Neuroleptic Malignant Syndrome.

This is an idiosyncratic reaction to a wide variety of phenothiazines or butyrophenones such as haloperidol.

Muscular rigidity and rhabdomyolysis may occur as well. Treatment, besides stopping the drug, is with bromocriptine or dantrolene.

Central Core Disease (CCD)

Central Core Disease (CCD) is a rare non progressive myopathy with autosomal dominant inheritance, presenting in infancy and characterized by hypotonia and proximal muscle weakness.

Five ‘Rs’ of intravenous fluid administration

Five ‘Rs’ of intravenous fluid administration

  • Resuscitation
  • Routine maintenance
  • Replacement
  • Redistribution
  • Reassessment

Red man syndrome

Red man syndrome is associated with rapid intravenous infusion vancomycin. It is a common adverse reaction of intravenous vancomycin use, and is a distinct entity from anaphylaxis due to vancomycin use.

Typical symptoms include redness, pruritus, and a burning sensation, predominantly in the upper body (face, neck, and upper chest). 
Severe cases can be associated with hypotension and chest pain.

The management of red man syndrome involves cessation of the infusion; and when symptoms have resolved, recommencement at a slower rate. 
In patients who are more symptomatic, antihistamines can be administered.  
Intravenous fluids may be required if the syndrome is associated with hypotension.

Diloxanide

Diloxanide furoate is the drug of choice for asymptomatic patients with E. histolytica cysts in the faeces. Metronidazole and tinidazole are relatively ineffective.
Diloxanide furoate is relatively free from toxic effects and the usual course is of 10 days, given alone for chronic infections or following metronidazole or tinidazole treatment.

Biphasic Pills

Biphasic pills are forms of COC pills containing two different dose combinations of oestrogen and
progestin usually in packets of 21 or 28 tablet e.g. in 21 active pills, 10 may contain one combination,
while 11 contain another. Examples include Biphasil, Ovanon, and Normovlar

Chvostek’s sign

Chvostek’s sign consists of twitching of muscles supplied by the facial nerve when the nerve is tapped about 2 cm anterior to the earlobe, just below the zygomatic arch.

When hypocalcemia develops from parathyroid disease, Chvostek’s sign, a facial spasm, may be an early symptom

Atopic dermatitis

Atopic dermatitis is a pruritic disease of unknown origin that usually starts in early infancy; approximately 85% of cases occur within first year of life. Usually presents with pruritus, eczematous lesions, xerosis (dry skin) and lichenification (thickening of skin)

Tactile or vocal fremitus

Tactile or vocal fremitus is the palpable vibration you feel when the patient speaks (says ‘99’).

Assessment of tactile fremitus is used to evaluate airflow and density of underlying tissue. Normally, the thicker the chest wall, the more diminished the fremitus; the lower the voice pitch, the greater the fremitus.

Increased fremitus (low voice pitch): conditions causing fluid or exudates in lungs (e.g consolidating pneumonia, atelectasis, pulmonary fibrosis, pulmonary edema, or pulmonary infarction) and sometimes lung tumor depending on size and mobility.

Decreased or absent fremitus (high pich): air trapping, solid tissue, or decreased air movement (e.g. emphysema, asthma, pleural effusion, pneumothorax, or distal to airway obstruction)

hypotonic uterine action

In this condition the contractions of the uterus are irregular, infrequent and ineffectual.

The diagnosis is made by palpation and timing the length of contractions. Repeated vaginal examination will demonstrate a cervix which fails to dilate.

Contractions may be strengthened by rehydration, relaxation (e.g. by epidural anaesthesia), rupture of the membranes and the use of intravenous syntocinon.

The dose of syntocinon must be titrated against the strength and duration of uterine contractions to prevent hypertonic uterine action or the formation of a constriction ring

Immunoglobulins and their roles

Ig G
-O
nly antibody that pass placental circulation causing passive immunity.
-
Short term protection.
-Has an Immediate action.
Ig A
–Present in all bodily secretions (tears, saliva, colostrums).
Ig M
–Acute in inflammation.
Ig E
–For allergic reaction.
Ig D
–For chronic inflammation

Growth Factors

These are substances that promote cell division.
Many act locally as autocrines or paracrines

  • Epidermal growth factor (EGF)
  • Platelet-derived growth factor (PDGF)
  • Fibroblast growth factor (FGF)
  • Nerve growth factor (NGF)
  • Tumor angiogenesis factors (TAFs)
  • Insulin-like growth factor (IGF)
  • Cytokines

Pancreatic islets (islets of Langerhans)

Pancreatic islets (islets of Langerhans)

  • Alpha cells (20%) produce glucagon
  • Beta cells (70%) produce insulin
  • Delta cells (5%) produce somatostatin
  • F cells produce pancreatic polypeptide

Posteriour pituitary gland hormones

Posterior pituitary gland does not synthesize hormones, but it does store and release two hormones made by the hypothalamus.

  • Oxytocin (OT)
  • Antidiuretic hormone (ADH)

Hormones of the anterior pituitary gland are;

Hormones of the anterior pituitary gland are;

  • Human growth hormone (hGH)
  • Thyroid-stimulating hormone (TSH)
  • Follicle-stimulating hormone (FSH)
  • Luteinizing hormone (LH)
  • Prolactin (PRL)
  • Adrenocorticotrophic hormone (ACTH)
  • Melanocyte-stimulating hormone (MSH)

Medications That Can Cause Acne

    Medications That Can Cause Acne Hormonal:

    ACTH Cortisone

    Anaboilc steroids

    High progesterone oral contraceptive pills

    Non-hormonal:

    Azathioprine

    Phenytoin

    Cyclosporine

    Lithium

    Isoniazid

    Fetal and Delivery complications of gestational diabetes mellitus

    Stillbirth
    Lung immaturity
    Intrauterine growth restriction
    Macrosomia
    Prematurity
    Underdevelopment (ie, sacral agenesis, ventricular septal defect, neural tube defect, cerebral palsy)
    Shoulder dystocia
    Hypoglycemia, Hypocalcemia, Hyperbilirubinemia

    Causes of dystocia

    Power(ie, poor or uncoordinated uterine contractions)
    Passenger(ie, fetus too large or malpresentation)
    Passage (ie, pelvis too small or unusual shape)

    Risk factors for ectopic pregnancy

    Ectopy( ie, previous ectopic pregnancy)
    PID(ie, pelvic inflammatory disease)
    IUD(ie, intrauterine device)
    Surger
    y (ie, previous lower abdominal surgery)
    Endometri (ie, endometriosis)

    HELLP Syndrome

    HELLP Syndrome is a severe variant of pre-eclampsia

    Hemolysis
    Elevated Liver enzymes
    Low Platelets

    Prerequisites for forceps Delivery

    Analgesia is adequate
    Bladder empty
    Cervix is dilated
    Descent past ischial spines
    Ead (ie, head) presentation

    Complications of polyhydramnios

    Prolapse of umbilical cord
    Placental abruption
    Preterm labour
    Presentation (ie, malpresentation)

    Causes of postpartum pyrexia

    Wind(ie, lung atelectasis)
    Water ie, urinary tract infection)
    Womb(ie, endomyometritis)
    Wow (ie, mastitis)
    Wind (ie, pneumonia)
    Wound (ie, C-section or episiotomy site)
    Walk (ie, deep venous thrombosis)

    Risk factors of preeclampsia

    Multiple gestation
    Age extremes (mother is younger or older)
    Diabetes mellitus
    Primigravida
    Renal disease
    Intrauterine growth restriction
    Mole (ie, hydatidiform mole)
    Increased blood pressure (ie, chronic hypertension)

    Common causes of bone metastases

    Malignant melanoma
    Breast
    Thyroid
    Kidney
    Lung
    Pants

    Causes of proptosis

    Tumour (eg, retinoblastoma)
    Hemorrhage (eg, traumatic posterior orbital hematoma)
    Endocrinopathy (eg, Graves' disease)
    Infection (eg, orbital cellulitis)

    Causes of persistent Pupillary dilatation

    3rd nerve palsy
    Anti-muscarinic eye drops (eg to facilitate fundoscopy)
    Myotonic pupil (Holmes Adie pupil):most commonly in young women, with absent/delayed reaction to light and
    convergence, and of no pathological significance.

    Innervation of the Extraocular Muscles

    All extraocular muscles are innervated by the third cranial nerve except the Lateral Rectus by the 6th cranial nerve and the Superior Oblique by the 4th cranial nerve

    Clinical Characteristics of Myopia

    Long eyeball is ...
    Myopic, requiring ...
    Minus diopter lens for correction, and the patient is ...
    Nearsighted

    Carpal Tunnel Syndrome Causes: TENS

    Trauma (eg, Colles' fracture, daily overuse at typing keyboard)
    Endocrinopathy (ie, pregnancy, hypothyroidism, diabetes
    mellitus, acromegaly)
    Neurological (C5-C6 disk herniation can mimics a CTS)
    Synovitis (eg, rheumatoid arthritis)

    Signs of compartment syndrome

    Passive stretching causes severe pain (moat reliable sign)
    Pain
    Pallor
    Paresthesiae
    Poor capillary refill
    Pulselessness (late sign)

    Epiphyseal Injury, Salter-Harris Classification: SALTER

    Type I: Straight through the epiphyseal growth plate
    Type II:
    Above the epiphyseal growth plate (ie, in a fragment of metaphysis attached to the epiphysis)
    Type III:
    Lower (ie, through and below the epiphyseal growth plate)
    Type IV:
    Through the epiphysis and metaphysis
    Type V:
    Emergency (ie, crush of the epiphyseal growth plate

    Neuromuscular causes of scoliosis

    Muscular dystrophy
    Muscular atrophy (i.e., spinal muscle atrophy)
    Myelodysplasia
    Mcocutaneous syndromes (e.g., neurofibromatosis)
    Arthrogryposis multiplex congenita
    Cerebral palsy

    Differentials for uncounciousness

    Fainted
    Illness/ Infantile febrile convulsions
    Shock
    Head injuries
    Stroke (CVE)
    Heart problems
    Asphxia
    Poisons
    Epilepsy
    Diabetes

    Criteria for Diagnosis of Cerebral Palsy,

    Posturing (especially abnormal extensor thrusting)
    Oropharyngeal problems (tongue thrusts, grimacing, W swallowing difficulties)
    Strabismus
    Tone increased or decreased in muscles
    Evolutional responses (ie, persistent primitive reflexes or failure to develop equilibrium and protective responses)
    Reflexes (ie, deep tendon reflexes are increased and plantar reflexes are up going.

    In order to diagnose CP require four criteria in a child older than one year who has no evidence of a progressive disease by history

    Organic causes of cinstipation in childhood

    Hirschprung's disease, Hypothyroidism, Hypercalcemia
    Anal fissure
    Neurogenic bowel (eg, spina bifida)
    Diabetes mellitus

    Causes of failure to thrive -7Cs

    Congenital abnormalities (eg, ventricular septal defect)
    Chromosomal abnormalities (eg, Down's syndrome)
    Cystic fibrosis
    Celiac disease
    Cow's milk protein intolerance (allergy)
    Calorie-protein malnutrition
    Cruelty (eg, parental neglect, abuse, environmental deprivation)

    Symptoms and Signs of Henoch-Schonlein Purpura,

    Rash (ie, purpuric rash over buttocks, estensor surfaces of legs, pre-tibial region)
    Arthralgia
    Sore abdomen
    Hematuria
    Hematochezia

    Complications of obesity in childhood

    Furunculosis
    Acanthosis nigricans
    Triad (1. diabetes mellitus, 2. atherosclerosis, 3. hypertension)
    Slipped femoral capital epiphysis
    Obesity in adulthood

    Causes of seizures in neonates- 5Hs

    Hypoxia
    Hypoglycemia
    Hypocalcemia
    Hypomagnesemia
    Hemorrhage (ie, periventricular, subarachnoid, subdural)
    Infection (ie, fever, meningitis, TORCH organisms)

    Components of Tunner syndrome

    Cardiac abnormalities (specifically Coartication)
    Lymphoedema
    Ovaries underdeveloped (causing sterility, amenorrhea)
    Webbed neck
    Nipples

    Kwashiorkor distinguishing features from Marasmus

    Fatty Liver
    Anemia
    Malabsorption
    Edema

    Components of APGAR score

    Skin color: blue or pink
    Heart rate: below 100 or over 100
    Irritability (response to stimulation): none, grimace or cry
    Respirations: irregular or good
    Tone (muscle): some flexion or active

    Features of potter syndrome

    Pulmonary hypoplasia
    Oligohydrominios
    Twisted skin (wrinkly skin)
    Twisted face (Potter facies)
    Extremities defects
    Renal agenesis (bilateral)

    Symptoms and Signs of epiglotitis

    Distressed
    Drooling
    Dysphagia
    Dysphonia
    Dyspnea

    Stages of Sexual Development in the Female ABCDE

    Accelerated growth (ie, height)
    Breast development
    Cunnus (vaginal) hair
    Distal hair growth (ie, axillae)
    Endometrial sloughing (ie, menarche)

    Metabolism enzyme inducers

    Mnemonic - "Randy's Black Car Goes Putt Putt and Smokes"

    Rifampin
    Barbiturates
    Carbamazepine
    Grisoefulvin
    Phenytoin
    Phenobarb
    Smoking cigarettes

    Effects of nicotine

    Nicotinic effects: MTWTF (days of week):
    Mydriasis/ Muscle cramps
    Tachycardia
    Weakness
    Twitching
    Hypertension/ Hyperglycemia
    Fasiculation

    Direct sympathomimetic catecholamines

    Dopamine
    Isoproterenol
    Norepinephrine
    Epinephrine
    Dobutamine

    ACE Inhibitor contraindictions

    Pregnancy
    Allergy
    Renal artery stenosis
    K increase (hyperkalemia)

    Burns, initial resuscitation: SAVE A PATIENT

    Stop the burning process
    ABCs of basic life support
    Visualize the patient for all injuries
    Estimate burn size and begin fluid resuscitation
    Airway (intubate if inhalation injury present)
    Penicillin (i.e., start antibiotics)
    Analgesic
    Topical therapy (e.g., flumazanine cream)
    Intoxicants/Inhalants
    Nasogastric tube
    Tetanus toxoid

    Carpal tunnel syndrome treatment

    Wear splints at night
    Rest
    Inject steroid
    Surgical decompression
    Take diuretics

    Burn Size Estimation by Total Body Surface Area: Rule of 9's

    Entire Head: 9%
    Entire trunk: 18% + 18% = 36%
    Entire arm: 9%
    Entire leg: 18%
    Whole body: 100%

    Alcoholism Screening Questions: CAGE

    Have you ever tried to Cut down on your drinking?
    Do people ever
    Anger you about your drinking?
    Do you ever feel
    Guilty about your drinking?
    Do you ever require an
    Eye opener (ie, drink of alcohol) to get going in the morning?

    Side effects of anticholinergic drugs

    Confusion
    Blurred vision
    Reduced lacrimation
    Reduced salivation
    Heart acceleration (tachycardia)
    Urinary retention
    Constipation

    Signs of delirium

    Acute onset, then fluctuation over days
    2. Inattentiveness (especially to conversation)
    3. Disorganized thinking (ie, incoherent speech)
    4. State of consciousness either reduced or hypervigilant


    For diagnosis of delirium need both 1 and 2 + either 3 or 4 (sensitivity 94-100%, specificity 90-95%)

    Signs and symptoms of depression

    Appetite diminished +/- weight loss
    Sleep disturbance (especially diminished number of sleep hours)
    Sexual libido diminished
    Energy diminished
    SuicidalitySelf-worthlessness and guilt
    Psychomotor agitation
    Anhedonia
    Thought process impaired

    Symptoms of Generalized Anxiety Disorder

    Scanning and vigilance
    Two or more worries
    Organic causes should be ruled out
    Motor tension
    Anxiety unrelated
    Course of mood or psychotic should be ruled out
    Hyperactive autonomics

    Side effects of lithium

    Vertigo
    Ataxia
    Nystagmus
    Intention tremor
    Stupor
    Hperreflexia
    Leukocytosis
    Insipidus (ie, nephrogenic diabetes insipidus)
    T-wave inversion on the electrocardiogram
    Heaviness (ie, weight gain), Hypothyroidism, Hyperparathyroidism

    Symptoms of mania

    Grandiosity
    Racing thoughts
    Euphoria
    Activities, goal-directed
    Talkative
    Sleep deprived
    Activities, reckless
    Disractibility

    Mental status examination

    Cognitive function (calculation, concentration, insight, judgment)
    Overview (appearance, attitude, level of consciousness, movements)
    Memory (recent and remote)
    Orientation (to person, place & time)
    Emotion (affect & mood)
    Speech (fluency, form, & comprehension)
    Thought (process, content, & perceptual disturbances)
    Attention (abstract thinking, recall, and intelligence)
    Something else (that might be important to the patient)

    Symptoms of Post-Traumatic Stress Disorder

    Insomnia and nightmares
    Re-experiences of traumatic event at a later date
    Arousal is increaseda
    Numbing of general responsiveness to the real world

    5 Drugs causeing depression

    Propranolol
    Reserpine
    Oral contraceptives
    Methyldopa
    Steroids

    Differentials of Dementia, Alzheimer's

    Drugs
    Encephalitis
    Metabolic (eg, electrolyte or liver abnormality, dehydration, acute intermittent porphyria)
    Endocrine (thyroid disease, diabetes mellitus)
    Normal-pressure hydrocephalus
    Trauma (eg, chronic subdural hematoma)
    Infection (eg, of lung or urine, AIDS, syphilis)
    Affective disorder (ie, depression manifesting as pseudodementia)
    Structural defect of brain (eg, infarction, tumour, abscess)

    Side effects of Tricyclic Antidepressants

    Anticholinergic (see above for Anticholinergic Drug Side Effects)
    Antihistaminic (eg, sedation, weight gain)
    Ani-alpha 1 adrenergic (eg, orthostatic hypotension)
    Arrhythmogenic (eg, quinidine-like ventricular cardiac effects)

    Causes of dyspnea of sudden onset

    Mucous plug
    Asthma,
    Aspiration, RDS
    Pulmonary embolus,
    P
    neumonia,
    P
    neumothorax,
    P
    ulmonary edema,
    P
    sychogenic
    Sepsis

    Causes of finger clubbing

    Fibroses of lung
    Infections (e.g., lung abscess, bronchiectasis, infective endocarditis)
    Neoplastic (e.g., lung adenocarcinoma)
    Gastrointestinal (e.g., chronic liver disease, inflammatory bowel disease, celiac disease)
    Endocrine (e.g., hyperthyroidism)
    Renal disease (chronic)
    Cardiac (i.e., cyanotic congenital cardiac disease)

    Differentials of chronic cough

    When cough in nursery, rock the "CRADLE"
    Cystic fibrosis
    Rings, slings, and airway things (tracheal rings)/ Respiratory infections
    Aspiration (swallowing dysfunction, TE fistula, gastroesphageal reflux)
    Dyskinetic cilia
    Lung, airway, and vascular malformations (tracheomalacia, vocal cord dysfunction)
    Edema (heart failure)

    Classification of arthritis

    Metabolic (ie, gout, pseudogout, hemochromatosis)
    Endocrine (ie, acromegaly)
    Degenerative (ie, osteoarthritis)
    Infectious (ie, septic joint, infectious synovitis, rheumatic fever)
    Connective tissue disorders (rheumatoid factor-positive) (i.e, systemic lupus erythematosus, rheumatoid arthritis, progressive systemic sclerosis/scleroderma, polymyositis/dermatomyositis)
    Inflammatory vasculitides (ie, polyarteritis nodosa, Wegener's granulomatosis, hypersensitivity vasculitis, giant cell arteritis)
    Seronegative spondyloarthropathies (rheumatoid factor-negative) (ie, ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, inflammatory bowel disease)

    Causes of joint pains

    Sepsis
    Osteoarthritis
    Fractures
    Tendon/muscle
    Epiphyseal
    Referred
    Tumor
    Ischaemia
    Seropositive arthritides
    Seronegative arthritides
    Urate
    Extra-articular rheumatism (such as polymylagia)

    Causes of drug induced lupus

    Chorpromazine
    Hydralazine
    Isoniazid
    Methyldopa
    Procainamide

    Radiological Features of Osteoarthritis

    Osteophytes
    Subchondral sclerosis
    Subchondral cysts
    Space between joint diminished

    Three Necessary Tests for Synovial Fluid Analysis

    Cell count and differential
    Crystal examination
    Culture and Gram's stain

    Systemic Lupus Erythematosus (SLE), Eleven Diagnostic Criteria:

    1. Photosensitivity
    2. and 3.
    Rashes (ie, 2. Discoid rash; 3. Malar rash)
    4.
    Ulcers in mouth
    5.
    Neurologic (ie, seizures, psychosis)
    6. and 7.
    Elevated blood tests (ie, 6. raised antinuclear antibody; 7. positive SLE cells seen, positive anti-double-stranded DNA antibody, positive antismooth muscle antibody, false-positive VDRL test)
    8.
    Renal (ie, proteinuria, hematuria, cellular casts)
    9.
    Arthritis (non-erosive)
    10.
    Serositis (ie, pleuritis, pericarditis, peritonitis)
    11.
    Hematologic (ie, hemolytic anemia, leukopenia, thrombocytopenia)

    Note: Need 4 of 11 criteria for diagnosis of SLE

    Incontinence, Causes of Transient Form

    Delirium
    Infection of urinary tract
    Atrophic urethritis
    Pharmacologic agents
    Endocrine (e.g., glycosuria)
    Restricted mobility ("geographic incontinence" of new setting)
    Stool impaction

    Urinary incontinence: causes of acute and reversible

    Delirium
    Restricted mobility/ Retention
    Inflammation / Infection/ Impaction [fecal]
    Pharmaceuticals / Polyuria
    "Drip" is convenient since it is urinary incontinence, so urine only drips out.

    Indications of dialysis - AEIOU

    Acid-base problems (severe acidosis or alkalosis)
    Electrolyte problems (hyperkalemia)
    Intoxications
    Overload, fluid
    Uremic symptoms

    Causes of enlarged kidneys

    Sclerderma
    HIV nephropathy
    Amyloidosis
    Polycystic kidney disease
    Endocrinophathy (diabetes)

    Causes of impotence

    Mnemonic - PLANE

    Psychogenic: performance anxiety
    Libido: decreased with androgen deficiency, drugs
    Autonomic neuropathy: impede blood flow redirection
    Nitric oxide deficiency: impaired synthesis, decreased
    blood pressure
    Erectile reserve: can't maintain an erection

    Penile Pain, Differential Diagnosis: P^8

    Priapism
    Phimosis
    Paraphimosis
    Peyronie's disease
    Penile tumour
    Purulence (ie, venereal disease)
    Prostatitis
    Push (ie, coitus-related trauma/overuse)

    NAMED ULCERS

    • CURLING- burns > 35% in body and fundus
    • PHAGEDENIC ULCER/TROPICAL: vincets organism
    • TROPHIC/PRESAURE SORES/NEUROGENIC MARTORELLES: hypertension
    • BURILLIS: m.ulcerans/m.marinum
    • MELENEYS: postoperative gangerene
    • BAZINS:  localised fat necrosis
    • CUSHINGS: raised ict
    • CAMERON ULCERS- linear gastfic erosikns in hiatal hernia
    • KISSING ULCER-both ant and post duodenal ulcers are present( seen in urinary bladder too)
    • HUNNERS ULCER- interstitial cystitis
    • MALENEYS ULCER- squamous cell cancer
    • MARJOLINS ULCER-squamous cell cancer
    • RODENT ULCER- basal cell cancer
    • MOORENS ULCER- Moorens ulcer-corneal ulcer
    • SEPTIC ULCER: slopping edge
    • TB ULCER: undermined edge
    • MALIGNANT ULCER-everted edge
    • RODENT ULCER: pearly edge
    • SYPHILITIC ULCER: puncuated edge

    Causes of Hypocalcemia in Surgical Patients

    1. Artifactual as a result of hypoalbuminemia
    2. Acute pancreatitis
    3. Surgically induced hypoparathyroidism (transient or permanent)
    4. Necrotizing fasciitis
    5. Inadequate intestinal absorption
    6. Excessive fluid losses from pancreatic or intestinal fistulae
    7. Chronic diarrhea
    8. Renal insufficiency with impaired calcium resorption
    9. Hypomagnesemia
    10. Hyperphosphatemia

    Vincristine

    Vincristine has a high neurotoxicity level and so must never be administered intrathecally, as it can cause ascending radiculomyeloencephalopathy -- which is almost always fatal.

    Side Effects of corticosteroids

    Side Effects of corticosteroids

    C - Cushing's syndrome

    O - Osteoporosis

    R - Retarded growth

    T - Thin skin I - Immunosuppression

    C - Cataracts

    O - Oedema

    S - Suppressed HPA axis

    T - Thin gastric mucosa

    E - Emotional

    R - Rise in BP

    O - Overweight

    I - Increased hair

    D - Diabetes

    S - Striae

    Metformin and IV contrast

    Metformin must be withheld before and for 48-hours after injection of IV contrast media - due to the increased risk of renal impairment, metformin accumulation, and lactic acidosis

    Impertigo

    Group A streptococci and S. aureus are the most common causes of impetigo

    Necrotizing fasciitis

    Necrotizing fasciitis is commonly associated with varicella infection, where the skin lesions are infected by Streptococcus or Staph

    Diaphragm

    The right hemidiaphragm will appear higher on a lateral x-ray and a PA film because the liver pushes it upward

    Interstitial Syndromes of the Lung

    Interstitial Syndromes of the Lung include:
    Sarcoidosis
    Histiocytosis X
    IPF (interstitial pulmonary fibrosis)
    Tumor
    Failure
    Asbestosis
    Collagen disorders
    Environmental
    Dust
    Drugs

    Tetracycline

    Tetracycline is an antibiotic.

    Don't take with milk or other things containing calcium, bc will cause chelation and change absorption.

    Also: Cholesteramine causes decreased absorption.

    Quinidine

    Quinidine is an anti-arrythmic drug.

    It impairs Warfarin liver metabolism, so increases the amount of active Warfain, thus increasing INR and bleeding risk.

    Also may be caused by decreased production of VitK in the gut.

    Also: if taken with digoxin, binds to muscle tightly, so causes Dig Tox.

    Probenecid

    Probenecid inhibits uptake of uric acid in renal tubules.

    Used in treatment of gout and to increase the action of penicillin and methotrexane (decrease excretion).

    Phemobarbital

    Phenobarbital is a barbituate.

    It induces liver P450 enzymes that metabolize Warfarin. Thus, need to take more Warfarin when on this drug.

    However, if taken patient off Penobarbital, INR rises, too much Warfarin effect.

    Also: cholesteramine causes decreased abosorption.

    Also: renal clearance is increased by alkalinization.

    Penicillin and warfarin

    Penicillin use increase risk of bleeding when taking Warfarin.

    2 possibilities

    1) change gut flora, so decrease amt of VitK, so increase action of Warfarin.

    2) inhibit liver enzyme responsible for Warfarin metabolism.

    Also: cholesteramine causes decreased abosorption.

    Also: excretion decreased by Probenecid and salicylate.

    Methotrexate

    Methotrexate is used as chemo,

    It can cause gout like symptoms from cell breakdown.

    However, the drug is metabolized by xantine oxidase, so dont give with Allopruinol, as that would increase the effects of chemo.

    Also: renal excretion decreased by Probenecid and Salicylate.

    Lidocaine

    Lidocaine is given  with epinepherine to vasoconstrict and keept drug local.

    Also: in CHF, increased action of the drug because decreased blood flow.

    Erythromycin and other macrolides

    Erythromycin and other macrolides increase risk of bleeding when taking Warfarin. 2 possibilities 1) change gut flora, so decrease amt of VitK, so increase action of Warfarin. 2) inhibit liver enzyme responsible for Warfarin metabolism.

    Also: increases Digoxin bioavailability by the above 2 mechanisms and also maybe inhibitin p-glycopritein transport system in kidney for Dig.

    Epinephrine

    Epinephrine is given with lidocaine to vasoconstrict and keep the drug local.

    Ditropan

    Ditropan is an anticholinergic.

    When taken with Amitriptyline, causes abdominal distension and constipation.

    Because of a pharmacodynamic interaction : tricyclics inhibit the cholinergic system via a different mechanism.

    Digoxin

    Digoxin binds to muscle tissue, Vd=400.

    If something else binds to muscle tissue, digoxin is displaced, leading to higher blood levels and lower Vd. = Digoxin toxicity. (eg, quinidine)

    Also: Can cause increased bleeding if taken with Warfarin.

    Also: Cholestyramine causes decreased absorption. Also: Erthromycin increases bioavail by 3 mechanisms.

    Warfarin effects and interaction

    Warfarin is an anti-coagulant, b/c reduces VitK dependent clotting factor production in the plasma.

    It has a narrow therapeutic index: with a little Warfarin, the INR = 2, but with a little more, INR = 6+. Highly bound to plasma (95%).

    Too much Warfarin leads to bleeding.

    Interactions: Increased bleeding (asprin), GI bleeding (NSAIDS), Impairment of Warfarin metabolism and increased bleeding (Quinolone or phenytoin), increased bleeding, maybe bc less VitK (sulfa drugs). Bartituates like phenobarbital increase metabolism, so need more Warfarin.

    Also: cholesteramine causes decreased abosorption.

    Cholestyramine

    Cholestyramine is an ion exchange binding resin. Used to lower cholesterol by disrupting enterohepatic circulation. It is a charged molecule, so it just sticks to the wall and blocks cholesterol absorption. Will also block the absorption of other drugs (decreased bioavail): such as digitalis, Warfarin, phenobarbitol, tetracycline, penicillin.

    Calcum

    Calcium is found in milk etc. Ion, so can cause chelation. Ion binds to drug, gets trapped inside drug in a wierd shape.

    It changes absorption of the drug (eg, Tetracycline).

    Asprin

    Asprin works by inhibiting platlet function/ anti-thrombosis/ decreases vasoconstriction. 

    Pharmacokinetic: Also, is highly bound to plasma (99%), so displaces Warfarin, leading to increased levels of Warfarin that is active. Therefore increases bleeding if taken with Warfarin.

    Also: decreases renal excretion of Penicillin and Methotrexate by competing for the transport mechanism.

    Amitriptyline and Ditropan

    Amitriptyline is a tricyclic antidepressant. If taken with Ditropan (an anticholinergic), causes abdominal distension and constipation. Because of a pharmacodynamic interaction: tricyclics inhibit the cholinergic system also via diff mech. Also: tricyclics affect membrane pump that moves nts and antihypertensive drugs into intracellular storage sites. So may alter anti-HTN treatments. Also: metabolized via CYP 2D6, inhibited by Prozac.

    Allopurinol

    Allopurinol is used in gout, xanthine-oxidase inhibitor. Xanthane-oxidase creates uric acid, but also metabolizes methotrexane. So, dont give this with methotrexane, even though it might be tempting to decrease gout symptoms in chemo. Also: Increased absorption if taken with iron.

    Alcohol and CYP

    Alcohol Induces CYP 2E1, increasing acetominophen toxicity.

    Acetaminophen and warfarin

    Acetaminophen Can cause GI bleeding if taken with Warfarin. If taken with alcohol, increased hepatotoxicity.