MedStudy Board-style Q+A's Flashcards
1
Q
Younger, intermittent dysphagia, solids not liquids, not progressive
A
Schatzki ring, do EGD
2
Q
Rectal bleeding with cramps
A
Ischemic colitis, do flex-sig
3
Q
Chronic diarrhea + GERD + Ulcers
A
Zollinger-Ellison syndrome, check gastrin level off PPI
4
Q
Familial polyposis coli- what surveillance?
A
Scope any rectum remaining after surgery, also EGD for gastric or proximal small bowel malignancies
5
Q
Common cause pill esophagitis
A
doxycycline. Rx supportive measures
6
Q
Older with watery diarrhea, mild cramping, abdominal pain
A
Microscopic colitis, dx with colonoscopy with biopsy
7
Q
Younger, recurrent severe GI bleeds, negative scopes
A
Meckel’s diverticulum; dx nuc med scan; rx surgery
8
Q
Hospitalized pt with MSOF, on TPN, US shows thickened GB wall with surrounding fluid, no stones
A
Acalculous cholecystitis; place percutaneous cholecystostomy tube
9
Q
Hep C with normal LFT’s- what rx?
A
No rx at this time
10
Q
Gastric bleed with visible vessel- rx?
A
Endoscopic rx with heater probe to the vessel
11
Q
Food poisoning: Chinese restaurant, fried rice; 4-6 hours after, diarrhea, vomiting
A
B. cereus
12
Q
Food poisoning: food left out at a picnic, mayonnaise
A
Staph aureus
13
Q
Food poisoning: fast food hamburgers
A
E. coli 0157:H7
14
Q
Lung mass, draining cutaneous lesion, budding yeast
A
Ohio/Mississippi basins: Blastomycosis
Southwest: Coccidioidomycosis
Rx itraconazole, amphoB if severely ill
15
Q
Treatment Pulmonary Arterial Hypertension
A
Warfarin, oxygen, calcium channel blockers, oral endothelin receptor antagonists, PDE inhibitors, prostacyclin analogues
16
Q
Causes decreased DLCO
A
Emphysema, interstitial inflammation and fibrosis, edema, infections; also reduced capillary lung volumes as in pulmonary hypertension, pulmonary embolism; anemia (unless corrected for hgb count)
17
Q
Drugs that interact with theophylline and can elevate levels causing toxicity
A
cipro, cimetidine, erythromycin, propranolol, tetracycline
18
Q
Necrotizing pneumonia that is contagious (possible bioterrorism)
A
Yersinia pestis (plague pneumonia)
19
Q
Cause of pleural effusion glucose < 30
A
Rheutoid arthritis pleural effusion
20
Q
Best test if suspect tuberculous effusion
A
Pleural biopsy
21
Q
Fever, malaise, headache, sore throat, nonproductive cough; sore throat seen 2-3 weeks prior to pneumonia
A
Chlamydophila pneumoniae (formerly Chlamydia) rx macrolide or doxycycline
22
Q
Definition severe persistent asthma
A
continual symptoms, frequent exacerbations, nighttime symptoms, limited activity, FEV1 or PEF 30%
23
Q
Calculate A-a gradient; normal A-a gradient
A
A-a gradient = 149 - (PaO2 + 1.25 x PaCO2);
Normal < 0.3 x age (years)
24
Q
Neurofibromatosis-2 associated with what tumor?
A
vestibular schwannoma
25
Neurofibromatosis-1 associated with what tumor?
optic glioma
26
Tuberous sclerosis associated with what tumor?
Giant cell tumors
27
Turcot syndrome and nevoid basal cell carcinoma syndrome associated with what tumor?
medulloblastoma
28
von Hippel-Lindau syndrome associated with what tumor?
hemangioblastoma
29
Treatment of hypercalcemia of malignancy
IV hydration, bisphosphonate, diuresis
30
Cell types ovarian cancer old vs younger
Older- epithelial; Younger- germ cell, more treatable
31
Cell type testicular cancer
Germ cell > 95% of time; do not do transscrotal resection
32
Side effect alkylating agents
infertility
33
What chemorx cause capillary leak syndrome?
IL-2, GM-CSF
34
derived from bark of the western yew tree
Paclitaxel
35
Which causes more nausea and nephrotoxicity: carboplatin or cisplatin?
cisplatin
36
Stages CLL
```
0- lymphocytosis
1- + LAD
2- + HSM
3- anemia
4- thrombocytopenia
```
37
Side effects 5FU
GI toxicity and mucositis
38
Side effects methotrexate
mucositis and diarrhea
39
Side effects vincristine
neurotoxicity
40
Side effects vinblastine
myelotoxicity
41
Basal cell ca facts
Related to sun exposure
Can be inherited
Locally aggressive
Uncommonly seen black skin
42
Features Gorlin syndrome (nevoid basal cell carcinoma syndrome)
```
Autosomal dominant
Numerous basal cell carcinomas
Palmar and plantar pits
Cysts of mandible
Bifid ribs
agenesis of the corpus callosum
hypertelorism
Generally good prognosis
```
43
Concussion recommendations
Grade I- no amnesia or LOC- ok return after 20 minutes
Grade II amnesia but no LOC out x 1 week
2nd concussion out one month
3rd concussion out for season
44
Coma with pinpoint pupils- dx?
opiate overdose or pontine infarct
45
Sx Creutzfeldt-Jacob disease
Rapidly progressive dementia
myoclonus (precipitated by sudden noises or startle)
Pyramidal, extrapyramidal, cerebellar signs
46
Anticonvulsant that is only could for absence seizures
Ethosuximide
47
Encephalitis with personality changes/encephalopathy dx
viral meningitis- HSV (usually 1 except in neonates) or WNV
48
Rx active TB
4-drug therapy x 2 months then INH+RIF x 4 months
| INH, RIF, Pyrazinamide, and either ethambutol or streptomycin
49
Upper lobe predominant lung diseases
Silicosis
Ankylosing spondylitis
Eosinophilic granuloma
50
What agent will effectively bronchodilate and not be blunted by beta-blockade?
Ipratropium
51
Lower lobe predominant lung diseases
Rheumatoid fibrosis
Asbestosis
Connective tissue diseases e.g. SLE
52
Sarcoidosis and berylliosis both cause non-caseating granulomas. How to differentiate?
Lymphocyte transformation test on BAL lymphocytes or blood;
| positive = berylliosis
53
Clinical features silicosis
```
Mining, stone cutting, quarrying, construction, glass manufacturing, sand-blasting
Restrictive lung function
"Eggshell calcification" of hilar nodes
Increased risk TB, lung cancer
Associated with scleroderma, RA
```
54
Clinical features coal worker's pneumoconiosis
Similar PFT findings to silicosis
| No eggshell calcifications or increased TB or lung cancer risks
55
Clinical features berylliosis
Exposure to electronics, nuclear material, ceramics
| Bilateral hilar LAD similar to sarcoid
56
Byssinosis
Related to exposure to impurities in cotton, flax, and hemp dusts
after > 10 years exposure, often "first day of work week"
associated with gm neg exotoxin
57
What is CD4 cutoff in HIV pt at which you are concerned for MAI/MAC?
CD4 < 50
58
Treatment latent TB?
INH 9 months
59
Appropriate ventilator settings for asthma
You want prolonged expiratory phase, therefore:
| low rate, low tidal volume, high flows
60
Clinical features of Hand-Schuller-Christian syndrome?
Lytic bone lesions
DI
exophthalmus
On lung bx look for eosinophilic granulomatosis
61
Clinical features Loeffler's syndrome
Pulmonary infiltrates
Peripheral eosinophilia
Due to Ascaris or other worm migrating through the lung
62
Light's criteria
Exudate if:
pleural:serum protein > 0.5
pleural:serum LDH > 0.6
pleural LDH > 2/3 upper limit of normal for serum LDH
63
Adenosine deaminase in pleural fluid
TB related effusion
64
Elevated triglycerides in pleural effusion
Chylous effusion from disruption of thoracic duct
65
Rx mild RA
ASA or other NSAID
66
Crystals gout
strongly negatively birefringent needle-like
67
Crystals pseudogout
weakly positive birefringent rhomboid; precipitated by infection, trauma, surgery
68
Clinical features drug-induced lupus
Procainamide can cause
+ anti-histone antibodies
Serositis, fever are common
Rash, CNS, renal involvement are rare
69
Eosinophilic fasciitis
scleroderma-like condition with eosinophilia and skin thickening (sparing the hands) that frequently starts after vigorous exercise
Unlike scleroderma, which always involves hands, causes Raynauds, + ANA, synovitis
70
In dermatomyositis, what autoantibody indicates possible pulmonary fibrosis?
Anti-Jo-1
71
Rx Behcets with retinal vasculitis
Thalidomide
Methotrexate
Colchicine
72
c-ANCA associated with
Wegeners; think if sinusitis and vasculitis
73
p-ANCA associated with
microscopic polyangiitis
74
anti-GBM associated with
Goodpastures
75
Rx sicca symptoms of sjogren's
Artificial tears and saliva and secretagogues such as pilocarpine or cevimeline
76
SLE: what antibodies associated with increased disease activity and nephritis?
anti-dsDNA and low complement levels
77
SLE: 17-30% positive what antibody?
anti-Sm
78
SLE: what antibody 100% for drug-induced but 25% of not drug-induced?
anti-histone
79
SLE: what antibody suggests better prognosis?
anti-U1 RNP
80
SLE: what antibody associated with complete heart block and neonatal lupus?
anti-Ro/SS-A
81
PPD: Positive at 5mm
Immunosuppressed such as HIV or organ transplant
Close contact with documented case
Fibrotic changes on CXR consistent with prior TB
82
PPD Positive at 10mm
High risk with normal immunity: Health care workers, IV drug users, prisoners, homeless
83
PPD Positive at 15
People with no risk factors
84
How to calculate pressure gradient across a valve?
modified Bernoulli equation
4 v squared
v = velocity of flow
85
Heart sound: pulmonary htn
Widely split S2 (delayed emptying RV)
86
Heart sound: severe AS
Either only P2, or paradoxical splitting 2nd sound
87
Paradoxical splitting S2
severe AS, permanent pacemaker, LBBB
88
Heart sound: ASD
fixed split S2
89
CXR findings rheumatic mitral stenosis
pulmonary vascular redistribution
large left atrium
normal sized left ventricle
calcified nodules from previous pulmonary hemorrhages
90
People from tropical environments develop what a decade earlier?
valvular disease from rheumatic fever
91
What is unique about congenital pulmonic stenosis?
Only right-sided heart sound to become softer on inspiration
92
Commonest abnormality at autopsy of young athlete
Hypertrophic cardiomyopathy
93
Features of apical hypertrophic cardiomyopathy?
Asians
Usually but not always autosomal dominant
No obstruction or murmur
Prominent voltage anterior or lateral leads
Atrial fibrillation is common due to elevated LV end-diastolic pressures
94
Cardiac tamponade: cath tracings
elevated and equalized diastolic pressure
95
Cardiac tamponade: H+P findings
History: carcinoma of lung or breast, lyphoma with dyspnea
Physical: hypotension, elevated neck veins with single rapid x descent, pulsus parodoxicus (arterial BP inspiratory fall > 10mmHG)
96
Post-splenectomy organisms
Strep pneumo
H. influenzae
N. Meningitidis
97
Meningococcemia: screen for ?
CH50 (terminal compliment deficiency
98
Pophyria cutanea tarda associated with what?
HCV
Vesicles of the skin, increased pigmentation, increased fragility, milia formation
Increased liver cirrohsis and cancer
99
Rash of syphilis
Diffuse maculopapular rash trunk, head, neck, palms, soles;
| Classically "round, nickel and dime-sized lesions"
100
Pyoderma gangrenosum
Leg ulceration hypersensitivity reaction to IBD, RA, multiple myeloma, other inflammatory disorders
101
Guttate psoriasis
hundreds of 2-5mm scaly red papules trunk and extremities, moderately pruritic
often after strep throat
102
Acute fatty liver of pregnancy
Late pregnancy with nausea, vomiting, liver dysfunction
103
Live vaccines that shouldn't be given during pregnancy:
MMR
Typhoid
polio
yellow fever
104
Antibiotics to avoid during pregnancy
Cipro
Tetracycline
Doxycycline
105
Treatment syphilis in pregnancy
PCN-
| even if highly allergic, desensitize her
106
Pregnant pt with new onset atrial fibrillation and pulmonary edema
mitral stenosis secondary to rheumatic fever
107
Tetralogy of Fallot
large VSD
right ventricular outflow tract obstruction
overriding aorta
RVH
108
Characteristics and rx of fibromuscular dysplasia
Sudden onset htn in young, caucasian female
renal bruit (30%)
hypokalemia (htn is mediated by stimulation of renin, aldosterone)
renal arteriography "beaded appearance" of renal artery
Rx ace-i or ARB, consider surgery or angioplasty
109
EKG: Right axis deviation
I: negative
aVF: positive
110
EKG: Normal axis
I: positive
aVF: positive
or
aVF: negative and II: positive
111
EKG: Left axis deviation
I: positive
aVF: negative
II: negative
112
EKG: classic PE findings
S1Q3T3
113
Indications for mitral valve replacement
Severe MR with symptoms or asymptomatic with LV systolic dimension > 55mm
114
Arkansas, tick-bite, lymphadenopathy
Francisella tularensis (tularemia)
115
Missouri, pancytopenia, tick exposure
ehrlichiosis
116
Dx cryptosporidium
acid fast stain of stool or stool antigen
| won't grow in culture
117
Malaria-like severe hemolytic anemia in splenectomized pt
Babesiosis
118
Dx amebic liver abscesses
do serology
119
When and what to start for HIV?
HAART @ CD4 < 350:
tenofovir, emtricitabine, efavirenz
If CD4 < 200 add TMP/SMX for PCP prophylaxis
120
EtOH, sepsis, oysters, gulf water
Vibrio vulnificus
121
Toxic shock with + blood cx: strep or staph?
strep
122
Young person with hearing loss
Syphilis
123
Arizona, fever, inguinal lymphadenopathy
Plague
124
Mississippi river valley, AIDS, pancytopenia, palatal ulcer
histoplasmosis
125
Isolated Bell's palsy can be presentation of ?
Lyme disease
126
Febrile neutropenia indications for vanco?
Hypotension/shock
Suspected IV catheter infection
Known MRSA colonization or resistant pneumococcus
Mucositis
127
nonspecific symptoms: weight loss, diarrhea, arthropathies, skin hyperpigmentation
```
Trophermyma whippleii (Whipple disease)
Dx bx lymph node or endoscopic and PAS staining;
Rx bactrim or ceftriaxone or chloramphenicol
```
128
Contraindications for breast-feeding
Active untreated TB, maternal HIV
129
HAGMA: D-lactic acidosis
Short bowel syndrome- increased carbs to colon, increased L and D lactate, but L lactate is metabolized.
130
dDx AG metabolic acidosis
```
lactic acidosis
renal failure
ketosis
ingestions
D-lactic acidosis
```
131
Steps of acid-base
1) pH
2) AG- ? HAGMA present?
3) Assess delta HCO3 vs AG to assess for NAGMA or metabolic alkalosis
4) Assess respiratory compensation: 15 + HCO3 should = CO2
132
HAGMA: Renal failure
Increase ammonia (BUN)
133
HAGMA: Ketoacidosis
diabetic
EtOH
starvation
134
HAGMA: Lactic acidosis
drugs
toxins
circulatory compromise
135
HAGMA: Ingestions
salicylates
methanol
ethylene glycol
136
What eye drops do not use with hyphema?
NSAID
137
Horner pupil
sympathetic denervation
Ipsilateral ptosis and anhidrosis
Normal responses to pupillary light, topical dilators and constrictors
138
AIDS with retinopathy
CMV retinitis
139
HIV + with good CD4 count (not AIDS)
HIV retinopathy
140
Renal complications of multiple myeloma
Nephrotic syndrome, usually due to secondary amyloidosis
Myeloma kidney- renal failure w/o proteinuria
Fanconi syndrome
141
Fanconi syndrome
```
Proximal, Type II RTA
Hypokalemia
Phosphaturia
Uricosuria
Glycosuria
Aminoaciduria
```
142
Bartter's, Gitleman's, Liddle's cause:
hypokalemia with metabolic alkalosis
Bartters and Gitleman's = normotensive
Liddle's = hypertensive
143
Hyperparathyroidism in ESRD
Control phosphorus level (< 5.5), can use calcium to bind but need to keep Ca x Phos < 60-70
O/W sevelamer binds phos w/o affecting Ca
If Ca and Phos both ok control hyperpara with 1,25 vit D (calcitriol) or zemplar or hectorol
144
dDx NAGMA
RTA
Diarrhea
Carbonic anydrase inhibitors
TPN
145
Type 1 RTA: findings/mechanism
Distal
Urine pH > 5.5
Serum K+: Low-nl
Decreased H+ secretin distal tubule
146
Type 1 RTA: Causes
Autoimmune (SLE, Sjogrens, RA)
Hereditary hypercalciuria
Drugs (amphotericin B, lithium)
147
Type 2 RTA: findings/mechanism
```
Proximal
Urine pH < 5.5 (high initially)
Serum K+: Low-nl
Fanconi's
Decreased resorption of HCO3 in proximal tubule
```
148
Type 2 RTA: Causes
```
Multiple myeloma
Acetazolamide
Ampho B
Heavy metals
Amyloidosis
```
149
Type 4 RTA: findings/mechanism
Distal
Urine pH < 5.5
Serum K: high
Decreased cation exchange distal
150
Type 4 RTA: causs
```
Diabetic nephropathy
Chronic interstitial nephritis
NSAIDS
Ace-i
Obstructive uropathy
Spironolactone
```
151
Red cell casts
Very specific for glomerulonephritis
152
White cell casts
pyelonephritis
153
Granular casts
nonspecific, often ATN
154
Waxy casts
advanced renal disease
155
hyaline casts
do not indicate disease, seen with concentrated urine
156
Nephritic syndrome urine findings
```
"Active sediment"
variable protein
red cells
white cells
red, white, and granular casts
```
157
Nephrotic syndrome definition
> 2.5gm proteinuria/day
hypoalbuminemia and hypogammaglobulinemia
hypercoaguable
hyperlipidemia
158
Nephritic
Low complement
Primarily kidney
Post-infectious glomerulonephritis (check strep antigen titers)
Membranoproliferative glomerulonephritis
159
Lithium toxicity symptoms
```
Ataxia
muscle weakness
nausea/vomiting
diarrhea
tinnitus
polyuria
mental status changes
```
160
Drugs which decrease lithium excretion
ACE inhibitors
Thiazides
Diuretics
161
Wernicke aphasia
Lesion posterior temporal gyrus of dominant hemisphere
Right superior quadrantanopia
Poor repitition
Fluent speech output
162
Nephritic
Low complement
Systemic
```
SLE (can cause anything type of glomerular disease- nephritic or nephrotic)
Endocarditis
Cryoglobulinemia (usually due to HCV, MM, or waldenstrom macroglobulinemia)
```
163
Neprhitic
Normal complement
Primarily kidney
IgA nephropathy
| Alport syndrome
164
Membranoproliferative glomerulonephritis
(idiopathic or SLE, cryos, HCV, HBV); basement membrane dz on bx, "tram tracking"
165
IgA nephropathy
AKA mesangial proliferative GN
worldwide most common GN
Hematuria concurrent with viral illness or exercise
Only dx with biopsy
Prognosis tied to creatinine, BP, degree of proteinuria
166
Alport syndrome
Nephritic-normal complement-primarily kidney
AKA hereditary (x-linked) nephritis
chronic
associated with nerve deafness, congenital eye probs (lens, retinas, corneas)
dx renal biopsy
167
Nephritic
Normal complement
Systemic
Anti-GBM disease
Vasculitides
TTP/HUS
168
Anti-GBM disease
when associated with pulmonary hemorrhage known as Goodpasture's
Not vasculitis- no weight loss or fevers
Dx biopsy or serum anti-GBM antibodies
169
Vasculitides that cause acute glomerulonephritis
```
Wegener's
microscopic polyangiitis
PAN
Churg-Strauss
HSP
```
170
RPGN
```
Rapidly progressive glomerulonephritis
Can have features of any cause nephritic syndrome
Crescents on biopsy
Goodpastures
Lupus
Wegener's
Immune-complex dz
```
171
Nephrotic
| Primarily kidney
Minimal change disease
Focal and segmental glomerulosclerosis
Membranous nephropathy
172
MCD associated with:
Drugs: NSAIDS, lithium, sulfa
Lymphoma
Inhaled and contact allergies
173
MCD findings
Urine sediment with oval fat bodies with "maltese crosses"
Dx renal bx- "no change"
Responds to steroids
Best prognosis of nephrotic syndromes
174
Bactrim can cause what in the elderly?
Hyperkalemia
175
High AG and osmolal gap acidosis
ethylene glycol
| methanol
176
Osmolal gap but not AG acidosis
isopropyl alcohol
177
Calculated osmolar gap =
2[Na+] + glucose/20 + BUN/3
178
Risk factors for thyroid cancer
```
FMH thyroid cancer
H/o neck radiation
Anterior neck pain or dysphagia
Respiratory obstruction
New nodule age < 20 or > 60
Vocal cord paralysis
Nodule firm, fixed, or growing or accompanied by LAD
```
179
Medullary thyroid cancer associated with what mutation?
Ret-proto-oncogene (RET)
180
Causes of high RAI uptake:
```
Graves
Iodine deficiency
Hot nodules
Toxic multinodular goiter
Elevated B-HCG
TSH secreting pituitary tumor
```
181
Causes of low RAI uptake:
Hashimoto thyroiditis
Other thyroiditites: subacute, postpartum, radiation, amiodarone-induced
Thyroid suppressive meds
Iodine excess
Ectopic thyroid tissue (struma ovarii)
Absent thyroid gland (surgery or radioablation)
182
Klinefelter syndrome
```
Small and fibrotic testes
47, XXY with Barr body
Gynecomastia and poor social skills
Normal arm span
High LH and FSH because testes won't respond
```
183
Kallman syndrome
Increased arm span
Normal genotype
Impaired smell
LH and FSH low or undetectable
184
Clinical course of DI after pituitary surgery
First DI (initial stunning)- dilute urine
Then cells die and ADH store is released so SIADH and concentrated urine
Then ADH gone so back to DI
185
Adrenal steroid pathways
Cholesterol --> Progesterone, 17OH progesterone, DHEA-S
Progesterone --> 11-doxycorticosterone --> aldosterone
17OH progesterone --> 11-deoxycortisol --> cortisol
DHEA --> testosterone
186
Excess mineralocorticoids cause:
Hypertension, hypokalemia, alkalosis
187
Schmidt syndrome
Combination of hypothyroidism and adrenal insufficiency
| Give steroids first
188
Pseudoprolactinoma
Can be caused by hypothyroidism- usually prolactin level is < 200
189
How to dx acromegaly
Check GH levels after a glucose load
High glucose normally would suppress GH
or check IGF-1 level
190
Cushings disease : DXMZ suppression
Does not suppress with low-dose, but does with high dose
191
What is nephrogenic DI?
DI (inability to concentrate urine) that does not respond to exogenous vasopressin (problem is in the kidneys)
192
Features of TTP
```
Mental status changes
Thrombocytopenia
Hemolysis
Renal dysfunction
Fever
associated with mitomycin C
Rx plasmapheresis
```
193
Which type of AML is associated with DIC?
M3
194
MDS findings
Hypercellular bone marrow with dysplasia in all lines
| Microcytic, pseudo-Pelger-Huet cells
195
Secondary thrombocytosis
caused by iron-deficient anemia
196
Diseases associated with splenomegaly
CML
CLL
hairy cell leukemia
Lymphoma
197
CLL
associated with AIHA and ITP
198
Philadelphia chromosome
better prognosis with CML
| worse with ALL
199
Iron low
TIBC low
Ferritin high
Iron sat low or normal
anemia chronic disease
200
```
Normal PT
normal or elevated PTT
Normal CBC
Elevated bleeding time
Abnormal RIPA
```
von Willebrand disease
201
abnormal PT
| Normal PTT
Labs vit K deficiency and FVII deficiency
202
normal PT and PTT, platelets, and bleeding time
Labs F XIII
203
pancytopenia
large spleen
dry tap
Hairy cell leukemia
204
Auer rods
AML
205
normal PT
| abnormal PTT
Labs F VIII
206
abnormal PT and PTT
Labs F X
207
Microcytic and slightly hypochromic red cell w/o significant anemia or hemolysis
alpha-thalassemia trait
208
normal PT
abnormal PTT
no bleeding
Labs F XII
209
Progressive dysphagia to solids and liquids
achalasia or scleroderma
210
Progressive dysphagia to solids first, then liquids
cancer or stricture
211
Intermittent dysphagia to solids
webs or rings
212
Organophosphate poisoning
DUMBELS
| defection, urination, miosis, bronchospasm/bradycardia, emesis, lacrimation, salivation, + fasciculations and weakness
