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first pass effect

oral drugs absorbed via GI tract and pass into the portal vein, goes to the liver for first metabolism
*these drugs require much higher oral dose to be as effective as IV


half lives of drugs

* 5 half lives of a new drug if no loading dose, drug level will be 97% of steady state, and same to stop drug and have it clear


warfarin interactions increase the INR
*TMP/SMX *propafenone
*erythromycin *azole antifungals
*amiodarone *metronidazole
*any antibiotic can affect INR

as they decrease vitamin producing bacteria in the intestine


Drugs that cause hyperkalemia
*spironolactone & other K sparing diuretics

*can be worse hyperK+ if these drugs are combined as in CHF tx
**trimethoprim (Bactrim) can cause and greatest risk is use if high dose bactrim in the elderly


Statin interactions
*most life threatening reaction=rhabdomyolysis
*greatest risk is combo with drugs that slow their metabolism:
-fibrates -amiodarone

-cyclosporine -protease inhibitors
_azole antifungals -verapamil, diltiazem
*grapefruit will markedly raise blood levels of statins
*lovastatin & simvastatin most affected
**pravastatin least affected-its metabolized by kidneys


gihydropyridines :



SSRIs cause

sexual dysfxn
may cause platelet dysfunction


Topiramate causes

non anion gap acidosis
kidney stones


HCTZ causes

hyper Ca++
hypo Na+
high uric acid


NSAIDS increase risk of

symptomatic CHF in pt at risk of CAD


bisphosphonates can cause

muscle and joint pain


PPIs may inhibit

antiplatelet activity of plavix


Risk factors for primary osteoporosis:
*hx of fragility fracture in 1st degree relative
*weight less than 127# or BMI<21
*alcohol intake of 2 or more drinks/day

*menopause before age 40
*current or prior steroid use: >3 months at dose of 5mg/d or more of prednisone
*personal hx of fragility fracture


patients with the following should be screened for osteoporosis regardless of age or gender:
*GI dz: UC, crohns, celiac, gastric bypass, malabsorption
*endocrine: hyperparathyroid, cushings, hypogonad, hyperthyroid
*anorexia nervosa

*prolonged bedrest or wheelchair bound
*medications: glucocorticoids, thyroxine over replacement, lithium,phenobarbital, phenytoin, cyclosporine


3 most accurate methods of diagnosis of osteoporosis:

*quantitative CT
*dual photon absorptiometry (DPT)
*dual energy x-ray absorptiometry (DEXA)


Universal recommendations for all patients with osteoporosis:

*dietary calcium 1200-1500mg/d
*vitamin D 800-1000 IU D3 daily >age 50
*regular weight bearing exercise
*fall prevention
*avoid tobacco and excess alcohol


drug tx of osteoporosis

calcionin salmon-nasal spray
raloxifene (evista)


potential S/E of bisphosphonates

*osteonecrosis of the jaw-especially IV-caution in those with jaw problems or upcoming extensive dental surgery
*severe muscle/joint/bone pain
*Odd fractures of long bones-femur


most serious consequence of osteoporosis

mortality due to hip fractures is 20% within the first year


other complications of hip fractures

*DVT occur in 48% without anticoag. , 25% with anticoagulants
*pressure ulcers
*constipation, fecal impaction


geriatrics-diagnosis of "frailty" if 3 or more of the following are present:

*unintentional loss of 10# or more/ 1 year
*exhaustion due to lack of endurance
*decreased hand strength
*walking slowly
*reduced activity


geriatric patients need interval assessment of function which is related to longevity:
*instrumental ADLs

*gait & balance
*driving ability


gait & balance assessed well with timed "get up and go test"
*get up from chair, walk 10 feet, then turn around and come back to sit.. If takes >20 seconds they are high risk for falls, 10-20s is moderate risk

**performance on vision, hearing, gait assessment will give adequate assessment of pts ability to operate a vehicle


Malnutrition is diagnosed in any of these circumstances:
*unintentional wt loss of 10# or more/6 months

*cholesterol <160
*any vitamin deficiency


major predictor for fracture from a fall is



risk factors for falls
*hx of falls
*rugs, untidy, dim lighting in the home

*poor vision
*orthostatic hypotension *cardiovasc. disease-syncope
*unsteady gait *psychotropic drug use
*cognitive impairment
*musculoskeletal disease


psychotropic drugs that increase the risk of falls in the elderly:

*neuroleptic agents
*BP meds


ALL forms of physical restaints in the elderly

INCREASE the risk of serious falls and injuries, so avoid if possible


decubitus ulcers
*main factor is sustained pressure over a prominent bone
*moist environment increase risk-ie urinary incontinence
*decub in NH patients increase risk of mortality- osteomyelitis and bacteremia/sepsis

*malnutrition increases risk-plus they wont heal !
*most common sites:heel, trocanter, sacrum, iliac crest
*if arterial/venous insufficiency they will not heal unless local blood flow is corrected-usually surgery


decubitus ulcer staging:

I: non blanching erythema
II: partial thickness skin loss-small superficial ulcer
**stage I & II heal quickly

III: full thickness skin loss
IV: loss of tissue down to muscle, tendon, or bone
*III & IV take months to heal
*tx: rotate side to side every 2 hours, saline cleaning is best, nutrition and correct all risk factors you can


decreased immunity is age related, thats why

herpes zoster and reactivation of TB is often seen in the elderly


General rules for medication in the elderly:
*start meds low dose-usually 1/2 the dose for non elderly
*any adverse event should be assumed as drug related
*look at med list for atypical antipsychotic if pt is falling as is most common causes of falls in NH

*taper BDZs over 3-6 months after switching to an equivalent dose of a water soluble BDZ (oxazepam-slower onset and less addictive)


endocrine in the elderly:
*only specific hormonal change that occurs w aging is ovarian failure
*pineal gland does not produce melatonin normally-so poor sleep and insomnia seen-can try melatonin at hs

*some have reduction of clearance of thyroid hormone so replacement may be with lower dose (TSH increases w age, but if no decrease in T4 dont treat for hypothyroidism)
*Vit D defic. is common-if age 70 or older take Vit D3 600 IU daily and 1500mg calcium daily over age 65-check 25(OH)2-D


diabetes in the elderly:
*insulin sensitivity & production declines with age
*hypoglycemia more often presents as cognitive impairment in the elderly, rather than tremors or sweats-glipizide causes less hypoglycemia

*caution w metformin due to high prevalence of renal insufficiency and they are more prone to develop lactic acidosis, DO NOT give to any patient w a CrCl


Hyperthyroidism in the elderly
*typical hyperthyroid symptoms are less seen in the elderly!

Apathetic hyperthyroidism is often seen:
*apathy, fatigue
*tachycardia, atrial fib
*anorexia, weight loss



do not give women >50 old combination HRT as it increases their risks for stroke, heart disease ,breast cancer, venous clotting and gall stones


delerium-confusion with altered consciousness
*main features: abnl attention span (easily distracted), disorganized thinking-may have hallucinations, altered consciousness- incr or decr mental activiy- these features fluctuate during the day an usually worse at night

*common causes: drugs, esp demerol, NSAIDs, any new antibiotic, benadryl, any cv drug or antidepressant, antiemetics, baclofen, H2 blocker, sleep inducer, herbal preps
*any acute discontinuation of alcohol, BDZ, SSRI, pain med may cause withdrawal delirium


differentiate delirium from "sundowning"

sundowning is a disturbance in behavior that PREDICTABLY occurs in the evening in some who live in chronic care environment


Dementia-progressive deterioration of cognition that is insidious and chronic, but no altered consciousness as with delirium

*presents as:

*difficulty learning & remembering new information
*decreased problem solving of simple and complex tasks
*decline in spatial organization-they get lost
*trouble w impulse control-unusual behavior


differentiation of depression vs dementia in the elderly

*depressed patients often complain of memory loss but demential patients brought in by family or friends with this complaint
*depressed pt have depressed affect & slowing of completion of Mental exams, demented patients have more normal affect and try harder,


score of <24 on Mini mental status exam is consistent with



First line tx of alzheimers

*cholinesterase inhibitors-aricept, cognex, exelon, razadyne
*best results are in mild-mod alz. dementia
*other causes of dementia may improve on these med
*CIs can be combined with Namenda and combo is better than CI alone. STOP CIs in pt w severe dementia


Depression in the elderly

*depression is most common mental problem in the elderly

*Tx: 1st line-SSRIs
-start with 1/2 dose and increase slowly
*watch for side effects: hyponatremia & tremors


Insomnia in the elderly

*assoc with worsening HTN, heart dz, lung dz, urinary incontinence, chronic pain, depression

*meds assoc w insomnia: corticosteroids,BB,beta agonists, stopping seditives or pain meds
*best tx is sleep hygiene/behavioral
*Rozerem (ramelteon) not assoc w any major S/E and good choice in elderly


RLS-Restless leg syndrome
*hallmark-leg discomfort +/- paresthesias at rest, relieved immediately with movement
*usually pain is deep seated and localized below the knees
*worse in the evening and night

*primary RLS or caused by:iron def anemia(even without anemia), dialysis, diabetic neuropathy, MS, Parkinsons, pregnancy, etc
**always check a ferritin level to rule out iron deficiency
*tx: dopamine agonists, levodopa


*common, not a normal consequence of aging
good hx to see if which of these they are describing:

*nonspecific dizziness



spinning, whirling, moving of self or the environment that is worse with head movement and occurs in spells (days to weeks), then eventually resolves


Nonspecific dizziness

unable to characterize better, sometimes lightheaded is used to describe



imbalance with standing and walking, expecially with turning



* almost fainting or blacking out with either standing or sitting (not laying), possible assoc with sweating, a sensation of warming, visual blurriness, and nausea


Benign Positional vertigo

*recurrent (lasts for weeks in spells), short lived (<1 minute) w episodes of vertigo w changes in position. N/V not uncommon.
*see more in elderly and consider Giant cell arteritis
*Dix Hallpike is + if nystagmus in supine/upright position
*tx-Epley or semont maneuver


walking more than 4 hours a week

dramatically decreases cardiovasc hospitalizations in persons >65


Isolated systolic HTN in elderly

*meds 1/2 usual start dose:
thiazides- esp chlorthalidone over HCTZ
dihydropyridine CCBs
**avoid BB for this as not as effective and incr mortality


CHF in the elderly

*#1 cause of hospitalization in the elderly

Tx: diet, diuretics and ACE inhibitors
**NSAIDS are impt precipitant of CHF in elderly
*mortality benefit: ACE, BB, spironolactone


urinary incontinence in the elderly
*common but is always considered a pathologic condition and is not a normal consequence of aging!
*normal age related changes: decreased flow rate and bladder capacity, increased residual volume

Urge-leakage w the feeling of urgency
Stress- leak assoc w incr abd pressure-cough, sneeze
Mixed- leak w both above
Incomplete bladder emptying-leak after voiding


urge incontinence
-related to overactive bladder-caused by uncontrollable bladder contractions (detrusor Instability)-usually due to CNS problem-loss of communication frontal lobes and micturition center in the brainstem

*tx-bladder training, oxybutynin if needed, Kegels also help

**remember anticholinergics can precipitate acute angle glaucoma


Stress incontinence

*urethra cant maintain the pressure gradient when intra abd pressure is increased-cough...

*assoc w :mult vag births, pelvic surg, postmenopause, males post prostatectomy
*tx: behavioral-esp kegels, pelvic floor physical therapy
surgery high cure rate but high risk of complications
*No effective drug treatment


fecal incontinence

usually due to fecal impaction and secondary overflow incontinence in the elderly



*does not increase risk of prostate cancer
*s/s: frequency, hesitancy, difficult start and stop stream, urgency, nocturia, bladder CA, cystitis

*2 tests must be done: digital rectal exam, urinalysis
*PSA levels increase as size of prostate increase, so less specific if has BPH
*tx only if signif affects or outlet obstr, hydronephr. or AKI
*alpha blockers or 5 alpha reductase inhibitors


ED - impotence

*ED that occurs in >75% of sexual encounters

Organic causes: neurogenic, vascular, hormonal, normal aging
Medications:SSRI, BB, thiazide diuretics, spironolactone
Psychogenic: acute onset, younger patient, continue to have nocturnal & morning erections, but libido is lost


ED due to neurogenic causes

*Diabetes,MS,ALS, parkinsons
*surgeries esp prostate surgery
*cyclists who spend >3 hrs/week on bike - pudendal nerve pressure


vascular causes of ED

*diabetes and/or cardiovasc dz
*pelvic frx, surgery, inflammatory conditions


Hormonal causes of ED

*often has loss of libido
*space occupying lesion- gradual onset frontal HA or vision change
*decreased androgens-hot flash, decr need to shave
*hypothyroid-fatigue, wt gain, dry skin, constipation


tx of ED

*sildenafil (viagra) PDE5 inhibitors, also cialis, etc-all have vasodilator properties
*cialis-one specific s/e is back pain
* all PDE5 risk of hearing loss with any of these drugs


decreased hearing is age related

*age related sensorineural hearing loss
*loss of higher frequencies
*hearing aids can help


Physicians duty to the patient is based on 3 principals -basis for all ethical interactions

*Beneficence-duty to act in best interest and welfare of pt &health of society
*Nonmaleficence-duty to do no harm to the patient
*Respect-for pt autonomy, make free, non-coerced choices


Patients right to accept or refuse health care is based on these 3 principles:

*personal autonomy
*personal liberty interest under the constitution
*common law right of self-determination


Informed consent

*the willing acceptance of medical intervention-after adequate disclosure by the physician- of the nature of the intervention and all the risks and benefits


Medical records

*physical chart belongs to hospital or physician
*information in the chart belongs to the patient


advanced directive

(living will is more focused form of advanced directive)

means by which patient have for stating which treatments they would accept or decline if they lost decision making capacity
*they have the right to change their minds and make changes
*fluids/nutrition are ethically the same as any other treatments


decision making capacity

the ability to comprehend, evaluate, and choose among realistic options


Surrogate (proxy)
*person authorized to make decisions on behalf of incapacitated person, can also be a power of attorney-if not a family member, this person would supersede the family members.

*decisions must promote the patients wishes & welfare
*surrogates authority ends when the patient dies


emergency situations

patient unable to express their preferences, the doctor may perform life-sustaining emergency procedures under the presumption that the alternative would be death or severe disability


Physician error

must disclose to patient any errors in judgement and procedure when the information is deemed "material to the patients well-being"
*always disclose errors



*only time CPR in not done is when there is an order stating DNR

3 considerations
-whether or not CPR would be futile
-preference of the patient
-expected quality of life


confidentiality & public welfare
*if the condition or disease of a patient can endanger other persons, the physician is legally and ethically obligated to report the situation to the appropriate parties
-STD,motor vehicle operation, seizure, severe cardiac arrhyth.

*those w serious, highly infective disease (TB, meningitis) should not be allowed to infect others. can be held against there will if threat to others. some dz may need to inform employer
*adolescent consent for birth control is acceptable in all states


Brain death

loss of entire brain function, including brain stem
*EEG not required
*organs can be donated without patients prior consent if next of kin or surrogate gives permission


Perioperative cardiac evaluation
*does pt need emergency noncardiac surgery? if yes, go to surgery.
*does patient have an active cardiac condition?
-unstable angina, recent MI (more than 7 days but

-decompensated heart failure, significant arrhyth. , severe valve dz **if yes to above, do evaluation & tx before non cardiac surg.
*is surgery low risk? if yes, proceed to surgery
* do they have good functional capacity? if yes, proceed to surg.


Who gets beta blockers perioperative?
*vascular surgery pt with positive pre-op stress tests
*pt already on them for HTN, angina, arrhythmia

**high dose BB in perioperative without hx of dose titration in pt not previously on BB: do reduce primary coronary events BUT carry increased risk of mortality and stroke so are NOT recommended


low risk procedures

-local biopsies
-breast bx


intermediate risk surgeries

-carotid endarterectomy
-intraperitoneal, intrathoracic surgeries

-orthopedic surg
-prostate surg
-head and neck surg


major risk surgeries

-aortic & major vascular surgery
-cardiothoracic surgery
-emergent major surgery

-long procedures w large blood loss and/or fluid shifts


Pre op screening labs
*hematocrit: >age 65 w major surg, all surg expect major bld loss
*electrolytes: Not unless reason to need to check
*creatinine: >age 50, major surg, hypotension likely, nephrotoxic drugs need to be used

*glucose, liver, PT/PTT, UA-only if clinical s/s warrant


Pre op EKG

*all vascular procedures
*non vascular procedures:

-men >45, women >55 -major surgical procedure
-known cardiac disease
-clinical eval suggests possible cardiac dz
-diuretic use
-DM, HTN, renal insufficiency


Pre op CXR

> age 50 for major surgery
suspected cardiac or pulm disease


Stents and surgery

*hold off on elective Non cardiac surgery if:

-within 4-6 wks of bare metal stent placement
-within 12 months of drug eluding stent if pt must stop anticoags
-within 4 weeks of balloon angioplasty


breast self exams

teaching pt to do these does NOT reduce their mortality from breast cancer , so most no longer recommend it


Know that smoking cessation can exacerbate



AAA screening

one time screening in men age 65-75 if they have ever smoked or men >60 if they had sibling or parent with AAA

*repeat screening not recommended


prostate screening

men >50 yearly PSA and digital rectal exam


cervical cancer screening

*start pap age 21
*when have 3 negative annual paps, continue every 3 years until age 60-65

* if paps have been negative and no new sex partners, patients >65 do not need further testing
*women age 30 + with ASCUS and high risk HPV types=>colposcopy


Overdose management-general mgmt obtunded/coma pt:
*airway-intubation unstable vitals or inability to maint. airway
*IV D50 if glucose low
*Thiamine 100mg IM or IV
*ABG +/- carboxyhemoglobin , tox screen, salic/acetam levels

*chemistries,CBC, measure serum anion& osmolar gaps
*CPK if immobilized long time
*CXR & supplemental oxygen
*Naloxone IV if suspect opiate OD


exam in toxic ingestions-"excited", aggitation, restless, HTN, tachycardia hyperventilation, hyperthermia, mydriasis (dilated pupils) think these categories of drugs:





*plants: nightshade (belladonna) & jimson weed




*amphetamines, meth
*blue mystic





toxic ingestions showing "depressed" obtunded state, hypotension, bradycardia, hypoventilation, hypothermia, miosis (constricted pupils)

*cholinergics: organophosphate, carbamate insecticides
*sympatholytics: clonidine
*opiates: oxycodone, hydrocodone


presentation of anticholinergic intoxication

*Red - cutaneous vasodilation
*Dry - anhidrosis
*Hot - hyperthermia

*Blind - mydriasis (dilated pupils)
*Mad - hallucinations
*Full - urinary retention
*Antidote - physostigmine


Isopropyl alcohol ingestion (rubbing alcohol)

*CNS depressant
*metab to acetone-sweet odor on breath

*osmolar gap >35
*abd pain, vomiting, some cardiac depression
*tx:supportive, lavage if <2 hrs post ingestion
*severe cases-hemo/peritoneal dialysis


Methanol ingestion (wood alcohol)

*contaminated moonshine
*many s/s delayed >24hrs ie visual blurr to blindness

*toxic metabolites: formaldehyde, formic acid
**incr anion & osmolar gap
*tx: fomepizole, folic acid, immediate dialysis
(folic acid to increase metabolism of the formic acid)


ethylene glycol
*metabolized to very toxic oxalate. oxalate is indicated by calcium oxalate crystals in urine and hypocalcemia (oxalate chelates calcium)

*suspect in pt acts drunk but no alcohol smell
*HAGMA and incr osmolar gap
*tx: fomepizole, bicarb for acidosis, calcium prn, immediate dialysis


Opiate overdose
*think if see:
-decreased bowel sounds

-constricted pupils
*all incl ultram are assoc w seizures in intoxicated & esp patients on dialysis
*methadone can incr QT interval=> torsades
*tx: naloxone IV 2mg up to max 10mg, titrate to normal resp rate!


salicylate overdose
**classic ASA overdose presentation:
-mixed acid base: HAGMA + respiratory alkalosis
-some tinnitus

*tx: activated charcoal with cathartic
serum/urine alkalinization with sodium bicarb
*severe cases: hemodialysis & charcoal hemoperfusion (salicylate levels >100)


acetaminophen overdose
*90% metabolized by liver w 5% goes thru P450 system to hepatotoxic NAPQI. with large ingestion, not enough glutathione to metabolize it all and toxic metabolites persists

*severe OD presents w N/V/D , the liver toxicity takes 24-48hours
*often see coingestions with this OD
*Tx: activated charcoal is beneficial if present within 4 hr of taking
*4 hr post ingestion level of acetaminophen >250=give N acetylcysteine (NAC) loading dose then 17 more every 4 hr


alcohol-acetaminophen syndrome

*chronic moderate to heavy alcohol use 2 fold effect:
-cytochrome P450 system is cranked up=more NAPQI produced
-amount of glutathione is decreased (cant detox as much)

* if drinker takes even normal doses of acetaminophen can get severe hepatotoxicity or liver failure


theophylline toxicity

*suspect if see COPD pt that has s/s: tremulous, tachycardia/ventricular arrhy, vomiting, +/- seizures and theo level >20

*usually due to another drug they started: macrolide, quinolone, zileuton
*tx:supportive and mult doses activated charcoal w cathartic, treat hypoK+,if too much vomiting use zofran + zantac


cont tx theo toxicity:
*stable vent arrhy-amiodarone

*hypotension-alpha agonists - phenylephrine or norepinephrine (if these dont reverse hypotension
*dialysis if seizures or vent arrhythmias is recommended


Lithium toxicity
>90% have mental status changes
*CNS s/s: poor memory, incoherence, disorientation
*N/ V/D
*parkinsonian movement disorders

*get level of lithium, but symptoms do NOT correlate with levels
*tx; gastric lavage (act. charcoal no help), restore fluids & lytes. hemodialysis in severe (level >3.5 or levels dont come down as expected)


TCA overdose
**lipophilic and protein bound so large volume of distribution and can NOT be removed by dialysis
*s/s:sedation, confusion, arrhythmias

*tx: activated charcoal w cathartic if within 2 hr ingestion
*EKG; tachy, PR, QT, QRS prolongation. QRS prolongation most closely correlates w degree of toxicity- use IV bicarb to keep serum pH 7.5-7.55, also lidocaine for arrhythmias
*benzodiazepam for seizures


digoxin toxicity
* narrow therapeutic index. levels do NOT correlate with toxicity, so pay attention to symptoms.
*s/s: anorexia, N/V, abd pain, confusion, weakness, change color vision, scotoma, bradycardia w hypotension

*common drugs that increase dig levels: diltiazem, verapamil, amiodarone.
*tx: activ charcoal if within 2 hr, serious arrhy-Fab fragment tx**but this will rapidly reverse the presenting hyperK+ so dont tx it aggressively before Fab given


*cardiotoxicity can occur regardless of route used
*causes rhythm disturb (VF/VT) , ischemia, myocarditis, systolic dysfunction

**suspect in young pt with MI
*seizures & strokes also common
**DO NOT USE BB- use nitroglycerine, CCB, BZDs are first line tx


*causes release of epi, norepi, serotonin, dopamine
*s/s: sweaty, severe agitation, psychotic, tachycardia, HTN

*acute tx: IV BZDs for agitation, then antipsychotics (haloperidol)
**watch for rhabdomyolysis- monitor their BMP, CPK, serum lactate, liver enzymes and clotting times


PCP - phencyclidine

*acute psychotic agitation, seizure, dystonia (incl laryngospasm)and dystonia can cause rhabdomyolysis, hypertensive crisis

*tx: calm environment
IV BZDs prn and supportive care


Heroin (opiate)

*CNS depressant
*also see constricted pupils and decreased bowel sounds

be careful w naloxone in chronic heroin users due to risk of causing withdrawl if overshoot the dose


MDMA (Ecstasy)

*euphoria, loss inhibitions, incr intimacy and sexual arousal
*OD can cause death, not benign drug

*s/s:bruxism, anxiety, sweating, HTN, tachycardia
**hyperthermia and rhabdomyolysis-esp when they dance all noc
*tx: activated charcoal if w in 1 hr, then BZDs. CCB for arrhythmia. NO BB! hypoNa+- water restrict if sz-use hypertonic saline


Carbon monoxide
*CO has 250X affinity to hemoglobin than O2=> tissue hypoxia
*fetal hemoglobin with even higher affinity so tx preg aggressively
* think in FIRES, car exhaust, winter in homes, generator use...
* do carboxyhemoglobin level-hand held can quickly tell to r/o

*levels 15-30% mild-moderate, >30% mod-severe, >50%often fatal (cherry red is rare)
*tx: 100% oxygen, hyperbaric in pregnant & if >25% or any level with LOC or neuro deficit, end organ damage-esp acidosis


Cyanide poisoning
**almond odor to breath
**lab draw : bright red venous blood
*it binds to ferric molecule and blocks aerobic metabolism
*dx is clinical

*think in those in fire, taking sodium nitroprusside or amygdalin (derived from apricot and peach pits used in some herbals)
*often signif. lactic acidosis
*s/s:HA, tachycardia, tachypenia, progress quick to coma, cardiac arrhyth,tx next card


Tx cyanide poisoning

1. amyl nitrate under nose for 30 seconds
2. 3% sodium nitrite IV

3. sodium thiosulfate IV


Lead (inorganic)

* 3 scenarios to test for lead exposure, depends on when exposure occurred

*ongoing exposure: whole blood lead level
*after exposure: RBC protoporphyrin & zinc protoporphyrin levels are elevated several months
*exposure years ago- 24hour urine lead after giving 1 gm of EDTA
*organic lead is rapidly excredet and prior exposure not detected


Insecticides - organophosphate & carbamate poisonings
*absorption is dermal

*organophosphate more toxic-bind irreversibly to acetylcholinesterase

*s/s: salivation, miosis (pinpt pupils), N/V/D, abd cramps, chest tight and gen weakness in some
Tx: decontaminate -showering w soap
-mod-severe s/s-atropine 1-2mg Iv, repeat q 5" prn. for organoph also give 2-protopam IV (2-PAM) Not for carbamate


Benzodiazepine withdrawal
* can be fatal
*s/s: anxiety, tremulous, melancholy, psychosis, sz

*time to withdrawal from last dose depends on half life
**up to 3 weeks for diazepam!
*taper over long period of time
*withdrawal tx w long acting BZDs


*insidious dz, prolonged elevated intraocular pressure causes progressive visual field loss due to optic nerve damage

-primary open angle
-closed angle


Primary open angle glaucoma
*most common
*they have progressive gradual loss of peripheral vision
*risk factors: advanced age, family hx, african americans, incr intraocular pressure

*cupping on funduscopic exam >50% of optic disc
*screening: eye exam after age 40, repeat 3-5 yr no risk factors, 1-2 yr if risk factors
*diabetics need yearly


Closed angle glaucoma
*primary closed angle -occular emergency
*risks: > age 40, female, hyperopia (farsighted) , asian , family hx
*rapid increase in intraocular pressure=>redness, severe eye pain, nausea, halos around lights, HA.

*low-light conditions that precipitate pupillary dilation is assoc w onset
*exam: fixed, mid-dilated pupil, decr vision, corneal edema, conjunctival hyperemia
*immed ophth. referral for laser iridotomy,if not within hr see tx


Retinal detachment

*flashes/streaks of light, showers of black dots, shade coming down or waving curtain in portion of visual field

risk factor: myopia- nearsightedness
*emergent referral


Retinal artery occlusion-true ocular emergency!!

*occlusion of central retinal artery-usually embolic
*sudden, painless, unilateral blindness

*see "cherry red spot" in the macula
*tx to dislodge embolus: ocular massage, paracentesis of anterior chamber and carbogen inhalation to dilate vessels
*while wait eye doc, trendelenburg, rebreathe into paper bag, massage globe 5sec pressure, 5 sec no pressure...


Retinal vein thrombosis
*sudden painless, near total loss of vision
* "blood and thunder" fundus with multiple hemorrhages
*Not an emergency- no acute treatment



Macular degeneration

age related-leading cause of irreversible acquired legal blindness
*risk factors: smoking, low levels of zinc & antioxidants
*atrophic type - gradual loss of central acuity down to 20/400- peripheral vision is spared
*neovasc type-some tx with laser photocoagulation


Optic neuritis

*inflam of optic nerve
*freq presentation of MS

*s/s: ocular pain,esp with eye movement
* exam- normal initially, later pallor
*tx: ophth urgent, IV glucoccorticoids improve vision more quickly
*MRI for MS eval


Ischemic optic neuropathy

feared complication of giant cell (temporal) arteritis
*malaise, fever, wt loss, muscle aches, jaw claudication, elevated ESR
*start corticosteroids presumptive before dx-dont delay tx


suspect CN involvement in patient presenting with

sudden onset of painless double vision


CN 6 - abducens

*supplies lateral rectus eye muscles
*paralysis: cant move eye laterally


CN 4 -trochlear

paralysis: eye deviated up and the head tilted toward the uninvolved side (Bielschowsky sign)


CN 3 - oculomotor

2 branches

*superior branch- superior rectus & levator palpebrae superioris (eyelid muscle)
*inferior branch-parasympathetic - tonic constriction of the pupil
*complete paralysis-eye deviates down and out,ptotic eyelid, dilated pupil


alkali eye injury

*tx delay of minutes can devastate the eye
*immed profuse irrigation with lid eversion

check pH of tears to confirm adequate irrigation


-most common cause of red eye
-viral (most common), bacterial, allergic

-diffuse conjunctival hyperemia is nonspecific
-preauricular adenopathy is suggestive of adenoviral cause
-purulent discharge suggests bacterial


eye symptoms of concern

-decreased visual acuity
-ciliary flush-red near corneal limbus only in sun ray like pattern
-eye pain


anterior uveitis

can be assoc w spondyloarthropathies, sarcoid, lupus, vasculitis

-autoimmune inflam of anterior eye structures
**ocular pain, photophobia, ciliary flush=emergent referral


periorbital cellulitis

*rapidly progressive cellulitis of periorbital area and may become orbital if not tx

*warm, red, edema around the eye-KEY: exam normal extraocular eye movement without diplopia or pain with eye movement
**if disconjugate gaze, diplopia, pain w eye movement -ORBITAL-get periorbital CT or MRI and IV abx w staph and strep coverage


conductive hearing loss

*something blocks sound from entering the inner ear
-OM, eustacian tube blockage, otosclerosis (autosomal dominant ), TM perforation, cerumen...


Sensorineural hearing loss

*either cochlear damage or CN VIII damage

*causes: viral, ototoxic drugs, meningitis, cochlear otosclerosis, Meineres, acoustic neuroma, aging (presbycusis)



1/3 pts older than 65
bilateral symmetrical sensorihearing loss in freq >2000 Hz


Meniere disease

*recurrent severe attacks vertigo
-lasts hours

-s/s: vertigo, vomiting, tinnitus, fullness in ear, progressive hearing loss (often one side)until deaf-at which time symptoms stop
*tx acute:BDZs & antiemetics
chronic: avoid caffeine & salt, diuretics


aoustic neuromas (vestibular schwannomas)

benign very slow growing tumors of CN VIII
*tinnitus, unilateral hearing loss, gait imbalance
*tx: radiosurgery or surgical resectin


acute sensorineural hearing loss

immed eval and treatment, if ENT cant see immediate, start prednisone 80mg/d and ASAP eval


Rinne test

*air conduted sound louder than bone.
*vibrating tuning fork-mastoid (bone) & in front of ear.

*no conductive hearing loss-louder in front of ear testing
*conductive hearing loss- louder on bone
*sensorineural hearing loss- both are decreased, but air is perceived as louder


Weber test

tuning fork middle of forehead

*if sound perceived as stay in middle=normal or symmetrical hearing loss
*if sound lateralizes there is either a conductive hearing loss-hear decrease that side or sensorineural loss in opposite ear


Neuroleptic malignant syndrome
*idiosyncratic response to potent neuoleptics=> autonomic dysfunction, extrapyramidal symptoms, and HIGH fever (up to 106)

*most common w: haloperidol, piperazine, thiothixene
*persists up to 10 days after drug stopped
*tx: stop drug, cool patient, oral dopamine agonists-#1 bromocriptine, others amantadine, dantrolene - to counteract the depletion of dopamine


Serotonin syndrome
*think if pt on serotonin drug ie SSRI-esp if on 2 or more of these drugs. occurs within 6 hours of starting a new or additional drug
*serotonin can cause derangement in thermoregulation

*s/s: anxiety, disorient, sweating, tachycardia, HTN, vomiting, diarrhea, HYPERTHERMIA can be marked. exam: rigidity, tremors, hyperreflexia
*tx, stop drug, supportive, heart monitor, BZD for anxiety & tachycardia, resolves 24hrs, may need intub/paralysis,cyproheptadine is serotonin antagonist in severe


Philadelphia chromosome

*first chromosomal abnormality found to be assoc w malignancy


Burkitt lymphoma and leukemic analog ALL

chromosome 8 to 14 translocation


Most leukemia and lymphoma patients have a

chromosomal abnormality


during pregnancy, GI procedure of choice for work up is

endoscopic ultrasound if pancreatic dz


2nd trimester of pregnancy

best time for GB surgery if needed


3rd trimester pregnancy

*hep E can cause fulminant hepatitis 20% fatal
*fatty liver of pregnancy- very serious: assoc encephalopathy, hypoglycemia, preeclampsia, pancreatitis, DIC, renal failure
*intrahepatic cholesatsis of preg-itching w incr AST & ALT


asthma tx in pregnancy

Budesonide is ok steroid in pregnancy, others are cat C


TB tx in pregnancy

DO NOT use PZA - causes birth defects


warfarin and pregnancy

absolute contraindication


normal cardiac findings in pregnancy:

*S3-common in children and pregnancy (high cardiac output) S3 always abnormal in nonpregnant and >age 40
*some pedal edema
*flow murmur (and S3 gallops) and increased jugular venous pressure


Abnormal cardiac issues in pregnancy:
*atrial fib of new onset and pulmonary edema indicates need to rule out both Mitral stenosis and Secundum ASD!
*secundum ASD itself is not a huge risk in pregnancy unless they develop atrial fib

*maternal rubella infection during pregnancy-common cause PDA, supravalvular aortic stenosis, branch pulmonic stenosis, other congenital cardiac defects
*3rd trimester aortic dissection
*valve surgery-porcine so no anticoag needed


Not used as primary or secondary prevention of cardiac disease in women

*hormone therapy
*folic acid
*aspirin in healthy women (is used STROKE prevention age 65+)


NOT contraindicated in pregnancy:
-heparin, LMWH
-digoxin, quinidine, propranolol, CCB, labatelol, clonidine
-sulfasalazine, beta-lactams, emycin , azithromycin, amp B

-chlorpheniramine (antihistamine)


UTI tx in pregnancy
*asymptomatic bacteriuria treat in all pregnant, neutropenic patients, diabetics and transplant patients pregnant or not!

*do tx w amp, keflex, macrobid-step agalactiae, E. coli
*listeria-think UTI in preg w negative urine culture-
*postpartum fever-think strep agalactiae (group B)-post partum endometritis and bacteremia


approx 5%pregnant have chlamydia trachomatis in genital tract

antibiotic ointment in newborns eyes does NOT treat this!


syphilis is often asymptomatic in

pregnant females


Gonorrhea in pregnancy

*more likely to disseminate in pregnant women
*NB at risk of GC conjunctivitis- tx w eye ointment at birth


viral infections in pregnancy that pose the greatest teratogenic potential: (especially if acquired 1st trimester)
-varicella zoster-chicken pox
-herpes simplex

*HIV mother to fetus transmission risk 30%, reduced to <1% with 3 drug antiretroviral therapy (ART) ALL pregnant HIV need TX!!


Toxoplasma gondii (parasite) in pregnancy

*serious in immunocompetent only if acquired during pregnancy

*causes congenital toxoplasmosis=> mental retardation and chorioretinitis. worse px if in later pregnancy


Gestational diabetes
*strict bs control even before preg impt.
*maintain FPG

and shoulder dystocia in NB
*during preg, insulin requirements incr t/o preg and gone immed upon delivery so cut insulin to 50% at birth
*all other than insulin contraind in pregnancy for diabetic control


Migraines and pregnancy

risk of inducing ischemia with triptans, do not use in pregnancy


seizures during pregnancy
*goal-control sz, as sz can cause placenta abruption and early labor and premature delivery. risk of seizure outweighs risk of meds!

*use monotherapy at lowest level as possible
*no "safe" but valproate is more risky so dont use
* use folic acid 1-2 mg/ day to help decr teratogenic risk of med
*vit K last month preg on sz meds which decrease bleeding risks assoc w sz meds


carpal tunnel and pregnancy

pregnancy can cause acute carpal tunnel that usually improves after delivery
splints best tx


pre existing renal or liver disease ie HBV, HCV, alcohol abuse and pregnancy

are definate contraindications to pregnancy


Predisposing factors to disseminated gonorrhea



SLE and pregnancy
*SSA (Ro)/SSB (La) antibodies-assoc w neonatal lupus & congenital heart block **counsel lupus pt about risk of pregnancy!
*higher risk failed preg, and preg complications esp if active dz or if woman has APS or anti ds DNA

*if lupus pt w recent flare and becomes preg-continue glucosteroids and flares during preg tx same


women w APS (antiphospholipid antibodies) and recurrent miscarriages can be treated with

heparin or LMWH PLUS ASA low dose to help decrease risk of miscarriage


causes of avascular necrosis of hip
-sickle cell dz

-gaucher dz
-hypercoaguable states


HPV testing for ASCUS

*NOT appropriate for adolescents as they have high rate of HPV but low rate of cervical cancer. for them do pap at 1 yr and if still ASCUS can observe another year, if at 2 yrs present=colpo

see above


women should undergo endometrial assessment if has postmenopausal bleeding:

*in absence of HRT therapy
*after on combined HRT continuously for 1 year without bleeding
*at an unexpected time during cyclic replacement


*menses may be too frequent, too long, or too heavy of flow
*dx of exclusion
*causes: hypothyroid, liver dz, renal dz, coagulopathies, pregnancy complications, anatomic lesions, drugs...

*tx young women - OCP - 4 tabs (35-50 of ethinyl estradiol OCP best) a day which increases bleeding for 1-2 days then stops bleeding in 3-4 days, then take only 2 pills/day for 20 days. withdrawal bleeding occurs in 2-5 days then give 2-3 months of OCP at usual dose and stop


complications of cocaine addiction
-vascular thrombosis -liver necrosis -nasal septum perf
-HTN -seizures -resp depression
-rhabdomyolysis -arrhythmias -sex dysfunction
-sinusitis -myocarditis

*crack smokers: cough, hemoptysis, pulmonary edema
*pregnancy: abortion, premature, stillbirth, abrupto placentae
*acute intox: hyperadrenergic ): Incr HR, Incr BP, incr temperature, blur vision, anxiety, sweating


Metabolic syndrome
*dx if 3 or more of the following risk factors are present
- obesity waist male >102cm (40"),female >88cm (35")
-TG150 or more
-HDL male <50

-BP 130/85 or higher
-FBS 110 or higher or prior dx diabetes


metabolic syndrome is associated with these risks:

-7 x incr cardiovascular event
-2 x incr diabetes
-1.5 x incr all causes of mortality


treatment of metabolic syndrome:
-weight control, exercise
-low glycemic diet,

-BP control <130/80
-LDL control


Factors that increase triglycerides
-incr alcohol intake
-incr carbohydrate intake

-nephrotic syndrome
-familial combineed hyperlipidemia
-drugs: steroids, estrogen, BB, retinoids


statins in stroke prevention

lowering LDL in patients with CAD reduces stroke by about 30%

*not proven in primary prevention of strokes


consider risk factors for hemorrhagic stroke before rx high dose (80mg) of atorvastatin in secondary prevention of stroke.

Risk factors

-older age
-prior hemorrhagic stroke
-chronic HTN
-male sex
-use of anticoagulants


aspirin for primary prevention of CAD
*intermediate to high risk pt with 10 yr risk of CV vent >15%, probable use if 10-15% but up to patient risk/benefit
*diabetics: >age 40,1or more CV risk factor, known vasc dz



most important preventable cause of death in USA



Smoking health risks:
*cardiovasc disease
*cancer: lung, head & neck, pancreas, stomach
*pregnancy: low birth wt, premature delivery

*effect on lipids: incr LDL & TG, decr HDL
*increase risk of invasive pneumococcal disease

- quit- risk death from CV dz by 50% in first year and cont to decr
-decr risk lung ca by 30-50% by 10 years


Heart Protection Study

in pt with high risk of coronary event due to existing CAD, DM, PAD, hx CVA, other cerebrovasc dz...

simvastatin reduces the risk of death, MI, CVA irrespective of cholesterol level


JNC definitions of HTN

Normal BP <120/80
Pre HTN 120-139/80-89

stage I HTN 140-159/90-99
stage II HTN >160/>100

Isolated systolic HTN: SBP >/=140 and DBP <90


lowering SBP by 10-12 and DBP by 5-6mmHg

lowers risk of CVA 40% and CAD by 15% within 5 years

risk of heart failure reduced by >50%


lifestyle modifications for HTN
-wt loss, BMI <25
-aerobic exercise daily
-limit alcohol intake

-low sodium intake
-adequate calcium, potassium and magnesium intake
-stop smoking
-diet fresh fruit/veg, low fat dairy, whole grain,fish, poultry


Benefits of regular exercise
-decr LDL, TG increase HDL
-protect against CAD & exertion related MI
-reduce body weight
-improve glucose metabolism

-reduce BP, stress, insulin resistance
-reduces death rate from all causes
-decreases risk of breast cancer
-decreases risk of osteoporosis
-increases stroke volume in CHF


Obesity-BMI best estimate of obesity

normal <25
over weight 25-30
class 1 30-35
class 2 35-40
class 3 40+


complications of obesity
-incr risk of CAD, BP and sudden death
-incr LDL & TG, decr HDL
-DM, insulin resistance
-gallstones, osteoarthritis

-sleep apnea
-increase risk of cancer: endometrial, breast, colon, prostate


Pneumococcal vaccine

*age > 65 or any younger with signif health problems, incl adults who smoke, asplenia ...

*single dose over age 65, except if given for any reason < age 65, give 2nd dose after age 65 or later if at least 5 years since last dose
*protects against invasive pneumococcal disease: bacteremia, meningitis


Influenza vaccine

*age 6 mo or olderr
*pregnant in any trimester
*intranasal : healthy, non pregnant age 2-49


Indications hepatitis B vaccine
-healthcare workers
-NH or prison
-sexually active homosexual/bisexual/hetero w multiple partners

-hemodialysis patients
-household & sex contacts of HBV carriers
-pt on long term use of plasma derivatives
-infants born to HBsAg + mothers


Exposure to HBsAg+ blood (needle stick or mucous membrane)

*unvaccinated: HGIB + HB vaccine

-known responder (anti HBs is adequate) no rx
-nonresponder- HGIB x 2 or HGIB + HB vaccine dose
-unknown : anti HBs adequate - no rx
inadequate HGIB + HB booster


Malaria prophylaxis

-no chloroquin resistance: chloroquin 300mg weekly, 1 wk prior and 4 wk post travel

-with resistance: Malarone (atovaquone + proguanil) 1po 1-2day prior and cont til 1 week post travel
or mefloquin ( not if hx of psych )
or doxycycline 100mg daily 1-2 day prior and to 4 wk post travel


high altitude illness
-rapid exposure to altitude >8000ft
-s/s:HA, fatigue, nausea, anorexia,insomnia, dizziness
-pulmonary edema and cerebral edema may occur
*prevention; acclimate 2-4 days at 6000-8000feet and grad ascent

-acetozolamide 250mg BID start 1-2 day prior and cont at high altitude for 48 hours
**tx: descent, O2, dexamethasone 4mg every 6 hours and acetazolamide (for AMS or HACE), nifedipine 20-30mg BID for HACE


travel and DVT risk

give single dose LMWH to reduce risk in high risk: hx thrombosis, obesity, malignancy, high platelets



*dx requires evidence of inattentive or hyperactivity w impulsivity or both starting < age 7

*must be some impairment of social, occupational or academic functioning.
*tx: methylphenidate (best initial), detroamphetamine, atomoxetine (SNRI-Strattera)


depression during pregnancy
*untreated depression may adversely affect the woman, fetus, other children and partner
*mild to moderate tx w cognitive behavioral therapy

*severe: SSRI (best- but NOT paroxetine), or SNRI + cognitive
-maternal complications are slight increase in: diabetes, preeclampsia, premature rupture of membranes, bleeding


Chronic Fatigue syndrome

*severe fatigue > 6 months plus 4 or more of the following:
-impaired short term memory or concentration
-sore throat

-tender cervical or axillary nodes -headache
-muscle pain -difficulty sleeping
-arthralgias without red or swelling
-postexertional malaise lasting >24hrs


Pharyngitis criteria for strep
*fever, no cough, tender ant. cerv nodes, tonsillar exudates
-rapid strep antigen test, tx if +

*tx PCN or emycin


*most viral, suspect bacterial if symptoms last 7days or longer and assoc with any one of the following:
-purulent nasal discharge
-maxillary tooth or facial pain

-unilateral maxillary sinus tenderness
-worsening symptoms after initial improvement
*tx: amox, sulfa, doxy


External otitis=>tx w local antibiotic & steroid drops

*malignant otitis (diabetes + otitis externa + swollen canal & granulation)=>pseudomonas=>IV cipro and local debridement

*Ramsey Hunt-facial paralysis + sensorineural hearing loss + vesicular eruption of ear canal =>herpes zoster=>rx antivirals


severe hyperthermia (heat stroke)
*core temp >40.5 (105)
*exercise/exertion in high heat or humidity, elderly or young in heat waves, elderly on anticholinergics, antiparkinson or diuretics most susceptible

*s/s: hot dry skin, delirium, dilated pupils, muscle rigidity, tachypnea, rhabdo, DIC, ARDS, renal failure, hepatic dysfuncton
*tx-rapid cooling, IV fluids, internal cooling by gastric or peritoneal lavage with iced saline


*core temp 35 or less (severe <28C)
*features: CNS, dehydration, bradycardia, AF ,hypotension, lactic acidosis
*tx: rewarming, warm isotonic fluids as external warming can drop

BP , warmed O2, peritoneal lavage w saline warmed to 40-45C, hemodialysis/cardiopulmonary bypass
*CPR and active internal rewarming should continue until core temp is >32 C


Adolescent medicine
* most common death causes: MVA, homicide, suicide
*parent concent for tx *routine vaccines

*emancipated: live away from home, economically self supporting, married, in military service
*tx severe depression=>fluoxetine & cognitive behavioral therapy