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205 Cards in this Set
- Front
- Back
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Transmissible Spongiform Encephalopathies cause problems due to
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failure to clear a protein (prion) leads to neuronal death
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Given the blood levels of ethanol of .15%, .4%, and .6%, describe the manifestations of intoxication
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what is the major distinguishing key of prion diseases
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transmissibility of a protein can lead to dz in other ppl
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• Differentiate familial large head from hydrocephalus
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Familial large head
Head larger than 95th percentile (larger than 2 SD) -follow normal growth pattern everything is normal, mom and dad just gave you a big head! Other large heads Mostly due to hydrocephalus |
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what structure of prion is damaging to a host? what is importance about this form?
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B-sheet (aberrant form)
Aberrant forms are resistant to degradation, and are non-immunogenic to host |
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Describe the mechanisms by which ethanol produces its effects. (sedative/ataxia/blackout)
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An action on the GABA receptor – increases GABA – mediated inhibition. This action may mediate sedative and ataxia effects.
May also inhibit NMDA receptors causing blackouts |
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common pathogenesis of Creutzfeld-Jacob Disease (CJD)
another important way? |
spontaneous conversion from alpha to beta prions
passed by person to person (reusing surgical tools, eating mad cow beef) |
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what makes up brain reward circuitry
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LC, VTA, NA
Locus ceruleus- largest group of adrenergic neurons Catecholamine (particularly dopamine) Ventral tegmental area are particularly important Nucleus accumbens |
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man hunts a deer and wants to take it home and eat it. If he is in CO, WV or a few other places what dz does he have to worry about?
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Chronic wasting disease (CWD, deer and elk)
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Describe the primary effects of ethanol on CNS
how do you get hypothermia ? |
Alcohol causes a dose-related depression of all areas of the CNS. Depression of hypothalamus results in hypothermia
Acute intoxication can be lethal due to depression of medullary respiratory and CV centers Stimulation observed after one or two drinks is a result of depression of inhibitory control mechanism of the reticular activating system. Chronic use can lead to irreversible neurological damage. |
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Clinical Guidelines for Prescribing Psychotropic Drugs : The 5 D’s
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Diagnosis
Careful diagnostic evaluation to identify specific target symptoms Drug selection Choice of drug based on patient factors, etc. Dosage Adequate dosing and trial of medication Duration Adequate duration before assuming failure Dialogue Discuss SE and expectations with patient |
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Rapidly progressive dementia and myoclonus. Death within year of onset. Due to an infective protein
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Creutzfeld-Jakob Disease
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Describe the primary effects of ethanol on respiratory and CV system
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Respiratory system:
At about 0.40% - depression of respiratory center results in death Cardiovascular system: Moderate amount – peripheral vasodilation causing slight ↓ BP and heat loss. Regular moderate consumption decreases risk of heart disease (↑ HDL, ↓ platelet aggregation). High dose – myocardial depression Chronic change – alcoholic cardiomyopathy |
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what 2 ways can you distinguish mad cow (nvCJD) from sporadic CJD?
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ncCJD: “florid” plaque
other finding is “Pulvinar sign” in MRI |
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Why are VLBW* infants at increased risk of CP?
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Infants who are born weighing less than 1000g are at high risk of ICH* and very high risk of PVL*
Immature oligodendroglia are vulnerable to oxidative damage (from stress, ischemia, infection, inflammation) *VLBW=very low birth weight ICH=intracranial hemmorhage PVL=periventricular leukomalacia |
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Describe the primary effects of ethanol on the GI (stomach, intestine, and pancreas)
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Stomach – at low doses, alcohol stimulates salivary and gastric acid secretion. High concentrations of alcohol (>20%) may inhibit gastric acid secretion and peptic activity.
Intestine – chronic ingestion will lead to ↓ absorption of folic acid, thiamine, niacin, other vitamins, constipation, or diarrhea. Pancreas – chronic ingestion may lead to pancreatitis |
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: inapp. Sexual or aggressive behavior, mood lability, impaired judgment & one or more of the following
Slurred speech Incoordination Unsteady gait Nystagmus Impairment in attention or memory Stupor or coma this is Intoxication or Withdrawal? of what? |
ETOH
intoxication |
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Describe the primary effects of ethanol on the liver
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Chronic ingestion → induction of hepatic microsomal enzyme system and other enzyme systems.
Chronic excessive use fatty → infiltration, hepatitis, and hepatic cirrhosis. Biochemical changes |
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• Differentiate obstructive and non-obstructive hydrocephalus
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Blockage of this flow anywhere within the substance of the brain (i.e. before the CSF passes through the foramina of Luschka and Magendie) results in obstructive or non-communicating hydrocephalus
Overproduction or decreased absorption at the arachnoid villi results in communicating or non-obstructive hydrocephalus. |
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what important endocrine effect does ethanol have?
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decreases ADH release
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what 3 drugs can kill you in withdrawal
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booze benzos barbs
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leading cause of teratogenesis
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booze
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define compulsive drug dependence
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Continued use of a drug despite adverse medical or social consequences
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Describe the metabolism and elimination kinetics of ethanol
what enzyme does this? |
90-98% of ethanol ingested is completely oxidized in the body. The rest is excreted via the urine and expired air.
At BAC > 0.01% the metabolism of ethanol follows zero-order kinetics alcohol dehydrogenase |
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2 or more of the following occurring a several hours or few days
Autonomic hyperactivity (sweating or pulse rate >100) Hand tremor Insomnia Nausea or vomiting Hallucinations (a/v/t) Psychomotor agitation Anxiety Grand mal seizure this is Intoxication or Withdrawal? of what? |
ETOH
withdrawal |
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how does drinking cause hypoglycemia
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NAD is used to metabolize etoh and you dont have any left for gluconeogenesis
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Bilateral spasticity of the legs greater than the arms
Brisk LE reflexes, ankle clonus, and bilateral Babinski sign In infants: often scissor their legs when held upright, may “commando*” crawl, and may be difficult to diaper because of hip adduction what is this? how is this pt intellect |
Spastic Diplegia
Intellect is usually unaffected |
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Wernicke-Korsakoff Syndrome
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memory loss and psychosis due to vitamin loss and booze
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tx for alcohol withdrawal
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Benzos
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moa of Disulfuram? use?
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Inhibition of aldehyde dehydrogenase leads to increase blood levels of acetaldehyde following ingestion of alcohol
causes a person to get really sick and deter them from drinking can also be used against cocaine |
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Can you terminate your relationship with a patient?
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In general, the AMA suggests giving 30 days notice. This suggestion is discretionary, depending on your individual circumstances; however, if you do not provide proper notice, you can be accused of patient abandonment.
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Naltrexone, an opiod antagonist has what other use?
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Opioid antagonist which blocks the rewarding effects of alcohol. Limitation is possibility of liver damage at high dose
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etoh dependence tx
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Disulfiram (Antabuse): inhibits aldehyde dehydrogenase causing a build-up of aldehyde causing flushing, sweating, nausea, and tachycardia
Naltrexone: opioid receptor blocker reduced craving and reward response Acamprosate (Campral): affects glutamate and GABA neurotransmitter systems |
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what kind of drug is acamprostate?
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An anti-craving drug approved by FDA August, 2004. Used to maintain abstinence in former drinkers.
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The most severe form of CP
Marked motor impairment of all 4 extremities... what is this? what is their intellect like? |
Spastic Quadriplegia
Classically associated with seizures, mental retardation, swallowing dysfunction |
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Describe the potential drug interactions between ethanol and CNS depressants, oral hypoglycemics, anticoagulants, salicylates, acetaminophen, anticonvulsants, and antimicrobial agents
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CNS depressants: potentiate effect
hypoglycemia: Alcohol causes potentiation of hypoglycemic effect. May also see disulfiram-like effect, particularly with chlorpropamide and tolbutamide anticoagulants: Half-life of warfarin decreased by chronic use of alcohol; however, anticoagulant effect may be enhanced in the presence of liver disease. Occasional moderate doses of ethanol unlikely to interfere with warfarin therapy in patients with normal liver function salicylates: Increase risk of gastric hemorrhage (aspirin) acetaminophen: potentiate breakdown to toxic metabolite-->liver damage anticonvulsants: Half-life decreased with chronic ingestion of large doses of alcohol due to induction of microsomal enzymes. Alcohol withdrawal associates with seizures antimicrobial agents: disulfram like rxns |
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why do many meth addicts go through depression when getting clean
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Methamphetamine appears to have a neurotoxic effect, damaging brain cells that contain dopamine and serotonin
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2 metabolites of methanol? things they cause
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formic acid (metabolic acidosis-death)
formaldehyde (damage retinal cells-->blindness) |
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what 2 malformations are commonly seen in Hydrocephalus in Older Children
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Foreshortened occiput (with Chiari malformation)
Prominent occiput (with Dandy-Walker malformation) |
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tx for methanol?
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Hemodialysis, support respiration
NaHCO3 administration to correct for metabolic acidosis Delay methanol metabolism with ethanol or Fomepizol (Antizol) - an inhibitor of alcohol dehydrogenase which decreases metabolism of methanol to toxic metabolites |
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Increased wakefulness
Increased physical activity Decreased appetite Increased respiration Hyperthermia Euphoria. signs of pts on... |
Methamphetamine
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Oxidation to glycoaldehyde and oxalate may cause serious metabolic acidosis (anion gap) and renal damage (oxalate crystals)....
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Ethylene Glycol
Solvent, antifreeze. Sweet taste attracts children and animals |
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Classically associated with
seizures, mental retardation, swallowing dysfunction Which Palsy? |
Spastic Quadriplegia
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pupillary dilation=
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meth intox
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define tolerance
pharmacodynamic tolerance pharmacokinetic tolerance |
Decreased response to a given dose of drug after repeated doses
can be due to: pharmacokinetic tolerance: body metabolizes more readily pharmacodynamic tolerance: down regulate receptors |
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Tachy/bradycardia
Pupillary dilation hi BP Perspiration/chills nausea/vomiting Wt. loss Psychomotor agitation/retardation Muscular weakness, respiratory depression, chest pain Confusion, seizures, dyskinesias, dystonias, coma intox or withdrawal? what drug |
intox
meth |
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Arm is more affected than the leg with difficulty in hand movement noted in infancy (early handedness before age 3)
Spasticity in the affected extremities (equinovarus* deformity of the foot) and a circumductive gait Weakness of the hand and foot dorsiflexors, may have unilateral ankle clonus and Babinski problem effects half the body...what do they have? intellect? |
Spastic Hemiplegia
25% have cognitive abnormalities (i.e. 75% do not) |
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Fatigue
Vivid, unpleasant dreams Insomnia/hypersomnia Increased appetite Psychomotor agitation or retardation Peak within 2-4 days and resolve in a week w/ most serious symptom being depression. intox or withdrawal? what drug |
withdrawal
meth |
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describe a CHIARI MALFORMATION
does it cause non-obstructive or obstructive hydrocephaly? |
Displacement of the cerebral tonsils into the cervical canal usually no sx until adolescence or adulthood. (Recurrent headaches, neck pain, urinary frequency, and progressive lower extremity spasticity. Etiology unknown.
Non-communicating or Obstructive |
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tx for ppl getting off meth
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Buproprion (Wellbutrin) produces feelings of well-being as they cope with the dysphoria
inhibit DA/NE reuptake |
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Infants are hypotonic with head lag
As they grow older they develop variable tone with rigidity and dystonia Oropharyngeal muscles frequently involved (speech, swallow, drooling, tongue thrust) what is this? intellect? most commonly 2ndary to? |
Extrapyramidal CP
intellect often intact CP most likely secondary to perinatal asphyxia |
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how do you get euphoria w/ cocaine
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strong DA reuptake inhibition in brain
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suicide is the 3rd leading cause of death in persons age ...
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15-24
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CT scan of brain, huge intaparenchymal bleed=
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cocaine
vasoconstriction |
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a pt is referred to your office with suspected CP, over time it appears to be gettin worse...what do you say
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this is not CP
doesnt progress A history of a progressive disorder should lead you to look elsewhere (for example, muscular dystrophy, spinal cord tumor, or neurodegenerative diseases |
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euphoria, apathy, dysphoria, psy. Agitation/retardation
Pupillary constriction and one or more of the following Drowsiness or coma Slurred speech Impairment in attention or memory intox or withdrawal? what drug? |
intox
opioid |
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describe a Dandy Walker Malformation
does it cause non-obstructive or obstructive hydrocephaly? |
Dandy-Walker Syndrome: a cystic expansion of the 4th ventricle with failure of formation of the roof of the forth ventricle 90% have hydrocephalus. Other associated anomalies include agenesis of the posterior cerebellar vermis and of the corpus collosum.
Non-communicating or Obstructive |
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: cessation of use and three or more
Dysphoric mood Nausea/vomiting Muscle aches Lacrimation/rhinorrhea Pupillary dilation, piloerection, sweating Diarrhea Yawning Fever insomnia intox or withdrawal? what drug? |
withdrawal
opiod |
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Maryanne is a 12 year old straight A student who walks with her right leg turned in and runs with her right elbow flexed and against her body. Which type of CP does she have?
Spastic diplegia Spastic quadriplegia Spastic hemiplegia Extrapyramidal CP Mixed type CP finding on neural exam? cause? |
Spastic hemiplegia
on neural exam: contralateral ventricular dilitation cause: stroke |
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*******
Alcohol and all drugs of this class (sedative/hypnotic/anxiolytic) are cross tolerant and their effects are additive. |
this is a test question
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• Describe psychotropic use in special populations:
children elderly pregnant/nursing medically ill |
Children
Begin with small doses and increase until clinical effects are observed Elderly Start with ½ the usual starting dose and increase slowly Pregnant and Nursing Women All psychotropic medications cross the placenta Try to avoid during pregnancy (esp. 1st trimester) or when nursing Consider ECT in severe cases Medically Ill Persons Treat using most conservative clinical practice |
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major sign of barbituate withdrawal?
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seizures
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Sally is a 3 year old with mental retardation, daily seizures, a feeding tube in her abdomen, and flexion contractures in her upper and lower extremities. Which type of CP does she have?
Spastic diplegia Spastic quadriplegia Spastic hemiplegia Extrapyramidal CP Mixed type CP finding on neural exam? |
Spastic quadriplegia
neuro imaging: cysts, brisk reflex, spasticity |
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tx for hydrocephalus?
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Acetazolamide and furosemide reduce CSF production, but are not definitive solutions
V/P* shunting is palliative not curative (complicated by infection or obstruction) |
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Sarah turns 16 this year and wants to get her driver’s license. Her parents have her car specially adapted to allow control of the gas and break with her hands because her legs are too spastic. What type of CP does she have?
Spastic diplegia Spastic quadriplegia Spastic hemiplegia Extrapyramidal CP Mixed CP |
Spastic diplegia
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What do the following conditions have in common?
Sexually transmitted disease Online pornography obsession Domestic abuse Constipation Job loss or academic failure Eating disorders |
SHAME
Patients rarely tell you they have an eating disorder. Patients may say they are depressed, anxious, or complain of GI problems. They may say nothing, but you can observe a change in affect or cognition, or body-checking or avoidant behavior. Their parents or significant others may tell you, and/or force them to see you |
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Michael is a 5 month old who was born following a very long, difficult labor. You notice considerable head lag when you hold him and excessive drooling. His mother is worried that he doesn’t nurse well. What kind of CP does he have?
Spastic diplegia Spastic quadriplegia Spastic hemiplegia Extrapyramidal CP Mixed CP |
Extrapyramidal CP
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which is more greatly affected in hydrocephalus: motor or intellect?
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Motor performance is more greatly affected than intellect because the gray matter of the brain is less affected by the hydrocephalus than the white matter (spasticity or coordination defects)
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what is Serotonin Syndrome? cause? sx? tx?
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Cause
Administration of drugs that can raise plasma serotonin concentration 22% SSRI OD/ MAOI/Tramadol Symptoms Nausea, vomiting, diarrhea Restlessness Extreme agitation Confusion Hyperreflexia Autonomic instability Myoclonus, seizures, *** hyperthermia, shivering, rigidity Delirium, coma, CV collapse, death Treatment Stop offending agents Supportive care Control agitation (benzodiazepines) Control autonomic instability Control hyperthermia 5-HT2A antagonists (cyproheptadine, olanzapine) |
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Which of the following will you find in a child with familial macrocephaly?
Rapid increase in head growth Cracked pot sound on percussion 1st degree relative with large head History of meningitis |
1st degree relative with large head
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A 78 year-old white male, recently widowed, comes to your office complaining of insomnia. Further questioning reveals that the patient is feeling depressed and hopeless. He tells you he has “no reason to live” since his wife died. He started drinking whiskey to help him sleep but now he is drinking “more than he should”. His only son and grandchildren live in another state.
what are his risk factors for suicide? |
white male
late age recent loss substance abuse depression |
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Which of the following is seen in an older child with untreated hydrocephalus?
Gaze disturbance Rapid increase in head size Bulging fontanelle Normal funduscopic exam |
Gaze disturbance
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12-24 hours – restless sleep, diluted pupils, anorexia, piloerection, irritability, tremor
withdrawal sx of? |
Opioids
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Most common congenital anomaly of nervous system?
due to? |
Neural Tube Defects
FOLATE DEF |
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what is Neuroleptic Malignant Syndrome? clinical findings?
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Cause
Complication of neuroleptic drugs Typicals > Atypicals Clozapine + lithium Clinical Features Hyperthermia Autonomic instability Extreme muscle rigidity, tremor Mental status change, confusion Dystonia or akinesia Mutism Agitation Leukocytosis Elevated CPK Coma, death |
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48-72 hours – peak intensity of syndrome, all earlier symptoms increased in intensity plus weakness, depression, nausea, vomiting, intestinal spasm, diarrhea, increase HR and BP, chills and flushes, muscle pain, and involuntary movements of limbs
withdrawal sx of? |
Opioids
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what percent of people w. polio will have sx?
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1%
but they can still transmit the dz |
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Midline defect with failure of closure of the posterior vertebral arches and laminae (typically lumbosacral)
Without protrusion of meninges or spinal cord Ordinarily asymptomatic and found incidentally on X-ray in 5 to 15% of the general population |
Spina Bifida Occulta
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tx for opiod withdrawal?
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Methadone detox – substitute and withdraw over next 3 weeks. (oral, legal, longer, less intense)
Methadone maintenance – substitute and maintain. Newer drug, levomethadyl (Orlaam), also available Opioid antagonists – to induce quick withdrawal or to prevent relapse Clonidine – a2 agonist to suppress autonomic signs of withdrawal Buprenorphine (Subutex, Suboxone) maintenance – first drug approved to maintain opioid dependence outside of specialized clinics. Physician must be certified by FDA to prescribe |
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define a Meningocele.
Sx? |
Midline defect in which the meninges herniate through a defect in the posterior vertebral arches, unaccompanied by neural tissue
Many patients have **gait abnormalities or loss of bladder control***, particularly during periods of rapid growth |
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give the demographic risk factors for suicide:
age gender race marital status religion occupation |
Age – elderly at highest risk for completed suicide
Gender – males at higher risk than females for completed suicide (more women will try) Race – white, Native American at highest risk Marital status – single, widowed, divorced Religion – Protestant, Jewish Occupation – professionals - especially physicians; unemployed |
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define a Myelomeningocele
how do sx vary based on location? |
Midline defect of the posterior vertebral arches with herniation of meninges and neural tissue
High lesions (above T11) are associated with higher morbidity, lower intelligence, and greater disability than low lesions (below L3) Mid-sacral to mid-lumbar region: flaccid paralysis of the legs lack of touch and pain sensation clubfeet and subluxed hips Chiari II malformation with hydrocephalus (~80%) Low sacral region: bladder and bowel incontinence perineal anesthesia no motor involvement |
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what is an important use of Buprenorphine
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maintenance – first drug approved to maintain opioid dependence outside of specialized clinics. Physician must be certified by FDA to prescribe
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A child is born with a low lumbar midline defect. MRI shows herniation of meninges through a spinal defect without neural tissue. What should you expect?
He will develop worsening spasticity in his legs He may have intermittent incontinence as he grows 80% are associated with Chiari II malformation Lack of touch and pain sensation in the legs |
correct: He may have intermittent incontinence as he grows
myelomeningiocele: 80% are associated with Chiari II malformation Lack of touch and pain sensation in the legs |
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what is the Most effective treatment for mood disorders, that is used for rapid response. One side effect is potentially forgetting large portions of your life
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ElectroConvulsive Therapy
Most Common Indications Major depressive disorder Bipolar disorder – depression or mania Refractory schizophrenia Catatonia (in mood disorders or schizophrenia) Mood disorders in pregnancy Relative Contraindications Increased intracranial pressure (NPH, benign intracranial hypertension, etc.) Intracranial lesions (tumor, hematoma, aneurysm, AVM, etc.) Recent myocardial infarction (< 3 months) Recent stroke Unstable aortic aneurysm |
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On the boards you will be asked about the most common cause of neural tube defects. You’ll answer:
Maternal drug use TORCH infection Radiation Malnutrition B9 deficiency |
B9 deficiency
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withdrawal from what kind of drugs can cause seizures?
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General CNS Depressants
Short acting barbs, BDZs like diazepam and flunitrazepam (“roofies”), non-barbs such as methaqualone, gamma hydroxybutyrate (GHB), and ketamine |
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A 5 month infant is brought to your office. At your visit a few months ago, you noted some flattening of the back of his skull. You advised repositioning. On review of yesterday’s CT scan, you note a premature fusion of bilateral lambdoid sutures. You advise the parents:
He should receive OMT He needs an MRI He should receive surgery OMT won’t be enough, he’ll need helmet therapy |
He should receive surgery
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inability to maintain body weight at or above a minimally normal weight for age and height.
Intense fear of gaining weight or becoming fat, even though underweight. |
Anorexia Nervosa
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A collective term for a set of late-onset and sometimes irreversible disorders which can include chorea, dysphonia, dystonia, tics, and myoclonus
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Tardive Dyskinesia
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what two psychiatric disorders have increase rates for completed suicide?
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MDD 15%
Substance Related Disorders 15% |
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why is cocaine so addictive?
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short half life and sensitization to the drug
have to use it more often and in higher dose to get euphoria |
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tx for Depression w/ seasonal pattern
Adjunct in non-seasonal depression Sleep disorders (e.g., shiftwork, jet lag) OCD w/ seasonal pattern |
Phototherapy
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what drug when abused can cause serious cardiotox?
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Cocaine
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~ 90% of community-acquired viral meningitis is due to what?
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Enteroviruses
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dental decay along with Memory loss
Learning impairment Motor deficits Psychiatric disorders are side effects of chronic use of which drug |
methamphetamine
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What are 2 of the biggest risk factors for suicide?
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History of previous suicide attempt!
Family history of suicide others: Feelings of hopelessness Suicidal ideation, plan for suicide Access to firearms Stressful life events, recent loss Lack of social support, lives alone Severe anxiety, panic attacks Insomnia or lack of sleep Chronic or terminal illness (e.g., AIDS, cancer) Prolonged pain, loss of function, disfigurement |
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what drug can be given to help you quit smoking
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buproprion
atypical anti-depressant, blocks 5ht and DA reuptake or Varenicline-partial nicotine agonist |
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Recurrent episodes of binge eating.
Recurrent inappropriate compensatory behavior in order to prevent weight gain…(exercise, diet pills, etc) The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months |
Bulimia Nervosa
Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of anorexia nervosa |
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what kind of drug is Varenicline? moa? use?
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partial nicotine agonist.
Blocks nicotine receptor in presence of full agonist (nicotine from cigarette smoke) This blocks pleasurable effect if person smokes. Stimulates receptor slightly to decrease cravings Thought to be the most effective drug for smoking cessation |
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what is Parasuicidal Behavior?
* |
Term that describes persons who engage in self harm (e.g., cutting the skin) without the expectation of dying.
Some are malingering – seeking admission to hospital to avoid situations such as incarceration Others want attention from significant others 10% go on to complete suicide More often: female; low lethality; <35 yr. old; high expectation of rescue Personality disorder, adjustment disorder, substance abuse common |
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person is trying to quit smoking but starts having crazy dreams...what is he on
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Varenicline
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how is polio mostly spread?
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Asymptomatic infection in 90-95%
(primary source of epidemic spread). fecal oral the only reservoir is man |
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Salvia divinorum is what kind of drug
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contains salvinorum A (a κ-opioid agonist), a short acting hallucinogen.
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when should you try to commit someone
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imminent risk to self or others
acutely psychotic/manic cant take care of themselves |
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: recurrent episodes of binge eating in the absence if the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa
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Binge-eating disorder
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pharmacological tx of:
amphetamines |
Lorazepam for agitation and haloperidol for psychosis
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a child presents to the ER with tightness of the neck and jaw muscles, hyperreflexia, tonic extensor thrusts...they parents thing he may have found some type of poison in their tool shed. What got him, moa, and how do you tx?
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strychnine
Produces CNS excitation by blocking glycine-mediated postsynaptic inhibition tx: IV diazepam, lorazepam, or anesthetic dose of short acting barbiturate Respiratory support Quiet surroundings Gastric lavage |
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pharmacological tx of:
benzos |
Flumazenil
antagonist |
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Static Risk Factors: Demographic for violence:
age gender SEC |
Age
Risk increased in teens to early 20’s Increased violence among those > 70 (esp. if have dementia) Gender Men 3 times more likely than women Socioeconomic status Lower SES associated with increased risk Research with higher SES not extensive |
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pharmacological tx of:
Cocaine |
Lorazepam for agitation or seizures
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usual onset of anorexia?
bullimia? binge eating disorder? |
arex: Usual onset in adolescence (14-18)
bulimia: Usual onset of late adolescence through early adulthood bed: affects individuals of all ages |
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pharmacological tx of:
Hallucinogens |
Lorazepam for agitation
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what is the greatest risk of violence?
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Substance abuse
in patients with or without mental illness substantially increases risk |
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pharmacological tx of:
Marijuana |
Lorazepam for agitation
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paralytic poliomyelitis only occurs in 1% of ppl, what are the sx of this? how does it kill you
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loss of fnction in limbs due to neuronal destruction
respiratory paralysis-->death |
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pharmacological tx of:
Opioids |
Naloxone
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what is the single best predictor of violence?
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Previous history of violence = single best predictor
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pharmacological tx of:
Phencyclidine |
Lorazepam for agitation and haloperidol for psychosis
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flip to see risk factors for eating disorders..objective
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Certain sports: ballet, figure skating, gymnastics, wrestling, track
First-degree family members with an eating disorder (13x greater risk) Type 1 Diabetes mellitus, especially with onset in adolescence History of physical or sexual abuse Comorbidity with affective & anxiety disorders, especially Obsessive Compulsive Disorder |
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The physician should suspect drug seekers if patients.....
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State that they are from out of town
Claim that the prescription has been lost Visit the physician during off-hours Present symptoms that contradict clinical observation (atypical symptoms) Will not permit a medical history and workup Seek a specific drug rather than treatment for symptoms |
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|
what is the most significant cause of fungal meningitis?
|
Cryptococcus neoformans
|
|
|
what is the female athlete triad?
|
Disordered eating
Amenorrhea Osteoporosis |
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what are the 2 tx for polio? which is used to eliminate the virus from the environment
|
Salk (killed)
Sabin (live, attenuated) vaccines --sabin prevents fecal-oral spread of wild type-->eliminates from environment Major disadvantage of sabin: but may lead to minor/major disease (including VAPP – vaccine associated paralytic poliomyelitis). |
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how is diabetes a risk factor for eating disorders?
|
Increased risk of AN among adolescent females with DM1
DM management can exacerbate ED Perfectionism, focus on #s, focus on body & food Insulin restriction is a purge equivalent Among adults with DM2, bulimia is more common than anorexia Success requires close collaboration of multidisciplinary team Exchanges instead of carb-counting No food records |
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|
what is the MOA of local anesthetcs?
|
Block voltage-gated sodium channels
bind to specific receptors at the INTRACELLULAR end of the voltage gated sodium channel prevent axonal conduction by a functional blockade |
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3. Explain the biopsychosocial etiology of eating disorders
|
Genetic predisposition
Serotonin NIMH genetics study Psychological vulnerability (ie, risk avoidant temperament) Relational dynamics Cultural phenomenon |
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children who get "aseptic" meningitis....normal cause??
when are they getting it? |
Coxsackie A, B, echoviruses
Late summer or early fall --when kids go back to school Both fecal-oral and respiratory transmission |
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what was the Key's study, what did it show?
|
36 healthy young men, caloric intake reduced to ½ of their usual intake for 6 months
Developed food preoccupation and feeding rituals, food-related hoarding behavior, depression… |
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MOA of caffeine?
|
– act as antagonists at adenosine receptors.
Adenosine receptors are located on presynaptic terminals of noradrenergic neurons and blocks NE release. So caffeine increases NE release. |
|
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brittle hair and dry skin
cachexia lanugo hypoactive bowel sounds hyper- or hyporeflexia cognitive impairment hypothermia hypotension bradycardia physical findings of what? |
anorexia nervosa
hypothermia hypotension bradycardia require hospitalization |
|
|
Patients present with fever, chills, headache, stiff neck, nausea
and vomiting, photophobia. May be signs of mental dysfunction. You suspect meningitis, but are unsure... your first step is to: send off labs to find out if it is viral or bacterial start anitbacterial tx immediately obtain an MRI dont worry about tx, most meningitis is viral and self limited |
start antibacterial therapy immediately
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eroded dental enamel
painless parotid gland enlargement Russell’s sign Hypoactive bowel sounds Peripheral edema physical findings of what? |
Bullemia Nervosa
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when given this general anesthetic, free radicals can build up (especially when used over multiple surgeries) and damage a specific organ...what is the drug? what is the organ?
|
Halothane hepatitis – free radical metabolites
|
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what are the Medical Complications of AN, BN, ad BED?
|
AN: complications result from malnutrition
BN & purging AN: complications result from mechanism of purging BED: complications result from obesity cardiovascular disease (CAD, hypertension), dyslipidemia, Diabetes mellitus, obesity-related hypoventilation syndrome and obstuctive sleep apnea, pressure sores, osteoarthritis |
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describe what your WBC count will be like in bacterial and viral meningits
|
bacterial: +1000, PMNs
viral: less, lymphocytes |
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when discussing eating disoders, what is key to remember, especially with anorexia?
|
high Mortality rate
Common complaints related to GI & CNS functions, and dermatologic effects |
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adverse effects of caffeine?
|
At 1 g dose of caffeine (12 cups coffee)
Insomnia, excitement, mild delirium, sensory disturbances Increased heart rate Increased respiration At higher doses (10 g) Clonic convulsions → death Chronic use in pregnant women may increase rate of spontaneous abortion Tolerance and physical dependence can occur. Withdrawal symptoms include lethargy, irritability, and headache |
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if a person is vomiting a lot what would Cl lvls be like?
|
decreased
|
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|
in the winter time, what 2 viruses could have caused meningitis?
|
enterovirus or herpes
|
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tx for AN?
BN tx goal? BED? |
AN: Nutritional rehabilitation--full weight restoration.
BN: goal of treatment for BN is normalization of eating behavior BED:complete abstinence from binge-eating and modest weight loss (5-10%) |
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what is the relationship btw pKa and rate of onset for local anesthetics?
|
lower the pKa the faster the onset of action
|
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|
when a pt is diagnosed w/ anorexia, what test should you run after a year?
|
DEXA
Treatment Weight restoration, smoking cessation Calcium +/- Vitamin D Calcium & Vitamin D plus alendronate compared favorably to placebo |
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|
what fungal infection can cause CNS infections without pts being immunocompromised??
|
C. gatti
more pathogenic than - Cryptococcus neoformans |
|
|
What is refeeding syndrome?
|
Typically develops on day 4
Not just seen in anorexia, but in rapid refeeding from any malnourished state Hypophosphatemia followed by fluid shifts and other serum electrolyte deficits Mortality due to heart failure, pulmonary edema |
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Therapeutic uses of caffeine?
|
combination with aspirin or ergot alkaloids (cafergot..tx of headaches)
|
|
|
what are some of the pathogenic factors of - Cryptococcus neoformans? 3
|
Negatively charged capsule (inhibits phagocytosis);
excess production of capsular material inhibits chemotaxis melanin production: from conversion of brain catecholamines (e.g., DOPA, acts as a chemoattractant); Also utilizes nitrogen from creatine, creatinine. melanin protects organism from oxidative compounds (free radicals) produced by macrophages |
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what is the tx for malignant hyperthermia?
|
Dantrolene
puts Ca back in SR |
|
|
how is Cryptococcus neoformans obtained?
|
Inhaled as a yeast:
From dried pigeon or blackbird droppings (nitrogen rich). No person-person spread. Does not cause disease in pigeon Primarily in immunocompromised, spread via blood to CNS |
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Methylphenidate is what kind of drug?
|
amphetamine
Ritalin |
|
|
if you suspect at all that a pt has cryptoccocal meningitis, what is the standard test?
*** |
Traditional:
India Ink Stain (of CSF) |
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how can you keep the ester and amide local anesthetics apart?
|
AMIDE LINKAGE (2 EYES!!)
LIDOCAINE lidocaine (Xylocaine) mepivacaine (Carbocaine) bupivacaine (Marcaine) etidocaine (Duranest) ropivacaine (Naropin) vs ESTERs PROCAINE procaine (Novocaine) tetracaine (Pontocaine) benzocaine cocaine |
|
|
tx for cryptococcal meninigits?
|
typically itraconazole
amp B or fluconazole would work |
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|
how do amphetamines work?
|
release NE, DA, and 5HT from nerve terminals
elevation of mood, euphoria, increased alertness Reduced feeling of fatigue Restlessness, increased motor activity Reduced appetite At very large doses, convulsions may occur |
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|
Halothane is what kind of drug?
|
Inhalation Anesthetic Agents
|
|
|
adverse effects of amphetamines?
|
Peripheral sympathomimetic effects (e.g., increased blood pressure). Avoid in patients with uncontrolled hypertension and coronary artery disease.
CNS irritability → depression Abuse potential Concern about long-term safety of stimulant treatment in children Recent concern about deaths in patients with structural cardiac defects taking methylphenidate and Adderall. FDA reviewing psychiatric (hallucinations) and CV effects of all ADHD drugs |
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|
which type of local anesthetic are more likely to cause allergic response
|
Esters are metabolized to common metabolite PABA
allergic remember esters only have 1 eye |
|
|
therapeutic uses of Amphetamines?
|
Narcolepsy – amphetamines/methylphenidate
Attention deficit-hyperactivity disorder – methylphenidate and d-amphetamine most commonly used. Long acting forms of both are now available and make once daily dosing possible (also transdermal). Clonidine may be effective in some children. |
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|
Isoflurane is what kind of drug?
* |
Inhalation Anesthetic Agents
|
|
|
phentermine is what kind of drug? moa? use?
|
Amphetamine
release NE, DA, and 5HT from nerve terminals Appetite suppression |
|
|
which type of local anesthetic are more likely to systemic response
|
amides
Hydrolyzed by liver microsomal enzymes (P450) Longer acting & more systemic toxicity than esters Caution with severely compromised hepatic function |
|
|
how does cocaine produce its CNS effects? what kind of drug was it again?
|
Cocaine produces its CNS effects (and peripheral side effects) by inhibiting re-uptake of catecholamines, particularly DA. It acts primarily on centers controlling alertness and responsiveness, and on the brain’s reward center.
local anesthetic (ester) |
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|
Enflurane is what kind of drug? tox to worry about?
|
Inhalation Anesthetic Agents
increase risk of seizure |
|
|
adverse effects of cocaine?
|
similar to amphetamine. Vasoconstriction and ↑ BP; cardiac arrhythmias
|
|
|
what terminates the action of Local Anesthetics
|
Systemic absorption (out of tissues) terminates local action (Not local metabolism)
|
|
|
What kind of drug is modafinil? moa? use?
|
Non-amphetamine stimulants used to treat excessive sleepiness due to narcolepsy, sleep apnea and shift work sleep disorder.
Stimulate cells in sleep/wake centers which release the neurotransmitters hypocretin 1 and 2. Results in increased wakefulness. help get your fil of sleep |
|
|
Desflurane is what kind of drug?
good thing about it? bad? * |
Inhalation Anesthetic Agents
rapid emergence (low lambda) more irritating to airway |
|
|
What kind of drug is armodafinil? moa? use?
|
Non-amphetamine stimulants used to treat excessive sleepiness due to narcolepsy, sleep apnea and shift work sleep disorder.
Stimulate cells in sleep/wake centers which release the neurotransmitters hypocretin 1 and 2. Results in increased wakefulness. help get your fil of sleep |
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|
what are the good effects of vasoconstictors when used w/ Local Anesthetics?
bad? |
good:
Decrease rate of systemic absorption and decrease systemic toxicity Increase local drug concentration and increase neuronal uptake of LA Increase local duration of action (e.g. lidocaine’s duration my increase two fold with epi) Bad: DON’T use in areas of toes, fingers, ear lobes, penis (ischemia) May produce tissue necrosis May produce systemic toxicity (cardiovasc) |
|
|
Sevoflurane is what kind of drug?
whats good about it? * |
Inhalation Anesthetic Agents
similar to desflurane except not irritating to airway (low lambda-Rapid emergence) |
|
|
adverse effects of this drug include:
Headache, nausea, diarrhea, dry mouth, anorexia are common. Nervousness, anxiety, and insomnia have been reported, but less than amphetamine, or methylphenidate. Psychiatric problems (hallucinations, suicidal ideation) and serious allergic rxns. Less abuse potential than amphetamine or methylphenidate |
Modafinil and armodafinil
|
|
|
what is used to induce anesthesia in kids??
|
Sevoflurane
|
|
|
what kind of drug is Atomoxetine? use? moa?
|
NOT a stimulant; included here because it is used to treat ADHD
Selectively inhibits NE transporter, blocking NE reuptake and resulting in increased attention and decreased impulsivity and hyperactivity. Since it doesn’t block DA reuptake, it’s not likely to be abused |
|
|
7. indicate which system is most sensitive to systemic effect of local anesthetics and which system is second most sensitive
|
1. CNS
First an apparent CNS stimulation (convulsions most serious) Followed by CNS depression (death due to respir depression) Premonitory signs include: ringing in ears, metalic taste, numbness around lips 2. CVS HYPOTENSION: Arteriolar dilation is a result of: Direct effect (procaine and lidocaine have most effect) Block of postganglionic sympathetic fiber function CNS depression Avoid by adding vasoconstrictor to prep Note: cocaine is exception: produces vasoconstriction, blocks NE reuptake ARRHYTHMIAS: direct effect (More resistant than CNS) Decrease cardioexcitability and contractility Decreased conduction rate Increased refractory rate (bupivicaine) Note: cocaine is exception......it stimulates heart ALL can cause arrhythmias if conc. is high enough |
|
|
how do stimulants help tx ADHD
|
increase attention span
|
|
|
what kind of drug is propofol?
use? |
IV anesthetic agent
used to induce pts |
|
|
black box for Atomoxetine
|
suicidal behavior in children and liver injury.
|
|
|
What drug is likely responsible for CV arrhythmia??
** |
bupivicaine
|
|
|
Guanfacine use? moa?
|
Also not a stimulant, but used as an adjunct in the treatment of ADHD.
It is an α2 –adrenergic agonist that decreases central sympathetic activity. |
|
|
what 2 drugs can be metabolized by rapid redistribution?
(comlex) |
thiopental or diazepem
|
|
|
Describe the potential adverse effects of ephedra.
|
) have been associated with heart attacks, sudden cardiac death, stroke, brain hemorrhage, seizures, and deaths
|
|
|
8. indicate in what ways cocaine differs from most local anesthetics with regards to CNS and vascular effects.
|
CNS: euphoria
CVS: cocaine is exception......it stimulates heart and: produces vasoconstriction, blocks NE reuptake |
|
|
moa of ephedra?
|
herbal product containing ephedrine, an indirect and direct acting sympathomimetic amine.
Ephedrine acts indirectly by releasing Norepinephrine and directly by stimulation of a, b1, and b2 adrenergic receptors. |
|
|
what kind of drug is ketamine? how does it work?
problem with it? |
IV anesthetic
doesnt exactly put pt to sleep, but will make them not care and not in pain--dissociative go ahead and cut me when a pt wakes up they can have hallucinations and get impaired recovery |
|
|
moa of LSD?
effects? |
agonist at presynaptic serotonin receptors (5HT2a) in the midbrain
Major effects Heightened awareness of sensory input; synesthesia Passive observer state Inward attention Diminished ability to determine boundaries |
|
|
what is cauda equina syndrome? what is responsible for this?
|
transient neurological symptoms after spinal anesthesia
LA can cause concentration-dependent nerve damage to central and peripheral NS |
|
|
Psilocybin and psilocin
mescaline all similar to what? so moa? |
LSD
agonist at presynaptic serotonin receptors (5HT2a) in the midbrain |
|
|
Dexmedetomidine is what kind of drug? moa?
use? |
IV anesthetic
α2 agonist used for intubation |
|
|
moa of marijuana?
|
Bind to specific cannabinoid (CB) receptors located in various brain areas. Endogenous ligands (endocannabinoids, EC) have also been identified.
Stimulation of CB receptors leads to activation of brain’s reward center (pleasurable effects) and also activates centers involved with eating. |
|
|
which LA is limited to surface or topical anesthesia only?
|
Benzocaine
|
|
|
as increased heart rate, dry mouth, increased appetite, and reddening of conjunctiva =
|
stoner
probably wearing tie dye listwning to phish with a necklace that has a little mushroom in it weeeeeeeeeeeeed |
|
|
Etomidate is what kind of drug?
use? |
IV anesthetic
short procedures |
|
|
adverse effects of weed
|
Decreased testosterone levels
Bronchitis Airway obstruction “Amotivational” syndrome (?) |
|
|
this drug is
topical, infiltration and spinal anesthesia Frequently used for topical ophthalomogical anesthesia slow onset and more prolonged effect than procaine (longest duration of the esters) ~10X more toxic and more potent than procaine |
Tetracaine
ester |
|
|
Therapeutic use of marijuana
|
Glaucoma
Antiemetic (dronabinol [Marinol] and nabilone [Cesamet]) approved for use) |
|
|
what anesthetic causes marked amnesia?
|
midazolam
|
|
|
moa of PCP
|
Acts by binding to high affinity sites in cortex and limbic system, resulting in blocking of NMDA-type glutamate receptors
http://www.youtube.com/watch?v=LzB03c6Dc10 |
|
|
most widely used local anesthetic?
|
LIDOCAINE
|
|
|
effects of PCP?
|
hallucinations (desired effect), detachment, disorientation, ataxia, violent behavior, distortion of body image, loss of proprioception, numbness, nystagmus, sweating, rapid heart rate, hypertension, acute psychotic reactions, and seizures. Can be fatal in overdose
|
|
|
what local anesthetic drug is most likely to cause sedation?
|
LIDOCAINE
|
|
|
3,4 methylenedioxymethamphetamine is what kind of drug? moa?
|
An amphetamine analog which produces central stimulation, euphoria, and hallucinations. MDMA causes DA release like amphetamine, but its major effect is on 5HT neurons. It causes 5HT release and blocks 5HT synthesis and reuptake. The net effect is more 5HT in the synapse and depletion of 5HT in the neuron.
this MDMA / Ecstasy |
|
|
what local anesthetic drug cannot be used in obstetrical anesthesia
|
mepivicaine
More toxic to neonates so not used in obstetrical anesthesia (fetus poorly metabolizes mepivicaine) |
|
|
pt comes in with in overheating and dehydration. Also causes involuntary grinding of the teeth. What drug were they on?
|
3,4 methylenedioxymethamphetamine (MDMA or Ecstasy)
|
|
|
which LA is most likely to produce vasoconstrictor effects
|
• cocaine
|
|
|
is reported to cause feelings of empathy, closeness to others and facilitates interpersonal relationships
|
3,4 methylenedioxymethamphetamine (MDMA or Ecstasy)
|
