Final Exam Flashcards

Question

Case Question: 78 year old female, 5' 6", 90 lbs, BP is 140/90, chief complaint is that husband explains that his wife moans and makes a strained facial expression when trying to eat, especially when she tries to chew her food. In addition, she has a severe drooling problem and sometimes chokes on the accumulated saliva. The patient was diagnosed with Alzheimer's disease at the age of 70, although the husband claims that his wife's memory had been deteriorating for the previous 5 years. According to the husband, the patient also started to struggle with mood problems approximately 3 years ago and was recently prescribed a mediation to deal with this problem as well as medication to control the drooling. He claims that while the medications seemed to help his wife's mood and reduce the drooling, they also appeared to cause her memory to deterioriate significantly. The patient has difficulty communicating with you and the spouse continually holds her hand to try and calm her down as she seems very anxious and not quite aware what is going on. Significant muscle atrophy and body wasting has occurred in the patient, likely due to poor nutrition. The husband is hoping that you can help his wife so that she can start to eat and feel better. Current medications: Sertraline, Benztropine, Ibuprofen, Vitamins The patient is diagnosed as edentulous except for teeth #3, 14, 19, 30 with significant maxillary and mandibular bone atrophy. All surviving teeth have severe periodontal involvement and are unstable. Examination of mucosal tissues reveals several areas of extreme inflammation on top and on both the buccal and lingual sides of the ridges with occasional ulceration present. The patient resists placement of her well-worn partial dentures when you ask her to put them into her mouth. **Which of the following would be the dental treatment for this patient most likely to have a satisfactory outcome if she were a healthy patient and 20-30 years younger?** **A. Treat all residual teeth with root canals and full crown restorations plus permament molar-to-molar bridges.** **B. Extract the remaining teeth. Attempt to build up the atrophied ridges using bone augmentation procedures followed by tooth implants to serve as abutments for new partials.** **C. Extract the remaining teeth and inform the patient and her spouse that due to the severe bone loss of the boney ridges there is not much that can be done and she will need to consume a liquid diet the rest of her life.** **D. Extract the teeth and make dentures even though it is obvious they will be poorly retained and not very functional, but at least they will help with cosmetics.**

Answer 1

B. Extract the remaining teeth. Attempt to build up the atrophied ridges using bone augmentation procedures followed by tooth implants to serve as abutments for new partials.

Answer 2

False * **Linaclotide** = **Used for irritable bowel syndrome (treats constipation**. b. Treatment: (1) Typically symptomatic (i.e., deal with diarrhea or constipation with diet and anti-stress changes) (2) Drugs: only linaclotide (Linzess) is FDA-approved for IBS with constipation • It is a **guanylate cyclase-C agonist**-it increases bowel movement, fluid secretion and reduces pain • Side effects: diarrhea, gas

Answer 3

True * **Imatinib =** Cancer treatment strategy. **Tyrosine hydroxylase inhibitor** used for multiple types of cancers such as myelogenous leukemia. * **Erlotinib =** Cancer treatment strategy. **Blocks ECGR (epidermal growth factor receptor**): treatment, n**on-small cell lung and pancreatic cancer.** * **Retinoic acid =** -induced differentiation of some leukemias (e.g., promyelocytic leukemia)

Answer 4

B. Fixed (stable) atherosclerotic stenosis of a coronary artery * Resistance to flow is inversely proportional to diameter^4 (i.e. inversely proportional to cross sectional area^2). Y**ou must have 75% stenosis (decreased cross sectional area) to clinically impede flow.** This increases resistance 16-fold. **Slow stenosis causes stable angina while abrupt stenosis or occlusion can cause infarcts/sudden death and is associated with a thrombus or embolus.** **A rupture/erosion causes a complicated lesion, and is the most common cause of most infarcts.** * **Main three types of angina:** 1. Stable angina 2. Variant angina 3. Unstable angina (most dangerous, prolonged pain) * **Stable** = Pain that feels like pressure for 2-5 minutes and associated with exertion. **Relieved by rest or vasodilators (nitroglycerine)**. It is subendocardial ischemia, and you get a ST-segment depression. Usulaly due to **fixed coronary stenosis.** * **Variant** = It classically occurs **at rest**. Brief, like stable angina. Reversible spasm, ST-segment elevation (instead of depression with stable angina). * **Unstable** = New or worsening angina, prolonged pain or pain at rest. You get an ST-segment depression, and often due to acute plaque change. **Most dangerous.** * **Abrupt stenosis** usually causes a thrombus in a coronary artery or pulmonary embolus * **Atherosclerosis Key Points =** * Exremely common cause of death. Due to endothelial damage, lipid deposits, inflammation, fibrosis/smooth muscle, and rupture or erosion causing thrombosis. **Thrombosis** (not stenosis) is the **main cause of infarcts.** Often happens in areas of only mild/moderate stenosis. **Stenosis (not thrombosis) is the main cause of predictable pain with exertion, like angina and claudication (leg pain).**

Answer 5

True ## Footnote Cholecystitis (bile is common mechanism for excretion of toxins and drugs) * Acute often caused by gallstones and obstruction. Can become chronic * Cholestasis causes jaundice

Answer 6

True * **Post infective endocarditis or rheumatic fever (strep sequelae)**. It is also common in congenital bicuspid valves or normal valves of elderly people. * **Main causes of aortic regurgitation**: Postinflammatory scarring, syphilitic aortitis, ankylosing spondylitis, rheumatoid arthritis, Marfan's syndrome * **These cause calcific aortic valve stenosis** * **Infective Endocarditis**: Usually takes place in Mitral valve and aortic valve - 25-35% of time Tricuspid valve, valve prosthesis, congenital defect - 10% of time. It consists of friable vegetations containing RBCs, fibrin, inflammatory cells and organisms. Caused by **Staph aureus, strep, pseudomonas, HACEK, polymicrobial**. Fever and murmur are common, and mortality is as high as **70% if staphylococcal.**

Answer 7

Hodgkin's Lymphoma * Hodgkin’s lymphoma much better controlled today * B-cell neoplasm (**Reed-Sternberg cell)** * **EBV virus found in ~80%** * Tx: **anthracycline, doxorubicin, bleomycin, vinblastine**

Answer 8

1. Increase stomach acid secretion 2. Decrease heart rate via the SA node 3. Decreases action potential duraction and contractility in the atria 4. Decrease conduction velocity in the heart 5. Decrease contractility in the ventricle 6. Contract GI smooth muscle (except sphincters (so poop comes gushing out)) 7. Increase secretions of secretory glands 1. Acetylcholine 2. Bethanechol 3. Pilocarpine

Answer 9

Caseous necrosis * Caseous -**See this in tuberculosis** -Due to the body trying to wall off and kill the bug with macrophages -Gross: White, soft, cheesy-looking (“caseous”) material -Micro: fragmented cells and debris surrounded by a collar of lymphocytes and macrophages **(granuloma)**

Answer 10

H * **Dopamine transporter and Norepinephrine transporter blocker. Similar to cocaine.**

Answer 11

True ## Footnote Invasive colonic adenocarcinoma * Responsible for 15% of all cancer related deaths in USA * Dietary features: increased risk with low fiber, high intake carbohydrates/fats Affects small bowel/colon

Answer 12

False * **Clonidine** = Is an alpha-2 agonist in the medulla that **reduces sympathetic tone, resulting in decreased blood pressure**. Remember that alpha-2 can be an autoreceptor. Dry mouth, sedation are common. Both effects are centrally mediated and dose-dependent.

Answer 13

D. Use of Sertraline * **Sertraline** has no dry mouth side effects, it is an SSRI. * Alzheimer's = anywhere from 3-4 million people have it at any given time -Once diagnosed, 10-20 years usually they live -It is broken down into three stages, and all of this relates to eliminating extra capacity of the brain -The brain determines what kind of capacity it will have later on when we are children and adolescents. Brain regions involved are frontal cortex, which is intelligence, judgement, and behavior, memory in the temporal lobe, and language right behind it in the parietal lobe. -**Early stage** is annoying stage, they have memory lapses and forget names, don’t like change -**Moderate stage** is when they have problems functioning, normal routine is disrupted -**Late stage** the motor system gets disrupted, they get less mobile, no judgment, immobile and stop eating.

Answer 14

True * Use AHA, acetohydydroxamic acid, or TMP-SMX

Answer 15

False * **Metabolic Disease of the Liver** * • Often associated with **iron** overloads * • Wilson’s disease: **copper** metabolic defect goes to hepatitis then cirrhosis

Answer 16

False * **Should be closed comodones and whiteheads**

Answer 17

Rosiglitazone * Used to **treat type II diabetes**, is a Thiazolidinedione. **reduces insulin resistance (especially muscle and fat cells) in type II DM by targeting PPAR-y receptor**. Also increased GLUT-4 expression. Side effect: **bone loss in women**, weight gain.

Answer 18

True * Somatic pain = Pain associated with musculo-skeletal system and skin - it is well defined. We will see mostly somatic pain in the dental office. * NSAIDS and Opioids help

Answer 19

B. Diminished activity of D2 receptors * **D2 receptor is more involved with the pleasure than D1**, and if you activate these too much, it could start to look like Schizophrenia (to treat Schizophrenia you use a D2 antagonist) * **After long time drug use**, The ability to experience rewards is damage, the receptors are not as receptive or plentiful because the body is trying to get rid of them because of the increased synapses that have been taking place bcause of the drug addiction. **If their D2 receptors are not receptive, they are not getting the same high from something that we might be getting high from**. * **Which tissue types and what effect does Dopamine have on D2 receptors?** It decreases neurotransmitter release in post-ganglionic sympathetic nerve terminals It causes nausea and vomiting in the chemoreceptor trigger zone CNS effect. * With Schizophrenia, Dopamine mechanism, **D2 receptor in excess**, and early anti-psychotics are **D2 antagonists** * Huntington's Disease = **Increase in dopamine and a decrease in GABA** because the cell bodies in GABA die. Patients have lost most of the cell bodies because the caudate has been lost, which sits right next to the ventricles on the outside. **The hunting gene seems to alter NMDA/AMPA receptors for Glutamate, and you end up killing these receptors from over-excitation of the glutamate system.** The hunting gene is found in the GABA neurons.

Answer 20

True * **Diltiazem** = This drug **(along with Verapamil and Nifedepine)** is a **direct vasodilator that reduces calcium influx, is a calcium channel blocker**. All the vasodilators that are useful in hypertension relax smooth muscle of arterioles, thereby decreasing systemic vascular resistance. Decreased arterial resistance and decreased mean arterial blood pressure elicit compensatory responses, mediated by baroreceptors and the sympathetic nervous system, and because these are still intact, vasodilator therapies generally do not cause orthostatic hypotension. This drug is also used to **treat angina** by prevent Ca influx through L-type channels and blocking contraction of smooth and cardiac muscles while reducing O2 demand. Can cause cardiac depression, bradycardia, flushing. This drug is also considered a **class IV anti-arrhythmia drug.**

Answer 21

B. History of poor compliance C. Poor prognosis for extended survival D. Need to avoid infection complications during cancer treatment

Answer 22

F * Is an SSRI. They are popular but can give GI upset, sexual dysfunction, and depression in adolescents. **They have no anti-cholinergic activity, so you don't get dry mouth.**

Answer 23

False * **Fatty liver disease (not an inflammatory disease)** * **Caused by ETOH, obesity, diabetes mellitus etc.**

Answer 24

True * **Sympathetic neurons release dopamine at dopamine receptors in renal vascular smooth muscle.**

Answer 25

Rheumatoid arthritis * a. **Autoimmune**- **1% prevalence** * b. Most common in **Caucasians/ uncommon in Asians** * c. Onset age: **25-50 yrs**.-75% female/ can have juvenile RA * d. Joint swelling, pain and tenderness—often cause extreme distortions of joints and surrounding bone—deforming and debilitating * e. Other areas also affected: * **• Ulcers** * **• Pulmonary nodules and fibrosis** * **• Carditis and pericarditis** * **• Vasculitis**

Answer 26

True * **Pyelonephritis =** Due to retrograde spread from cystitis or hematogenous spread, commonly seen with urinary obstruction, stenosis, can cause flank pain, fever, or asymptomatic, it is more severe in diabetics and with obstruction, can cause scarring.

Answer 27

False * **Binge Drinking** = NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. This usually occurs after 4 drinks for women and 5 drinks for men—in about 2 hours.

Answer 28

B. Endometrial polyps and endometrial carcinoma * **Polyps = hypertension, obesity, and late menopause** * **Endometrial Carcinoma** = **obesity, hypertension, diabetes** * **Characteristics of breast cysts =** * Fibrolytic changes * • Higher risk of breast cancer * • Occurs 20-40 years old * • **Doesn’t typically occur after menopause** * • **Can calcify** * • **Can look like cancer on mammogram** **Risk factors for cervical cancers =** Risk factors - * **multiple sex partners** * **-Immunosuppression** * **-early age of first sexual contact** * **-oral contraception for \>5 years** * **-nicotine use**

Answer 29

False * Main complications of MI's:Most to least common 1. Arrhythmias 75-95% 2. Congestive heart failure and pulmonary edema 60% 3. Pericarditis 4. Mural thrombosis 5. None 10-20% 6. Cardiogenic shock 7. Rupture of ventricle or papillary muscle 4-8% * **Symptoms of MI's =** Retrosternal chest pain, dyspnea, diaphoresis (sweating), nausea/vomiting, palpitations, anxiety, or can be asymptomatic or present as sudden death.

Answer 30

A. Dopamine beta hydroxylase insufficiency * Big side effect of Monoamine Oxidase inhibitors and Non-selective alpha antagonists. * **Dopamine Beta Hydroxylase** = For this to happen, it all starts with Tyrosine again, which is converted to Dopamine and Dopamine's same process takes place but once it enters the synaptic vesicle via VMAT, **Dopamine is then converted to NE by** **Dopamine Beta Hydroxylase.** * **Tryptophan** **Hydroxylase** = tryptophan enters the neuron, is then converted by **Tryptophan Hydroxylase** to 5-HTP, and 5-HTP is then converted by AAD to 5-HT **(Serotonin)** * **Phenoxybenzamine and Phentolamine**. Uses of **non-selective α antagonists (often cause orthostatic hypotension)** include treatment of **pheochromocytoma** (catecholamine secreting tumor) * **Propranolol is a Beta-1 and Beta-2 receptor antagonist (beta blocker)**

Answer 31

True * Used for GERD. Antacids-neutralize gastric HCl • * Types: magnesium salts (can cause diarrhea); * bicarbonate (causes gas); * calcium carbonate (chalky and constipation); * aluminum salts (not very effective)

Answer 32

True * **Main types of lung diseases** = * **1. Restrictive**: caused by **fibrosis** or chest wall abnormalities; gas exchange impaired; difficulty inhaling and expanding lungs * **2. Vascular**: gas exchange impaired by obstruction or hemorrhage; may be abrupt or insidious * **3. Obstruction**: blocked airways; gas exchange through septal walls not impaired; unable to exhale * **Fibrosing lung diseases** = **Associated with collagen vascular diseases such as rheumatoid arthritis**-**restrictive lung disease**: stiff lung and hard to expand lungs. Usual Interstitial Pneumonitis is UIP and is idiopathic pulmonary fibrosis and this type has the worst prognosis. RB-ILD and DIP is common in smokers, but good prognosis if they quit. * **Occupational lung diseases** = They are restrictive, and are mineral dust induced lung injury and **fibrosis** (**restrictive**), e.g., mineral dust-induced, silicosis [inhalation of crysalline silica by sandlblasters and miners], asbestosis [mesothelioma].

Answer 33

D. Hypersensitivity-related hives in response to antigens such as pollens and drugs mediated by IgE * **Allergic contact dermititis** is A * **Erythemia multiforme** is B. Erythema multiforma (hypersensitivity to infections and drugs-dermal edema-can have blisters and necrosis)-wide range of expressions and severity -can be severe life-threatening reaction known as **Stevens-Johnson Syndrome**—generalized all over the body—reaction to medicines (e.g., sulfonamides, salicylates)—can also be a reaction to infections such as herpes virus or fungal infections * **Eczematous dermatitis is****C** (e.g, contact dermatitis most common, delayed hypersensitivity reaction, can be pruritic, edematous or oozing plaques/vesicles),

Answer 34

True * Late complication of alkylating agents * Most frequent is **acute myelogenous leukemia**—observed as early as 2-4 years after; also see Non-Hodgkin’s lymphoma and bladder cancer * Treat with Imatinib

Answer 35

False **Breast Carcinoma Stats** = Rarely occurs * ~30% incidence by 70 yrs of age * No racial influence, but there is environmental influences * Inherited=5-10% (BRCA 1 and 2 the most common inherited genes) * ~250,000 new breast cancers in U.S./yr.

Answer 36

True * Main complications of MI's:Most to least common 1. Arrhythmias 75-95% 2. Congestive heart failure and pulmonary edema **60%** 3. Pericarditis 4. Mural thrombosis 5. None 10-20% 6. Cardiogenic shock 7. Rupture of ventricle or papillary muscle 4-8%

Answer 37

D. Alpha-synuclein lewy bodies * **Lewy bodies** = They are abnormal aggregates of protein that develop inside nerve cells in **Parkinson's disease (PD)**, Lewy body dementia, and some other disorders. The primary structural component of which is **alpha-synuclein**. These are associated with Genetics. * **Alzheimer's** = **Senile plaques (they are inside of the neuron),** associated with the **B-amyloid plaques -Neurofibrillary tangles,** associated with a **tau protein -Protein aggregates precipitate and cause inflammation and kills cells. Diminish capacity of brain, not able to do multiple tasks concurrently.**

Answer 38

Acarbose * Used to **treat type II diabetes**, is an **alpha-glucosidase inhibitor**. **Slows the digestion and absorption of starch, disaccharides**, etc. by inhibiting alpha-glucosidase in the brush border of the small intestines and pancreatic alpha-amylase. Side effects are bloating and flatulence.

Answer 39

D. Female, diagnosed at 30, neither parent has history of schiz, has positive symptoms Best prognosis = 1. Chronic equals poor 2. Residual = poor prognosis 3. Institutionalized a lot, that is indication of severity, not a good sign 4. Life expectancy is shortened = 10% suicide, not taking care of selves 5. **Best prognosis = temporary, cause-related, principally positive symptoms, If onset is later than 30 years, if person is female, and if there is no family history** * Types = * 1. **Disorganized type** - -Blunted affect, nothing to read about facial expressions -They are incoherent, don’t make sense -Not particularly dellusional -Bizarre mannerisms * 2. **Catatonic type** - -Nonresponsive, but aware of what is going on -Rigid/bizarre posture * 3. **Paranoid type** - -**Positive symptoms**, so they are ofen delusional, halllucinations -Aggressive and uncooperative -You would actually want this type if you were a doctor giving medications because of the positive symptoms, **most likely to respond** * 4. **Residual type** - -**Negative symptoms**, so no delusions, socially withdrawn -Flat affect -Later stages is when these all get worse -**This type is most difficult to treat**

Answer 40

A. Prostaglandin receptors * Four basic processes in nociception: **Transduction, transmission, modulation, and perception**. **Transduction** happens in primary afferent nociceptor, then **transmission** happens when action potential passes through dorsal root ganglia to actual spinal cord, where **modulation** takes place, crosses the midline, and goes up spinothalamic tract to the thalamus, and then into the cortex where pain **perception** takes place. * What are the four different subtypes of specific ion channels on free nerve endings that respond to actual or potential tissue damage? * **1. Mechanical 2. Chemical 3. Thermal 4. Polymodal** * **MODULATION** = Nociceptive input is heavily modulated at the dorsal horn both facilitatory and inhibitory influences * Central sensitization is when dorsal horn projection neurons become sensitized and hyper-responsive to nociceptive input, which contributes to hyperalgesia, and to touch input, which contributes to allodynia. **Prostaglandins released from neurons** and/or glia in the dorsal horn in response to neural input and inflammatory mediators are probably involved in central sensitization as well. And NSAIDS can inhibit the synthesis of prostaglandins in the dorsal horn that participate in central sensitization, this is considered a second mechanism for the anti-nociceptive action of NSAIDS.

Answer 41

True ## Footnote No structural defect –not sure of the exact cause * Typically episodic pain and bloating * Could be 5HT-dependent neuromuscular disorder * 20% of population have suffered (most common GI disorder) * Most common in young adults and ~50 Years old—possible association with stress and poor diet

Answer 42

C. Infections of the periodontal tissues may be a particular problem with this patient D. With proper treatment, the HbA1c value can be returned to a normal range. * **What does HbA1c measure?** When the body processes sugar, glucose in the bloodstream naturally attaches to haemoglobin. The amount of glucose that combines with this protein is directly proportional to the total amount of sugar that is in your system at that time. Because red blood cells in the human body survive for 8-12 weeks before renewal, measuring glycated haemoglobin (or HbA1c) can be used to reflect average blood glucose levels over that duration, providing a useful longer-term gauge of blood glucose control. If your blood sugar levels have been high in recent weeks, your HbA1c will also be greater. * **Pre-Diabetes state** = 14%, 41 million in US. • 75 gm glucose tolerance test: glucose \>200 mg/dL after 2 hours • **HbA1c\>6.5%** (this determines the extent to which your hemoglobin is glucosylated-it provides a good estimate of the average level of glucose for the previous 3 months: * **Type I diabetes** symptoms **=** Polydipsia, polyphagia (hunger and thirst) • Polyuria (lots of diluted urine) • Unexplained weight loss 1. Type 1 (insulin-requiring) a. features: young (3-20 yrs old), loss of islet beta cells, 5% of cases, typically thin • no natural insulin • loss of beta cells an autoimmune process-probably triggered by environment such as a viral infection • ketoacidosis (Use of fatty acids in metabolism results in formation of ketone bodies (acetone)) (ketone bodies such as acetone)-dehydration; deep labored breathing (caused by acidosis); nausea, coma * **Type II diabetes** = 2. Type II DM, “adult onset”, Non-insulin dependent DM a. Features • 95% diabetics are type II • Insulin levels often normal, problem is resistance of insulin receptors to insulin stimulation • Correlates with excessive visceral fat (80-90% are obese): restricted diet controls ~20% of diabetic expression • Correlates with hypertension and risk for atherosclerosis • Metabolic syndrome (see below for details) • Some genetics-likely polygenic autosomal • Most over 30 yrs old, but increasing numbers of younger Type I DM patients due to obesity • Minimal ketones or acidosis, but very high glucose --Hyperosmolar coma—enough insulin to prevent lipolysis, but still have elevated glucose * **Type III diabetes** = Pancreatitis * **Type IV diabetes =** Gestational * **Oral problems associated with diabetes** = 1. Increased gingivitis and periodontitis and abscesses 2. Poor wound healing (issue with oral surgery or implants) 3. Abnormal infections such as thrush/candida 4. Xerostomia (increased caries) 5. Hypoglycemic event if patients don’t eat before experiencing the stress of a dental procedure * **Addison's Disease** = Chronic adrenocortical insufficiency. Addison's Disease. • Cause: autoimmune • More common in white women • 65% of adrenal insufficiency cases • Adrenals reduced • Increased infection ACTH is increased Caused by infections such as TB

Answer 43

Kaposi's Sarcoma * HHV 8 herpes virus- Kaposi sarcoma (often linked with AIDS)

Answer 44

D. Beta-Blocker and radioactive iodine * **Methimazole =** Is a thioamide that is used to treat hyperthyroidism. It inhibits thyroid peroxidase reactions, blocks iodine organification. * **Also** = **Beta Blockers like Propranolol can inhibit T4 to T3 conversion**, and help treat hyperthyroidism, and **Radioactive iodine can destroy some of the gland to help out**. A simple iodide can be given as well to inhibit organification and hormone release. * **Levothyroxine =** **Simulates T4 and is used to treat hypothyroidism**. The T4 products are prescribed more frequently and have fewer side effects because less potent. * **Liothyronine** = Simulates T3 and is used to treat hypothyroidism.

Answer 45

True * a. HBV infection most significant occupational dental hazard (vectors: blood, saliva, nasopharyngeal secretions) * b. In mouth, **highest concentration is gingival sulcus** * c. Manifestations (infections and bleeding based): • **Lichen planus • Periodontal disease • Candidiasis • Increased oral bleeding • Increased incidence of type II diabetes • Sjogrens syndrome** * Accidental exposure: * • Carefully wash wound-don’t rub (embeds viruses) * • Use antiviral disinfectant (e.g., iodine or chlorine formulations) * • Initiate HBV vaccine series * • Don’t be judgmental

Answer 46

A. Diarrhea * **Main side effects**: * 1. Respiratory depression/**decreased pulmonary reflex** * 2. **Constipation**/slow bowel movement * 3. Sedation/a**dditive or synergistic** with other CNS depressants (e.g., alcohol, antianxiety, sleep aids and natural sleep * 4. **Euphoria**/dependence, addiciton * -Mostly Mu opioid receptor mediated

Answer 47

Lispro * Is a rapid-acting insulin, mimics after meal insulin, rapid onset, early peak action, can be taken right before a meal, duration is about 4 hours so it prevents post-meal hypoglycemia.

Answer 48

F * Fluoxetine and Sertraline are the two main SSRI's

Answer 49

Dysplasia. * It is an ambiguous term used in pathology to refer to an abnormality of development or an epithelial anomaly of growth and differentiation. It is **disordered hyperplasia without maturation**. * What type of cell change is the **uterine cervix, bowel in IBS, esophagus with Barrett's** = **Dysplasia**

Answer 50

K * **Benzodiazepenes** = They are agonists on BDZ receptors (allosteric modulators of GABA A receptors). BDZ doesn’t directly activate the GABA receptor, isn’t an agonist, but it indirectly regulates the sensitivity of the receptor so making it more or less receptive to GABA. These have little effect on respiration, most popular CNS depressants, anxiolytic, helps with alcohol withdrawal, treats insomnia (is short-acting, so they don't sleep the whole day). Tolerance is common with long-term use, interacts synergistically with other depressants, drowsiness, motor impairment, kids can have paradoxical reaction, don't use with people with intellectual disability to avoid suicide. * Two sedative benzodiazepene drugs = **1. Diazepam 2. Alprazolam -Sedative are longer-lasting (8-12 hours), while hypnotic are shorter lasting (2-4 hours).** * **Buproprion** is not a sedative.

Answer 51

B. Denosumab * **Alendronate** = Is a bisphosphonate taken daily that inhibits osteoclasts, thereby slowing bone loss. Used in the prevention and treatment of osteoporosis, Paget's disease, bone metastasis (with or without hypercalcemia), multiple myeloma, primary hyperparathyroidism, osteogenesis imperfecta, fibrous dysplasia, and other conditions that feature bone fragility. Be careful of osteonecrosis of the jaw though after IV administration of bisphosphonates. * **Denosumab** = Is a monoclonal anti-RANKL antibody treatment of excess bone resorption in osteoporosis and some cancers. it prevents RANKL from stimulating osteoclast differentiation and activity.

Answer 52

A. Increased gastric acid secretion * Muscarinic receptors: * Ach Agonists: **Bethanechol (**Specifically, is a cholinesterase inhibitor) and Pilocarpine * Antagonists: Atropine and Scopalamine * So Bethanechol **decreases heart rate, contracts GI smooth muscles (except sphincters), decreases the heart working, increases bodily secretions, muscarinics also work for sympathetic sweat glands**. * **Urinary retention = Phenylephrine, and non-selective, alpha agonists** * **Alpha-1 contracts sphincters** * **Beta-2 relaxes bladder wall**

Answer 53

True Usually **immunosuppressed** (often Herpes, Candida, and cytomegalovirus [CMV]) * Often ulcers * CMV: * Affects entire GI tract * Neonates acquire thru birth canal or infected breast milk * Adults acquire through sexual transmission or needles * Multiple discrete, well-circumscribed superficial ulcers.

Answer 54

Hyperplasia * It is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It is distinguished from **hyperplasia**, in which the cells remain approximately the same size but increase in number. You are born with about all of the cardiac myocytes that you will get, but they can get bigger, this is hypertrophy.

Answer 55

True * **Asthma** = It is a reactive airway disease and narrowing of airways-hyperreactivity: **hyperinflated lungs, thick mucus plugs in airways, smooth muscle hypertrophy** • Types: • **Atopic**- childhood onset often with allergic rhinitis, **type I hypersensitiviy response**. • **Non-atopic**- **non-immune, occupational exposures, like aspirin or viral infections.**

Answer 56

Lung cancer * Lung cancer, followed by prostate **(elevated PSA and acid phosphatase)** in men and breast in females.

Answer 57

True * It exhibits passive diffusion, gets everywhere, food slows its absorption, it is distributed everywhere, **even through placental barrier and breast milk**. it exhibits **zero order kinetics, meaning constant rate, and independent of original concentration.**

Answer 58

Hypertrophy * **It is the increase in the volume of an organ or tissue due to the enlargement of its component cells**. It is distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number. **You are born with about all of the cardiac myocytes that you will get, but they can get bigger, this is hypertrophy.**

Answer 59

Dyskeratosis

Answer 60

C. Anterior pituitary adenoma * **four common kinds of pituitary adenoma** = . **Prolactinoma** (**32%**, galactorrhea, mass effects) 2. **Growth Hormone** (20%, acromegaly, gigantism) 3. **Null cell / unclassified** (30%, mass effects, can make clinically trivial amounts of FSH/LH) 4. **Corticotroph** (14%, Cushing disease) * **Most common cause of hypopituitarism** = Most common cause are nonsecretory pituitary adenomas * **Anterior pituitary insufficiencies** = • Loss of sex characteristics-sterility • Retard growth in children • Hypothyroidism * **Posterior pituitary insufficiencies = Diabetes insipidus** –no glucose or insulin involved • Polydipsia (thirst) • Inappropriate ADH secretion from pituitary • Consequences : alters kidney function-volume (water) expansion, hyponatremia (low blood sodium levels) and hemodilution • Causes: metastasized carcinoma, CNS infection But problems can correct with administration of ADH. * **Anterior Pituitary** = 1. TRH - TSH - Thyroid, T4 2. CRH - ACTH - Adrenal Cortex, Cortisol 3. GNRH - FSH, LH - Reproductive tissues 4. GHRH - GH - Liver, IGF-1 5. GIH 6. Dopamine And Prolactin is released from the anterior pituitary and is for lactation. * **Posterior pituitary =** The posterior pituitary receives axons of nerves from hypothalamus, where ADH and oxytocin are produced. ADH (for water retention) & oxytocin (for nursing) are stored and released from neurohypophysis into systemic circulation, avoiding blood-brain barrier. * **Cushing's Disease** = **Leading cause of hypercortisolism**: **women 5X more likely** • Adrenal hyperplasia • **ACTH low, cortisol high** • Adrenals act autonomously • Symptoms: **moon face, osteoporosis**, hypertension, buffalo hump, obesity, **thin skin, amenorrhea**, muscle weakness, mood changes, poor wound healing (remember: **this looks like someone on chronic corticosteroid treatment**-e.g., for chronic major arthritis or other inflammatory diseases)

Answer 61

D. Simple partial * A **complex partial** is localized onset, spreads bilaterally usually, either awareness, memory, or consciousness is lost during seizures, and they usually last 15 sec to 3 minutes. * An **absence seizure** probably represents abnormal interactions between cortical and thalamic transmissions. 2-15 seconds. * What is the main difference between tonic-clonic actions happening with secondary generalized seizures and generalized tonic-clonic seizures? And how long does tonic-clonic usually last? **The two are synchronized with generalized tonic-glonic seizures. Lasts 1-2 minutes.** Tonic clonic also have postictal phase after, confusion. **Tonic is stiff, clonic is jerking.**

Answer 62

True * What percentage of patients with a history of myocardial infarctions have arrhythmias? **80% because of all the scar tissue** * Usual cause of sudden death? **Arrhythmias, most often from coronary atherosclerosis, although infarct is not needed**.

Answer 63

1. Increase heart rate via SA node 2. Increase conduction velocity and contractility of atria 3. Increase automaticity and conduction velocity of AV node 4. Increase automaticity and conduction velocity of His-Purkinje System 5. Increase automaticity, conduction velocity, and contractility of ventricles 1. Isoproterenol 2. Dobutamine 1. Propranolol 2. Atenolol 3. Metoprolol

Answer 64

A. Nopaine improved the gastric mucosal protection against acid reflux * Should have caused GI problems * COX-1 usually does GI protection, platelet aggregation, renal activities, **vasoconstriction**. * COX-2 usually does Cardiovascular protection, renal activities, pain, fever, inflammation, **vasodilation**. The pain, fever, and inflammation are the inducible activities of COX-2, while the others are constitutive.

Answer 65

Warfarin * **Vitamin K is reversal agent for the extrinsic pathway** * Warfarin Works everywhere you have **vitamin K - 2, 7, 9, and 10** * **Dabigatran** = Is an alternative drug for warfarin, has fewer side effects and is more popular than heparin or warfarin, it affects PTT sensitive pathway, but has unique mechanisms that makes it distinct from heparin and warfarin, used on out patient basis.

Answer 66

True * The Plexus of Raschkow, or Sub-Odontoblastic Plexus. It consists of **sensory afferents of the trigeminal nerve** and **sympathetic branches from the superior cervical ganglion.**

Answer 67

C. Haloperidol * **Parkinson's** = you have low dopamine so you want to increase it, and you want to decrease ACh, and **Haloperidol** has no anti-cholinergic effects. * Six main drugs used to treat Parkinson's disease: * 1. **L-dopa + Carbidopa** (L-dopa gets across blood-brain barrier much better than dopamine, and **Carbidopa blocks the metabolism of L-dopa** and dopamine so it can last longer.) * 2. **Benztropine** * 3. **Trihexyphenidyl** * 4. **Selegiline** (This is an MAO inhibitor, blocking monoamine oxidase B from metabolizing dopamine in the brain, so prolonging the effects of levodopa) * 5. **Entacapone** * 6. **Pramipexole** (This is a **dopamine agonist, a D2 agonist**, which bypasses the depleted neurons int he substantia nigra and provides long-lasting direct stimulation of dopamine receptors) * **Selegiline =** MAOI so it increases dopamine * **Haloperidol** is a butyrophenone that is used to treat Psychotic disorders. **High extrapyramidal side effects, lacks anticholinergic action.**

Answer 68

True * **Atrial Fibrillation** * It is the most common sustained arrhythmia in adult clinical cardiology. Atrial flutter is different and involves very rapid atrial contractions, and can turn into atrial fibrillation. AF increases with age and often co-exists with other cardiovascular diseases like congestive heart failure, valvular heart disease, and hypertension. 10% of Americans older than 65 years old have AF. It is associated with electrical and structural changes of the atrium. You get electrical remodeling, meaning shorter atrial action potentials, loss of rate of adaptation to action potential duration, and loss of myocytes and replacement with collagen and fibroblasts. AF causes inefficient atrial contraction, which causes decrease in cardiac output, due to loss of atrial contribution to ventricular filling, and i**s also involved with a high risk of thrombosis and embolization.**

Answer 69

A. He is legally compromised * **0.08 is legal limit** * **.05-.1 = slower reflexes, sedation, lower reaction time** * **.1-.2 = impaired motor function, slurred speech** * **.2-.3 = Stupor, throw up** * **.3-.4 = coma** * **\>.4 = Respirtaory depression, death**

Answer 70

D. Increases bone adsorption * **Diethylstilbesterol = It is a non-steroidal synthetic estrogen that decreases bone adsorption** * **Ethinyl estradiol is the steroidal synthetic estrogen** * **Estrogen functions:** 1. Sexual maturity 2. Increased CNS excitability (seizure inducing?) 3. Increased endometrial and uterine growth 4. Maintain skin elasticity 5. Reduce bone adsorption 6. Increase blood coagulability **What are the natural estrogens at different ages?** 1. **_Estrone_ (predominant during menopause)- E1** 2. **_Estradiol_ (predominant during productive years)—E2** 3. **_Estratriol_ (predominant during pregnancy)—E3** * **Clinical uses for estrogens =** * Primary hypogonadism * • Postmenopausal * (1) Guidelines for use * • Always use the smallest dose for the shortest period of time possible * • Sometimes local creams are preferred to minimize exposure

Answer 71

* Heb B virus, 2 billion chronically exposed in world, 350 infected. 15-25% of infected will go into chronic phase and most will die from complications. Can lead to cancer of liver (hepatocarcinoma) * -important to get vaccinated. * Caused by **DNA virus** * Cirrhosis (chronic phase)= portal hypertension; **causes ascites 85% of time in chronic phase with cirrhosis**

Answer 72

C. Sleep The nine main seizure precipitants are: 1. **Metabolic and/or Electrolyte Imbalance (People’s blood glucose too high or too low, too low sodium, calcium, magnesium, potassium too high)** 2. **• Stimulant or other pro-convulsant intoxication** 3. **• Sedative or ethanol withdrawal** 4. **• Sleep deprivation** 5. **• Reduction or inadequate ASD treatment** 6. **• Hormonal variations** 7. **• Stress** 8. **• Fever or systemic infection (HSV can be linked)** 9. **• Concussion and/or closed head injury**

Answer 73

B. Calcium oxalate * **Four main types** = * 1. Calcium oxalate (75%) **Use hydrochlorthiazide** * 2. Magnesium ammonium phosphate (struvite, triple phosphate, 15% stones, alkaline urine), **correlated with UTI's,** **Use AHA, acetohydydroxamic acid, or TMP-SXS** * 3. Uric acid stones (5%), half are gout associated **Use Allopurinol** * 4. Cystine stones (5%), defective tubular transport of cystine **Use Penicillamine or sodium bicarb for this and uric acid** * a. Calcium/oxylate: excess calcium and oxalate in urine (~80% of stones) -**men more likely than women Alkalinize urine** (stop drinking carbonated soft drinks) b. Struvite (~10% of stones)-magnesium ammonium phosphate crystals-**often associated with urinary infections- only type where treatment is to acidify urine**. -**more common in females** (the only type) * c. Uric acid- excess waste, uric acid, in urine mineralizes into stones when urine is too acidic-often associated with gout -more common in men, **must decrease uric acid production and alkanize urine pH** d. Cysteine - excess cystine production causes hypercystinuria and deposition when urine is too acidic. Must dissolve cystine, thus **alkanize urine** and increase water consumption to flush kidneys.

Answer 74

True * What can an ectopic focus that is firing rapidly or multiple ectopic foci collectively causing a fast rhythym end up causing? **Tachycardia and Tachy-arrhythmias**

Answer 75

Osteogenesis imperfecta * 1. Osteogenesis imperfecta a. Deficient or defective type 1 collagen—too little bone b. Generalized osteopenia * Multiple fractures and bone deformities * Malformed teeth (dentin deficiency)

Answer 76

True * **Vincristine and Vinblastine =** Is a natural product cancer, chemotherapy drug. * 2. **Inhibits tubulin polymerization-cytoskeleton component—arrests in cell division and causes cell death** * 3. Toxicity: mucositis, myelosuppression * 4. Treat: **breast cancer and Kaposi’s lymphoma**

Answer 77

D + G * **Chlorpromazine** = Phenothiazine, **anti-psychotic drug**. Least expensive, older, more sedation and weight gain, less extrapyramidal side effects, antiemetic action. **Anticholinergics** mask the effects of tardive dyskinesias but the damage is still being done. **Anticholinergics are also used to treat Parkinson’s Disease. Remember that Parkinson's need anti-cholinergics (heavy drooling)** * **Clozapine** = **Atypical anti-psychotic drug**. Can cause serious agranulocytosis. Besides D2 antagonism, these typically are also good 5HT2A antagonists. Little extrapyramidal side effects. **Most effective against the 􏰂negative􏰄 symptoms** in some forms of schizophrenia.

Answer 78

False ## Footnote **92%, Stage IV = 14%**

Answer 79

True * Both **para and sympathetic** use Nicotinic receptors at the **pre-ganglionic stop** as well, and **Para uses muscarinic at the post-ganglionic while sympathetic uses alpha/beta, some dopamine, and even muscarinic for sweat glands.**

Answer 80

Protamine * **Intrinsic pathway, PTT and Heparin**

Answer 81

False * **Essential (primary) Hypertension: No obvious cause, very common, nearly 50 million in US, 95% of all hypertensive patients**. Possible causes include increased sodium retention; intravascular volume, narrowing of arteries, high TPR lowers blood pressure in kidneys, kidneys sense lower pressure and signal to retain sodium to increase BP, vicious cycle. * Risk factors: Risk factors for essential hypertension: Increasing age. Black. Family history of hypertension. Obesity and metabolic syndrome. High salt diet. Lack of physical activity.

Answer 82

Muscle Relaxants-**enhance levels of inhibition, usually via CNS (GABA-mediated)** 1. Antispasmotics (muscle relaxants)-reduce muscle stretch reflex * Diazepam * Baclofen **(GABA B agonist)** * Dantrolene **(alters Ca++ trafficking)** * Carisoprodol (Soma)- **muscle relaxant/sedative**; may have some dependence problems 2. Non-deplolarizing neuromuscular blocking * **D-tubocurarine**—blocks ganglionic nicotinic receptor * **Acetylcholinerase inhibitor blocks by overwhelming the blockade with increased ACh** 3. Depolarizing neuromuscular blocking * **Succinylcholine**—block ganglionic nicotinic receptors by **desensitizing (overstimulating?)** * fast acting, get initial twitching before paralysis * **acetylcholinesterase inhibitor does not reverse.**

Answer 83

False **Hirschsprung disease** * Congenital defect in **colonic innervation** * Failure to pass meconium The small bowel, colon.

Answer 84

True * **Renal Cell Carcinoma = 80-90% of all renal maligancies** * Most common in Male, \>40, smoker, analgesic users, obesity * Often clinically silent until large, painless hematuria, dull flank pain, fever, fatigue. Most likely metastasized to lungs or bones. * **Two types** = 1. **Papillary** (If you see a bunch of macrophages, think papillary RCC) 2. **Clear cell** (abundant glycogen or lipid), and you see a lot of vascular background with RBC's in clear cell RCC.

Answer 85

False * The ones that treat **Meniere's disease are H1 blockers.** * **Meclizine, Promethazine,** * **Cimetidine and Ranitidine** are Used for GERD. H2 receptor blockers-not effective at the H1 receptors (i.e., not good antihistamines)-reduce gastric secretions by blocking H2 receptors in gut. * Side effects: headaches, diarrhea, drowsiness.

Answer 86

True * **Addison's Disease** = Addison’s—adrenal glands produce too little cortisol (chronic)—often insufficient aldosterone as well • Symptoms • Weakness • Fatigue • **Weight loss** • **Hyperpigmentation** • Treatment—corticol supplements: cortisones (hydro-) or prednisone

Answer 87

False * **I think it is diabetes, obstruction, spread from cystitis**

Answer 88

True * Opioids do somatic and visceral, are antitussive, and antidiarrheal

Answer 89

True * A pathophysiological process resulting from abnormal sensory processing, which does not signal actual or potential tissue damage, does not promote healing or repair, and may be considered a disease. Fibromyalgia is an example of neuropathic pain. * **Five examples of neuropathic pain:** 1. ****Phantom Limb 2. Shingles 3. Fibromyalgia (9 common points of pain) 4. Diabetes Neuropathies 5. Trigeminal Neuralgia (tic douloureux)

Answer 90

A. Remova all teeth, let heal for 1-2 weeks before cancer treatment

Answer 91

* Intestinal malabsorption of vitamin D or calcium • Chronic reduction of serum of Ca++ usually a consequence of chronic renal failure Stimulates PTH secretion, causes hyperplasia

Answer 92

D. Effects are blocked by tamoxifen * **Tamoxifen blocks just estrogen,** **Estrogen receptor antagonist. Blocks actions of estrogen in breast-used to treat breast cancers.** * **Effects of progestins =** * Increase fat deposition * Decrease CNS excitability (e.g., antiseizure—**opposite of estrogen**) * Increase aldosterone---increase Na+ retention—increase BP—increase water retention and blood volume * Increase body temperature * **Clinical uses of progestins** = * Replacement therapy * • Oral contraception * • **Long-term ovarian suppression** (e.g., dysmenorrhea or endometriosis)—in contrast to estrogens, no problem with bleeding or clotting * • **Contraindications:** * • Breast cancer is a risk * • Severe hypertension or heart disease is risk

Answer 93

False * **It is TMP-SMX**

Answer 94

A. The most likely status of the two sensitive teeth (2 and 3) is that there is pulap caries involvement and they are no longer viable D. Based on the presentation of this patient he most likely is being prescribed a promethazine-like drug * **Dexamethasone =** **Given as a shot in the ear for otitis media, Treats Meniere disease**. Long-acting steroid/inject into the ear—it reduces fluid. * **Not amoxicillin because not otitis media,** Antibiotics used to treat acute otitis media. Second level drugs include Trimethoprim or macrolides.

Answer 95

B. She is using clomiphene * **Clomiphene =** Clomifene or clomiphene is a selective estrogen receptor modulator that has become the most widely prescribed drug for ovulation induction to reverse anovulation or oligoovulation. Ovulation-inducing; for promoting fertilization and pregnancy (increased risk of multiple births—e.g., twins). Clomed. * **Danazol =** Danazol is a derivative of the synthetic steroid ethisterone that suppresses the production of gonadotrophins and has some weak androgenic effects. Suppresses ovarian function (has a masculinizing effect). Treats **endometriosis**, fibrocystic breast disease, and hereditary angioedema. * **Progestin only—referred to as the “minipill” (no estrogen); fewer side effects, but less effective**

Answer 96

Necrosis * Reversible and Irreversible (cell death), **with inflammation**. An example of reversible is mild acute tubular necrosis of kidney, toxic livery injury, severe exercise. An example of irreversible is holes in cell membrane, long Ca++ influx, mitochondrial loss, and the two types of irreversible are necrosis and apoptosis.

Answer 97

True **Hepatitis C** * Source: blood body fluids * Route of Transmission: Percutaneous, permucosal * Chronic Infection: Yes * Prevention: blood screening, risk behavior modification 6. **Hep C virus found in \>170 million carriers worldwide** • Acute phase usually asymptomatic and not diagnosed • Chronic phase, Ab present at 5-20 weeks • **60% related to parenteral exposure** • **Caused by RNA virus** • Can lead to hepatocarcinoma • **No vaccines, but there is a very expensive cure**

Answer 98

Acanthosis

Answer 99

D. Asprin A. Lyrica D. Prescribe celecoxib (celebrex) * **Aspirin** and other Cox-1 inhibitors can cause ulcers, stomach problems, and aspirin is a blood thinner. **Salicylates** are a COX-1 and COX-2 inhibitor. Analgesia is 600 mg Anti-inflammation is 1 gm Antipyretic is 300-600 mg Duration is 4h -Causes GI irriation, anti-clotting (-You are permanently damaging the platelet when you take these, and you have to regrow platelets, and this anti-clotting can happen with less than 100 mg of salicylates. Don’t prescribe salicylates when you are doing surgery on patients. -When the acetyl group breaks off, this turns into an acid. It has direct and indirect effects on this.), ringing in ears, and Reyes Syndrome in children (With Reyes- You can have permanent damage done to the brain, that is why aspirin-containing products are forbidden in children) * **Lyrica and Gabapentin** are two drugs used to treat neuropathic pain. Both are **anti-convulsant**. * **Duloxetine, Nortryptiline are also used for neuropathic pain. And Tramadol is a next-in-line treatment for it.** * Prescribe Celebrex because it is a selective Cox-2 inhibitor and doesn't have GI side effects. Celebrex. Cox-2 selective antagonist. • Prescription only • Same analgesia as ibuprofen • Lacks GI and anti-clotting action • Warning about **cardiovascular side effects**

Answer 100

B. Do careful plaque removal and root planing to reduce the discomfort on the right mandibular quadrant and help relieve the periodontal problems * Lyrica and Gabapentin are two drugs used to treat neuropathic pain. Both are anti-convulsant.

Answer 101

False * Used to treat peptic ulcer disease. * Cure if H pylori-related –H pyloria is contagious especially within family members * • Prevpac; combination of lansoprazole (a PPI) and the antibiotics amoxicillin and clarithromycin

Answer 102

True * When does urinary obstruction cause severe, irreversible renal damage if it is a complete obstruction? Partial? * **3 weeks, 3 months** * Get **dilated ureter and hydronephrosis (unable to concentrate urine)** * If distal to bladder can get dilated bladder with a thickening of the bladder wall * **What are the main renal diseases?** = * 1. Single or fused kidney * —**horse shoe kidney** (congenital) * 2. Renal dysplasia * **Multiple cysts, cartilage**, etc * Urinary tract dysfunction * 3. Adult polycystic kidneys –genetic * Renal insufficiency * Linked to **intracranial aneurysm** * Other organs also have cysts * Enlarged kidneys

Answer 103

C. Cyclothymia * **Cyclothymia** = Cycles of dysthymia to minor state of mania-minor bipolar-longer than two years-no gender bias -No drugs for these usually, some of our most brilliant people like Einstein entered this manic part of cyclothymia and was productive. Minor bipolar, not treated with meds. * **Autism** = 1. Problem with social interactions 2. Verbal or non-verbal communication problems 3. Problems with repetivie behavior. Causes = **Genetics and environment.** It tends to associate with certain medical conditions, like **Fragile X syndrome, congenital rubella syndrome, PKU**. **They are also more vulnerable to toxins because they can't metabolize them as well.**

Answer 104

True * • Opened comodones (blackheads) * • Closed comodones (white heads) * • Cysts, pustules and abscesses -vulgaris: * • Hormone changes (i.e., sex hormones)-increases testosterone influence * • Blocks hair follicle and sebaceous gland * • Hair follicle have proliferation of lining cells and cellular sloughing—forms a cellular plug and **traps bacteria, cellular debris and sebum** * • Gland ruptures and contents spreads to form cysts, abscesses and scarring—area is inflamed and swollen • Treatments: -antibiotics -keratolytics -drying agents -vitamin A (topical and systemic-Accutane)

Answer 105

* **Meniere disease** * Symptoms: vertigo, hearing loss, nausea, sometimes migraine headaches, hearing loss, swimming feeling, tinnitus, balance problems * Pathology: * **endolymphatic hydrops—swelling/excess fluid in labyrinth** * Risks- * Improper inner ear fluid drainage * Allergies * Viral infections * Head trauma * Migraines * Diagnostic tests: * Hearing and balance assessments * Some surgical interventions, but extreme * Pharmacology: * **Meclizine** (Antivert): **H1 blocker**, anticholinergic, CNS depressant-antimotion sickness medication, xerostomia * **Diazepam** * **Promethazine**: **H1 blocker**, anticholinergic, antinausea and motion sickness, xerostomia * **Hydrochlorothiazide**: diuretic-regulate fluid volume and pressure in inner ear * **Dexamethasone**; **long-acting steroid/inject into the ear—it reduces fluid.**

Answer 106

False * **Hep A** * Source: Feces * Route of Transmission: Fecal/oral * Chronic Infection: No * Prevention: pre/post exposure, immunization * **Hep E** * Source: feces * Route of Transmission: fecal/oral * Chronic Infection: oral * Prevention: ensure safe drinking water

Answer 107

Atrophy * **Cell shrinkage or loss**, caused by lack of hormonal signals, loss of innervation, lack of use, loss of blood supply, starvation, individual cell death

Answer 108

A. Enhanced GABA receptor activity * Ca2+/Mg2+ can kill neurons and result in degenerative disorders * **Main Causes =** **1. Hypoxia 2. Excitatory Amino Acids 3. Ion Fluxes 4. Free Radicals 5. Immune Responses 6. Infections 7. Apoptosis 8. Protein Aggregation** * **Huntington's disease** = Increase in dopamine and a **decrease in GABA** because the cell bodies in GABA die. Patients have lost most of the cell bodies because the caudate has been lost, which sits right next to the ventricles on the outside. The hunting gene seems to alter **NMDA/AMPA receptors** for Glutamate, and you end up killing these receptors from over-excitation of the glutamate system. The hunting gene is found in the GABA neurons. * **Parkinson's** is abnormal protein aggregation

Answer 109

False * b. Struvite (~10% of stones)-magnesium ammonium phosphate crystals-often associated with urinary infections- only type where treatment is to acidify urine. -more common in females (the only type) * Use AHA, acetohydydroxamic acid, or TMP-SXS

Answer 110

D. Lovastatin * Triglicerides: 200 high * Total Cholesterol = \>200 mg/dL desirable 200-239 mg/dL borderline high \>240 mg/dL high * Primary Hypercholesterolemia = Also called familial, and it is an autosomal dominant gene. LDL ranges from 260-500 mg/dl, but triglycerides are usually normal. Coronary disease is often premature, and you have defects in LDL receptors. * **Fenobrate** = This drug, used to treat hypercholesterolemia, is a fibrate that increases oxidation of fatty acids in liver and muscles (causes lipolysis). It **reduces VLDL and has modest effect on LDL, and a moderate increase in HDL while reducing triglycerides.** It's main side effects are GI symptoms. * **Cholesteramine** = This drug is used to treat hypercholesterolemia and it is a bile acid-binding agent. It **reduces absorption of bile acids** and metabolites. It all goes to the stool though so you end up **getting constipation and bloating**. * **Ezetimibe** = This drug is used to treat hypercholesterolemia and it is an **inhibitor of intestinal sterol absorption**. It **inhibits intestinal absorption of cholesterol and reduces LDL**. **If you have a genetic problem though, this won't do much good. This is great if you have a diet problem.** * **Lovastatin** = This drug is a **competitive inhibitor of HMG-COA reductase,** which helps form cholesterol. These should be avoided during pregnancy. Statins reduce synthesis of cholesterol and **have most effect on LDL.** These drugs have liver toxicity, and give weakness in skeletal muscles because of increased creatine kinase. **If you use them for months, you can have permanent damage to skeletal muscle**.

Answer 111

True * **Mannitol** = It is an **osmotic agent.** It draws free water out of tissues (including the brain) and into the intravascular space, and can transiently decrease cerebral edema (until excreted by the kidneys). Mannitol is freely filtered in the glomerulus, but cannot be reabsorbed. Thus, it remains in the lumen of the nephron and lowers osmotic pressure. Water then "follows" mannitol into the lumen due to the osmotic pressure.

Answer 112

False * Treats diarrhea. **Imodium**; mild opioid agonist: if severe, can use strong opioid agonists

Answer 113

False * Crohn's is an IBS. * (1) **Crohn’s disease** * (a) Symptoms: • Chronic diarrheal problems • Can affect entire GI, but more intense in ileum and colon and **intermittent areas** with strictures between -ulcerations -swelling and scarring • Hypogastric pain • Perianal fissures/fistules • Higher incidence of arthritis • Fatty liver • Possible genetic link • Perhaps abnormal inflammatory response to normal flora • Has remission • Increase incidence of colon cancer• It skips lesion and has intermediate constrictures • Granulomas • **Fistulas and perianal disease** • Also affects upper GI tract • **Transmural inflammation** • Fistulas, perianal * • Oral manifestation: ➢ **0.5% have oral lesions** ➢ Usually males ➢ Linear and deep ulcerations * **Ulcerative colitis** • **More continuous especially in the colon** • **No transmural inflammation • No fistulas and not perianal** * • Oral manifestation: ➢ Less common than in CD ➢ **Usually males** ➢ Edematous oral submucosa

Answer 114

* Excoriation * Traumatic breakage of the skin from scratching * Lichenification * Thickened skin due to repeated rubbing * Papule * Elevated dome or flat-topped lesion \< 5mm * Patch * Flat circumsribed area \> 5mm * Pustule * Discrete, pus-filled raised lesion * Scale * Dry, plate-like excresence, due to imperfect cornification * Vesicle * Fluid filled raised area \< 5mm * Bulla * Fluid filled raised area \> 5mm * Acantholysis * Loss of intracecllular adhesion keratinocytes * Acanthosis * Diffuse epidermal hyperplasia, regular or irregular * Dyskeratosis * Abnormal keratinization occurring prematurely within individual cells below stratum granulosa * Hyperkeratosis * Hyperplasia of stratum cornum * Lentiginous * Linear proliferation along basal cell layer * Papillomatosis * Surface elevation caused by hyperplasia and enlargement of dermal papillae * Parakeratosis * Keratinization characterized by retention of nuclei in stratum corneum * Spongiosos * Intercellular edema of epidermis * Macule * flat, circumscribed (5 mm) * Plaque * elevated flat-topped lesion (\> 5mm) * Nodule * elevated dome (\> 5mm)

Answer 115

B. Huntington's disease * **MS** = It all comes down to oligodendrocytes getting damaged and the myelin is then lost, which results in abnormal or missing conduction. They believe that a **virus might trigger** it causing acute inflammation and an auto-immune response. * **Huntington's disease** = Increase in dopamine and a decrease in GABA because the cell bodies in GABA die. Patients have lost most of the cell bodies because the caudate has been lost, which sits right next to the ventricles on the outside. The hunting gene seems to alter NMDA/AMPA receptors for Glutamate, and you end up killing these receptors from over-excitation of the glutamate system. The hunting gene is found in the GABA neurons. * **Major anxiety disorder** = It is a natural response but in excess. Involves adrenaline and the sympathetic nervous system

Answer 116

E * **Donepezil** = Cholinesterase inhibitor. Used to treat Alzheimer's. We need for ACh with Alzheimer's!!

Answer 117

C. 85% * **The remaining you find by palpation, 10-15%**

Answer 118

True * Stones, catheter, other foreign objects, reflux, short female urethra, obstructing lesions, diverticula.

Answer 119

True * **Bronchiectasis** = Results from obstruction of the bronchi and persistent necrotizing infections. * **You get destruction of elastin and muscles in bronchial walls-congenital expression often caused by cystic fibrosis**. You get persistent productive cough, and the infection which causes the suppurative pneumonia is usually caused by TB, Staph, Klebsiella (Alcoholics).

Answer 120

A. Succinylcholine * **Non-depolarizing blockers are reversed by acetylcholinesterase (AChE) inhibitors, since they are competitive antagonists at the ACh receptor.** * **Succinylcholine** = Depolarizing blocking (paradoxical depolarizing blockade (**desensitization**) (succinylcholine) of the ganglionic nicotinic ACh receptor) = not reversed by ACh inhibitors * Non-depolarizing blocking (produce muscle paralysis by either nondepolarizing blockade (**d-tubocurarine**)) * **Spasmolytics** (reduce spasticity by modifying the stretch reflex arc and/ or interfering directly with excitation-contraction coupling of the skeletal muscles. (Diazepam, **Baclofen**, Tizanidine, Dantrolene) * **Dantrolene** = An anti-spasmotic that is used as a muscle relaxant. is a postsynaptic muscle relaxant that lessen excitation-contraction coupling in muscle cells by inhibiting Ca2+ ions release from sarcoplasmic reticulum stores by antagonizing ryanodine receptors.-It is the primary drug used for the treatment and prevention of malignant hyperthermia, a rare, life-threatening disorder triggered by general anesthesia.-Its direct effect is peripheral only. * **Carisoprodol** = Muscle relaxant/sedative; may have some dependence problems, works by blocking pain sensations. * **D-tubocurarine** = Is a non-depolarizing neuromuscular blocker. Blocks ganglionic nicotinic receptor.

Answer 121

A. Stimulates DNA induction of apoptosis 1. **Develop a signal to proliferate** 2. **Avoid apoptosis** 3. **Invade stroma (if carcinoma)** 4. **Metastasize** 5. **Induce angiogenesis** 6. **Alter DNA in order to allow continued mitosis (normally cells stop dividing after 15X doubling)** 7. **Develop telomerase to prevent cellular senescence** **Genetic Targets for Tumors** 1. Oncogenes (promote proliferation)-e.g. growth factors or corresponding receptors 2. • Tumor suppressor genes (inhibit tumor growth-e.g., BRCA-1 and BRCA-2 (breast and ovary) 3. • P53 gene is most common suppressor gene mutation (lost in 50% of malignancies) 4. • WT-1 gene- regulates apoptosis such as in Wilms tumor 5. • APC-adenomatous polyposis coli-tumors in bowel and pancreas 6. • Apoptosis regulating genes (P53 gene also affects apoptosis) 7. • DNA repair genes 8. • Mismatched repair genes- e.g., HNPCC gene (hereditary nonpolyposis colon cancer) 9. • Angioneogenesis (tumors release vascular endothelial growth factor) 10. • Develop properties for invasiveness

Answer 122

True * 1. Calcium oxalate (75%) 2. Magnesium ammonium phosphate (struvite, triple phosphate, 15% stones, alkaline urine) 3. Uric acid stones (5%), half are gout associated 4. Cystine stones (5%), defective tubular transport of cystine

Answer 123

C. Complex partial seizure **All generalized seizures involve loss of awareness or lack of responsiveness:** * • Primary Generalized Seizure * • Absence, or “petit mal” * • Tonic-Clonic,or“grandmal” * • **Atonic,Myoclonic(jerking/spasms),or Tonic (stiffening)** **Secondary generalized: They begin as simple or complex partial seizures, and when it continues to spread, it becomes generalized**. Has tonic (stiffening) and clonic (jerking) phases once it becomes generalized. And all of this is finishes with a postictal phase.

Answer 124

A. entacapone * **Azilect** inhibits **dopamine breakdown** while **Entacapone** improves the effect of Carbidopa-levodopa by **inhibiting COMT**, Catecholamine Methyl Transferase, which metabolizes neurotransmitters like MAO does.

Answer 125

True * **Secondary Hypertension**: Uncommon, 5% of all hypertensive patients, **possible causes include endocrine (steroid, pheochromocytoma), drugs, pregnancy, renal failure, sleep apnea, pain, stress.**

Answer 126

B. ACh, NE, ACh * Beta and Alpha are called adrenergic receptors. * Both para and sympathetic use Nicotinic receptors at the pre-ganglionic stop as well, and Para uses muscarinic at the post-ganglionic while sympathetic uses alpha/beta, some dopamine, and even muscarinic for sweat glands * **So remember that ACh and Nicotinic receptors are involved in every pre-ganglionic receptor stop** * **And ACh and Nicotinic receptors are at somatic skeletal muscle junctions, where there are no pre- and post-ganglionic axons.**

Answer 127

B C D E F G * **Diabetes insipidus =** increased thirst and diuresis becaues of low ADH and glucocorticoids

Answer 128

A. basal cell carcinoma * **BCC = least aggressive and slow growing** * **Squamous Cell** - next most common, intermediate aggression, no metastasis -red scaling plaques—locally aggressive**, can form keratin pearls** * **Melanoma** = least likely, typically aggressive and metastasizes -warnings: rapid enlargement of nevus; new pigmented lesion-not from pre-existing nevi; irregular borders; irregular surface and colors -caused by UV exposure and genetics -prognosis: poor if metastasized (**common sites are lungs, liver and brain**)

Answer 129

C. Generalized absence

Answer 130

1. Contract the radial muscle of the iris, causing dilation 2. Constrict the GI and GU sphincters 3. Constrict vasculature **Phenylephrine** 1. Prazosin 2. Terazosin

Answer 131

B. Arthritis * Causes include: -**diabetes -UV exposure -aging** * • Treatment is typically surgical removal * **Diabetic Retinopathy** = associated with hemorrhaging and ischemic spots (expressed as cottonwool spots) -hypertension causes similar retinopathies as diabetes

Answer 132

D. Lorcaserin * **Phentermine =** **inhibits NE and dopamine uptake** * Is used for weight loss, is an amphetamine. Phentermine inhibits norepinephrine and dopamine uptake • Side effect: weight loss, dry mouth, hypertension, palpitation • Interactions with sympathomimetics like MAOIs and SSRIs (including vasoconstrictors in local anesthetics) * **Qysmia** **=** anti-convulsant that induces weight loss * It is a drug used for weight loss and it is a combination of Phentermine and Topiramate (anti-convulsant). Qysmia is contraindicated during pregnancy. **Topiramate can give feeling of "fullness" through decreased GI motility**, increased taste aversion, increased energy expenditure. * **Lorcaserin** = Is used for weight loss, 5-HT2C agonist, suppresses appetite in hypothalamus. * **Glucagon** = Is produced in alpha cells of pancreas. It increases **gluconeogenesis**. Used to treat severe hypoglycemia, a side effect of diabetes drugs usually in an emergency setting.

Answer 133

True * Due to retrograde spread from cystitis or hematogenous spread, commonly seen with urinary obstruction, stenosis, can cause flank pain, fever, or asymptomatic, it is more severe in diabetics and with obstruction, **can cause scarring**.

Answer 134

True * A delta and C fibers are the main two types of sensory nerve fibers that transmit pain. They carry nociceptive transmission to the spinal cord. * A delta fibers are **small, myelinated, fast conducting, associated with mechanical, thermal nociceptors, and they transmit "first" or "fast" pain**, diameter of 1-6 mm, **sharp localized pain** when dentin is first exposed, and **more associated with a reflex** than C fibers. C fibers are **small, unmyelinated, slow conduting,** associated with **polymodal nociceptors**, and they transmit **"slow" or "second" pain**, diameter of 2 mm, associated with conduction of **dull, difuse pain**.

Answer 135

B. Promotes glucose uptake in kidney cells * **Functions of insulin (physiological)** = Promote transport of glucose and amino acids through membranes of **skeletal/smooth/cardiac muscle cells, fibroblasts, FAT cells** (this is most important because can cause diabetes by selectively blocking insulin effects in fat cells ; it is an anabolic hormone • **Does not affect glucose uptake in: neurons, kidney and red blood cells, retina, lens** * • **Insulin and C-peptide (are linked in precursor peptide)** are secreted from beta cells in islets of Langerhans (pancreas) in response to glucose

Answer 136

Calcium oxylate, uric acid, and cysteine (all but struvite)

Answer 137

True * A delta fibers are small, myelinated, fast conducting, associated with mechanical, thermal nociceptors, and they transmit "first" or "fast" pain, diameter of 1-6 mm, sharp localized pain when dentin is first exposed, and more associated with a reflex than C fibers. **C fibers are small, unmyelinated, slow conduting, associated with polymodal nociceptors, and they transmit "slow" or "second" pain, diameter of 2 mm, associated with conduction of dull, difuse pain.**

Answer 138

True * Benzoyl peroxide (5%)-containing preparations also work as peeling agents to increases skin turnover, clearing pores (comedolyDc) and reducing the bacterial count (P. acnes) as well as acting directly as an antimicrobial. Benzoyl peroxide is an oxidant and may cause local irritation, dryness and, rarely, bleaching of the hair or colored fabrics it contacts.Higher concentrations available by prescription

Answer 139

False * Chronic gastritis * a. H. pylori gastritis-duodenal and pyloric ulcers; may lead to cancer * b. Autoimmune gastritis **The main eight diseases associated with the stomach** 1. **Reactive (erosive gastritis) gastropathy** a. Induced by: **alcohol**, NSAIDS, iron, Stress, bile reflux 2. **Acute injury** a. Acute gastritis—asymptomatic with possible significant blood loss 3. **Acute peptic ulceration** a. Nausea, vomiting, NSAIDs, stress 4. **Chronic gastritis** a. H. pylori gastritis-duodenal and pyloric ulcers; may lead to cancer b. Autoimmune gastritis 5. **Peptic Ulcer Disease** a. H. pylori and NSAIDs causative b. Increased acid c. Punched our ulcers-potential for perforation and hemorrhage d. Likely also involved in adenocarcinoma development 6. **Polyps** a. Hyperplastic, sporadic • Response to gastric injury, around ulcers 7. **Gastric carcinoma** • Looks like intestinal tissue, and diffuse • Some have hereditary connection 8. **Autoimmune atrophic gastritis** • Genetic factors • **No ulcers • Decreased gastric acid** • Intestinal metaplasia • Long-term effects relate to malabsorption of B12 (pernicious anemia)

Answer 140

D. Cognitive therapy * **Cognitive therapies** help out with the **frontal cortex.** * **Motivational enhancement** therapies help out with the **Orbital Frontal Cortex**, where your saliency or your priority list is kept * **Contingency management therapies** help out with the **cortical-amygdala region**, this is saying, if you stay drug-free, I am going to give you a reward.

Answer 141

A. Alpha-1 agonist * **Phenylephrine** is an **alpha-1 receptor agonist** and it causes vasoconstriction to sinus vessels in order to act as a decongestant, helps with mydriasis for eye exams. Also causes a decreased heart rate from baroreceptor reflex essentially.

Answer 142

D. An alpha-1 agonist or a muscarinic antagonist * **Phenylephrine and other alpha-1 anogists cause the radial muscle of iris to contract, which causes dilation.** * **Pilocarpine (muscarinic agonist) is used for open-angle glaucoma and it causes the iris sphincter muscle to contract the pupil, so a muscarinic antagonist will dilate the pupil.** * **Beta-blockers** lower the amount of fluid your eyes produce, so they can help with glaucoma, and **pilocarpine** increases aqueous outflow (ACh1 agonist). Epinephrine can treat glaucoma as well. * **Acetazolamide** (carbonic anhydrase inhibitor) **can reduce aqueous humor secretion.** * **ANTICHOLINERGICS AND STIMULANTS WORSEN GLAUCOMA, so anything that DILATES will WORSEN GLAUCOMA**

Answer 143

1. **Growth and metastasis** 2. **Involve vital organs** 3. **Get a flood of cytokines that shut down organ functions** 4. **Cachexia**

Answer 144

True * **Captopril** = This drug is an **ACE inhibitor (**any drug that ends with pril, is usually an ACE inhibitor). It inhibits the converting enzyme (peptidyl dipeptidase) that hydrolyzes angiotensin I to angiotensin II, so you can't get increased blood pressure through the ACE pathway. This also allows bradykinin to stay active (because ACE turns it off usually), which is a potent vasodilator that stimulates the release of nitric oxide and prostaglandins. **You also get major hyperkalemia with these drugs. Also used to treat heart failure.**

Answer 145

D. Parathyroid adenoma * **Primary Hyperparathyroidism** = A very common endocrine disorder; usually an adenoma (80% of time) • Symptoms: osteoporosis (fractures), constipation, nonspecific weakness, anorexia, stones, peptic ulcers, depression, or even coma. Bones, stones, groans, and moans. • Arrhythmias (1) Treatments usually surgical (2) Metastasis and carcinomas are rare * **Secondary hyperparathyroidism** = Intestinal malabsorption of vitamin D or calcium • Chronic reduction of serum of Ca++ usually a consequence of chronic renal failure Stimulates PTH secretion, causes hyperplasia * **Ibandronate and Alendronate** are bisphosphonates used for multiple myeloma

Answer 146

False * **Reflux Esophagitis** Relaxation of gastroesophageal sphincter b. Symptoms: Burning, Excessive salivation, Choking c. Aggravating factors: obesity, pregnancy, (decrease esophageal pressure: alcohol/tobacco, narcotics, nicotine patch) use d. Medical treatment: antacids, H2 blockers, PPI -lose weight, stop smoking/drinking e. lifestyle treatment: lose weight, stop smoking and drinking f. Complications: ulceration, stricture, Barrett esophagus (long tongues of extended columns of epithelium cells into esophagus

Answer 147

Enoxaparin * Low molecular weight heparin. Improved morbidity and mortality for cancer patients for DVT as compared to warfarin.

Answer 148

True **Omeprazole = (prazoles are PPI's)** * Used for GERD. Proton pump inhibitors (PPIs) –available OTC and by Rx * • Mechanism: **disrupts hydrogen exchange for K in parietal cells, which blocks production and release of HCl into gut.** * • Side effects: diarrhea, interferes with digestion, increases food allerges, oral sores/ulcers * • Often combined with H2 blockers - Can also add sodium bicarbonate for fast release. **To Treat Peptic Ulcer Disease** 1. Treatments: 1. Suppress acidity to heal sores (but not cure) * Antacids, PPIs, H2 blockers 1. Cure if H pylori-related –H pyloria is contagious especially within family members * **Prevpac**; combination of **lansoprazole (a PPI) and the antibiotics amoxicillin and clarithromycin** * **Milk of Magnesia** (magnesium based) may also help kill Bacteria

Answer 149

C + K * **Alprazolam** = **Sedative** benzodiazipene drug used to treat anxiety disorder. **Sedative** are longer-lasting (8-12 hours), while **hypnotic** are shorter lasting (2-4 hours). * **Buproprion** = It is used to treat anxiety disorders, and it is a **non-sedating sedative**, not a depressant, but still has anxiolytic activity. We use it for **everyday stress** and anxiety. Usually for short-term use. Not very addicting, can interact with MAO inhibitors or anti-seizure medicines.

Answer 150

False * **Mesalamine** = Used for Crohn's disease. Is an anti-inflammatory. Corticosteroids-act systemically and Metronidazole has an antibiotic mechanism and they can also be used for Crohn's. b. Ulcerative colitis • Similar to Crohn’s disease but limited to colon and more generalized (no strictures) • Medications are similar to Crohn's disease * **Metronidazole =** Antibiotic used for acne, but mainly **Crohn's Disease**. nitroimidazole antibiotic for anaerobic bacterial; parasitic infections and the inhibition of Demadex brevis (parasitic mites) – Demodex mites are ~3x more prevalent in acne vulgaris patients than in healthy controls. – Anti-inflammatory effect (inhibits neutrophils) – * **Corticosteroids = act systemically**

Answer 151

True * Heart rate of less than 60 beats per minute * Disturbances in impulse generation to the sinus node, impulse propagation from the sinus node to the atria, impulse propagation through the AV node/His-Purkinje system. Bradycardia due to abnormal impulse propagation is known as a conduction block.

Answer 152

False * **Slow closure of drainage canals** **Open-angle glaucoma**: wide space between iris and cornea * most common-90% * slow clogging of drainage canals * symptoms subtle and often undetected * 3 million cases in US * **African Americans** especially vulnerable Increased risk with diabetes and HP * **Closed-Angled Glaucoma =** * Closed-angle glaucoma: iris fused to cornea, Rapid closure of drainage canals Symptoms typically noticeable Surgery usually necessary

Answer 153

J + I * **Lithium Carbonate** = Used for Bipolar Disorder. Slow onset, likely works by altering 2nd messenger systems such as those involving **adenylyl cyclase** and **G proteins**, often combined with anti-depressants, still among the most potent mood stabilizers, **has many side effects, requires monitoring blood levels** (narrow therapeutic window), tremors are common, kidney damage, weight gain, edema, high rate of compliance problems. * **Carbamezepine** = anti-epileptic, along with 1. Valproic Acid 2. Carbamazepine 3. Lamotrigene, **these all treat bipolar.** These have fewer side effects, better compliance, more expensive, usually for maintenance after lithium starts, GABA/Glutamate pathways might be responsible for some of the bipolar cycling, depression and manic staging, and that is why antiepileptic agents work.

Answer 154

B. A muscarinic antagonist * **Atropine and Scopalamine** are the muscarinic antagonists. Used for Parkinson’s disease (adjunctive therapy), motion sickness, COPD, urinary urgency...... * **Sarin** (nerve gas), **Donepezil** (Alzheimer's), and **Physostigmine** are the main **acetylcholinesterase inhibitors.** * A sympathomimetic is NE, amphetamines, anything that mimics the action of NE is sympathomimetic. * **You only transport choline, not acetylcholine**, so that is bull crap.

Answer 155

False * evidence that antioxidants (e.g., vit. C or zinc oxide may help reduce development, but benefit is minimal) for wet AMD. No treatment for dry AMD.

Answer 156

Metaplasia * It is the reversible replacement of one differentiated cell type with another mature differentiated cell type. The change from one type of cell to another may generally **be a part of normal maturation process or caused by some sort of abnormal stimulus**. In simplistic terms, it is as if the original cells are not robust enough to withstand the new environment, and **so they change into another type more suited to the new environment.**

Answer 157

E. Fluticasone * **Theophylline** = Is a type of **methylxanthine drug used as an add-on controller for asthma**, it is a phosphodiesterase inhibitor and **increases cAMP and relaxes airway smooth muscle.** Available as t**ablet or inhaler through tea.** Monotherapy for mild asthma. **Combine with corticosteroids** to reduce steroid doses and side effects. Also helps relax diaphragmatic fatigue in COPD. Toxicity: nausea, headache and anxiety. Requires plasma level monitoring. * **Montelukast = Selective leukotriene receptor antagonist** (leukotrienes are associated with the pathophysiology of asthma (airway edema, smooth muscle contraction)). Used for **prophylaxis** and chronic treatment of asthma. So this blocks the synthesis of leukotrienes, **this would be good for patients who comply poorly to inhaled therapies.** * **Cromolyn** = This drug is considered a **mast cell stabilize**r, is used to treat asthma, **inhibits release of inflammatory mediators such as histamine** (mast cell stabilizer). **Prophylactic use often before exercise and allergen exposure—no rescue action (i.e., not a replacement for albuterol).** * **Omalizumab**-inhibits IgE binding to mast cells-very expensive, only for severe non-responsive asthma * **Albuterol =** Fast acting reliever, the only true "rescue" reliever, acts within 15 minutes and is effective for 4-6 hours. directly relax airway smooth muscle and bronchodilate. **Salmeterol is same thing but longer acting.** * **Fluticasone** = **Inhaled steroid for controlled asthma,** prevents transcription of inflammatory mediators in the nucleus, resulting in a decrease in inflammation. Side effects: nose bleeds, sores in nose, mouth, tongue that don’t heal, oropharyngeal candidiasis **(thrush)**, interfere with growth in children. * **Don't Forget the Antimuscarinics** * **Ipratropium** (related to tiotropium-Spriva-which is not approved for asthma, but is approved to treat COPD) –reverses contraction of smooth muscle from vagal activity-usually backup for beta 2 agonists-sometimes combine antimuscrinics with b2 agonists (eg, albuterol) * Side effect of dry mouth * Used as an inhalant for bronchospasms

Answer 158

False * **Premature atrial or ventricular contractions are the most common cause for arrhythmias** and they can be ignored if infrequent, no heart disease, or EKG normal. * **Ventricular is the most dangerous.**

Answer 159

1. Relaxes the ciliary muscle for far vision 2. Relaxes vasculature, especially skeletal muscle (vasodilation) 3. Relaxes lungs (tracheal and bronchial smooth muscle 4. Relaxes urinary bladder, uterine wall 1. Isoproterenol 2. Albuterol 3. Terbutaline 1. Propranolol

Answer 160

False * Most hepatotoxic events occur around the **‘central vein’** * **Drugs** are the #1 cause of liver toxicity! * Biopsy of liver can be potentially dangerous due to major hemorrhaging * 1. Fatty (fat globules in hepatocytes) liver-**steatosis** • Worst destruction is fibrosis. It leads to collagen scar and permanent injury. End stage is **cirrhosis** • Causes—a**lcohol, obesity and diabetes (known as the metabolic syndrome)** * 2. If hepatocytes die in large sheets, the areas fill up with blood. Blood can build up due to heart failure and cause backflow around the central vein * 3. If cannuliculi in liver fill with bile due to cholestasis, the person becomes jaundiced (often caused by drugs) * 4. **Acute more lobular, chronic is more portal with fibrosis and collagen bridges** * 5. Hepatitis is inflammation of liver. If caused by viruses can be contagious and dentists must be very careful with these patients • Can also be caused by toxins and drugs • Acute can often resolve itself. Chronic less likely to recover (fibrosis often a part of this) • Acute caused by Hepatitis A and E viruses (1-3 months) • **Hep B and C viruses start with acute hepatitis and progress to chronic with fibrosis progressing to cirrhosis and hepatocellular carcinoma: tend to be the more severe** *

Answer 161

False * **Allodynia** = **pain evoked by normally non-painful stimuli**. On same line as hyperalgesia. * **Hyperalgesia** is an **increased perception of pain in response to painful stimuli**. On same line as allodynia.

Answer 162

D. Valproic acid * **Ethosuximide** is **used for uncomplicated absence seizures.** Has a very narrow clinical spectrum. It's MOA is reduces T-type Ca+ channel currents in thalamic pacemaker neurons to quiet rhythmic discharges. * **Perampanel** is a newer anti-epileptic drug, similar actions to topiramate. * **Carbamazepine**, **Used for all Partial seizures as well as Tonic-Clonic seizures**. Although rare, **Steven-Johnsons Syndrome** is a side effect. This drug may also activate spike-wave seizures. It is also associated with toxic levels when patients drink **grapefruit juice**. It is a great drug for epilepsy but the potential for a drug-to-drug interaction is high. It's MOA is it blocks Na+ channels to inhibit repetitive firing from neurons. Also used for Bipolar Disorder. * **Valproic acid** is used for **all Partial seizures as well as uncomplicated absence seizures, atypical absence seizures, primary tonic-clonic seizures, and myoclonic epilepsy.**

Answer 163

True * **Physioloic affect =** **Affects GABA A receptors** (although not an agonist)—ethanol interacts with other sedative/hypnotic drugs in a synergistic manner and can lead to OD deaths due to respiratory depression. • **Increases release of dopamine and endorphin** • **Affects almost all organs**: e.g., • Liver toxin-increases fat deposits and can cause fatty livers in the extreme -causes **cirrhosis** in ~**5-10% alcoholics -bad combination with acetaminophen** • Kidneys- it is a diuretic • G.I.- irritating to mouth through the intestines—causes inflammation and enhances chances of cancer -stimulates gastric secretions -food slows its absorption • Suppresses immune system/perhaps partially due to malnutrition • CVS- **low doses increase HDL—high doses increase hypertension, coronary artery disease, and arrhythmias** • Brain: order of effects--- cortex (cognition)-limbic (emotions and reward)-cerebellum (motor and balance)-hypothalamus (endocrine)-medulla (respiration and CV regulation) • Disrupts lipid membranes

Answer 164

False * **Loss of central vision**

Answer 165

* Rapidly acting * Dramatic effect on inflammation and **slowing bone erosions** in rheumatoid arthritis * Side effect: **loss of muscle mass, osteoporosis, diabetogenesis, peptic ulcers, round face, buffalo hump** * Drugs: * _dexamethasone_: long-acting * -_cortisone_, _prednisone_: short- to medium-acting

Answer 166

A. Docusate * **Docusate** = * Laxative used for constipation. Loperamide treats diarrhea, and Linaclotide (for IBS) treats constipation. * • Water retention in stools, softens stools * • OTC (e.g., Dulcelax) * **Bismuth** = * Treats diarrhea. Is Pepto-Bismol. * Anti-cholinergics such as atropine can also be used to treat diarrhea.

Answer 167

True * Main complications of MI's:Most to least common 1. Arrhythmias 75-95% 2. Congestive heart failure and pulmonary edema 60% 3. Pericarditis 4. Mural thrombosis **40%** 5. None 10-20% 6. Cardiogenic shock 7. Rupture of ventricle or papillary muscle 4-8% * **Mural Infacrts** = It is due to an anuerysm in the heart wall and it has full thickness, endocardium to epicardium. Usually involving left ventricle anterior and posterior free wall or septum with extension into right ventricle wall in 15-30% of cases. More severe than MI, correlates with ST segment elevation myocardial infarct on EKG.

Answer 168

B. dynorphins * Three main classes of opioid receptors and what are the three endogenous opioid peptides that interact with them = **Mu, Delta, and Kappa. Enkephalin, Beta-Endorphin, and Dynorphin.** * **Dynorphins** = **Act on Kappa receptors**. 17 amino acids long. There are A and B Dynorphins, they are inhibitory, they tend to block a lot of the typical reward functions. The kappa receptors are antagonistic to mew and delta, but they still have analgesic properties. * **Enkephalins** = **Act on Delta and Mu receptors**. 5 amino acids long. Made up of Methionine and Leucine. * **Beta-Endorphins** = **Act on Delta and Mu receptors**. 91 amino acids long. -You can’t give a Beta-endorphin therapeutically, it would be proteased too quickly, but we have drugs that have opioid agonist properties that have a number of naturally occurring narcotics that have selective activities that act on mu or delta receptors. * **Substance P** is a neuropeptide, helps with pain sensitization, along with glutamate, is **an important pain neurotransmitter that is released from A delta and C fibers in order to excite the projection neurons to go up into the thalamus from the dorsal horn**

Answer 169

True Addison’s—adrenal glands produce too little cortisol (chronic)—**often insufficient aldosterone as well** • Symptoms • Weakness • Fatigue • Weight loss • Hyperpigmentation • Treatment—corticol supplements: cortisones (hydro-) or prednisone * **Mifepristone** = Used for Cushing's syndrome. Is an antagonist at steroid receptors.**Also called the "morning after" contraceptive. B****locks progesterone and glucocorticoid receptors****—suppresses ovarian function (has a masculinizing effect)**

Answer 170

A. What medications are you taking? E. Do you have a history of osteoporosis or Paget's disease? **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** B. I have osteoporosis and I am taking alendronate

Answer 171

Metformin * Used to treat type II diabetes, also called Metformin. Mechanism not fully understood—decreases glucose production in the liver and likely increases efficiency of insulin binding • Advantage: insulin-sparing, does not provoke hypoglycemia when used alone • May prevent some of the CVS effects of type II DM • Side effect: GI irritation, B12 deficiency, not for use in alcoholics

Answer 172

True * I**t is the most common sustained arrhythmia in adult clinical cardiology**. Atrial flutter is different and involves very rapid atrial contractions, and can turn into atrial fibrillation. AF increases with age and often co-exists with other cardiovascular diseases like congestive heart failure, valvular heart disease, and hypertension. **10% of Americans older than 65 years old have AF**. It is associated with electrical and structural changes of the atrium. You get electrical remodeling, meaning shorter atrial action potentials, loss of rate of adaptation to action potential duration, and loss of myocytes and replacement with collagen and fibroblasts. **AF causes inefficient atrial contraction, which causes decrease in cardiac output, due to loss of atrial contribution to ventricular filling, and is also involved with a high risk of thrombosis and embolization.** * **Ventricular Fibrillation** = It is a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them quiver rather than contract properly. P waves are absent here, and can quickly lead to sudden cardiac arrest or death.

Answer 173

Adenoid carcinoma * Adenocarcinoma (eg, colon or breast adenocarcinoma) • forms glands • tumors of cuboidal or columnar cells • types include: ➢ colon ➢ prostate-fairly innocuous looking ➢ breast-many positive for estrogen receptors ➢ l**ung-small cell carcinomas are aggressive with poor prognosis -large cell carcinomas are slower with better prognosis**

Answer 174

D. Acetylcholine The main monoamines are Dopamine, Epinephrine, Norepinephrine, and Serotonin. Histamine is also a monoamine. But remember, serotonin is not a catecholamine like the first three are. Neither is acetylcholine. * **Dopamine, Epinephrine, NE** are catecholamines

Answer 175

B. A reduction in cardiac stroke volume * What is congestive heart failure? **It is when the cardiac output is insufficient for metabolic needs of the body**. You can get systolic dysfunction, which is decreased myocardial contractility (heart pumps weakly), diastolic dysfunction, which is insufficient expansion (heart does not fill with blood between beats). And problems are accentuated by increased demand. * **5 main methods** of Compensation: * 1. Tachycardia * 2. Frank-Starling (increased end diastolic volume results in increased stroke volume) * 3. Myocardial hypertrophy * 4. Increased catecholamine activity leading to positive ionotropic effect (they tell the myocytes to keep contracting the best you can), as well as renin-angiotensin-aldosterone system * 5. Redistribution of blood flow

Answer 176

False * Doesn't destroy, just dries and opens * Salicylic acid (3-6%) has been extensively used in dermatologic therapy . Salicylic acid works as a keratolytic, comedolytic, and bacteriostatic agent, causing the cells of the epidermis to shed more readily, opening clogged pores and neutralizing bacteria within, preventing pores from clogging up again by constricting pore diameter, and allowing room for new cell growth. Higher concentrations available by prescription.

Answer 177

True ## Footnote Laxative used for constipation. * Stimulant of smooth muscles * Fast acting * OTC * Suppository/oral * Cramps

Answer 178

B. Neurons * The cells that are most prone to injury are **those that have a high metabolic activity and those that proliferate rapidly** * **High Metabolic Activity** 1. Cardiac myocytes 2. Renal tubular cells 3. Hepatocytes * **Proliferate Rapidly** 1. Testicular germ cells 2. Intestinal epithelium 3. Hematopoietic cells

Answer 179

B * **Prednisone** = Prednisone is most common, it is a steroid used for anti-inflammation. Interferons are more extreme, as well as methyltrexate, which are both anti-cancer treatments. Drug that treats Multiple Sclerosis. Bladder dysfunctions, bowel dysfunction, depression, fatigue, pain, tremors.

Answer 180

D. Monoamine oxidase * **Tyrosine hydroxylase = Tyrosine is converted to DOPA** by this * Tryptophan enters the neuron, is then converted by **Tryptophan Hydroxylase** to 5-HTP, and 5-HTP is then converted by AAD to 5-HT **(Serotonin)** * **Dopamine** can be metabolized by MAO, Monoamine Oxidase, which **converts dopamine into DOPAC.** * **Dopamine, NE, epinephrine, serotonin, histamine could all be degraded by monoamine oxidase.**

Answer 181

True * **Furosemide =** It is a **loop diuretic. It inhibits the luminal Na/K/2Cl transporters in the thick ascending limb of the loop of Henle, thus reducing NaCL reabsorption and increasing its secretion.** Can also cause **hypokalemia**, because it increases luminal sodium and thus stimulates the aldosterone-sensitive sodium pump to increase sodium reabsorption in exchange for potassium and hydrogen ions, which are lost to the urine. Also this drug can be inhibited by NSAIDs under certain conditions. Diuretics, especially furosemide, can also be used to treat heart failure. Does not have positive ionotropic effect, but you are getting fluid accumulation because heart is not working very well, which will cause problems to whole body so you use a **potent diuretic** like furosemide. * **Hydrochlorthiazide** = It is a loop diuretic and it is a thiazide. **It inhibits NaCl reabsorption from the luminal side of epithelial cells in the distal convoluted tubule by blocking the Na/Cl transporter.** Can also cause **hypokalemia**, and this is a problem because of cardiac arrhythmias, because it increases luminal sodium and thus stimulates the aldosterone-sensitive sodium pump to increase sodium reabsorption in exchange for potassium and hydrogen ions, which are lost to the urine. Also this drug can be inhibited by NSAIDs under certain conditions.

Answer 182

B. Tuberculosis 1. **Usually lungs but can affect other organs** 2. **Flourishes in crowded, impoverished areas** 3. **Non-contagious during long periods of dormancy** 4. **Problems with multidrug antibiotic resistance** 5. **Forms necrotizing granulomas**

Answer 183

True * Endocarditis can cause Cardiac complications, which are coronary artery emboli, abscesses, erosion of valve or chordae tenineae. Non-cardiac complications, which are septic emboli, immune complex diseases in vessels or kidneys.

Answer 184

1. **Non-responsive to normal physiologic cues** 2. **Lack of response to growth inhibitory signals** 3. **Avoid normal cell cycle mediated death** 4. **Develops own angiogenesis** 5. **Evades immune detection** 1. **Develop a signal to proliferate** 2. **Avoid apoptosis** 3. **Invade stroma (if carcinoma)** 4. **Metastasize** 5. **Induce angiogenesis** 6. **Alter DNA in order to allow continued mitosis (normally cells stop dividing after 15X doubling)** 7. **Develop telomerase to prevent cellular senescence**

Answer 185

True * Usual MI symptoms: **Retrosternal chest pain, dyspnea, diaphoresis (sweating), nausea/vomiting, palpitations, anxiety, or can be asymptomatic or present as sudden death.** * Main complications of MI's:Most to least common 1. Arrhythmias **75-95%** 2. Congestive heart failure and pulmonary edema **60%** 3. Pericarditis **50%** 4. Mural thrombosis **40%** 5. None **10-20%** 6. Cardiogenic shock 7. Rupture of ventricle or papillary muscle **4-8%**

Answer 186

False * A delta fibers are small, myelinated, fast conducting, associated with mechanical, thermal nociceptors, and they transmit "first" or "fast" pain, diameter of 1-6 mm, sharp localized pain when dentin is first exposed, and more associated with a reflex than C fibers. C fibers are small, unmyelinated, slow conduting, associated with polymodal nociceptors, and they transmit "slow" or "second" pain, diameter of 2 mm, associated with conduction of dull, difuse pain.

Answer 187

B. Phenytoin * **Phenytoin**, Used for **all Partial seizures as well as Tonic-Clonic seizures.** It **masculinizes (hirsuitism) and causes severe gingival hyperplasia**, osteopenia, anemia, acne. This drug is special because it has z**ero-order kinetics** at high doses. Most drugs have first-order kinetics. * **Carbamezepine =** CYP3A4, liver enzyme, grapefruit with drug increases amount. Steven Johnsons syndrome. Sodium blocker. * **Phenytoin =** sodium blocker * **Ethosuximide** = reduces Ca currents * **Barbiturates** increase the duration of opening time of GABA channels

Answer 188

Choriocarcinoma * TNM grading -T, size and extent of primary tumor -N, presence and number of lymph node metastases -M, presence of distant mestatses * Serological tests- most useful for assessing cancer recurrence after treatment * -**PSA**: prostate specific antigen * -**CBA**: carcinoembryonic antigen-colon carcinoma * -**CA-125**: serous ovarian carcinoma * -**HCG:** Choriocarcinoma

Answer 189

False * **Doxorubicin/Bleomycin** = * Is an **antitumor antibiotic, in the class of anthracyclines, that treat breast cancer.** * Mechanism: **formation of free radicals that bind to DNA, causing breaks** * Treat: lymphomas, breast cancer and thyroid cancer * Toxicity: nausea and **red (not blood) urine** * **Fluorouracil** = Treats cancer. * 1.**Inhibits thymidine synthase**, decreases NDA synthase and decreases DNA synthesis and function * 2. treats: **colorectal, anal, breast, head neck, and hepatocellular cancers**

Answer 190

1. **Liver disease (slows metabolism)** 2. **Breast/endometrial cancers** 3. **Thromboembolytic disorders**

Answer 191

D **(not G because clozapine is an atypical, not phenothiazine)** * **Increased activity of D2 is associated with Schizophrenia, so we treat it with D2 antagonists.**

Answer 192

False * **Procarbazine should be this one.** * **Procarabazine =** Treats cancer, is a nitrosourea. **Used for combination regimens for Hodgkin's Lymphoma**. Passes blood brain barrier and used to treat brain tumors. * Cyclophosphamide is an alkylating agent. * **Cyclophosphamide** = * Treats cancer, is an alkylating agent. * 1. E.g, Cyclophosphamide • Hodgkin’s lymphoma • Multiple myeloma • Leukemia • Breast cancer * 2. Mechanism: **Transfer their alkyl groups to various cell constituents such as DNA,** alkylation of DNA in nucleus—cause miscoding—can break DNA strands * 3. Resistance: increased capacity to repair damaged DNA * 4. Adverse effects: • Nausea, vomiting • Damage to rapidly growing tissues (bone marrow, G.I. tract, reproductive tissue) • **Carcinogenic in nature (increases risk of secondary cancer)**

Answer 193

D. Pemphigus * **Impetigo = Staph infection. I**mpetigo: staph and strep infections superficial) on face and extremities, contagious through contact, --primarily kids; honey color crust-pustules * **Stevens-Johnson syndrome** = medicine, or herpes or fungal infections. * **Lichen planus** = -middle age -extremities and oral cavity -lace-like white markings. -resolve after 1-2 years although often persists in oral cavity **Hyperkerotosis, and epidermal hyperplasia** -Unknown inciting mechanisms * **Pemphigus** = Bulbous blistering prominent feature: pemphigus (painful flaccid blister like-deep erosions and crust after rupture-hypersensitivity reaction), dermatitis herpetiformis-use **immunosuppressive treatment** -tend to be **auto-immune responses**

Answer 194

Burkitt's Lymphoma * Burkitt’s Lymphoma- a type of non-Hodgkin’s lymphoma linked to Epstein-Barr infection and can affect maxilla and mandible; very aggressive from B lymphocytes. Prognosis can be poor.

Answer 195

True * **Complications of reflux esophagitis**: ulceration, stricture, Barrett esophagus (long tongues of extended columns of epithelium cells into esophagus

Answer 196

1. Constrict vasculature 2. Decrease NE release from NE terminals 3. Decrease NE release from brainstem 1. Clonidine 2. Guanfacine

Answer 197

B. Albuterol * **Albuterol** is a beta-2 agonist, so it relaxes the lungs and causes vasodilation to skeletal muscle, along with terbutaline and isoproterenol. * **Phentolamine** is a non-selective α antagonist that is in treatment of pheochromocytoma & hypertensive emergencies, vasodilator, decreases TPR and Blood pressure * **Atenolol** is a beta-1 blocker, treatment of hypertension, angina, open- angle glaucoma. * **Epinephrine** = NE favors Beta more, whereas Epi likes both. **At lower doses of epi, may see decrease TPR and diastolic pressure. At higher doses, see increased TPR and blood pressure.**

Answer 198

1. Succinylcholine = Depolarizing (desensitizing), and non-competitive 2. D-Tubocurarine = Non-Depolarizing, and competitive. ACh inhibitor can increase the levels of this.

Answer 199

Tolbutamide * Is a 1st generation sulfonylurea that is **used to treat type II diabetes** by **increasing insulin release** from beta cells by **blocking potassium channels** on their membranes. Side effects include hypoglycemia and weight gain because they can bind to carrier proteins in the blood, be dislodged by other drugs, leading to rapid increase in their activity and hypoglycemia

Answer 200

False, the opposite is true

Answer 201

B. acute lymphoblast leukemia * **Most common acute form of leukemia in adults** = Acute Myelogenous Leukemia **(AML)**. Cytarabine is the most single active agent. * **Most common GI malignancy** -= Colorectal cancer * **Hodgkins lymphoma** -younger patients -usually good prognosis -sometimes characterized by Reed Sternberg cells (large, multinucleated B lymphocytes) * **Acute Lymphoblast Leukemia** = most common cancer in children * **Multiple Myeloma** = * 1. Plasma cell malignancy, primarily in bone marrow * 2. Symptoms: • Bone pain • Fractures • Anemia * • Tx: alkylating agent; prednisone

Answer 202

True **Main Five Diarrheal Diseases** a. Celiac sprue • Immune mediated—triggered by ingestion of gluten • Malnutrition: • Fe, B12 malabsorption • Atrophic glossitis • Dental effects: enamel defects, delayed tooth eruption, recurrent aphthous ulcers, cheilosis, b. Lymphocytic colitis • Increased intraepithelial lymphocytes c. Irritable bowel syndrome • Relapsing pain, bloating, relapsing and alternating constipation/diarrhea • Diet, abnormal motility and stress are factors • No gross microscopic abnormalities d. Infectious self-limiting colitis • Caused by microorganisms such as **salmonella, E. coli, shigella, clostridium** e. Pseudomembranous colitis, cells slough off • Usually caused by clostridium difficile • Spread via person to person • Often follows broad spectrum antibiotic therapy • Most common nosocomial infection in older adults

Answer 203

A. Metoprolol * **Metoprolol** = **Beta-1 antagonist used to lower blood pressure, angina, glaucoma**. **Effects include decreased HR and contractility, increased TPR because of beta-2 blockage in skeletal muscle** (seems counterintuitive, what decreased HR is more important factor), **decreased renin release**, bronchial constriction, **decreased glycogenolysis** in response to hypoglycemia, decreased aqueous humor production. Also used to treat heart failure. * **Dobutamine** = This drug is a **beta-1 agonist** that is used to treat heart failure. Can cause arrhythmias, and it **increases HR**. * **Captopril** = This drug is an **ACE inhibitor** (any drug that ends with **pril,** is usually an ACE inhibitor). It inhibits the converting enzyme (peptidyl dipeptidase) that **hydrolyzes angiotensin I to angiotensin II**, so you can't get increased blood pressure through the ACE pathway. **This also allows bradykinin to stay active (because ACE turns it off usually), which is a potent vasodilator that stimulates the release of nitric oxide and prostaglandins. You also get major hyperkalemia with these drugs. Also used to treat heart failure.** * **Hydralazine** = This drug is a **direct vasodilator that releases nitric oxide from the drug or from endothelium.** All the vasodilators that are useful in hypertension relax smooth muscle of arterioles, thereby decreasing systemic vascular resistance. Decreased arterial resistance and decreased mean arterial blood pressure elicit compensatory responses, mediated by baroreceptors and the sympathetic nervous system, and because these are still intact, vasodilator therapies generally do not cause orthostatic hypotension. Also used to treat heart failure. * **Digitalis** = This drug is a **positive ionotropic drug**, and digitalis is a genus plant name that provides cardiac glycosides such as digoxin. It **increases** **intracellular Ca and cardiac contractility, only temporarily though. It helps treat heart failure**. It increases blood ejection. It is not just selective for cardiac calcium channels so its side effects are that it affects all excitable tissues. Can cause premature depolarizations and ectopic beats.

Answer 204

False * Birth defects * etinoid (Vitamin A) used for acne. Isotretinoin (Accutane) – oral retinoid used for severe cystic acne and acne that has not responded to other treatments. • Considered the only true “cure” for acne. It also reduces the amount of oil secreted by glands in the skin. • Isotretinoin has been associated with bowel diseases (Crohn’s disease), liver damage, depression, teratogenicity and miscarriage. • contraindicated during pregnancy as they have been shown to cause CNS, craniofacial, cardiovascular and other birth defects. – At least two negative pregnancy tests are required and either signed statement of abstinence (iPledge contract) or confirmation of 2 forms of contraception is required to obtain a prescription.

Answer 205

True * **No treatment for Dry Age-Related Macular Degeneration**

Answer 206

True * Psoriasis = Auto-rejection or environmentally induced, it is a form of **acanthosis**

Answer 207

C. Determines the carcinogenic properties of a chemical by measuring the bacterial DNA responses to this substance

Answer 208

* **Drugs:** * (1) T**opical keratolytics** * ****-removes keratin layer and opens sebaceous glands (also used as wart removers) * **Salicylic acid** * **Benzoyl peroxide** * (2) Antibiotics: * **erythromycin, tetracycline, clinidimycin and Dapson,** * -eliminate the bacteria that cause the infection and inflammation associated with acne. Can use either topical or systemic. Drugs concentrate in skin. * (3) Retinoids: * vitamin A-derivatives; tretinoin (retin A: topical); isotretinoin (Accutane: systemic) * Side effects: **dry skin, sores, major birth defects with isotretinoin** * Non-drug treatments * UV phototherapy—acne-causing bacteria are UV sensitive

Answer 209

Osteoarthritis ## Footnote a. **Loss of articular cartilage** with secondary changes in bone b. Presents in some degree in **most persons \>65 years of age. Symptoms worsen with excessive use.** c. Due to wear and tear **d. No inflammatory changes**

Answer 210

False * **Preganglionic sympathetic neurons are thoracolumbar in origin.** * The cell bodies of the parasympathetic nervous system are in the **craniosacral region.** * **Parasympathetic pre-ganglionic axons are long**, they extend to ganglia near effector organs, so the post-ganglionic are short. These are all coming out of the craniosacaral region. * **Sympathetic pre-ganglionic axons are short.**

Answer 211

A. Inadvertent removal of parathyroid glands during thyroid surgery * Chief cells of the parathyroid glands secrete parathyroid hormone. * Parafollicular cells of the thyroid gland secrete calcitonin * Its main action is to mobilize calcium from bone to increase serum Ca2+ and and increase urinary phosphate excretion. * **Parathyroid Gland** = Secrete parathyroid hormone (PTH) regulated by free calcium in blood-reverse relationship (low calcium increases PTH) • PTH activates osteoclasts and bone resorption and increases serum calcium; also increases tubular reabsorption of calcium, activates vitamin D and increases GI absorption • Usually 4 glands close to thyroid poles * **Primary Hyperparathyroidism** = A very common endocrine disorder; usually an adenoma (80% of time) • Symptoms: osteoporosis (fractures), constipation, nonspecific weakness, anorexia, stones, peptic ulcers, depression, or even coma. Bones, stones, groans, and moans. • Arrhythmias (1) Treatments usually surgical (2) Metastasis and carcinomas are rare * **Secondary hyperparathyroidism** = Intestinal malabsorption of vitamin D or calcium • Chronic reduction of serum of Ca++ usually a consequence of chronic renal failure Stimulates PTH secretion, causes hyperplasia * **Most common cause of hypoparathyroidism** = Very uncommon. Most often accidental removal at thyroid surgery, congenital absence of all glands. Symptoms: hypocalcemia, anxiety, depression, decreases PTH, tetany, dental changes in children (poor enamel, brittle teeth, missing teeth).

Answer 212

False * Treated with NSAIDS **The two main chronic inflammatory skin conditions =** psoriasis and lichen planus **Psoriasis =** * inciting antigen—auto-rejection or environmentally induced -1-2% in US -can be accompanied by **increased heart attacks and arthritis** -treatment includes **NSAIDS and immunosuppressant drugs** -well-marked by pink to salmon colored plaques -regular **acanthosis** in epidermis

Answer 213

Streptokinase * Dissolve clot • Drugs include: streptokinase and urokinase • Are potentially very dangerous and can cause hemorrhagic strokes • Don’t use unless formed clot is in a very dangerous place

Answer 214

B. Fentanyl * Fentanyl at 0.1 mg equipotent IM dose, most potent opioid narcotic * Fentanyl at 0.1 mg * Oxymorphone at 1 mg * Hydromorphone at 1.5 mg * Morphine at 10 mg * Oxycodone at 20 mg * **Hydrocodone** at 30 mg * Codeine at 200 mg * Tramadol = (Ultram). It is a **schedule 4 drug**. Low drug abuse potential, but some minor opioid action. Works at brain level. Is the **"next-line" of drug treatment for neuropathic pain like Trigeminal neuralgia.**

Answer 215

B. Graves disease * Elevated free T4 or T3. Low TSH. Presence of serum TSI (immunoglobulins) is diagnostic of Graves disease. * What causes 90% of hyperthyroidism cases? **Graves Disease**, found in 2% of adult females. The other cases are from toxic multinodular goiter (plummer's disease). * **Causes =** Autoimmune-antibodies function as agonists to thyroid-related receptors-causing excessive thyroid receptor activation. T-cell related autoimmune reaction * **Symptoms** = Find elevated Ab to TSH receptor. Thyroid gland has a diffuse enlargement (2-3 times normal size). Symptoms: • Hyperthyroidism • Exophthalmos (protrusion of eyeballs), 1/3 of the cases * **DeQuervain thyroiditis = also called subacute granulomatous thyroiditis =** • **Viral cause** (e.g., flu virus) • **Painful** • **Usually self-limited and surgery not advised** * **Hashimoto's =** • Autoimmune; usually females --**antithyroid peroxidase Ab present** • **May start as hyperthyroidism followed by permanent hypothyroidism** • Thyroid enlarges- then atrophies over years • Most often in **females** • Radiation may cause • **Most common cause of thyroid deficiency** • **High TSH, low free T3 and T4.** * **Gioter** = Most common lesion of the thyroid-usually a thyroid enlargement • Rarely associated with hypothyroidism • Not a cancer • **Usually associate with deficiency of iodine** • Diagnosed with fine needle aspiration (versus biopsy) to determine if have large follicles filled with colloid and relatively few cells • Can be confused with thyroid neoplasm—usually very cellular and little colloid

Answer 216

D. Methamphetamine * **Amphetamines** cause the most dopamine release, by far, so it causes the greatest amount of neurotixicity. 1000 for meth and 350 for cocaine. * Amphetamines work by **they release dopamine from vesicles and then they pump them in reverse out of the dopamine transporter so they can be in the synaptic cleft and activate dopamine receptors.** * All abused substance enhance dopamine activity in the **nucleus accumbens** * **Nicotine** causese dopamine release by activating nicotinic receptors. * **Methylphenidate** is an indirect adrenergic agent, similar to amphetamine, cocaine, SNRI's and TCA's. This drug **blocks DA reuptake**. It is **Ritalin, is used for ADHD, it is a stimulant.**

Answer 217

Gangrenous necrosis * Gangrenous necrosis -See this when an entire limb loses blood supply and dies (usually the lower leg) -This isn’t really a different kind of necrosis, but people use the term clinically so it’s worth knowing about -Gross: skin looks black and dead; underlying tissue is in varying stages of decomposition -**Micro: initially there is coagulative necrosis from the loss of blood supply (this stage is called “dry gangrene”); if bacterial infection is superimposed, there is liquefactive necrosis (this stage is called “wet gangrene”)**

Answer 218

C. Transduction * Starts at injury, the noxious stimuli activate the sensitive peripheral ending of the primary afferent nociceptor by the process of **transduction**. The message is then transmitted over the peripheral nerve to the spinal cord, projection neurons send axons across the midline, where it synapses with cells of origin of the major ascending pain pathway, the spinothalamic tract. The message is relayed in the thalamus to the somatosensory cortex 1 and 2. * **Transduction** happens in primary afferent nociceptor, then **transmission** happens when action potential passes through dorsal root ganglia to actual spinal cord, where **modulation** takes place, crosses the midline, and goes up spinothalamic tract to the thalamus, and then into the cortex where pain **perception** takes place. * Transient Receptor Potential (TRP) = They are a group of **ion channels** located mostly on the plasma membrane of numerous animal cell types. They are indirect mediators of pain, **making things more or less sensitive. They are involved with transduction.**

Answer 219

D. Meperidine * The three other NSAIDS that are **prescription only:** * 1. **Indomethacin** - potent non-selective NSAID/ due to side effects not a common analgesic * 2. **Meloxicam** - **preferentially inhibits Cox-2 over Cox-1**/ **means less GI problems** * 3. **Diflunisal** - Related to salicylates- supposed to be good for **bone pain** * The two Ibuprofen-like NSAIDS are **Ketoprofen** and **Naproxen**. Ketoprofen is same properties, but more potent; 50 mg is recommended analgesic dose. Naproxen is longer-lasting and slower-acting **(Aleve)** * Other Opioid Narcotic: * 1. **Meperidine** (for moderate pain, demerol)

Answer 220

Osteomyelitis Osteomyelitis (inflammation of bone/marrow) a. blood-born or direct b. trauma from compound fractures c. **pyogenic infections (e.g., staph aureus or salmonella)** d. **granulomatous (TB or fungal)- called “Pott disease” when associated with TB** e. **Diabetes**—due to poor circulation in the extremities-if chronic can form a drainage site and can even become osteosarcoma

Answer 221

Decrease their effectiveness

Answer 222

1. • Loss of interest in performing daily routines (brushing, flossing) 2. • Cariogenic diet (increase in refined sugars) 3. • Rampant caries 4. • Medica5on related xerostomia

Answer 223

Systolic = 120 Diastolic = 80 Systolic goes up by 20's Diastolic goes up by 10's 1. Normal \<120/80 2. Pre-Hypertensive 3. Mild 4. Moderate 5. Severe \>180/110

Answer 224

1. Don’t exceed 0.04 mg/apt of epinephrine (4 carpules) 1. Each carp of 1:100,000 has 0.01 mg/ml of epi 2. Avoid use of Marcaine 0.5% (Bupivicaine) 3. Consider using Carbocaine 3% plain (Mepivicaine) (no epi so you have to work fast because it runs out faster)

Answer 225

* Severe Hypertension * • Defer elective treatment until BP is better controlled * • Consider referral to OMFS for emergencies * • Hypertensive Urgency or Crisis * • Send pt. to emergency room immediately * • Life threatening (don’t adopt an “I can manage the situation” aftude) * **Patients on Nifedipine may have gingival overgrowth**

Answer 226

Hypo = \< 50 mg/dL Hyper = \>180 mg/dL

Answer 227

* **Signs and symptoms of hypoglycemia** * • \<50 mg/dL * • Bizarre behavior/changes in personality * • Weakness, dizziness * • Pale, moist skin * • Normal or depressed respira\>ons * • Headache * • Altered level of consciousness (syncope) * • Monitor pt. for at least 1 hour before leang them leave office * **• Signs and symptoms of hyperglycemia** * • \>250 mg/dL blood glucose * • Dry, warm skin * • Kussmaul’s respirations * • Fruity, sweet breath odor * • Rapid, weak pulse * • Normal to low blood pressure * • Altered consciousness

Answer 228

* **Hypoglycemia** * • Terminate dental tx * • Posi\>on pa\>ent comfortably * • Administer 100% Oxygen * • Administer Oral carbs if **conscious**: * • Icing, juice, soda, glucose tablets etc * • Administer if **unconscious:** • * Icing under the tongue * • 50% dextrose (20-50 ml) IV * Glucagon 1 mg IM or IV * • Epineprnine 1/1000 o.5 mg IM * • Get medical assistance if needed * • **Hyperglycemia (conscious) ASA IV** * • No dental treatment should be rendered * • Refer to physician * • **Hyperglycemia (unconscious) ASA IV** * • Terminate dental tx * • Posi\>on Supine (legs elevated) * • BLS * • Summon Emergency Assistance(call 911) * • Administer 100% Oxygen * **Schedule morning appointments for diabe\>c pa\>ents** * **• If fas\>ng blood glucose is \<70mg/dL, defer or give carbs** * **• If fas\>ng blood glucose is \>200mg/dL, defer and refer to physician** * **• If pa\>ent is uncontrolled diabe\>c, has open skins sores, in a wheel chair, or amputa\>on of limbs, MED CONSULT prior to any procedures**

Answer 229

1. ́ Pocket depths 6 mm or more 2. ́ Excessively mobility or purulence 3. ́ Periapical inflammation 4. ́ Broken down, non-restorable teeth 5. ́ Non-functional, partially erupted (pt. is non-compliant with OH measures) 6. ́ Pt. is uninterested in saving a particular tooth or teeth 7. ́ Tooth is associated with an inflammatory, infectious or osseous disease

Answer 230

* ́ Perform extractions with minimal trauma * ́ At least 2-3 weeks prior to initiation of radiation therapy (3 is ideal) * ́ At least 5 days (in maxilla) before initiation of chemotherapya * ́ At least 7 days (in mandible) before initiation of chemotherapy * ́ Trim bone at wound margins to eliminate sharp edges * ́ Obtain primary closure * ́ Avoid intra-alveolar hemostatic packing agents (nidus for bacteria) * ́ Delay if white blood cell count is less than 2,000/mm3 or absolute neutrophil is less than 1,000/mm3, or expected to be this level within 10 days * ́ Antibiotic Prophylaxis can be used with extractions that are mandatory * **Also if they have or are suspected of osteoradionecrosis,** Use non-lidocaine local anesthetic (e.g., Prilocaine plain or forte) for dental procedures. Minimize or avoid vasoconstrictor, if must use low concentration of epi (1:200,000). Consider Hyperbaric oxygen. **Minimize hypovascularity after radiation therapy, and do Endo over Extraction, less trauma.**

Answer 231

* Consists of **6** licensed dentists, **2** licensed dental hygienists, and **1** member of the general public

Answer 232

1. • Class I permit- Allows for local anesthesia (topical and local anesthetics) 2. • Class II permit- Allows for minimal sedation **(Nitrous Oxide)** 3. • Class III permit- Allows for moderate sedation 4. • Class IV permit- Allows for deep sedation

Answer 233

* Dental professional should recommend use of OTC drugs with cau

• OTC drugs are intended for short-term use • Never recommend off-label use of OTC drugs

• Never recommend higher doses than indicated

Answer 234

* • Acetaminophen * • **500 mg q4-6h prn pain** * • Not to exceed **3,000** mg per day * • Ibuprofen (mild to mod pain) * • **400-600 mg q6h prn pain** * • Not to exceed **3200** mg per day * • Ibuprofen (severe pain) * • **800 mg q8h prn pain** * • Not to exceed **3200** mg per day

Answer 235

* Prostatic adenocarcinoma is most common malignancy (except skin cancers) in older men; 60% of men \>80 years old— * Most often detected by rectal exams * Many are small and not clinically significant * Most metastasize to bone and occasionally to regional lymph nodes * However, can be deadly in some patients, especially in younger men * PSA (prostate specific antigen)-only associated with prostate tissue * \>4-6 mg/ml is abnormal (usually higher with age) * Rapidly increasing PSA means high risk for cancer * The more PSA bound to alpha-1-antichymotrypsin, the greater the risk of cancer * Treatment * Prostatectomy (affects bladder function) * Radiation * Hormonal: block androgen receptors-affects male functions * Chemotherapy or bisphosphonate