plasma protein loss)
Monckebergs Arteriosclerosis 110. Calcification of the media (usually radial & ulnar aa.)
Munchausen Syndrome 111. Factitious disorder (consciously creates symptoms, but doesnt know why)
Nelsons Syndrome 112. 1 Adrenal Cushings surgical removal of adrenals loss of negative feedback to pituitary
Pituitary Adenoma
Niemann-Pick 113. Lysosomal Storage Disease (sphingomyelinase deficiency sphingomyelin accumulation)
114. Foamy histiocytes
Osler-Weber-Rendu Syndrome 115. Hereditary Hemorrhagic Telangiectasia. Seen in the Mormons of Utah.
Pagets Disease 116. Abnormal bone architecture (thickened, numerous fractures pain)
Pancoast Tumor 117. Bronchogenic tumor with superior sulcus involvement Horners Syndrome
Parkinsons 118. Dopamine depletion in nigrostriatal tracts
Peutz-Jeghers Syndrome (AD) 119. Melanin pigmentation of lips, mouth, hand, genitalia + hamartomatous polyps of small intestine
Peyronies Disease 120. Subcutaneous fibrosis of dorsum of penis
Picks Disease 2 Different
Diseases -
121. 1. Progressive dementia similar to Alzheimers
122. 1. Constrictive pericarditis sequel to mediastinal tuberculosis
123. Calcium-frosting, unyielding layer heart chambers may be unable to dilate to receive blood during diastole
Plummers Syndrome 124. Hyperthyroidism, nodular goiter, absence of eye signs (Plummers = Graves - eye signs)
Plummer-Vinson 125. Esophageal webs & iron-deficiency anemia, spoon-shaped nails, SCCA of esophagus
Pompes Disease 126. Type II Glycogenosis Glycogen storage disease cardiomegaly ( 1,4 Glucosidase deficiency:
Glycogen)
Potts Disease 127. Tuberculous osteomyelitis of the vertebrae
Potters Complex 128. Renal agenesis oligohydramnios hypoplastic lungs, defects in extremities
Raynauds 129. Disease: recurrent vasospasm in extremities = seen in young, healthy women
130. Phenomenon: 2 to underlying disease (SLE or scleroderma)
Reiters Syndrome 131. Urethritis, conjunctivitis, arthritis non-infectious (but often follows infections), HLA-B27, polyarticular
Reyes Syndrome 132. Microvesicular fatty liver change & encephalopathy
133. 2 to aspirin ingestion in children following viral illness, especially VZV
Riedels Thyroiditis 134. Idiopathic fibrous replacement of thyroid
Rotor Syndrome 135. Congenital hyperbilirubinemia (conjugated)
136. Similar to Dubin-Johnson, but no discoloration of the liver
Sezary Syndrome 137. Leukemic form of cutaneous T-cell lymphoma (mycosis fungoides)
Shavers Disease 138. Aluminum inhalation lung fibrosis
Sheehans Syndrome 139. Postpartum pituitary necrosis = hemorrhage & shock usually occurred during delivery
Shy-Drager 140. Parkinsonism with autonomic dysfunction & orthostatic hypotension
Simmonds Disease 141. Pituitary cachexia can occur from either pituitary tumors or Sheehans
Sipples Syndrome 142. MEN type IIa = pheochromocytoma, thyroid medullary CA, hyperparathyroidism
Sjogrens Syndrome 143. Triad: dry eyes, dry mouth, arthritis risk of B-cell lymphoma
Spitz Nevus 144. Juvenile melanoma (always benign)
Stein-Leventhal 145. Polycystic ovary: see amenorrhea; infertility; obesity; hirsutism = LH secretion
Stevens-Johnson Syndrome 146. Erythema multiforme, fever, malaise, mucosal ulceration (often 2 to infection = mycoplasma or sulfa
drugs)
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Stills Disease 147. Juvenile rheumatoid arthritis (absence of rheumatoid factor)
Takayasus arteritis 148. Aortic arch syndrome
149. Loss of carotid, radial or ulnar pulses = pulseless disease. Night sweats.
150. Common in young Asian females
Tay-Sachs (AR) 151. Gangliosidosis (hexosaminidase A deficiency GM2 ganglioside) Cherry Red Spots of the Macula
Tetralogy of Fallot 152. 1.VSD, 2.overriding aorta, 3.pulmonary artery stenosis, 4.right ventricular hypertrophy
Tourettes Syndrome 153. Involuntary actions, both motor and vocal Txt w/ Pimozide
Turcots Syndrome 154. Colon adenomatous polyps plus CNS tumors
Turners Syndrome 155. 45, XO = most common cause of Primary Amenorrhea. No Barr body on buccal smear.
Vincents Infection 156. Trench mouth acute necrotizing ulcerative gingivitis due to Fusobacterium
Von Gierkes Disease 157. Type I Glycogenosis Glycogen storage disease (G6Ptase deficiency) Glycogen accumulaiton
Von Hippel-Lindau 158. Hemangioma (or hemangioblastoma) = cerebellum, brain stem, & retina
159. Adenomas of the viscera, especially Renal Cell Carcinoma
160. Chromosome 3p
Von Recklinghausens 161. Neurofibromatosis & caf au lait spots & Lisch nodules (Chromosome 17)
Von Recklinghausens Disease of Bone 162. Osteitis fibrosa cystica (brown tumor) 2 to hyperparathyroidism = osteoclastic resorption w/
163. fibrous replacement
Von Willebrands Disease (AD) 164. Defect in platelet adhesion 2 to deficiency in vWF. aPPT, Bleed time
Waldenstroms macroglobinemia 165. Proliferation of IgM-producing lymphoid cells in men 50-70 yoa; PAS(+) Dutcher bodies
Wallenbergs Syndrome 166. Posterior Inferior Cerebellar Artery (PICA) thrombosis Medullary Syndrome
167. Ipsilateral: ataxia, facial pain & temp; Contralateral: body pain & temp
Waterhouse-Friderichsen 168. Adrenal insufficiency 2 to DIC
169. DIC 2 to meningiococcemia
Webers Syndrome 170. Paramedian Infarct of Midbrain
171. Ipsilateral: mydriasis; Contralateral: UMN paralysis (lower face & body)
Wegeners Granulomatosis 172. Necrotizing granulomatous vasculitis of paranasal sinuses, lungs, kidneys, etc.
Weils Disease 173. Icteric Leptospirosis non-icteric prgresses to renal failure & myocarditis
174. Dark field microscopy for dx
Wermers Syndrome 175. MEN type I = thyroid, parathyroid, adrenal cortex, pancreatic islets, pituitary
Wernickes Aphasia 176. Sensory Aphasia impaired comprehension
Wernicke-Korsakoff Syndrome 177. Thiamine deficiency in alcoholics; bilateral mamillary bodies (mediodorsal nucleua) (confusion, ataxia,
ophthalmoplegia)
Whipples Disease 178. Malabsorption syndrome (with bacteria-laden macrophages) & polyarthritis
Wilsons Disease 179. Hepatolenticular degeneration (copper accumulation [Txt w/ Penicillamine ] & decrease in ceruloplasmin)
180. Mallory Bodies in the Liver & also w/ alcoholic hepatitis & Hyaline change
181. Chromosome 13
Wiskott-Aldrich Syndrome 182. Immunodeficiency: combined B- &T-cell deficiency (thrombocytopenia & eczema)
183. IgM w/ IgA
Wolff-Chaikoff Effect 184. High iodine level ()s thyroid hormone synthesis
Zenkers Diverticulum 185. Esophageal; cricopharyngeal muscles above UES
Zollinger-Ellison 186. Gastrin-secreting tumor of pancreas (or intestine) acid recurrent ulcers
Rogers Disease 187. Interventricular septal defect
Barlows Syndrome 188. Floppy vale syndrome women b/t 20-40 yoa
Bracht-Wachter Lesions 189. Minute abscesses found in subacute bacterial endocarditis
Lutembachers Syndrome 190. Combination of septum secundum atrial septal defect w/ mitral stenosis
Schmidts Syndrome 191. Autoimmnue thyroid Disease (Hashimotos ) & insulin-dependent diabetes
Hallmark Findings
Albumino-Cytologic Dissociation 192. Guillain-Barre (markedly increased protein in CSF with only modest increase in cell count)
Antiplatelet Antibodies 193. Idiopathic thrombocytopenic purpura
Arachnodactyly 194. Marfans
Aschoff Bodies 195. Rheumatic fever
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Auer Rods 196. Acute promyelocytic leukemia (AML type M3)
Autosplenectomy 197. Sickle cell anemia: switch a glu val in chain
198. Low O2 sickling
199. Aplastic crisis w/ B19 (Parvovirus ssDNA) infection
200. Salmonella osteomyelitis
201. Vaso-occlusive painful crisises
202. Hydroxyurea as Txt ( Hb
F
) & Bone marrow transplant
Babinski 203. UMN lesion
Basophilic Stippling of RBCs 204. Lead poisoning
Bence Jones Protein 205. Multiple myeloma free light chains (either kappa or lambda)
206. Waldenstroms macroglobinemia
Birbeck Granules 207. Histiocytosis X (eosinophilic granuloma)
Blue Bloater 208. Chronic Bronchitis (at least 3 months for at least 2 years of ecessive mucus secretion & chronic
recurrent productive cough)
Boot-Shaped Heart 209. Tetralogy of Fallot
Bouchards Nodes 210. Osteoarthritis (Proximal IP joint of the fingers)
Boutonnieres Deformity 211. Rheumatoid arthritis flex proximal & extend distal IP joints
Brown Tumor 212. Hyperparathyroidism
Brushfield Spots 213. Downs
Call-Exner Bodies 214. Granulosa cell tumor: associated w/ endometrial hyperplasia & carcinoma
215. Granuloma-Theca cell tumor
Cardiomegaly with Apical Atrophy 216. Chagas Disease
Chancre 217. 1 Syphilis
Chancroid 218. Haemophilus ducreyi
Charcot Triad 219. Multiple sclerosis = nystagmus, intention tremor, scanning speech
Charcot-Leyden Crystals 220. Bronchial asthma
Cheyne-Stokes Breathing 221. Cerebral lesion
Chocolate Cysts 222. Endometriosis
Chvosteks Sign 223. Hypocalcemia facial spasm in tetany
Clue Cells 224. Gardnerella vaginitis
Codmans Triangle 225. Osteosarcoma
Cold Agglutinins 226. Mycoplasma pneumoniae
227. Infectious mononucleosis
Condyloma Lata 228. 2 Syphilis
229. New coffee flavor at Bagel & Bagel
Cotton Wool Spots 230. HTN
231. Aka, cytoid bodies seen w/ SLE (yellowish cotton wool fundal lesions)
Councilman Bodies 232. Dying hepatocytes HepB
Crescents In Bowmans Capsule 233. Rapidly progressive (crescentic glomerulonephritis)
Currant-Jelly Sputum 234. Klebsiella
Curschmanns Spirals 235. Bronchial asthma
Depigmentation Of Substantia Nigra 236. Parkinsons
Donovan Bodies 237. Granuloma inguinale (STD)
Eburnation 238. Osteoarthritis (polished, ivory-like appearance of bone)
Ectopia Lentis 239. Marfans
Erythema Chronicum Migrans 240. Lyme Disease
Fatty Liver 241. Alcoholism
Ferruginous Bodies 242. Asbestosis - & Iron laden
Ghon Focus / Complex 243. Tuberculosis (1 & 2, respectively)
Glitter Cells 244. Acute Pyelonephritis
Gowers Maneuver 245. Duchennes MD use of arms to stand
Heberdens Nodes 246. Osteoarthritis (Distal IP joint of the fingers)
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Heinz Bodies 247. G6PDH Deficiency
Heterophil Antibodies 248. Infectious mononucleosis (EBV)
Hirano Bodies 249. Alzheimers
Hypersegmented PMNs 250. Megaloblastic anemia
Hypochromic Microcytic RBCs 251. Iron-deficiency anemia or Thalassemia
Jarisch-Herxheimer Reaction 252. Syphilis over-aggressive treatment of an asymptomatic pt. that causes symptoms 2 to rapid lysis
Joint Mice 253. Osteoarthritis (fractured osteophytes)
Kaussmaul Breathing 254. Acidosis / Diabetic Ketoacidosis
Keratin Pearls 255. Squamous Cell CA of skin Actinic Keratosis is a precursor
Keyser-Fleischer Ring 256. Wilsons
Kimmelstiel-Wilson Nodules 257. Diabetic nephropathy: Nodular Glomerulosclerosis nodules of mesangial matrix
Koilocytes 258. HPV 6 & 11 (condyloma acuminatum - benign) and HPV 16 & 18 (malignant association)
Koplik Spots 259. Measles
Lewy Bodies 260. Parkinsons (eosinophilic inclusions in damaged substantia nigra cells)
Lines of Zahn 261. Arterial thrombus
Lisch Nodules 262. Neurofibromatosis (von Recklinhausens disease) = pigmented iris hamartomas
Lumpy-Bumpy IF Glomeruli 263. Poststreptococcal glomerulonephritis prototype of nephritic syndrome
Mallory Bodies 264. Alcoholic hepatitis
McBurneys Sign 265. Appendicitis (McBurneys Point is 2/3 of the way from the umbilicus to anterior superior iliac spine)
Michealis-Gutmann Bodies 266. Malakoplakia lesion on bladder due to macros & calcospherites (M-G Bodies): usually due to E. Coli
Monoclonal Antibody Spike 267. Multiple myeloma this is called the M protein (usually IgG or IgA)
268. MGUS
Myxedema 269. Hypothyroidism
Negri Bodies 270. Rabies
Neuritic Plaques 271. Alzheimers
Neurofibrillary Tangles 272. Alzheimers
Non-pitting Edema 273. Myxedema
274. Anthrax Toxin
Notching of Ribs 275. Coarctation of Aorta
Nutmeg Liver 276. CHF = causing congested liver
Owls Eye Cells 277. CMV
278. Reed Sternburg Cells (Hodkins Lymphoma)
279. Aschoff cells seen w/ Rheumatic Fever
Painless Jaundice 280. Pancreatic CA (head)
Pannus 281. Rheumatoid arthritis, also see morning stiffnes that w/ joint use, HLA-DR4
Pautriers Microabscesses 282. Mycosis fungoides (cutaneous T-cell lymphoma), Sezary
Philadelphia Chromosome 283. CML
Pick Bodies 284. Picks Disease
2 types of COPD 285. Pink Puffer Type A: Emphysema
286. Blue Bloater Type B: Bronchitis
287. Emphysema Centroacinar smoking Panacinar - 1-antitrypsin deficiency
Podagra 288. Gout (MP joint of hallux)
Port-Wine Stain 289. Hemangioma
Posterior Anterior Drawer Sign 290. Tearing of the ACL
Psammoma Bodies 291. Papillary adenocarcinoma of the thyroid
292. Serous papillary cystadenocarcinoma of the ovary
293. Meningioma
294. Mesothelioma
Pseudohypertrophy 295. Seen w/ Duchenne muscular dystrophy @ the claf muscles, due to fat
Punched-Out Bone Lesions 296. Multiple myeloma
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Rash on Palms & Soles 297. 2 Syphilis
298. RMSF
299. Coxsackie virus infection: Hand-Foot-Mouth Disease
Red Morning Urine 300. Paroxysmal nocturnal hemoglobinuria. You would use Hams test to confirm.
Reed-Sternberg Cells 301. Hodgkins Disease
Reid Index Increased 302. Chronic bronchitis = d ratio of bronchial gland to bronchial wall thickness
Reinke Crystals 303. Leydig cell tumor
Rouleaux Formation 304. Multiple myeloma RBCs stacked as poker chips
S3 Heart Sound 305. LR Shunt (VSD, PDA, ASD)
306. Mitral Regurg
307. LV Failure
S4 Heart Sound 308. Pulmonary Stenosis
309. Pulmonary HTN
Schwartzman Reaction 310. Neisseria meningitidis impressive rash with bugs
Smith Antigen 311. SLE (also anti-dsDNA)
312. Malar Rash, Wire loop kidney lesions, Joint pain, False (+) syphilis test (VDRL)
313. 90% 14-45 yo females
314. also seen w/ use of INH; Procainamide; Hydralazine = SLE-like syndrome
Soap Bubble on X-Ray 315. Giant cell tumor of bone
Spike & Dome Glomeruli 316. Membranous glomerulonephritis = Nephrotic syndrome
317. Spike = basement membrane material & Dome = immune complex deposits (IgG orC3)
String Sign on X-ray 318. Crohns bowel wall thickening
Target Cells 319. Thalassemia in Thalassemia w/ no gene: Hydrops Fetalis & Intrauterine death associations = HbBarts
Tendinous Xanthomas 320. Familial Hypercholesterolemia
Thyroidization of Kidney 321. Chronic pyelonephritis
Tophi 322. Gout
Tram-Track Glomeruli 323. Membranoproliferative GN: Nephritic syndrome basement membrane is duplicated into 2 layers
Trousseaus Sign 324. Visceral ca, classically pancreatic (migratory thrombophlebitis)
325. Hypocalcemia (carpal spasm)
326. These are two entirely different disease processes and different signs, but they unfortunately have the
same name.
Virchows Node 327. Supraclavicular node enlargement by metastatic carcinoma of the stomach
Warthin-Finkeldey Giant Cells 328. Measles
WBC Casts 329. Pyelonephritis
Whipples Triad 330. CNS disfunction Hypoglycemic episodes glu injection reverses CNS Sympts
Wire Loop Glomeruli 331. Lupus nephropathy, type IV (diffuse proliferative form)
AFP in amniotic fluid or
mothers serum
332. Spina Bifida
333. Anencephaly
Uric Acid 334. Gout
335. Lesch Nyhan
336. Myeloproliferative Disorders
337. Diuretics (Loop & Thiazides)
FEV1/FVC 338. COPD
Ground Glass on chest x-ray
(Hyaline)
339. Due to Pneumocystis carinii
340. Seen w/ Atelectasia
Honey Combing of the lung 341. Seen w/ Asbestosis (a restrictive lung disease)
Crescents 342. Goodpastures syndrome (pneumonia w/ hemoptysis & rapidly progressive glomerulonephritis)
Linear Ig Deposits 343. Goodpastures syndrome
45 Degree Branch Points 344. Aspergillosis
PAS(+) Dutcher Bodies 345. Waldenstroms Macroglobulinemia = IgM = Hyperviscosity
Ground Glass in Abdomen(Hyaline) 346. Seen in the hepatocytes of healthy carriers of HBsAg in liver biopsies
Signet Ring Cells 347. Cells that replace the ovaries, due to Krukenbergs tumor that has metastasized from the
stomach
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Ground Glass Appearance (Hyaline) 348. Seen w/ Progressive Multifocal Leukoencephalopathy oligodendrocytes
349. Nuclei seen in Papillary CA of the thyroid (malignant)
Congo Red 350. Shows amyloid deposition in plaques & vascular walls
Meningiomas & Progesterone 351. Some meningiomas have Progesterone receptors = rapid growth in pregnancy can occur
Tuberous Sclerosis Triad 352. Seizures; Mental retardation; Leukoderma (congenital facial white spots or macules):
angiofibromas
Cowdry A Inclusions 353. Seen w/ Herpes Simplex Encephalitis in oligodendroglia
Devics Syndrome 354. Neuromyelitis Optica
355. A variant of multiple sclerosis: rapid demyelination of the optic nerve & spinal cord w/ paraplegia
c-erb B2 356. Breast Cancer association
Foster-Kennedy Syndrome 357. A tumor causing blindness & loss of smell w/ papilloedema
Hoffmans Sign 358. Flicking of the middle fingers nail
Red Nucleus Destruction 359. Intention tremors of the arm
Ventral Spinocerebellar tr. 360. Unconscious proprioception of lower extremities
Dorsal Spinocerebellar tr. 361. Unconscious prorpioception & fine motor movements
Cuneocerebellar tr. 362. Unconscious proprioception & fine motor movements of upper extremities
Dorsal Column 363. Conscious proprioception of the body
Lateral Spinothalamic tr. 364. Pain & Temperature sensation
Ventral Spinothalamic tr. 365. Light touch perception
SVA 366. Taste & Smell
GSE 367. Muscles of the eye & of the tongue
SSA 368. Vision; Hearing; Equilibrium
GVA 369. Sensation of tongue; soft palate. Carotid Body & Sinus innervation
GVE 370. Edinger Westphal = parasympathetic eye innervation
371. Gland innervation = secretions
372. Viscera
GSA 373. Pain & temperature of face
374. Sensation of external ear
SVE 375. Innervation of muscles of masticaiton, facial expressions, larynx & pharynx
LMN Lesion 376. Werndig Hoffman (progressive infantile muscular atrophy)
377. Poliomyelitis
Sensory Pathway Lesion 378. Subacute Combined Degeneration = Friedrichs Ataxia = B12 deficiency
379. Tabes Dorsalis (Neurosyphilis)
Both UMN & LMN Lesion 380. ALS = Lou Gherigs Disease
Both Sensory & Motor Lesion 381. Brown Sequard
382. Anterior Spinal artery Occlusion
Suprachiasmatic Nucleus 383. Controls circadian rhythm
Ventromedial Nucleus 384. Satiety center. Savage behavior & obesity when lesioned
Lateral Nucleus 385. Induces eating. Starvation when lesioned
Arcuate Nucleus 386. Releases PIF (dopa-ergic neurons)
Mamillary Body 387. Can have hemorrhages as seen in Wernickes Encephalopathy
Acanthocytes 388. RBSc w/ spiny projections. Seen in Abetalipoproteinemia.
Most Common
1
o
Tumor arising from bone in
adults
389. Osteosarcoma
Adrenal Medullary Tumor Adults 390. Pheochromocytoma: 5 Ps: Pressure; Pain (Headache); Perspiration; Palpitations;
Pallor/Diaphoresis
Adrenal Medullary Tumor
Children
391. Neuroblastoma
Agent of severe viral encephalitis 392. Herpes simplex
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Aggressive lung tumor 393. Small cell or oat cell
Associated with gallstones 394. Adenocarinoma
Bacterial Meningitis adults 395. Strep pneumoniae & in young adults = Neisseria meningitidis
Bacterial Meningitis elderly 396. Neisseria meningitidis
Bacterial Meningitis newborns 397. E. coli / Group BStrep.
Bacterial Meningitis toddlers 398. Hib
Benign epithelial tumor of oral
mucosa
399. Papilloma
Benign fallopian tube tumor 400. Adenomatoid
Benign ovarian tumor 401. Mature(Native) Teratoma = benign dermatoid
Benign tumor of soft tissue 402. Lipoma
Benign tumor of the breast <25yoa 403. Fibroadenoma
Benign tumor of the liver 404. Hemangioma
Benign tumor of the vulva 405. Hidroadenoma
Benign uterine tumor 406. Leiomyoma: estrogen sinsitive: changes size during pregnancy & menopause
Bone Tumors 407. Metasteses from Breast & Prostate
Brain Tumor Child 408. Medulloblastoma (cerebellum)
Brain Tumor Adult 409. Astrocytoma (including Glioblastoma Multiforme) then: mets, meningioma, Schwannoma
Breast Carcinoma 410. Invasive Duct Carcinoma
Breast Mass 411. Fibrocystic Change: premenopausic women (Carcinoma is the most common in post-menopausal
women)
Bug in Acute Endocarditis 412. Staph aureus
Bug in debilitated, hospitalized
pneumonia pt
413. Klebsiella
Bug in Epiglottitis 414. Hib
Bug in GI Tract 415. Bacteroides (2
nd
E. coli)
Bug in IV drug user bacteremia /
pneumonia
416. Staph aureus
Bug in PID 417. N. Gonnorrhoeae
Bug in Subacute Endocarditis 418. Strep Viridans
CA of urinary collecting system 419. Transitional cell CA (assoc. w/ benzidine; naphthylamine; analine dyes; long term txt w/
cyclophosphamide)
Cardiac 1
ry
Tumor Adults 420. Myxoma: Ball Valve
Cardiac 1
ry
Tumor Child 421. Rhabdomyoma associated w/ Tuberous sclerosis
Cardiac Tumor Adults 422. Metasteses
Cardiomyopathy 423. Dilated (Congestive) Cardiomyopathy: Alcohol, BeriBeri, Cocaine use, Coxsackie B, Doxorubicin
424. Systolic Dysfunction
Cause of 2
ry
HTN 425. Renal Disease
Cause of Addisons 426. Autoimmune (2
nd
infection)
Cause of breast lumps 427. CA of the breast
Cause of chronic endometriosis 428. TB
Cause of Congenital Adrenal
Hyperplasia
429. 21-Hydroxylase Deficiency: NaCl lost & Hypotension (then, 11- NaCl retention & HTN)
Cause of Cushings 430. Exogenous Steroid Therapy (then, 1
ry
ACTH, Adrenal Adenoma, Ectopic ACTH)
Cause of Death in Alzheimer pts 431. Pneumonia
Cause of Death in Diabetics 432. MI
Cause of Death in premature 433. NRDS = hyaline membrane disease
Cause of Death in
SLE pts.
434. Lupus Nephropathy Type IV (Diffuse Proliferative) = Renal Disease
Cause of Dementia 435. Alzheimers
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Cause of Dementia
(2
nd
most common)
436. Multi-Infarct Dementia
Cause of Dwarfism 437. Achondroplasia
Cause of Food poisoning 438. Staph aureus
Cause of Hematosalpynga 439. Ectopic pregnancy
Cause of Hypoparathyroidism 440. Throidectomy
Cause of Hypothyroidism 441. Corrective surgery I31 treatment
Cause of Kidney infections 442. E. coli
Cause of Liver disease in US 443. Alcohol consumption
Cause of Malignancy in children 444. Acute leukemia
Cause of Mental retardation 445. Downs
Cause of Mental retardation (2
nd
most common)
446. Fragile X
Cause of NaCl loss and
Hypotension
447. 21 hydroxylase deficiency
Cause of PID 448. N. ghonorrhea
Cause of Portal cirrhosis 449. Alcohol
Cause of Preventable Blindness 450. Chlamydia (serotypes A,B,Ba,C)
Cause of Pulmonary HTN 451. COPD
Cause of Secondary Hypertension 452. Renal disease
Cause of SIADH 453. Small Cell Carcinoma of the Lung
Cause of UT Obstruction in men 454. BPHyperplasia
Cause Pernicious Anemia 455. Chronic atrophic gastritis = no production of intrinsic factor
Chromosomal Disorder 456. Downs
Common Tumor of the Appendix 457. Carcinoid tumor: flushing; diarrhea; bronchospasm; RHeart valvular lesions
458. Txt: Methysergide (5HT antagonist)
Congenital Cardiac Anomaly 459. VSD (membranous > muscular)
Congenital Early Cyanosis 460. Tetralogy of Fallot =right to left shunt
Coronary Artery Thrombosis 461. LAD artery: MI
Demyelinating Disease 462. Multiple Sclerosis: (Charcot Triad = nystagmus, intention tremor, scanning speech)
463. Periventricular plaques w/ Oligodenrocytes
464. IgG in CSF, Optic Neuritis, MLF Syndorme = Internuclear Ophthalmoplegia, bladder
incontinence
Dental Tumor 465. Odontoma
Dietary Deficiency 466. Iron
Disease of the Breast 467. Fibrocystic disease
Disseminated Opportunistic
Infection in AIDS
468. CMV (Pneumocystis carinii is most common overall)
Esophageal Cancer 469. SCCA
Fallopian Tube Malignancy 470. AdenoCA
Fatal Genetic Defect in
Caucasians
471. Cystic Fibrosis (chromosome 7q)
Female Tumor 472. Leimyoma
Form of Amyloidosis 473. Immunologic (Bence Jones protein in multiple myeloma is also called the Amyloid Light Chain)
Form of Tularemia 474. Ulceroglandular
Germ Cell Tumor of Testes 475. Seminoma (analogous to dysgerminoma of ovaries)
Gynecological Malignancy 476. Endometrial Carcinoma
Gynecological Finding 477. Endometrial CA
Heart Murmur 478. Mitral Valve Prolapse
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Heart Valve in Bacterial
Endocarditis
479. Mitral
Heart Valve in Bacterial
Endocarditis in IV drug users
480. Tricuspid
Heart Valve involved in Rheumatic
Fever
481. Mitral then Aortic
Hereditary Bleeding Disorder 482. Von Willebrands Disease
Hormone secreted in Pituitary
Adenoma
483. Prolactin
Inherited disease of the Kidney 484. Adult polycystic kidney disease: associated w/ polycystic liver, Berry aneurysms, Mitral prolapse
485. APD1 chromosome 16
Intracranial tumor in adults 486. Glioblastoma mulitforme
Islet Tumor 487. Insulinoma = cell tumor
Liver 1
ry
Tumor 488. Hepatoma
Liver Disease 489. Alcoholic Liver Disease
Location of Adenocarcinoma of
the Pancreas
490. Head (99%)
Location of Adult Brain Tumors 491. Above Tentorium
Location of Childhood
Brain Tumors
492. Below Tentorium
Lung Tumor, malignant or benign 493. Malignant
Lung Tumor, primary or secondary 494. Secondary
Lysosomal Storage Disease 495. Gauchers
Malignancy in Women 496. Lung (2
nd
breast)
Malignancy of the Larynx 497. Glottic CA (squamous cell)
Malignancy of the Small Intestine 498. Adenocarcinoma
Malignancy Vulva 499. Squamous cell CA
Malignant Eye Tumor in Kids 500. Retinoblastoma
Malignant Tumor of the Liver 501. Hepatocellular CA
Motor Neuron Disease 502. ALS
Muscular Dystrophy 503. Duchennes: Dystrophin deletion. Presents <5yoa weakness at pelvic girdles w/ upward
progression
Nasal Tumor 504. Squamous cell CA
Neoplasm Child 505. Leukemia
Neoplasm Child (2
nd
most
common)
506. Medulloblastoma of brain (cerebellum)
Neoplasm of the West 507. Adeno CA of the rectum and/or colon
Neoplastic Polyp 508. Tubular adenoma
Nephrotic Syndrome in Adults 509. Membranous Glomerulonephritis
Nephrotic Syndrome in Children 510. Minimal Change (Lipoid Nephrosis) Disease (responds well to steroid txt)
Non Hodgkins Lymphoma 511. Follicular small clear cell
Number of Deaths per year in
Women
512. Lung CA
Skin tumor 513. Basal cell CA
Opportunistic infection in AIDS 514. PCP
Ovarian Malignancy 515. Serous Cystadenocarcinoma
Ovarian Tumor 516. Hamartoma
Pancreatic Tumor 517. Adeno (usually in the head)
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Patient with
ALL / CLL / AML / CML
518. ALL Child / CLL Adult over 60 / AML - Adult over 60 / CML Adult 35-50
Patient with Goodpastures 519. Young male
Patient with Reiters 520. Male
Pituitary Tumor 521. Prolactinoma (2
nd
Somatotropic Acidophilic Adenoma)
Place for Primary Squamous Cell
CA of esophagus
522. Mid 1/3
Place for Peptic Ulcer Disease 523. Lesser curvuture in antrum associated w/ blood group O
Primary Benign Salivary Tumor 524. Pleomorphic Adenoma (Mixed) 90% localized to the parotid
Primary Hyperparathyroidism 525. Adenomas (followed by: hyperplasia, then carcinoma)
Primary Malignancy of Bone 526. Osteosarcoma
Primary Malignancy of Small
Intestine
527. Lymphoma
Pt. with Hodgkins 528. Young Male (except Nodular Sclerosis type Female)
Pt. with Minimal Change Disease 529. Young Child
Renal Malignancy 530. Renal cell CA
Renal Malignancy of Early
Childhood
531. Wilms tumor (neohroblastoma) chromosome 11p
Salivary Tumor 532. Pleomorphic adenoma
Secondary Hyperparathyroidism 533. Hypocalcemia of Chronic Renal Failure
Sexually Transmitted Disease 534. Chlamydia (sero types D-K)
Site of Diverticula 535. Sigmoid Colon
Site of Embolic Occlusion 536. Middle cerebral aa: contralateral paralysis; aphasias; motor & sensory loss
Site of Metastasis 537. Regional Lymph Nodes
Site of Metastasis
(2
nd
most common)
538. Liver
Sites of Atherosclerosis 539. Abdominal aorta > coronary > popliteal > carotid
Skin CA of Fair Skinned People 540. Malignant melanoma
Skin Cancer 541. Basal Cell Carcinoma
Small Intestine Congenital
Anomaly
542. Meckels diverticulum
Stomach Cancer 543. Adeno associated w/ blood group A
Testicular Tumor 544. Seminoma = malignant painless testes growth
Thyroid Anomaly 545. Thryoglossal duct cyst
Thyroid CA 546. Papillary CA
Tracheoesophageal Fistula 547. Lower esophagus joins trachea / upper esophagus blind pouch polyhydramnios association
Tumor in men <20 548. Germ cell tumor
Tumor of Infancy 549. Benign vascular tumor = port wine stain = Hemangioma
Tumor of the Stomach >50 years
of age
550. CA of stomach (adeno CA)
Type of Hodgkins 551. Mixed Cellularity (versus: lymphocytic predominance, lymphocytic depletion, nodular sclerosis)
Type of Non-Hodgkins 552. Follicular, small cleaved
Type of Portal Cirrhosis 553. Micronodular
Type of Soft Tissue
Tumor of Childhood
554. Rhabdomyosarcoma
Vasculitis
(of medium & small arteries)
555. Temporal Arteritis (branch of Carotid Artery)
Viral Encephalitis 556. HSV
Worm Infection in US 557. Pinworm (2
nd
Ascaris)
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Worst Prognosis in Thyroid Cas 558. Follicular CA
Cause of Lobar Pneumonia 559. Strep. Pneumoniae
Cause of Death b/t 24-44 yoa 560. AIDS
Cause of Pneumonia in Cystic
Fibrosis
561. Pseudomonas
Cause of Osteomyelitis in IV Drug
Users
562. Pseudomonas
Cause of Infection in Burn Pts 563. Pseudomonas
Mental Problem in Males 564. Specific phobia
Intelligence Test 565. Stanford Binet (ages 6 & under)
566. WIPSI (ages 4-6)
567. WISK-R (for ages 6-17)
568. WAIS-R (for > 17 yoa)
Paraphilia 569. Pedophilia
Metabolite seen w/
Pheochromocytoma
570. VMA: vanillylmandelic acid (NE metabolite)
Severe Shigella 571. Dysenteriae
Bug in Otitis Media & Sinusitis in
Kids
572. Strep. Pneumoniae
Cause of a Solitary Brain Abscess 573. A. Israelli
Cause of Bacterial Diarrhea in
U.S.
574. Campylobacter jejuni
Shigella Type 575. S. Sonnei
Cause of Non-Ghonococcal
Urethritis
576. Chlamydia trichomonas
Pneumonia 577. Strep. Pneumoniae
Urethritis 578. N. ghonorrhea
Cause of Glomerulonephritis 579. IgA Nephropathy = Bergers Disease
Cause of Viral Pneumonia 580. RSV infants
581. Parainfluenza kids
582. Influenza virus adults
583. Adeno virus military recruits
Complication of COPD 584. Pulmonary infections
Cause of Death
w/ SLE
585. Renal failure
Atrial Septal Defect 586. Ostium Secundum Type
Warm Antibody 587. Most common form of immune hemolytic anemia
588. IgG auto antibodies to RBC
589. See spherocytosis; (+) Coombs test; complication to CLL
Immunodeficiency 590. IgA Deficiency
Congenital GIT Anomaly 591. Meckels Diverticulum: persistence of vitelline duct/yolk sac stalk
Cause of Congenital Malformation 592. Fetal Alcohol Syndrome
Pharmacology
Autonomic Nervous System
Epinephrine 1. 1, 2, 1, 2
Norepinephrine 2. 1, 2, 1 (no 2 activity)
GABA 3. Causes an inhibitory cell hyperpolarization
Muscarinic-r 4. Uses DAG & IP3 as 2
nd
messengers
5. Parasympathetic control
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14
Bethanechol 6. Cholinergic. GI & Bladder motility. Txt atonic bladder post-op
Pilocarpine 7. Cholinergic. Pupillary constriciton= miosis. Ciliary constriction= accomodation.
8. Txt acute glaucoma
Isoflurophate 9. Organophosphate. Irreversible acetylcholinesterase (-)r
Pralidoxime 10. 2PAM. Reverses organophosphate binding to acetylcholinesterase
Neostigmine 11. Reversible acetylcholinesterase (-)r
12. Txt Myasthenia Gravis
Myasthenia Gravis 13. Anitbodies to Ach-r. g muscular weakness due to Achs weak postsynaptic effect @ NMJ.
Inactivates-r
Tubocurium 14. Nondepol. Competitive cholinergic N-r (-)r.
15. Prevents Ach binding but does not activate NMJ
16. Histamine release= BP & bronchospasm
Trimethaphan 17. Nonselectively binds N-r of the PS- and SNS
Pancurium 18. More potent than tubocurium w/o histamine release
Succinylcholine 19. Depol. Non competitive (-)r of muscle aciton
20. Opens Na Ch.= fasciculations. Closes Na Ch.= paralysis. Continuous infusion.
1 & Eye 21. Mydriasis due to norepinephrine. Prazosin (-).
M-r & Eye 22. Miosis due to Ach. Atropine (-).
Sympathetic 23. Post ganglionic symapthetic fibers releases norepinephrine
Parasym. 24. Post ganglionic parasympathetic fibers release Ach
M3-r & Eye 25. Contracts sphincter = miosis. Contracts ciliary = accomodation.
M2-r & Heart 26. Negative chronotropy: HR = vagal arrest
27. Negative inotropy: contractility
M3-r & Lung 28. Bronchospasm secretions
M3-r & GI 29. motility (cramps & diarrhea). Involuntary defecation
Tacrine 30. Acetylcholine esterase (-)r. Txt Alzheimers
Atropine 31. DOC w/ vagal arrest
Glycoperrolate 32. M-r(-). Antispasmodic. Txt peptic ulcers.
Pirenzepine 33. M-r(-). Antispasmodic. Txt peptic ulcers.
Doxacurium 34. Most potent competitive non-depol NMJ (-)r. No cardiovascular side effects. No Histamine
release.
bungarotoxin 35. Prevent the releasal of Ach from vesicles @ the pre synaptic nerve ending
bungarotoxin 36. Irreversible N-r (-)r = action potentials
1 & Eye 37. Contracts radial muscle = mydriasis (pupil dilation)
1 & Arterioles 38. Constiction: TPR = Diastolic pressure = Afterload
1 & Venules 39. Constriction: Venous return = Preload
1 & Sex Function 40. Ejaculation
Diastolic 41. 1 = TPR
Diastolic 42. 2; Direct acting vasodilators; (+)Cholinergics
1 & Heart 43. (+)chronotropism = HR.
44. (+)inotropism = contractility; SV; CO; O2 consumption.
45. conduction velocity
Phenylephrine 46. 1 (+) Nasal decongestant.
2(+) Asma Drugs 47. Metaproterenol; Albuterol; Terbutaline; Ritodrine; Salmeterol
Ritodrine/Turbutaline 48. Relaxes myometrium used in pre-mature labor pains
Phentolamine 49. Epi reversal. Blocks , vasodilation occurs. Pt goes from HyperTN to HypoTN.
50. Txt pheochromocytoma = BP
Terazosin 51. Txt BPH
Yohimbine 52. sympathetic outflow = 2 (-). Txt impotence.
Cardioselective NMJ 53. Pancuronium = HR due to atropine-like anti muscarinic vagolytic effect & Gallamine (-)r
Ecothiophate 54. Irreversible cholinesterase (-)r.
Pyridostigmine 55. Cholinomimetic that s M & N-r effects. (-) acetylcholinesterase & plasma cholinesterase
56. DOC for the oral Txt of MG
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15
Cardio
Digoxin 1. AV nodal conduction/ inh. Na/K/Atpase = inc. Ca conc. in heart cells = inc. contraction force
Diltiazem 2. Txt black men. Txt AV nodal re entrance
Quinidine 3. AV nodal conduction. Cinchonism. Anticholinergic= aggravate MG. Hypotension= block
Verapamil 4. AV nodal conduction. BP. Negative inotrope= no CHF use
Propranolol 5. AV nodal conduction. BP. Negative inotrope(= block) Aggravates Asthma and Diabetes
Melitus via 2 block.
Diazoxide 6. Balanced vasodilator.
Niroprusside 7. Balanced vasodilator. Unloads heart. s cyanide= pre-txt w/ thiosulfate. Txt Acute HTNv Crisis
Reserpine 8. Txt severe & resistant HTN. Depletes CA. See stuffy nose. No to pts w/ peptic ulcers.
Dobutamine 9. At high doses 2(+) offsets 1 = 1 CO w/o systemic vascular resistance
Dopamine 10. At low doses Txt Shock= dilates renal and mesenteric aa= maintain urine output
Esmolol 11. Short acting (-)
Captopril 12. Balanced vasodilator. Txt Outpt. CHF see dry cough(bradykinin induced)
Digoxin 13. Txt CHF & Atrial Flutter - inotropic - K+ levels= dig. Toxicity
Dig. Toxicity 14. Fatal ventricular arrhythmias w/ sever AV block
Quinidine 15. ClassIa anti arrhythmic. Moderate Na Ch. Block
Lidocaine 16. ClassIb anit arrhythmic. Normalizes conduction. Txt initial MI= control arrhythmias
Flecanide 17. ClassIc anti arrhythmic. Marked conduction slowing
Amiodarone 18. Long t1/2= need potent doses to obtain desired level for action. See blue skin, ocular deposits,
Pulmonary Fibrosis.
NE 19. AV nodal conduction via 1. Metoprolol(-) 1
Ach 20. AV nodal conduction via M receptor. Atorpine(-) M-r
Atenolol 21. Controls catecholamine induced arrhythmias
Bretylium 22. Txt Malignant Ventricular Arrhythmias but causes passing catecholamine release that can
aggravate arrhythmias briefly
Nimodipine 23. Txt Acute subarachnoid hemorrhage by preventing post hemorrhagic vasospasm
Atropine 24. excess vagal tone as seen in Sinus Bradycardia
Nitrates 25. preload= venous pooling. MVO2= reflex tachy. ventr work= dec O2 demand
Propranolol 26. Blocks reflex tachy but causes excess brady= diastole time= EDV
Verapamil 27. O2 supply via in vasospasm Txt Prinzmetals variant angina
Aspirin 28. Prevents arterial platelet adhesion (not DVThrombi). Inactivates COX= platelet production of
TxA2, a potent vasoconstictor
Warfarin 29. (-)Vit. K dependent gamma carboxylation of clotting factors= anticoagulation state
Heparin 30. Dependent on Antithrombin III activation
TPA 31. Binds to fibrin clots & activates plasminogen on the spot. Short t1/2, given IV.
32. Does not discriminate b/t fibrin-based clots= bleeding & stroke complications arise
Streptokinase 33. From bacteria= allergies arise. Can see excess bleeding in post-op pts.
Urokinase 34. Human source. plasmin. Can see excess bleeding in post-op pts.
Colestipol 35. Bile acid sequestrants. Interrupt bile acid reabsorption= LDL uptake. Cholestyramine same
MOA.
Lovastatin 36. HMGCoA reductase(-)= LDL-r synthesis. Pravastatin/ Mevastatin same MOA.
Losartan 37. Aldosterone. Renin 2-3xs
Diazoxide 38. Txt insulinomas. Not balanced vasodilator= onlt dilates arterial smooth muscle
Clonidine 39. Central 2(+). TPR via symapthetic effect
Methyldopa 40. Central 2(+). (++) Coombs= Hemolytic anemia
Phenytoin 41. ClassIb. Reverses mild AV block due to digitoxin toxicity
Procainamide 42. ClassIa. SLE like syndrome.
Indopamide 43. Only Thiazide that will have no effect on cholesterol levels
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16
Thiazides 44. Older black men w/ HTN due to Renin.
(-) 45. Young white men w/o asthma (cause bronchospasm)
ACEIs 46. (-) change AI AII. (-) Bradykinin inactivation. Captopril/ Enalapril
47. Cause renal failure = use w/ caution in the elderly
Epinephrine 48. contraction rate & force via 1.
49. systolic but diastolic BP.
50. peripheral resistance via 2 vasodilaiton
Norepi. 51. heart rate and systolic and diastolic BP
52. peripheral blood vessel resistance
Methyldopa 53. DOC for pregnancy induced HTN
Quinidine pre-txt 54. Atrial arrhythmia pretxt w/ a drug that will ventricular response: Dig.;(-); Ca Ch.(-)
ClassII 55. (-) risk fo reinfarction & sudden death following MI
Gray man 56. Amiodarone: ClassIII antiarrhythmia
Beperidil 57. Ca Ch(-). Limited clinical use due to Torsades de Pointes
ACEIs 58. Vasodilate renal efferents > than afferent arterioles: GFR & Filtration pressure
59. Diabetic renal failure progression
Adenosine 60. Its receptor is blocked by Methylxanthines (ie Theophyline)
61. Favored for the Txt of Reentrant Supra Ventricular Tachycardia
Enoxaparin 62. Low molecular weight heparin = Oral anticoagulant
Isoproterenol 63. HR & MAP
Variant angina 64. Use Ca Ch. (-)r ie Nifedipine
Contraindicated in CHF 65. (-)r = you dont want to the hearts pumping strength
CNS
TOM 1. Short acting BDZs:
2. Triazolam
3. Onazelam
4. Midazolam
Butyrophenone 5. Haloperidol & Droperidol
Atypical D4 6. Clozapine Thioridazine Olanzepine Risperidone = Do not cause EPS
Flumazenil 7. BDZ antidote for OD
Methylphenidate 8. Txt attention deficit disorder
Phenytoin 9. Causes aplastic anemia/ gingival hyperplasia/ cleft lip & palate
Thiopental 10. Short acting Barb
Carbamazepine 11. DOC trigeminal neuralgia. Txt lennox gestaut seizures in kids
Atypical D4-r 12. Thioridazine; Olamzapine; Clozapine
Pimozide 13. Txt Tourettes
Risperidone 14. Good for negative symptoms
Thioridazine 15. Most anti cholinergic neuroleptic
Haloperidol 16. Neuroleptic malignant hyperthermia due to chronic D2 block. give Dantrolene and Bromocriptine
Imirpamine 17. Enurisis
Clomirpramine 18. Txt OCD See aggressive behavior w/ use
Trazadone 19. Priapism
Bupropion 20. Helps to quit smoking
SSRIs 21. Primarily used for OCD
Fluoxetine 22. Good for negative symptoms
Phenelzine 23. Irreversible MAOI
Lithium 24. Txt manic phase of Bipolar Disorder
25. Causes goiter by (-) conversion of T4 to T3
26. Nephrogenic diabetes insipidus
27. Low salt diet will lead to Li toxicity
Alprazolam 28. DOC stage fright
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Propranolol 29. Social phobia
-r 30. Spinal analgesia. Euphoria. ++euphoria. ++sedation. Constipation.
-r 31. Supraspinal analgesia. Dysphoria. +respiratory depression. +sedation.
Morphine & O2
32. Admin. is contraindicated to pts on morphine sedation= CO2 sensitivity and O2 admin. can stop
breathing.
Morphine 33. ICP = do not give to pt. with head trauma
Morphine OD 34. 1.pinpoint pupils 2.d respiraiton 3.coma
Meperidine 35. Anesthetic used during labor
Hydromorphone 36. (+) used in renal failure
Tramadol 37. Ambulatory txt for mod. to severe pain
Naloxone 38. Txt opioid OD. Reverses respiratory depression
Pentazocine 39. Part (+) & part (-)
Butorphenol 40. Part (+) & part (-)
Nalbuphene 41. Part (+) & part (-)
GABA 42. seizure focus= Barbs & BDZs
Fast Na Ch. 43. electrical activity spread = Phenytoin & Carbamazepine
Methoxyflurane 44. Can be nephrotoxic. Needs low MAC for anesthetic induction.
Enflurane 45. Can cause tonic/clonic muscle spasms
Isoflurane 46. Can cause bronchospasm
Halothane 47. Can cause ventricular extrasystoles & Malignant hyperthermia & Hepatitis
Nitric Oxide 48. No effect on HR. Needs high MAC for anesthetic induction.
Thiopental 49. Short acting Barb.
Kentamine 50. Dissociative anesthetic
Droperidol 51. Can be used in combo w/ Fentanyl for neuroleptoanalgesic effect
52. Neuroleptic tranquilizer. Has mild alpha block
Fentanyl 53. Can be used on combo w/ Droperidol for neuroleptoanalgesic effect
54. Used transdermally for chronic pain
Midazolam 55. Pre anesthetic. Induces amnesia
Primidone 56. Biotransformed to Phenobarb.
C & A delta Fibers 57. First fibers to be blocked w/ anesthesia
Esters 58. Procaine, Tetracaine, Benzocaine
59. Broken down and make PABA (allergen)
Amides 60. Lidocaine, Mepivaciane, Bupivaciane, Etidocaine= i before caine always an amide
61. Metabolized in the liver
Amphetamine 62. DA reuptake (-)r. MAOI. Parkinsons txt
Bromocriptine 63. D2(+). Used w/ L-Dopa for on-off phenomenon of Parkinsons
Benztropine 64. Ant M w/ some DA reuptake (-). Parkinsons txt
Amantidine 65. DA reuptake. Can cause livido reticularis= skin mottling.
Diphenhydramine 66. Txt early Parkinsons stages
Pergolide 67. > Effective & longer acting than Bromocriptine
Ethosuximide 68. DOC for Absence seizures
Tranylcypromine 69. MAOI = antidepressant
SSRI & MAOI 70. Fatal combo, especially seen with the use of Paroxetine or Fluoxetine (SSRIs) and
Tranylcypromine (MAOI)
Labor opioids 71. Meperidine & Nalbuphine
Desipramine causes 72. Sudden cardaic death in children
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Anti-Infective
Primaquine 4. Malaria profylaxis
5. Used for extraerythrocytic forms Plasmodium vivax or P. ovale
Ciporfloxacin 6. Quinolone derivative
Sulfonamides 7. PABA structural analogs
8. Inhibit Folic acid synthesis
Tertacyclines, anuria & the
exception
9. Should not be used in anuric pt due to production of (-) Nitrogen balance & d BUN levels.
10. Doxycycline is the exception
Ceftriazone 11. 3
rd
generation cephalosporin
12. DOC for bacterial meningitis in kids (ie HiB)
13. One dose txt of gonorrhea
Hepatic coma DOC 14. Neomycin (aminoglycoside) it supresses the normal flora = g NH4 production = g free
nitrogen levels in the bloodstream.
Clavulanic acid 15. Irreversible (-)r of lactamases, but ot of transpeptidase = use w/ a lactamase sensitive
penicillin
Piperacillin 16. Txt Pseudomonas aeruginosa & Klebsiella
17. Broad spectrum antibiotic
Streptomycin (aminoglycoside) 18. Txt Mycobacterium tuberculosis
Isoniazid 19. Most commonly used drug for TB.
20. Usually combined w/ Rifampin and/or Ethambutol
21. Pre Txt w/ Pyridoxine (Vit B6) can prevent peripheral neuritis
Pyrantel Pamoate 22. Txt of Hookworm disease
23. Depolarizing NMJ (-)r
Buy AT 30, CELL at 50 24. A = Aminoglycosides
25. T = Tetracyclines
26. C = Chloramphenicol
27. E = Erythromycin (macrolide)
28. L = Clindamycin
29. L = Lincomycin
Cefoxitin 30. Txt intraabdominal infections (ie w/ Bacteroides fragilis)
31. Traditional txt has been Clindamycin & Gentamycin
Chloramphenicol 32. Broad spectrum antibiotic
33. Bone marrow depression (common) Aplastic anemia (rare)
34. Gray baby syndrome (chloramphenicol cannot be conjugated)
35. DOC Typhoid Fever (symptomatic Salmonella infection)
36. DOC HiB meningitis in kids especially resistant strain to ampicillin
Nifurtimox 37. Txt trypanosomiasis
Metronidazole 38. Txt Leishmaniasis & Amebiasis
39. Good for anaerobic bacteria = Bacteroides fragilis
40. DOC Trichomoniasis
41. DOC Giardia lamblia
Txt P. carinii 42. TMP-SMX & Pentamidine
Tetracycline 43. Txt of Brucellosis & Cholera
44. Txt Rocky Mountain Spotted Fever
45. Txt spirochete infections = Lyme disease (Borrelia burgdorferi)
TMP-SMX 46. (-) dihydrofolate reductase activity
Benzathine Penicillin G 47. Long duration of action = given once every 3-4 weeks for Txt of Syphilis
Praziquantel 48. Txt Schistosomiasis (trematode [fluke] infections)
Melarsoprol 49. Txt Trypanosomiasis that has neurological symptoms
Stibogluconate 50. Txt Leishmaniasis
Fluconazole 51. Txt fungal encephalitis
Amphotericin B 52. Polyene antifingal
Ketoconazole MOA 53. (-) fungal ergosterol synthesis = disrupts membrane
Griseofulvin MOA 54. Accumulates in keratinized layers of the skin = used in dermatomycoses infections
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Mefloquine 55. Anti malarial
56. Txt Chloroquine resistant strains = P. falciparum
Chloroquine 57. Txt for Malaria when inside RBC
Nifurtimox 58. DOC Chagas disease due to Trypanosoma cruzi
Erythromycin 59. Used in pts allergic to penicillins
Nystatin 60. Topical txt of superficial mycotic infections = Candidiasis
Acyclovir 61. Guanine analog
62. Txt Herpes infections
Imipenem 63. Used w/ Cilastatin
64. Can cause seizures
Cefoperazone side effects 65. Bleeding due to vit K level alterations
66. Contraindicated in pts w/ bleeding disorders
Vancomycin 67. Used for MRSS (methicillin resistant Staph. Aureus)
68. Red neck: due to histamine release causes facial flushing
Meropenem 69. used w/ Cilastatin
70. Does not cause seizures (cf w/ Imipenem)
Nafcillin 71. Only penicillin that does not need dose adjustment in renal impairment
Peripheral neuropathy 72. Seen w/ use of:
73. Metronidazole Isoniazid Vincristine ddI AZT Allopurinol
Sulfonamides & newborns 74. Kernicterus can occur
O.N.E. for gonorrhea 75. Fluoroquinolones used in a one dose deal for gonorrhea:
76. O = Ofloxacin
77. N = Norfloxacin
78. E = Enoxacin
Ribavirin 79. Txt RSV (Respiratory Syncytial Virus)
Anti-Neoplastics
Cyclosporine 80. Protects against rejections from organ transplants
81. Does not induce bone marrow depression
Cyclophosphamide 82. Alkylating agent of both purine & pyrimidine bases of DNA
83. Txt CLL
Cisplatins toxicities 84. Nephro- & Ototoxicity
Methotrexate 85. Antimetabolite of folic acid: (-)dihydrofolate reductase
Leucovorin Rescue 86. Can block/reduce Methotrexate = folic acid via a reduced folate
Bleomycin toxicities 87. Pneumonitis & pulmonary fibrosis
Azathiorine 88. Used in organ transplantation = kidney allografts
89. Allopurinol can its activity by (-) its biotransformation to xanthine oxidase
MOPP 90. Chemotherapy used in the txt of Hodgkins disease
91. M = Mechlorethamine nitrogen mustard
92. O = Oncovin (Vincristine) prevents microtubule assembly
93. P = Procarbazine
94. P = Prednisone glucocorticoid, inducing apoptosis
Tamoxifen 95. (-) estrogen receptor
96. Txt of breast tumors, can see associated endometrial CA
Flutamide 97. Antiandrogenic
98. Used w/ Leuprolide (LH-RH analog)
99. Txt prostatic CA
Megestrol 100. (-) progesterone receptor
101. Txt endometrial CA
Fluoxymesterone 102. Androgenic steroid
103. Txt mammary CA in postmenopausal women
Methotrexate 104. Folic acid analog that (-) tetrahydrofolate synthesis by (-) dihydrofolate reductase
105. Txt of ALL
106. Txt of Psoriasis
Brain tumor Txt 107. Lomustine
108. Carmustine Causes pulmonary fibrosis
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Streptozocin 109. Attaches to cells
110. Txt of pancreatic insulinomas
Cytarabine (AraC) 111. Pyrimidine analog
112. DOC for AML
Dactinomycin 113. Used for Wilms tumor & rhabdomyosarcoma
Etoposide 114. Used for oat cell CA
Paclitaxel 115. Used for ovarian CA
Amifostine 116. Can nephrotoxicity due to chronic use of Cisplatin
Pathology
Mobitz I 117. Usually due to inferior MI. Rarely goes into 3
rd
degree block.
118. Txt w/ Atropine or Isoproterenol.
Mobitz II 119. BBB association. Often goes to 3
rd
degree AV block. Usually due to anterior MI.
P wave 120. Atrial depol.
a wave 121. LA contraction
T wave 122. Vetricular repol.
Wavy fibers 123. Eosinophilic bands of necrotic myocytes. Early sign of MI.
Janeways lesions 124. Acute bacterial endocarditis.
125. Nontender, erythematous lesions of palms & soles.
Oslers nodes 126. Subacute bacterial endocarditis.
127. Tender lesions of fingers & toes.
Thiamine defcy 128. Wet Beri Beri heart. Dilated (congested) cardiomyopathy due to chronic alcohol consumption
129. Dyr Beri Beri = peripheral neuropathy
130. Wernicke-Korsakoff = ataxia; confusion; confabulation; memory loss
Fibrinous Pericarditis 131. Associated w/ MI: Dresslers
Serous Pericarditis 132. Associated w/ nonbacterial; viral (Coxsackie) infection; immunologic reaction.
Friction Rub 133. Pericarditis association
Hemorrhagic Pericarditis 134. Associated w/ TB or neoplasm
Restrictive Cardiomyopathy 135. Aka infiltrative cardiomyopathy that stiffens the heart
136. Due to amyloidosis in the elderly
137. Due to , also see schaumann & asteroid bodies in young (<25 yoa).
PMLs infectious agent 138. JC Virus (Papovavirus = dsDNA, naked icosahedral capsid)
Edema 139. Pc (more seeps out)
140. c (less reabsorbed)
141. permeability
142. Block lymphatic drainage
Adult Polycystic Kidney Disease 143. Commonly see liver cysts & Berry aneurysms along w/ kidney cysts. Hematuria & HTN also
present.
144. 3 cysts in ea. Kidney w/ + family history confirms diagnosis
Malignant HTN & Kidneys 145. Petehial hemorrhages are seen on kidney surfaces = Flea-Bitten surface = young black men
Nephritic signs 146. Hematuria; RBC casts; HTN
Nephrotic signs 147. Proteinuria; Hypoalbuminemia; Edema
Podocyte Effacement seen w/ 148. Minimal Change (Lipoid nephrosis) disease
ASO seen in 149. Acute post-streptococcal GN (due to HGASrtep)
150. Anti streptolysin O
Crescentic GN 151. Rapidly progressive GN nephritic syndrome
152. Associated w/ multi system disease or post-strep/post infectious glomerular nephritis
Hereditary Nephritis 153. Alports syndrome. X linked
154. Renal disease w/ deafness & ocualr abnormalities
Membranoproliferative GN 155. Can be secondary to complement deficiency; chronic infections; CLL
156. See tram tracking
TypeI Membrano Proliferative GN
deposits
157. C3 & IgG deposits
TypeII Membrano Proliferative
GN deposits
158. Only C3 deposits
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GN deposits 159. Aka Dense deposit disease
Focal segmental glomerulosclerosis
deposits
160. IgM & C3 deposits
Cold agglutinins 161. Seen in atypical pneumonia
162. It is IgM Ab with specificity for I Ag on adult RBCs
Scrofula 163. TB in the lymph nodes
Aspirin-Asthma Triad 164. Nasal polyps Rhinitis bronchoconstriction
Ferruginous bodies 165. Hemosiderin (pigment w/ Fe
3-
) covered macrophages that have been pahgocytised
Pancoasts tumor causes 166. Ulnar nerve pain & Horners syndrome
Fatty degeneration 167. Made up primarily of triglycerides
168. Most commonly due to alcoholism which commonly leads to hepatic cirrhosis
169. Associated w/ CCl4
-

Cloudy swelling 170. Failure of cellular Na pump
171. Seen in Fatty degeneration of the liver and in Hydropic (Vacuolar) degeneration of the liver
Hydropic degeneration 172. Severe form of cloudy swelling
173. Seen with hypokalemia induced by vomitting/diarrhea
Liquefaction necrosis 174. Rapid enzymatic break down of lipids
175. Seen commonly in Brain & Spinal cord (CNS) injuries
176. Seen in suppurative infections = pus formation
Coagulation necrosis 177. Result of sudden ischemia
178. Seen in organs w/ end arteries limited collateral circulation) = heart, lung, kidney, spleen
Caseation necrosis 179. Combination of both coagulation & liquefaction necrosis
180. Seen w/ M. tuberculosis & Histoplasma capsulatum infection
Fibrinoid necrosis 181. Seen in the walls of small arteries
182. Associated w/ malignant hypertension, polyarteritis nodosa, immune mediated vasculitis
Fat necrosis 183. Result of lipase actions liberated from pancreatic enzymes
184. Seen w/ Acute pancreatitis = saponification results
Hemoptysis 185. Blood in sputum
Pulmonary embolism 186. Most commonly thrombus from lower extremity vein
Phlebothrombosis 187. From a vein of lower extremities, of a pregnant uterus, in Congestive heart failure, bed ridden
pt,
188. As a complicaiton in a pt w/ Pancreatic CA due to d blood coagulability
Saddle embolus 189. Embolus lodged in bifurcation of pulmonary trunks
190. RV strain = RV & RA dilate = Acute cor Pulmonale
Paradoxical embolism 191. Right to Left shunt allows a venous embolism to enter arterial circulation
192. Patent ovale foramen or Atrial septal defect
Tuberculoid granuloma 193. Collection of macrophages w/o caseation
194. Seen w/ Sarcoidosis (non-caseating); Syphilis; Brucellosis and Leprotic infections
Cellulitis 195. Spreading infection due to streptococcus
PSA 196. Prostate Specific Antigen = elevated in prostatic CA
5-HT 197. In cases of metastatic carcinoid, txt w/ Methysergide (5HT antagonist)
Feto Protein 198. Hepatocarcinoma
199. Neural tube defects
CEA 200. Carcinoembryonic Antigen = elevated in Colon CA
Chromosome 13 201. Retinoblastoma
Chromosome 11p 202. Wilms tumor of the kidney
Vinyl Chloride 203. Associated w/ Angiosarcoma of the liver
Agent Orange 204. Contains dioxin
205. Implicated as a cause of Hodgkin;s disease, non-Hodgkins lymphoma & soft tissue sarcomas
Parasites & CA 206. Schistosoma haematobium = Urinary bladder CA
207. S. mansoni = Colon CA
208. Aspergillus flavus = potent hepatocarcinogen
Ochronosis 209. Alkaptonuria
210. Error in tyrosine metabolism due to Homogentisic acid (oxidizes tyrosine)
211. Involving intervertebral disks = Ankylosing Spondilitis = Poker spine
212. See dark urine; dark coloration of sclera, tendons, cartilage
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Lead poisoning 213. Acid fast inclusion bodies
214. urinary coproprophyrin
215. Anemia: microcytic/ hypochromic
216. Stippling of the basophils
217. Gingival line & lead line in bones: x-ray
218. Mental retardation
Heroin OD, clinically 219. Massive pulmonary edema w/ frothy fluid from the nostrils
Fetal alcohol syndrome 220. Small head, small eyes, funnel chest, ASD, mental deficiency, and hirsutism
Atypical mycobacterium 221. M. kanasasii & M. avium intracellulare
Cold abscesses 222. Liquefied TB lesions similar to pyogenic abscesses but lacking acute inflammation
Actinomyces isrealli 223. Farmers infection
224. Lumpy jaw (from chewing grain) & PID (IUD), but most common is due to saprophyticus
Congenital Syphilis 225. Saddle nose, Saber shin, Hutchinsons teeth, nerve deafness, interstitial keratitis
Warthin-Finkeledy cells 226. Reticuloendothelial giant cells on tonsils, lymph nodes, spleen
227. Seen with Rubeola (measles) due to paramyxovirus
Diphyllobothrium latum 228. Tapeworm infection causing megaloblastic anemia by consuming large amount of vit B12 in the
host
Subacute Bacterial Endocarditis 229. Hemolytic Streptococci (S. viridans) = usually in pt w/ pre-existing heart problem
Acute Bacterial Endocarditis 230. Staph aureus, Hemolytic Streptococci, E. coli
231. Common among drug addicts & diabetics
Mitral Insufficiency 232. Ruptured papillary muscle
Left Anterior Descending branch 233. Branch of the Left Coronary artery
234. Highest frequency of thrombotic occlusion
235. MI = anterior wall of the LV, especially in apical part of interventricular septum
Left Circumflex branch 236. Branch of the Left Coronary artery
237. Occlusion = MI of posterior/lateral wall of the LV
Dissecting Aneurysm 238. False aneurysm: it is splitting of the media of the aorta
239. Usually accompanied w/ long history of severe hypertension, also seen w/ familial hyperlipidemia,
atherosclerotic disease, Marfans Collagen disease
240. Zones of medial necrosis +/- slitlike cysts = Medial Cystic Necrosis of Erdheim
Cor Pulmonale 241. Right ventricular strain, associated w/ right ventricular hypertrophy
Acute Cor Pulmonale 242. Sudden right ventricular strain due to a massive pulmonary embolism
Bronchopneumonia 243. Lobular (rather than lobar)
244. Due to Staph aureus; Pseudomonas aeruginosa; Klebsiella; E. coli
245. Abscess formation is common
Lobar pneumonia 246. Due to Strep. Pneumoniae infection (5% due to Klebsiella)
247. Red Hepatization: days 1-3 of the pneumonia
248. Gray Hepatization: days 3-8 of untreated pneumonia
249. Complicaitons: pleural effusion; atelectasia; fibrinous pleuritis; empyema; fibrinous pericarditis;
otitis media
Bronchiectasis 250. Permanent dilatation of the bronchi predisposed by chronic sinusitis and post nasal drip
251. Supparation associated
252. Lower lobe > than upper lobe involvement
Cold Agglutinins 253. Found w/ Mycoplasma pneumoniae
Panlobular Emphysema 254. 1 antitrypsin deficiency, causing elastase = compliance in the lung
Bulla 255. Associated w/ Emphysema = Bleb = outpouching - If it ruptures causes Pneumothorax
Farmers Lung 256. Due to Micropolyspora faeni (thermophilic actinomycetes)
Bagassosis 257. Due to M. vulgaris (actinomycetes)
258. Inhalation of sugar cane dust
Silo-Fillers Lung 259. Due to Nitrogen dioxide from nitrates in corn
G6PDH Deficiency 260. Sex-linked chronic hemolytic anemia w/o challenge or after eating fava beans
261. Heinz Bodies appear in RBCs
HbF 262. Sickle Cell Anemia
Multiple Myeloma 263. Lytic lesions of flat bones (salt & pepper lesions) = vertebrae, ribs, skull; Hypercalcemia; Bence-
Jones protein casts
Hodgkins Disease 264. Malignant neoplasm of the lymph nodes causing pruritis; fever = looks like an acute infection
265. Reed Sternberg cells
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Polyarteritis Nodosa 266. Immune complex disease of Ag-Ab complexes on blood vessel wall
267. Half of the immune complexes have Hepatitis B Ag
268. Can see fever; abd.pain; wt; HTN; muscle aches
Sprue 269. Celiac disease due to a gluten-induced enteropathy = small intestine villi are blunted
270. High titers of anti-gliadin Abs & IgA levels
Regional Enteritis 271. Crohns Disease
272. Association w/ Arthritis; Uveitis; Erythema Nodosum
Whipples Disease 273. Intestinal Lipodystrophy = malabsorption syndrome
Kulchitsky cells 274. Neural cest cells from which carcinoids arise = of the Bronchi; GIT; Pancreas
Ulcerative Colitis 275. Inflammatory disease of the colon w/ colon CA incidence
276. Crypt abscess in the crypts of Lieberkuhn
277. Pseudopolyps when ulcers are deep
278. Not transmural involvement
Vaginal Adenosis 279. Women exposed to DES (Diethylstilbesterol) in utero before the 18
th
week of pregnancy
280. Some develop clear cell adenocarcinoma of the vagina & cervix
Scirrhous Carcinoma 281. Infiltrating Duct Carcinoma w/ fibrosis most common type of breast carcinoma
Hofbauer Cells 282. Lipid laden macrophages seen in villi of Erythroblastosis Fetalis
Retinopathy of Prematurity 283. Retrolental Fibroplasia = cause of bindness in premies due to high O2 concentrations
IgA deficiency 284. Pt has recurrent infections & diarrhea w/ respiratory tract allergy & autoimmune diseases
285. If given blood w/ IgA = develop severe, fatal anaphylaxis reaction
Priamry Sjorgens 286. Dry eyes & dry mouth, arthritis. risk for B cell lymphoma. HLA-DR3 frequent. Autoimmune
disease.
Secondary Sjorgens 287. Rheumatoid arthritis, SLE, or systemic sclerosis association
288. RA association shows HLA-DR4
LDH1 & LDH2 289. Myocardium. LDH1 higher than LDH2 = Myocardial Infarction
LDH3 290. Lung tissue
LDH4 & LDH5 291. Liver cells
Keratomalacia 292. Severe Vit A deficiency. See Bitots spots in the eyes = gray plaques = thickened, keratinized ET
Metabisfite Test 293. Suspending RBCs in a low O2 content solution
294. Can detect Hemoglobin S, which sickles in low O2
Microangiopathic Hemolytic
Anemia
295. Can be due to Hemolyitc Uremic Syndrome & Thrombotic Thrombocytopenic Purpura (TTP)
296. See Helmet cells
Wrights stain 297. Stain for Burkitts lymphoma
Mononucleosis 298. Due to EBV infeciton
299. If Mono is treated w/ Ampicillin, thinking that it is a strep pharyngitis, a rash will occur.
T(8;14) 300. Burkitts lymphoma = c-myc oncogene overexpression
T(9;22) 301. CML = c-abl/bcr gene formation = Philadelphia translocation
Langerhan Cell Histiocytosis 302. Letter Siwe syndrome; Hand Schuller Christian Disease; Eosinophilic Granuloma
303. Birbeck granules are present = tennis racket shape
Myeloid Metaplasia 304. Alkaline phosphatase /normal compare to CML = low to absent
305. Anemia; splenomegaly; platelets > 1 million = extensive extra-medullary hematopoiesis
Multiple Myeloma 306. Weakness; wt. loss; recurrent infection; proteinuria; anemia; proliferation of plasma cells in BM
= plasma cell dx
307. Serum M protein spike most often of IgG or IgA
308. Hypercalcemia ( bone destruction)
T(14;18) 309. NH Lymphoma = bcl2 proto-oncogene overexpression seen w/ Small Cleaved Cell (Follicualr)
Lymphoma
Focal Segmental GN exs 310. IgA Focal GN = Bergers disease; SLE; PAN; Schonlein-Henoch purpura (anaphylactoid purpura)
Nephrotic Syndrome exs 311. Focal (Segmental) GN; Membranous GN; Lipoid (Minimal Change) GN; Membranoproliferative GN;
Hep B; Syphilis; Penicillamine
Schistosoma Haematobium 312. Infection is assocaited w/ Squamous cell CA of the Bladder (most common Bladder CA is
transitional cell type)
313. Associated w/ portal HTN due to intrahepatic obstruction
Penicillin Resistant PID 314. PID is usually due to N. Gonorrhoeae, but if unresponsive to penicillin think of Bacteroides
species
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Duret Hemorrhages 315. Severe in ICP w/ downward diplacement of cerebellar tonsils into Foramen Magnum causing a
compression on the brainstem w/ hemorrhaging into the pons & midbrain
316. Nearly always associated w/ death due to damage to the vital centers in these areas
Hypertensive Hemorrhage 317. Predilection for lenticulostriate arteries = putamen & internal capsule hemorrhages
Cerebral Embolism from 318. MI w/ Mural Thrombi; Atrial Fib Thrombi = Marantic thrombi; L-sided Bacterial Endocarditis;
Paradoxical Embolism of septal defect
Neurosyphilis 319. Tabes Dorsalis = joint position sensation, pain sensation, ataxia, Argyl Robertson pupils
320. Syphilitic meningitis
321. Paretic neurosyphilis
5p- 322. Cri di Chat: mental retardation; small head; wide set eyes; low set ears; cat-like cry
Trisomy 13 323. Pataus: small head & eyes; cleft lip & palate; many fingers
Acute Cold Agglutinaiton 324. Abs to I blood group Ag. Mediated by IgM Abs
325. Complication of EBV or Mycoplasma pneumoniae infections
Chronic Cold Agglutinaiton 326. Associated w/lymphoid neoplasms. See agglutination & hemolysis in tissue exposed to cold. IgM
Abs
RBC Osmotic Fragility 327. Hereditary Spherocytosis
Non-Hodgkins Lymphomas 328. Small Lymphocytic: low grade B cell lymphoma of the elderly. Related to CLL.
329. Small Cleaved cell (Follicualr): low grade B cell lymphoma of the elderly. T(14;18) bcl-2 oncogene
330. Large Cell
331. Lymphoblastic: high grade T cell lymphoma of kids progressing to T-ALL
332. Small Non Cleaved = Burkitts: high grade B cell lymphoma. EBV infection. Starry sky histo
appearance. T(8;14) c-myc proto-oncogene. Related to B-ALL
Singers Nodules 333. Benign laryngeal polyps associated w/ smoking & overuse of the voice
Paraseptal emphysema 334. Associated w/ blebs (large subpleural bullae) that can rupture and cause pneumothorax
Superior Vena Cava Syndrome 335. Obstructed due to bronchogenic carcinoma. Causing swollen face & cyanosis.
Betel nuts 336. Associated to oral cancer.
Fundal (Type A) Gastritis 337. Antibodies to parietal cells; pernicious anemia; autoimmune diseases
Antral (Type B) Gastritis 338. Associated w/ Helicobacter (Campylobacter) pylori infection. 90% of duodenal ulcer
Primary Biliary Cirrhosis 339. Autoimmune origin; middle aged women; anti-mitochondrial Abs
340. Jaundice; itching; hypercholesterolemia (can see cutaneous xanthomas)
Acute Pancreatitis 341. pancreatic enzymes = fat necrosis; sapponification = hypocalcemia; serum amylase
342. Severe epigastric ab pain; prostration; radiation to the back
Radiating Back Pain 343. Chronic pancreatitis
Complete Hydatidiform Mole 344. No embryo. Paternal derivation only. 46XX
Partial Hydatidiform Mole 345. Embryo. 2 or more sprems fertilized 1 ovum: triploidy/tetraploidy occurs
Cold Nodules 346. Hypoplastic Goiter nodules that do not take up radio active iodine. [Opposite: hot & do take up
iodine]
Acidophils 347. Mammotrophs = Prolactin
348. Somatotrophs = GH
Basophils 349. Thyrotrophs = TSH
350. Gonadotrophs = LH
351. Corticotrophs = ACTH & FSH
Lacunar Strokes 352. Small/focal aa occlusions. Purely motor or sensory.
353. Sensory: lesion of thalamus
354. Motor: lesion of internal capsule
CSF of Bacterial Meningitis 355. Glucose; Protein; Neutrophils; Pressure
CSF of Viral Meningitis 356. Normal Glucose; +/- Protein; Lymphocytes
Marble Bone Disease 357. Osteoporosis: Albers-Schonberd Disease = inspite of d bone density, many fractures =
osteoclasts
C5a 358. Involved in Chemotaxis (for Neutrophils)
C3b 359. Involved in Opsonization (& IgG)
Anaphylotoxins 360. C3a & C5a (mediate Histamine release from Basophils & Mast cells)
Vasoactive Mediators 361. Vasoconstriction: TxA2; LTC4; LTD4; LTE4; PAF
362. Vasodilation: PGI2; PGD2; PGE2; PGF2
; Bradykinin; PAF
363. d Vascular Permeability: Hist.; 5HT; PGD2; PGE2; PGF2
; LTC4; LTD4; LTE4; Bradykinin; PAF
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Platelet Aggregation 364. ADP; Thrombin; TxA2; collagen; Epinephrine; PAF
Platelet Antagonist 365. Prostacyclin (PGI2)
Intrinsic Pathway 366. F XII (Hagman): APTT
Extrinsic Pathway 367. F VII: PT
Lines of Zahn 368. Aterial thrombi = pale red colored (dark red is venous thrombi)
Currant Jelly appearance 369. Post mortem clots
Emigration: Chemotaxis 370. Margination
371. Pavementing
372. Adhesion
373. Chemotaxis
374. Phagocytosis
375. Intracellular microbial killing
Transudate 376. Specific gravity < 1.012 low protein
Exudate 377. Specific gravity > 1.020 high protein
Hurlers 378. Lysosomal storage disease L Iduronidase Heparan/Dermatan Sulfate accumulation
Galactosemia 379. Deficiency of Galactose 1 Phosphate Uridyl Transferase. Galactose 1 Phosphate
Phenylketonuria 380. Deficiency: Phenylalanine Hydroxylase. Phenyalanine & degradation products
381. Mousy body odor
Autosomal Dominant Diseases 382. Adult Poly Cystic Kidney Disease
383. Familial Hypercholestrolemia Disease
384. Hereditary Hemorrhagic Telengectasia (Osler-Weber-Rendu)
385. Hereditary Spherocytosis
386. Huntingtons Disease (chromosome 4p)
387. Marfans Syndrome
388. Neurofibromatosis (von Recklinghausens)
389. Tuberous Sclerosis
390. Von Hippel Lindau Disease
Autosomal Recessive Diseases 391. Tay-Sachs
392. Gauchers
393. Niemann-Pick
394. Hurlers
395. Von Gierkes
396. Pompes
397. Coris
398. McArdles
399. Galactosemia
400. PKU
401. Alcaptonuria
X Linked Recessive Diseases 402. Hunters Syndrome (L-Iduronosulfate Sulfatase deficincy, Heparan/Dermatan Sulfate)
403. Fabrys Disease ( Galactosidase A deficiency, Ceremide Trihexoside)
404. Classic Hemophilia A (Factor VIII deficiency, F8 Gene on X chromosome is bad, Ceremide Trihexoside)
405. Lisch-Nyhan Syndrome (HGPRT deficiency, Uric acid)
406. G6Phosphatase deficiency (G6PDH deficiency, Ceremide trihexoside)
407. Duchennes Muscular Dystrophy (Dystrophin deficinecy, Ceremide Trihexoside)
Hypersensitivity Reactions
ACID
408. Type I (Anaphylactic): IgE mediated. Exs: Hay Fever; Allergic asthma; Hives
409. Type II (Cytotoxic): Warm Ab autoimmune hemolytic anemia; hemolytic transfusion reactions;
Erythroblastosis Fetalis; Graves Disease; Goodpastures
410. Type III (Immune Complex): Insoluble complement bound aggregates of Ag-Ab complexes. Exs:
Serum sickness; Arthus Reaction; Polyarteritis Nodosa; SLE; Immune Complex Mediated
Glomerular Disease
411. Type IV (Delayed = Cell mediated immunity): Delayed hypersensitivity. Involves memory cells.
Exs: Tuberculin reaction; Contact dermatitis; Tumor cell killing; Virally infected cell killing
Transplant Rejections 412. Hyperacute Rejection = occurs w/in minutes of transplant. Ab mediated.
413. Acute Rejection = occurs w/in days to months of transplant. Lymphocytes & macrophages. Only
rejection type that can be treated w/ therapy.
414. Chronic Rejection = occurs months to years of transplant. Ab mediates vascular damage.
Blood Metastasis 415. Sarcoma, exception renal cell CA: early venous invasion
Lymph Metastasis 416. Carcinoma, exception renal cell CA: early venous invasion
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Aflatoxin 417. Seen w/ Aspergillus. risk for Hepatocellular CA
Cleft Lip 418. Incomplete fusion of maxillary prominence w/ median nasal prominence
Cleft Palate 419. Incomplete fusion of lateral palatine process w/ each other & median nasal prominence & medial
palatine prominence
Craniopharyngioma 420. Pituitary tumor - usually calcified
Lateral Geniculate Nucleus Inolved in Vision relay
Medial Geniculate Body Involved in Hearing relay
Lung Development Glandular: 5-17 fetal weeks
Canalicular 13-25 fetal weeks
Terminal Sac 24 weeks to birth
Alveolar period birth-8yoa
Hearts 1
st
Beat 21-22 days
Foregut Mouth Common Bile Duct - supplied by Celiac Artery
Midgut Duodenum, just below Common Bile Duct Splenic flexure of the Colon supplied by Superior
Mesenteric artery
Hindgut Splenic Flexure Butt crack supplied by Inferior Mesenteric Artery
Hypnagogic Hallucinaitons Narcolepsy
Type I Error : Convicting the innocent accepting experimental hypothesis/rejecting null hypothesis
Subdural Hematoma Ruptured cerebral bridging veins
Epidural Hematoma Ruptured middle meningeal artery intervals of lucidness, 2
ry
to Temporal bone fracture
Type II Error : Setting the guilty free fail to reject the null hypotesis when it was false
Power 1 -
Sensitivity TP/TP + FN
Specificity TN/TN + FP
Positive Predictive Value TP/TP + FP
Negative Predictive Value TN/TN + FN
Odds Ratio ad/bc
d-Dimers DIC
Delusion Disorder of thought content
Loose Association Skip from topic to topic
5 Stages of Death Denial Anger Bargaining Depression Acceptance
1
st
Branchial Arch Meckels cartillage gives rise to incus/malleus bones of ear
2
nd
Branchial Arch Reicherts cartillage gives rise to stapes bone of ear
Median nerve lesion No pronation
Radial nerve lesion Wrist drop seen w/ humerus fracture
Common peroneal lesion Foot drop. No dorsiflexion or eversion of the foot
Diract inguinal hernia Goes through superficial inguinal ring.
Medial to inferior epigastric artery
Seen in older men
Indirect inguinal hernia Goes through deep & superficial inguinal ring
Lateral to inferior epigastric artery
Seen in young boys processus vaginalis did not close
@ Diaphragm T8, T10, T12 T8 = Inferior vena cava
T10 = Esophagus/ Vagus
T12 = Aorta/ Thoracic duct/ Azygous vein
Hemiballism Wild flailing of 1 arm. Lesion of the sub thalamic nucleus
O Linked Oligosaccharide In the Golgi
N Linked Oligosaccharide In the RER
MLF Syndrome Internuclear Ophthalmoplegia: medial rectus palsy on lateral gaze; Nystagmus on abducting eye.
Seen w/ MS
ADA Deficiency SCID
Raphe Nucleus Initiation of sleep via 5HT predominance
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waves Alert; Awake; Active mind also seen in REM, therefore we say paradoxical sleep
Irreversible Glycolysis Enzymes Hexokinase
PhosphoFructo Kinase = Rate Limiting Step
Pyruvate Kinase
Pyruvate Dehydrogenase
Irreversible Gluconeogenesis
Enzymes
PyruvateCarboxy Kinase
PEPCarboxyKinase
Fructose 1,6 BiPhosphatase
Glucose 6 Phosphatase
**muscle dose not take part in Gluconeogenesis, only takes place in the liver, kidney & GI epithelium
Pellagra Diarrhea, Dermatitis, Dementia
Niacin Deficiency (Vit B3 deficiency)
Hartnups Disease
Malignant Carcinoid Syndrome
INH use
TLCFN Needed as co-factor for Pyruvate DH complex & Ketoglutarate DH complex
LCAT or PCAT Esterification of cholesterol: lecithin cholesterol acetyltransferase
Lecithin = Phosphatidylcholine, therefore phosphotidylcholine acetyltransferase
HMGCoA Reductase Rate limiting step in cholesterol synthesis
Changes HMGCoA Mevalonate
(-) by Lovastatin
Ketogenic amino acids Leucine & Lysine
Glucogenic amino acids Methionine, Threonine, Valine, Arginine, Histadine
Keto & Gluco amino acids Phenylalanine, Trytophan, Isoleucine
Carnitine Shuttle Feeds FA into the mitochondria for their consumption
Cori Cycle Keeps muscles working anaerobically.
Transfers lactate to the liver to make glucose which is sent back into the muscles for energy use
(-) Na
+
Pump (ATPase) Ouabain [(-) K
+
pump]
Vanadate [(-) phosphorylation]
Digoxin [ heart contractility]
TCA Cycle Products Citric Acid Is Krebs Starting Substrate For Mitochondrial Oxidation
Citrate Aconitate Isocitrate Ketoglutarate Succinyl Succinate Fumarate
Malate OAA
Cones Color vision. Contain Iodopsin = Red-Blue-Green specific pigment. For acuity.
Rods Contain Rhodopsin pigment. High sensitivity. Concentrated in the fovea. Night vision.
Gastrula Seen @ 3
rd
week: Ecto, Meso & Endo
Epiblast @ 2
nd
week: forms the primitive streak, from which Meso & Endo come from. Directly gives rise to
Ecto.
Sydenhams Chorea Post streptococcal infection. Necrotizing arteritis of the caudate, putamen, thalamus
(+) Frei Test Chlamydia trachomatis types L1, L2, L3 = Lymphogranuloma venereum
Sabourauds Agar Culture for all Fungi ieCulture Cryptococcus neofromans which is found in pigeon droppings
FMR1 Gene Defect Fragile X Syndrome: macro-orchidism; long face; large jaw; large everted ears; autism, mental
retardation
Barr Body Present in Kleinfelters: Male: XXY
Not present in Turners: Female: XO
Aortic Insufficiency Signs Traube Sign = Pistol shot sound over the femoral vessels
Corrigan pulse = water hammer pulse over coratid artery = aortic regurgitation
Scleroderma :CREST Calcinosis; Raynauds; Esophageal; Sclerodactyl; Telangiectasis
Cretinism Sporadic: bad T4 phosphorylation or developmental failure of thyroid formation
Endemic: no Iodine in diet: protruding belly & belly button
Hemochromatosis Triad Micronodular pigment cirrhosis; Bronze Diabetes; Skin pigmentation = due to Fe
3+
deposition
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Signature Drug Toxicities
Agranulocytosis 421. Clozapine, Chloramphenical
Aplastic Anemia 422. Chloramphenicol
423. NSAIDs
424. Benzene
Atropine-like Side Effects 425. Tricyclics
Cardiotoxicity 426. Doxorubicin
427. Daunorubicin
Cartilage Damage in Children 428. Fluoroquinolones (Ciprofloxacin & Norfloxacin)
Cinchonism 429. Quinidine
Cough 430. ACE Inhibitors
Nephrogenic Diabetes Insipidus 431. Lithium (Txt w/ Amiloride)
Disulfiram-like Effect 432. Metronidazole
433. Sulfonylureas (1
st
generation)
Extrapyramidal Side Effects 434. Antipsychotics (Thioridazine, Haloperidol, Chlorpromazine)
Fanconis Syndrome 435. Tetracycline
Fatal Hepatotoxicity (necrosis) 436. Valproic Acid
437. Halothane
438. Acetaminophen
Gingival Hyperplasia 439. Phenytoin
Gray Baby Syndrome 440. Chloramphenicol
Gynecomastia 441. Cimetidine
442. Azoles
443. Spironolactone
444. Digitalis
Hemolytic Anemia in G6PD-
deficiency
445. Sulfonamides
446. Isoniazid
447. Aspirin
448. Ibuprofen
449. Primaquine
Hepatitis 450. Isoniazid
Hot Flashes, Flushing 451. Niacin
452. Tamoxifen
453. Ca
++
Channel Blockers
Induce CP450 454. Barbiturates Phenobarbital
455. Phenytoin
456. Carbamazepine
457. Rifampin
Inhibit CP450 458. Cimetidine
459. Ketoconazole
Interstitial Nephritis 460. Methicillin
461. NSAIDs (except Aspirin)
462. Furosemide
463. Sulfonamides
Monday Disease 464. Nitroglycerin Industrial exposure tolerance during week loss of tolerance during weekend headache, -
ach, dizziness upon re-exposure
Orange Body Fluids 465. Rifampin
Osteoporosis 466. Heparin
467. Corticosteroids
Positive Coombs Test 468. Methyldopa
Pulmonary Fibrosis 469. Bleomycin
470. Amiodarone
Red Man Syndrome 471. Vancomycin
Severe HTN with Tyramine 472. MAOIs
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SLE-like Syndrome 473. Procainamide
474. Hydralazine
475. INH
Tardive Dyskinesia 476. Antipsychotics (Thioridazine, Haloperidol, Chlorpromazine) Clozapine: only antipsychotic to not
477. give you tardive dyskinesia
Tinnitus 478. Aspirin
479. Quinidine
Microbiology
Lactose formers 1. CEEK
2. Citrobacter
3. Enterobacter
4. E.Coli (K1 capsule most important)
5. Klebsiella
Non lactose formers 6. SHYPS
7. Shigella
8. Yersinia enterolytica (AKA Pestis)
9. Proteus
10. Salmonella
May lack color 11. These rascals may microscopically lack color:
12. Treponema
13. Ricksetta
14. Mycobacterium
15. Mycoplasma
16. Legionella
17. Chlamydia
cAMP 18. CAPE
19. Cholera
20. Anthracis (Poly D glutamate capsule)
21. Pertusis (via Gi)
22. E.coli (LT enterotoxin)
Have Capsules [ie are Quellung
Reaction (+)]
23. Some killers have pretty nice capsules
25. Klebsiella
26. HiB
27. Pseudamona Aeroginosa
28. Neisseria meningitis
29. Cryptococcus neoformans (only encapsulated fungal pathogen)
Dimorphic Fungi 30. Can Also Have Both Shapes
31. Cocciodes
32. Aspergillus
33. Histolpasma
34. Blastomyces
35. Sprothrix schenkii
Have Prophage 36. OBED
37. O = Salmonella
38. B = Botulinum
39. E = Erythrogenic strep
40. D = Diptheria
Spore Forming Bacteria 41. Bacilus & Clostridium (have calcium di-picolinate)
IgA Proteases 42. Neisseria, Haemophilus, S. pneumoniae
Widal Test 43. Salmonella (Salmonella begins in the ileocecal region) agglutination indicates Abs to O, H, Vi Salmunella Ags
Waysons Stain 44. Yersinia
Pneumonic Plaque Transmission 45. Person to person cf w/ Bubonic plaque that was via infected flea
Splenectomy 46. Predisposes to septicemia
Invasins 47. Yersinia pseudotuberculosis
Fusiform 48. Vincents trench mouth
Motile:
make H2S
Non Motile: noH2S
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S. viridans 49. Dextran mediated adherence
Obligate Aerobes 50. Pseudomonas & Mycobacterium
Obligate Anaerobes 51. Clostridium, Actinomyces, Bacteroides
Staph aureus 52. A Protein, Catalase +/ Coagulase +
Spirochetes 53. Treponema, Borrelia, Leptospira
Non Motile Gram (+) Rods 54. Corenybacterium D & Nocardia
Acid Fast Organisms 55. Mycobacterium; Cryptosporidium; Nocardia (partially); Legionella micdadei; Isospora
Pigment Producing Bacteria 56. Serratia red (can cause pseudohemoptysis)
57. Pseudomonas A piocyanin blue/green
58. Staph Aureus yellow Protein A
59. Mycobacteria photo/scoto chromogenic caritinoid yellow/orange
60. Corneybacterium D black/gray pseudomembrane plaque in throat
61. Bacteroides (Porphyromonas) melaninogenicus black (heme)
62. E. coli irredescent green sheen
Bacterial Morphology 63. Pneumococci lancet shaped diplococci
64. Neisseria kidney bean shaped diplococci
65. Camphylobacter gulls wings/comas
66. Vibrio Cholera coma shaped
67. Corneybacterium D club shaped (nonmotile, G+Rod)
68. Yersinia safety pin seen in Waysons stain
Inclusion Bodies 69. Rabies Negri bodies intracytoplasmic
70. Pox virus Guarnieri intracytoplasmic & acidophilic
71. CMV Owls eyes intracytoplasmic & intranuclear
72. HSV Cowdry bodies intranuclear
Schistosoma Japonicum Monsoni 73. Intestinal contact w/ bad water
Schistosoma Haematolium 74. Vesicular contact w/ bad water
Non Human Schistosom 75. Swimmers itch contact w/ bad water
Clonorchichis 76. Chinese liver fluke eating raw fish. Txt: Praziquantel
Fasciola Hepatica 77. Sheep eating raw fish. Txt: Praziquantel
Fasciola Biski 78. Giant intestinal flukes eating raw fish. Txt: Praziquantel
Paragonimus Westermani 79. Lung fluke eating raw fish. Txt: Praziquantel
Oxidase (+) 80. Neiserria and most Gram (-)s
Micro Aerophilic 81. Camphylobacter & Helicobacter
Urease (+) 82. All Proteus can cause Staghorn/Struvite calculi (NH4
-
Mg
2-
stones): alkaline urine
83. Ureaplasma
84. Campylobacter pylori (Helicobacter)
85. Cryptococcus
86. Nocardia
Coagulase (+) 87. Staph A & Yersenia pestis
Obligate Intracellular Bacteria 88. Chlamydia Pistacci (Chlamydia do not make own ATP); Mycobacterium Leprae; all Rickettsia except
Roachalimea (make suficient ATP to survive)
Protozoa 89. Plasmodium; Toxoplasma ghondi; Babesin; Leishmania; Trypanosoma Cruzi
Obligate Non Intracellular
Parasites
90. Treponema palidum & Pneumocystis Carinii (cannot be cultured on inert media but can be found
extra cellularly in the body)
Haemophilus Factors 91. X = Protoporphyrin & V = NAD
All cocci are 92. Gram (+) except for Neisseria & Moraxella
Eaton Fried Eggs 93. Mycoplasma pneumoniae has fried egg colonies on Eaton agar (needs cholesterol)
Mycoplasma 94. No cell wall. Membrane has cholesterol. Smallest living bacteria.
95. P1 protein inhs ciliary action
96. Fried egg colonies
97. Atypical pneumonia young adults
Sabrands 98. Fungal media
Malassazia furfur 99. Spaghetti & meat ball
Measles 3Cs 100. Cough Coryza Conjunctivitis. Can also have photophobia
101. May lead to subacute Sclerosing Panencephalitis
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Non Motile Bacilli & Clostridium 102. B. Anthracis & C. Perfringens
Bloody diarrhea agents 103. EIEC EHEC Shigella - Yersenia enterocolitica Entaemeba histolytica Salmonella
Campylobacter jejuni
YW-135CA 104. N. meningitidis vaccine capsualr polysaccharide strains
Indian Ink 105. Cryptococcus neoformans
Naegleria causes 106. Colonization in the nasal passages after swimming
Need Cysyeine for growth 107. Ella likes cysteine:
108. Francisella
109. Brucella
110. Legionella
111. Pasturella
Endotoxins, G(+) or G(-) 112. Gram (-): N. meningitidis
Ecthyma Gangrenosum, seen w/ 113. Pseudomonas aeroginosa. Target shaped skin lesions w/ a black center and red ring surrounding
the lesion
Endospores G(+) 114. Gram (+): Bacillus & Clostridium made up of dipicolinate & Keratin
Multi Brain Abscess 115. Nocardia
Single Brain Abscess 116. Actinomyces israelli
risk for Strep pneum Infection 117. Asplenic; Sickle cell anemia; immunocompromising illness
Hemolysis/Optochin Sensitive 118. Strep. Pneumoniae
Hemolysis/Optochin Resistant 119. Strep. Viridans (Subacute Endocarditis)
Staph. Saprophyticus 120. Novobiocin Resistant (UTIs)
Staph. Epidermidis 121. Novobiocin sensitive (Endocarditis in IVDUs)
Hemolysis/Bacitracin Sensitive 122. Strep. Pyogenes (pharyngitis; Scarlet fever; cellulitis; impetigo; Rheumatic fever))
123. Hyaluronic capsule; non-motile; M proteins; Endotoxin A
Hemolysis/Bacitracin Resistant 124. Strep. Agalactiae (Diabetes predisposes to infection)
EFII Ribosylation 125. Diphtheria toxin & Pseudomonas exotoxon A
Bacillus Anthracis: 3 toxins
(work via adenylate cyclase)
126. Protective Antigen (PA)
127. Lethal Factor = toxic to macrophages
128. Edema Factor = cAMP
Woolsorters Disease 129. Bacillus anthracis. DOC: Penicillin
Grows in Rice 130. Bacillus Cereus
Clostridium Perfringens 131. Double Zone Hemolysis (test)
132. Lecithinase: toxin = lyses RBCs
133. 80% of gas gangrene (myonecrosis) cases
Clostridium Difficile 134. 2 Toxins: Enterotoxin (Exotoxin A) & Cytotoxin (Exotoxin B)
135. Pseudomembranous colitis (can be precipitated by clindamycin/ampicillin)
Spastic Paralysis toxin 136. Clostridium Tetani toxin
Clostridium Botulinum 137. Bad canned foods have neurotoxin = flaccid paralysis (block Ach release)
Infant Botulinum 138. Floppy Baby Syndrome. Pre formed toxin in honey
Thayer Martin Agar 139. Neisseria ID
DOC for N. gonorrhoeae 140. Ceftriazone
K1 E. Coli Capsular Ag 141. Related w/ neonateal meningitis
The As of Klebsiella 142. Alcoholics
143. Aspiration pneumonia
144. Abscesses in the lungs
Rice H2O Diarrhea 145. Vibrio Cholera: metabolic acidosis
Raw seafood intoxicaiton 146. Vibrio parahemolyticus
Helicobacter Txt 147. Bismuth salts; Metronidazole; Tetracycline (or amoxicillin)
risk of P. aeroginosa infection 148. Burn patients & Cystic fibrosis
Contact lens infection 149. Pseudomonas aeroginosa
Cat Bites 150. Pasteurella multocida
Undulant Fever 151. Brucella
Bordet Gengou Agar 152. Bordetella pertusis ID
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Lowenstein-Jensen medium 153. M. tuberculosis ID
Cat Scratch Disease 154. Bartonella henselae. Leion can resemble Kaposis sarcoma.
155. Toxoplasmosis
Pink Eye 156. Adenovirus (type 8)
True Hemaphrodite 157. Testes & Ovaries are present
Pseudo Hemaphrodite 158. External genitalia does not coincide w/ gonads
Male Pseudo Hemaphrodite 159. Testicular Feminization
HLA Genes Location 160. 6p
Parvovirus B19 161. Fifth Disease: Erythema Infectiosum (ssDNA). Linked w/ sicle cell anemia
Interferon MOA 162. Inhibits viral replication (translation or transcription)
Acute Hemorrhagic Conjunctivitis 163. Seen w/ infections from Enterovirus & Coxsackie A
Parainfluenza Causes 164. Croup (Laryngotracheobronchitis)
Swimming Pool Conjunctivitis 165. Adenovirus (types 3 & 4)
RSV 166. Bronchiolitis in infants
Removed tonsils, find what virus 167. In 80%, Adenovirus. In the immunosuppressed, activation can occur
Bone Fever 168. Dengue: Group B Togavirus, from the Arbovirus, transmitted by mosquitos
HbsAg 169. Appears in blood soon after infection, before onset of acute illness
170. Disappears w/in 4-6 months after the start of clinical illness
HbeAg 171. Appears early acute phase, indicates higher risk of transmitting the disease
172. Disappears before HbsAg is gone
Anti-Hbc 173. Present in beginning of clinical illness
174. Seen in the window phase
Filamentous Bacteria 175. Actinomycetes = Nocardia; Actinomyces; Streptomyces
Listeria contaminates 176. Milk, cheese, vegetables (coleslaw) in recent infections
Shiga like Toxin 177. E. Coli 0157/H7: Hemorrhagic colitis & Hemorrhagic uremic syndrome
Necrotizing Fasciitis 178. Group A Streptococci
Relapsing Fever 179. Borrelia recurrentis
Lofflers Medium 180. Corneybacterium diphtheriae
Chlamydiae Developmental Cycle 181. Elementary Body: infeccious particle that Enters the cell
182. Reticulate Body: made from elementary body. Replicates, differentiates and releases elementary
bodies to infect other cells
183. W/ infection you will see Glycogen containing inclusions
184. Cell wall lacks muramic acid
Trench Fever 185. Rochalimaea quintana
Spotted Fever Members 186. Rickettssia rickettsii (RMSF) & R. akari (rickettsial pox) in the U.S.
187. R. sibirica (tick typhus in China) & R. australis (typhus in Australia)
Thrush Txt 188. Nystatin txts candidiasis of the mouth
Rose Bush Thorns 189. Have Sporothrix schenckii
Contact lens solution infection 190. Acanthamoeba
Filiariasis Causant 191. Wucheria bancrofti (infection aka elephantitis & wucheriasis
Freshwater lake infection 192. Causes amebic meningoencephalitis due to Naegleria fowleri
Reduviid bug bite 193. Transmits Trypanoma cruzi (Chagas disease): Romanas Sign
Schistosoma Haematobium causes 194. Bladder calcificaiton & cancer
Schistosoma Mansoni causes 195. Presinusoidal HTN, splenomagaly, esophageal varices
Snail, intermediate host of 196. Schistosomiasis
Ixodes scapularis transmits 197. Babesia (clinically rembles malaria) & Borelia burgdorferi
Nantucket Protozoa 198. Babesia microt
Infection by Reduviid Bug 199. Trypansoma cruzi: Chagas Disease
Infection by TseTse Fly 200. Trypansoma brucei gambiense & rhodiense: African Sleeping Sickness
Infection by Sandfly 201. Leishmaniasis: Mucocutaneous Diseases by L. braziliensis & Visceral Disease by L. donovani & Dermal
Leishman by L. tropica, mexicana, peruviana
Infection by Ixodes Tick 202. Babesia microti: Babesiosis & Borrelia burgdorferi: Lyme Disease
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Infection by Anopheles Mosquito 203. Malaria
Trophozoites w/ Face-Like
Appearance
204. Giardia lamblia
Nonseptate Hyphae 205. Zygomycosis: Rhizopus & Mucor. Only mycosis w/o septate. Infect Ketoacidotic Diabetics.
Histoplasmosis Geography 206. Ohio, Mississippi, Misouri River valleys
Coocidioidomycosis Geography 207. Southwestern deserts, California
Blastomycosis Geography 208. States east of Mississippi River
Paracoccidioidomycosis
Geography
209. Latin America
Roseola Infection, aka 210. Exanthema Subitum: Sixth Disease (Human Herpes Virus-6 dsDNA, enveloped)
Herpangina 211. Hand-Foot-and-Mouth Disease: Coxsackie A (Picornavirus +ssRNA)
Orthomyxovirus 212. ssRNA, enveloped virus.
213. Spike Glycoproteins (peplomeres): HA = Hemagluttinin & NA = Neuraminidase. These peplomeres
are what give the virus antigenis variation
214. Influenza A & B
Paramyxovirus 215. RNA, enveloped. Most common cause of respiratory infections in kids
216. Mumps
217. Croup(Parainfluenza virus)
218. Rubeola(Measles virus)
219. RSV
Togavirus 220. +ssRNA, enveloped
221. 3 Day Measles: German Measles: Rubella/ Rubivirus
222. Encephalitis viruses: Alphaviruses: Eastern (more severe) and Western Equine Encephalitis
Flaviviris 223. Dengue Fever icterus & hemorrhage w/ blac vomit
224. Yellow fever
225. St. Louis Encephalitis no hepatitis or hemorrhage
Bunyavirus 226. ssRNA, enveloped
227. California Encephalitis severe bifrontal headaches
228. Hantavirus hemorrhagic fever w/ acute resp. distress syndrome
IgA Protease Activity 229. H. Influenzae (needs factors V & X for growth)
231. N. meningitidis
232. N. gonnorhoae
233. W/ this activity these bugs are able to colonize the oral mucosa.
Diphtheria: ABCDEFG 234. Adenopathy
235. Prophage encodes the exotoxin
236. Corneybacteria is Club shaped
237. Diphtheria
238. Elongation Factor II
239. Granules (metachromatic)
Only ssDNA 240. Parvovirus: Part of a virus
Only dsRNA 241. Reovirus, RepeatOvirus
Naked RNA 242. Naked for CPR: Calcivirus; Picornovirus; Reovirus
2 circular DNAs 243. Papovavirus & Hepadnavirus
BK 244. Papovavirus. Seen in kidney transplant patients (causes renal disease)
Hepadna, Retrovirus? 245. No, but has reverse transcriptase
Picornovirus: PERCH 246. Poiliovirus; Echo; Rhino; Coxsackie; Hep A
Hemorrhagic Fevers Filovirus & Bunyavirus (Hantavirus)
Segmented viruses All are RNA: Orthomyxo; Arena; Bunya; Reo
Eclipse Phase No internal virus. 1 total virus per cell
Latent Phase No external virus. Extracellular virus found
Naked Capsid Virus Nucleocapsid. DNA or RNA + Structural proteins
Enveloped Virus Membrane. Nucleocapsid + Glycoprotein
Interferon Non virus specific. Works by RNA endonuclease = digests viral DNA + inh viral prot synth
AIDS structural prots Gag, pol, env
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AIDS regulatory prots Tat, rev, nef
AIDS gp41 env prot Transmembrane
AIDS gp120 env prot Surface
AIDS p17 gag prot Matrix
AIDS p24 gag prot Capsid
AIDS p7p9 gag prot Nucleocapsid
DNA Viruses A = Adeno
E Brick. Rep H = Herpes
In Cyto H= Hepadna
AH H PPP --- ico Rep in Nuc P = Pox
P = Parvo
SS P = Papova
Circ
(+) RNA Viruses E C = Calici
P = Picorno
R = Reo
C P R F T C ------ ico (+) Linear. F = Flavi
No segment. Rep in Cyto T = Toga
Helical C = Corona
R-Tase &
Rep in Nuc
(-) RNA Viruses 8 F = Filo
2 3 O = Orthomyxo
R = Rhabdo
F O R P A B ---- (-) E Helical P = Paramyxo
Linear. Non seg. A = Arena
B = Bunya
Bullet
Anti sense
Hepatitis Window Period After HbsAg disappears & Before HbsAb appears
Hepatitis A B C D E
Picorna Hepadna Flavi Delta Calici
Downey Type II cells EBV
Infection by Aedes Mosquito Yellow Fever: Flavivirus: Black vomit, jaundice, high fever
Hot T-Bone stEAk: ILs IL1 = Temp: HOT
IL2 = stimulate T cells
IL3 = stimulate Bone Marrow stem cells growth & differentiation (GM CSF)
IL4 = stimulate IgE (& IgG)
IL5 = stimulate IgA (& eosinophils)
ILs Secreted by CD4s IL2, IL4, IL5, IFN gamma
ILs Secreted by Macrophages IL1 & TNF
C5a Neutral chemotaxis.
When it is w/ C3a, participates in anaphylaxis
C5 Convertase When both Alternative and Classic pathways come together
Alternative: C3b, Bb, C3b + C3a C5
Classic: 2b, 3b, C3a + C4b C5
Only Richettssia not Intracellular
Quintana
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Plasmodium Life Cycle Sporozoites: from blood to liver
Primary tissue schizont
Trophozoites: in RBC
Erythrocytic schizont
Merozoite: ruptured RBC
Gametozyte
Zygote: inside the mosquito
Acanthamoeba Star shaped cysts
Mucor, Rhizopus, Absidia Nonseptate, filamentous, 90 degree branching, indian in, capsular halos
Cryptococcus Neoformans Monomorphic
Candida Yeast normally, pseudo & true hyphae in tissue infections
Aspergillus Fumigatum 45 degree branching point, asocd w/ cystic fibrosis & burns pt
Cocciodes Hyphae in wild. Artroconidia. Arthocondida & Hyphae. Sherules w/ endospores
Histoplasma Cap Hyphae in wild. Microcondida w/ tuberculate macrocondida. Fac intracellular. In the tissue its a yeast
w/ a small neck.
Blastomycosis Hyphae in wild
Sporothrix Schenkii Hypahe in wild. Potas iodide in milk. Pneumonia in alcoholics.
PCP Obligate parasite. Kills type I pneumo cells. Ground glass
Gram (-) Bugs w/ Exotoxins E. Coli; V. Cholera; Bordetella Pertussis
Dermatophytes Trichophyton: SHN
Microsporium: SH
Epidermophyton: SN
Tinea tavus: permanent hair loss
Transmission Diagnosis
E. Histolitica Cysts Trophozoites or cysts in stool
Giardia Cysts Trophozoites or cysts in stool
Cryptosporidium Cysts Acid fast oocysts
Balantium C. Cysts Trophozoites or cysts in stool
Trichomonas V. Trophozoites Motile trophozoites
Fever Fever Spike
Vivax Benign 3 degrees 48h Enlarged Host Cell
Ovale Benign 3 degrees 48h Oval/Jagged
Malariae 4 degrees of Malarial 72hrregular Crescent
Falciparum Malignant 3 degrees
Miscellaneous
1. Fastest growing tumor Burkitts
2. PEs are found in half of all autopsies
3. Courvoisiers Law: tumors that obstruct the common bile duct cause enlarged gallbladders, but obstructing
gallstones do not (too much scarring), so if you can palpate the gallbladder youe probably looking at cancer.
4. Only DNA virus to replicate in cytoplasm: Pox
5. Only RNA virus to replicate in nucleus: Influenza
6. Bacillus anthracis has the only protein capsule
7. Bordetella pertussis (Whooping Cough) elicits lymphocytosis rather than granulocytosis
8. Bronchioalveolar carcinomas grow without destroying the normal architecture of the lung
9. Cryptococcus neoformans often lacks a capsule and, when stained with GMS, looks just like Pneumycistis carinii,
except that Cryptococcus lacks the prominent nucleoli.
10. Weil Felix reaction: (+)R. rickettssi & (+)Proteus vulgaris & P. mirabilis
11. Treponema pallidum (Syphilis) tests: 1)VDRL 2)FTA-Abs: most widely used 3)TPI (immobilization test most
expensive but the Gold Standard)
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36
Cytokine Source Function
IL 1 12. Monocytes, macrophages Stimulates T cell proliferation & IL2 produciton
IL 2 13. Macrophages, T & NK cells Stim prolif of B, T & NK cell
IL 3 14. T cells GF of tissue mast cells & hematopoietic stem cells
IL 4 15. T cells growth of B & T cells/ HLA II Ags
IL 5 16. T cells Maturation of B plasma cell
IL 6 17. T cells, monocytes Maturation of B & T cell/ (-) fibroblasts
IFN 18. B cells, macrophages Antiviral activity
IFN 19. Fibroblasts Antiviral activity
IFN gamma 20. T & NK cells Antiviral activity, (+) macrophages, HLA II Ags
TNF 21. Macrophages, T & NK cells T cell prolif, IL 2 prod, cytotoxicity
TNF 22. T cells T cell prolif, IL 2 prod, cytotoxicity
Tumor Suppressor Genes
Genes Chrom. Associated Tumors
VHL 3p Von Hippel Lindau, Renal Cell CA
APC 5p Familial adenomatous polyposis, Colon CA
WT-1 11p Wilms tumor
Rb 13q Retinoblastoma, Osteosarcoma
BRCA-2 13q Breast CA
p53 17p Most human Cas
NF-1 17q Neurofibromatosis type 1
BRCA-1 17q Breast CA, Ovarian CA
DCC 18q Colon & Stomach CA
DPC 18q Pancreatic CA
NF-2 22q Neurofibromatosis type 2 = bilateral acoustic neuroma
Physio Equations:
Resistance in Series: Add all
Resistance in Parallel: Invert the answer
RENAL:
Filtration Fraction =
RPF
GFR
GFR: Glomerular Filtration Rate RPF: Renal Plasma Flow
Filtered Load = GFR x [Conc] Excretion Rate = [Urine] x VelUrine
Clearance =
] [
) ( ] [
Plasma
Urine xVel Urine
or
] [Plasma
Excretion
Clearance of PAH = [ERPF] ERPF: Eff renal plasma flow
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37
Renal Blood Flow =
Hct
ERPF
1
Free Water Clearance = VelUrine -
) (
) ( ) (
osm P
urine xVel osm Urine
CARDIO:
CO = HR x SV CO =
difference VO PulmonaryA
consumed O
2
) ( 2
Pulse Pressure = Systolic Diastolic

MAP = Diastolic + 1/3 Pulse Pressure CO =
TPR
MAP
MAP = TPR x CO F =
R
P P 2 1
LUNGS:
PAO2 = (760 47) FO2 -
R
PACO2
Where:
FO2 = [O2] PACO2 = Alv. Press. Of CO2 R = Resp. Exchange Ratio
consumed O
produced CO
2
2
.8 or 1
Flow =
difference AtoVO
consumed O
2
2
Velgas Diffusion =
Thickness
Area
x Gas Diffusion Constant x Difference of Partial Press
VentTot = VentTidal x #of Respirations VentAlv = (VentTidal VentDead) x # of Respirations
Compliance =
ess
Vol
Pr
P =
Radius
Tension
1.0 = Va/Q Diffusing Capacity =
2 PACO
COuptake
Resp Doubles: 150mmHg & 40mmHg New PCO2 = 20 New PO2 = 170
1 www.brain101.info
Neuro Test
1. A 63-year-old man complains of trouble swallowing and hoarseness. On physical exam, he is noted to have ptosis
and a constricted pupil on the left, and a diminished gag reflex. Neurological examination shows decreased pain and
temperature sensation on the left side of his face and on the right side of his body. Which of the following vessels is
most likely occluded?
A. Anterior inferior cerebellar artery (AICA)
B. Anterior spinal artery
C. Middle cerebral artery (MCA)
D. Posterior cerebral artery (PCA)
E. Posterior inferior cerebellar artery (PICA)
2. A 3-year-old child is brought to the emergency room by her concerned parents. They state the girl has been
complaining of a severe headache and has had two episodes of vomiting. On physical examination, there is bilateral
papilledema and an impaired level of consciousness. Emergency contrast CT scan demonstrates displacement of the
ventricular system by a multilocular "mass" with well-defined white high-attenuation rings around black low-
attenuation centers. The lesion involves the cerebellum. To which of the following conditions is this lesion most
likely related?
A. Bacteremia following tooth extraction
B. Bacterial meningitis
C. Lung abscess
D. Otitis media
E. Sinusitis
3. An 80-year-old woman dies after a long history of progressive memory loss, apraxia, and recurrent episodes of
confusion. In the last months of life she was bedridden and unable to recognize familiar faces and objects. The
pathologist identifies numerous flame-shaped intracytoplasmic inclusions in neurons of the neocortex and
hippocampus. These consist of paired helical filaments (PHFs) on electron microscopy. Which of the following
biochemical changes most likely accounts for the development of PHFs in this condition?
A. Abnormal degradation of amyloid precursor protein (APP)
B. Abnormal phosphorylation of tau
C. Accumulation of advanced glycosylation end (AGE) products
D. Increased expression of APP
E. Precipitation of insoluble a-tubuli
4. A 54-year-old white male presents with gradual onset of mild dementia, ataxic gait, and startle myoclonus. An
MRI scan is normal, and an examination of his cerebrospinal fluid reveals no abnormalities, but the patient's EEG is
remarkable for recurrent bursts of high-voltage slow waves. Over the next 6 months, the patient's dementia rapidly
worsens, accompanied by general hypertonicity and profound dysarthria. The patient dies shortly thereafter. Which
of the following is the mostly likely neuropathological finding on autopsy?
A. Cerebellar hyperplasia
B. Diffuse spongiform change
C. Multiple lacunar infarcts
D. Negri bodies
E. Neurofibrillary tangles
5. In which of the following neurodegenerative conditions would you expect to observe the phenomenon known as
anticipation?
A. Familial Alzheimer disease (FAD)
B. Familial amyotrophic lateral sclerosis (ALS)
C. Huntington disease
D. Pick disease
E. Progressive supranuclear palsy
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6. A 37-year-old woman is in a serious automobile accident and sustains a closed head injury. She does not
immediately seek medical attention, but is brought to the emergency room two hours later by her brother. On
physical examination, there is mydriasis and loss of the pupillary light reflex. Several hours later, she is unable to
follow a flashlight with her eyes. Which of the following types of herniation is most likely occurring in this patient?
A. Cerebellar tonsils into the foramen magnum
B. Cerebellum upward past the tentorium
C. Cingulate gyrus under the falx
D. Medulla into the foramen magnum
E. Temporal lobe under the tentorium
7. A 10-year-old boy with history of epilepsy and mental retardation is brought to a specialty clinic for evaluation.
Physical examination is remarkable for several ovoid hypopigmented areas on the trunk and large numbers of red
and yellow papules on the face, particularly near the mouth. Biopsy of the papules demonstrates angiofibromata.
This patient is most likely to have which of the following central nervous system pathologies?
A. Acoustic neuromas
B. Capillary hemangioblastomas
C. Herniation of cerebellar tonsils into foramen magnum
D. Large cortical hamartomas
E. Leptomeningeal angiomatosis
8. A 25-year-old man presents with bilateral hearing loss. MRI reveals bilateral tumors within the cerebellopontine
angles. Surgery is performed, and the tumors are removed. Both are found to be neurilemomas ("schwannoma").
Which of the following is the most likely diagnosis?
A. Metastatic disease
B. Multiple sclerosis
C. Neurofibromatosis type 1
D. Neurofibromatosis type 2
E. Tuberous sclerosis
9. Which of the following is the most frequent primary malignant tumor of the CNS?
A. Glioblastoma multiforme
B. Medulloblastoma
C. Meningioma
D. Oligodendroglioma
E. Pituitary adenoma
10. A child develops a tumor of the cerebellum. Biopsy reveals evidence of both neuronal and glial differentiation.
Which of the following is the most likely diagnosis?
A. Astrocytoma
B. Glioblastoma multiforme
C. Medulloblastoma
D. Meningioma
E. Oligodendroglioma
11. Which of the following nuclei undergo transsynaptic degeneration as a consequence of primary degeneration
affecting dorsal root ganglia in Friedreich ataxia?
A. Cerebellar dentate nucleus
B. Contralateral gracile and cuneate nuclei
C. Ipsilateral gracile and cuneate nuclei
D. Pontine nuclei
E. Vestibular nuclei
12. An adult patient presents with persistent headaches. A CT scan of the head demonstrates a 2-cm spherical mass
at the junction of the white and gray matter of the lateral aspect of the cerebral hemisphere. Which of the following
would most likely produce this lesion?
A. Astrocytoma B. Ependymoma
3 www.brain101.info
C. Glioblastoma multiforme
E. Metastatic carcinoma
D. Meningioma
13. Which of the following regarding dementia is true:
A. To make the accurate diagnosis of dementia memory impairment is not enough, impairment in
every day activities is also required.
B. Patients with Alzheimer's disease often have problems with balance and abnormal gait.
C. Neuronal loss is not observed in Alzheimer disease
D. Finding Lewy bodies is often diagnostic postmortem for Alzheimer's disease
E. Progressive Supranuclear palsy is often associated with symptoms of visual hallucinations
14. A 34-year-old man with AIDS suddenly falls to the floor and has a tonic-clonic seizure. His concerned friends
call paramedics, who take him to the hospital. On arrival at the hospital he is conscious, but confused. Physical
examination is remarkable for cachexia and oral thrush. Neurological examination reveals isolated weakness of
lateral gaze on the right. MRI reveals multicentric mass lesions in the brain and meninges. One of the masses is
biopsied and appropriate immunohistochemical stains are performed. From which of the following cell types did the
masses most likely derive?
A. Astrocyte
B. B lymphocyte
C. Ependymal cell
D. Melanocyte
E. Oligodendrocyte
15. Which of the following nuclei play a central role in auditory reflexes and descending efferent pathways?
A. Superior Olivary Nucleus
B. Inferior Olivary Nucleus
C. Cochlear Nucleus
D. Inferior Colliculus
16. A 63-year-old man has taken an antidepressant for the past 3 months. He is on no other medications and is
generally in good health. After attending a graduation party for his son at which he consumes wine, bread, and
cheese, he is rushed to the emergency room with tachycardia, headache, and a blood pressure of 200/100 mm Hg.
Which antidepressant is he most likely taking?
A. Fluoxetine
B. Imipramine
C. Phenelzine
D. Trazodone
E. Venlafaxine
17. Which of the following statements regarding the nasal anatomy is false?
A. Obstruction of the ostiomeatal complex results in congestion of the Anterior ethmoid, frontal
and maxillary sinuses.
B. The most common site of bleeding is from Kesselbach's plexus
C. The primary form of treating allergic rhinitis is Avoidance
D. Triad asthma (which includes the symptoms of asprin sensitivity, asthma, and polyps) should
lead to a suspicion of cystic fribrosis.
E. All of the above statements are true.
18. Wegener's disease is associated with which of the following nasal conditions?
A. Saddle Nose Deformity
B. Septal perforation
C. Allergic Rhynitis
D. Cystic Fibrosis
E. A and B
4 www.brain101.info
F. A and D
G. B and D
H. B and C
19. A 52-year-old female complains of sudden visual abnormalities. Her history reveals a 30 pack-year history of
smoking, hypertension, and hypercholesterolemia. A head CT shows a lesion in the right occipital lobe and an
angiogram reveals an embolic stroke of the right posterior cerebral artery. What type of visual deficit is she most
likely experiencing?
A. Bitemporal hemianopia
B. Central scotoma
C. Left homonymous hemianopia
D. Left superior quadrantanopia
E. Right homonymous hemianopia
F. Right superior quadrantanopia
G. Total left eye blindness
H. Total right eye blindness
20. A 38-year-old woman with multiple sclerosis (MS) has stable neurologic deficits resulting from old
demyelinated plaques. Which of the following histopathologic features would be prominent in this patient's old
plaques?
A. Complete loss of axons
B. Gliosis
C. Histiocytic infiltration
D. Lymphocytic infiltration
E. Myelin breakdown
21. A patient with long term severe hypertension develops progressive dementia. CT scan of the head demonstrates
a diffuse loss of deep hemispheric white matter. Which of the following terms best describes the pathological
process that is occurring?
A. Anemic infarcts
B. Hemorrhagic infarcts
C. Hypertensive encephalopathy
D. Lacunae
E. Subcortical leukoencephalopathy
22. A 40-year-old man with adult polycystic kidney disease is brought to the emergency room in a coma. CT scan of
the head demonstrates a subarachnoid hemorrhage without parenchymal hemorrhage. Which of the following is the
most likely source of the bleeding?
A. AV malformation
B. Bridging veins
C. Charcot-Bouchard aneurysm
D. Circle of Willis
E. Middle meningeal artery
23. During a boxing match, a contestant is "knocked out" by a blow to the lateral skull. He recovers after a few minutes, and is
asymptomatic for the next 12 hours. He then develops a severe headache, changes in mental status, nausea, and vomiting. Which
of the following is the most likely diagnosis?
A. Basilar skull fracture
B. Epidural hemorrhage
C. Intracerebral hemorrhage
D. Subarachnoid hemorrhage
E. Subdural hematoma
24. A 60-year-old man presents to a physician because of difficulty in reading and coming down stairs, which he attributes to an
inability to "look down." Physical examination reveals that the patient looks around by moving his head rather than his eyes and
also shows a distinctive axial rigidity of neck, trunk, and proximal limb muscles. He shows poverty of movement and dysarthric
speech. Mentally, the patient responds very slowly but has better memory and intellect than are initially apparent. Which of the
following pathologic findings of the brain would most likely be present?
A. Depigmentation of the substantia nigra and locus ceruleus
B. Diffuse cortical atrophy with relative sparing of primary motor and sensory areas
C. Selective frontal and temporal lobe atrophy
D. Striking degeneration of the caudate nucleus
E. Widespread neuronal loss and gliosis in subcortical sites
5 www.brain101.info
25. A neurological examination of a 47-year-old woman reveals a normal corneal reflex in her right eye, but no consensual corneal
reflex in her left eye. Which of the following additional findings might be expected?
A. Absence of pupillary light reflex of the left eye
B. Hyperacusis of the left ear
C. Inability to abduct the right eye
D. Loss of pain and temperature of the left face
E. Loss of taste from the anterior two-thirds of the right tongue
F. Ptosis of the left eye
26. A 64-year-old man begins to show behavioral changes and irritability, and is found wandering in the park near his home. On
neurological examination, there is evidence of mild aphasia and cognitive dysfunction, but motor function is preserved. CT scan of
the head demonstrates selective atrophy of the cortex of the frontal lobes. Which of the following is the most likely diagnosis?
A. Alzheimer's disease
B. Friedreich's ataxia
C. Huntington's disease
D. Parkinson's disease
E. Pick's disease
27. Careful testing of the visual fields in a patient complaining of difficulty reading demonstrates a central scotoma involving one
visual field. This defect is most likely due to a lesion involving which of the following structures?
A. Macula
B. Optic chiasm
C. Optic radiations in the parietal lobe
D. Optic radiations in the temporal lobe
E. Optic tract
28. In the evaluation of a 73 year old man who complains of frequent confusion and disorientation. His neighbor has noticed that
he no longer is keep up his garden and is concerned about his frequent wandering in the neighborhood. She also noticed that he
often looks disheveled, which is particularly abnormal for him. All of the following lab exams would be relevant in the
assessment for dementia except:
A. Blood sample for CBC, glucose, electrolytes and LFT's.
B. Imaging studies such as CT and MRI
C. Urinanalysis
D. Presenilin (sequencing)
E. All are appropriate
29. A 76-year-old female presents with complaints of difficulty reading. Ophthalmologic examination is remarkable for bilateral,
white opacifications in her eyes, consistent with cataract formation. In which of the following structures are the opacifications
located?
A. Aqueous humor
B. Cornea
C. Lens
D. Optic nerve
E. Retina
30. A middle-aged woman comes to her physician's office with complaints of visual difficulties. A review of systems and physical
examination are unremarkable except for her eye exam. When a light is shined in her right eye, there is no pupillary response in
either eye. However, upon shining a light in her left eye, both ipsilateral and contralateral pupillary responses are apparent. Her
extraocular movements are intact. What is the most likely location of her lesion?
A. Oculomotor nerve, left side
B. Oculomotor nerve, right side
C. Optic nerve, left side
D. Optic nerve, right side
E. Trochlear nerve, left side
F. Trochlear nerve, right side
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31. In attempting to introduce a catheter into the right internal jugular vein, a resident inadvertently damages the cervical
sympathetic trunk in a patient. Which of the following findings is most likely to be seen in this patient as a result of the injury?
A. Constriction of the right pupil
B. Dilation of the right pupil
C. Inability to abduct the right eye
D. Inability to close the right eye
E. Paralysis of the platysma muscle on the
right side
32. During a follow-up visit to her psychiatrist, a 17-year-old female admits that she is contemplating suicide. She has been
morbidly depressed for the past 2 months; she denies drug abuse or excessive drinking. After a complete evaluation, her physician
prescribes imipramine. This drug acts by
A. increasing dopamine release
B. inhibiting monoamine oxidase
C. inhibiting the reuptake of serotonin and norepinephrine
D. potentiating GABA
E. selectively inhibiting the reuptake of serotonin
33. If an Acoustic Reflex Test was being performed on the right ear of a normal man with a loud sound we would expect a
tympanogram from the right ear to have a:
A. Higher than normal compliance peak
B. Lower than normal compliance peak
C. A shift in the compliance peak to the left
D. A shift in the compliance peak to the right
E. no change
34. Which of the following statements are true regarding hearing aids:
A. Amplified sound does not have the same fidelity
B. completely in the canal hearing aids are reserved only for patients with severe hearing problems
C. Bond conduction aids are useful for people with conductive hearing loss
D. All of the above are true
E. None of the above are true
35. You have a patient who was diagnosed with a large pituitary tumor. Which of the following visual fields most likely would be
affected?
A. Right nasal field and left temporal field
B. Left nasal field and right temporal field
C. Right nasal field and left nasal field
D. Right temporal field and left temporal field
E. Right nasal and right temporal field
36. An elderly patient dies with chronic dementia. At autopsy, the brain shows diffuse cortical atrophy with relative sparing of
primary motor and sensory areas. Which of the following would most likely be a prominent feature on microscopic examination of
her brain tissue?
A. Central chromatolysis
B. Lewy bodies
C. Gliosis of the caudate nucleus
D. Loss of pigmented neurons
E. Neurofibrillary tangles
37. In the patient above (Q. 36) which types of cells are most likely affected?
A. GABAnergic neurons
B. Cholinergic neurons
C. Dopaminergic neurons
D. Glutamatergic neurons
E. Glial cells
7 www.brain101.info
38. A 6-year-old girl manifests acute vomiting and nuchal rigidity. MRI reveals a tumor in the posterior
fossa consisting of a large cyst with a nodular mass attached to its wall (cyst with "mural nodule").
Histologic examination shows elongated astrocytes with long bipolar processes and numerous Rosenthal
fibers. Which of the following is the most likely diagnosis?
A. Astrocytoma, WHO grade II
B. Ependymoma
C. Glioblastoma multiforme
D. Medulloblastoma
E. Pilocytic astrocytoma
39. A 35-year-old man is referred to a psychiatrist because of erratic behavior. The man had been adopted
in infancy, so his family history is not known. Over the next year, he develops uncontrollable erratic
movements, such that attempts to pick up a cup or use a pencil produce sudden uncontrolled lurches. When
he tries to walk, he staggers, thrusts, and abruptly changes direction. Eventually, with disease progression,
he develops increasing rigidity and is unable to move, and finally dies ten years after the onset of
symptoms. Which of the following changes would most likely be seen on examination of his brain at
autopsy?
A. Depigmentation of the substantia nigra and locus ceruleus
B. Diffuse cortical atrophy with relative sparing of primary motor and sensory areas
C. Selective frontal and temporal lobe atrophy
D. Striking degeneration of the caudate nucleus
E. Widespread neuronal loss and gliosis in subcortical sites
40. All of the following appear to play a role in depression except:
A. Puberty
B. Oral Contraception
C. Pre mentrual
D. Time Zone changes
E. Menopause
41. Which of the following drug is most appropriate for treating a unipolar patient?
A. Fluoxetine
B. Lithium
C. Oxazepam
D. Clozapine
E. Midazolam
42. Which of the following statements are true regarding the tensor tympani and stapedius muscles?
A. They are similar in that they are both innervated by the facial nerve
B. They are similar in that they are both innervated by the trigeminal nerve
C. They are different in that the stapedius muscle is innervated by the CN. V and tensor tympani is
innervated by CN. VII
D. They are similar in that they both act to dampen sound. They both act in opposition of each
other; the stapedius dampens sound and tensor tympani amplifies sound
43. A 48-year-old male is brought to the psychiatric emergency room after an attempted suicide. He claims
to hear voices telling him to kill himself. The patient's family notes that he has been on several different
kinds of antipsychotic medications, with no improvement of his symptoms. The attending psychiatrist
places the patient on a new medication, and admits him. One week after therapy has begun, a routine blood
test reveals profound depletion of polymorphonuclear leukocytes. Which of the following drugs is most
likely responsible for these symptoms?
A. Chlorpromazine
B. Clozapine
C. Fluoxetine
D. Haloperidol
E. Imipramine
F. Phenelzine
8 www.brain101.info
Answers
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
e
d
b
b
c
e
d
d
a
c
c
e
a
b
a
c
e
e
c
b
e
d
e
e
b
e
a
d
c
d
a
c
b
a
d
e
b
e
d
e
a
d
b
7. The correct answer is D. The disease is tuberous sclerosis. The facial angiofibromata are also called
adenoma sebaceum, and the hypopigmented patches on the trunk are called ash-leaf spots. This disease is
one of the neurocutaneous disorders called phacomatoses. Tuberous sclerosis is inherited as an autosomal
recessive trait, and epilepsy and mental retardation are commonly seen in this disorder. Large, firm, white
hamartomatous nodules (tubers) are seen in the cortex and in subependymal sites. The tubers consist of
aberrantly arranged neurons and/or glia. Patients may also have pancreatic cysts, renal angiomyolipomas,
and cardiac rhabdomyomas. Rarely, an astrocytoma will arise in a tuber.
9 www.brain101.info
24. The correct answer is E. The disease is progressive supranuclear palsy, a degenerative disorder
characterized by ophthalmoplegia, pseudobulbar palsy, axial
dystonia, and bradykinesia. The presentation described in the question is typical. The pathologic changes
consist of widespread neuronal loss and gliosis in subcortical sites with sparing of the cerebral and
cerebellar cortices.
26. The correct answer is E. Pick's disease is a condition that is clinically similar to Alzheimer's disease. It
differs from Alzheimer's disease in that the pronounced brain atrophy characteristically involves the frontal
and temporal lobes, with sparing of the posterior aspects of the cortex. Microscopically, the affected cortex
contains characteristic ballooned neurons (Pick cells) or cytoplasmic inclusions (Pick bodies). Clinically,
there is a slowly progressive dementia with language disturbances and behavioral changes that may
eventually lead to mutism. The progressive nature of the dementing process has been termed a "descent
into a sea of mindlessness."
CHOLINOMIMETIC:
Direct StimuIating
Name ADMIN INFO USE/CONTRA/RXN's
Choline Ester DYNAMICS: eye - miosis, facilitates the outflow of aqueous humor; CV -
Hypotension and brady, reflex tachy {4 effects 1) vasodilation 2) dec in cardiac
rate 3) dec conduction of SA and AV 4) dec in force of cardiac contraction};
Resp - bronchospasm, inc tracheobronchial secretions; GI - inc peristalitic act
and relaxation of sphincter, inc salivary and gastic secretions; GU - stim of
detrusor muscle and relax the trigone and sphincter; Secretetory glands - stim
of secretory activity of the lacrimal, tracheobroncial, salivary, digestive, and
exocrine; CNS - nicotine has mind altering action, tremors, emesis, and stim of
resp centers, cunvulsions, and fatal coma; NM junct - nicotinic effect -
fasiculation to strong contraction of entire muscle - lead to depolarization
blockade
CONTRA: Asthma, hyperthyroidism (inc
receptors), Coronary insufficiency, acid-
peptic disease. TOXICITY: pilocarpine
and choline esters: Nausea, vomiting,
diarrhea; salivation, sweating; cutaneous
vasodilation, tremors, bronchial
constriction, AV block, bradycardia, and
PVC's. TOXICITY: nicotine: acute - CNS
stimulation, Hypertension, Cardiac
arrhythmias, convulsions, coma,
neuromuscular blockade resulting in resp
paralysis: Chronic exposure - recurrance
of ulcer in pts with peptic ulcers
Acetylcholine* - no therapeutic value;
forms from glucose and choline
V, Oral
Rapid hydrolysis by Ach-esterase and plasma esterase - butylcholinesterase;
rapid hydrolysis in G tract; CNS penetration limited
USE: diagnostic tool, no therapeutic value
Methacholine - clinical apps twice as resistant to hydrolysis; > muscurinic activity then nicotinic; See effects
when administered subcutaneously
USE: diagnostic tool for broncial
hyperactivity
Bethanechol - clinical apps; carbomic
esters = long acting - 6 hrs
activates bowel and bladder smooth muscle; mainly muscurinic action USE: postoperative abdominal distention
and gastric atony; postoperative and
postpartum urinary retention; promotes
salivation
Carbachol - clinical apps; carbomic esters
= long acting - 6 hrs
substantial nicotinic activity (especially on autonomic ganglia, therefore can
activate the adreanal medulla
USE: glaucoma
Natural Alkaloids
Pilocarpine Well absorbed; from leaf of SA shrub pilocarpus; muscurinic exceeds nicotinic;
Hypertension after a brief hypotensive responce
USE: glaucoma
Muscurine from poisonous mushroom (amanita muscuria); muscurinic receptor site
Arecoline from areca or betel nuts (areca catechu); nicotinic receptors
Notes by T. Chengot - 2002 Page 1
CHOLINOMIMETIC:
Indirect StimuIating
(AntichoIinesterases) -
accumulates ACH
DYNAMICS: Muscurinic Effects - miosis, bronchoconstriction, inc secretions,
inc peristaltic activity, brady, hypotension. Nicotinic Effects - dose dep effect -
higher dose results in fibrillation of muscle fibers, fasciculation, and non-
depolarizing blockade. CNS Effect - dose dep effect - low conc. results in
diffuse activation of the ECG and subjective alerting response. High conc.
results in generalized convulsions, coma, and resp arrest.
Reversible - Carbamoyl
Esters
Physostigmine carbamate ester that covalently bonds with Achesterase. KINETICS: well
absorbed (lipid soluble); duration 1/2 - 60 hrs
USE: in glaucoma, Alzheimer's disease,
atropine overdose
Neostigmine - also has some direct
nicotinic agonist activity
carbamate ester that covalently bonds with Achesterase. KINETICS: poorly
absorbed; post-op; duration 1/2 - 6 hrs
USE: adynamic ileus, non-obstructive
urinary retention, diagnostic tool and
treatment of myasthenia gravis,
Nondepolarizing neuromuscular blockade
reversal
Edrophonium - quaternary alcohol forms reversible electrostatic and hydrogen bonds to active site of the enzyme
~ short duration; diag-X-short; 2-10 min duration
USE: diagnostic tool for myasthenia gravis
Pyridostigmine [Mestinon] KINETICS: poorly absorbed
Donepezil [Aricept] - 1st piperidine-
type reversible cholinesterase inhibitor; > affinity
for CNS, therefore less peripheral effects
oral: t1/2 = 70
hrs
KINETICS: 1st pass 100%; metabolized CP450 2D6 and 3A4 and
glucoronidation; excreted in urine (17% unchanged), no food interaction, peak
levels 3-4 hrs, once a day dosing. TOXIC: G - nausea, vomiting, diarrhea,
anorexia. Also reported - headache, pain (various locations), syncope,
ecchymosis, weight loss, arthralgia, insomnia, dizziness, dyspepsia, and
increase urine frequency
USE: alzheimer's disease. CONTRA: G
bleeds and hepatic disease (for cautionary
measures - not hepatotoxic but could be)
Tacrine [Cognex] - has direct agonist
activity (both direct cholinomimetic and reversible
inhibition of ACH-esterase
oral: t1/2 =1.5-
4 hr
KINETIC: 1st pass 5-30%; metabolized CP4501A2; excreted in urine, food dec
absorption by 30-40%, peak levels 1-2 hrs. TOXIC: hepatic* - elevated liver
enzymes; G* - nausea, vomiting, diarrhea, anorexia, constipation, dyspepsia,
flatulence; CNS* - myalgia, syncope, dizziness, tremors, insomnia and mental
status change; also seizures, asthma, exacerbations [*-expected]
USE: alzheimer's disease. CONTRA: G
bleeds and hepatic disease
Irreversible -
Organophosphates
Bind with phosphates and form covalent phosphorus-enzyme complex that may
undergo 'aging' where bond is strengthened
Parathion
Malathion
soflurophate [Floropryl] USE: in glaucoma
Echothiophate [Phospholine] KINETICS: not well distributed in body USE: in glaucoma
Treatment for Poisoning:
Antidotes
80% exposure to pesticides - occupational exposure, dermal absorption 1) CV support 2)Decontamination 3) TX of
seizures (anti siezure meds)
Atropine antagonist to Ach
Pralidoximine (2-PAM)
[Protopam]
effect in 24 hr (best), no later then 48 hrs; Ach-esterase reactivator
pesticides -
KINETICS: highly toxic b/c not detoxed in vertebrates; highly toxic pesticide -
absorbed dermally
decrease effect of too much Ach
AntichoIinergics
Belladonna Alkaloids
Atropine* - From atropa belladonna
{nightshade]; Reversible Competitive antagonism
of Ach @ muscurinic receptor sites (however non
specific for subtypes); low potency at nicotinic; @
high conc. Able to produce partial blockade
-PROTOTYPE
Oral, Conjunct:
t 1/2 = 2-4 hr
KINETICS: Well distributed 30 min - 1 hr; well absorbed G and conjunctival;
metabolism liver, excretion - 60% unchanged in urine. DYNAMICS: CNS -
dose dependent - @ low dose mild vagal excitation as a result of stim of
medulla and higher cerebral centers. Ocular - mydriasis, cycloplegia, reduction
of lacrimal secretion; CV - tachy; Blood Vessels - moderate to toxic doses
cause atropine flush; Resp - bronchodilation and decreased secretory gland
secretions, dec mucillary clearance; G - dec motility, reduction in gastric
secretions, dec salivation; GU - relax sm of ureter and bladder wall (reduce
voiding); sweat glands (suppressed)- thermoreg, inc body temp. TOXIC: CNS -
restlessness, irritability, disorientation, hallucinations, and delirium; @ inc conc.
- circ collapse, paralysis of parasym organs, coma, death
CONTRA: glaucoma, prostate
hyperplasia, gastric ulcer. SIDE
EFFECTS: dry as a bone, blind as a bat,
hotter then a hen red as a beet, mad as a
hatter, plus tachy
Scopolamine [Transderm-
Scop] - greatest CNS penetration
dermal patch
to Atropine except the CNS toxicity; @ thereputic doseage = depression;
TOXIC: CNS - drowsiness, amnesia, fatigue
USE: treatment of motion sickness
Semisynthetic/Synthetic
Derivatives of the
Belladonna Alkaloids
*QUATERNARY: mech is same as atropine w/ greater nicotinic ganglionic
blocking resulting in adverse rxn that are attributable to ganglionic blockade.
KINETICS: Absorption - poorly and unreliable after oral (10-30%) absorption;
distribution - more ionized less cross @ BBB and conjunctival barrier;
duration of action longer. PHARM: less CNS penetration. TOXIC: = to
belledonna, but less CNS effects; significant ganglionic blockage produce sig
nicotinic side effects; OD leads to curariform NM block - respiratory paralysis.
*TERTIARY: better lipid soluability, useful in ophthalmic and centrally
mediated diseases. TOXIC: equal to that of natural products, systemic effects
possible, but less likely.
pratropine [Atrovent] - Quaternary
inhalation
(<1%
absorbed, 90%
swallowed):
max response 30-90 mins, 4 hr duration, eliminated in feces; PHARM:
bronchodilations with no effect on mucillary clearance
USE: COPD
Methscopolamine [Pamine] -
Quaternary
less potent then atropine, poorly absorbed, duration 6-8 hrs; derivative of
scopolamine w/o central effects (different then atropine - MECH unknown)
USE: Gastrointestinal diseases (adjunct to
treating ulcers - decrease secretion)
Benzatropine [Cogentin] - tertiary similar to trihexyphenidyl but less CNS effects; synthetic compound similar to
atropine and diphenhydramine; [has anti-muscurinic, anti-histaminic, and local
anesthetic effects. ]
USE: parkinsonism and drug induced
extrapyramidal side effects
Tropicamide [Mydriacyl] - tertiary
Cyclopentolate [Cyclogy] -
tertiary
Dicyclomine [Bentyl] - tertiary less potent the atropine and minimal effect on salivary or sweat glands or CV
system
USE: irritable bowel disease
[antispasmodic properties]
Homatropine hydrobromide
[sopto Homatropine] - tertiary
topical,
ophthalmic
semisynthetic derivative of atropine; USE: topical administration [ophthalmic
formula]; Mydriasis, induction of
cycloplegia
topical,
ophthalmic
shorter duration then atropine, scopolomine or homatropine USE: topical administration [ophthalmic
formula]; Mydriasis, induction of
cycloplegia
Oxybutynin [Ditropan] - tertiary synthetic antimuscurinic compound - has nonspecific relaxation effect USE: adult urinary incontinence and
neurogenic bladder (relaxation of
sphincter)
Tolterodine [Detrol] - tertiary M3 receptor selective; effects similar to oxybutynin, but lipophilicity is 30x less -
limited CNS penetration - less CNS side effects
USE: Adult urinary incontinence
Trihexyphenidyl [Artane] - tertiary CNS permeability exploited; synthetic compound similar to atropine USE: parkinsonism and drug induced
extrapyramidal side effects
Drugs effecting the
GangIia
Indirect Ganglionic Blocker
Nicotine [Nicoderm, Nicotrol,
Hibitrol, Nicorette]
absorbed from
resp tract,
buccal mem,
and skin;
ionized in
stomach: t1/2
= 2 hr
DYNAMICS: Ganglionic Blockade - initial stim, followed by depression; NM
junction initial stim followed by paralysis, NM bloackade by receptor
desensitization; CNS - stim followed by depression, dose dep tremors,
convulsions, resp stim followed by depression = death - central paralysis and
peripheral blockade; CV - vasoconstriction, tachy, and elevated BP; G -
parasym stim, nausea, vomiting, and occasional diarrhea; Exocrine glands -
initial stim of salivary and bronchial secretions then inhibition. KINETIC:
majority of absorption in sm intestines; 80-90% altered in body by liver (also in
kidney, lung); Renal elimination - dependent on pH b/c it is basic; found in
breast milk. TOXIC: acute exposure - accidental ingestion/sprays, nausea,
salivation, abdominal pain, vomiting, diarrhea; cold sweat, headache, dizziness;
disturbing hearing and vision, mental confusion, and marked weakness,
hypotension, resp diff, CV collapse, terminal convulsions, death due to resp
failure.
*inhaled nicotine - metabolized mainly by
the lungs
Ganglionic Blockers
Mecamylamine [nversine] - non-
competitive antagonist at several nicotinic
acetylcholine receptor subtypes
oral
KINETICS: absorption decreased by effect of ganglionic blockade on the G
tract; readily enters CNS; accumulates in liver and kidney, excreted slowly by
kidney in unchanged form - long duration of action. PHARM: CNS - sedation,
tremors, choreiform movements, mental aberrations reported; Eye -
cycloplegia, moderate mydriasis; CV - hypotension, ortho hypo, tachy; G -
reduction in secretions, inhibition of motility, GU - hesitancy in urination,
impaired erection; loss of thermoregu control. TOXIC: exacerbation of side
effects, visual disturbances, dry mouth, urinary hesitancy, moderate
constipation, abdominal discomfort, anorexia, heartburn, nausea, postural
hypotension; SEVERE RXN: - marked hypotension, constipation, syncope,
paralytic ileus, urinary retention, cycloplegia, CNS - tremors, mental confusion,
seizures, mania, or depression
USE: hypertensive emergencies
CONTRA: history of cardiac problems,
uremia, glaucoma (b/c moderate
mydriasis), organic pyloric stenosis.
Drugs effecting the
NeuromuscuIar
Junction BIockers
Depolarization results in the Na+ and K+ influx; Ach is metabolized by ACH-
esterase; Transmission inhibited by competative agaonitst of Ach receptors
(nondepolariziing blockade; Excessive agonist result in initial depolarization
and desensativation
Name ADMIN INFO Indication/CONTA
Depolarizing (Non
competitive Antagonist)
Succinylcholine* - 2 Ach molocules
together - PROTOTYPE
parenteral, M,
V
Mech: PHASE 1: depolarization - binds to post synaptic nicotinic receptors, not
metabolized in the synapse - remains depolarized resulting in flaccid paralysis
PHASE 2: despite continued exposure, endplate becomes repolarized, AND
desensatived to stimulation. KINETIC: duration 5-10 mins, ionized - no X @
BBB, rapid hydrolysis by plasma cholinesterases @ liver and plasma (effects
prolonged in pts w/i abnormal plasma choilesterase. DYNAMICS: skeletal
muscle paralysis (1st fasiculations over chest and abdomen, 2nd arms legs and
neck, 3rd respiratory muscle weakness); CV - arrhythmias and bradycardia;
hyperkalemia - leads to cardiac arrest; inc intraocular pressure, inc intragastric
pressure - emisis, muscle pain. TOXIC: muscle fasiculations, tremors, jaw
rigidity, postoperative myalgia, muscular weakness/pain, renal tubular
obstructuon, muscle paralysis, prolonged apnea & CV collapse, hpersensativity,
malignant hyperthermia (ine Ca release - muscle rigidity, Tx Dantrolene
[Dantrium] )
DRUG INTERACTIONS: Antibiotics -
exacerbate or potentiate; local anesthetics
- enhance NM transmissions; non-
depolarizing NM junct blocker - 50% more
needed for effect. CONTRA: malignant
hyperthermia, burns (extra inc in K+),
cardiac disease. [Malignant hyperthermia -
autosomal dominant; release of
inordinaent Ca++ from sarcoplasmic
reticulum; Tx - w/ Dantrolene {Dantrium} -
controls levels of Ca++]
Non-Depolarizing
(Competitive Antagonist)
Tubocurarine* - PROTOTYPE
V
long acting non depolarizing NM junction blocker; causes release of greatest
amount of histamine. MECH: competative antagonism of Ach @ nicotinic
receptor sites, higher dose - block the ion channels, theory - block prejunctional
Na channels interfering w/ Ach release, BLock reversed by lg amts Ach or
choinesterase inhibitors. KINETICS: onset 2-3 mins, distribution <1.5 hr,
duration 30-60 min, limited VD of 80 - 140 ml/kg, high ionized - not X BBB,
excreted unchanged in bile/urine. DYNAMICS: Skeletal Muscle - initial
weakness - then paralysis, sm then lg effetced, last is diaphram - recovery is in
reverse order; CV - hypotension, liberation of histamine - WHEALS when
ntraQ or A, bronchospasm, hypotension, excessive bronchial and salivary
secretion, histamine relase is direct mast cell effect. TOXIC: histamine
release + ganglionic blockade - rash and puritis, (flushing, edema, urticaria,
puritus, erythema - rare), hypersalivation & bronchospasm, wheezing and
arrhythmias, hypotension; sinus tachy; muscle paralysis, apnea, dyspnea, and
resp depression, malignant hyperthermia
USE: for surgical anesthesia (intubation),
diagnostic tool in myasthenia gravis.
DRUG INTERACTIONS: inhaled
anesthetics, antibiotics - inc Ach release;
local anesthetics; non-depolarizing NM
junct blocker - more needed for effect.
ANTIDOTE: cholinesterase inhibitors
(neostigmine - b/c inc Ach competatively).
Atracurine [Tracrium] - intermediate
acting
V
produces a mild/moderate histamine release; readily crossed BBB, laudanosine
is a toxic metabolite (responsible for seizures); less potent then Pancuronium or
Vecuronium; has faster recovery time compares to tubocurarine or
Pancuronium; less hypotension then Tubocurarine.
USE: adjunct to general anesthesia,
tracheal intubation
Mivacurium [Mivacron] - Shorter
acting
V
short acting; rapidly metabolized by plasma cholinesterase (inc duration in pts
w/ renal failure due to dec plasma levels); duration less then Atracurium, less
hypotention then Tubocurarine
USE: endotracheal intubation,
neuromuscular blockade
Pancuronium [Pavulon] - long
acting
V
long acting agent, minimal histamine release, metabolized in liver to active
metabolite, excreted in urine; potency is 5x Tubocurarine
Vecuronium [Nocuron] -
ntermediate acting
intermediate acting agent, minimal histamine release and is less likely to cause
side effects (as opposed to Atrcurium, Mivacurium, Succinylcholine,
Tubocurarine) , meabolized by liver; excreted in bile (85%) and urine (15%);
more potent the Pancuronium or Atracurium
Sympathomimetic
Drugs
Thereputic uses: Shock, Hypotension, Hypertension, Cardiac Arrhythmias,
Congestive Heart Failure, Limiting Hemorrhage (topical vasoconstictor effects),
inc duration of action of local anesthetics, nasal decongestion, asthma, allergic
rxn, opthalmic indications: mydiriasis, narcolepsy, weight reduction, ADHD
Direct acting
Epinephrine* - endogenous
catacholamine
parenteral,
inhalation
MECH: potent stimulant of both and adernergic receptors; KINETICS:
metabolized by hepatic COMT and MOA; excretion urine; slow absorption
following subQ - local vasoconstricion. DYNAMICS: CV - powerful stimulant w/
direct activity of 1 receptors, hypotension (potent vassopressor), raise systolic
> then diastolic, inc CO, inc O2, arrhythmias(stim different pacemakers of the
heart); Vasoconstriction; Smooth Muscle - relaxation of G smmoth muscle,
inhibits uterine tone and contraction, uriniary hesitancy and retension;Resp -
relaxation of bronchial muscles, bronchodilation, negligable CNS due to
polarity. TOXIC: fear, anxiety, tenseness, restlessness,; headaches,
weakness, dizziness, pallor; resp difficulty; palp; hypertension (esp w/
hyperthyroid & hypertensive; cerebral hemorrhage and cardiac arrhythmias -
depends on administration
METABOLIC EFFECTS: elevation of
glucose and lactate blood levels, inc O2;
(other effects stim lacrimation, mydrisis).
CONTRA: pts who receive nonselective b-
andrenergic blocking drugs - see only
alpha response.
norepinephrine [Levophed] -
endogenous catacholamine
(ineffective
oral) poor
subQ
95% and 5% ; blood flow reduced to kidney, liver, and skeletal muscles.
KINETICS: rapid met by COMT and MAO; small amount excreted in urine
unchanged, ineffective orally; DYNAMICS: equipotent to epi @ 1 receptor, lil
action @ 2; potent agonist at (<epi) however, it is less potent then epi on
the receptors of most organs; CV - hypertension w/ inc systolic and diastolic
pressures and pulse preassure are inc, marked vascoconstriction, inc total
peripheral resistance, dec HR due vagal reflex, peripheral vascular resistance
inc (blood flow reduced to kidney liver and skeletal muscle); hyperglycemia
(<epi), inc. freq of contraction in pregnancy. TOXIC: ~ to epi, less pronounced
and less frequent, anxiety, resp diff.; awaeness of slow, forceful beating heart,
transient headaches; O.D. - severe hypotension, photophobia, retrosternal pain,
pallor, intense sweating, and vomiting.
CONTRA: anesthesia with agents that
sensatize the automatic tissue of the heart
(Halothane); pregnancy
soproternol [suprel] -
adernergic agonist (low affinity to for -
adernergic receptors) - potent synthetic
parenteral or
inhalation
KINETICS: metabolized by COMT in liver & others, poor substrate for MAO;
longer duration then Epi and norE. DYNAMICS: CV - lowers peripheral
vascular resistance, hypotension, inc CO (+ inotropic and chronotropic effect);
relaxation bronchial and G smoother muscle. TOXIC: palpatations, tachy,
headache, fluched skin (common); lipolysis = epi
METABOLIC EFFECTS: less
hyperglycemia then epi'; lipolysis equal to
epi;
Dopamine [ntropin]
V
metabolic precursor of norE and Epi; KINETICS: substrate for COMT and MAO
- ineffective orally; DYNAMICS: CV - vsodilation (low conc. - inc GFR, renal
blood flow, and Na+ excretion); positive inotropic effects on the myocardium
acting on 1 receptors and stimulates release of norE; Less tachy then
soperternol; nc systolic blood pressure and pulse pressue (min effect on
diastolic); stim of vascular 1 (high dose) - adernergic receptors leading to
vasoconstriction and dec renal blood flow and urinary output; no CNS effects -
no X BBB. TOXIC: Nausea, vomiting; tachy, anginal pain, arrhythmias,
hypertension, vasoconstriction; headache
USE: Shock; Oliguria and with low or
normal pheripheral vascular resistance
Doubutamine [Dobutrex] -
adernergic agonist (stuct sim to
Dopamine)
DYNAMICS: inc CO(>isoperternol); TOXIC: hypertension and tachy, facillitates
AV conductance, tolerance, myocardial infacts
Clonidine [Catapres] - 2
adernergic agonist
oral: t1/2 = ~12
hrs
KINETIC: peak plasma concentration 1-3 hr;renal elimination (50%
unchanged); ~100% bioavailability. PHARM: CV - transient hypertensive
response followed by prolonged hypotension; Bradycardia. TOXIC: Dry mouth
and sedation (50%); Sexual dysfunction; Marked Brady; Contact dermatitis (15-
20%); withdrawl rxn w/ abrupt discontinuation of long term therapy
USE: Hypertension, adjunct in narcotics,
alcohol, and tobacco withdrawl
Indirect acting
Amphetamine non specific and
Promotion of the release of Norepinephrine
CNS stimulant; MECH: releases biogenic amines from their storage sites in
nerve terminals. DYNAMICS: CV effect - hypertention, reflex brady,
arrhythmias (large doses); Effect on smoother muscle is similar to other
sympathomimetic drugs; CNS stim, dec fatique, elevation of mood, euphoria,
inc motor activty and speech; Resp stim; appetite suppressent (hypothalimic
activity on feeding centers). TOXIC: CNS STIM - restlessness, dizziness,
tremors, hyperactive reflexes, irritability, weakness, insomnia, fever, and
euphoria; confusion, aggressiveness, anxiety, delirium, paranoid hallucinations;
CNS DEPRESSION - fatique and depression; CV effects - headaches, pallor,
flushing, palpatations, cardiac arrhythmias, anginal pain, blood pressure
changes, and circ collapse; GI - dry mouth, metallic taste, anorexia, nausea,
vomitting, diarrhea, and abdominal cramps; Convusions, coma, and cerebral
hemorrhages; psychological dependence adn tolerance
Methamphetamine [Desonxyn]
- 2 adernergic agonist
Dextroamphetamine [Dexedrine]
3x greater potency then Amphetamine; Greater CNS effects
Dual Acting
Ephedrine - direct and indirect acting
sympathomimetic and Promotion of the release of
Norepinephrine in excess
oral: t1/2 = 3-6
hrs
and andrenergic agonist; promotes release of NE from nearve terminal;
KINETIC: majority excreted in urine unchanged; DYNAMICS: potent CNS
stimulant; cardiac stimulan, tachy, inc CO, inc pheripheral resistance,
hypertension; dec renal flow; bronchodilation; TOXIC: hypertension and
arrhythmias, insomnia, tachyphylaxis(a decreased response to a medicine given over a period of time so
that larger doses are required to produce the same response)
Methoxamine [Vasoxyl] - 1
adernergic agonist (less specific @ high conc.)
Direct acting vasoconstrictiors; lacks CNS stim; dose related inc in peripheral
vascular resistance; hypertension, reflex brady
USE: hypotensive states, paroxysmal
atrial tachy
Pseudoephedrine [Sudafed]
Phenylpropanolamine
Phenylephrine
[NeoSynephrine] - a1 adernergic
agonist
V
Direct acting vasoconstrictors; ~ Methoxamine, marked atrial vasoconstriction
during V infusion
USE: nasal decongestant, mydrriatic
agent
Anti-Asthmatic ADVERSE EFFECTS OF 2-Selective Agonist: Skeletal muscle
tremor(most common); Feeling restless, apprehhension, and axiety;
tachy; arrhythmias or MI - inc risk in pts w/ heart disease, talking MAO
inhibitors, tricyclic antidepressents.
METABOLIC EFFECTS for 2-
selective agaonist: elevation in
glucose, lactate, and free fatty acids
Terbutaline [Brethine] - 2
adernergic agonist
oral, subQ,
inhalation
not metabolized by COMT USE: obstructive airway diseases, acute
bronchospasm (COPD and asthma)
Metaproterenol [Alupent,
Metaprel] - 2 adernergic agonist
oral, inhalation
less 2 selective then albuterol or terbutaline; resistanct to methylation by
COMT
USE: obstructive airway diseases, acute
bronchospasm (COPD and asthma)
Uterine Release
Ritodrine [Yutopar] - 2 adernergic
agonist
oral and V
renal elimination; 2 fold administrations: 1st IV, 2nd oral dose USE: tocolytic - inhibits uterine
contractions
Inhibitor of Norepineprine
release from the nerve
terminal
Bretylium [Bretylol] prevent release of NE from nerve terminal (Cardiac Drug)
Interference with
Norepineprine release from
the nearve terminal
Metyrosine [Demser] nhibition of tyrosine hydroxylase (inhibits tyrosine change to Dopa)
Methyldopa [Aldomet] inhibition of L-amino acid Decarboxylase (False Dopa competes w/ Dopamine)
Depletion of Vesicle Stores
Reserpine block the vesicular uptake of amines, promoting depletion of the transmitter
from the vesicles and consequently the metabolism by MOA
USE: old time hypertensive
Interference with the
reuptake of the transmitter
Cocaine
mipramine [Tofranil]
Interference with the
Destruction of the
transmitter
Tolcapone [Tasmar] inhibitors of COMT
Selegiline [Carbex] inhibitiors of MOA
Tricyclic Antidepressensts
- Adernergic
Receptor Antagonist
DYNAMICS: CV - pheripheral vascular resistance and blood pressure; tachy (
agonist - inc HR b/c inhibited); compensatory inc in blood volume (chronic
use); postural hypotension (dizy when standing) and reflex tachy; Ocular -
miosis (dilation is antagonized) ; resp - nasal stuffiness; block constriction of
trigone and sphincter muscle in the base of the urinary bladder in the prostrate
(promotes urinations - promotes voiding)
Name ADMIN INFO Indication/CONTA
Nonspecific reversible
Phentolamine [Regitine] -
antagonist
parentral only
MECH: An imiadazoline derivative that is a competative inhibitor of 1 and 2
receptors; produces an antagonist response @ muscurinic and H1 and H2
receptors. KINETICS: unknown, but is extensively metabolized. TOXIC: CV -
hypotension, severe tachy(stim of unapposed ), arrhythmias, and M
(exacerbation by inc CO, O2 demand - exacerbation); G diarrhea and inc
gastric acid production
USE: Pheochromocytoma
(catacholamine secreting tumor - causes
hypotension), erectile dysfunction - non
FDA approved method; used to prevent
locally to prevent dermal necrosis after the
inadvertent extravastation of an a
adrenergic agonist(needle stick w/ epi).
CONTRA: Acute M, Angina, CAD, Peptic
ulcer disease, Pregnancy (efficacy not
established)
Ergotoamine [ergomar] -
antagonist
MECH: adrenergic antagonist/partial agonist, seratonin receptor
antagonist/partial agonist and dopamine receptor antagonist/partial agonist.
DYNAMIC: potent peripheral and coranary vasoconstriction, brady, inc smooth
muscle activity (uterus). TOXIC: Nausea and vomiting (essentially mediated
side effects), vascular insufficiency and myocardial inschemia and gangrene
(extreme vasoconstriction)
USE: post partum stim of uterus (dec
bleeding); migraines - seratonin effect on
vasculature CONTRA: pregnancy
Tolazoline [Priscoline] - dicontinued
Nonspecific Irreversible
new receptors MUST be created
Phenoxybenzamine
[Dibenzyline] - antagonist - only one
MECH: covalent bond to a receptors (duration 14-48 hrs), some selective for
1(but less so then Prazosin); inhibits reuptake of released norE by
presympathetic; blocks H1, Ach, and seratonin receptors. KINETICS:
absorption well after oral administration, low bioavailability, renal elimination.
DYNAMICS: hypotension, Tachy, arrhythmia and M, diarrhea, inc gastric
secretion. TOXIC: CNS - fatigue, sedation, and nausea; Carcinogenic in
animals
USE: Pheochromocytoma - catacholamine
secreting tumor
1 receptor specific
antagonist
also inclused in this group is Labethalol [Normodyne, Transdate]
Prazosin [minipress]
oral: t1/2 - 2-3
hr
MECH: highly potent and selective 1 receptor antagonist (low affinity for 2).
KINETIC: 50-70% bioavailability on first pass (loose 50-30%); renal excretion;
95% protien bound. DYNAMICS: less tachy then Phentolamine; dec peripheral
vacsular resistance.
USE: hypotension; [congestive heart
failure = off lable use - build up tolerance]
Terazosin [hythrin] - struc analog
of prazosin
t1/2 - 9-12 hrs
less potent then prazosin; highly specific for 1 receptors KINETICS: 90%
bioavailability, duration 18 hrs, renal excretion, 10% unchanged
USE: hypertenssion, benign prostatic
hypertrophy
Doxazosin [cardura] - struc
analog of prazosin; once a day dosing
t1/2 - 10-22 hr
duration of action 36 hr. TOXIC: first dose phenomenon ( marked postural
hypotension and syncope; headache, dizziness, drowsiness, and nausea. O.D.:
effects indistinguishable from - non selective (@high enough conc.)
USE: hypertenssion, benign prostatic
hypertrophy CONTRA: Acute M, angine,
CAD, peptic ulcer,pregnancy
- Adernergic
Receptor Antagonist
DYNAMICS: CV - inc peripheral resistance (acutely); lowers peripheral
resistance in pts with hypertension (chronically - reflex becomes desensatived
and resistance lowers back to normal); negative chronotrope (dec HR) and
inotrope (dec CO) - lowers blood preassure; PULMONARY - Bronchospams (1
specifics not completely void of 2); METABOLC effect - inhibition of lipolysis
and glycogenolysis; OCULAR - reduced intraocular preassure - dec aqueous
humor production. TOXIC: CV - congestive heart failure (in pts w/ CAD;
Bradycardia (only ones with SA); cold extremities intermittent claudication (a
effect is vascoconstriction); rebound effect - exacerbation of angina, sudden
death; Bronchospasm; CNS - fatigue, sleep distrubances( insomnia,
nightmares in elderly); metabolic - delayed recovery from insulin induced
hypoglycemia, inc triglycerides; other - constipation, diarrhea, or indigestion,
sexual dysfunct.
O.D.: hypotension, brady, prolonged AV
cunduction times, widened QRS; siezures;
hypoglycemia; bronchospasm. DRUG
interactions: aluminum salts (kelation);
Cholestyramine (clolesterol reducing agent
- binds reducing absorption); phenytion,
rifampin, phenobarbital ( induces P450);
Cimetidine (H2 blocker, inhibit P450);
CA++ channel blockers (orthostatic
hypotension). CONTRA: abrupt
discontinuation, asthma, bradycardia, AV
block
Nonselective ISA - Intrinsic Sympathomimetic activity; MSA - Membrane-stabalizing activity
propanolol [inderal]* - prototype
oral
Large Vd (4 l/kg); high lipid soluability - X's BBB; MetaboIism - extensive first
pass (25% bioavailability); renal elimination
USE: Hypertension (dec CO); Angina (b/c
dec O2 demand); arrhythmias; CV effects
seen with hyperthyroidism (seem to have
inc # of receptors); migraine (prophalaxic,
effect on cerebral vasculature); dec
lipolysis - dec prostoglandins
timolol [ timoptic]
oral and
topical: t1/2 =
4 hrs
Non selective agent with no SA and no MSA. KINETICS: hepatic metabolism
and renal elimination, 50% bioavailability
USE: glaucoma (dec intraocular
preassure), migraine
nadolol [corgard]
t1/2 - 20 hr
Non selective agent with no SA and no MSA. Longer duration, less lipid
solubility then Propanolol (less penetration into CNS); limited metabolism -
majority excrete unchanged in urine (Accumulatetion in pts w. renal failure)
USE: Glaucoma
pindolol [ visken]
oral: t1/2 - 4 hr
Non selective agent with no SA and low MSA. Mepatic metabolism; 20%
metablized, 80% bioavailable; renal elimination of metabolites and unchanged
drug
USE: Hypertention
Labetolol [Normodyne,
Trandate] - specific a1 and
nonspecific b adrenergic antagonis
oral, V: t1/2 -
8 hr
competative antagonist at 1 and adrenergic receptors; affinity for 1 less then
phentolamine; b inhibition is less then propranolol; less tachy (reflex) then
Propanolol. KINETICS: extensive first pass metabolism with 20-40%
bioavailability, renal elimination of metabolites
USE: hypertension
1 selective
Metoprolol [lopressor]
oral: t1/2 - 3- 4
hr
no SA, weak MSA; extensive metabolism with bioavailability of 40%; renal
elimination of metabolite and unchanged (10%)
USE: Hypertension and phrophylaxtic for
migraine
Atenolol [terormin]
oral: t1/2 - 5-8
hr
no SA; highly hydrophillic (limited BBB Xing). KINETICS: excreted unchanged
in the urine
USE: Hypertension
Esmolol [brevibloc]
V: t1/2 = 8
mins
minimal SA; causes hypotension in norm individuals. KINETICS: metabolism
w/ plasma esterases; excreted in urine
USE: critically ill pts in which there is a
need for rapid withdrawal of drug =
hypertensive crisis
Acebutolol [sectral] - NOT a
prodrug - Diacetolol - active metabolite
oral: t1/2 = 3 hr
(A), 8- 12 hr
(D)
has SA and MSA. KNETCS: metabolized in liver to active metabolite
Diacetolol; excreted in urine
USE: hypotension, ventricular
arrhythmias
Chemotherapy of
Parasitic Infections
Anti-Malarials
*sporazoites invade liver cells; Schizonts mature in liver; Merozoites from liver invade RBC
Choroquine [Aralen] - used also
and an antiaemebial - not a prodrug, but has active
metabolite
oral, parentral:
t1/2 1-2 mo
MECH: uncertain concentrates in food vaculoes of parasite; ntercalation with
parasite DNA/RNA; Resistance - alteration of drug transport resulting in a dec
ability to concentrate in cells; KINETICS: Vd - 100-1000 l/kg; plasma protien
binging - 50%; accumulates w/in erythrocytes. METABOLISM: active metaolite
is monodesethylchloroquine - contributes to avtivity. TOXIC: G - Nausea,
vomiting, adbominal pain; CNS - headache, anorexia, malaise; Ocular and
dermal - blurring of visions, opacification, retinopathy, urticaria, puritics;
discoloration in nail beds and mucous membrane (conc in melanin tissue);
prolonged neuropathy(prolonged tx); Hypotension, vasodilation, EKG changes -
eventual cardiac arrest; Hemolysis and blood dyscrasias (G-6-P difficiency)
USE: non-falciform, and sensative
falciform; blood schizonticide;
gametocytes of vivax, ovale, malariae;
effective only in erythrocytic phase;
Hepatic Amebiasis CONTA: pregnancy,
ocular disease, hepatic disease or severe
G, Neurological, blood disorders, G-6-P
Dehydrogenase dificiency; Porphyria
psoriasis
Hydrocychloroquine
[Plaquenii]
Mefloquine [ lariam]
oral only; t1/2 -
20 days
MECH: theory ~ choroquine; moy form toxic complexes with free heme;
resistance (like chloroquine). KINETIC: absorption enhanced by food; high
distribution, 98% protien bound; excretion mainly feces, min urine, 5% excreted
unchanged. TOXIC: G (most common) - Nausea, vomiting, abdominal pain,
diarrhea, dysphoria, diziness; ataxia, headache, EKG changes(AV block),
severe neuropsychiatric rxn - disorientation, siezures, encepholopathy, psycosis
USE: prevention and tx of chloroquine
resistance and multidrug resistant
faliciform; effective blood schizonticide,
mature trozoite and schizont forms; no
activity against hepatic stages and mature
gametocytes of faliciform or latent vivax.
CONTRA: pregnancy; epilepsy,
psychiatric disorders (perputuate
siezures); cardiac disease (EKG changes);
Quinine or quinidine hypersensativity (X
allergic rxn)
Primaquine
oral only: t1/2 -
6 hr
Drug of choice for the eradication of dormant liver forms of vivax and ovalis;
MECH: uknown - theory - generates reactive O2 (superoxides) species or
interfereing with electron transport in parasite KINETICS: three active
metabolites (1 antimalarial, 2 toxic - hemolytic anemia); renal elimination.
TOXIC: Nausea, epigastric pain, abdominal cramps, headache, cardiac
arrhythmias; hematological effects - mild anemia, methemoglobinemia,
leucopeonia, agranulocytosis and leukocytosis (rare)
USE: terminal prophylaxis and radical
cure of vivax and ovale (relapsing);
ineffective agains falciform erythrocytic
stage; marked gametocideal effect against
all 4 species (esp falciform).
CONTRA: Pregnancy, history of
Granulocytopenia or methemoglobinemia,
parenteral administration (b/c of severe
inc K); G-6-P dehydrogenace difficiency;
iodine hypersensativity (X react w/ drugs);
SLE and Rheumatoid Arthritis
Quinine [ QM-260; Quinamm]
oral or
parentral (V
no longer
used): t1/2 - 11
hr
from bark of cinchona tree. MECH: Unknown ~ chloroquine (inhibit heme
polymerase. KINETIC: distribution - 1.5 l/kg; metabolism in liver, excretion is
renal. TOXIC: VERY TOXC! Cinchoism - tinnitis, headache, nausea, and
blurred vision(take pts off @ this pt.); vomiting, diarrhea, abdominal pain, dec
auditory acuity, photophobia, night blindness; hypersensativity RXN -
blackwater fever (hemolysis, hemoglobinemia, and hemogloinuria);
Hematologic Effects - hemolysis, leucopenia, agranulocytosis, and
thrombocytopenia; severe hypoglycemia(b/c quinine inc. insulin release); stim
of uterine contractions (esp 3rd trimester); severe hypotension DRUG
INTERACTIONS: Digoxin (dec clearance - toxicity); oral anticoagulants -
warfarin - inc toxicity b/c Quinine inhibits clottong factors formed by K); NM
blocking Drugs - potentiates NM blocking effects; Cimetidine - inhibits
metabolism - increases Quinine toxicity
USE: Falciform malaria; blood
schizonticide, little effect on sporozoite or
preerythocytic forms; gametocidal for
vivax, malariae, but not falciparum.
CONTRA: pregnancy(congenital
malformation - catagory X), previous
hypersensativity; hypoglycemia(b/c of
insulin stim effect); tinnitus, optic neuritis;
cardiac arrhythmias, G-6P
dehydrogenase)
Pyrimethamine [Daraprim]
oral: t1/2 - 3.5
days
MECH: inhibits plasmodial dihydrofolate reductase (needed to form folic acid);
resistance (mutation of enzymes). KINETICS: 87% protien bound, widely
distributed with conc occuring in the liver and kidney; extensive metabolism.
TOXIC: G effects, skin rash, pruritis; thrombocytopenia
USE: erythrocytic forms of all species, not
effective agains gametocytes, not
effective agains liver stage of vivax and
ovale CONTRA: anemia, pregnancy
(crosses placenta), Breat feeding (folate
dif in infants); M injections - localized side
effects
Pyrimethamine + Sulfadoxine
[Fansidar]
Oral: t1/2 - 170
hr (sulf) & 90
hrs (Pyr)
MECH: inhibits plasmodial dihydrofolate reductase (needed to form folic acid-
Pyrimethamine) and onhibit dihydropteroate synthetase (Sulfadoxine)
KINETICS: Renal elimination. TOXIC: G effects; skin rash, pruritis; dermal
rxn - erythema multiforme (steven johnson syndrome - is a severe and
sometimes fatal form of erythema multiforme, a disorder that occurs in
response to medications, illness, or infections) and toxic epidermal necrolysis
USE: Suppression of malaria esp
chloroquinine strains of faciparum;
toxoplasmosis; pneumocytosis.
CONTRA: Infants <2mo; hepatic/renal
diseae; hypersensativity; megoblastic
anemia; *pregancy*; breast feeding; M;
andy pre-existing anemia - folic acid dif.
Atovaquine; Proguanil
[Malarone]
oral: t1/2 (A)=2
3 days and
(P)=12-21 hrs
combo to treat falcipram. MECH: Atovaquone - interferes w/ mitochondrial
electron transport and ATP and pyrimidine buisynthesis; Proguanil (prodrug) -
active metabilte Cycloguanil inhibits dihydrofolate reductase-thymidylate
synthase of plasmodia (inhib DNA synthesis and folate depletion); KINETICS:
A - 23% bioavailabilty; 99% protien binding; hepatic met; 94% excreted
unchanged in feces; P - 75% protien bound; hep met by P4502c19 to
cytoguanil; elimination mainly feces, minor urine
Tetracycline - tertracycline antibiotic
therapy
No effect in liver stage adjunct to therepy in treament of
erythrocytic
Doxycycline - tetracycline antibiotic
therapy
schozonts of all malarial parasites
Anti-Protozoals
Chloroquine [Aralen] - see
malaria
Metronidazole [Flagyl] -
antiamebial
oral: t1/2 = 7.5
hrs
MECH: unkown - toxic rxn from formation of reative products and interactions
of these products with the DNA in anearobic bact and protozoans (nitro grp.
Reduced inside bact or prot - forms reactive product; Resistance - dec
reduction in these cells. KINETICS: well distributed (CNS and breast milk -
high lipophilicity); metabolism - liver; excretion - renal. TOXIC: CNS -nausea,
headache, dry mouth or metallic taste; vomitting, diarrhea, insomnia,
weakness, dizziness, thrush, rash, dysuria, dark urine, vertigom paresthesia,
neutropenia; pancreatitis, siezures, encephalopathy
USE: Amebiasis; Giardiasis;
Trichomoniasis DRUG INTERACTIONS:
alcohol (disulfram like rxn) - build up of
acetoaldehyde - adverse rxn; Warfarin -
inhibit metabolism of warfarin (toxicity);
phenytoin, phenobarbital - inc hepatic
enzymes - dec effect of drug; Cimetitidine -
enzyme inhibitor - drug toxicity
odoquinol [Yodoxin] - antiamebial
oral: t1/2 - 11-
14 hr
MECH: unknown - activity is limited to G. KINETICS: 10/% absorbption,
excreted renally as glucuronide conjugate. TOXIC: diarrhea, anorexia,
nausea, vomitting, abdominal pain; headache, rash, pruritus; neurotoxicity -
optic neuritis, optic atrophy, and peripheral neuropathy; alopecia and
agranulocytosis (rare)
USE: Amebiasis CONTRA: do not use
in the renally and hepatically impaired; pre-
existing optic neuropathy, or iodine;
Hypersensativity or hypersenstivity to 8-
hydroxyquinolines
Pentamidine [Pentacarinat] - anti
amebial; damdage to pancrease with prolonged
use - as pancreas get more destoryed there is inc
in secretions resulting in hyperglycemis)
Parenteral or
inhalation: t1/2
2-4 wk
MECH: Unknown - theories: interfearance w/ incorpotation of nucloetides into
DNA/RNA; inhibition of oxidative phophorylation and biosynthesis of DNA,
RNA, protiens, and phospholipids; inhibition w/ formation of folates.
KINETICS: widely distributed; 69% protien bound; metabolism unknown; renal
emilination. TOXIC: (VERY) nephrotoxicity (25%) - renal tubule necrosis;
hyperkalemia (prevents reabsorption of NA in distal tubule, K can't exchange
with NA); hypotension, tachy; pancreatitis; hypoglycemia/hyperglycemia
(reflection of pancreatic damage: hypoglypancrease becomes more
destroyedinc secretions (hyperglycemia); dizziness , dyspnea; rash, metallic
taste, fever, nausea, vomiting
USE: Pnuemosytosis, African
Trypanosomiasis; leishmaniasis CONTRA:
M (bruising/bleeding)
Diloxanide Furoate [Furamide]
- CDC only
oral
MECH: Unknown. KINETIC: hydrolyzed to diloxanide and furoic acid in the
intestinal lumen or mucosa; unabsorbed diloxanide has local amebicide activity;
excreted renally as conjugate metabolite. TOXIC: Flatulance, vomiting,
pruritis, and urticaria
USE: asympotomatic Luminal Amebiasis.
CONTRA: pregnancy; children <2 years of
age
Dehydroemetine [Mebadin] -
CDC only
Synthetic derived from Emetine (not available in US), natural product derived
from pecac w/ amebicidal prps. MECH: unknown - theory - inhibits protien
synthesis TOXIC: diarrhea, nausea, vomiting; polyneuritis, CV effects,
Hypotension, congestive heart failure, arrhythmias
USE: extraintestinal amebiasis in pts who
do not respond to or cannot receive
metronidazole
Paromomycin [Humatin] -
antibiotic for treatment
oral
MECH: direct amebicidal activity and indirect activity by interfering with the
enteric flora essential for pathogen prolif. KINETICS: 100% fecal elimination;
no extraintestinal efficacy. TOXIC: abdominal cramping and diarrhea
USE: Luminal Amebiasis. CONTRA:
Aminoglycoside hypersensativity; G
obstruction and leus (retain in G tract
longer - liklihood of absorption)
Erythromycin - antibiotic for treatment MECH: interferes w/ enteric flora essential for pathologic prolif of amoebae
Anthelmintics
local or systemic - eradicate adult helminthes or developmental forms that have invadedd organs and
tissues
GENERAL CONTRAINDICATIONS:
pregnancy; ulcers of G tract (b/c inc
systemic absorption)
BENZMDAZOLE oral t/1/2: - A
(8-12hr), M (2-
6hr), T (1.2 hr)
MECH: impairment of glocose uptake by nematodes (inhibit microtubule synthesis) KINETICS: limited
absorption; inc w/ fatty meal; Metabolized in liver; elimination fecal (A & M) and urine (M & T)
Albendazole [Albenza] -
compassionate use; Benzimidazole
ELIMINATION FECAL. TOXIC: abdominal pain, diarrhea, nausea, dizziness,
and headache; NC in serum aminotransferase activity, jaundice or chemical
cholestasis (rare)
USE: Ascariasis, Trichuriasis, hookworm,
pinworm, Stronglyoidiasis, Hydatid
disease, Neurocysticercosis
Mebendazole [Vermox] -
Benzimidazole
dec t1/2
inc toxicity
ELIMINATION FECAL AND URINE. TOXIC: abdominal pain, diarrhea;
Allergic rxn, alopecia, reversile neutropenia, agranulocytosis (rare)
USE: Ascariasis, Trichuriasis, hookworm,
pinworm, cutaneous larvea migrans
Thiabendazole [Mintezol] -
Benzimidazole
ELIMINATION URINE. TOXIC: Dizziness, anorexia, nausea, votiming;
epigastic pain, abdominalcramps, diarrhea, pruritus, headache, and giddiness;
fever, rashes, erythema multiforme, hallucinations, sensory disturbances,
steven johnson syndrome; angioneurotic edema, shock, tinntus, convulsions
and intrahepatic cholestasis (rare)
USE: Stongliodiasis
vermectin [Mectizam] - retained in
G tract
oral: t1/2 16-27
hr
MECH: unknown, may paralyze the nematode and arthropods by intensifying
GABA mediated trasmission signals in peripheral nerves (paralyzes N and A).
KINETICS: excretion in feces unchanged (retained in G tract). TOXIC:
fatigue, nausea, vomiting, abdominal pain and rashes; Mazzotti-like RXN - due
to dying microfilariae (milding itching and swollen, tender lymph nodes)
USE: Onchocerciasis; Stronglyoidiasis.
CONTRA: pregnancy and breat feeding.
DRUG INTERACTIONS: barbituated and
benzodiazephines
Niclosamide [Niclocide]
oral
MECH: inhibits mitocondrial oxidative phosphorylation and inhibits glucose
uptake in parasites. KINETICS: minimal absorption; fecal elimination (kept in
G for max effect). TOXIC: Nausea, vomiting, diarrhea, abdominal discomfort,
anorexia, drowsiness, headache, rash
USE: Taeniasis (tape worm); Hymenoleps
anan (dwarf tapeworm); intestinal flike
infections
Piperazine
oral
MECH: Non depolarizing drugs that blocks Ach at the myoneural junction of the
Ascaris Muscle, causing flacid paralysis of the worm. KINETICS: excreted
renally unchanged. TOXIC: Nausea/vomiting, abdominal cramps; headache,
dizziness, vertigo, ataxia, seizures (CNS); cateracts, blurred vision
USE: Ascariasis. CONTRA: epilepsy,
renal dysfunction
Prazquantel [Bitricide] - mild CNS
effect
oral: t1/2 - 2 hr
MECH: nc. cell membrane permeability to calcium - inc muscular activity
followed by contraction and spastic paralysis, dislodgement and death.
KINETIC: Extensive first pass; 80% plasma protien bound; elimination feces
and urine; TOXIC: malaise, abdominal discomfort, anorexia, dizziness,
headache, fever; transient elevation of liver enzymes
USE: Schistosomiasis; Clonorchiasis;
Opisthorchiasis. DRUG INTERACTION:
carbamazepine; phenobarbital
Pyrantel Pamoate [Antiminth]
oral
MECH: depolarizing nm bloackade of the nicotinic receptors - stimulates Ach
release and inhibits ACHesterase @ ganglionic neurons w/ worm - resulting in
paralysis, detachment, and expulsion. KINETICS poor absorption, activity
limited to luminal oranism; fecal and renal elimination of unchanged drug and
metabolites. TOXIC: G - Nausea, vomiting, diarrhea, abdominal cramps; CNS
-dizziness, drowsiness, headache, insomnia; rash, fever, weakness
USE: enterobius vermicuraris; Ascariasis;
Hookworm and Trichostrongylus orientalis;
trichinosis
SuIfonimindes
derivatives of sulfonilamide; MECH: sulfonamides are struc analogs and
competative antagonist of PABA, inhibiting dihydropteroate synthare and dec
synthesis of folic acid; effective against bact that produce own folic acid; bact
that use preformed folic acid not affected; inc levels of PABA counteract
bacteriostasis produced by sulfonimides (competative); Must get into cell to
take effect ANTI-BACTERIAL SPECTRUM: (broad spectrum) E-coli, Strep.
Pneumoniae, Strep Pyogenes, H. nfluenza, H. Ducreyi, Yersinia pestis,
Chlamydia trachomatis, Actinomyces, Nocardia asteroids, Plasmodium
Falciparum, Toxoplasmosis Gondii. TOXIC: Renal - crystaluria (greater
incidence w/ older compounds); Hemetological effects - G-6-P - acute
hemolytic anemia, Agranulocytosis, aplstic anemia; Hypersensativity rxn -
rashes (urticarial, erythema nodosum, erythema multiforme(steven-johnson
type), exfoliative dermatitis, and photosensativity; Fever malaise, and pruritis;
Hepatic - necrosis, hepatomegaly, jaundice, kernicterus (displaces bilirubin in
newborns - causes encephalopathy); GI - anorexia, nausea, and vomiting
Resistance: alteraction in
dihydropteroate synthase; inc metabolism
of the sulfonamide by the bact, alternative
mech for folate production; inc production
of PABA (competative antagonism) USE:
UT (Primary Tx), Trachoma and inclusion
conjunctivitis DRUG INTERACTIONS:
Oral anticoagulant; oral sulfonyurea
(hypoglycemic); Phynytoin; Tetracycline
(side effect is photosensativity -
potentiated); Local anesthetics -
metabolite PABA formed, dec
effectiveness; Acsorbic Acid - acidifies
urine - inc crystalluria; Salicylates, NSADs
- displaces sulfonimides; Methotrexate in
some populations causes bone marrow
suppression
rapidly absorbed/eliminated
Sulfisoxazole [Gantrisin] - rapidly
absorbed and eliminated; oral - 70-100%
absorption; topical - limited absoption
oral and
topical: t1/2 - 5
8 hrs
Highly protien bound, inc likelihood of displacement rxn (wide distribution);
readily X's BBB; metabolized in liver - Acetylation (non-microbial metabolite)
and Glucuronidation (anti-microbial metabolite); renal elimination - 70%
unchanged; high soluability of drug decreases liklihood of crystalluria
(insoluable in urine - obstruction)
USE: Trachoma and nclusion
Conjunctivitis; Nocardiosis
Sulfamethoxazole [Gantanol] -
rapidly absorbed and eliminated
oral
metabolism - hepatic with a higher formation of crystalluria USE: UT; Trachoma and nclusion
Conjunctivitis; Nocardiosis
Sulfadiazine - rapidly absorbed and
eliminated
oral
hepatic metabolism w/ renal elimination of uncharged drug and aceylated form
(15-45%); Poor soluability of drug increases likelihood of crystalluria(slower
rxn); less water soluable, higher precipatiation
USE: Combination w/ Pyrimethamine for
treatment of toxoplasmosis and Malaria;
Nocardiosis
Poorly abosrbed
Sulfasalazine [Azaline,
Azulfidine]* - poorly absorded; PRODRUG
Metabolized by intestinal bact to Sulfapyridine (responcible for toxic effect) and
5-aminosalicylic acid (mesalamine - anti-inflamitory; responsible for drug
efficacy); Phase 2 drug. TOXIC: Nausea, fever, arthragias (severe joint
pains), and rashes; Heinz-body anemia, acute hemolysis in pts w/ G-6-P
dehydrogenase deficiency, and agranulocytosis
USE: ulcerative colitis and rheumatoid
arthritis (disease modifying agent - NOT
1st choice). CONTRA: same as
sulfonimide plus salicylate
hypersensativity (asprin/NSAD allergy)
Sulfonimides for topical use only
Sulfacetamide
[isoptocetamide, Sulamyd
sodium] - for topical use
opthalmic or
topical
derivative of Sulfanilamide; inc soluability and stabe in solution at pH 7.4 allows
it to be used in an opthalmic formulation (most sulfonimides have alkaline pH);
90% more soluable
USE: opthalmic infections CONTRA:
persons w/ sulfer allergy
Silver Sulfadiazine
[Silvadene] - for topical use
topical
MECH: does NOT inhibit folic acid synthesis; toxicity is due to disruption of the
bacterial cell membrane and cell wall (silver contributes to toxicity) TOXIC:
sulfonamide profile + buring, rash, itching, and skin discoloration
USE: Prophylaxically; topically to reduce
microbial colonization and the incidence of
infection of wounds from burns.
SENSATIVITY: bacteria and yeast
Mafenide [Sulfamylon] - for topical
use
topical
has Gram -/+ coverage. TOXIC: intense pains @ site of application, allergic
rxn, and loss of fluids by evaporization from burn surface (not used w/ dressing -
open site); Metabolic acidosis, hyperventilation (ability to inhibit carbonic
anhydrase - elimination of bicarbonate)
USE: adjunctive therepy to second and
third degree burns
Long Acting
Sulfadoxine - long acting TOXIC: severe, fatal, steven-johnson syndrome USE: n combination with pyrimethamine
for malaria and toxoplasmosis
SYNERGIST
Trimethoprim-
Sulamethoxazole [bactrim] -
synergist - SuIfonimide: competative antagonist of
PABA inhibiting dihydropteroate synthase and dec
synthesis of folic acid; Trimethoprim: competative
inhibitor of microbial dihydrofolate reductase, dec
metabolism of folic acid to terahydrofolate and the
precurso required in purine synthesis (does not
form DNA).
Oral: t1/2
(T)=11 hr and
S=10 hr
KINETICS: (T) is rapidly distributed on concentrated in tissue, @ 40% is bound
to plasma protien in presence of (S); Vd of (T) is 9x (S); 65% of (S) is bound to
plasma protien; renal elimination of uncharged drug and metabolite TOXIC:
Megoloblastosis, leukopenia, or thrombocytopenia in pts w/ dec folic acid
levels; derm - exfoliative dermatitis, steven johnsome syndrome and toxic
epidermal necrolysis; GI nausea, vomiting, glossitis. and stomatitis (common*);
mild and transient Jaundice (allergic cholestatic hepatitis); *hematological* -
enemia (aplastic, hemolytic, macrolytic), coagulation disorders,
granulocytopenia, agranulocytosis, purpura, Henoch-Schonlein purpura,
sulfhemoglobinemia(dec in folic acid synthesis); nephrotoxicity
ANTI - Bact sprectrum - most gram -/+;
E. colr, Proteus mirabilis, P. Morganii, P.
rettgeri, Salmonella, Shigella, Brucella
abortus, Chlamydia diphtheriae, N.
Meningitis, N. Asteroides, Serratia,
Klebsiella, Enterobacter species. USE:
UT, Resp. tract infect., G infect, nfec by
P. Carinii, Propylaxis in Neutropenic pts.,
nocardia infect., brucellosis.
RESISTANCE: mutation of the enzymes.
QuinoIones
oral: t1/2 = 3-
10 hr
MECH: inhibition of toperisomerase (DNA gyrase) and Toperisomerase V -
dec bacterial synthesis; resistance - alterination in enzyme binding sites, or dec
premeability of drug into bact. KINETICS: bioavailability 80-90%, wide
distribution, renal elimination (some feces)
DRUG RXN: Antacids - dec absorption
(Al, Ca, Mg - kelate); Caffine and
Theophylline - dec met -
caffine/theopylline toxicity; Warfarin -
drug displacement rxn - inc bleeding time;
drugs which inc QT - interval (some Gen
); Digoxin - inc drug levels; retinoids -
photosensativity potentiation; probenecids -
sequesters release of quinolones - stops
renal tublue secretion of quinolones
First Generation: Quinolones
Cinoxacine [Cinobac] - 1st oral
antibiotic
Oral
suseptable org. : enterobacter sp., E. coli, Klebsiella sp., Proteus Miribilis,
Proteus vulgaris
USE: UT caused by gram - org.
Nalidixic acid [NegGram]
oral
suseptable org. : enterobacter sp., E. coli, Klebsiella sp., Morganella morganii,
Proteus Miribilis, Proteus vulgaris, providencia rettgeri, Salmonella sp., Shigella
sp.
USE: UT caused by gram - org.
Second Generation:
Fluoroquinolones
Norfloxacin [Noroxin] - mainly gram -
, some gram +
oral and
opthalmic
SHORTEST
t1/2
Poor oral bioavailability SUSEPTBLE ORGS.: Citrobacter freundii;
Enterobacter cloacae; E. coli; Klebsiella pneumoniae; Proteus mirabilis;
Pseudomonas aeruginosa; Staph. Epidermidis; ndole + Proteus species (grm
+) Groupd D strep; Neisseria gonorrhoeae. **TOXIC:** GI - nausea, vomiting,
abdominal pain, anorexia; Hepatic - elevated hepatic enzymes, hepatitis,
jaundice, pancreatitis (rare); CNS - headaches (2.9%), Dizziness (1.8), and
Fatigue; Maculopapular rash; hypersensativity rxn - erythema multiforme and
stenvens johnsons syndrome, and exfoliative dermatitis; Hematologic -
hemolytic anemia, leukopenia, neutropenia, thrombocytopenia; Crstalluria
(dose dependent)
USE: UT; uncomplicated ponorrhea;
bacterial conjunctivitis CONTRA:
Previous hypersenstivity to any quinolone;
pregnancy, breast feeing children <18
(tranfer to fetus - chill - joint
pain/changes); tendon pain (rupture)*
Ciprofloxacin [Cipro]
Oral, parentral
and topical
BEST COVERAGE FOR PSUDOMONAS. Suseptable org.: broad spectrum
antiinfective agent, not effective against anaerobic organisms; most potent
floroquinolone agains P. aeruginosa (no effect on anaerobic organisms).
TOXIC: GI - nausea, vomiting, abdominal pain, anorexia; Hepatotoxicity; CNS
- headaches (2.9%), dizziness (1.8%), and fatigue; RARE - siezures, inc
intracranial pressure and toxic psychosis (has occured @ high concentrations);
Hypersensativity rxn - maculopapular rash, fever, eosinophillia; can lead to
jaundice, hepatic necrosis - DNCONTNUE USE
USE: bact. Conjucntivitis, bone and joint
infection, lower respiratory infection,
gonorrhea, typoid fever, sexually
transmitted diseases, skin and soft tisse
infections, UT. CONTRA: ~Norafloxacin
Ofloxacin [Floxin]
oral, V,
opthalmic, otic
most complete oral bioavailability in class, highest renal elimination of
uncharged drug; less potent then Ciprofloxacin; Most effective against gram -
org.; TOXIC: GI - nausea, vomiting, diarrhea; CNS: nsomnia, headache,
dizziness, drowsiness and dysarthria (slurred speech)
USE: UT, Prostatitis; lower resp tract
infect.; skin infect.; uncomplicated
gonorrhea; non-gonococcal urethritis and
cervicitis; otis media CONTRA: Same as
Norfloxacin
Enoxacin [ Penetrex] more limited bacterial spectrum then other floroquinolones. Greatest effect on
hepatic metabolism of other drugs; TOXIC: Same as Norfloxacin
USE: UT; gonorrhea. CONTRA: Same
as Norfloxacin
Lomefloxacin [Maxaquin]
Oral
long t1/2 allows once a day dosing, no food interactions (lesser incidence of
interactions). TOXIC: greater incidence of phototoxicity; same as Norfloxacin
CONTRA: Same as Norfloxacin
Third Generation
Moxifloxacin [Avelox]
Oral and V
long t1/2 allows once a day dosing, no effect on P450. TOXIC: Q-T
prolongation; same as Norfloxacin
USE: Bronchitis, Sinusitis, Pneumonia
CONTRA: pts w/ QT prolongation; same
as Norfloxacin
Levofloxacin [Levaquin] - levo
isomer of Olfoxacin
oral, V,
opthalmic
once a day dosing. TOXIC: Same as Moxifloxzcin *BUT no QT prolongation USE: Bact. Conjucntivitis, Sinusitis,
Bronchitis, community-aquired
pneumonia, skin and skin structure infect.,
UT, Pyelonepritis. CONTRA: same as
Moxifloxacin
Gatifloxacin [Tequin]
oral and V
an 8-methoxyfluroquinolone; broad spectrum once a day dosing; no interaction
w/ hepatic P450 enzymes. TOXIC: Same as Moxifloxzcin
USE: UT; Community-acquired
pneumonia; acute sinusitis; gonorrhea.
CONTRA: same as Moxifloxacin
Sparfloxacin [Azgam]
Oral
TOXIC: same as moxifloxacin and QT prolongation USE: community aqired pneumoia;
bronchitis. CONTRA: same as
Moxifloxacin
Fourth Generation
Trovafloxacin/Alatrofloxacin
[Trovan] - alatrofloxacin is a prodrug
oral (T) and iv
(A)
T is the active form of the drug; A is an iv formulation and a PRODRUG that is
metabolized into active trovofloxacin TOXIC: elevation og hepatic enzymes
and hepatic failure; same as moxifloxacin
USE: life of limb threatening infection for
which the need for the antibiotic out weight
the potential risk of hepatic disease
CONTRA: hepatic disease ; same as
moxifloxacin
Antiseptic and
AnaIgesic Against for
UTI
Methenamine [Hiprex] - degraded
spontaneouly to formaldehyde
oral admin of
enteric coated
compound
MECH: @ low pH, spontaneous decomposistion to active form, formaldehyde,
and ammonia occurs (broad spectrum use); renal elimination. TOXIC: G
(severe) effects include nausea/vomiting, diarrhea, abdominal cramps,
stomatitis, and anorexia; dysuria, albuminuria, hematuria, and rashes;
crystalluria(b/c of low water output)
USE: UT CONTRA: renal insufficiency
and hepatic nsufficiency(b/c inc ammonia
accumulation); Dehydration - likelihood of
crystaluria
Nitrofurantoin [Furadantin]
oral: t1/2 = 20-
60 mins
MECH: reduction of parent drug to form highly reactive intermidiates that
interact with bacterial DNA (alter DNA resulting in cell death). KINETICS: wide
distribution, X's placenta, breast milk; Renal elimination, 40% unchanged.
TOXIC: Pulmonary - cough, dyspnea, pneumonitis, pulmonary fibrosis ,
respiratory failure (occus quickly and severely); G - nausea, vomtning,
anorexia, diarrhea, and abdominal pain; rashes; CNS (widely distribtuted) -
headaches asthenia, dizziness, drowsiness, nystagmus, and vertigo, peripheral
neauopathy; hemolytic anemia; urine discoloration - brown; hepatotoxicity (rare)
USE: UT. ANTIMICROBIAL ACT.: E.
coli, enterococci. CONTRA: (pulmonary
probs not a contra); renal impairment,
oliguria, anuria (due to 40% unchanged);
G-6-P dehydrogenase dificiency -
hemolytic anemia; Pregnancy and caution
breat feeding (to neonates).
Phenazopyrdine [Pyridium] - azo
dye
provides analgesic action on the urinary tract, NOT a urinary antiseptic;
TOXIC: Discoloration of urine - orange or red; Methemoglobinemia and
hemolytic anemia; acute renal failure; hepatotoxicity; G - nausea, vomiting
USE: decrease symptoms of dysuria,
frequency, buring, and urgency.
CONTRA: G-6-P dehydrogenase
dificiency; hepatic disease; renal disease;
uremia
Beta-Lactam
Antibiotics
MECH: inhibition of cell wasll synthesis; Peptidoglycans is required comp of
cell wall that maintains struct and rigidity of cell wall; cell wall prevents cell
lysis; the LAST STEP is synthesis of peptidoglycan is the removal of terminal
alanine from D-ala-Dala subtrate w/ transpeptidase; transpeptidase is catalyzed
by penacillin;Beta-lactam form covalent bond w/ penicillin binding proteins
inhibiting transpeptidase rxn; ONLY WORK WHEN CELL IS GROWING.
RESISTANCE: inactivation by beta-
lactamases; modification of target protein;
impaired penetration of drug to target
penicillin binding protien(alter transport
mech); presence of efflux pump (drug
moved out of cell)
Penicillins: OraI,
parentraI
(IM, IV)
KINETICS: oral absorption is dependent upon the stability of the compound in
acid (most have rapid absorption; food delays reabsorption); Parentral (M or
V) - absorption is rapid and complete; Distribution (liver, bile, kidney, semen,
joint fluid, lymph, and intestine), w/ min penetration of BBB (except in
inflamation, inc permeability) and wide range of plasma protien binding; Renal
elimination. TOXIC: hypersensativity rxn - rash, urticaria, stevens-johnson
syndrome, anaphylaxis; interstitial nephritis; phlebitis and thrombophlebitis (V -
irritating drug); GI - Nausea, vomiting Diarrhea, Psuedomembranous colitus
(rare); Neurotoxicity; seizures (high enough dose); Hema - leukopenia,
thrombocytopenia; Electrolyte disturbances - hyperkalemia, hypokalemia (pen
G) DRUG INTERACTIONS: probenecid - dec renal elimination;
aminoglycosides antibiotics - chemical antagonism (kelate); methotrexate -
inhibit renal tubule secretion of methotrexate ( toxicity of bone marrow
suppression); Potassium sparing diuretics ( Hyperkalemia - PEN G
potentiates); Warfarin - dec W effectiveness; oral contraceptives
SuceptibIe to: inactivation by beta-
lactamases; Susceptible - strep,
meningococci, enterococci, pneumococci,
Non-beta lactamase producing
staphylocooi, tremponema pallidum
(syphillis); bacillus anthracis; clostridium
species,actinomyces CONTRA: previous
penicillin hypersensativity; V
administration (Pen G procaine and
Bezathine); procaine sensativity - pts w/
cross hypersensativity w/ cephalosporins
(10%)
Penicillin G
M, V
TOXC: Electrolyte disturbances - hyperkalemia, hypokalemia (pen G)
Penicillin G Benzathine
[Bicillin]
M
extended release formulation CONTA: V
Penicillin G procaine
M
extended release formulation
Penicillin V
oral
Antistaphylococcal
Penicillins
Resistance to stalyococcal peniciilins; Suseptibille Orgs - Beta lactamase
producing staph, strep, pneumococci
USE: bacteremia, soft tissue injections,
bone and joint infections, UT, upper
respiratory infections
Nafcillin [Unipen]
oral and
parentral
Hepatic Metabolism ~ 60%; excretion - bile and urine(minimal); less risk of
nephritis TOXIC: Neutropenia
Oxacillin [Bactocil]
oral and
parentral
Better oral absorbtion compared to Nafcillin; less incidence of phlebitis from V
compared to Nafcillin; hepatic Metabolism ~50%; elimination by bile and urine;
better oral absorption ten dicloxacillin - 2x; TOXIC: hepatotoxicity
Cloxaciilin [Cloxapen]
oral and
parentral
Hepatic Metabolism ~ 10%; excretion - bile and urine
Dicloxacillin [Dynapen]
oral only
Hepatic Metabolism ~ 10%; excretion - bile and urine
Extended Spectrum
Penicillins: -
Natural, greater coverage
Greater efficacy against gram - org, inactivated by beta lactamases;
Susceptible orgs. - strep, menigococci, enterococci, pneumococci, non-beta-
lactamase producing staph, treponoma palladium, bacillus anthracis,
clostridium species, actinomyces, listeria mocytogenes, salmonella species,
gram negative cocci and bacilli
USE: otis media, sinusitis, bacterial
cystitis, skin infection, upper resp tract
infect, UT
Carbenicillin [Geocillin]
Oral
1st extended release penicillin; renal elimination CONTA: coagulopathy - show to inhibit
platelet coagulability so don't give to
hemophilliacs
Amoxicillin [Amoxil] -
aminopenicillin
Oral
Better oral absorbtion compared to Ampicillin; Min hepatic Metabolism; Renal
emimination; lesser incidence of G side effect compared to Ampicillin; TOXIC:
skin rash - non allergy - direct derm responce
Ampicillin [Omnipen] -
aminopenicillin
oral and
parentral
renal elimination; TOXIC: skin rash - non allergy - direct derm responce
Bacampicillin [Spectrobid]
Mezlocillin [Mezlin]
parentral only
hepatic metabolism; renal and bile elimination;acid labile - destroyed by gastric
secretions
Piperacillin [Pipracil]
parentral only:
t1/2 - 1 hr
hepatic metabolism; renal and bile elimination; renal dysfunct - t 1/2 3-6 hr and hepatic
dysfunct t 1/2 - 11 hrs
Ticarcillin [Ticar]
parentral only
more potent the Carbenicillin; hepatic metabolism; renal and bile emilination
Cephalosporins - Struc differences create a more stable drug which is more resistacnt to beta-
lactamase and which have a broader spectrum of activity. TOXIC:
hypersensativity rxn (same as penicillin) - anyphylaxis; fever, skin rashes,
nephritis, granulocytopenia, hemolytic anemia, X allergy w. penicillins of 5-10%;
G - nausea, vomiting, diarrhea, pseudomembranous colitis (clostridium
difficile); Local irrataiton @ site of injectiong (thrombophlebitis); renal toxicity -
inerstitial nepritis and tubular necrosis; hypoprothombinemia (Cefmadole,
Moxalactam, Cefmetazole, Cefotetan, Cefoperazone) - dec vit K absorption in
G tract - dec clotting factors; Disulfiram - like rxn (Cefmadole, Moxalactam,
Cefmetazole, Cefotetan, Cefoperazone) - build up of acid aldehyde - nausea ,
vomiting, death
Super infection: eradication of normal bact
- prolif of resistanct org and fungi. DRUG
interactions - aminoglycoside - not a
kelating effect - potentiate nephrotoxicity;
probenacid - inhibit renal tubule secretion
of cephalosporines; loop diuretics -
potentiate nephrotoxicity. CONTRA:
penacillin hypersensativity, cephalosporin
hypersensativity
[First Generation]
Cefadroxil [Duricef] - oral
Cefazolin [Ancef] - V, M
Cephalexin [Keflex] - oral
Cephapirin [Cefadyl] - V, M
Cepharadine [Anspor] - oral
SuseptibIe Orgs: (mostly gram + cocci) - Pneumococci, streptococci,
stapylococci, (limited gram -) - E. coli, Klebsiella, H. nfluenza; not effective
against methicillin resistanct strains of staph; effect against anaerobic cocci.
KINETICS: Wide distribution, does not X BBB at thereputic levels; renal
elimination; dosage reduction required in pts w/ renal impairment
USE: UT, Minor Staphyococcal lesions,
cellulitis, surgical prophylaxis (cefazolin
ONLY ONE)
[Second Generation]
Cefaclor [ Ceclor] - oral
Cefamandole [Manole] - V, M
Cefmetazole [Zefazone] - V, M
Cefonicid [Monocid] - V, M
Cefotetan [Cefotan] - V, M
Cefoxitin [Mefoxin] - V, M
Cefprozil [Cefzil] - oral
Cefuroxime [Ceftin] - oral
Loracarbef [Lorabid] - oral
Susceptible org: braod spectrum - same as first gen, extended gram -
coverage KINETICS: widely distributed, does not penetrate the BBB, renal
elimination, dosage reduction required in pts with renal impairment (renal
insufficiency); Greates incidence of side effects (Cefamandole, Cefmetazole)
USE: UT, Lower resp tract infect,
peritonitis, septicemia, minor otapholocial
lesions, cellulitis
[Third Generation]
Cefdinir [Omnicef] - oral
Cefixime [Suprax] - oral
*Cefoperazone [Cefobid] - parentral
Cefotaxime [Clatoran] - parentral
Cefpodoxime proxetil [Banan]*- oral
Ceftazidime [Ceptaz, Fortaz] -parentral
Ceftibuten [Cedax] - oral
Ceftizoxime [Cefizox] - parentral
Cefditoren [Spectracef] - oral
*Ceftriaxone [Rocephin] - parentral
more gram + coverafe; less gram - coverage; anearobic coverage; resistance
to Beta-lactamase; SuseptibIe oragaism same as first and second gen;
extended gram - coverage except for Cefoperazone; less potent then first gen
for gram + coverage; NOT effective against hydrostable enterobacter
chromosomal beta-lactamase; can see resistacne due to production of
cephalosporinase from serratia providencia and citrobacter KINETICS: most
penetrate the meneges @ thereputic levels; Renal elimination; dosage
reduction in those with renal impairments
Cefoperazone [Cefobid] - extended
gram - coverage except for Cefoperazone;
ELIMINATION - bile and urine;
Ceftizoxime [Cefizox] - Longest t 1/2 =
11 hrs; Ceftriaxone [Rocephin] -
ELIMINATION - bile and urine. USE:
gonorrhea, meningitis, sepsis, skine
infections, upper resp infect.
[Fourth Generation] Cefepime
[Maxipine]
Parentral
Susceptible org: (braod spectrum - more resistant to some extended spectrum
beta lactamases(MAJOR DIFFERENCE) that inactive 3rd gen); P. arruginosa,
Enterobacteriaceae, S. Auereus, S. Pneumoniae, Heamophilus, Neisseria,
good act. w/ penicillin resistant strep KINETICS: good BBB penetration, renal
elimination
USE: same at 3rd gen
Monobactams
Aztreonam [Azactam]
V: t1/2 = 1-
2hr
MECH: same as penicillin. KINETICS: Plasma protien binding ~60%; wide
distribution X's BBB and placenta; renal elimination TOXIC: GI - nausea and
vomiting, Skin rashes, Elevation of serum aminotransferase; phlebitis (V);
Pseudmembranous Colitis
Spectrum for: gram - only USE: UT,
lower respiratory tract infections;
Septicemia
Carbapenems Struct related to Beta-lactam antibiotics (resistanct to hydrolysis); less potential
for hydrolysis by beta-lactamases; NOT resistant to metallo beta lactamases
ass w/ - enterococcus faecium*, meth resistant staph*, Clostridium difficile*,
Burkholderia cepacia*, stenotrophomonas maltrophilia resistanct. MECH -
inhibit cell wall synthesis KINETICS: Wide distribution, X's BBB and placenta,
low protien binding, Renal elimination TOXIC: nausea, vomiting, diarrhea,
skin rashes, infusion site rxn(thromboplebitis, phlebitis), seizures (BBB Xing),
esp real compromised pts
USE: infection resistant to other drugs,
UT, Lower respiratory tract infec, pen
resistant strain pneumococci, enterobacter
infections, septicemia, bone and joint
infections, endocarditis (stap aureus),
childhood bact meningitis [Meropenem
only] CONTRA: pen & cephalosporin
hypersensativity, X senstivity
mipenem/Cilastatin
[Primaxin]
metabolized in the renal tubules by dehydropeptidase to toxic metbolites - renal
damage; co-admin w/ Cilastin (dyhydropeptidase inhibitor); good penetration
into bact, resistant to beta lactamases
Spectrum for activity: gram negative rods,
gram positive org, anaerobes
Meropenem [Merrem V]
V only
Does not require renal dehydropeptidase inhibitor, less gram + activity
compared to imipenem.
Erapenem [nvanz]
Beta-Lactamase Inhibitors:
Clavulanic Acid &
Sulfactam & Tazobactam
MECH: resembles beta lactam struct, but have weak antibact action (activity
depends on antibact its paired with); potent inhibitor of many bact beta
lactamases; most active against plasmid encoded beta lactamases - stph, H.
influenza, N. gonorrheoeae, Slomonella, Shigella, E. coli, Kleb pneumoniae;
Effective in chromosomal beta lactamases for legionella*, bacteroides,
branhamella; NOT effective in chomosomal beta lactamases for Enterobacter*,
Citrobacter*, Serratia*, Pseudomonas*; available in fixed combination products;
1) Ampicillin/subbactam sodium [Unasyn];
2) Amoxicillin potassium clavulanate
[Augmentin]; 3)
Piperacillin and tozobactam sodium
[Zosyn]; 4)
Ticarcillin and clavulanate potassium
[Timentin]
Misc. Inhibitors of ceII
waII synthesis
Vancomycin [Vancocin] - Renal
elimination is really long
Parentral
glycopeptide
antibiotic: t1/2 -
6 - 10 days
MECH: same as Pen; NOT A BETA-LACTAM; Resistance - modification of D-
ala-D-ala binding site; KINETICS: Oral -poor, V - used most often; Wide
distribution, X's BBB; Renal elimination TOXIC: Phelbitis; Chills, fever;
Ototoxicity - MAJOR SDE EFFECT; Red - neck syndrome - flushed neck due
to histamine flush; DRUG INTERACTIONS: Cholestyramine - kelate vanco
and dec absorption; Aminoglycosides - potentiate ototoxicity and renal toxicity
Spectrum: gram + only, particular
staphyococci; USE: Sepsis, endocarditis
caused by methicillin resistant staph,
antibiotic associated entercolitis causeby
clostridium difficile (Per os)
ANTI-VIRAL AGENTS:
Antiherpes and Anti-CMV
agents
Acyclovir [Ziagen] - Acyclic guanosine
derivative
V, topical;
Oral: t1/2 = 3-
4 hr ,
MECH: three phosphorylations - 1) in virus - concversion to monophosphate
derivative by thymidine kinase; 2) in host - conversion to diphosphates and
triphosphates (competative inhibition of deoxy GTP for viral DNA polymerase
and Binding to DNA template - resulting in chain termination).
KINETICS: Bioavailability: 15 - 20% (oral); widely distributed X's BBB;
elimination - renal. TOXIC: Nausea, diarrhea, heaches (GI -most common);
Renal insufficiency and CNS effects - tremors and delirium (doses are higher,
fast infusion rate = V)
RESISTANCE: alteration of thymidine
kinase or DNA polymerase. USE: HSV-1,
hsv-2, Vericella
Valacyclovir [Valtrex] - Prodrug -
ester of acyclovir - remember the herpes comercial
with the hot girls. oh baby
MECH: converts to acyclovir for activity; KINETICS: >absorption with serum
levels 3-5 x greater then Oral Acyclovir, and is almost = to V Acyclovir.
TOXIC: = Acyclovir
USE: HSV, Vericella, CMV
Famciclovir [Famvir] - diacetyl ester
derivative of penciclovir
Penciclovir [Denavir]
Ganciclovir [Cytovene] - Acyclic
guanosine analog that
oral and V t1/2
- 2-4 hr
Req. triphosphorylation for activation. MECH: ~ Acyclovir ( EXCEPTON -
enzyme used for initial step is dependent on virus targeted); CMV - protein
kinase phosphotransferase UL97; HSV - viral thymidine kinase. KINETIC:
poor oral bioavailability (6-9%); wide distribution - X's BBB; Renal clearance;
TOXIC: NEUTROPENIA (20-40%); CNS - headaches, mental status changes,
siezures; Carcinogenic and embryotoxic (Catagory 'C') in animals; G side
effects
USE: CMV
Cidofovir [Vistide] - Cytosine
nucleotide analog
V: t1/2=2-3 hr
MECH: the phosphorylation step does not req the viral enzyme; competative
inhibiton of the DNA synthesis via inhibiton of DNA polymerase and false
incorporationin the viral DNA chain (~ Acyclovir); KINETICS: Renal
elimination. TOXIC: Nephrotoxicity(w/in 1-2 doses), ocular hypotony (12%);
RARE - NEUTROPENA and metabolic acidosis (directly related to
nephrotoxicity)
RESISTANCE: pt mutation in the DNA
Polymerase; X resistance seen w/
Ganciclovir. USE: administered with
Probenicid to dec renal tubular secretions
(w/ CMV) CONTRA: creatinine > 1.5
mg/dl; creatinine clearance <55ml/min;
urine protien >2+ (b/c of potential of
nephrotoxicity)
Foscarnet [Foscavir] - norganic
pyrophosphate compound
V: t1/2=4-7 hr
MECH: does not require phophorylation; Direct inhibition of DNA polymerase,
RNA polymerase, and HV reverse transcriptase. KINETICS: wide distribution,
X's BBB; Renal elimination. TOXIC: Renal insufficiency, CNS:
headache(30%), hallucinations and siezures(10%); G: 50% - nausea and
vomiting
RESISTANCE: Pt mutation in the DNA
Polymerase gene (HSV and CMV);
mutation in HV-1 reverse transcriptase
gene. USE: HSV, CMV
oral(F),
topical(P)
. MECH: Famciclovir is a prodrug of Panciclovir, req hepatic metabolism;
Penciclovir required the same three phosphorylation steps as Acyclovir
EXCEPT - triphosphate form blocks DNA synthesis via competative inhibition
of viral DNA polymerase only (NO effect on chain termination); X resistance
with Acyclovir, Valacyclovir, and Ganciclovir. KINETICS: Bioabailability =
70%, elimination is renal. TOXIC: Nausea, Diarrhea, Headache
USE: HSV
Fomivirsen [Vitravene]
intervitreous
MECH: Binds to target mRNA resulting in inhibition of immediate early region
2-protien synthesis. KINETICS: Admininstered intervitreally (w/in vitreous
humor). TOXIC: ritis; vireitis; increased ocular preassure
USE: CMV retinitis in ADS pts
Trifluridine [Viroptic] - a fluorinated
pyramidine nucleoside
opthalmic
topical
(interaction w/ DNA synthesis). MECH: req triphosphorylation; competes with
thymidine triphosphate for false incorporation into the DNA by DNA
polymerase. KINETICS: opthalmologic topical. TOXIC: Ocular irritation -
buring, stinging, sandy feeling; ncreased intraocular pressure
USE: keratoconjunctivitis and epithelial
keratinitis due to HSV-1 and HSV-2
Vidarabine [Vira-A] - an adenine
arabinoside and is an adenosine analog.
topical
ointment
MECH: phosphorlyation by host enzyme to ara-ATP (~Acyclovir); the ara-ATP
inhibits viral DNA polymerase; ara-ATP is falsely incorporated into the viral and
host DNA = cell death). KINETICS: rapid metabolism to hypoxanthine
arabinoside by adenosine deaminase. TOXIC: limited side effects because it
is just topical
USE: HSV-1; HSV-2; Epstien-Barr virus,
Varicella
Antiretroviral agents:
Nucleoside Reverse Transcriptase Inhibitors
(NRTIs)
MECH: require s the same three phosphorylation steps as Acyclovir (EXCEPT
final interaction differs) - competative inhibiton of HV1 reverse transcriptase
and incorportatuon into viral DNA chain
USE: most have activity against HV-1
and HV-2
Zidovudine [AZT, Retinovir] -
synthetic thyamine AZT = Azidothymidine - (a
deoxythymidine analog)
Oral and
Parentral: t1/2
1 hr
KINETICS: wide distribution including CNS; high protien binding 35%; hepatic
metabolism; renal elimination. TOXIC: Myelo-suppression (anemia,
neutropenia, thrombocytopenia); G- intolerance; Headaches, insomnia;
Hyperpigmentation of nails; Myopathy - long chronic use; Rare fatal
lacticacidosis and severe hepatomegly (every reverse transcription inhibitor)
USE: HV
Didanosine [Videx] - synthetic analog
of deoxyadenosine
Oral: t1/2 <1.5
hr
KINETICS: food decreses AUC; wide distribution including the CNS; plasma
protien binding <5%; renal elimination. *Toxic: Pancreatitis (dose dependent) -
major side effect; peripheral distal neuropathy (tingling in hands); Diarrhea -
25% of pts get this GI side effect; Hepatitis; esophageal ulcerations;
cardiomyopathy; hyperuricemia; retinal changes; [rare reports of lactic acidosis
or severe hepatomegaly (indication of removal)]
USE: HV
Lamivudine [Epivir] - is a cytosine
analog
orally only: t1/2
- 2.5 hrs
KINETICS: NO FOOD INTERACTION; Bioavailability >80%; wide distribution,
X's BBB; Plasma protien binding <5%; renal elimination. TOXC: headache,
insomnia, fatigue (most common -30%); GI discomfort
USE: HV and Hepatitis B
Zalcitabine [Hivid] - is a cytosine
analog
orally only: t1/2
- 2 hrs
Less effective against HV-1, used in combination with Zidovudine.
KINETICS: food dec absorption (dec peak levels up to 39%); antacids dec
absorption; wide distribution, X's BBB; plasma protien binding <2%; renal
elimination. TOXIC: periperal neuropathy(50% - most common); oral and
esophageal ulcerations (stomotitis - mouth); *Pancreatitis (less then
didanosine); Headache, nausea, rash, and arralgias (CNS); (RARE -
cardiomyopathy, lactic acidosis with severe hemmorage)
USE: HV
Stavudine [Zerit] - a thymidine analog
oral only: t1/2 -
3.5 hrs
KINETICS: high bioavailability - 80%; no food interactions; negligable plasma
protien binding; wide distribution, X's CNS; renal elimination. TOXIC:
peripheral sensory neuopathy, rash (potentiation - 52%); pancreatitis; skin rash
(very common) ; elevation in serum transferase levels; (RARE -
cardiomyopathy, lactic acidosis with severe hematomegaly)
USE: HV
Abacavir [Ziagen] - Guanosine analog
that is more effective than other agents w/in this
class
oral only t 1/2 -
1.5 hrs
Not metabolized by P450. KINETICS: good absorption - 83%; no food
interactions; 50% plasma protien binding; wide distribution, X's BBB;
metabolized by alcohol dehydrogenase and glucuronosyltransferase to inactive
metabolites. TOXIC: Fatal hypersensativity rxn = 2-5% (multiple organ
systems from mild to extreme, fever, malaise, G complaint, skin rash); nausea,
vomitning, diarrhea, headache, fatique (most common); infrequent -
pancreatitis, hyperglycemia and lactic acidosis
USE: HV
Antiretroviral agents: Non-
Nucleoside Reverse Transcriptase Inhibitors
(NNRTIs)
MECH: they do not require phosphorylation for activation; they do not compete
with the endogenous nucleoside triphosphates; bind (different site) to viral
reverse transcriptase that is so close to but different from the binding sites used
by the nucleoside reverse transcriptase inhibitors; *this results in a blockade of
RNA and DNA dependent DNA polymerase activity; little cross risitance seen
w/in this class, the nucloeside reverse transcriptase inhibitors class or protease
inhibitors (good)
USE: HV-1
Nevirapine [Viramune]
oral only
good absorption - 90%; no food interactions; 60% plasma protien binding; wide
distribution, X's BBB; Metabolized by CYP3A P450 to inactivate metabolites
(inc and dec effectiveneess using hepatic inhibitors/promotors); renal
elinimation. TOXIC: Mild to severe life threatening skin rashes(1-2 months
30% require hospitalization); fever, nausea, headache, somnolence, fulminant
hepatitis
USE: HV
Delavirdine [Rescriptor]
oral only
KINETICS: good absorption - 85%; extensive plasma protien binding - 98%;
wide distribution with limited penetration of CNS; Extensive Hepatic
metabolism by CYP3A P450 and CYP2D P450; Able to inhibit its own
metabolism therefore caution in pts with hepatic surgery. TOXIC:
skin rashes (35%) first month; 5% of incidences - headaches, fatigue, nause,
diarrhea, inc serum aminotransferase levels
USE: HV
Efavirenz [Sustiva]
oral only: t1/2 -
40-55 hrs
Formally known as DMP 266. KINETICS: good absorption 45% (inc 65% w/
fatty meal); wide distribution w/ limited penetration into the CNS; extensive
hepatic metabolism by CYP3A4 and CYP2B6 P450 enzymes to inactivate
metabolite; Elimination - feces. TOXIC: CNS(50%) - drowsiness, dizziness,
insomnia, headaches, confusions, amneisiaagitation, delusion, depression,
nightmares, euphoria; Skin rashes (28%) resolves w/ continuation of
medication; nausea, vomiting; diarrhea; elevated liver enzymes; inc serum
cholesterol
USE: HV CONTRA: congenital
malfomation in primate test
Protease Inhibitors imp role in viral replication in the late stage protien synthesis of HV growth
cycle. COMMON SIDE EFFECTS: cushing's-like syndrome of abnormal fat
distribution, insulin resistance and hyperlipidemia; inc bleeding in hemophilia
(spontaneous)
Saquinavir [nverase,
Fortovase]
oral only: t1/2 -
12 hr
KINETICS: poor absorption - 4% (), 12% (F); extensive plasma protien
binding - 98%; wide distribution with limited penetration of CNS; Extensive first
pass CYP3A P450; elimination - feces. TOXIC: GI - nausea, diarrhea,
abdominal discomfort, dyspepsia; headache, lethargy, dizziness
USE: HV
Ritoavir [Crixivan]
oral only: t1/2 -
3-5hr
KINETICS: High bioavailability - 75% inc when taken with food; Wide
distribution with limited penetration into the CNS; extensive metabolism by
P450 enzymes to inactive metabolites; Elimination - feces. TOXIC: nausea,
vomiting, and abdominal pain (30%); Asthenia, fever (15%); paresthsia;
Elevated serum aminotransferase levels; Hyperlipidemia (45%) - cushingnoid
effect
USE: HV
dinavir [Crixivan]
oral
KINETICS: high bioavailability - 60% dec when taken with food; Wide
distribution good, with penetration into the CNS; extensive metabolism by P450
enzymes to inactive metabolites; Elimination - feces. TOXIC:
hyperbilirubinemia and nephrolithiasis; thrombocytopenia; elevation in serum
transferase levels; nausea, diarrhea, hemolytic anemia.
USE: HV
Nelfinavir [Viracept]
oral: t1/2 - 3.5-
5hr
KINETICS: food inc absorption; extensive first pass by CYP3A P450;
Elimination - feces. TOXIC: principle side effects; flatulance and diarrhea G.
USE: HV
Amprenavir [Agenerase]
oral: t1/2 - 3.5-
5hr
KINETICS: no effects on absorption is seen with food; P450 metabolism.
TOXIC: Rash; Paresthesia; Nausea, vomiting, diarrhea (G)
USE: HV
Anti-Influenza Agents
Amantadine [Symmetral] -
orthostatic hypotension; peripheral edema
(Amantadine - 5% of pts)
Rimantadine [Flumadine]
Rabavirin [Virazole] MECH: Phosphorylation by the host cells' enzymes is essential - interferes w/
Guanosine triphosphate synthesis; inhbiits capping of viral messenger RNA;
inhibits viral RNA-dependent RNA polymerase. TOXIC: Primary side effect is
Hemolytic anemia (10% of pts); psychiatric side effects (depression, suicidal
behavior); tetrogenic in animals( CATAGORY X - embryocidal )
USE: nfluenza A and B; Respiratory
Syncytial Virus (RSV)
Zanamivir [Relenza]
Osteltamivir [Tamiflu] - PRODRUG
nhalation(Z),
oral(O)
MECH: nhibiton of Neuaminidase, the enzymes essential for viral replication
and release from the host cell. KIETICS: (Z) has limited plasma protien binding
and rapid renal elimination; (O) is a pro-drug metabolized in the G tract and
liver to its active form; Renal elimination. TOXIC: (G for Z and O are ~); (Z) -
*GI: diarrhea, nausea, vomiting; Sinusitis, bronchitis, cough, nasal congestion
(seen alot); (O) - *GI - diarrhea, nausea, vomiting; bronchitis (seen more often then placebo
group); nsomnia, vertigo
USE: influenza A and B
oral
Mantadine is the derivative of Amantadine. MECH: nhibition of the uncoating
of viral RNA reventing viral replication; Specifically targets the M2 protien
within the viral membrane that is specific for the influenza A virus (nfluenza B
does not have M2) TOXIC: G intolerance (b/c is it oral); CNS - dizziness,
anxiety, impaired coordination, insomnia, nervousness;
USE: prophylaxis and treatment of
nfluenza A, in high risk pts - 50-90%
efficacy
AminogIycosides - derived
from streptomycete; 2 or more amino sugar w/
glycosidic linkages to a hexose nucleus
oral, topical,
parentral (M,
V)
MECH: Often used with beta-lactam antibiotics to enhance activity (better
penetration into cell but at high concentration both become chemical
antagonist); rriversible inhibition of protien synthesis (passively diffuse through
the porin channels of the bact cell wall, then by energy and O2 dependent
transport through cell membrane); irriversibly binds to 30S ribosome (except
Streptomycin - binds 12S); cell membranes becomes leaky - lyse -cell death.
KINETICS: Oral absorption is poor(,1% bioavailability); Distribution limited
distribution into cells due to ionic properties; negligable binding to plasma
protiens; Vd - 25%; poor CNS penetration; X's placenta and by breat milk; Acc.
in reanal cortex and inner ear; Renal elimination. TOXIC: Ototoxicity - tinnitis,
vertigo, deafness; nephrotoxicity - protienuria, hyaline and granular cast,
reduction in glomerular filtration rate, actue tubular necrosis; NM blockade and
apnea; Peripheral neuritis - injection directly into nerve; paresthesia - 30-60
mins after administration and last hrs; hypersensativity rxn - rash, blood
dyscrasias; anaphylaxis; psudomembranous colitis (oral only)
RESISTANCE: failure of permeation of
antibiotic (must have high conc. n cell);
low affinity of drug to bact ribosome;
inactivation of drug by microbial
enzymes(most common). SPECTRUM:
gram - baccilli, minimal effect on
anaerobic bact CONTRA:
Amninoglycoside hypersensativity rxns;
intestinal obstructive or ulcerative lesions;
pregnancy (deaf child); renal impaiment
(nephrotoxicity). DRUG INTERACTIONS:
Gen Anesthetics; NM blockers; loop
diuretics(ototoxic); Nsaids and Salicylates
and Cephalosporins and Vancomycin
(nephrotoxic)
Streptomycin*
M
least effective antibiotic of gram - rod (resistance); high ototoxicity; used in
combination (beta lactams)
USE: streptococcal or Enterococcal
endocarditis(used w/ penicillin); Tularemia;
plague; tuberculosis
Gentimicin [Geramycin]
M, V, Topical,
nterthecal
No anerobic effect; gram negative antibiotic derived from Actinomycetes
Micromonospora
USE: Sepsis, Pneumonia, Endocarditis,
Skin Lesions, burns (topical); meningitis,
Peritonitis
Tobramycin [Nebcin] - Parentral;
[Tobrex] - opthalmic
M, V,
Opthalmic
Similar spectrum of antimicrobial activity to Gentamicin (similar Gram - ability
BUT less activite againts Serratia, more active against pseudomonas)
USE: Same as gentamicin
Amikacin [Amikin]
M, V
Synthetic derivative of Kanamycin; less side effects then Kanamycin (nephro
and ototoxicity s less); Broad spectrum agains Gram - Activity, no effect
against gram + anaerobic activity; Resistant to Aminoglycoside-inactivating
enzymess
USE: same as gentimicin; Nosocomial
gram - bacillary infection in hospitals
where resistance to gentamicin and
tobramycin; disseminated atypical
mycobacterial infection in ADS pts
Netilmicin [Netromycin] - newest
M, V, Topical,
nterthecal
gram - antibiotic derived from Actinomycetes Micromonospora; synthetic
derivative of sisomicin; no \anaerobic effect; resistant to Aminoglycoside-
inactivating enzymes;
USE: same as gentimicin
Neomycin [Mycifradin] - different
then the rest
Gram - and gram + (broad spectrum); limited oral and topical use - SEVERE
renal and otic toxicity w/ parentral tx; Elimination in feces (unabsorbed), urine
(absorbed)
USE: Skin infection; preparation for
elective bowel surgery; hepatic coma
Kanamycin [Kantrex]
oral, parentral
b/c of toxicity and emergence of resistance - limited use; gram - antibiotic;
*elimination via feces (unabsorbed) and urine (absorbed)
USE: Tuberculosis; hepatic coma
Spectinomycin [Trobicin]
M
Aminocyclitol antibiotic prodced by streptomyces spectabilis; struc related to
aminoglycosides MECH: same as aminoglycosides; Broad spectrum activity.
TOXIC: nsomnia, dizziness; Urticaria, puritus; nausea, vomiting; chills, fever;
Anaphylaxis (any drug)
USE: Acute gonorrheal urethritis in
males; acute gonorrheal cervicitis and
proctits in females
Paromomyin [Humatin]
TertracycIine
Antibiotics
MECH: inhibit bact protien synthesis by 1) enters bact cell via passive
diffusion through porion channels in the membrane and through an energy
dependent active transport pump; 2) the tetracycline concentrates w/in the
bacterial; 3) reversibly binds to the 30S bacterial ribosome and prevents the
aminoacyl tRNA from binding to the acceptor site on the mRNA-ribosome
complex, resulting in inhibiton of protien synthesis. TOXIC: GI - nausea,
vomiting, diarrhea (severe enough for discontinuation); esophagitis, esophaeal
ulcers, Pseudomembranous Colitis; Dizziness, Vertigo(vestibular
effectsDoxycycline); Discoloration of teeth(binds to Ca+); Growth
deformation(b/c binds to Ca+ in bones); hepatic necrosis (high V dosages);
Renal Tubular Necrosis - Fanconi Syndrome (out dated teracycline);
photosensativity (demicocycline); Pseudomembranous cerebri (benign in in
intracranial pressure ass w/ children); Hypersensativity rxn.
RESISTANCE: 1) dec conc in bact(efflux
pump is primary method); 2) alteration of
ribosomeal protiens(can't bind, can't
inhibit); 3) enzymatic degradation
Spectrum: tetracyclines are broad
spectrum; bacteriostatic, aerobic and
anaerobic gram +/- orgs, rickettsiae,
mycoplasmas, chlamydiae. USE:
Rickettsial infection (RMSF), mycoplasma,
chlamydia, psittacosis, trachoma, STD's,
brucellosis, Tularemia, Cholera, Acne
DRUG INTERACTIRONS: Food - kelate; Divalent cations; Dairy products
(Ca+); Alkaline pH; Antacids - bind to tertacyclines and decrease their
absorption; Cimetidine - dec absorption of tetracyclines due to changes in pH;
Digoxin - tetracyclines can alter G flora DECREASNG amt of digoxin
absorbed; Iron Salts - bind to tertacycline and dec G adsoprtion); Litium - can
inc/dec litium concentrations; Methoxyflurane - additive nephrotoxic effects;
Oral contraceptives - dec effectiveness - results in break through bleeding or
pregnancy - enterohepatic recirculation; Bleeding, pregnancy; Sulfonimide -
potentiates photosensativity
Chlortetracycline
[Aureomycin] - short acting
oral, topical (1
use),
opthalmic; t1/2
= 6-8 hr
use limited to topical and opthalmic routes of administration b/c of the low oral
bioavailability. TOXIC: Burning, stining, pruitus, rsh, nausea, vomiting,
headache
Tertracycline [Panmycin] - short
acting
oral, topical;
t1/2 = 6-8 hr
Produced semisynthetically from chortetracycline; oral bioavaillability is 60-
70%; wide distribution - bones, CNS, placenta, and breast milk; NOT
metabolized; excreted in the feces
Oxytetracycline [Terramycin] -
short acting
Oral and V;
t1/2 = 6-8 hr
Demeclocycline [Declomycin]
- intermediate acting
t1/2 = 12 hr
Product of mutant strain of Strep. Aureofaciens; *Main clinical use if to treat
inapporpriate secretion of ADH secondary to its ability to produce nephrogenic
Diabetes Incipidus; Photosensativity is more frequent and more severe then
with other tetracyclines; not metabolized; renal elimination. TOXIC: as above
PLUS polydipsia and polyuria
Doxyxycline [Doxy] - long acting
oral, V,
Subgingival;
t1/2 = 16-18
hr
Semisynthetic derivatives tetracycline dervived from oxytetracycline;
tetracycline of choice in pts with poor renal function due to its limited renal
clearance; Oral absorption ~ 95-100%; NO food interactions; more lipid
soluable then short and intermidiate acting tetracyclines; less penetration into
the CNS; NOT metabolized; elimination - feces; Neutropenia and eosinophillia -
chronic useage; drug interaction with CP450 inducers (effect t1/2)
Minocycline [Minocin] - long acting
oral, V; t1/2 =
16-18 hr
Semisynthetic derivativves, most lipid soluable and considered the most active
of this group; oral absorption ~95-100%; minimal hepatic metabolism (partially
metabolized); excretion bile and urine(4-19%); Lupus like symptomes have
been seen (autoimmune rxn)
MacroIide Antibiotics
MECH: Bacteriostatic agents; inhibit protien syntheis by binding reversibly to
the 50S ribosomal subunits of sensative microorganisms Spectrum of
activity: Bacteriostatic (low dose) and Bactericidal (high dose); broad spectrum
(gram +>-); Stapylococcus aureus; Streptococcus Agalactiae; S Pyogenes; S.
pnumoniae; S. Viridans; Corynebacterium diptheria, clamydia trachomatis;
entamoeba histolytica; listeria monocytogenes; borrelia burgdorferi;
mycoplasma pneumoniae; treponoma pallidum; ureaplsma urealyticum - (no
effet on virus, yeast, fungi) TOXIC: Hypersensativity rxn - fever,
eosinophilia, and skin eruptions; cholestatic hepatitis (erythromycin estolate) -
nausea, vomiting, dbominal cramps, jaundice w/ fever, leukocytosis,
eosinophilia, and elevated activites of transaminases; Epigastric distress -
abdominal cramps, nausea, vomiting, and diarrhea; Thrombophlebitis - V)
DRUG INTERACTIONS: + Ergot alkaloids, digoxin, warfarin, theophylline =
inhibits P450, therefore inc t1/2
RESISTANCE: 1) decrease in the
permeation of the drug (efflux); 2) Dec
drug bindingto the ribosomal sub unit via
production of methylase enzzyme;
3) hydolysis of macrolides by esterases;
4) mutation of the 50S ribosomal protien.
USE: Mycoplasma pneumoniae infections;
legionnaires' disease; chlamydia
infections; diptheria; pertussis,
streptococcal staphylococcal,
campylobacter, tetanus, syphilis,
gonorrhea, Atypical mycobacterial
infections; Rhumatic Fever (prophylaxis);
Penicillin-allergic pts - prevention of
endocarditis (Clinamycin)
Erythromycin* - Prototype
oral, parentral:
t1/2* - 1.5-2 hr
(shortest t1/2)
poor oral absorption - number's of different oral dosage forms are available to
inc oral bioavailability; protien binding is 73-81%; wide distribution, but limited
penetration to CNS; X's placenta and is distributed into breast milk; metabolism
- liver ; excretion - feces and urine(minor)
Clarithromycin [Biaxin]
oral: t1/2 = 3-4
hr
better penetration of pulmonary tissue and macrophages compared to
Erythromycin; hepatic metabolism; excretion is feces and urine (minor)
Dirithromycin [Dynabec] - not a
prodrug (active metabolite)
oral: t1/2* = 8
hr
better oral bioavailability compared to Erythromycin; non-enzamatic hydrolysis
to active metabolite Erythromycylamine; excretion - feces and urine(minor)
Azithromycin [Zithromax]
oral, V; t1/2 =
68 hrs
better oral bioavailability compared to Erythromycin; better penetration of
tissues and reaches higher intracellular concentrations (up to 100x greater then
Erythromycin); NOT metabolized**; Excreation - feces and uring(minor)
CIindamycin [CIeocin] -
derivative of lincomycin(too toxic; off market)
oral, parentral,
topical: t1/2
~2.9 hr
MECH: SAME as Erythromycin. SPRECTRUM OF ACTIVITY: Gram +
(anarobic and aerobic)and anaerobic gram - (not for aerobic gram -); S.
Pyogenes; S. Pneumoniae; S. Viridans; Mycoplasma Pneumoniae. KINETICS:
good oral absorption, wide distribution, including bones (limited to CNS); X's
placenta and distributed into breast milk; hepatic metabolism; Excretion - feces
and urine(minor). TOXIC: Psuedomembranous colitis, Nausea, vomiting,
hypersensativity rxn (rashes to stevens-johnson syndrome); thrombosis (V);
Neutropenia (rare hemotological effect)
USE: anaerobic infections; acne; bacterial
vaginosis
Bacitracin - also in aminoglycoside group;
bacteria from tracy; Polymixin B - gram - w/
detergetnt like effect on cell membrane
topical
Polypeptide antibiotic, consisting of a mixture of three components, bacitracin
A (chief), B, and C. MECH: inhibits the incorporation of aminoacids and
nucleotides into the cell wall, inhibiting bacterial cell wall synthesis.
SPECTRUM: gram + cocci and bacilli . No metablism; Renal elimination
TOXIC: hypersensativity RXN; Nephrotoxicty (parentral use) - very severe
USE: topical treatment of skin and skin
structure infections such as minor burns or
skin abrasions; external opthalmic
infections caused by susceptible orgs.
www.brain101.info
1
SYNDROMES
ENVIRONMENTAL CAUSES
ACUTE RADIATION SYNDROME: Radiation
exposure.
o 12 hours post-exposure: Vomiting
o 24 hours post-exposure: Prostration (extreme
exhaustion), fever, diarrhea
o Later: Petechial hemorrhage, hypotension,
tachycardia, profuse bloody diarrhea, maybe
death.
CHINESE RESTAURANT SYNDROME: MSG
reaction ------> Chest Pain, burning sensation over
parts of body.
BROWN-SEQUARD SYNDROME: Damage
(injury) to half of spinal cord ------> symptoms:
o Loss of pain and temperature sensation on
contralateral side of body.
o Loss of proprioception and discriminatory
touch on ipsilateral side of body.
CARDIOVASCULAR
ADAMS-STOKES SYNDROME: Heart block, with
slow or absent pulse, often accompanied by
convulsions.
BARLOW SYNDROME: Floppy Mitral Valve
Syndrome; Massive Mitral Valve Prolapse ------>
Late apical systolic murmur, systolic click, or both.
EISENMENGER'S SYNDROME: Ventricular-
Septal Defect ------> Pulmonary hypertension and
cyanosis.
FLOPPY-VALVE SYNDROME: Mitral
Incompetence due to myxomatous degeneration of the
leaflets.
LERICHE'S SYNDROME: Occlusion of distal
aorta ------>
o Hip, thigh, and calf fatigue.
o Impotence
BEHCET'S SYNDROME: Vasculitis ------>
secondary symptoms:
o Oral and genital ulcers
o Uveitis
o Optic atrophy
SHOULDER-HAND SYNDROME: Pain in
shoulder and swelling in hand, sometimes occurring
after Myocardial Infarction.
SICK SINUS SYNDROME: Chaotic atrial activity;
continual changes in P-Waves. Bradycardia,
alternating with recurrent ectopic beats and runs of
tachycardia.
SUPERIOR VENA CAVA SYNDROME: Caused
by a tumor. Obstruction of SVC ------>
o Edema
o Engorgement of the vessels of face,
neck, and arms.
o Nonproductive cough
o Dyspnea
TAKAYASU'S SYNDROME: Arteritis of the
Aortic Arch, resulting in no pulse. Seen in young
women.
WOLF-PARKINSON WHITE SYNDROME:
ECG pattern of Paroxysmal Tachycardia.
o Short PR interval
o Delta wave = early QRS complex.
IATROGENIC (or Secondary to Medical Treatment)
AFFERENT LOOP SYNDROME:
Gastrojejunal loop obstruction, proximal to a
gastrojejunostomy.
o Ingestion of food produces nausea, pain,
and duodenal distension.
ASHERMAN'S SYNDROME: Adhesions
within the endometrial cavity, causing
amenorrhea and infertility.
o Adhesions probably were caused by
surgery.
ULYSSES SYNDROME: Ill effects from
follow-up diagnostic tests following a false-
positive screening test.
NEOPLASTIC (Malignant or Benign)
CARCINOID SYNDROME: Carcinoid tumor
producing Bradykinin + Serotonin ------>
secondary symptoms:
o Cyanotic flushing
o Diarrhea
o Bronchial spasm
o Edema, ascites.
CRONKHITE-CANADA SYNDROME: GI-
Polyps with diffuse alopecia (hair-loss) and nail
dystrophy.
o May see protein-losing enteropathy and
malabsorption.
GARDNER'S SYNDROME: Multiple
inherited tumors, hereditary dominant trait.
o Skull osteomas, Fibromas, Epidermoid
cysts
o Colonic polyposis (APC gene) ------>
predisposition to colonic
adenocarcinoma.
LAMBERT-EATON SYNDROME:
Progressive proximal muscle weakness
secondary to a carcinoma.
MEIGS' SYNDROME: Fibroma of ovary with
ascites and hydrothorax
PANCOAST SYNDROME: Tumor near
pulmonary apex ------>
www.brain101.info
2
o Neuritic pain of chest and arm
o Muscle atrophy of the arm
o Horner's Syndrome (impaired cervical
sympathetics)
PEUTZ-JEGHERS SYNDROME: Polyposis
(hamartomas) of small intestine
o Also see melanin pigmentation of buccal
mucosa and skin around mouth and lips
CONGENITAL
CEREBELLAR SYNDROME: Congenital
Cerebellar Ataxia
CERVICAL SYNDROME: Supernumerary C7 rib -
-----> Pressure on brachial plexus ------> pain
radiating over shoulder, arm, and forearm over C7
distribution.
DANDY-WALKER SYNDROME: Obstruction of
Foramina of Magendie and Luschka in infants ------>
Hydrocephalus.
DIGEORGE SYNDROME: Congenital absence of
3
rd
and 4
th
Branchial Arches (Thymus and Parathyroid
Glands) ------> secondary symptoms:
o No cell-mediated immunity ------> Frequent
viral and fungal infections
o Characteristic facial deformities
DOWN SYNDROME: Trisomy 21. Mental
retardation, characteristic facial features, Simeon
crease in hand.
FANCONI'S SYNDROME Type I: Bone-marrow
hypoplasia ------> refractory anemia, pancytopenia.
EHLERS-DANLOS SYNDROME: Congenital
defect in collagen.
o Hyper-elasticity and friability of the skin.
o Hyperextensibility of the joints.
FETAL ALCOHOL SYNDROME: Fetal
malformations, growth deficiencies, craniofacial
anomalies, limb defects.
GOODPASTURE'S SYNDROME: Autoantibodies
against basement membranes ------>
Glomerulonephritis (kidney) and hemoptysis (lungs).
o Often, death by renal failure
KLINEFELTER'S SYNDROME: Trisomy XXY ---
---> testicular atrophy, increase in gonadotropins in
urine.
KLIPPEL-FEIL SYNDROME:
o Cervical vertebrate fused
o Congenital short neck, limited neck rotation
o Abnormalities of the brainstem and
cerebellum
o Low hairline.
LESCH-NYHAN SYNDROME: Deficiency of
HGPRT (Hypoxanthine-Guanine Phospho-
ribosyltransferase ------>
o Hyperuricemia, uric acid kidney stones
o Choreoathetosis
o Mental retardation, autism, spastic
cerebral palsy
o X-Linked recessive
MARFAN SYNDROME: Connective Tissue
disorder ------>
o Arachnodactyly: Abnormally long
digits and extremities
o Subluxation of lens
o Dissecting aortic aneurism
POSTRUBELLA SYNDROME: Infantile
defects resulting from maternal Rubella infection
during first trimester.
o Microphthalmos, cataracts
o Deafness
o Mental retardation
o Patent ductus arteriosis, Pulmonary
arterial stenosis
PRADER-WILLI SYNDROME: Short stature,
mental retardation, polyphagia with marked
obesity, sexual infantilism.
RENDU-OSLER-WEBER SYNDROME:
Hereditary hemorrhagic telangiectasia.
SUDDEN INFANT DEATH SYNDROME:
Unexplained death in sleeping infants.
TURNER'S SYNDROME: XO monosomy.
o Dwarfism
o Webbed neck
o Valgus of elbow.
o Amenorrhea
WILSON SYNDROME: Congenital defect in
Ceruloplasmin, leading to buildup of copper -----
-> mental retardation, cirrhosis, hepatolenticular
degeneration.
ENDOCRINE, REPRODUCTIVE
AMENNORRHEA-GALACTORRHEA
SYNDROME: Non-physiologic lactation,
resulting from endocrinologic causes or from a
pituitary disorder.
CONN'S SYNDROME: Primary
Hyperaldosteronism ------> muscular weakness,
hypertension, hypokalemia, alkalosis.
CUSHING'S SYNDROME: Hypersecretion of
cortisol ------> secondary symptoms and
characteristics:
o Fatness of face and trunk with wasting
of extremities
o Buffalo hump
o Bone decalacification
o Corticoid diabetes
o Hypertension
PREMENSTRUAL SYNDROME: Abnormal
sensation in breasts, abdominal pain, thirst,
headache, pelvic congestion, nervous irritability.
o Ocassionally nausea and vomiting.
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3
SHEEHAN'S SYNDROME: Post-partum pituitary
necrosis ------> hypopituitarism.
STEIN-LEVENTHAL SYNDROME: Polycystic
ovary ------> infertility, amenorrhea, hirsutism. Seen
in obese women.
TESTICULAR FEMINIZATION SYNDROME:
Insensitivity to Testosterone. Male
Psuedohermaphroditism
o Complete female external genatalia,
incompletely developed vagina, rudimentary
uterus.
PULMONARY
KARTAGENER'S SYNDROME: Situs Inversus
(lateral transposition of lungs) resulting from chronic
sinusitis and bronchiectasis.
HAMMAN-RICH SYNDROME: Interstitial fibrosis
of the lung.
MIDDLE-LOBE SYNDROME: Chronic
pneumonitis and atalectasis of middle lobe of right
lung.
CHURG-STRAUSS SYNDROME: Allergic
Granulomatous Angiitis: Asthma, fever, eosinophilia.
INFECTIOUS
FITZ-HUGH-CURTIS SYNDROME: Gonococcal
Periphepatitis in woman, as a complication of
Gonorrhea.
GUILLAN-BARRE SYNDROME: Infectious
Polyneuritis of unknown cause.
HUNT'S SYNDROME: Herpe's Zoster infection of
Facial Nerve (CN VII) and Geniculate Ganglion ------
> facial palsy.
o Zoster of ear
REYE'S SYNDROME: Loss of consciousness and
seizures in kids, after a viral infection treated by
aspirin.
REITER'S SYNDROME: Symptom cluster.
Etiology is thought to be Chlamydial or post-
chlamydial.
o Urethritis
o Iridocyclitis (Conjunctivitis)
o Arthritis
o Skin lesions like karatoderma
blenorrhagicum
o Also can see fatty liver or liver necrosis.
SCALDED SKIN SYNDROME: S. Aureus toxic
epidermal necrolysis.
STEVENS-JOHNSON SYNDROME: Erythema
Multiforme complication.
o Large areas of skin slough, including mouth
and anogenital membranes.
o Mucous membranes: stomatitis, urethritis,
conjunctivitis.
o Headache, fever, malaise.
TOXIC SHOCK SYNDROME: Caused by
superabsorbent tampons. Infection with Staph
Aureus and subsequent toxicity of exotoxin
TSST ------> systemic anaphylaxis.
o Fever, vomiting, diarrhea
o Red rash followed by desquamation
WATERHOUSE-FRIEDRICHSON
SYNDROME: Meningeococcal Meningitis ------
> DIC, hemorrhagic infarct of adrenal glands ----
--> fulminant adrenal failure.
o Vomiting, diarrhea.
o Shock
o Extensive purpura, cyanosis, circulatory
collapse.
RENAL
KEMMELSTIEL-WILSON SYNDROME:
Diabetic Glomerulosclerosis.
BARTTER'S SYNDROME: Juxtaglomerular
Cell Hyperplasia ------> secondary symptoms:
o Hyperaldosteronism, Hypokalemic
Alkalosis, elevated renin and
angiotensin
o No hypertension.
o Compare to Conn's Syndrome
FANCONI'S SYNDROME Type II: Renal
aminoaciduria, glycosuria, hypophosphaturia,
cysteine deposition, rickets.
THORN'S SYNDROME: Salt-losing nephritis.
NEUROLOGICAL
CARPAL-TUNNEL SYNDROME:
Compression of Median Nerve through the
Carpal Tunnel ------> pain and parasthesia over
distribution of Median N.
FROIN'S SYNDROME: Block in CSF flow ----
--> xanthochromia (yellow discoloration) of
CSF.
ACUTE-BRAIN SYNDROME: Delirium,
confusion, disorientation, developing suddenly in
a person that was previously psychologically
normal.
GERSTMANN'S SYNDROME: Lesion
between occipital area and angular gyrus ------>
symptoms:
o Finger agnosia, Agraphia, acalculia
o Right-left disorientation
HORNER'S SYNDROME: Loss or lesion of
cervical sympathetic ganglion ------>
o Ptosis, miosis, anhydrosis
o Enophthalmos (caved in eyes)
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4
KORSAKOFF SYNDROME: Loss of short-term
memory in chronic alcoholism, caused by
degeneration of mamillary bodies.
RILEY-DAY SYNDROME: Familial dysautonomia.
GASTROINTESTINAL
MALLORY-WEISS SYNDROME: Laceration of
lower end of esophagus from vomiting ------>
hematemesis. Often seen in alcoholics.
MALABSORPTION SYNDROME: Impaired
absorption of dietary substance ------> diarrhea,
weakness, weight loss, or symptoms from specific
deficiencies.
BARRET SYNDROME: Chronic peptic ulcer of the
lower esophagus, resulting in metaplasia of
esophageal columnar epithelium ------> squamous
epithelium.
ZOLLINGER-ELLISOHN SYNDROME: Gastrin-
secreting tumor in pancreas ------> Severe peptic
ulcers, gastric hyperacidity.
PLUMMER-VINSON SYNDROME: Esophageal
Webs, leading to dysphagis and atrophy of papillae of
tongue.
o Also see hypochromic anemia,
splenomegaly.
RETICULOENDOTHELIAL, HEMATOLOGIC
BANTI'S SYNDROME: Chronic Congestive
Splenomegaly with anemia, caused by either Portal
Hypertension or Splenic Vein Thrombosis.
BUD-CHIARI SYNDROME:
o ACUTE: Hepatic Vein Thrombosis ------>
Massive ascites and dramatic death.
o CHRONIC: Gradual hepatomegaly, portal
hypertension, nausea, vomiting, edema,
ulimately death.
DUBIN-JOHNSON SYNDROME: Defect in
excretion of conjugated bilirubin ------> recurrent
mild jaundice. Buildup of direct builirubin in blood.
CHIDIAK-HIGASHI SYNDROME: Abnormalities
in leukocytes with large inclusions.
CRUVEILHIER-BAUMGARTEN SYNDROME:
Symptoms cluster:
o Liver cirrhosis
o Caput Medussae
o Venous hum and thrill
FELTY'S SYNDROME: Rheumatoid Arthritis with
splenomegaly, leukopenia, anemia, and
thrombocytopenia.
LOFFLER'S SYNDROME: Eosinophilia with
transient infiltrates in lungs.
UNCATEGORIZED
YELLOW-NAIL SYNDROME: Stop growth
of nails ------> increased convexity, thickening,
and yellowing of nails.
o Found in Lymphedema, bronchitis,
chronic bronchiectasis.
COSTOCHONDRAL SYNDROME: Pain in
chest with tenderness over one or more
costochondral junctions.
o Similar to Tietze's Syndrome but no
specific inflammation.
TIETZE'S SYNDROME: Costochondritis.
Swelling and tenderness of the costal cartilege.
MIKULICZ'S SYNDROME: Salivary and
lacrimal enlargement as seen in several diseases:
o Sarcoidosis
o Tuberculosis
o Leukemia
MUNCHAUSEN SYNDROME: Malingering -
- fabrication of a clinically convincing disease by
an itinerant malingerer.
PICKWICKIAN SYNDROME: Symptom
cluster
o Obesity
o Hypoventilation
o Somnolence
o Erythrocytosis
RESTLESS LEGS SYNDROME: Need to
stretch legs at night before going to sleep; twitch
in legs causing insomnia.
STRAIGHT BACK SYNDROME: Loss of
normal kyphosis of thoracic spine ------>
o Straight spine
o Ejection murmur
o Widened cardiac silouhette on x-ray
SJGREN'S SYNDROME: Autoimmune
complex
o Keratoconjuctivitis Sicca (dry eyes and
mouth)
o Dryness of Mucous membranes
o Telangiectasias in face
o Parotid enlargement
1 www.brain101.info
Tutti Frutti - Step 1
Graphs, Radiology, Slides, etc:
Quality of x-rays, great; quality of histo +-; quality of macro
satisfactory; quality of diagrams, too small (at least for me,
extremely difficult to read letterheads); quality of graphs
(curves, drugs) simple and understandable
*: right ans
1. CXR w/pneumothorax, also obvious from q stem
2. CTA, asked about liver perfusion, ?position intraart cath for
injection: radiologist inserted catheter through _fem artery,
aorta, celiac _ proper hepatic artery
3. Cerebral angiography; clinica of ACA infarct (leg), show artery
on cerebral angiography
4. Cervical rib - cervical spine x-ray, obvious symptoms from q
stem
5. Calcific tenditinis on shoulder x-ray, ?calcification:
?supraspinatus* ?subscapularis
6. Infant w/Hx of perinatal infection, non communicating
hydrocephalus, sagittal MRI, show site of obstruction:
_aqueductal stenosis*
7. Large SDH (acc to brain CT image); cannot exclude Epidural;
however after following day/24h..LOC, interval pt was
lucid, asked about what ruptured, both choices: middle
mening art (epi) and bridging veins (SDH); tricky
8. Endometrial ca path micro (even not related to q); MOA
estrogen* as carcinogen
9. 35 y o female, CIN slide, multiple partners, asked about assoc _
HPV
10. Diarrhea, slide w/probably Giardia, asked about cause of
malabsorption sy
11. History of HIV w/ abn CSF(meningitis like, lymphocytes etc) and
multiple ring enhancing lesions of varying sizes on CT (not
showed, just described on q stem); showed histo slide (not India
ink), ?bug: ?nocardia, ?toxoplasma, ?cryptococcus
12. Brainstem lesion- gross, show area according to clinica
13. Arrow on aqueduct of Sylvius -gross anatomy, ?lesion at this
level; non-communicating hydrocephalus*
14. Diagram about protein translation
15. Drawing of alveolar wall (quite bad) which cell of the horrible
diagram is a pneumocyte type II
16. EM slide: asked about connexons
17. EM slide: show desmosome, asked about function
18. Multiple myeloma path micro, asked about pathogenesis
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19. ECG with extrasystole, choose the strongest complex (immediate
after extrasystole*)
20. Gross spinal lesion in dorsal columns (same as CD) asked about
pathogenesis
21. LOTS of physio diagrams
22. Celiac disease; path slide; asked about protein malabsorption (?)
23. Gross kidney + staghorn calculus, asked about bug: Proteus*
24. Gross kidney, young boy + Tu: asked about tu supp gene: WT1
25. Picture of pt w/superficial varices in lower extremity,
?pathogenesis (?stasis, ?insuff valves, ?chronic DVT)
26. Picture w/vesicles within great toe of kid.? Perhaps HSV,
asked about virus: ans incl shape, dna/rna, single/double strand
but did not mention the virus
27. Pedigree of Duchennes in a girl (Mec of inheritance)
28. Picture with child w/blue sclera (OI), asked about pathogenesis
29. Funduscopy of diabetic pt
Pathology + Physiology:
1. Pt described with hematuria, flank mass,?disease: Renal cell ca
(hypernephroma*)
2. Pt with vertebral compression # + multiple blastic lesions, most
likely? Metastatic prostate adenoca
3. Pt w/Hx of working in an asbestos factory + heavy smoker, now
SIADH + weight loss ?small cell* ?mesothelioma
?bronchioalveolar
4. Pt w/abn CSF, lymphocytosis, cranial nerve palsies,? most likely:
TB meningitis*
5. Pt w/severe osteoporosis: arrows for PTH, ca++, P,etc know this
table from BRS path very well..at least 2 or 3 qs
6. Newborn at term, infant of diabetic mother, resp distress,?most
likely: Meconium aspiration sy
7. Described pt suffering from Horners sy, etc ?underlying
disease: Lung ca*
8. Description child w/findings consistent w/ nephrotic sy ,
urinanalysis? ovoid fat cells*, RBCcasts, WBC casts etc
9. Atrophic pancreas + calcifications on CT, ?underlying disease:
?alcoholism*, ?gallstones
10. Pt w/incr amylase, midepigastric pain, known cholelithiasis;
?etiology: ?cbd stone, stone in ampulla?, stone in cystic duct?
11. Bartholins abscess
12. Pt w/hydatiform mola, ?karyotype
13. Pt a month after resection of hydatiform mola, incr hCG, ?
chorioca ?residual placenta
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14. Type of diarrhea in AIDS pt
15. Type of diarrhea in Immunocompromised
16. AIDS pt +ring enhancing lesions on CT, abn CSF, +path slide;
not India ink!, ?Nocardia, ? Toxoplasma ? Cryptococcus
17. Von Willebrand /ITP/TTP 3 or 4 qs w/different values of incr,
decr or N PT, PTT, etc know this well
18. Female 80 yo, on X-rays Dx of OA, pt with articular + muscular
pain, given NSAID, got better, ?mostlikely: ?polymyalgia
rheumatica ?RA
19. Boy with large polyp in rectum containing different tissue types:
?hamartoma, ?Angiomyolipoma etc
20. What happens to GFR, RPF, etc if u constrict efferent arteriole
(arrows)
21. Soccer player injured, ligamentous rupture; didnt wan to move,
died week after,?most likely at autopsy: ?large PE*, ?small PE
22. Female w/URI, a week after presented w/pain described to me
sounding like (relieve when she lies like muslin praying etc)
pericarditis*
23. Pancreatic secretion as prohormone/proenzyme (dont
remember): insulin + peptide C
24. Coupling actin/myosin, ryanodine receptor, at least 2 or 3 qs
25. Most precise for diagnosis of DIC? Incr fibrin degradation
products*
26. Melanoma, ?worst prognosis: vertical growth*
27. s/p tear muscle, fibrosis at scar, what would be affected?
Tension? relaxation? Etc
28. s/p terminal ileum resection, what would be affected? Lipid
absorption*? Intrinsic factor secretion?( READ the stems VERY
carefully.many of u ans very quicklyand I remember LOTS
of qs that were like this one.vit B12 absorption would be
impaired but not secretion..)
29. Pt w/HCCa, single test that would be most diagnostic: HCV* (no
option w/HBV)
30. Infant with retinal hemorrhages, fell from sofa while mother
boyfriend was taking care of him: Shaken baby sy*(theres an
identical qs in webpath.)
31. Patient described w/bilateral hilar lymphadenopathy, bilateral
parenchymal infiltrates, epitheliod cells, no fever, etc (sarcoidosis
*, TB not an optionsimilar q in BRS)
32. Pt w/testicular tu? Assessment spread, whats better: ?CT abdo,
?CT pelvis, (tricky/bad q)?palpate ingu. LNetc
33. Pregnant female w/Sheehans sy ?pathogenesis: ?ac interruption
hypophyseal portal system*, ?slow interruption etc
34. Inhibin regulates?: FSH*
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35. N pt w incr pH (7.6), decr bicarb, what mixture is
breathing:?20% O2, 75% CO2, 5%N2?; N2 75%, 5% CO2;
20% O2?
36. Hb shift to the right: Metabolic alkalosis, graph
37. Pt w/ systolic murmur, thrill apex, etc ?VSD*
38. Female from SE Asia, pregnant, murmur described as MVP,
?pathogenesis
39. Calculate SV from Ficks principle
40. 16 yo girl w/1
o
amenorrhea, 1.40m 45kg, ?most likely ovarian
appearance: ?atrophy* (Turners), ?policystic
41. Endometrial ca
42. Pt w/known gralized complex sz; now described w/partial sz
(only hand etc), where is the focus? temporal lobe*
43. Pt goes for routine check up on thread mill, ST elevation,
coronary art OK on angiocath, ? which TX, with arrows: to decr
afterload, decr CO etc
44. Headaches types. Migrainewoman vomits, etc at least 3 or 4
qs about headaches
45. Cluster headache *: M.C in men
46. Barbiturates intoxication, ?typical liver findings on
biopsy/autopsy: incr SER* (BRS path)
47. To prevent reperfusion injury in mice (during experiment): give
antioxidant 1h before, just before injury etc
48. Factor XIIa*: links coagulation, kinin and complement
49. AAA incr risk for damage in/after surgery?, sigmoid colon?,
jejunum?, ileum? cecum?
50. Length, tension, force velocity relationship
51. Calculate diffusion or not, given weird numbers of hydrostatic P,
oncotic P etc
52. Hyperaldosteronism, different forms, many qs
53. HyperPTH, osteoporosis, ca++, P and PTH relationship
w/arrows, at least 3qs
54. Diabetes, lots of qs, receptor for insulin, receptors for
sulfonylureas, glucophage/lactic acidosis, Tx etc, HY!
55. Child w/GI hemorrhage, chronic anemia, given H2 blocker, gets
better, ?most likely disease: GE reflux*
56. Ca thyroid _ radiation exposure*
57. CF, ?receptor: transmembrane conductance regulator*
58. Constriction efferent arteriole, ?consequences: incr GFR, decr
RPF, incr filtration fraction (in arrows)
59. Drug which incr bronchial dilatation and decr heart rate, +
other (?x) etc?isoproterenol? other? Not mentioned on q stem
name of first drug..kinda weird
60. which option would incr concentration of 1 25 DHD3?
Hypocalcemia*(similar in Gannong)
61. Hypoxic vasoconstriction, ?Site: lungs*
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62. Patient w/multiple skin ca types,? pathogenesis: defective dimers
repair*
63. Decr FEV1sec/FEV relationship, in obstructive disease, asthma
64. Alcoholic + thyamine deficiency, ?findings in autopsy:
destruction of mamillary bodies*.
Anatomy:
1. Infant described w/hydrocele (transillumination etc),
?pathogenesis: patent processus vaginalis*
2. Fx medial humeral epicondyle, ?nerve injury: ulnar nerve*
3. Ant compartment sy, lower extremity, ?damage: tibial artery*,
deep peroneal nerve* (2qs)
4. Pudendal block for delivery: landmark, ischial spine*
5. Injury upper trunk of brachial plexus, 2 qs
6. Stillborn, olygohydramnios, lung hypoplasia, ?most likely:
kidneys agenesis* (Potter)
7. Hydronephrosis + hydroureter in newborn, ?pathogenesis _Post
urethral valves BUT they wrote instead: congenital stenosis of
membranous urethra*
8. Pt lies supine, with flexed knee, we ask to raise his leg against R
about his thigh, ? which muscle are we testing: ?quadriceps
femori, ?iliopsoas, etc
9. Dye passes between cells: connexons* (HY!)
10. S/p thyroidectomy, pt described w/tetany symptoms, ?Tx: give
ca++ (*)
11. PTH, on surgery, found only 2 sup and 1 inf parathyroid glands,
where to look for the 4
th
missing one? Thymus*
12. Barbiturates toxicity, pathology in liver? Incr SER*
13. Elderly pt with distended SB on AXR and large bowel just to
mid transverse colon, lactic acidosis, ?most likely: SMA
occlusion*
14. How we get retropneumoperitoneum, location of perforation:
ascending colon*, jejunum, ileum, cecum, sigmoid
15. Pt described w/huge hiatal hernia, ? associated symptoms:
?lymphatic obstruction*, ?incr vagal activity, ?DVT, varicocele
etc(no GER, or GI symptoms mentioned)
16. Embriology middle ear, 1
st
arch?, 1
st
cleft?, 1
st
pouch?, 2
nd
arch?
17. Why females get more peritonitis from STD?, fallopian tubes
open within the peritoneum*
18. Meiosis I: 1
o
oocyte +- mitotic spindle? 2
nd
oocyte? Etc
19. Innervation by chorda tympani: 2/3 post tongue +
submandibular+submaxill glands*
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20. Macrophages of liver: Kupffer cells* (Kidney - mesangial cells/
Lungs - alveolar macrophages/ Brain - microglial cells/ Lymph -
circulating macrophages)
21. PDA closure noted on fetal US,? Drug mother took:
indomethacin*
22. In which part of the adrenal gland mineralocorticoids are
secreted? Zona glomerulosa*
23. Description of 16 y old w/primary amenorrhea, short slightly
overweighted (this mentioned just in measurement), poor
secondary sex charact, , if u biopsy ovaries, what would u see?
Atrophy?; polycystic ovaries?.etc (there were 2 qs one was
clearly Turner.the other might be polycystic ovaries as well)
Biochemistry:
1. Alkaptonuria, ?parents asked u about long term prognosis:
?arthritis*, ?renal calculi
2. Pathogenesis of CGD of childhood
3. Menkes disease, MOA
4. In which part of the cell removal of the introns from mRNA take
place?: nuclei*?, RER? Golgi? Etc
5. CF, MOA receptor, CF transmembrane conductance regulator
gene _ defect in Cl- channels* (CF is HY, many qs)
6. SCD (but not in q stem), they said disease caused by substitution
val for glu, question about which type of bond of bond is
affected.
7. Mother Hx of myelomeningocoele, son with MMC, which
vitamin decreases risk for this abnormality? Folate*
8. Hypercholesterolemia, ?pathogenesis: ans description of LDL
receptor (Receptors and second messengers r extremely HY!)
9. tRNA wobble diagram, asked to show site of different functions
(2 qs..similar q in retired or self test)
10. Fetal alcohol sy: 2 qs
11. Tx child with hyperammonemia, etc
12. ?Reason some pts get lactic acidosis post alcohol
ingestion.know everything u can about OH
13. McArdles described, ? enzyme: muscle phosphorilase
14. Von Gierkes*, description disease
15. Drawing IG, where does the Ag bind?
16. Multiple skin ca (xeroderma pigmentosum), ?whats wrong;
DNA repair defect*
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17. Mother has 2 y old son w/ MPS w/ decr iduronidase and w/N
chromosomes, now she is pregnant again, amniocentesis is done,
demonstrated decr iduronidase, what else is necessary to be
done: ?check for MPS in amniotic fluid*, ?chromosomal
analysis, ?fetal biopsy of the liver, ?mothers liver biopsy
18. Prader Willi sy, paternal imprinting, microdeletion 15q*
Beh. Sciences:
1. Pt described w/delirium* post cholecystectomy
2. Girl with IDDM, not compliant, feel embarrassed about disease,
etc
3. Informed consent, 2qs
4. Calculate odds ratio, all values were not given in tables, u have to
make ur own table and understand where in the q stem u have to
pick the valuesvery imp!! Lots of qsthis is not difficult and
worth knowing this..of course for everything sensitivity,
specificity, PPV, NPV etc
5. Asked about a new test, check values glucose many times, given
the measurements, what r u checking; ?precision*, ?accuracy
6. Test with high specificity is useful to confirm a diagnosis
7. Clinical trial described u have to choose it from the options
8. Power
9. Boy w/ADHD, last year at school, he did ok, present year not,
who is ashamed: ?teacher, ?parents etc (doctor at least not
mentioned)
10. Bipolar disorder (student says her project would save the world,
doesnt sleep, etc..1 y before, 1month depressed all time in bed..)
11. Adolescent pt w/symptoms of depression, highest risk for suicide
attempt: previous attempt w/ASA
12. Asked about narcissistic personality
13. Schyzoid pt? Schizophrenia?, etc
14. Woman doesnt want to have sex more than once in 2 months;
?name of disorder
15. 8 y o girl with pain etc in introitum, doesnt allow physician to
check that area, starts yelling not again, Dr asks about abuse,
mother gets upset, wants to leave the room, what do u do next:
?inform the mother that she has to stay until u check the girl
adequately, ?Call security.
16. 20 y o pt with ribs fractures, bruises etc while checking her she
realized its late, and she says she has to go back home, if not her
husband gets very upset, how do u approach her?
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17. 30 + y o, mom of 3 kids, says she feel hopeless, cries all days, etc,
?TX
18. Pt referred for primary amenorrhea, eventually she is XY, and
how do u explain this to the patient?
19. Pt w/ breast lesion on palpation, what do u tell the patient: feel
something there, u dont know what is it, so u would like her to
have a mammo done (most reasonable option)
20. Tx of bulimia
21. Pt w/certain ca type, according to statistics: 1y sv: 90%; 2y SV:
85%; 3y SV:80%; 4y:75%; 5y sv: 70%*; pt has this ca for 2 y,
?survival by 5y .this is very simple when u talk about survival
u dont have to make calculations.it doesnt matter how many
years that pt has the disease
22. Q about Chlamydia in students, prevalence decrease /increase of
what? (options incl they treat more pts, less awareness (dont
remember exactlyso they described u several situations that
might cause these changesso u need to understand what they r
talking about, very HY epidemiology/stats!)
23. Old male with classical podagra symptoms, + incr ESR, u have
to TX w/steroids, lots of AE to this TX, what makes u decide to
biopsy?: If its going to change management*?, to show medical
student? etc
24. Narcolepsy
25. Pt that does what she wants goes and chat all time at nurse
station, etc, how do u treat this pt? be assertive
26. Elderly pt recovered from CVA, pt speaks slowly, daughter says
he is depressed, bad mood, etc, ?what do u do next: ?ask the
patient* (ALWAYS whenever possible), ?ask the nurses etc
27. Person who committed brutal suicide, which NT is decr?
Serotonin, ?NE
28. Scheme about sensitivity, etc similar to CD
29. Phenotype mentally retarded, fragile X, at least 3 qs of fragile X.
30. Most important preventable cause of cancer: smoking
31. Depression
32. Normal grieving
Micro, Immuno:
1. Pt w/CF and bronchiectasis, gets pneumonia, ?bug: P.
aeruginosa
2. HZV, why do u give acyclovir? To reduce duration and severity
of symptoms of present disease
3. virus: description disease, asked about etiology: virus not
mentioned just morphologic description: DNA/ RNA, double or
9 www.brain101.info
single stranded, icosahedral, naked etc (3 or 4 qs like this, 1
w/HSV, 1 w/mumps, 1w/exanthema subitum)
4. Female from NW USA, gets cardiomyopathy? Etiology? Viral?
Bacterial..
5. Nasopharyngeal ca a/w: EBV
6. Girl from rural area, no immunizations, doesnt go to school,
sore throat, high fever, exudative membranes-likes (not
pseudomemebarnes; ? diphtheria, ?Group A strep (it seemed to
b diphtheria..esp since they said no immunization, similar qs in
Pretest vignettes)
7. boy 13 y o, swims every morning, on physical exam, pain why u
press tragus, pain EAC, etc ?Bug; pseudomona
8. Nurse with sinusitis and air-fluid level on x-rays; bug needed
factor V and X, ?source: from hospital?, from patient? N flora
from nares?, N flora from nasopharynx?
9. Ig A deficiency vs. Hyper Ig M syndrome
10. Boy and brother get meningococcus, ?deficiency (late
Complement)
11. Pt described w/HZV, Gramm and Wright stains
done?findings.multinucleated giant cells
12. Experimental mice w/Brutons tirosinase deficiency, which bug r
they more prone to get infections from?
13. CIN a/w HPV
14. Picture w/staghorn, ?bug: proteus
15. Mother gets a cold, her child gets a more compl disease a week
later w/symptoms like epiglottitis; ?bug: ?parainfluenza, ?RSV
16. Which bugs are used for quality control of a laboratory: ?E.coli
+ H.influenza, ?E.coli +.
17. Pt went to Africa, came back w/malaria, given 2 drugs incl
primaquine, ?why
18. Pregnant female gets CMV, ?perinatal infection, ?congenital
infection etc
19. CGD described, pathogenesis?
20. HIV, why Tx w/3 drugs? For high frequency of mutational R
21. Giardia slide _ malabsorption
22. CD4 _ MHC II
Pharmaco:
1. Pt treated for severe trychophytosis w/griseofulvin, what other
drug works at the same timing? Paclitaxel
2. MOA acetazolamide
10 www.brain101.info
3. MOA tiazides
4. MOA loop diuretics (diuretics HY)
5. Male w/CHF, gets gynecomastia, ? drug: spironolactone
6. Tx: nephrogenic DI
7. Pt Tx w/captocril, cant stand cough _ Losartan
8. tricyclics + urinary retention
9. Pt w/agranulocytosis: Tx: G-CSF
10. Pt with documented severe allergic reaction to penicillin, what
do u give? Cephalosporins? Aztreonam? Vanco?
11. MOA Cyclosporine (asked which one suppresses IL-2.)
Cyclosporin A - direct suppressive effect of B and T helper cells.
12. Tx Hay fever; choose MOA DOC
13. MOA antihistaminic drug
14. MOA Sulfonylureas
15. INH _ hepatitis
16. Procainamide + SLE
17. Flumazenil, diagram, ?competitive antagonist: chlordiazepoxide
18. heroin, now on methadone program, ?adverse effects;
?constipation, SE methadone: constipation
19. Pt treated w/captopril, get cough, change to similar: losartan
20. Prophylaxis contacts w/meningococcus: Rifampin
21. Anions, cations, + acetazolamide
22. Classic: Nortryptiline + MAO inh
23. Nitrates MOA (molecular level) activate guanylate cyclase NO
24. Amiodarone, AE: pulmonary fibrosis
25. Milrinone
26. Female 30w pregnant, on prenatal US ductus is closed, ?drug
given: indomethacin
27. Showed diagram of stomach physiol.asked which drug acts on
H2 receptorscimetidine
28. Spindle poisons _ plant alkaloids
29. Tx addisons: fludrocortisone + glusocortic
30. tPA + MOA intrinsic plasminogen? Extrinsic?
Exogenous.kinda confusing
31. 2 curves with effect of 2 drugs X and Y why is Y steeper and
lower than X? because of quicker reabsorption/ elimination/
bioavailability volume of distribution.. etc
32. Antagonist drug response curve
33. Parathion poisoning;atropine + ? = Pralidoxime
34. Tx migraine in asthmatic
35. Description of pt. having Absence seizures, Tx? Ethosuxomide
36. Adverse effects of lovastatin _ muscle pain.
www.brain101.info 1
USMLE/COMLEX Most Common
Addisons Autoimmune (2
nd
infection)
AMI - children Kawasaki disease
Aneurysm Abdominal aorta
Aneurysm of Circle of Willis Anterior communicating a.; bitemporal hemianopsia
AV fistula Penetrating knife wound.
Blindness Diabetic retinopathy
Blindness - preventable Chlamydia
Breast Mass Fibrocystic Change Carcinoma is the most common is post-menopausal women
Bug in Acute Endocarditis Staph aureus
Bug in Bacterial Arthritis in young Adults Neisseria ghonorrhea
Bug in Bacterial Meningitis elderly Strep pneumoniae
Bug in Bacterial Meningitis newborns E. coli
Bug in Bacterial Meningitis toddlers Hib
Bug in Bacterial Meningitis young adults Neisseria meningitidis
Bug in debilitated, hospitalized pneumonia pt Klebsiella
Bug in Epiglottitis Hib
Bug in food poisoning Staph aureus
Bug in GI Tract Bacteroides 2. E. coli
Bug in IV drug user bacteremia / pneumonia Staph aureus
Bug in opportunistic infection of AIDS CMV Pneumocystis carinii is most common overall
Bug in PID N. Gonnorrhoeae or Chlamydia
Bug in Pneumonia - Community - typical Strep pneumoniae 2. H. influenza 3. Klebsiella
Bug in Pneumonia - Hospital aquired Klebsiella 2. Psuedomonas 3. E. coli
Bug in Pneumonia - Community - atypical Mycoplasma 2. Legionella
Bug in Subacute Endocarditis Strep Viridans
Cancer - Leukemia - <14 yo ALL
Cancer - Leukemia - >60 yo CLL
Cancer - Leukemia - 15 -39 yo AML
Cancer - Leukemia - 40 -60 yo CML
Cancer in Gynecologic - malignancy Endometrial Carcinoma
Cancer in Infancy Hemangioma
Cancer in Kids Leukemia 2. Medulloblastoma of brain, cerebellum
Cancer in Men Prostate CA
Cancer in Women Leiomyoma aka fibroids
Cancer in Women - malignant Breast CA
Cancer of the Adrenal Medulla adults Pheochromocytoma
Cancer of the Adrenal Medulla kids Neuroblastoma
Cancer of the Appendix Carcinoid - rare metastasis
Cancer of the Bone Metasteses from Breast & Prostate
Cancer of the Bone - primary - adults Multiple Myeloma
Cancer of the Brain Child Medulloblastoma (cerebellum)
Cancer of the BrainAdult Astrocytoma (including Glioblastoma Multiforme) then: mets, meningioma, Schwannoma
Cancer of the Breast Infiltrating ductal adenocarcinoma
Cancer of the Connective Tissue -benign Lipoma
Cancer of the Esophagus Leiomyoma
Cancer of the Esophagus SCCA
Cancer of the Esophagus - malignant SCC (60%) > adenocarcinoma (40%)
Cancer of the Heart - adults Metasteses
Cancer of the Heart - Primary adults Myxoma Ball Valve
Cancer of the Heart - Primary kids Rhabdomyoma
Cancer of the Liver Metastasis; lung > GI
Cancer of the Liver - benign Cavernous hemangioma
Cancer of the liver - Primary Hepatocellular CA
Cancer of the liver - Primary, benign Cavernous Hemangioma
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Cancer of the Mouth SCC or Mucoepidermoid CA
Cancer of the Mouth - upper lip Basal Cell CA
Cancer of the Nasal cavities SCC
Cancer of the Ovary - benign Serous cystadenoma
Cancer of the Ovary - malignant Serous cystadenocarcinoma
Cancer of the Pancreas Adeno (usually in the head)
Cancer of the Pituitary Prolactinoma (2
nd
Somatotropic Acidophilic Adenoma)
Cancer of the Placenta - benign Cavernous hemangioma
Cancer of the Salivery Glands Pleimorphic Adenoma
Cancer of the Skin Basal Cell Carcinoma
Cancer of the Small Bowel Carcinoid - frequent metastasis from ileum
Cancer of the Spleen - benign Cavernous hemangioma
Cancer of the Stomach Gastric Adenocarcinoma; intestinal type or diffuse type
Cancer of the Testicles Seminoma
Cancer of the Thyroid Papillary Carcinoma
Cancer that invades the Female GU tract Endometrial Adenocarcinoma
Cancer; malignant lymphoma in kids Burkitt's lymphoma
Cancer; Site of metastasis Regional Lymph Nodes
Cancer; Site of metastasis (2
nd
most common) Liver
Cancer;Genetic Alteration p53
Cardiomyopathy Dilated (Congestive) Cardiomyopathy
Carpal bone dislocation Lunate
Carpal bone fx Scaphoid
Chromosomal disorder Downs
Cirrhosis Alcohol
Congenital Adrenal Hyperplasia 21-Hydroxylase Deficiency then, 11-
Congenital cardiac anomaly VSD membranous > muscular
Congenital early cyanosis Tetralogy of Fallot
Congenital GI anomaly Meckel's diverticulum
Coronary Artery thrombosis LAD
Cushings Exogenous Steroid Therapy (then, primary ACTH, Adrenal Adenoma, Ectopic ACTH)
Death in Alzheimer pts Pneumonia
Death in Diabetics MI
Death in HTN AMI 2. lenticulostriate stroke 3. renal failure (benign nephrosclerosis)
Death in SLE pts. Lupus Nephropathy Type IV (Diffuse Proliferative)
Death in USA Ischemic Heart Disease
Dementia Alzheimers 2. Multi-Infarct Dementia
Demyelinating Disease Multiple Sclerosis
Diarrhea - children Rotavirus
Dietary Deficiency Iron
Disk herniation L4-L5
End-stage Renal Disease Diabetes
Enzyme deficiency 21 hydroxylase - 95% of CAH
Fatal genetic defect in Caucasians Cystic Fibrosis
Form of Amyloidosis Immunologic Bence Jones protein in multiple myeloma is also called the Amyloid Light Chain
Form of Tularemia Ulceroglandular
GI obstruction Adhesions 2. Indirect inguinal hernia
Glomerulonephritis IgA nephropathy aka Berger's
Heart Murmur Mitral Valve Prolapse
Heart Valve in bacterial endocarditis Mitral
Heart Valve in bacterial endocarditis
in IV drug users
Tricuspid
Heart Valve involved in Rheumatic Fever Mitral > Aortic
Hereditary Bleeding Disorder Von Willebrands Disease
Hernia Indirect
www.brain101.info 3
Hypercalcemia hyperparathyroidism
Hyperparathyroidism - Primary Adenomas (followed by: hyperplasia, then carcinoma)
Hyperparathyroidism - Secondary Hypocalcemia of Chronic Renal Failure
Hypertension Essentail (95%) 2. Renal disease
Hypertension - children Renal disease; cystic disease, Wilm's tumor
Hypertension - young women Oral contraceptives
Hyperthyroidism Graves' Disease
Hypopituitarism - adults Nonfunctioning pituitary adenoma
Hypopituitarism - kids Craniopharyngioma
Hypothyroidism Hashimoto's thyroiditis
Intussusception terminal ileum into cecum
Liver Disease Alcoholic Liver Disease
Liver infection Viral Hepatitis - HVA
Location of Adult brain tumors Above Tentorium
Location of Childhood brain tumors Below Tentorium
Lysosomal Storage Disease Gauchers
Mental retardation Downs or Fragile X , Fetal alcohol syndrome
Motor Neuron Disease ALS
Myocarditis Coxsackie B virus
Nephrotic Syndrome - adults Membranous Glomerulonephritis
Nephrotic Syndrome - kids Minimal Change Disease
Opportunistic infection in AIDS PCP
Peripheral Neuropathy Diabetes
Portal Hypertension Cirrhosis
Protozoal Diarrhea Giardia
Pulmonary HTN COPD
Renal Failure Acute tubular necrosis
Right Heart Failure Left heart failure
Secondary Hypertension Renal disease
Sexually transmitted disease Chlamydia
SIADH Small Cell Carcinoma of the Lung
Single Gene Disorder Thalassemia
Site of Diverticula Sigmoid Colon
Sites of atherosclerosis Abdominal aorta > coronary > popliteal > carotid
Surgical Emergency Acute Appendicitis
Thyroid disease Goiter
Tracheoesophageal Fistula Lower esophagus : trachea / Upper esophagus : blind
pouch
Type of Hodkins Mixed Cellularity versus: lymphocytic predominance, lymphocytic depletion, nodular sclerosis
Type of Non-Hodgkins Follicular, small cleaved
Vasculitis (of medium & small arteries) Temporal Arteritis
Viral Encephalitis HSV
Worm infection in US 1. Pinworm 2. Ascaris

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Pulse Pressure = Systolic Diastolic

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