today we continue on 5/5
still on pulmonary in diagnostics and psychiatry in pharm
____________________________________



these are pulmonary function tests. the patient gives a max exhalation after a max inhaltion. that is the FVC, or forced vital capacity. A normal person should be able to exhale at least 80% of the air in one second or FEV1

in the obstructive pattern as seen on the graph, you see a decrease in the FEV1 and FVC, however FEV1 decreases even more. This gives an abnromally low ration of FEV1 to FVC of <90%. The residual volume goes up and that is why the pt gets a barrel chest and a flat diphragm. This is caused by COPD. in lay man's terms as I struggled with this, ppl in COPD have alot of air trapped that they can't get rid of that is what is called residual volume
FEV1 - Forced Expiratory Volume in One Second - this is the volume of air which can be forcibly exhaled from the lungs in the first second of a forced expiratory manuever. It is expressed as liters. This PFT value is critically important in the diagnosis of obstructive and restrictive diseases.
FVC - Forced Vital Capacity - after the patient has taken in the deepest possible breath, this is the volume of air which can be forcibly and maximally exhaled out of the lungs until no more can be expired. FVC is usually expressed in units called liters. This PFT value is critically important in the diagnosis of obstructive and restrictive diseases.
FEV1/FVC - FEV1 Percent (FEV1%) - This number is the ratio of FEV1 to FVC - it indicates what percentage of the total FVC was expelled from the lungs during the first second of forced exhalation - this number is called FEV1%, %FEV1 or FEV1/FVC ratio. This PFT value is critically important in the diagnosis of obstructive and restrictive diseases.
..
the other graph with the restrictive pattern
. all the volumes are diminished, but they are diminished proportionately to all the ratios stay normal. restrictive lung disease is caused by interstitial fibrosis.

the PFT is the most accurate way to distinguish obstructive and restrictive lung dz.
the most accurate part of PFT is the FEV1/FVC ratio.
__________________________________

serum Ace levels
are associated with sarcoidosis in 75% of pts. Ace levels are contributory to establishing the diagnosis of sarcoidosis --
Ace is best to do when an african american female presents with cough, dyspnea , chest pain and bilateral hilar adenopathy on chest xray.

the most accurate test is the presence of noncaseating granulomas on biopsy.
____________________________________________

aerum lpha 1-Antitrypsin level
(AAT) is measured in a young nonsmoker with emphysema and liver disease, it may also be measured in a pt with a strong fam hx of emphysema, low levels indicate AAT deficiency, in which the body lacks elastase.
________________________________

Arterial blood gas

directly measures ph, partial pressure of carbon dioxide, and partial pressure of oxygen. The bicarbonate level is determined based on a calculation from the ph and pCO2. This allows you to calculate the alveolar-arterial A-a gradient.. for actualy formula please refer to earlier post.

the saturation determined from an oximeter is within 1-2% of that obtained on an ABG, so we do not need to do an ABG for O2 saturation. An ABG allows you to know how hard someone is working in order to become oxygenated and where there is life threatening acidosis.
ABG is the answer f there is a COPD or another possibility of respiratory acidosis. ABG is the answer is there is low serum bicarbonate and there maybe severe metabolic acidosis.
____________________________________________
purified protein derivative PPD

the PPD is to screen for exposure to TB and the possibility of latent infection. PPD testing is only to screen asymptomatic pts
the test is positive based on the following
>or = 5 mm: HIV positive, recent contact with person with active TB, patient with changes on CXR suggestive of prior TB, patients with organ transplants or other immunesuppressed pts,
>or= 10 mm recent immigrants from countries with high TB prevlance, injection drug users, residents, employees of hospitals, nursing homes, and homeless shelters, and pts with diabetes, renal failure, or hematological malignancies.
>or = 15mm person with no risk factors for TB
all pts with +ve PPD should get a CXR to exclude active disease. Positive tests are treated with isoniazid for 9 months.
Previous vaccinations with BCG has no impact on these recommendations
a test result >10mm is not to be considered a false positive because of previous BCG.
__________________________________________________ _

pharm psychiatry/pulmonary

32 year old woman comes to ER because of acute onset of facial grimacing, toticollis, oculgyric crisis, and abnormal contractions of the spinal muscles. She has been started on the antipsychotic medication fluphenazine as well metoclopromide for nausea

the patient has an acute dystonic reaction from both the antipsychotic meds as well as the metocloprimide. her sx consist of an acute oculogyric crisis as well torticollis
the precise mechanism of acute dystonic rxn is unclear. it occurs because of the antidopaminergic effect of antipsychotic meds as well as metochlopromide.
Acute dystonic reactions are treated very effectively and rapidly with diphenhydramine and benztropine.
__________________________________
lithium
is an alakali metal that has no effect in a normal person but can treat sx of certain mood disorders. the proposed mechanism may be through suppression of inositol triphosphate. although lithium's precise mechanism is unknown
adverse effects
tremor, ataxia, seizures
nephrogenic diabetes insipidus through inhibition of the ADH receptor.
hypothyroidism by inhibiting thyroglobulin iodination and coupling
teratogenesis, particularly ebstein's anamoly
lithium is indicated for bipolar disorder, and acute mania. it is prophylactic against migraine headache and cluster headaches.
__________________________

a pt has been started on anti psychotic meds ziprasidone after being on risperidone at high dose. He becomes febrile to 105 degrees F and is somewhat catatonic with muscle rigidity, confusion and a elevated CPK level.

neuroleptic malignant syndrome is managed with dopamine agonists, such as bromocriptine. Dantrolene is used as well and can help relieve muscle rigidity
________________________________________

pulmonary

anticholinergic respiratory therapy
ipratropium
tiotropium

inhaled anticholinergics with ipratropium or tiotropium are the best answer to the question 'what is the best initial drug therapy for a person with chronic obstructive pulmonary disease. They offer additonal bronchodilation for pts with asthma. while they don't work as rapidly as inhaled beta agonists, they can be added to inhaled beta agonists when the pts needs an acute rescue medication for asthma exacerbation. tiotropium has superior efficacy to ipratropium.
ipratropium/tiotropium antagonizes the effect of ach at muscarinic receptors in the lung. this results in bronchodilation and decrease in the amount of mucus production. they dilate and dry bronchi
.
because they are virtually nonabsorbed these drugs almost have no adverse side effects. at high dosages may cause pupil dilation, tachycardia, constipation, dry mouth and urinary retention due to their antichoinergic effects.
_____________________________________________
prostacyclin analogs
Epoprostenol
Treprostinil
Iloprost
Epoprostenol/treprostinol/Iloprost are the correct treatment for severe pulmonary htn. look for pt with slowely progressive SOB that is worst on exertion with a loud P2 heart sound, clear lungs, and pulmonary HTN on echocardiography.

prostacyclin analogs cause potent pulmonary artery vasodilation, inhibit platelet aggregation and inhibit the proliferation of blood vessles.
adverse effects are hypotention, flushing, bradycardia, and dizziness.

>>>>>>>>>>>>>>>>>>>>>>>>>.

Today's five and five-- finish pulmonary in diagnostics move on to hematology, and pulmonary in pharm
___________________________

sweat chloride test

is the gold standard for the diagnosis of cystic fibrosis.
Pilocarpine is given and the amount of sodium and chloride is measured in sweat.

this is done for child with chronic respiratory problems such as cough, wheezing and SOB.. there will also be signs of malabsorption such as bulky stools and fat soluble vits deficiency ADEK, also inability to have children, look for an infant with failure to thrive. blood gas will reveal hypoxemia.
__________________________________

Heme



this is a hypersegmented neutrophil. Normal neutrophils contain an average of 3.5 lobes per cell. When the average is above 4 lobes, or there are 5% above 5 lobes, or a single 6-lobed cell, hyper segmentation is present. this is the defining feature of megaloblastic anemia.

hypersegmented neutrophils or megaloblastic anemia is present with vit B12 and folate deficiency.
the most accurate test is B12 and folate levels. B12 deficiency is also confirmed with an elevated methylmalonic acid level. The etiology of B12 deficiency is confirmed with anti-intrinsic factor and antiparietal cell antibodies, which are diagnostic for pernicious anemia.

__________________________________________________ _



both slides show a blood smear, cells with cytoplasmic projections consistent with hairy cell leukemia.
look for middle aged man presenting with gradual onset of fatigue, splenomegaly is present and maybe massive. The liver is enlarged in 50% of cases. Pancytopenia is the hallmark of hairy cell leukemia.
the most accurate test is tartarate-resistant acid phosphatase (TRAP) this is done on bone marrow biopsy.
_____________________________________________



this peripheral smear of RBCs shows Heinz bodies. Heinz bodies are precipitated, oxidized hemoglobin. They are found in glucose-6-phosphate dehydrogenase deficiency (G6PD). G6PD is an x-linked recessive disorder affecting 10-15% of African American males..
pt is usually healthy until exposed to oxidant stress and suddenly developes intravascular hemolysis resulting in weakness, tachycardia, jaundice and dark urine. The most common type of oxidative stress is from infection, not drugs. Drugs associated wit this stress include sulfa, primiquine, dapsone, quinidine, and nitrofurantoin. Fava beans also cause hemolysis.
Heinz bodies are removed resulting in cells called bite cells.
The definitive test for this disorder is a G6PD level. You must wait two months to do the level because the G6PD level will be artificially elevated immediately following a hemolytic event. All the most deficient cells are destroyed.

__________________________________________


This is an Auer rod.. which is an eosinophilic needle shaped inclusion in the cytoplasm.
Auer rods are pathognomonic for acute myelogenous leukemia (AML)
Auer rods will be found in a pt with pancytopenia, and blasts on peripheral smear of greater than 20% blasts on the bone marrow exam. Histochamical stains demonstrating myeloid enzymes such as peroxidase may further aid in choosing AML as the answer
_____________________________________-

Pharm
pulmo/renal
____

Bosentan

Bosentan is the RX for severe pulmonary HTN. Look for a pt with severe, progressive shortness of breath and a high pulmonary artery pressure on echocardiogram on right heart catheterization
Bosentan is a potent inhibitor of endothelin-1. Endothelin-1 causes vasoconstriction of the pulmonary artery as well as proliferation of the smooth muscle artery.
Bosentan is hepatotoxic and extremely teratogenic.
__________________________________________________ _

a young woman has persistent asthma not controlled with albuterol inhaler.

inhaled steroids have the best efficacy of all the long term asthma controlling medications. Inhaled steroids also have the best effect on mortality.
Adverse effects and mechanisms:
Inhaled steroids: oral thrush and dysphonia
Salmeterol: tremor, heart block, and bradycardia
Moteleukast: headache
Cromolyn : stablizes mast cells
Theophylline: tremors, seizures and arrhythmias. Theophylline has a narrow therapeutic index. it is very toxic with limited efficacy.
use meds in the following circumstance
-for Asthmatics not controlled with albuterol inhalers, inhaled steroids have the best efficacy if these do not work long acting beta agonists such as salmuterol should be used.
Moteleukast is best when the pt. has an atopic allergic disorder such as rhinitis.
Cromolyn is best when an environmental allergen is at work
Tehophylline is rarely used.
___________________________________________
Omalizumab
Omalizumab is the treatment for an asthmatic patient with an extrinsic allergic trigger that isn't controlled by inhaled beta agonosts combined with inhaled steroids or a leukotriene inhibitor, such as monteleukast. Look for a patient with an elevated IgE level or a positive skin test for a specific allergen.
Omalizumab blocks IgE antibody. This prevents IgE from binding to the mast cell or esoinophil. In this way, it prevents asthma exacernation. Look for a pt who is refractory to inhaled steroids, whom you are trying to keep off oral steroids.
___________________________________

Renal..
Conivaptan and Tolvaptan
Conivaptan and tolvaptan are used in the treatment of severe hyponatremia from syndrome of inappropriate antidiuretic hormone secretion (SIADH) a pt with neurological symptoms and a very low sodium level with a normal volume status call for this answer. Conivaptan is used in conjunction with hypertonic saline.
These medications are vsopressin (Antidiuretic hormone or ADH) receptor antagonists. conivptan and tolvaptan increase free water diuresis and raise the sodium level.
adverse effects are orthostatic hypotension, peripheral edema, headache, increased thirst, and hypokalemia. serious adverse is A fib.
_________________________________
Aliskerin
Alisekerin is used to rx HTN
is a direct renin inhibitor. Aliskerin blocks the conversion os angiotensinogen to angiotensin 1. This action leads to a marked decrease in the level of angiotensin II and alodesterone
Aliskerin can cause hyperkalemia, It doesn't cause cough or angioedema as do ACE inhibitors...

>>>>>>>>>>>>>>>>>>

5/5

start with pharm still on renal
_________________
a man comes in for a preoperative evaluation of his episodic htn, he has palpitations, headaches, surgical removal of his adrenals is planned

phenoxybenzamine is the best preoperative medication prior to surgical removal of a pheochromcytoma. this is followed by propanolol.

phenoxybenzamine is a nonspecific alpha blocker. it is superior to the alpha blocking agents prazosin, terazosin, or doxazosin, propranolol is also a nonspecific beta blocker.

____________________________________

chlorthalidone
is a thiazide diuretic, inhibits sodium re absorption in the early distal tubule.

chlorthalidone and thiazide diuretics are the best initial therapy for hypertension, when there are no other compelling indications such as coronoary disease, CHF etc.. chlorthalidone also prevents recurrent kidney stones in calcium overexcreters.
chlorthalidone causes hypokalemia , hyperglycemia, hyperurucemia and hypercalcemia.
_____________________________________

42 year old man comes in for evaluation of hypertension. blood pressure is 146/94
HTN is defines as blood pressure >140/90. the most effective life-style modification is weight loss. Sodium restriction, dietary modification, and exercise are not as effective as weight loss.

for specific indication, specific indications, the best therapies are as follows:
Diabetes: Angiotensin-converting enzymes (Ace) inhibitors, angiotensin receptor blockers ARB's
coronary artery disease: beta blockers
CHF, ace inhibitors, beta blockers
osteoporosis: Thazides they decrease calcium excretion
prostate hypertrophy, alpha blockers, doxazosin
depression: don't prescribe beta blockers
Asthma: don't describe beta blockers.
___________________________________________

Demeclocycline

demeclocycline is a tetracycline antibiotic that is used in the treatment of chronic syndrome of inapproriate antidiuretic hormone secretion (SIADH)

demeclocycline inhibits the effect of antidiuretic hormones at the collecting tubule.

When the question describes a case of SIADH in which the underlying cause cannot be corrected, demecloycline is the answer. It is not used as an antibiotic.
like all tetracycline antibiotics, demeclocyline can cause photosensitivty.
_______________________________________________

Sirolimus, Tacrolimus, and pimerrolimus

sirolimus, tacrolimus, and pimercrolimus are T-cell inhibiting immuno-suppressive medications used for a number of autoimmune diseases and to prevent organ rejection.

sirolimus inhibits interleukins. Tacrolimus is a calcineurin inhibitor like cyclocsporine. Pimercellimus' mechanism is not known.
These medications are used to treat the following conditions:
sirolimus: prevents renal transplant rejection, prevents coronary stent restenosis. Treats graft versus host disease.
Tacrolimus: prevents liver transplant rejection and is used to atopic dermatitis, treats graft versus host disease
pimercolimus is only approved for atopic dermatitis.

Tarcolimus causes both renal and neurological toxicity. Just as cyclosporine. Bot sirolimus and tacrolimus cause lymphoma..

>>>>>>>>>>>>>>>>>>>>>>>>>>>

Diagnostics
____






these are bite cells. They are formed when Heinz bodies (see previous post) denatured hemoglobin are removed from the cells by the spleen. Macrophages in the spleen remove denatured hemoglobin.

bite cells are seen with GPD deficiency, which is an x-linked disorder. It is the most common enzymatic disorder of the red blood cells in humans.

Patients with G6PD deficiency are prone to devloping hemolytic anemia in response to sulfonamides such as dapsone and sulfasalazine. Other precipitating factors are infections, diabetic ketoacidosis, and favism.
________________________________________



Schistocytes
are fragmented red cells and are seen in a variety of shapes and sizes the individual pieces called helmet cells. collectively this is known as intravscular hemolysis or microangipathic hemolytic anemia.
Fragmented cells are seen in the thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome, major blood grou incompatibility, disseminated intravascular coagulation (DIC), paroxysmal nocturnal hemoglobinuuria, artificial heart valves, and snake bites.
All forms of hemolysis are associated with elevated LDH, indirect bilirubin, elevated reticulocyt count, and decreased levels of haptoglobin.
__________________________________________________ _____



this is ringed sideroblasts. Prussian blue stain is necessary in order to visualize it. The ringed sideroblasts is caused by iron accumulation within mitochondria in the red cell. This is the main findings in sideroblastic anemia...

look for case of microcytic anemia with an elavted serum iron level in an alcoholic. Acquired sideroblastic anemia can occur as a result of the ingestion of drugs such as alcohol, isoniaizid and chloramphenicol, or toxins such as lead or zinc.
ringed sideroblasts are also a feature of myelodysplastic syndrome..

__________________________________________________ __________


Rouleaux formation occurs when red blood cells form stacks or rolls..Rouleaux formation may form due to presence of abnromal globulins or fibrinogen. This formation of red blood cells is found in multiple myeloma and macroglobulinemia. other clues that suggest multiple meyloma might be anemia, hypercalcemia, renal failure and abnormal SPEP or UPEP.
__________________________________________________ _________

last and not least.. sob7an Allah.. it has been a long day..


Spherocytes are red blood cells that are almost spherical in shape. They have no area of central pallor like a normal red blood cell...
the most accurate test for heriditary spherocytosis is the osmotic fragility test. MCHS is not an accurate test..
the defect is in the ankyrin gene. which leads to spectrin deficiency, which results in membrane instability.
look for a pt. with recurrent hemolysis, a big spleen, and a family hx of anemia. The CBC reveals anemia and an elevated mean cell hemoglobin concentration (MCHC )

>>>>>>>>>>>>>>>>>>>>>>>>>

today's 5/5 still in hematology for diagnostics
__________________________



these are sickled cells.

only sickle cell disease that is homozygous (SS) will produce sickled cells. Homozygous disease (AS) will be 'hematologically' normal

the most accurate test for sickle cell disease is a hemoglobin electrophoresis.

________________________________

this image is really cool, it shows target cells being ingested by macrophages.. anyhow, this is what a target cell looks like



these cells are associated with liver disease and certain hemoglobinopathies such as sickle cell disease, thalassemia and most notably hemoglobin C disease, iron deficiency can also have target cells.

the most accurate test if a hemoglobin electrophoresis.

despite their abrnomal appearance, they don't have a shorter life cycle compared to normal cells.

_________________________________________



these are tear drops cells.. and it because they hurt that they are crying .. just checking to see if you are reading lol

when tear dro cells are either shown or described, you should always think bone marrow disease such as myelofibrosis. look for a case of pancytopenia and massive splenomegaly in which hairy cell leukemia has been excluded. The bone marrow biopsy will show reticulin fibers.

__________________________________________________

anti-intrinsic factor antibodies, antiparietal cell antibodies

are highly confirmatory for pernicious anemia. They are nearly 100% specific for the disease. Pernicious anemia is an autoimmune disease in which you become allergic to you own IF, and gastric parietal cells.

Answer anti-IF and antiparietal cell antibodies when you see a case of B12 deficiency and you want to determine the etiology. The case will describe a pt in whom B12 is low, or te methylmalonic acid level is high. These antibodies are not to diagnose B12 deficiency, they are to determine the etiology.

______________________________________________




burr cells, also called echinocytes, are RBC's with many blunt, regular sicules. They are present in end stage renal disease and liver disease...



compared to spurr cells or acanthocytes, which have only a few irregular spicules, they are also seen in severe liver disease and in some forms of hereditary spherocytosis, nd myelodysplasia.

________________________________________________

ok Now Pharm.. still on Renal

_____

Clonidine

this is an old hypertensive in the archives lol.. no longer recommended for the rx of HTN because of the large number of adverse side effects and limited evidence of mortality benefit

clonidine is a centrally acting alpha 2 agonist. This decreases the release of vasconstrictive neurotransmitters, such as norepinephrine.

clonidine can cause sedation, and dry mouth and rapid withdrawl which can lead to hypertensive crisis.

clonidine has no room in rx of HTN however it is used as an adjunct to treat opaite withdrawl, diarrhea related to diabetes and occasionally tourette's syndrome.

________________________________________

a woman comes to the ER dept. after falling while running a marathon, she is also taking a statin medication. she has dark urine that is dipstick positive for large amounts of blood. There are no red blood cells seen on the microscopic examination. Her serum bicarbonate is low.

this pt most likely has rhabdomyolysis. The dark urine that is dipstick positive for blood with o red cells seen is myoglobin.

te best initial therapy for rhbdomyolysis is vigorous hydration, bicarbonate adminstration and possible mannitol.
the hydration and mannitol decrease the amount of time that the nephrotxic myoglobin is in contact with the kidney tubule. Bicarbnate prevents precipitation of myoglobin in the kidney tubule. In addition, it drives potassium intracellularly by causing an alkalosis.

The cause of death in rhbdomyolysis is hyperkalemia and acidosis. both of these can cause an arrhythmia.

__________________________________________________

a man has just undergone combination chemotherapy for widespread non-hodgkins lymphoma. The EKG shows peaked T waves

Hyperkalemia with EKG changes should be immediately treated with intravenous calcium chloride or calcium gluconate. This will protect the heart from an arrhythmia. Insulin and glucose should be used to drive potassium intracellularly, but they take 15-20 minuted to work. The calcium will protect the heart from an arrhythma while the Insulin and glucose take time to work.

Kayexcelate is a sodium/potassium cation-exchane resin and is adminstered orally to remove potassium from the body vua the gastrointenstinal tract. It takes several hours to work.

Tumor lysis syndrome can be prevented by adminstering intravenous hydration and allopurinol before chemotherapy is given.

__________________________________________

Azathioprine
is a purine inhibitor that is used to control autoimmune diseases.
azathioprine is converted to 6-mercaptapurine, whose metabolites inhibit purine metabolism. Purine synthesis is needed for the proliferation of B and T lymphocytes. This redices antibiody production.

Azathiprine can be bone marrow suppressive and can cause infection. Allopurinol interfers with azathiopurine, because the active metaboolite is metabolized by xanthine oxidase. Pancreatitis happens from direct toxicity.

Azathioprine is used for the following conditions

Inflammatory bowel disease
Vasculitis and mysthenia gravis to spare the pt from chronic steriod use
lupus nephritis that isn't responding to steroids, cyclphasapmide, or mycophenolate
renal translanation
rehumatoid arthritis

_________________________________________

mycophenolate mofetil
is an immunosuppressive agent with less toxicity than cyclophosphamide, azathioprine or cyclosporine.

mycophenolate inhibits purine synthesis, this prevents the proliferation of lymphocytes.
mycophenolate has a few adverse effects.
It can cause infection via leukopenia

mycophenolate is the drug of choice for lupus nephritis. it is superior to cyclophasmide, oter indications are the following
organ transplant rejection prevention.
Nephrotic syndrome, not responsive to sterioids and cyclophosamide
it can be used as a second line treatment for myasthenia gravis, atopic dermatitis, vasculitis and crohn's disease to prevent dteroid dependence

>>>>>>>>>>>>>>>>>>>>>>>>>>>

today's 5/5 still on heme in diagnostics, renal in pharm and will move on to rheumatology insha'Allah
____________________________________

Bleeding Time

a test for the ability of the platelet to adhere to the endothelial lining of the capillary. Do not use it when the platelet count is abnormally low. Everyone with a low platelet count will have an abnormal bleeding time.

a blood pressure cuff is inflated to 40mm Hg to encourage the blood vessles, then small cuts are made, the test is the amount of time it takes for the bleeding to stop.

bleeding time is the answer, when the pt seems to have a bleeding disorder, examples are von willebran's disease or uremia induced platelet dysfunction.

the most accurate test for von willebrand factor level, ristocetin cofactor assy, or in vitro platelet aggregation studies..

__________________________________________________

decay-accelerating factor (DAF) or CD55/CD59 assay

Cd55/59 is a test for paroxysmal nocturnal hemoglobinuria (PNH), also knows as decay accelerating factor. DAF is a membrane component of the complement system.

Assay for DAF is the most accurate test for diagnosing PNH

DAF when you see a pt with intermittent dark urine, particularly in the morning, pancytopenia, and large vessel thrombosis..

_____________________________________________

Cold Agglutinins

are IgM autoantibodies directed against RBC antigens. Titers are measured when Cold Agglutinins disease, which is a type of autoimmune hemolytic anemia, is suspected.

high titres have been found to be associated with malignancies such as lymphoma, CLL, and Waldenstrom's macroglobulinemia, as well as mycoplasma infections and infectious mononucleosis.

Answer cold agglutinins when you see a patient with hemolytic anemia as well as skin discoloration when exposed to cold temperatures. Do not confuse this with cryoglobulins. which give purpuric skin lesions and glomerulonephritis.
________________________________________________

Coombs' Agglutinin test

coombs test measures the presence of antibodies against red blood cells.

Coombs tests is used for the diagnosis of autoimmune hemolysis. A positive coombs tests shows the agglutination of the patient's red blood cells.
a total of 20-50% of coombs positive hemolytic anemia is iodiopathic. the most common identifies etiologies are PCN, quinidine, alphamethyldopa, sulfa drugs and ASA.

_____________________________

D-Dimer/Fibrin split products

D -dimer is the by=product of the degradation of fibrin by plasmin. Fibrin split products (FSPs) are produced by the activation of fibrinogen by thrombin. They are abnromal only if they are present in increased amounts.
D-dimer can be measured by levels either latex agglutination (more rapid) or Elisa (more accurate). Elisa is far more sensitve.
elevated levels indicate pathology involving clot formation and lysis from activation of the coagulation cascade. They provide no information about platelet function.
Elevated D dimer/FSP levels are evidence of DIC, a negative result from the ELISA rules out DVT and PE but a positive results does not confirm the diagnosis.
order these tests to confirm suspected DIC and to rule out PE in pts with a low pre=test probability

____________________________

pharm/Renal

Man comes in with severe headache, confusion, blood pressure of 190/124, head CT is normal
Hypertensive emergencies are treated with IV agents that allow rapid lowering of BP with greater control han oral agents. Labetolol is the best initial therapy for hypertensive crisis. Labetolol is a mixed alph and nonspecific beta blocker that is very effective. Nitroprusside is used in the intensive care unit and usually requires monitoring with an arterial line. Other choices are enalaprilat, hydralazine or nicardipine.

in a hypertensive emergency, you should not lower the blood pressure more than 25% over the first several hours.
blood pressure lowered too rapidly can result in a stroke.

__________________________________________________ _

a patient with end stage renal disease is preparing to start dialysis. his phosphate level is markedly elevated ..

hyperphosphatemia from renal failure is treated with calcium carbonate, calcium acetate, sevelamer or lanthanum . Cinacalcet is a calimimetic agent that treats secondary hyperparathyroidism. it is used is there is hypercalemia from secondary hyperparathyroidism.

Calcium carbonate, calcium acetate, sevelamer and lanthanum all bind phosphate in the bowel. the calcium containing medications form complex with phosphate, which is then excreted in the sool. Sevelamer is a nonabsorbed polymer that also binds phosphate in the bowel. Cincalcet acts like calcium on the parathyroid gland and inhibits the release of parathyroid hormone.
All of these medications case some gastrointenstinal discomfort. calcium carbonate and calcium acetate can lead to hypercalcemia. if this happens, treatment should be switched to sevelamer or lanthanum.

__________________________________________________ ____

Pharm rheumatology

Tumor necrosis factos (TNF) inhibitors
infliximab, etanercept, adalimumab

tumor necrosis factor inhibitor are used to treat the following conditions:
inflammatory bowel disease --particularly crohn's with fistula formation

Rheumatoid arthritis, that is not responsive to methotrexate as a DMARD
psoriatic arthritis, when it is moderate to severe, as an alternative to systemic therapy such as methotrexate or UV light

ankylosing spondylitis
TNF inhibitor are immunosuppressive but less toxic than steroids.
TNF inhibitors can reactivate or worsen serious bacterial infections by inhibiting the immune system. TB reacivation in PPD positive pts is te most important adverse effect.
All pts who go on TNF inhibitor should have a PPD test done first. TNF inhibitors are also associated with the development of lymphoma.

___________________________________________

methotrexate..

this is the answer as to which slows down the progression of disease, in virtually all pts wit rhumatoid arthritis. It is the number one DMAR for rheumatoid arthritis.
it is also used for the following
severe psoriasis, particularly psoriatic arthritis
leukemia, lymphoma and certain solid tumors.

Methorexate causes
liver toxicity
pulmonary fibrosis
bone marrow suppression (myelosuppression)
kidney damage (precipitation of methotrexate crystals)

______________________________________
rheumatoid arthritis and alternate DMARDS

hydroxychloroquine
sulfasalazine
anakinra
abatacept
leflunomide

Alternative DMARDS to methotrexate are the correct answer to the following
pt is intolerant to methotrexate
methorexate fails to control disease
cases of mild disease where it is preferable to avoid the toxicity of methotrexate, sulfasalazine ad hydroxycloroquine can be used initially in this way..

adverse effects are as follows..
hydroxychloroquine-- renal damage, hemolysis
sulfasalazine--rash, heptaitis, agranulocytosis
anakinra--interluekin-1 antagonist-causes neutropenia
abatacept-- inhibits t cell activation-->infections
leflunomide-- inhibits pyramidine synthesis--causes rash, alopecia, mylosuppression and liver dysfunction...

>>>>>>>>>>>>>>..

Rheumatology pharm and on to tox.

NSAIDS
Naproxen
Sulindac
ibuprofen
diclofenac
etodolac
indomethacin
ketrolac
piroxicam

Cox-2 inhibitors:

Rofecoxib
celecoxib-- removed from market
Valdecoxin (removed)

NSAIDS and COX-1 inhibitors are indicated as analgesics.. also useful for the folowing

Inflammatory syndromes , such gou, pseudogout, rheumatoid arthritis, and ankylosing spondylitis.
cystic fibrosis
fever
still's disease
Both NSAIDS and COX-2 inhibit prostaglandins

NSAIDS cause peptic ulcer disease, and renal insufficiency, such as interstitial nehritis and nephrotic syndrome . Although COX-2 inhibitors have less effect on the gastic mucosa, they hae very severe cardiac toxicity. The COX-2 inhibitors rofecoxib, and valdecoxib were removed from the market because of excess cardiac deaths, only celecoxib remains on the market.

___________________________________________

1 48 year old man comes to the ER with severe sudden pain in left knee after a beer binge
over the weekend. on examination, he has a fever. The knee and toe are red and swollen. Joint aspiration shows 25,000 white cells that are predominantly neutrophils, and crystals are present. The crystals are needle shaped and negatively birefringent . creatinine is 2.4

colchicine is the best initial therapy for acute attachs of gout, particularly when NSAIDS are contraindicated. In this case, a creatining elevation is contraindicated to NSAIDS. Colchicine is also used to treat familial mediterranean fever.

Colchicine inhibits leukocyte mobility, decreasing the white cells ability to phagoctytose within the joint space and decrease lactic acid within the joint. This action reduces the deposition of the urate crystals that perpetuate the inflammatory response.

the most common adverse effect of colchicine is diarrhea. in fact you should give colchicine to relieve pain until it produces diarrhea, rarely, colchicine may produce aplastic anemia.

If there is no response to colchicine then the next therapy is intracrticular steroids.

______________________________________

Allopurinol

Allopurinol is a drug that lowers urate synthesis and ecreases the serum uric acid level.

Allopurinol is a xanthine oxidase inhibitor. this reduces the uric acid level in both blood and urine.
Answer allopurinol when the question describes a patient with recurrent gouty attacks, tophi, and uric acid stones and who has failed pobencid or sulfinpyrazone. The patient should be between attacks. Allopurinol has no benefit during acute attack of gout, because it is not anti-inflammtory.

AAllopurinol is highly allergenic and can cause rash, eosiniphilia and interstitial nephritis.

__________________________________

Toxicology Pharm

two drunk men come to the ER. one has visual disturbances, the other hyperemia of the retina. The other has developed kidney stones, he has envelope shaped crystals in his urine, both have a metabolic acdosis with an increased antion gap

the first drunk with visual disturbance and an abnromal fundoscopic exam has methanol intoxication. The second patient who is drunk with oxalate crystals in the urine has ethylene glycol intoxication. oxalate crystals appear in the shape of an envelope. both cause metabolic acidosis.

Fomepizole is the best initial therapy for ethylene glycol or mathanol poisoning. Fomepizole is considered superior to ethanol infusion, because it isn't intoxicating. Definitive therapy is with dialysis to remove the substances.

Fomepizole inhibits alchol dehydrogenase. This prevents the production of the toxic metabolite and gives time for dialysis to be effective.

__________________________________________

32 year old woman comes to the ER dept. six hours after having ingested a bottle of 50 extra-strength (500 mg each)
acetamiophen tablets

best initial therapy for an overdose of acetominophen is acetyl-cysteine (NAC) and charcoal. Giving NAC is more important than getting a specific level of acetamiophen when the pt states she took a potentially harmful amount.

NAC works by replacing the glutathione reductase that is depleted from metabolites of acetominophen. When glutathione reductase has been depelted, the liver cells start to necrose.

charcoal can be used at the same time as the NAC. Charcoal doesn't bind enough of the NAC to result in a clinically significant impairement of its effect.

__________________________________________


Diagnostics still in heme

Factor V leiden mutation

factor V leiden predisposes to thrombosis by resistance to the antithrombotic effects of activated protein C. Protein C normally slows the clotting cascade by inhibiting factor V. the mutation allows factor V to ignore the natural anticogulant action of protein C. Factor V leiden i the most common cause of inherited thrombophilia.

Answer factor V leiden mutation as the most accurate test in a young person with an unprovoked DVT or PE. Thrombotic events after plane flights should evoke and investigation for thrombophilia.

the other tests of hypercogulable state are
protein S
Protein C when you see skin necrosis
lupus anticoagulant when you see an elevated PTT or spontanous abortions in the case
antithrombin III mutation, when you see resistance to heparin in the case.

________________________________

philadelphi chromosome

represents a genetic translocation between 9 and 22. it is associated with chronic mylogenous leukemia. It is also known as a BCR/Abl and can be detected by PCR.
answer Philadelphia chromosome when presented with a case pf probable CML. the white cell count will be very high, mostly neutrophils, and the LAP score will be low. The Philadelphia chromosome also has prognostic value. If you give imitanib (geelvec) the philadelphia chromosome goes away the prognosis is good.

__________________________________

Haptoglobin levels

used to determine hemolysis. It is a proten that binds to free hemoglobin. so when we ave hemolysis, RBCs will release free hemoglobin that will bind to haptoglobin. This will result in decreased haptoglobin levels. In hemolysis we also find elevated LDH, reticulocytes, and indirect bilirubin

typical scenario is sudden anemia without Gi blees. the presence of Jaundice is also highly suggestive. Acute enamia minus the Gi bleeding equals hemolysis.

____________________________________________

Hemoglobin electrophoresis,
is the most sensitive test to diagnose hemoglobinopathis such as SCD or thalasemia. The most accurate way to diagnose the presence of the hetrozygou forms of these disease or the trait
with respect to SCD, clinical presentations include ulcerations of the skin, of the legs, recurrent infections with pneumococcus or haemophilus, retionpathy, aseptic necrosis of the femoral head, osteomyelitis, growth retardation, and splenomegaly, Typically, the pt will be African American with a possible fam hx of the disease, Sickle cell trait will be in a pt who is asymptomatic with a family member with sickle cell disease or with unexplained hematuria.
with respect to thalassemia, clinical rpesentations range from normal to severely symptomatic with growth failure, hepatomegaly, jaundice and bone deformities..

____________________________________

Leukocyte alkaline phosphatase LAP score
this is an enzyme in WBC. If the cells are elevated in number and the function os normal, the LAP score will go up in proportion to the elevated count.
LAP is a test for CML, LAP white count is extremely hight and the differential shows mostly neutrophils. The case is likely to have a big spleen, giving upper quadrant pain and early satiety. LAP score should be LOW in CML, and are used to differentiate CML from leukemoid reaction..

>>>>>>>>>>>>>>>>>>>>>>>>>

ok today's 5/5..
still on heme for diagnostics
lymph node biopsy
is used to detect infections such as TB, fungi and staphylococcus. Infections are suggested by nodes that are warm, tender and sometimes red.

excisional lymph node biopsy is a single lymph node that is most accurate to diagnose a lymphoma. A needle biopsy is a wrong answer. you need to see architecture. In addition, the individual lymphocytes will appear normal on a needle biopsy. The diagnosis of lymphoma requires the visualization of the architecture of the entire node. Noses with lymphoma are nontender, not red, not warm as they usually are in an infection.
_________________________________
methylmalonic acid (MMA) builds up when vit B12 is deficient. MMA has greater sensitivity than Vit B12 levels. Homocystine is elevated in both B12 and folic acid deficiency.

this is the test for a pt with macrocytic anemia and hypersegmented neutrophils but a normal B12 level.

______________________________________

Mixing studies

are done to distinguish between a clotting factor deficiency and an inhibitor of the clotting factor as the cause of an abnromal partial thromboplastin time (aPTT) you mix normal pooled plasma with the patient's plasma.
this is the best test wen you have a pt with an abnromal APTT.
if the test normalizes after mixingg, then the elevated aPTT is caused by a clotting factor deficiency.
The next best test if the mixing normalizes is individual clotting factors assyas of the patient's plasma to determine which factor is deficient.
if the test doesn't normalize it means that an inhibitor is present i.e factor VIII inhibitor of the lupus anticoagulant.

__________________________________
osmotic fragility test

is the test for heriditary spherocytosis.
it measures the amount of emoglobin released from red blood cells RBCs placed in hypotonic solution. RBC's with a reduced surface to volume ratio will lyse at concentrations that not affect normal cells. This is because they don't have enough cell membrane. They 'stretch' an then 'pop' when put into hypotonic solution.

this is the test for a case of hemolytic anemia and splenomegaly with spherocytes on the peripheral smear. The other features that push the diagnosis and this test are:
family history of recurrent episodes of anemia and bilirubin gallstones.

______________________________________
Ristocetin cofactor assay.
is a test for the function of von willebrand's VWF. Along with a VWF level. it is the most accurate test for Von willebrans's disease. Ristocetin acts and an artificial endothelial lining. if VWF is present and is functioning normally then platelets should adhere to Ristocetin.

this is the test for a pt with platelet type bleeding and a normal platelet count and normal VWF level. Platelet type of bleeding is superficial. Examples are epistaxis, petechiae, purpura, and gum or gingival bleeding.

_________________________________________

in pharm, I will finish the last of tox and start cardio, like infectious disease cardio will be a large review..

tox.

70 year old woman with hx of osteoarthritis comes to the ER because of SOB, tinnitus, and decreased hearing. Her blood gas is initially alkalotic but changes to a ph of 7.28, wit a PCO2 of 23. Her Serum bicarbonate is low nd the anion gap is increased

this is classic salicylate toxicity... pts presents with hyperventillation secondary to direct stimulation of the respiratory center in the brain. In addition, ASA tox can cause tinnitus, encephalopathy, and with severe toxicity, pulomary edema and yperthermia. In early tox there is respiratory alkalosis from direct stimulation of the brain, followed by metabolic acidosis, because ASA poisons the mitochondria and you lose te aerobic metabolism of oxidative phosphorylation. Lactic acidosis accumulates from anerobic glycolysis.

bicarbonate is the best initial therapy for ASA poisoning.
Bicarbonate will alkalinize the urine, resulting in increased excretion of ASAP at the kidney tubule
_________________________________

An alacoholic pt with seizure disorder is admitted with drowsiness, dysarthria, and difficulty walking. She does not know which meds she is on for her seizures. On. P.E there is ataxia ad vertical nystagmus. The head CT is normal

phenytoin toxicity is the agent most likely to cause drowsiness, ataxia, and nysstagmus. The tye os nystagmus correlates with the severity of the phenytoin tox. Mild tox leads to horizontal nystagmus. in fact, horizontal nystagmus maybe present even at the upper end of normal therapeutic leve of phnytoin .. severe tox leads to vertical nystagmus.

there is no specific antidote for severe tox.

________________________________

a man with a HX of depression and an empty bottle of amitriptylene comes to the ER dept with obtundation, dry mouth, dizziness, flushing and dilated pupils.

and EKG is the most urgent ste in the evaluation of tricyclic antidepressants overdorse. The EKG will show prolongation or widening of the QRA.
the most common case of death from TCA are arrhythmias and seizures.

TCAs inhibit the fast sodium channels in the His-Purkinje system as well the atrial and ventricular myocardium. this decreases conduction velocity, increases the duration of repolarization, and prolongs the absolute refractory periods. This effect is similar to that of quinidine.

Bicarbonate should be given if the QRS prolongation is above 100millisecons.
________________________________________

a guard is being evaluated after a nerve gas attack, he is found to be lacrimating, urinating and defecating, in addition he has respiratory distress and bradycardia


Atropine is the best initial therapy for organophosphate poisoning. Atropine reverses the effect of the anti-cholinsterase inhibitor and the massive amount of acetylcholine that accumualtes. Organophosphates are absorbes through the skin. Further absorption is prevented for removing the patient's clothes and washing the patient.

Pralidixime is the definitive treatment for reversing organphosphate toxicity. pralidoxime reactivates acetylcholinesterase.
______________________________________________

Angiotensin-Converting Enzyme (ACE) inhibitors:

Ramipril, Lisinopril, Fosinopril, Enalapril, Perindopril, Captopril, Trandolopril
ACE inhibitors are indicated for the following conditions:

Congestive heart failure with low ejection fraction (prevents left ventricular (LV) remodeling
hypertension (particularly in diabetics)
proteinurea, including microalbuminurea
Acute myocardial infarction prevents worsening LV function
hypertensive crisis

Ace inhibitors block the production of angiotensin II (AT II) in the lung. At II is a potent vasconstrictor. AT II also stimulates the release of aldosterone from the zona glomerulosa of the adrenal gland.

The most common adverse effect of ACE inhibitors is a dry cough. Angioedema and hyperkalemia may also occur. Ace inhibtors transiently decrease the gloerular filtration rate (GFR) but are renal protective in long term.

>>>>>>>>>>>>

Still on heme in diagnostics

Russel's Viper Venom Clotting Time (RVVT)

RVVT is a phospholipid-dependent coagulation test.
it is used in detection of antiphospholipid antibodies or lupus anticoagulant. Think of this in a patient who has a prolonged PTT that doesn't correct with a mixing study. The dilute Russell viper Venom test maybe indicated to confirm that the inhibitor is a lupus anticoagulant.

Clinical scenario may be of a woman with or without features of SLE, with repeated abortions or giving birth to an infant with heart block or presenting with venous or arterial thrombosis.

_________________________________________

Shilling's test

is ded to find the etiology of a B12 deficiency. The most common cause of B12 deficiency is pernicious anemia, where there is decreased intrinsic factor due to antibodies against IF

_________________________________

in the first stage, radiolabeled cyanocobalamine is given orally, followed by an intramuscular injection of cyancobalamine 1 hour later, urine is collected for determination of the percent excretion of the oral dose. In pernicious anemia, or malabsorption, excretion in the urine is low. The test is repeate with added oral intrinsic factor, Adding IF should normalize cyanocobalamine absorption and urinary excretion in pts with pernicious anemia, but not in those with intenstinal malabsorption.
schillings's test is hardly ever used, except in cases with dx of B12 deficiency where the diagnosis isn't pernicious anemia..

_________________________________________________

Serum protein electrophoresis (SPEP)

the SPEP is the separation and fractionation of the pt serum proteins in order to assess the individual component, i.e how much os the protei is albumin how much is mmunoglobulin

SPEP is used to evaluate a high total serum protein. SPEP is the best initial test to diagnose myeloma, particularly if an x-ray of the bone looking for lytic lesions has already been done, or is x-ray is not one of the answer choices.
the most common reason to have an abnormality on the SPEP is a monocolonal gammopathy of unknown significance.
the most accurate test for an IgG abnromality detected as an SPEP spike is a bone marrow. A total o >10% plasma cells is indicative of myeloma. Waldenstrom's macroglobulinemia will also give an abnromal SPEP with an IgM spike.

__________________________________________________ __

Sucrose lysis test
is a screening test for paroxysmal nocturnal hemoglobinuria (PNH) a sample of the patient's blood is tested with sucrose and observed for evidence of hemolysis from complement activation. The hemolysis of PNH is caused by increased sensitivity of the patient's red blood cells to lysis by complement and evoked hemolysis.
sucrose lysis is key when the t presents with dark urine in the morning, with or without evidence of venous thrombosis and pancytopenia. The coomb's test will be negative,

the most accurate test for PNH is flow cytometry for the presence of CD55 and CD59, also known as decay accelerating factor. (DAF)

_________________________________________

last is on opthalmology



this is a photograph of proliferative diabetic retinopathy (PDR). There is neovascularization over the disc, covering much of the surface area of the retina. Neovascularization differentuates PDR from non PDR. the aberrant blood vessles are fragile and leaky causing recureent retinal and vitreous hemorrhages. Dot blot hemorrhages, micoaneurysms, hard exudates, cotton wool spots, and intraretinal microvascular abnromalities (IRMA) are present in both PDR and none PDR

PDR can lead to retinal detachment and neovascular glaucoma
the treatment is with pan retinal photocoagulation.
___________________________________________

Now Pharm cardiac
___________

64 year old woman with a HX of HTN comes to the ER dept with palpitations, she is found to have atrial fibrillation and pulse rate of 125/mins

atrial fibrillation and atrial flutter with a rapid ventricular rate are best treated with either a calcium channel blocker, such as verapmil or diltiazem, a beta blocker such as metoprolol or digoxin. The target rate is less than 100 BPM

calcium channel blockers cause hypotension, constipation, peripheral edema and heart block.
beta blockers, cause hypotension, bronchospasm, depression, erectile dysfunction and worsening dyslipidemia
dignoxin causes dysrhytmia, hyerkalemia, confusion, diarrhea and visual changes.
chronic atrial arrhythmias should be treated with coumadin with an international normalized ratio (INR) of 2-3 to avoid an embolic stroke.

Electrical cardioversion is indicated when the patient is hemodynamically unstable, exhibiting such symtoms as hypotension, hemodynamically related confusion, shortness of breath or chest pain.

_______________________________________

calcium channel Blockers
Diltiazem, Verapamil, Nifedipine, Felodipine, Nicardipine, Amlodipine, Nitrendiine, Nislodipine, Isradipine
Calcium channel blockers are correct for the following conditions
HTN (in pts with diabetes or high risk coronary disease)
Atrial arrhythmias
ulmonary hypertension
Hypertrophic cardiomyopathy
Raynaud's phenomena
Subarrachnoid hemorrhage

CCB's work by causing vasodilation by relaxing smooth muscle in the vascular lining. CCB's also inhibit conduction in the AV node of the heart
All CCB's cause postural hypotension, flushing, constipation, and edema, diltiazem and verapamil can cause AV block. The others particularly nifedipine can cause tachycardia.
___________________________________________

Spironolcatone/Eplerenone
Maybe appropriate treatment for the following conditions
congestive heart failure (CHF): as one of the medication that will lower mortality. Eplerenone is an alternative for CHF only
Ascites: as the best initial diuretic therapy
Acne, especially for women because of its anti-androgenic qualities
HTN-rarely
Amenorrhea
Adrenal hyperplasia or aldosterone producing adenomas
this is best for CHF however along with ACE inhibitors and beta blockers.

Spirinolactone is an aldosterone antagonist, it has antiandrogenic effects, which is why it helps with hirsutism, acne and amenorrhea. but it can also cause gynecomastia and hyperkalemia.
Eplerenone is used for CHF and HTN as well but does not inhibit testosterone receptors, so it can cause hyperkalemia but not gynecomastia

________________________________________

Propanolol

is indicated for the following conditions
Cluster migraine headache prophylaxis: Must be taken for several weeks to prevent headaches
Portal HTN, decreases the frequency of bleeding from esophageal varices.
Thyroid storm, propanolol decreases symptoms acutely
Essential tremor
pheochromocytoma

propanolol is a nonspecific blocker of beta -1 and beta -2 receptors
associated with worst side effect profile than beta one specific, such as atenelol, metoprolol. propanolol can cause bronchospasm and depression, bradycardia and hypotension and erectile dysfunction. it can also cause hyperkalemia by inhibiting sodium/potassium Atpase. Propanolol can have adverse effects on glucose and peripheral arterial disease which rarely occurs with selective blockers.

________________________________________

34 year old woman comes to the ER with palpitation. An EKG shows supraventricular tachycardia at a rate of 160 min, there is no response to vagal maneuvers, such as carotid sinus massage.

adenosine is the drug of choice for SVT that is not responsive to vagal tone carotid sinus massage.
Adensine reduced calcium currents and is antiarrhythmic by increasing AV nodal refractoriness. It transiently slows the sinus rate and the AV nodal conduction velocity. It is thought to open potassium channels, hyperpolarizing nodal tissue and making it less likely to fire.
Adenosine causes transient asystole, but this usually lasts less than 5 seconds, a bolus can precipitate a bronchospasm.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>

I am going through a rough time folks wal7mdllah, so If you are reading this, pls remember me in your du3a

ok.. on with opthalmology



this isn't a clip from the incredible hulk, it is fluorescein stain of cornea

after manul staining with fluorescein, the eye is exposed to blue light tht detects foreign bodies or damage to the cornea. fluorescein staining i used in the evaluation of the following conditions
Corneal Abrasion
infection
injury or trauma
foreign bodies
abnormal tear production
kertoconjunctivitis sicca
abnromalities in the surface of the cornea will be stained and appear green
normally the dye stays in the tear film (water, mucus, oil) and doesn't adhere to the cornea
the most likely question in which fluorescein stain is the answer, is whe you are shown a person who had an ocular truama and there is severe pain, and you need to exclude corneal abrasion .
_______________________________________________


pts with retinal detachment often describe an ascending/descending vein in front of one eye with flashes, floaters. The unilateral loss of vision is sudden and painless.
retinal detachment is usually caused by a retinal tear
retinal detachment is a medical emergency. Laser surgery or cryoplexy is always used to help reattach the retina. A scleral buckle may be placed like a belt around the outside of the eye to push the wall against the detached retina, or a vitrectomy may be done where the vitreous is removed and replaced with a gas that pushes the retina against the wall of the eye.

______________________________________



Roth spot is actually a cotton wool spot (infarct) with surrpunding hemorrhage.
Subacute bacterial endocarditis is commonly associated; however, roth sports are not specific for subacute bacterial endocarditis, and maybe present in other disorders, such as diabetes, Leukemia, anemia, hypertension and HIV

Roth spots in subacute bacterial endocarditis are an immunological phenomenon.

_______________________________________



slit lamp exam is a microscopic examination of the anterior half of the eye by projecting a thin beam of light through a slit. The anterior half includes lids, lashes, adnexa, conjunctiva, sclera, cornea, iris, pupil, and lens. When combines with special lenses, the slit lamp may also be used to examine the posterior eye (cup/disc, macula, vessles, periphery)

in this photo


you see kayser fleischer ring in Descemet's membrane on slit lamp, which are basically copper deposits. This finding is diagnostic of Wilson's disease, a disorder of copper excretion.

Slit lamp is the test for a pt. with red painful eye with pain worsened by shinning a light in the eye or photophobia. When severe photophobia isn't associated with meningitis, it can be from iritis or uveitis, which is an inflammation of the iris. Slit lamp is also a good way to detect cataracts or corneal injury.

___________________________________________



Gonioscopy is visualization of the angel between the cornea and the iris. This is performed to assess for narrow angle or angle closure in glaucoma

in Gonioscopy, light from the slit lamp is deflected obliquely through the cornea using a prism or mirror in order to get a view between the cornea and iris. The trabecular mshwork and schlemm's canal, the drainage system of the eye, lie in thi angle.

Answer Gonioscopy when you see a case of glucoma with a red, painful eye with fixed, mid dilated pupil and tonometry has already confirmed glaucoma. Gonioscopy is used to determine the types of glaucoma after the diagnosis has been made.

________________________________________

now cardio in pharm

________________

Aspirin
used for the following

Acute coronary syndromes (myocardial infarction \[MI} and unstable angina as well as post stent and post surgical bypass pts.
Stroke and transient ishchemic attack (TIA)
Peripheral arterial disease
fever reudction (antipyretic)
rheumatoid arthritis
essential thrombocytopenia
kawasaki's disease
Arthrtis, gout and in general as an analgesic

Asa irreversibly inhibits platelets b inhibiting cycloxygenase
the most common adverse effect is bleeding. Aspirin also causes peptic ulcers, asthma, renal insufficiency and rash. In toxic amouns, aspirin leads to metabolic acidosis, tinnitus, encephalopathy, renal insufficiency, and increased anion gap.

________________________________________________

Dipyridamole

is never used as first line therapy for anything.
but can be used for the following conditions
Stroke in combination with Aspirin
preventing heart embolic complications
peripheral arterial disease with asa
as diagnostic testing in myocardial perfusion stuies with thallium

dipyridamole inhibits adenosine deaminase and phosphodiesterase, which increase levels of cyclic adnosine monophosphate (cAMP) cyclic AMP inhibits platelets
adverse effects can include the following
dizziness and headache
gastrointenstinal bleed
____________________________________________

Clopidogrel and ticlopidine
are not the best initial therapy for anythng, clopidogrel is the right choice after ASA can't be tolerated or has faled. clopidogrel is used for acute coronary syndromes, stroke, peripheral vascular disease and post stent placement in combination with ASA

clopidogrel and ticlopidine inhibit platelet aggregation, they prevent adenosine diphosphate (ADP) from stimulating platelet and fibrinogen binding

the most common adverse effect for both is bleeding, Ticlopidine is always the wrong answer therapeutically. Ticlopidine is most often associated with neutropenia and thrombotic thrombocytopenic purpura.

++++++++++++++++++++++++++++++++++++++++++++++++++ +++

Cliostazol
is a phosphodiesterase inhibitor that is used or peripheral arterial disease
cilostazole increases levels of cyclic adenosine monophosphate (cAMP) it irreversibly inhibits platelet aggregation by inhibiting thrombin, adenosine diphosphate (ADP), collagen and epinephrine. It is also a vasodilator that is greatest in the femola bed and less in the vertebral carotid and mesenteric arteries.

a patient with intermittent claudicaton from vascular disease should be treated with cilostazole. It is the single best therapy for PAD. It is used in addition to ASA, dipyridamle and exercise.
adverse
it canses edema, dizziness, and vertigo. The most serious effect is Afib, ventricular tachycardia and CHF.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

73 year old man with CHF recently started onramipril, metoprolol and spirinolactone, and furosamide. He has developed chronic dry cough that makes it difficult for him to sleep..

ACE are the most likely medication to be causing chronic cough, the sx is secondary to their effect on bradykinin levels

Angiotensin receptor blockers (ARBs) should be started in pts who are intolerant of ACE inhibitors. ARB's have the same indications as ASC, such as CHF, HTN, and acute mycordial infarctions. They seem to have an equivalent mortality benefit as well. ARBs include losartan, olmessartan, valsartan, irbesartan, candesartan, telmisartan and eprosartan.
The most common side effect o ARBs are hypotension and hyperkalemia.
_______________________________

ok.. still on cardio today and almost done with opthalmology we'll be moving on to other endeavors

Pharm cardio
_____________
Glycoprotein IIb/IIIa
inhibitors (GPIIb/IIIa)

abciximab
tirofiban
eptifibitide
lamifiban
Orbofiban

Glycoprotein IIb/IIIa inhibitors (GPIIb/IIIa) are platelet aggregation inhibitors that are useful in keeping the coronary artery open in acute setting

Glycoprotein IIb/IIIa work by reversibly antagonizing the IIb/IIIa receptor on the platelet. This prevents fibringoen and Von Willebrand's factor from binding to the receptor on the platelet and thus, prevents the platelet from binding to the endothelial lining of each other.

Glycoprotein IIb/IIIa inhibitors are an adjunctive therapy for angioplasty and other percutaenous coronary interventions. They are also useful for non-ST segment elevation myocardial infarctions when thrombolytics are not indicated.

Glycoprotein IIb/IIIa inhibitors (GPIIb/IIIa) can cause bleeding, thrombocytopenia, and coronary artery dissection.

_____________________________________________

Thrombolytics
tPA
Anistreplase
streptokinase
Alteplase
Tenecteplase

Thrombolytics are recombinant versions of tissue plasminogen activator tPA that are used to reopen acutely thrombosed coronary arteries.
tPA cleaves plasminogen to plasmin. plasmin will dissolve fibrin that has been freshly deposites. After several hour, fibrin is cross linked by factory XIII or 'clot stablizing factor' this makes fibrin refractory to dissolution by plasmin.

Thrombolytics are contraindicated when there is a major bleed occuring. Such as melena or intracranial bleeding. It is also contraindicated with aortic dissection, head trauma or BP > 180/110

tPA is the answer when the question describes chest pain within 12 hrs and a 1mm St elevation of a new left bundle branch block. tPA has less efficacy than primary angioplast for an acute infarction. tPA is also indicated for ischemic heart disease within 3 hours as well as pulomnary emboli with hemodynamic instability, such as hypotension.
___________________________________________

Digoxin

dig has two main indications. rate control of Afib and symptomatic control of CHF
Dig DOESN'T LOWER MORTALITY, in CHF but it does decrease the severity of sx and frequency of hospitalization. dig will not convert afib to sinus rhythm, but it will slow the rate.

dig inhibits the Na/K Atpase. this increases cystolic calcium levels and increases the force of contraction of cardiac muscle..

dig at toxic levels can cause nausea, vomiting, arrhythmias, confuscion, hyperkalemia and visual disturbances.
________________________________________

a pt with CHF is maintained only on a diuretic and digoxin is admitted because of confusion, hypotension, nausea, bradycardia and visual disturbances. His dix levels is markedly elevated


Severe dg toxicity should be treated with dig binding antibodies (digibind) the indications for dig specific fab fragments (d-fab) are hyperkalemia, arrhythmias, encephalopathy, or hypotension.

The most common electroradiographic abnromality is ectopy, hwever the most common serious rhythm disturbance is atrial tachycardia with variable block. Sinus bradycardia may occur.

dig toxicity may lead to hyperhalemia because dig inhibits the Na+/K Atpase.

____________________________________

Amiodrone

is a potent antiarrhythmic medication with excellent efficacy but multiple side effects from long term use. It is the drug of choice for venticular fibrillation in an acute resuscitation.
Amiodarone is structurally similar to thyroid hormone. It blocks inactivated Na+ and ca 2+ channels and has a beta blocking effect. It potently inhibits abnromal automaticity.

Adeverse effecs are
Hyperthyroidism, hypothyroidism, pulmonary fibrosis and non sight threatening corneal deposits.

this is the DOC for ventricular fib and ventricular tachy
treating a fib with systolic dysfunction


____________________________________

Diagnostics

Tonometry

this is the test to measure intraocular pressure. it tests for glaucoma

there are several ways of performing tonometry: pneumotonometry is used as a screening tool. It measures IOP with a puff of air to flatten the cornea. Golmann tonometry is the more accurate way to measure IOP. It combines a slit lamp with a special probe that flattens the cornea and a weight that determines the amount of pressure

the most accurate test is electronic indentation tonometry where a small pinlike instrument is laces directly on the cornea and the pressure is read back on a monitor

it is the best initial and most accurate test for glaucoma .

______________________________

all right we are now up to infectious disease in diagnostics





Trichomonas vaginitis


this is treated with oral metronidazole with concurrent treatment of sexual partner. Single dose therapy is perferred because of increased pt adherence

The pelvic exam will show a strawberry cervix which is cause by multiple punctate hemorrhages visible on cervix

trichomonas is the only organism known to be mobile on wet mount, as the flagealla has it swim across the slide.

_________________________________________

alright the other three after I come back from a break
___________________
aight back from break



this is s india ink of the cereberal spinal fluid showing cryptococcus neoforman. The organism has a mucopolysaccharide capsule that provides a 'halo' around it that pushes away the india ink.
this is the best initial test for cryptococcus neoforman, when you see a pt with AIDS with <100 CD4 cells who presents with fever, headache, and possibly a stidd neck. CSF will show a mild elevation of lymphocyts. The presentation is a 'subacute' which means it is slower in onset and milder than bacterial meningitis. Caution: Normal CSF protein and white cell counts do not exclude cryptococcal meningitis.

The most accurate test for cryptococcal meningitis is either a cryptococcal antigen or fungal culture of the CSF.

__________________________________________________ _______________



the smear is a wet mount and shows clue cells. they are abnormal epithelial cells with ground glass appearance and a hazy border. The tiny dark dots are bacteria stick to the surface of the epithelial cells.

there will be a thin discharge and itching, also dyspareunua. fishy odor positive for the whiff test adding KOH to slide. The PH is usually > 4.5
pregnant women with BV are at an increased risk for miscarriage, early preterm delivery and infection after the pregnancy.

++++++++++++++++++++++++++++++++++++++++++++

ah the kit for a bone biopsy
look for a pt with peripheral vascular disease, with leg pain, warmth and an ulcer, wo has an abnromality on x-ray or MRI consistent with osteomyelitis.

needle aspirate is gold standard
for
osteomyelitis
bone tumors
metastatic bone disease

radiological evidence of osteomyelitis and positive blood cultures can replace the bone biopsy if osteomyelitis is suspected.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

on with pharm
_________________

68 year old woman is being evaluated in your office for worsening sob with minimal exertion. her echo shows ejection fraction of 32%

The medications that have a clear mortality benefit in CHF are as follows

beta blockers, metoprolol, and carvedilol
ACE
ARBs candasartan and valsartan
spironolactone

An implantable cardioverter defeibrillator has benefit for reducing mortality with ishcemic cardiomyopathy and an ejection fraction <35%

____________________________

27 year old woman from ecuador is being evaluated because of increasing shortness of breath. she shows rales on exam. she has an early diastolic decrescendo murmur. The symptoms have become worst because of pregnancy

the patient has mitral stenosis
mitral stenosis is most often from rheumatic fever in the past.

best initial therapy for mitral stenosis is pre-load reduction with sodium restriction and a diuretic. This is problematic however, because of her pregnancy. Diuresis can potentially cause IUGR.
The most effective therapy for mitral stenosis is baloon valvuloplasty. this procedure is ideal for a pregnant woman. pregnancy increases plasma volume by 50% and worsens sx. baloon valvuloplasty is safe in pregnancy and is by far preferable to open heart surgery.

____________________________________________

Your pt has recently been diagnosed with coronary artery disease by stress test. He is a nonsmoker, he doesnt have diabetes or htn, his LDL is 145 after three months of life style modifications. including diet, exercise and attempts at weight loss

the best initial therapy for high levels of LDL despite life style modification is a statn. LDL above 130 needs drug therapy.

adverse effects: hepatotxicity, LFT's should be checked for thabdomyolysis or myositis though neither is as common as liver tox.
The goal therapy for CAD is an LDL <100.

________________________________________________

a diabetic hypertensive obese smoker is found on angiography to have CAD, her LDL is 110

a diabetic is found to have an LDL of 122

a man with CAD has an LDL of 170 despite rx with a statin and life style modifications for the last 6 months. his triglcerides are elevated and his HDL is low

the best therapy initially is always a statin

the goal therapy for a person with CA and diabetes or CAD and multiple risk factors is an LDL <70. established risks are diabetes, smokin, htn, and an age >45 in men and >55 in women

case one statin
2 the goal in a diabetic is an LDL <100

when the goal can't be met with a statin, seconf medication should be added, cholestyramine bind cholesterol in the bowel but leads to bloating, abdominal pain and flatus. The best therapy specifically for triglycerides is a fibric acid derviative such as gemfibrozol.

Niacin is the best med to raise HDL. Niacin causes flushing and elevations of glucose and uric acid. Ezeetamibe lowers levels but has no proven mortality benefit.

the goal is an LDL < 100. the for for triglycerides is <150

_________________________________________

53 year old experiences syncope while at the opera. she loses her pulse, she is found to have ventricular tachycardia. Electrical cardioverson restores her to sinus rhythm

an implantable cardioverter/defib is the best initial therapy to prevent sudden death from either ventricular tachycardia or ventricular fibrillation. Electrophysiologic studies aren't necessary. she has already sustained v tach with loss of pulse. inducing an arrhythmia is not necessary. Beta blockers may be helpful to prevent the arrhythmia from developing but the life threatening nature of this rhythm disturbance makes having a defirillator essential.

_______________________________________________


infectious dz in diagnostics

Bone scan or technetium pyrophosphate nuclear bone scan

Bone scan is a method of detecting occult disease that has deposited in bone

technetium is picked up by osteoblasts and deposited in the bone as they lay down new matrix. You must have osteoblastic activity in order for it to light up

bone scans can be abnromal from both infections and malignancies and cancer are detected by bone scans. Bone scans lack specificity and often can't distinguish soft tissue infections from nearby involvement of the bone.

The rpecise etiology of the abnormality on a bone scan often requires a bone biopsy to confirm dianosis

____________________________________

CD4 (t-Cell) counts

CD4 count is used to monitor HIV positive pts. serum measurement of CD4 (t-Cell) markers is representative of the number of helper T lymphocytes in the blood count. CD4 is used to monitor the response to reatement. start antiretroviral therapy: CD4 <350 or viral load >55,000.
answer CD4 count as the best test to determine the severity of immunosuppression in HIV/AIDS

prophylaxis should be initiated in the following scenarios

CD4 count less than 200 cell/ul: TMP/SMX for pneumocystis jirovrci
CD4 count less than 100 cells/ul: TMP/SMX for toxoplasma
CD4 counts less than 100 cells/ul: itraconazole for histoplasmosis in endemic areas.

CD4 counts less than 50 cells/ul: azithromycin for mycobacterium avium complex (MAC)

___________________________

will finish the last three after a break insha'Allah
_________________________

Darkfield microscopy

the most accurate test for primary syphilis
a scraping of swab from the syphilitic cancre is rubbed on a slide

answer darkfield microscopy for primary syphilis when the questions asks for most accurate test. primary syphilis there is a false negative rate of about 25% for the RPR or VDRL. The darkfield is more sensitive than an RPR
___________________________________
Gallium scanning

is a nuclear scan that detects infection and some cancers. Gallium builds up in areas where white blood cells are present and there is increased iron metabolism. Gallium is transported on transferrin. Gallium is a nonspecific test that can help localize the site for subsequent CT or MRI scanning

Gallium is considered on pts with persistent fever without localizing symptoms and the initial blood cultures, chest x-ray and urinalysis are negative. Gallium detects the source of fever os unknown origin, lymphoma, and abscesses.

Ultimately, a biopsy is the most accurate way to determine the etiology of an abnromal gallium scan. Cancers require histology and infections require culture to be confirmed.
__________________________________________

herpes simplex PCR
is done on CSF and is the single most accurate test for herpes encepalitis.

look for a pt with fever, headache, and confusion of less than 2 weeks duration. The PCR of CSF is more accurate than an EEG, head CT, MRi or even brain biopsy.

>>>>>>>>>>>>>>>>>

today's 5/5



indium labeled leukocyte scan
is a nuclear medicine test of occult infection or FUO. A sample of the pt's blood is drawn and incubated with indium. The indium tags the white blood cells then localize to the site of infection.

look for a case of occult infection not found on routine testing such as blood cultures, chest x-ray, or urinalysis. Indium is useful when gallium is inaccurate such as with intrabdominal infections.

a biopsy is more accurate than an indium scan.

_______________________________________



this is a KOH prep of candida
is is the best initial test to diagnose superficial fungus. KOH is applied to a wet mount samle of vaginal discharge/secretions or to a skin scraping to identify the fungus. This is seen under the microscope. Epithelial cells dissolve an the fungal structures remain behind and are visible

KOH is used for the following

Tinea (pedis, manus, corporis, cruris, capitis)
onchomycosis
tinea versicolor
candidiaisis

applying KOH to a wet mount and smelling/whiffing immediately after yeilds fishy odor (amine) is bacterial vaginosis.

_______________________________________________



Monospot test is the initial test used to diagnose infectious mono .. it detects hetrophile antibodies that are charcteristic of Epstein barr virus

monospot is the best initial test for a pt with a sore throat, fever, lymphadenopathy, and malaise, a total of 50% of pts will have splenomegaly, rash is present in 15% unless they have been given ampicilin. When it is present closer to 90%. Exudative pharyngitis may occur

the most accurate test acutel is the IgM to EBV viral capsid antigen (VCA). antibodies to EBV nuclear antigen (EBNA) rise in 3-4 weeks
_______________________________________



legionella urine antigen is found in legionella pneumonia. it is the best initial test
legionella urine antigen has a 100% specificity with L. pneumophila type i. Only 70-80% of disease is caused by L- pneumoophila type 1. sputum culture or a culture of the tracheal aspirate on specialized charcoal/ yeast extract remains definitive.

suspect legionella antigen when seeing a nursing home resident admitted for pneumonia that presents with fever, confusion, diarhhea and hyponatremia. CPK, liver function test and creatinine can also be elavated

_________________________________________

.

polymerase chain reaction HIV RNA viral load

the PCR HIV viral load is a quantitative measurement of the amount of virus circulating in the pt's blood

this test is the first thing to change in response to treatment. PCR HIV viral load is also the first thing to become abnromal is the patient stops taking medications or the treatment fails. The viral load test tells how fast the CD-4 T-elper cells will drop. The higher the viral load the faster the disease process.

measurements should be made at the time of the HIV diagnosis and every 3-4 months thereafter. The PCR viral load is also the basis of HIV sensitivity testing in order to determine the presence of resistance in failing regimen.

________________________________________

Now Pharm, finish cardio and move on to endocrine

_______________________

A man with metastatic cancer develops DVT/ woman with metallic heart valve presents for routine care.

those with deep venous thrombosis (DVT) can receive either low molecular weght heparin or IV-unfractionated heparin, their efficacy is identical. The measurement is followed by warfarin (coumadin) to international normalized ratio (INR) 2-3

heparin potentiates the effect of antithrombin on the clotting cascade

those with a first DVT should be maintained on warfarin for at least 6 months

most common adverse effect of both therapies is bleeding. Haparin can result in thrombocytopenia

metal heart valves maintain lifelong coagulation with warfarin. pts with metal heart valves are the only pts n which you routinely maintain target INR above 2-3. the target INR is 2.5-3.5
warfarin inhibits vitamin K dependent clotting factors (II,III,VII,IX and X)

__________________________________

a 32 year old woman in her third trimester with HTN, edema and proteinurea, se is being prepared for dleivery.

67 year old man develops torsades de pointes post infarction, he is hemodynamically stable.

Magnesium sulfate (Mg2+) is the best medical therapy for pre-eclampsia and eclampsia as well torsades de pointes. Magnesium prevents seizure in exlapmpsia.

Mg2+ works by decreasing ACH in motor nerve terminals and acting on the myocardium by slowing the rate of SA node impulse formation an prolonging conduction time. Mg2+ appears to inhibit calcium uptake into smooth muscle cells, reducing uterine contractilty . in general Mg2+ relaxes excitable neural and muscular tissue

Magnesium sulfate can lead to muscular weakness and loss of reflexes it causes diarrhea by promoting bowel evacuation through osmotic retention of fluid, which distends the colon. Severe magnesium toxicity can lead to respiratory paralysis
__________________________________

31 year old woman comes to the ER dept with palpitations, the EKG reveals a short PR interval, supraventricular teachycardia develops. When diltiazem is adminstered, the pt develops ventricular tachycardia. The pt remains hemodynamically stable .

Wolff=parkinson white syndrome

is best treated with procainamide or amiodarone. if an acute arrhythmia such as SVT or VT develops. these agents are effective against both atrial and ventricular arrhythmias, making them drugs of choice.

Cardioversion for a pt hemodynamically unstable. this is defined as chest pain, SOB from CHF, confusion, hypotension defined as systolic BP <90

radiofrequency catherter ablation after electrophysiologic studies is curative. The accessory conduction pathway is destroyed in an electrophysiology laboratory.

_________________________________________

Propylthiouracil (PTU) and Methimazole

PTU and methimazole are the best initial therapies for hyperthyroidism. They are used to lower the level of thyroid hormone.
they don't block the target organ effect. PTU is safe during pregnancy.

PTU and methimazole inhibit the peroxidase enzyme. This blocks the oxidation of iodine, inhibits the incorporation of iodine onto tyrosine, and stops coupling of these compounds into T3 and T4. hence these meds block three essential steps in the formation of thyroid hormone.

the most important adverse effect of these compounds is neutropenia. Both lower granulocyte levels by inhibiting bone marrow. Purpuric skin lesions may also occur.

______________________________

50 yea old man with psostate ca comes to ER after having experienced lethargy, constipation and generalized weakness for four days. His calcium is markedly elevated at 14.5 and the WKG shows a short QT, hydration with saline and loop diuretics have been given

Bisphosphonates are the best initial therapy to lower calcium levels after fluids and diuretics have been initiated. Bisphosphonates (pamidronate, zolendronic acid, alendronate, ibandronate risendeonate) are also used for osteoporosis when the T score is 2.5 standard deviation beloe normal (t-scre-2.5)

bisphosophantes work by inhibiting osteocalsts, prevnting bone resorption. they bind calcium hydroxyapatite in the bone and prevent its dissolution.

oral admin can cause esophagitis and for this reason they should be taken sitting up while drinking lots of water. rarer adverse is hypocalcemia and osteomalacia . osteonecrosis of the jaw has been associated with the use of bisphosphontes.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>

thought I'd forget about this thread today.. it has been a bad day sob7an Allah..
maybe tomorrow will be better insha'Allah

on with pharm /endocrine
___________
Calcitonin

is indicated for the following conditions
acute hypercalcemia
paget's disease
osteoporosis

calcitonin works predominately by inhibiting osteoclast activity.
calcitonin can cause flushing, rash, and constiption it rarely causes depression and bronchospasm. The most common adverse effects are rhinitis, and flulike sx.

________________________________

ok we now move on to derm

minocycline
is the best oral antibiotic for severe acne, that is not controlled by topical antibiotics or topical vitamin A derivatives such as terintoin. Other indicaations for minocycline include the following
nocardia
actinmycycosis
rosacea

minocycline is a tertracycline antibiotic that inhibits production in bacteria

minocycline can cause blusing discoloration of the skin but doesn't cause photosensitivity rash as doxycycline can. miocycline can bring on vertigo by causing vestibular dysfunction.

________________________________

a woman comes in with mild acne, she has a few comdones with an occasional inflammed papule or pustule

a man has failed initial theray for acne and has numerous papules and postules with mild scarring

your pt is very distressed and depressed because of numerous laege cysts on the face and trunk he is severely scarred

case one mild comodonal acne, is treated with topical benzoyl peroxide and a topical atibiotic such as erythromycin or clindamycin. Benzoyl peroxide is both antibacterial and comedolytic. topical antibiotics will eliminate the causative organism proionbacteium acnes from the comoedones.

case two, severe acne resulting in scarring in addition to benzoyl peroxide. the patient should be treated with a topical vitamin A derivative (tretionin) an oral antibiotic such as minocycline should be used.

case three is severe cystic acne. an oral antibiotic and oral vitamin A are needed, isotrentinoin will decrease sebum producton but is extremely teratogenic and can cause severe depression, dry skin and hyperlipidemia
_______________________________________

an adolescent boy comes to see you for rx for a long standing itchy eczematous rash on his face, hands, and feet in the flexural areas, the skin is lichenifies from scratching, he also has seasonal rhinitis and occasional utricaria

Atopic dermatitis is treated with antihistamines such as fexofendaine, cetrizine or loratadine. hydroxyazine and diphenhydramine are more potent but much more sedating. Doxepine is a tricyclic with extensive antihistamine effects.

Atopic dermatitis sx can be lessedned in the long terms by moisturizing skim, avoiding harsh sopas and treating skin infections. although topical steriods are effective to control symptoms acutely, in the long term they lead to skin atrophy. Topical calcineurin inhibitors such as tarcolimus and pimercrolimus can control atopic dermatitis in the long term without using steriods.

Antihistamines, such as fexfenadine are also used in the following condiions

Allergic/ seasonal rhinitis
angioedema
utricaria

_______________________________

a woman comes to the offic for pruritic, silvery, scaly, lesions of the knees, elbows, and hands, the lesions are on the extensor surfaces

localized psoriasis is treated with topical steriods to prevent skin atrophy. treatment with calcipotriene a vitamine D analog should be used. topical tazarotene, a vitamin A analog is also used. Tacrolimus and pimercrolimus are also used

widespread disease is treated with UV light. the most effective systemic therapy is methotrexate, but it also has the most adverse effects. Biological agents such as etanercerpt, alefacept and efalizumab are used as alternatives to methotrexate.

______________________________________

diagnostics infectious dz

VDRL/RPR

serume measurement for these nontreponemal examinations are used to diagnose or screen for syphilis

in the primary stage, you would expect the patient to present with a chancre and painless regional lymphadenopathy. in the secondary stage rash, lymphadenopathy, condylomata lata and alopecia can be expected.
teritiary syphilis is charcterized by cardiac or neurological dz.

false positives connective tossue disease, infectious mono, malaria, leprosy, IV drug use, hep C, infective endocarditis and pregnancy

false negatives prozone phenomenon- very high antibody titers are prestnt

when your clinical sspicion is high yet the nontreponemal tests are negative, you would want to do a darkfield examination in primary syphilis and FTA-ABS test for other stages..

The RPR and VDRL decrease or disappear in response to RX, the FTA can remain positive life long..

_____________________________________


Tzanck smear

are used to dx the skin manifestation of either herpes simplex of varicella zoster. You are looking for multinucleated giant cells. Tzanck smear is not necessary if the diagnosis is clinically clear from the presence of vesicles.

the most accurate test for a herpetic infection of the skin or genitals is a viral culture.

_____________________________





arthrocentesis is a needle aspirate of synovial fluid for microscopic analysis. The cell count is the most accurate ways of telling is there is an infection vs inflammation.

counts from 0-2000 are normal
from 2000-20,000 are from inflammatory disorders such as gout. counts above 50,000 are from infections, counts between 20,000, to 50,000 are intermediate

look for a pt with new onset of joint that is warm to the touch, painful, and swollen from an effusion, and decreased with mobility. serum uric acid maybe elevates

gout is negatively birefringent needle shaped crystals, these are monosodium urate crystals

pseudogout is positively birefringent rhomboid shapes crystals

___________________

aldolase

is released from damages skeletal muscle and is elevated in inflammatory myopathies such as polymyositis and dermatomyosistis. Creatine and CPK are also elevated.

look for a case of an older woman with difficult rising from a chair, there maybe a heliotrope rash and Gottron's papules. Aldolase or CPK is the answer to the question best initial diagnostic

the most accurate tests are the electromyogram and the muscle biopsy. these confirm the diagnosis of polymyositis and dermatomyosisits when the alodolase is elevated.
_______________________________________

Allergy testing

is a subdermal exposure to trace amounts of suspected allergens with subsequent visual inspection for signs of hypersensitivity.

this is contraindicated when there is a high risk of anaphylaxis.

beta blockers such as propanolol should be stopped prior to testing for allergens for which there might be severe reactions during desensitization. If anaphylaxix occurs, we want to use epinephrine to reverse it, and beta blockers will make the epi less effective..
>>>>>>>>>>>>>>>>>>>

was out for Eid today.. insha'Allah will resume tomorrow, might add another sections of most likely diagnosis if my time permits insha'Allah...

I am going to introduce a new most likely dx here, will do it at a rate of 15/5/5 to catch up with the other topics..

starting with cardiology

________________________________

1- Man comes into the Er with chest pain, that changes with respiration. the pain is sharp, and is worsened by inhalation. He is short of breath, as well but the symptoms are hard to assess because a deep breath causes pain, so he takes short fast shallow breaths...

most likely dx
a- te pain changes with bodily position. it is worse when lying flat, and better when sitting up.

b-cough, fever, hemoptosis
c- sudden onset of SOB with a normal lung exam
d-hx of astham or COPD with sudden onset of SOB, decreased breath sounds on one side

pericarditis is associated with pleuritic chest pain that also worsens with changed in bodily position. typically the pain of pericarditis is releverd when the person sits up, and stretch is relieved from the pericardium. only 30 % of pts have a pericardial friction rub. if it is present, it helps answer, the most likely diagnosis question. if the rubs are absent, this excludes nothing EKG shows PR depression and diffuse concave ST elevation.

Pneumonia is associated with cough, sputum, and hemoptysis. fever is nonspecific, every cause of pleuritic chest pain is asspciated with fever.

Pulomnary embolus presents with the sudden onset of shortness of breath and clear lungs on exam. There is no charcteristic physical findings of PE to allow you to resolve the dx in question.

sudden onset plus normal lings = PE. pt maybe on a long trip

pneumothorax, when large breath sounds decrease on one side. obstructive lung disease ca predispose to pneumothraces, particularly when there are blebs with COPD.

__________________________________

A man is brought to the ER dept after losing consciousness at home, he wakes after a few mins

a- sudden loss of consciousness and rapidly regaining consciousness, he is fully intact when regaining consciousness.
b- sudden loss but was disoriented for an hour or two on regaining consciousness
c-gradual loss of consciousness with shaking, sweating, palpitatons, and nausea

d- has a 10 point rise in pulse and a 20 point drop in systolic pressure when going from lying to upright posture.


crdiac syncope such as an arrhythmia or obstructive cardiac lesions results in the sudden loss and regaining of consciousness. Ventrcular rhythm disturbance such as a ventricular tachy or fib will result in syncope

seizures can result in sudden loss of consciousness but the regaining of alertness is slow because of being post-ictal results in a gradual regaining of consciousness described as post ictal state.

metabolic probs such as hypoglycemia, hypoxia or drug intoxication lead to a gradual loss of consciousness. this is often accompanies by signs of autonomic hyperexcitability such as tachycardia, palpitations and diophoresis. you may see metabolic respiratory acidosis or alkalosis.

orthostatic instability leads to syncope in association with a >30 pt drop in systolic blood pressure on changing position with a 10 point rise in pulse.

________________________________________


a patient comes to the office with palpitations for the last several weeks. she denies chest pain or SOB, the sensation is like her heart will flutter away at her chest..

1- the pulse is irregularly irregular

2- she drinks lots of coffee and the EKG is normal

3- she is losing weight and has diarrhea, her eyes are bulged forwars (exophthalmos)

4- there is episodes of flushing and low BP

A fib presents with palpitations and an irregularly irregular pulse. arial rhythm disturbances rarely result in syncope.

caffeine can easily lead to the feeling of palpitations even with normal EKG

hyperthyroidism results in weight loss, anxiety, tachycardia, diarrhea, and palpitations, about one third have ocular findings such as exopthalmus


carcinoid syndrome leads to papitations from the oversecretion of the neurotramsitter seratonin, episodic flushing, diarrhea, and episodes of HTN are common. palpitations with HTN should make you think of pehochromocytoma

________________________________________________


patient comes to ER with palpitations found to have an SVT after admin of filtiazem his rhythm deteriorates to Vtach

Wolff-Parkinson-white syndrome can present with an Atrial arrhythmia, alternating with ventricular arrhythmia. The key to answering the question is worsening of the rhythm after giving a calcium channel blocker CCB such as dilitizem or verapamil. the rhythm may also worsen with dig. CCB and DIg block conduction through the normal AV nodal pathway and force conduction through the abnromal aberrant tract. resulting in a deterioration of the rhythm.

EKG showing a short PR interval or delta wave. EKG is the best initial test.

elecreophysiological studies are the most accurate for pre-excitation syndrome.

___________________________________


a pt comes for toutine visit on PE he is found to have a pulse of 45

1- he is asymptomatic, he runs five miles each day
2-he has canon 'a' waves in the his neck. occasionally he is light headed.

sinus brady is common finding in well trained athelets. You can't be sure if bradycardia originates at the sinus node without an EKG

third degree complete heart block is associated with canon 'a' waves in the neck. it is often associated with symptomatic hypotension or syncope, and that is why a pacemaker is necessary. canon 'a' waves result from atrial systole against a closed tricuspid valve. the only condition to have bradycardia and conon 'a' waves is a complete heart block.

________________________________________


62 year old man is the ICU after an MI he is no suddenly lightheaded and hypotensive

1- there is a holosystolic murmur at the apex radiating to the axilla, the lungs are congested.

2-oxygen saturation increases from 40% in the right atrium to 82% in the right ventricle

3- he had an inferior wall infarction. he has tachycardia and clear lungs

4-bradycardia and canon 'a' waves are present

mitral valve rupture leads to acute pulmonary edema, the murmur of mitral regurgitation is holosystolic and radiates to the axilla

valve rupture leads to a step up in oxygen saturation as you go from right atrium to the right ventricle, this is from left to right cardiac shunting

right ventricular infarction accompanies 30-40% of inferior wall infarctions. This is because they are both supplied by the right coronary artery. The lungs are clear, patient may also have rupture of both left ventricular free wall, but outcome then is immeiate death.

complete heart block leads to bradycardia. hypotension and canon 'a' waves.

____________________________________________

a man is admitted for an MI of the anterior wall, he suddenly loses pulse

1- most likely DX

2- best initial dx test

3- initial therapy

sudden loss of pulse can be from asystole, Vfib, vtach or pulseless electrical activity

EKG is the best initial DX

in Asystole start with epinephrine and atropine

Vfib and Vtach-unsyncrhonized cardioversion
pulseless electrical activity, correct the underlying cause such as tension pneumothoraz, PE, hypovolemia and tamponade.

____________________________________________

28 year old woman seen for severe HTN, pressure is repeatedly elevated
1- abnromal sound auscultated in the flanks of the abdomen
2-hypokalemia
3-episodic with palpitation
4-upper extremity blood pressure is greater than lower extremity pressure
5-hirsuitism, clitromegaly


1- enal artery stenosis is most likely when bruits are heard on examination and most common cause of secondary hypotension
2- when you see hypotension combined with hypokalemia, think Conn's sndrome, or primary hyperaldosteronism.
3-pheochromocytoma is the only for of htn that is episodic
4-coarctation of the aorta results in higher blood pressure in the arms compared to the legs. the pressure can also differ between the arms, if coarctation occurs before 'offshoot' of left subclavian artery.
5-CAH with 11-hydorxylase deficiency leads to HTN when pt is under 30 and the HTN is very hard to control such as needing more than two antihypertensive meds.

________________________________________________

Man presents wih SOB and TIA, he has intermittent fever. The murmur changes markedly with bodily posotion. The SED rate is high

1-most likely DX
2-Most accurate diagnostic
3-RX


atrial myxoma is a benign cardiac tumor that is charcterized by a murmur that changes with bodily positions. This is also called a tumor plop. Myxoma presents with a murmu that is similar to mitral stenosis because it obstructs diastolic filling. There are also systemic sx such as fever, elevated SED rate, and anemia. TIA is likely due to embolization of myxoma, myxoma can be friable

Echo dignoses myxoma

treated with surgical removal only.

____________________________________


Man comes in with CP, Dyspnea and diaphoresis, occurs on exertion

1- pain happens every time he walks one or two flights of stairs. EKG normal
2-pain occured wih much less exertion. EKG shows ST depression
3-EKH shows ST elevation

stable angina is Cp occuring with the same level of exercise, stable angina is pain with exertion and relieved by rest, with a normal EKG

unstable angina is a type of acute coronary syndrome with a worse pattern of chest pain or pain occurin at rest. Acute coronary syndrome is the proper name, because you can't tell if the cardiac enzymes such as the troponins will be elevated until later. this may turnout to be a nonstemi infarction if cardiac enzymes are elevated
3- acute MI is assumes where there is chest pain with st elevation even before cardiac enzymes results are obtaines. The majority of pts with chest pain and stemi develop elevated troponins and CPK-MB levels. The pT would be a candidate for thrombolysis and or immediate cardiac cathe.

_______________________________________________


a man comes with pain his his leg, the last several weeks. the pain occurs while he is walking and is relieved when he sits down.

1- pain is unilateral and occurs with any forms of exertion of the leg, the skin is mooth with hair loss and skin appendages.
2- the pain is bilateral and made worse when walking downhill, he has no pain when bicycling.


PAD occurs as pain with any form of exertion of the lower extremity and is relieved by rest. as it wosens, loss of skin appendages such as hair follicles and sweat glands. sx may improve when dangling the head of the bed, gravity increases blood flow to legs.

spinal stenosis results in bilateral leg pain that is highly dependent on bodily postion. it is much worse with anything that has the pt leaning back. such as walking downhill. it is relieved by leaning forward such as sitting or bicyling. it isn't exertion that leads to pain, it is the pressure on the spinal cord on the ligamentum flavum in the spinal canal. MRI of the spine, likely lumbar will demonstrate stenosis.

___________________________

34 year old woman comes to the office with palpitations and atypical CP. The pain has no fixed patter. PE reveals a mid-systolic murmur. The murmur worsens with valsalva and improves by a leg raise

what is the dx and rx

MPV is the most likely DX when the question describes atypical CP in a young female. There is a midsystolic click followed by a murmur. Valsalva will worsen only the murmus of MVP and hypertrophic obstructive cardiomyopathy

MVP is confirmed with echo, and treated with beta blockers. Endocarditis prophylaxis prior to dental procedures is no longer recommended
________________________

a healthy young man experiences SOB with exertion. he has an episode of syncope while playing basketball. exam reveals
a systolic murmur worsens with valsalva and improves on squatting

hypertrophic cardiomyopathy most often presents with SOB, it can also cause syncope and may lead to sudden death. The murmur has the same crescendo/ decrescendo pattern of aortic stenosis but is heard best at te lower left sternal border. Aortic stenosis is heard best at the 2nd right intercoastal space and radiates to the carotid arteries.

HOCM shouls be treated with beta blockers. if Syncome occurs, an implantable cardioverter/defibrillator should be placed. Endocarditis prophylaxis prior to dental procedures is no longer recommended.

__________________________________________

woman comes with progressively worsened SOB on exertion and a murmur. there is edema

1- pregnant woman with a diastolic extra sound followed by a murmur. she has dysphagia and hoarseness

2-older man with angina and a systolic murmur radiating to the carotid arteries.

3- diastolic decrescendo murmur with a wide pulse pressure

mitral stenosis, often becomes symptomatic during pregnancy because of marked increase in plasma volume during pregnancy.

dysphagia hoarseness happen from enlargement of the left atrium pressing on the esophagus and recurrent laryngeal nerve. another clue is opening snap

aortic stenosis is a systolic murmur radiating to the carotid arteries and is the most common presentation of aortic stenosis

aortic regurgitation presents with SOB, but this is a nonsepecif finding, the key to the answer is the diastolic decrescendo murmur at the left lower left sternal border and th wide pulse pressure.

__________________________________________________

A man with a hx of HTN comes to the ER dept with a sudeen onset of sharp CP radiating to his back, there is a 15 point difference in BP between the left and right arms. a dastolic decrescndo murmur is present .

Aortic dissection presents with sudden onset of CP radiating to the bck, particularly the shoulder blades. HTN by far is the most common risk factor. the key to diagnostic is the pain radiating to the back, the wide pressure from aortic regurg and the difference in pressure between the arms.

the best initial test is a CXRAY, which may show a widened mediastinum

transesophageal echo, CT angiogram and MRI each have about a 90-95% sensitivity. aortic angiography is the single most accurate test. Transthoracic echo is not the test of choice due to its limited accuracy \; management is aggressive control of systolic BP (100-120mmhg)

__________________________________________________

ok.. now one with pharm endocrine
Sitagliptin, exenatide, and parmlintide

sitgaliptin, exenetide and pramlinitide are used as adjunctive therapies for diabetes. in addition to sulfonylurea, metformin or both. prmlinitide can also be combined with insulin.

mechanism

exenatide is an incretin mimetic. Incretin is released by the intestinal tract and increases after you eat. incretin increases insulin synthesis and release by pancreatic beta cells. Incretin decreases glucagon production

sitagliptin- blocks degradation of incretin
pramlintide- suppresses glucagon release via undetermined mechanism , delays gastric emptying, and has CNSS mediated anorectic effects

most common adverse effect is hypoglycemia.

________________________________________
Orlistat

used to RX obesity
is a reversible inhibitor of pancreatic lipases. This action blocks the absorption of fat in the intestine. fecal excretion is increases, this may cause mild decrease in fat soluble vits such as ADEK
advers, oily stools, diarrhea, flatus, abdominal pain and other sx, similar to celiac d and steatorrhea.

___________________________________________

fludrcortisone

is a steroid with very potent mineralocorticoid activity. being adminstered, is is the closest thing to eating aldosterone.

fludrcortisone causes sodium rention. it also causes hydrogen ion, acid excretion, leading to metabolic alkalosis

fludrocortisone is the rx for the following conditions

Addison's dz. (adrenal insufficiency)
orthostatic hypotension
septic shock rx (adjunct to hydrocortisone)
type IV renal tubular acidosis

fludrocortisone can lead to hypokalemia, edema, and HTN. like all steroids, fludcortisone can lead to osteoporosis, impaired wound healing and easy bruising
_______________________________________________

Alpha glucosidase inhibitors

acarbose
miglitol

these are oral hypoglycemic agents that are used in the RX of Dm
alpha glucosidase inhibitors are an adjunct for DM when sulfonylurea, metformin, or both are not able to control pts glucose level/ the pill must be taken with each meal to prevent glucose absorption

the adverse are bloating, diarrhea and flatulance.
________________________________________________

Metformin

is a biguanide used in rx of DM
it decreases hepatic gluconeogensis, and increases peripheral sensitivity to insulin. it doesnt require beta cells and will not therefore cause hypoglycemia.
metformin may be associated with lactic acidosis. Metformin is renally cleared and therefore a rise in creatining can cause the levels to rise, metformin is contraindicated in RF

metformin is the initial therapy for type II Dm, this is particularly true for obese pts who have peripheral insulin resistance.
______________________________________

now diagnostics still in rheumatology

ANA, double stranded DNA, and anti-SM antibodies

ANA is more than 98% sensitive for SLE but ANA isn't specific for SLE.
a negative ANA excludes SLE with 98% negative predictive value. Anti- DS-DNA antibodies are 99% specific for SLE. anti-smith antibodies are extremely specific for lupus.

Answer ANA, anti-SM, and ds-DNA when you see a young female with multiple spontaneous abortions (lupus anticoagulant) rash, joint pain
__________________________________________________ __

Anticentromere antibodies

Anticentromere are specific for CREST syndrome.
CREST is calcinosis, Rynaud's phenomenon, esophageal dysmotility, telangeictasia, Antitopoisomerase (SCL-70) is specific for systemic sclerosis)

anticentromere is the best initial test in a female 30-50 with positive rheumatoid factor positive DNA

__________________________________________________ __

Anti-histone antibodies
are often associated with drug induced lupus SLE. The most common drug that cause lupus are procainamide, hydralazine, sulfonamides, INH, and pencilamine.

stop meds
____________________________________


anti-Ro and anti-La antibodies are associated with Sjögren syndrome presents with a positive ANA, anti RO/Anti La and positive for rheumatoid factor.

best used when you see a triad of kertoconjunctivitis (sicca syndrome) xerostomia and arthritis, or dry eyes, dry mouth and arthritis
_________________________________________________

Anti-scl 70 antibodies

are directed against topoisomerase-1 and are ordered when systemic sclerosis, particularly the diffuse type is suspected.

look for polyarthralgia; Raynaud's phenomenon, thick, hidebound skin, dysphagia, and GI tract hypomotility as well as pulmonary and renal abnromalities.

Anti-SCL 70 has a low sensitivity 30%. hence negative test will not rule out dz.

it is however, strongly correlated with severe lung involvement, such as pulmonary fibrosis.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>