Pt with meningitis symptoms. Elevated PT & PTT. Hypotensive. Water-Freidrichson syndrome. What is the cause?
N.meningitides (or p.aueruginosa). leads to bilateral destruction of adrenal glands (fatal)
Cushing’s DISEASE cause
Pituitary adenoma
Neuroblastoma. Good prognosis sign?
pseudorosettes
Arterial supply to adrenals.
Inf phrenic a.
Abdominal aorta
Renal a.
Venous drainage of adrenals
Left suprarenal v -> L renal v
R suprarenal v -> IVC
Prolactin control
DA in the periphery
GH receptor type
membrane-bound. uses JAK-STAT signalling
Hypothyroid pregnant woman taking Levothyroxine. What to do.
Increase dosage.
Initial treatment of thyroid storm
Esmolol
Craniopharyngioma. Where does the tumor arise from?
Rathke’s pouch
Where do hormones ACTING on the anterior pituitary first drain into?
Primary capillary plexus
When TSH binds the thyroid receptor, how does Iodine get taken up by the colloidal material?
Chloride0iodide symporter
Homeless person inhaled something. Low muscle tone.
Anesthetic– isoflurane
Mechanism of Open Angle glaucoma?
trabecular meshwork is blocked— fluid cannot drain.
Pathophysiology of proliferative DM retinopathy.
Hypoxia –> VEGF release –> angiogenesis –> increased neovascular membrane
Pic of Retinal a. occlusion
Retinal a. occlusion.
Amaurosis fugax
Hypothyroid symptoms. Fine needle aspiration shows lymphocytes and germinal centers. Underlying process of this condition?
Hashimoto’s Thyroiditis. formation of auto-antibodies against thyroperoxidase
Medullary Thyroid Carcinoma. Cell origin?
C-Cells
Cretinism. Diagnostic marker @ birth to prevent?
Increased TSH
Patient with meningitis. CSF report shows it’s viral. Pain in temporal regions.
HSV (MCC viral encephalitis in US)
– Necrotizing and hemorrhagic encephalitis
@ Temporal & frontal lobe
Show Cowdry A bodies (eosinophilic intranuc. inclusions)
Bit by animal. Stop rabies????
Dipoloid vaccine & Igs
Weakness, comes & goes, loss of eye sight…. What is the diagnostic marker?
Multiple Sclerosis: oligoclonal bands @ spinal tap
Tired at end of the day. Tired chewing meals. Underlying process?
Abs attacking ACh receptors
Trouble combing hair. Had the flu. Dx?
Guillan Barré
Upper AND Lower Motor problems
ALS
Girl gets tired exercising.
MS??
ADHD– parents don’t want treatment. What could happen?
Poor academic performance. Drug abuse.
Bacterial meningitis in a NEONATE. Cause?
S. agalactiae (MCC)
Alcohol withdrawal. What do you give?
Benzo – prevent seizures and other sx
Meningitis in INFANT/CHILD/ADULT. MCC?
S.pneumo
Patient wants to quit smoking. Give him partial nicotine agonist. What is it?
Varenicline
Heroine addict. You give Buprenorphine to quit. How does it work?
Displaces heroin & other opiates from mu receptor– decreases cravings, blocks effect of heroin
** can cause withdrawal if given while heroin still in system!
Patient is agitated, high-energy, hasn’t eaten in forever, sweating, aggressive, hasn’t slept in forever. What caused this?
Cocaine
Catatonic types?
Paranoid- delusions, aud. hallucinations
Disorganized - disorg speech/behavior, flat affect
Catatonic - extreme negativism/mutism, waxy movement, echolalia, echopraxia, excessive motor activity
You want to remove a piece of pancreas and you know there is an anastomoses between the gastroduodenal artery and the inferior pancreaticoduodenal artery where there is a tumor. Where is it?
Head of pancreas
Parkinson’s off period? What do you give?
Apomorphine– rescue
Parkinson’s patient is taking L-DOPA/carbidopa, having N/V. What area is this stimulating?
chemoreceptors
What drug can you give to prevent L-DOPA from breaking down in the BBB once it crosses?
Entacapone (or tolcapone)- COMT inhibitor
MOA of Phyngolomide
phosphoryalted into Fingolimod-phosphate by spingosine kinase 2….
-> Agonist @ spirociene-1-phosphate (S1P) receptors
For Relapsing-Remitting MS
Repaglinide is used only for postprandial hypoglycemia. Why?
Short duration
Man is on insulin for DM I. He knows the symptoms of hypoglycemia, so he is aware. What drug would interfere with his ability to detect hypoglycemia?
B-blockers
MS. On section of brain, what can you say?
Areas of demyelination. (gray)
50yo with Muscular dystrophy. Cousin and grandpa has it.
Becker’s Muscular Dystrophy
Being treated for bipolar disorder. Also taking ACE inhibitors for HTN. Develops hyponatremia. Why?
Taking Lithium for bipolar. Co-admin with ACE causes hyponatremia.
Anti-epileptic monotherapy or adjunct for secondary generalized tonic-clonic.
Lamotrigine. Blocks inactivated? Na+ channels & inhibits glutamate release
Arnold Chiari II. Vermis went through foramen magnum. Meningomyelocele too. What else associated?
Syringohydromelia
Pt with Chiari II dies– on 4th day, what do you see on the brain?
Macrophages & reactive astrocytes
Patient has surgery. Next day is aggressive, agitated, screaming. Within a couple days is fine again. What can she have?
ICU psychosis. Delirium. Acute Confusion. Encephalitis. whatev
What drug can you give in the middle of the night if someone can’t go back to sleep?
Zaleplon– shorter duration
Melatonin agonist
Rameloton
S/S Major Depressive Disorder
SIGECAPS
Patient has been spending money like crazy, has financial problems, loves drinking and partying. He’s been depressed for several weeks.
Bipolar 2?
Autopsy: pseudopalisading, necrosis, hemorrhage.
Glioblastoma
Child. Picture of tumor in central line in vermis. Homer-Wright Rosettes.
Medulloblastoma
Kid has ADHD. Give drug that blocks reuptake & facilitating release of NE & DA
Dextroamphetamine
ADD kid started meds, has been having tics. What drug?
Methylphenidate
Bupropion: errthang
Blocks reuptake sites fo NE & DA
T/U: Major depression, SAD, Nicotine, ADD & ADHD (off label)
AE: dry mouth, constipation, weight loss, anorexia
Conversion disorder
Symptoms with no medical or chemical reason.
Drug in patch form avoids HTN crisis
Selegiline. avoids GI, so won’t get HTN crisis with tyramines.
Patient is taking SSRI. Having AEs. What adjunct can you give that will block receptors?
Mirtazapine blocks 5HT2A and 2C receptors, as well as a2 heteroreceptors.
Anti–nausea :)
What drug works by blocking the receptors to increase the level of NE & 5HT?
Mirtazapine
Woman had baby, hemorrhaged. Now has no libido. low hormone levels of ant pit stuff. What else is associated?
Hypogonadism (loss of hair, loss of libido, amenorrhea), weight loss (low GH), cold intolerance (low TSH), hypopigmentation (low ACTH)
Hypothyroid with galactorrhea. Pituitary adenoma. Elevated prolactin.
Prolactinoma. suppresses GnRH –> amenorrhea.
How to treat prolactinoma in pt who DOESN’T want to get preg?
D2 agonist. Cabergoline. (bromocriptine in woman who wants to get preg)
Acromegaly. What else can be eleveated?
Hyperglycemia due to increase in gluconeogenesis.
MOA of Pegvisomant?
GH receptor competitive antagonist– DOESN’T activate JAK-STAT signalling or stimulate IGF-1 secretion, so IGF-1 decreases and GH remains high.
Craniopharyngioma. Embryologic origin?
Rathke’s pouch
Hyperosmotic urine. Hypoosmotic plasma. Decreased sodium. = SIADH. What is causing it?
SMALL cell carcinoma
How does Conivaptan block V2 receptors in the kidney?
Decreases cAMP
Guy lives with mother in law. Goes to nursing home, and thinks the old people are after him. Otherwise, is NORMAL and a successful NEUROSURGEON.
Delusional disorder
Intracerebral hemorrhage –> uncal herniation. Where is the bleed?
Duret hemorrhage—several small ruptures in pons.
Lens-shaped hematoma. Patient is lucid.
Epidural hematoma
Generalized Anxiety Disorder. First line treatment?
SSRI
Benzos & anxiety
Limit to 5 weeks, often @ start of SSRI / SNRI treatment to decrease suicide risk. Used short term for siutational stress.
Who is most likely to develop secondary obesity???
Asian BMI 24
Hispanic BMI 29
Sedative lifestyle + fast food
Secondary: rapid weight gain Signs of hyperthyroidism (pretibial edema, delayed tendon reflex) Signs of Cushing Steroid treatment Atypical antipsychotic treatment
DM II. What is the main source of energy when not exercising? Fatty acids. When they start working out, what happens?
Get glucose in the muscle.
DM II. What stain?
Congo red! buildup of amyloid
Elevated glucose. What is released? Decrease in glucose? then what?
incr glucose -> INSULIN;
decr glucose -> glugacon
Patient has cancer that causes hypercalcemia. What drug can you give?
Bisphosphanate (Zoledronic acid)– malignancy of hypercalcemia
Parathyroids gone. What else could be?
Thymus (DiGeorge)
Take BP, tetany!
Hypoparathyroid (Trousseau’s sign– neuromusc irritability)
Person with stroke. Fever. What drug?
Acetominophen
Man is having stroke. Wife calls ER. What to do?
give baby aspirin.
What does Cinacalcet do?
Calcium mimetic– sensitizes Ca2+ sensing receptr. thus PTH secretion is suppressed by lower amounts of Ca2+ than normal.
Amaurosis Fugaz: hollenhorst plaque.
Retinal artery occlusion.
Man acting strange (altered consciousness??!). Had seizure the day after?.
Partial Compex Seizures
Patient whose hand then arm shakes. Then loses consciousness and shakes everywhere.
Simple partial with secondary generalization
Global Cerebral Ischemia: errthang
Pathophys: Ischemic damage of cytomembrane -> depolarization -> release of glutamate & aspartate -> blockatge of ligand-gated cation channels on postsynaptic cells -> Ca2+ & Na+ influx
Gross: Laminar necrosis in neocortex & hippocampus; watershed infarcts
Histo:
12-24h: ischemic neuron death
2-3d: neuron dissolution, leukocyte influx
4-7d: Macrophage influx & activation
>2w: Liquefaction; debris removal, reactive gliosis
Pale infarct- thrombus; Red infarct - embolus
that’s all.
Diabetes. What is found in BVs?
Amyloid– congo red w/apple
Rapid hemorrhage. Sudden, severe headache. Where could it have been?
Bifurcation
Left arm & face > leg. Oh wait. right shoulder is weak too.
Watershed. (on both sides)
11-hydroxylase deficiency. What WON’T be elevated?
glucocorticoids??
Purulent exudate of brain. ewe. cause?
Bacterial meningitis.
Meningitis with HIV. Virchow-robbins space is enlarged.
Cryptococcal meningitis.
CAPSULATED– larger- open up lumen of vessels!
What happens in a diabetic (pathologically)?
Thickening of endoneural artery wall
Patient with schizophrenia has been taking the same drug for over 60 years. Begins to have chorea. Drug?
Haloperidol– causes tardive dyskinesia
Drug blocks receptors at one location, causing increase in DA at another location… uh..
Aripiprazole (DA partial agonist)
Patient takes drug. Now keeps getting infections. What drug and why?
Clozipine. can cause AGRANULOCYTOSIS
mystery drug induces and metabolizes enzyme
Carbamazepine
Pt taking another anti-epileptic. Gum hyperplasia– give folic acid.
Phenytoin
Valproic acid— causes weight gain. What drug has least effect of weight gain?
Coffin’s slides say: “Don’t see weight gain in children with carbamazepine, lamotrigine, and phytoin.”
Also, TOPIRAMATE causes weight loss.
Josh said Carbamazepine.
What anti-epileptic inhibits the release of glutamate and blocks Na+ receptors, delaying reactivation of Na+ receptors?
Lamotrigine
Status epilepticus. What drug to give first?
BENZO
Hyperthyroid baby, showing cretinism. What could you have screened for?
TSH
Something something TRH & TSH.
NOT TRH because you can’t measure TRH
Von Gierke’s kid. What enzyme is not work.
Glucose-6-Phosphatase (josh and jeff are WRONG bro)
Readiness to change stages. Patient has DM. Hasn’t been taking care of herself but wants to start.
Contemplation.
Abuse vs. dependence
Dependence– tried to and wants to stop but failed. Abuse– social, legal problems.
Within 3 days- coarse tremors, disorientation. Alcoholic.
Delirium Tremens
Cogwheel tremor, but no resting tremor.
Still Parkinson’s
Polydypsia, polyphagia, polyuria associated with?
BOTH DM I & II
Intensive therapy– where do you want HbA1c?
6.5-7.5 (according to beezle’s graph)
What causes micro and macro-angiopathies
Non-enzymatic glycosilation
Pt with diabetic foot infection. What is the worst that can happen?
Osteomyelitis (gangrene, amputation not option). Also, sepsis?
Patient in coma with DM I & elevated glucose. What to do?
Give saline then read potassium. Aggressively give saline and insulin if normo- or hyperkalemic.
Diabetic ketoacidosis. What is the compensation?
Respiratory (Kussmaul breathing)
Patient takes Cholinesterase inhibitor. What drug can you give that blocks glutamate function?
Memantine
Huntington’s tx
Tetrabenazine to treat chorea
Triptans (sumatriptan). Something something AE.
Cardiovascular events are rare but serious.
Persona with heart problem going to undergo sedation. Don’t give?
Meperidine (causes tachycardia)
also, methadone, pentazocine
Partial agonist at mu and antagonist at delta & kappa
Buponorphine
OD with opiate. Give?
Naloxone– an opioid antagonist
Patient with ringing in both ears. What gene?
NF2 (Schwannoma)
Axis I vs Axis II
Axis II presents early adulthood
Likes to be alone. Doesn’t like people, does’n’t want friends. Likes to do complex math.
Schizoid Personality Disorder
D.nozzle late to dr. appt. yelling.
Narcissistic (Josh says Borderline)
Dependent Personality Disorder. Has broken ankle. What is response to doctor?
dunno, but
-Difficulty making decisions without excessive support
–Needs others to assume responsibility
- Difficulty disagreeing ‘due to fears of losing support
– Difficulty doing things on own’
– Volunteers for unpleasant tasks to gain nurturance from’others
– Feels uncomfortable or helpless when alone
– Urgently seeks a new relationship when one ends
– Preoccupied with fears of having to take care of self
Glasgow Coma Scale: pupils
Small, reactive: Diencephalon
Midpoint: Midbrain
Pinpoint: Pons
Dilated: Medulla
Test to check for brain dead?
Cerebroangiography
Demyelination in brain. Preventricular deep white matter disease, slight atrophy, minimally enlarged ventricles. Gyri less prominent.
Alzheimers
Histo of alzheimer’s
Neurofibrillary tangles
Stroke. Starts to develop dementia.
Something vascular
Repeated falls. Pleasant hallucinations.
Lewy Body dementia
Behavioral change with hyperphagia over 1 year in older woman
Pick’s
Behavioral change with hyperphagia over 1 year, in younger man
Picks
Throbbing headache. Pain with movement. SLOW progression
Acute migraine
Male, just drank alcohol. Worst headache ever. Watery eyes, nasal stuffiness.
Cluster headache
What nucleus causes stress?
Locus Coeruleus
Alcoholic patient. Doctor wants him to go to AA, but he doesn’t want to go for fear of discrimination.
Social Anxiety Disorder
PTSD S/S
Exposure to traumatic event. Re-experience. Hyperarousal. Avoidance.
Shadow sign used to diagnose…?
Acute Angle Closure Glaucoma
Bacterial vs. Viral vs. Fungal:
- glucose
- leukocytes
Bacterial- low glucose, PMNs
Viral- normal glucose, PMNs then lymphocytes
Fungal- low glucose, lymphocytes
AIDS patient. Cryptococcal meningitis characteristics
Budding yeast. encapsulated
Sinus infection. Ring enhancement in brain.
S. pneumona (or any strep?)
Meningitis + ring enhancement + tooth extraction
abcess
Watery eyes, swimming pool, periauricular nodal inflammation. What virus?
Adenovirus
Neonate with purpulent exudate from eyes. Other twin is fine.
Chlamydia
Prednisolone causing cushing syndrome.
blah blah insulin not working
Start taking prednisolone, start to get infection. What to do?
Lower dose.