Final Flashcards
1
Q
When do you screen for developmental delays
A
Status done at every visit; more thorough screening at 9,18, and 24 or 30 months; autism screen at 18 and 24 months
2
Q
What are the domains of development
A
Gross motor, fine motor, language, cognitive/social-emotional and behavioral
3
Q
What is M-CHAT-R
A
Modified checklist for autism in toddlers; administer at 18 and 24 months
4
Q
What should a baby be able to do at 6 months
A
Babble; sits momentarily
5
Q
What should a baby be able to do at 9 months
A
Mama/dada, pulls up, cruises, sits well without support
6
Q
What can a baby do at 1 year
A
Separation anxiety, mama/dada, stacks 3 cubes, stands momentarily
7
Q
What should a baby be able to do at 2 years
A
Walks well, runs, walks up stairs, kicks ball forward, 2 words together, 1/2 of langue understood by people who don’t live in the home, starting interest in potty training; 6 blocks stacked, copy a line
8
Q
What should a 3 year old be able to do
A
Tricycle, 3 words together, playing in groups (3), 9 blocks, 3/4 of speech understood by strangers
9
Q
What should a baby be able to do at 4 years
A
Balance on one foot, hop on one foot, 4 body parts, all speech understood by strangers, small sentences, use past tense, copies cross
10
Q
What should a 6 year old be able to do
A
Tie shoes, skips, draw person with 6 parts
11
Q
When does Becker MD present
A
After 5 years of age
12
Q
How are congenital MDs inherited
A
AR
13
Q
What is Pompe dz
A
AR; alpha glucosidase mutations; build up of glycogen in lysosomes; presents in infancy as hypotonia, hypertrophic cardiomyopathy, resp failure, feeding difficulty, hearing loss; treat with enzymes (myozyme) - can reduce cardiac mass and improve ejection fraction
14
Q
What is myotonia congenita
A
Mutation in chloride channel (CLCN 1) AD or AR; first symptoms in childhood; muscle stiffness relieved by exercise; muscles hypertrophic; fainting goat syndrome
15
Q
What is periodic paralysis
A
Repeated episodes of flaccid paralysis of extremities
- hypokalemia: mutation in calcium and sodium channel; occurs after exercise and carb rich foods
- hyperkalemia: mutations in sodium channel; occurs while eating potassium rich food or rest after exercise
Treat with acetezolamide
16
Q
What is juvenile dermatomyositis
A
Most common idiopathic inflammatory myopathy in children; mean onset 7 years; proximal m weakness, heliotrope rash, gottron papules, thrombi or hemorrhage in peri-ungual cap bed; acquired
17
Q
What can GGT tell you
A
If elevated, think liver
If normal, think muscle
18
Q
What are the results of nerve conduction studies in Myopathies
A
Normal
19
Q
What kind of autoab is RF
A
IgM that targets Fc portion of IgG *produced by B cells in synovial joints
20
Q
What other conditions is RF present in
A
Sjograns, cryoglobulinemia, PBC, mixed connective tissue, endocarditis, SLE, sarcoidosis, malignancy
21
Q
Is anti CCP or RF more specific for RA
A
CCP
22
Q
What does a homogenous pattern of ANA suggest
A
Drug induced lupus - histone ab
23
Q
What does a Rim pattern ANA suggest
A
anti dsDNA; SLE
24
Q
What does a speckled ANA pattern indicate
A
Anti SM (SLE) or anti SS-a/B sjogren
25
What is anticentromere ab specific for
Scleroderma CREST
26
What is anti scl 70 specific for
CREST
27
What are the joint fluid analysis results indicative of
Noninflammatory: 200-2000 mononuclear cells
Inflammatory: 2000-50000; >50000 septic
28
How do you treat acute gout
NSAIDs, colchicine, steroids
29
Is CT or MRI better for bone
CT
30
What is the definition of number joints involved in arthiritis
Oligo: 3 or <
Pauci: 5 or <
Poly: >6
31
What endocrine problems can cause arthritis
Diabetes: chariots and cheiroarthropathy
Thyroid: carpal tunnel
acromegaly
32
What is cANCA also called
PR3-ANCA
33
What is pANCA also called
MPO-ANCA
34
What is a speckled staining pattern indicative of
Sjogren’s most common
35
What is the SLE serology
Positive ANA, dsDNA (dz activity), smith, decreased complement
36
What are the 3 types of antiphospholipid abs
- type 1: causes biologic false positive test for syphilis; VDRL
- type 2: lupus anticoagulant; risk for venous and arterial thrombosis and misarriage; prolonged aPTT; confirmed with abnormal dilute Russell viper venom time (DRVVT) - corrects with phospholipid but not plasma
- type 3:anti-cardiolipin abs beta2GPI
*abs should be measured on 2 occasions 12 weeks apart
37
How do you treat hypercoagulability in lupus
Start with LMWH/unfractionated heparin then bridge to vitamin K antagonists (warfarin) to achieve goal INR of 2.5
38
How do you treat antiphospholipid ab in pregnancy
Low molecular weight heparin (enoxaparin) + aspirin
39
What retinopathy is seen with SLE
Cotton wool spots
40
What will you seen in drug induced lupus
No renal or neuro sx; positive Ana, positive anti-histone abs
Causes: hydralazine, isoniazid, minocycline, TNF inhibitors, quinidine, chlorpromazine, methyldopa, procainamide
41
What drug can case an SLE flare
Sulfa antibiotics
42
What is neonatal lupus
Affects children born of mothers with lupus; anti Ro or La abs transient (rashes, thrombocytopenia, hemolytic anemia, arthritis) permanent complete heart block*
43
What is SLE treatment
Avoid sun exposure, NSAIDs, corticosteroids, hydroxychloroquine
44
What increases mortality in SLE patients
In early years: infections; kidney or CNS dz
| Later: atherosclerosis; MI; leading causes of death in first decade of dz
45
What are preventative measures for SLE
Avoid smoking, minimize risk factors for atherosclerosis, influenza vaccine, pneumococcal q 5 years;cancer screening
46
What does systemic sclerosis affect
Skin, lungs, GI, kidneys, MSK , heart; obliteration of eccrine sweat and sebaceous glands leads to dry itchy skin
47
What is the treatment for systemic sclerosis
No disease modifying therapy; control sx and slow progression; education - warm clothing, smoking cessation; calcium channel blockers for raynauds, ACEI for HTN; antireflux, glucocorticoids for pericarditis (*high doses assoc with renal crisis), cyclophosphamide for lung function, PDE5 inhibitor or CP in patients with pulm HTN
48
What is morphea
Patches seen in localized scleroderma
49
What is the serology of scleroderma
Diffuse: anti-scl 70, anti-DNA topoisomerase, anti-RNA pol III
Limited: anti-centromere
50
What is the work up for scleroderma
CXR, barium swallow, hand x Ray can show distal tuft resorption and calcinosis; ECG, echo, PFT, skin bx
51
What are the sx of diffuse systemic sclerosis
Fatigue, stiffness, malaise, erythema, pruritis, raynaud later, inflammatory edematous phase -> fibrotic phase - skin induration, hyperpigmentation, loss of body hair and impaired sweating; renal crisis - hemolytic anemia*
52
How can diffuse scleroderma affect skin
Hyper/hypopigmentation, dry itchy skin, mask facies, mirostomia, telangitasia, atrophic skin, calcium deposits, raynaud
53
How can diffuse scleroderma affect GI
```
Malnutrition - fat, b12, vit D def
Xerostomia
GERD - strictures - Barrett, hoarsnesss, chronic cough
Gastroparesis
GAVE: watermelon stomach
Chronic diarrhea
PBC: anti-mitochondrial ab
```
54
What is the primary cause of morbidity and mortality in diffuse and limited scleroderma
Pulm involvement
Increased incidence of bronchoalveolar carcinoma
55
What MSK findings can you seen in scleroderma
Carpal tunnel, tendon friction rubs, hypothyroidism
56
What cancer is sjogrens assoc with
B cell NHL
57
What serology would you see for sjogren
Positive ANA, RF, hypergammaglobulinemia, anti-SSA (can lead to newborn complete heart block)/SSB; low C4, high ESR, anemia of chronic dz
58
What is the treatment for sjogren
Dentist and eye doc; cyclosporine drops (cyclin adenosine monophosphate), sips of water, sugarless candy; pilocarpine or cevimeline, hydroxychloroquine for myalgias, glucocorticoids for extra glandular manifestations; avoid atropine drugs and decongestants; no immunomodulatory drug is effective
59
Who are inflammatory Myopathies more common in
AA Women
60
What are the typical dermal features of inflammatory Myopathies
Gottron, heliotrope, periungual erythema, v neck erythema (shawl sign)
61
What serology would you see in dermatomyositis
Elevated CK and aldolase; anti-Jo, anti Mi2, anti-MDA5, anti-P155/140
62
What is the most common malignancy assoc with dermatomyositis
Ovarian - do transvaginal US, CT ab/pelvis, CA-125
63
What serology would you see with polymyositis
Elevated CK, anti-jo; muscle bx: endomysial inflammation
64
What are the treatment steps for PM and DM
Glucocorticoids, taper, IV Ig, trial of rituximab, cyclosporine, cyclophosphamide or tacrolimus
65
Which myopathy is more common in men
Inclusion body myositis and more common in whites
66
What are the sx of inclusion body myositis
Finger flexion or quad weakening; CK mild elevation or normal; bx: endomysial inflammation rimmed vacuoles - anti-cN1A abs
67
What are some differentials for prox m weakness
- hypothyroid: elevated CK
- hyperthyroid normal CK
- cushing: Normal CK
- polymyalgia rheumatica: pain but no weakness, CK normal
68
What does takayasu arteritis affect
Women; large vessels (aorta and branches - subclavian and innominate), age <40; long smooth tapered stenosis; no UE peripheral pulses; pulm involvement; reintophaty(copper wire), aortic dilation, aortic regurgitation, AAA; *diagnose with MRI or CT; hx: granuloma with giant cells; treat with glucocorticoids
69
What are the features of behcet syndrome
HLA-B5; Asia; recurrent mouth ulcers, genital ulcers, uveitis; large vessel - aneurysms; venous involvement - DVT; pathergy -> pustules at site of sterile needle pricks; mimics MS;ulcers in ileum or cecum; treat with low dose glucocorticoids
70
Who is PAN more common in
Men
71
What are the sx of PAN
Skin- liver reticularis, subcutaneous nodules, ulcers, digital gangrene; vasculitis neuropathy; intestinal angina (postprandial ab pain); renin mediated HTN, renal infarct; CHF; *lungs are spared*
72
Ho do you confirm dx of PAN
Bx: destruction of bv by inflammatory cells; fibrinoid necrosis; no granulomas
Angio: micro aneurysms
Treat with steroids
73
How do you treat Kawasaki
IVIG w/in 10 days of sx and high ASA
74
What are the features of Wegners
Small vessels; males; ANCA+ (PR3); saddle nose; nodule -> alveolar hem; cavitary lesions on XR; kidney; hearing loss orbital masses, keratitis, venous thrombosis, granulomatous inflammation, necrotizing vasculitis, segmental glomerulonephritis
75
How do you treat wegners
Cyclophosphamide and high dose glucocorticoids or rituximab; methotrexate considered if renal function normal
76
What is eosinophilic granulomatosis with polyangitis
Churg-Strauss; MPO-ANCA; granulomas with eosinophilia; asthma; necrotizing vasculitis; palpable purpura; treat with steroids
77
What is thromboangiitis obliterans
Burger dz; medium vessels; males; smokers; distal vessels first; thrombosis; diagnose with angio: corkscrew appearance
78
What is nailfold capillaroscopy used to diagnose
Raynauds; primary will be normal; in secondary, will show distorted and widened and irregular loops, dilated lumen and areas of vascular dropout
79
What can cause secondary raynaud
Beta blockers, cisplatin or bleomycin; if u/l think thoracic outlet or carpal tunnel
80
What is treatment for raynaud
Keep warm, lotion, stop smoking, limit use of sympathomimetic drugs (decongestants, diet pills, amphetamines), calcium channel blockers, surgery
81
What populations does polymyalgia rheumatic and giant cell arteritis occur in
Women; white; frequently coexist; fever, malaise, weight loss with normal CBC
82
What are the features of giant cell arteritis
Large vessel; cranial aa (temporal, facial, ophthalmic); aortic arch; HA, jaw claudication, PMR, amaurosis faux or diploma; incrased ESR
83
How do you treat giant cell
Steroids before biopsy
84
What are the features of polymyalgia rheumatica
Proximal severe symmetrical morning and daylong stiffness and pain; trouble combing hair; no inflammation on muscle bx, muscle enzymes and EMG normal; elevated ESR and CRP; treat with steroids
85
What are people with RA at increased risk for
Infection, renal dz, GI dz, heart dz, malignancy
86
Who should be tested for RA
At least one joint with definite clinical synovitis not better explained by another dz
87
What is involved in the scoring system for the test for RA
Amount and type of joints affected, serology, acute phase reactants, duration of sx
88
What abs do you use to measure treatment response in RA
ESR and CRP
89
What part of the spine does RA affect
C1-C2
90
What is pyoderma gangrenosum
Tender reddish purple papule leads to necrotic non healing ulcer; seen in RA
91
What is rheumatoid vasculitis
Purpura, petechiae splinter hemorrhages, digital infarct
92
What is the most common pleural manifestation of RA
Pleuritis; nodules; Caplan syndrome - nodular densities after exposure to coal or silica dust
93
Is feltys positive for RF and CCP
Yes
94
What are the labs for RA
Anemia, thrombocytosis, hyperglobulinemia, leukopenia low glucose
95
What do you have to monitor with methotrexate
CBC, LFTs, Creat q 4-8 weeks
96
What should you not give leflunomide with
Cholestyramine
97
What is enthesitis
Inflammation of insertion points of tendons and ligaments; seen in seronegative spondyloarthropathise
98
What is dactylitis
Swelling of finger or toe seen in reactive or psoriatic arthritis
99
What is spondylitis vs spondylolisthesis vs spondylolysis
Spondylitis: inflammation of vertebrae
Spondylolisthesis: anterior displacement of vertebral body relative to adjacent vertebral body belo
Spondylolysis: defeat of bone btw inf and sup articular process of vertebrae
100
Which arthritides are more common in men
Ankylosing spondylitis, reactive arthritis
101
What manifestations besides the SI joint can ankylosing spondylitis have
Achilles tendinitis, plantar fasciitis; iritis (not found in RA)
102
What is schober test
Restricted forward flexion seen in ankylosing spondylitis; if <4 cm decreased mobility
Also will see restricted chest expansion (fabere test) if <5cm decreased
103
What will the vertebrae look like on imaging of ankylosing spondylitis
Squaring (loss of anterior convexity), shiny corners, sclerosis at edge of vertebral bodies
104
What is DISH
Diffuse idiopathic skeletal hyperosteosis - calcifications along lateral aspect of 4 continuous vertebrae bodies; men, back pain, stiffness; no SI involvement
105
What is osteitis condensans ilii
Young females normal SI joints; X ray shows sclerosis os iliac side of SI joint
106
What is the treatment for ank spondylitis
Exercise, PT, swimming, stretching, NSAID, TN alpha inhibitors, DMARD (ok but doesn’t help axial dz)
107
What is dactylitis a manifestation of
Reactive arthritis
108
What are the clin manifestations of reactive arthritis
SI pain, urethritis, conjunctivitis, oral ulcers, circunate balanitis, keratoderma blennorrhagicum (painless eruption on palms and soles), uveitis
109
What is the treatment for reactive arthritis
Usually self limiting; NSAIDs, steroids, if chronic progression use DMARD
110
What are the features of enteropathic arthritis
Parallels activity of IBD; large joints LE small joints UE; pyoderma gangrenosum, erythema nodosum, uveitis, nephrolithiasis, thromboembolism
111
What spondyloarthropathy are DMARDS useful for
Psoriatic
112
What would the lab serology show for OA
Normal; ESR can be elevated
113
What would you see on XR of OA
Asymmetric joint - space narrowing, subchondral sclerosis, osteophytes and marginal lipping, bone cyst, joint mice
114
What is erosive OA
Inflammatory; affects DIP and PIP; see seagull appearance central erosions on radiograph (RA is marginal erosions)
115
Where would you see secondary OA
Hemochromatosis, joint infection, trauma, surgery, pseudogout, hyperparathyroidism
116
What is the treatment for OA
Joint protection, strength training, NSAIDs, duloxetine, tramadol, acetominophen, topical capsaicin
117
What are the most common cervical nerve root compressions
C6 and C7
118
What are the most common lumbar nerve compressions
L5. And S1
119
What would you see with C5 radiculopathy
Pain in scapula and shoulder; loss of sensation in lateral arm; weakness of shoulder abd; loss of biceps reflex
120
What would you see in C6 radiculopathy
Pain in scapula, proximal arm and shoulder; loss of sensation in 1st and 2nd digit an lateral arm; weakness in shoulder abd and elbow flexion; loss of biceps and BR reflex
121
What would you see with C7 radiculopathy
Pain in scapula, shoulder, elbow and forearm; loss of sensation in 3rd digit; weakness in elbow ext and wrist ext; loss of triceps reflex
122
What would you see with C8 radiculopathy
Pain in scapula, shoulder, medial forearm; loss of sensation in 4th and 5th digit; finger abd and flexion weakness, loss of finger flexor reflex
123
What would you see with L4 radiculopathy
Pain in anterior lateral thigh, kneee and medial calf; loss of sensation in medial calf; weakness of hip flexion and knee extention; DTR loss patella
124
What would you see with L5 radiculopathy
Pain in dorsal thigh and lateral calf; sensory loss in lateral calf and dorsum of foot; weakness in hamstrings, foot dorsiflexion, inversion and eversion; no loss of DTRs
125
What would you see with S1 radiculopathy
Pain in posterior thigh and calf; sensory loss in posterior lateral calf and lateral foot; weakness in hamstrings and foot plantarflexion; loss of Achilles reflex
126
What is the dermatome for medial forearm
T1
127
What is the dermatome for inguinal area
L1
128
What are some etiologies of brachial plexopathy
Stretch from surgery (CABG), inflammatory (parsonage-turner), radiation injury (upper trunk, lateral cord, painless), neoplastic (medial cord, painful), traumatic injury, ischemia (diabetic, usually lumbar)
129
What causes positive sx in peripheral neuropathies
Paresthesias caused by injury to large myelinated fibers (pins and needles)
Pain secondary to small unmyelinated dz (dysesthesias - pain upon gentle touch, hyperalgesia, hyperpathia)
130
What would loss of large myelinated sensory fibers do
Impairment of light touch (cotton swab), two point, vibration, joint position sense
131
What would loss of small unmyelinated fibers lead to
Impairment of temperature perception, pain perception (pin prick)
132
What is pronator syndrome
Diffuse dull ache of prox forearm; pain exacerbated with forced forearm pronation; easy fatigue of forearm mm; diffuse numbness of hand (particularly median n distribution); no nocturnal awakening
133
What would a needle EMG show in anterior interosseous syndrome
Abnormalities in FPL, FDP, PQ
134
What would an EMG should abnormalities in for ulnar mononeuropathy
1st dorsal interosseous, abd digiti minimi, add policis, flexor carpi ulnaris, flexor digitorum profundus
135
What is froment sign
Grab piece of paper with bent thumb; ulnar neuropathy
136
What would peroneal n entrapment lead to
Foot drop, weak eversion, sensory loss in dorsum of foot
137
What would femoral neuropathy lead to
Weak knee extension; absent knee jerk
138
What deficiencies can cause peripheral neuropathy
B1,6,12, E, copper
139
What is paraneoplastic neuropathy
Only sensory
140
How do you confirm small fiber polyneuropathy
Decreased epidermal nerve fiber density on skin bx
141
What is the difff btw CMT 1 and 2
1 is demyelinating; 2 is neuronal
142
What are the features of CMT 1
Onset 1st or 2nd debate; difficulty walking or running; distal symmetric atrophy (legs >arms), Areflexia, mild sensory loss, skeletal deformities (Pes cavus, hammer toes, scoliosis); EMG shows slowing of motor nerve conduction
143
What is diff about CMT 2 presentation
Later; EMG shows normal conduction velocity
144
What is fabry’s dz
Alpha galactosidase def
145
Does guillaine barre have sensory signs
No
146
What indicates a poor prognosis in Guillain barre
EMG findings of low amplitude motor n responses
147
What is miller fisher syndrome
Ophthalmoplegia, ataxia, Areflexia, Facial weakness, dysarthria, dysphagia, GQ1b an GT1a abs
148
What is multifocal motor neuropathy
Males; initially in distribution of single nerve; progressive distal weakness hands > feet; no sensory signs or UMN signs; elevated GM-1 ab; EMG shows conduction block; CSF normal; treatment is IVIG
149
What would Hu ab test for
Carcinomatous sensory neuropathy
150
How would you test for heavy metals
Urine
151
When can EMG lead to a specific diagnosis
GBS, CMT1, MMN
152
What are the presynpatic disorders of NMJ
Lambert Eaton, botulism, steroids, magnesium, black widow venom, congenital myasthenic syndrome, aminoglycosides, tetanus, tick paralysis
153
What are the synaptic disease of NMJ
Organophosphate, edrophonium, neostigmine, congenital end plate AChE def, nerve agents
154
What are the postsynaptic disorders of NMJ
Myasthenia, succinylcholine, D penicillamine, curare, classic slow channel syndrome
155
What are the EMG findings for myasthenia
Decreased response on repetitive stimulation; increased jitter on single fiber EMG
156
What’s the treatment for myasthenia
AChEI, prednisone, plasma exchange, IVIG, thymectomy
157
What drugs can unmask or exacerbate myasthenia
-NMJ blockers: succinylcholine, pancuronium
-Excessive AChEI
-corticosteroids and ACTH with high initial dose*
-thyroid supplements
-BOTOX
-magnesium salt
-antiarrhythmics: lidocaine, quinine, procainamide, verapamil, beta blockers
-abx: aminoglycosides
D penicillamine
158
What is MUSK syndrome
3 types, mainly in women
-oculopharyngeal weakness, neck, shoulder, resp weakness, poor response to AChEI and thymectomy; PLEX, IVIG and rituximab best
159
What is the clinical presentation of lambert Eaton
Prox weakness, loss of DTRs, dry mouth, impotence
160
How do you treat lambert Eaton
AChEI, 3-4 diaminopyridine, guanosine hydrochloride (bone marrow suppression)
161
How do you treat botulism
ICU monitoring until toxin clears
Antitoxin - but can cause serum sickness and anaphylaxis
Guanidine hydrochloride: bone marrow suppression
162
How do you treat nerve gas poisoning
Remove clothes, sodium hypochlorite; antidotes - atropine until secretions recede; 2-pralidoximine chloride; seizures respond to benzo only
163
What are the nondepolarizing NM blocking drugs
- isoquinoline derivatives: atracurium, cisatracurium, doxacurium, mivacurium, turbocharging
- steroid derivatives: pancuronium, pipercuronium, rocuronium, vecuronium
164
What is the depolarizing NM blocking drug
Succinylcholine
165
What are the AChEI
Ambenonium, donepezil, echothiophate, edrophonium, galantamine, neostigmine, physostigmine, pyridostigmine, rivstigmine, tacrine
166
What are the antimuscarinics
Atropine, glycopyyrolate
167
What are the cholinesterase reactivators
Pralidoxime
168
What are the centrally acting spasmolytics
Baclofen, carisprodol, cyclobenzaprine, diazepam, tizanidine
169
What are the noncentally acting spasmolytics
Dantrolene and botulinum toxin
170
What are the drugs for MS
Glucocorticoids, glatirmer acetate, IFN (beta1a and b), mitoxantrone
171
What are NM blockers used for
Adjuncts during anesthesia
172
What are the long acting NM blockers
Doxacurium, pancuronium, pipercuronium
173
What are the short acting NM blockers
Mivacurium, ultra short is succinylcholine
174
What are the intermediate NM blockers
Atracurium, cisatracurium, rocuronium, vecuronium
175
How must you administer nondepolarizing NM blocking agent
Parenterally
176
How do you reverse nondepolarizing NM blockers
AChE inhibitor, anticholinergics coadministered (atropine, glycopyyrolate)to minimize bradycardia, bronhoconstrition, salivation, N/V
177
What are the adverse effects of nondepolarizing agents
Some produce histamine release; at large doses, tubocurarine can produce Ach receptor blockade at autonomic ganglia and adrenal medullary which can cause decreased BP
178
Which inhaled anesthetic has the largest drug interaction with nondepolarizing NM agents
Isoflurane potentiates NM blockade
Aminoglycosides also potentiate;
179
How is atracurium eliminate
Hoffman reaction
180
Which nondepolarizing muscle relaxant can be used in hepatic and renal failure
Cisatracurium
181
How is mivacurium metabolized
Cholinesterase
182
Which NM blocking gents have the least tendency to cause histamine release
Steroidal; vecuronium, rocuronium (used more often), pancuronium, pipercuronium
183
Which nondepolarizing agent has the most rapid time of onset and can be atlernative to succinylcholine
Rocuronium
184
How is succinylcholine metabolized
Butyrlcholinesterase and pseudocholinesterase in liver and plasma
185
What are the adverse effects of succinylcholine
Bradycardia - reverse with anticholinergic
Hyperkalemia in patients with burns or nerve damage
Increased intraocular pressure
Black box* cardiac arrest; acute rhabdo in kids with undiagnosed myopathy
186
Which AChE inhibitors are irreversible
Echothiophate, parathion, malathion, sarin, soman
187
What are the quaternary AChE inhibitors
Neostigmine, pyridostigmine, edrophonium, echothiophate
188
What are the tertiary AChE inhibitors
Physostigmine, donepezil, tacrine, rivstigmine, galantamine
189
What are the uses of AChE inhibitors
Myasathenia, atonic bladder, glaucoma
190
What are the AChE inhibitors used for myasthenia
Pyridostigmine, neostigmine and ambenonium
191
What AChE inhibitor is use to reverse pharmacological paralysis
Neostigmine
192
What AChE inhibitors are used for Alzheimer’s
Donepezil, rivstigmine, galantamine, physostigmine
193
Which nondepolarizing NM blocking agent is potentiated by AChE inhibitors
Mivacurium
194
How do you treat AChE inhibitor poisoning
Atropine, pralidoxime and benzo
195
What is baclofen
Centrally acting spasmolytics; MOA: agonist at GABAa receptor - hyperpolarization due to increased potassium conductance; causes less sedation than diazepam and does not reduce overall m strength; adverse effects: drowsiness and increased seizure - withdrawal slowly; slurred speech
196
What is carisprodol
Acts as CNS depressant; addictive potential - use only short term; dizziness and drowsiness; met by CYPC19; metabolized to meprobamate
197
What is cyclobenzaprine
Reduces motor activity by influencing alpha and gamma motor neurons; structurally related to TCAs and produces antimuscarinic side effects - section, confusion, hallucinations; met by CYP450; xerostomia
198
What is diazepam
Long acting benzo; sedation; MOA: promotes binding of inhibitory neurotransmitter in CNS GABA to GABAa receptor; anxiolytics and anticonvulsant; controlled substance
199
What is tizanidine
MOA alpha 2 agonist; decreases excitatory input to alpha motor neurons; causes drowsiness, hypotension, dry mouth, muscle weakness
200
What is dantrolene
Non-centrally acting spasmolytic; reduces skeletal m strength (in contrast to centrally acting drugs); MOA; inhibitor of ryanodine receptor; sedation and hepatitis; used to treat UMN disorders
201
What is botulinum toxin
Non-centrally acting spasmolytic; MOA cleaves SNARE complex preventing release of ACh; usd for strabismus, axillary hyperhydrosis, chronic migraine prophylaxis
202
How often are glucocorticoids given for MS
Monthly bonus IV;
203
What is glatiramer acetate
MS drug; MOA: mixture of AA (alanine, glutamic acid, lysine, tyrosine) - induces Treg cells specific for myelin antigen
204
What is the MOA of IFN in MS
Acts on BBB by interfering with T cell adhesion to endothelium by binding VLA-4 on T cells or inhibiting T cell expression of MMP; reduces relapses and slows brain atrophy
205
What is mitoxantrone
MS drug; antineoplastic; intercalated into DNA resulting in cross links and strand breaks. Related to anthracycline abx
206
What infections can cause motor neuron dz
Polio, west Nile, HIV
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What metabolic syndromes can cause motor neuron dz
Alpha glucosidase def (pompe), cancer, thyroid
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What is hirayama’s dz
One upper limb affected; monomelic amyotrophic
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What is diagnostic testing for ALS
EMG shows widespread denervation and reinneration; CPK normal; CSF normal; imaging normal; assess for HIV; muscle bx only needed in confusing cases
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What are the things you will NOT SEE in ALS
No sensory sx; no loss of mental function, no extraocular mm involvement, no bowel or bladder sx, no decubitus, fasciulations rarely the presenting sx
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What are the common causes of death in ALS
Resp failure, pneumonia, pulm embolus
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What is rituzol
Glutamate inhibitor that may prolong life in ALS by 3 to 6 months
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What is progressive bulbar palsy
Selective involvement of lower cranial n motor nuclei; dysarthria, dysphagia, dysphonia, chewing difficulty, drooling, resp difficulty; rarely runs course as isolated syndrome almost always progresses to ALS
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What is spinal muscular atrophy
More common in males; mean onset is 64; LMN deficits predominate due to degeneration of anterior horn cells; no UMN involvement; symmetric UE involvement first; usuallly doesn’t progress to ALS; survival >15 years; better with earlier age of onset
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What is primary lateral sclerosis
UMN (corticospinal) deficit prevails; weakness, spasticity, hyperrreflexia, babinski; slow progression but can evolve into ALS; survival rate better than ALS
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What is Hopkins syndrome assoc with
Asthma; adult motor neuron dz
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What is the diff btw cream and ointment
- Cream: half water half oil with emulsifier, spreads easily; well absorbed and washes off with water; can’t pump;; better than ointments for oozing skin conditions
- ointments: more oil than water; feel greasy and are occlusive; stay on surface of the skin; not absorbed; best used for dry skin since they trap moisture ; provide for more absorption of active ingredient; less likely to cause allergic reaction
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What is important about hand hygiene
Should wash 15-30 seconds; should use plain soap
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What are emollients
Form oily layer on top of skin that traps water - petrolatum, lanolin, mineral oil and dimethicone
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What are humectants
Draw water into outer layer of skin; glycerin, lecithin, and propylene glycol
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What are horny substance softeners
Loosens bonds between top layer of cells which helps dead skin cells fall off and helps skin retain water; urea, alpha hydroxy acids, allantoin
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What are the ingredients in sunscreen
PABA: UVB
Benzophenones: less effective
Dibenzoylmethanes: UVA - useful for photosensitivity; and lupus
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What are sunshades
Opaque material that reflex light; ex: titanium dioxide
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What is glutaraldehyde
Antiseptic that cross links proteins
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What are the disinfectants that affect the inner membrane
- quaternary amine: membrane damage involving bilateral
| - chlorhexidine: congealing of cytoplasm
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What are the oxidizing antiseptics
- halogens: oxidation of thiol groups
| - peroxygens: hydrogen peroxide
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What is chlorhexidine effective against
Prevents development of spores but doesn’t kill them; mycobacteriostatic, yeasts, low activity against viruses; high activity against Protozoa
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What is cadexomeer iodine
Reduces bacterial load while providing moist wound environment
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How do you debride a wound
Remove dead tissue, flush with NS,
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What is becplermin
Platelet derived growth factor that promotes cell proliferation and angiogenesis *only agent approved for treatment of chronic diabetic foot ulcers; **BLACK box warning - malignancy
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What should you use to keep wounds moist depending on stage
Debridement stage: hydrogels
Granulation stage: foam and low adherence dressings
Epithelialization stage: hydrocolloid and low adherence dressing
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What are the topical antibacterial agents
- bacitracin: peptide abx; inhibits cell wall synthesis; active against gram +, neisseriae, tetanus, diptheria; often causes contact derm
- neomycin: aminoglycoside abx; binds to 30S; gram neg; contact derm
- polymyxin B: peptide abx; binds to phosphor-lipids to alter permeability; gram neg; rarely causes allergic reaction
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What are the topical antifungal imidazoles
Topical imidazoles: block ergosterol synth; miconazole (cream, vaginal cream), clotrimazole (cream, vaginal cream), efinaconazole (onychomycosis give for 48 weeks), ketoconazole (cream, shampoo)
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What is ciclopirox
Topical antifungal; activity against candida and malezzia
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What is terbinafine
Inhibits squalene epoxidase - neeed for syn of ergosterol; less active against yeast; cream can cause local irritation; avoid contact with mucous membranes
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What is tolnaftate
Antifungal; not effective against candida
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What is nystatin
Binds to fungal sterols and alters membrane permeability;; limited to topical treatments of cutaneous and mucosal candida
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What is amphotericin B
Binds fungal sterols; alters membrane perm; treatment of candida; may cause yellow staining of skin
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What are the oral antifungals for cutaneous infection.
Fluconazole, itraconazole: tinea versicolor
Terbinafine: onychomycosis
Griseofulvin:infections of scalp and non-hairy skin caused by epidermophyton, micro sprout and trichophyton; ineffective against candida and malassezia
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What can topical calcineurin inhibitors be used to treat
Anogenital pruritus
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What are the topical therapies for itching
Doxepin, menthol, capsaicin (neuropathic itch), salicylic acid, local anesthetics (lidocaine, pramoxine - face assoc with CKD)
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What kind of topical steroid potency should you use in diff areas
On face, genitals and skin folds use low potency; anywhere else start high potency then titrations down
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How does salicylic acid help with itching
Causes epidermal cells to shed more rapidly; need protection from sun
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What antidepressants are helpful in itching
- mirtazapine: nocturnal pruritis
- paroxetine
- fluvoxamine
- sertraline: cholestatic pruritis
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What mu opioid receptor antagonists are useful for itching
Naltrexone: cholestatic pruritis and CKD assoc
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What kappa opioid receptor agonists/mu antagonists are useful for itching
Butorphanol: nocturnal and intractable itching
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What anticonvulsants are used for itching
Gabapentin and pregabalin: neuropathic pruritis; can cause weight gain
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What substance P antagonist is used for itching
Aprepitant: used to control N/V of chemo but benefits in intractable pruritis
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What is used to get the red out of rosacea
- brimonidine: alpha 2 agonist topical; vasoconstriction by stimulating post synaptic receptors
- oxymetazoline: alpha1/2 agonist applied topically
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What is used for eye redness
Naphazoline, tetrahydrozoline, phenylephrine, oxymetazoline - all adrenergic agonists
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What drugs are used to kill ectoparasites
- malathion: topical; organophosphate cholinesterase inhibitor
- permethrin: topical; binds to insect Na channels and blocks repolarization
- ivermectin:oral; binds glutamate gated Cl channels and hyperpolarizes it
- lindane: topical;disrupts GABA transmission in insects but toxic so used last
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What is the treatment for mild acne
Topical retinoid
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What is the treatment for moderate acne
Oral abx + topical retinoid + BPO
If female, can try hormonal therapy + topical retinoid + topical abx
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What is the treatment for severe acne
Oral isotretinoin
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What is tretinoin
Topical retinoid; once daily at bedtime; can cause dryness; fish allergy
Similar: Adapalene, tazarotene (cant use in pregnancy)
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What are the topical antimicrobials
- benzoyl peroxide: can bleach hair or clothing
- clindamycin
- erythromycin
- dapsone
- sulfacetamide
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What is azaleic acid
Dicarboxylic acid; white powder found in plants; it kills acne bacteria and decreases production of keratin; used to treat mild to moderate acne and post inflammatory hyperpigmentation
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What oral abx can you give for acne
- tetracycline
- doxycycline
- minocycline - drug induced lupus
- erythromycin
- azithromycin
- TMP-SMX - Steve Johnson
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What kind of acne is spironolactone usd to treat
Adults women with menstrual cycle related breakouts; contraindicated in pregnancy
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What are the adverse effects of isotretinoin
Teratogenic, mucocutaneous effects, hypertriglyceridemia
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What is the initial choice for mild to moderate psoriasis
Emollients and corticosteroids
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What are the other topical therapies for psoriasis
Topical vit D (calcipotriene, calcitriol), tar, tazarotene, calcineurin inhibitors, anthralin, salt water bath
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What is a good initial choice for moderate to severe psoriasis
UVB; photochemo (PUVA) - patients typically ingest plant photosensitizer psoralen before; increases risk of melanoma
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What are the systemic therapies for psoriasis
Methotrexate, apremilast (PDE4 inhibitor), retinoids, systemic calcineurin inhibitors, biological (ustekinumab - IL12 and 23, secukimab and ixekuzumab - IL17)
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What are the effects of apremilast
Decreases NO synthase, TNF alpha and IL23; increase IL 10; oral; HA most common complaint
Crisaborole is topical
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How is ustekinumab given
SQ; increases risk of infections and SCC
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What is the treament for actinic keratoses
Liquid nitrogen cryotherapy, surgery, pharm (5FU, imiquimod, ingenol mebutate - derived from plants, diclofenac, retinoids), red light therapy, dermabrasion, chemical peels
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What does 5FU do
Inhibits thymidylate synthetase - causes destruction of lesion with blistering, necrosis, and then re-epithelialization
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What is used to treat advanced BCC
Vismodegib or sonidegib: oral hedgehog inhibitors
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What chemo is used for melanoma
Dacarbazine
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What MAPK inhibitors are used for melanoma
Used if BRAF mutation; vemurafenib
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What are treatments for male pattern baldness
- minoxidil: vasodilator due to K opening;increases growth phase and shortens rest phase
- finasteride: oral inhibitor of dihydrotestosterone production; can cause sex dysfunction; increases hair count
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What is the treatment for female pattern hair loss
Minoxidil is first line
| Anti-androgens second line: spironolactone, finasteride, flutamide
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What is the treatment for alopecia areata
Corticosteroid (topical), topical immunotherapy(diphenylcyclopropenone) - used to cause contact derm which increases hair growht
