General Medicine Flashcards
Sample size of a study must be large enough to reject __, which is that no difference exists in the group that received the intervention compared with the group that did not.
Null hypothesis
Power of a study depends on these three factors
Sample size, expected difference in outcome of interest between groups, variability of outcome of interest (standard deviation)
This occurs when a researcher expects a different result in intervention group and adjusts his measurement of the outcome of interest to satisfy this expectation.
Investigator bias
This is the appropriate statistical test to compare an intervention and control group if data are normally distributed and continuous (ex: macular thickness)
Student’s t-test
This is an appropriate statistical test to compare an intervention and control group if data are not normally distributed but are continuous
Wilcoxon rank sum test
This statistical test can be used for categorical data (present or absent; small, medium, or large)
Chi-square test
This is the percentage of those who have disease and also have abnormal test results
Sensitivity
This is the percentage of disease-free people with normal test results
Specificity
This is the percentage of those with disease + abnormal test and all those with an abnormal test
Positive predictive value
This is the percentage of disease-free people + negative test and all those with a negative test
Negative predictive value
This is a graphical representation of sensitivity and specificity, where sensitivity is on the y-axis and (1 - specificity) is on the x-axis.
Receiver operating characteristic (ROC) curve
These six hormones increase plasma glucose levels.
Somatotropin, adrenocorticotropin, cortisol, epinephrine, glucagon, thyroxine
Diagnosis of diabetes is made with one of these four criteria (confirmed with retesting on a subsequent day)
HbA1c >/= 6.5%, FPG >/=126 mg/dL, 2hr gluc >/=200 (75g OGTT), random gluc >/= 200 w/ symptoms
Fasting plasma glucose level and 2-hour, 75g OGTT results diagnostic of impaired glucose tolerance (IGT)
Fasting gluc 110-126, 2-hr 75g OGTT 140-200
This is the occurrence of rebound hyperglycemia after hypoglycemia.
Somogyi phenomenon
This occurs when a normal physiologic process is exaggerated, resulting in substantial hyperglycemia (characterized by early-morning hyperglycemia not preceded by hypoglycemia or waning of insulin -> surge of GH shortly after falling asleep)
Dawn phenomenon
Symptoms of this include: palpitations, perspiration, pallor, tachycardia, HTN, dilated pupils (from hyperepinephrinemia); HA, paresthesia, blurred vision, drowsiness, irritability, bizarre behavior, AMS, combativeness (neurologic manifestations).
Hypoglycemia
These are three second-generation sulfonylureas, which reduce HbA1c by 0.5-1.5%. They are inexpensive and act by stimulating pancreatic insulin secretion. ADE: hypoglycemia, weight gain.
Glimepiride, glipizide, glyburide
This is a biguanide medication that is used first-line in the treatment of DM2; it reduces HbA1c by 1.5%. It increases insulin sensitivity and can lead to modest weight loss. ADE: GI upset, metallic taste, lactic acidosis.
Metformin
These are two alpha-glucosidase inhibitors, which reduce HbA1c by 0.5-0.8%. They delay absorption of carbs by inhibiting the breakdown of complex carbs into monosaccharides. ADE: flatulence.
Acarbose, miglitol
These are two thiazolidinediones, which reduce HbA1c by 0.5-1.4%. They increase insulin sensitivity in muscle and adipose tissue and inhibit hepatic gluconeogenesis. ADE: weight gain, fluid retention with CV complications, higher rates of DME.
Pioglitazone, rosiglitazone
These are two meglitinides, which reduce HbA1c by 0.5-1.5%. Their mechanisms and ADEs are similar to sulfonylureas.
Nateglinide, repaglinide
These are three glucagon-like peptide-1 (GLP-1) agonists, which reduce HbA1c by 0.5-1.0%. They are incretin mimetics that enhance pancreatic insulin secretion, inhibit glucagon secretion, and promote satiety. ADE: GI upset, pancreatitis, thyroid C-cell tumor development.
Exenatide, liraglutide, lixisenatide
These are four dipeptidyl-peptidase IV (DPP-IV) inhibitors, which reduce HbA1c by 0.7-1.2%. DPP-IV normally deactivates incretins, so these medications function similarly to GLP-1 agonists. They are expensive.
Linagliptin, saxagliptin, sitagliptin, vildagliptin
These are two sodium-glucose transporter-2 (SGLT2) inhibitors, which reduce HbA1c by 0.6-1.0%. They increase urinary glucose excretion, leading to weight loss and improved glucose levels. ADE: hypotension, dehydration, UTI.
Canagliflozin, dapagliflozin
These cells secrete calcitonin and play a role in calcium homeostasis.
Parafollicular (or C) cells
These are made up of a single layer of epithelial cells surrounding colloid, which consists mostly of thyroglobulin, the storage form of T4 and T3.
Thyroid follicles
This is the main secretory product of the thyroid gland.
T4 (thyroxine)
This is the metabolically active form of thyroid hormone, 80% of which is created by deiodination of its predecessor in the liver and kidneys and 20% of which is secreted directly by the thyroid gland.
T3 (triiodothyronine)
These two thyroid tests are elevated in pregnancy and with OCP use.
TBG and total T4 (free T4 remains WNL)
This antibody is found in 95% of patients with Hashimoto thyroiditis, 55% of patients with Graves, and 10% of adults with no apparent thyroid disease.
Thyroid microsomal antibody
High serum levels of thyroid-stimulating Ig and the absence of thyroperoxidase antibody are both risk factors for this complication of Graves disease.
Thyroid (Graves)-associated ophthalmopathy
Clinical findings of _ include exophthalmos, chest palpitations, excessive sweating, diarrhea, weight loss, heat sensitivity. It can progress to _, which is often precipitated by surgery, infection, or trauma and presents with fever, tachycardia, n/v, agitation, and psychosis. Patients can become comatose 2/2 hypotension, and it is fatal if untreated.
Hyperthyroidism (thryotoxicosis); thyroid storm
This is brawny, non-pitting swelling of the pretibial area, ankles, or feet that is almost always associated with thyroid eye disease.
Infiltrative dermopathy
This is non-pitting edema caused by subcutaneous accumulation of mucopolysaccharides in severe cases of hypothyroidism.
Myxedema
This is manifested by weakness, fatigue, memory loss, dry skin, hair loss, deepening of the voice, weight gain (despite loss of appetite), cold intolerance, arthralgias, constipation, and muscle cramps.
Hypothyroidism
This is the most common form of thyroid cancer. There appears to have no adverse effect on survival if removed before extension outside the capsule of the gland.
Papillary carcinoma
Like papillary carcinoma, this thyroid cancer is associated with a normal lifespan if identified before it becomes invasive, but late metastases can occur.
Follicular carcinoma
This thyroid cancer arises from C cells and produces calcitonin. It can occur as a solitary malignant tumor or as part of MEN 2.
Medullary carcinoma
This rare tumor is the most malignant tumor of the thyroid gland, found mainly in patients >60 y/o. In the giant cell form, survival is <6 months from the time of diagnosis. In the small cell form, 5-year survival is 20-25%.
Anaplastic carcinoma
Size of pituitary microadenomas vs macroadenomas
micro: <10mm; macro: >/= 10mm
This results from hemorrhage or infarction in a pituitary adenoma. Symptoms include sudden excruciating HA, visual field loss, diplopia (pressure on oculomotor nerves), and hypopituitarism (including hypocortisolism). Reduced vision and AMS are indications for transsphenoidal surgical decompression.
Pituitary apoplexy
This is characterized by parathyroid, enteropancreatic, and pituitary tumors. S/S include hyperparathyroidism, Zollinger-Ellison syndrome, insulinomas, prolactinomas, etc. Carcinoid and adrenal tumors can develop as well.
Multiple endocrine neoplasia type 1 (MEN 1)
This is characterized by medullary thyroid carcinoma, pheochromocytoma, and hyperparathyroidism.
Multiple endocrine neoplasia type 2a (MEN 2a)
This is characterized by medullary thyroid carcinoma, ganglionomas (on lips, eyelids, and tongue), pheochromocytoma, and marfanoid features (pectus excavatum and scoliosis but without lens subluxation or aortic disease). Patients also have prominent corneal nerves in a clear stroma (100% of patients), making ophthalmologists potentially instrumental in early diagnosis.
Multiple endocrine neoplasia type 2b (MEN 2b)
This secondary cause of HTN presents with a flank mass.
Polycystic kidney disease
This secondary cause of HTN presents with unilateral abd bruit in a young patient with marked HTN; new-onset HTN with severe end-organ disease
Renovascular disease
This secondary cause of HTN presents with markedly labile BP with tachycardia and HA.
Pheochromocytoma
This secondary cause of HTN presents with persistent hypokalemia in the absence of diuretic therapy or marked drop with low-dose diuretics.
Hyperaldosteronism
This secondary cause of HTN presents with delayed or absent femoral pulses in a young patient.
Coarctation of the aorta
This secondary cause of HTN presents with truncal obesity and abdominal striae
Cushing syndrome
BP goal in DM or renal disease
<130/80
These medications increase sodium load in the distal tubules and initially decrease plasma volume and cardiac output through natriuresis. As the RAAS compensates for decreased plasma volume, CO returns to normal and PVR is lowered.
Thiazide-type diuretics (chlorothiazide, chlorthalidone, HCTZ)
These medications act on the ascending loop of Henle and block sodium resorption, causing an initial decrease in plasma volume. BP is eventually lowered due to decreased PVR. They are used in pts with moderate renal insufficiency.
Loop diuretics (furosemide, bumatenide, torsemide)
These medications competitively block the action of aldosterone to prevent potassium loss from the distal tubule, or they act directly on the distal tubule to inhibit aldosterone-induced sodium resorption in exchange for potassium.
Potassium-sparing diuretics (amiloride, triamterene, eplerenone, spironolactone)
The ADE of these medications include a dry cough, angioneurotic edema, hypotension, hyperkalemia, abnormal taste, leukopenia, proteinuria, and renal failure (in pts with pre-existing renal insufficiency). They should be avoided in pts with angioedema, and they are contraindicated in pregnancy (adverse effects on fetal renal function, fetal death)
Angiotensin-converting enzyme (ACE) inhibitors (benazepril, captopril, enalapril, fosinopril, lisinopril)
These medications cause fewer ADEs than ACE inhibitors (no cough), and angioedema is rare. They are also contraindicated in pregnancy.
Angiotensin II receptor blockers (ARBs) (candesartan, irbesartan, losartan)
These medications act by blocking entry of calcium into vascular smooth muscles, leading to decreased myocardial contractility and decreased SVR. ADE include constipation, HA, fatigue, dizziness, nausea, palpitations, flushing, edema, gingival hyperplasia, arrhytmias, and cardiac ischemia.
Calcium channel blockers (non-dihydropyridines: diltiazem, verapamil; dihydropyridines: amlodipine, nicardipine, nifedipine)
These two medications have both alpha- and beta-blocking properties, so in addition to acting as a beta blocker, they produce additional vasodilatory effects.
Carvedilol, labetalol
These medications have a “first-dose effect,” in which BP is decreased more with the initial dose than with subsequent doses. They can also cause orthostatic hypotension, HA, dizziness, and drowsiness.
Alpha-1 blockers (dexazosin, prazosin, terazosin)
These are potent, central-acting anti-hypertensive that decrease sympathetic tone, cardiac output, and PVR. ADE: fluid retention, dry mouth, dizziness, orthostatic hypotension, rash, impotence, hepatitis, positive Coombs and ANA test, and heart failure in patients with left ventricular dysfunction.
Alpha-2 agonists (and other centrally acting drugs) (clonidine, guanfacine, methyldopa, reserpine)
These are two direct-acting vasodilators that decrease PVR. They are generally reserved for pregnancy or intractable HTN. They should be used with caution in ischemic heart disease. ADE: HA, tachycardia, edema, n/v, lupus-like syndrome, hypertrichosis.
Minoxidil, hydralazine
This is a direct renin inhibitor used to treat HTN. It is more likely to be effective in young, white patients or in any patients receiving diuretics or CCBs (renin system activation). ADE: diarrhea.
Aliskiren
This is defined as the presence of central obesity and two of the following: triglyceride >150, reduced HDL, SBP >130 or DBP >85, fasting gluc >100.
Metabolic syndrome
This is characterized by pregnancy, HTN, proteinuria, generalized edema, and possibly coagulation and liver function abnormalities after 20wks gestation
Preeclampsia (eclampsia = preeclampsia + generalized seizures)
This grade of hypertensive retinopathy is characterized by arteriolar narrowing, AV nicking, opacity (“copper wiring” due to thickening of arteriolar wall, or a combination of these.
Mild
This grade of hypertensive retinopathy is characterized by hemorrhage (blot, dot, or flame-shaped), microaneurysm, cotton-wool spot, hard exudates, or a combination of these signs.
Moderate
This grade of hypertensive retinopathy is characterized by signs of moderate retinopathy (hemorrhage, microaneurysms, cotton-wool spots, and/or hard exudates) plus swelling of the optic disc.
Malignant
This is manifested by precordial chest pain or tightness often triggered by physical exertion, emotional distress, or eating. It is due to atherosclerotic heart disease. It typically lasts 5-10 minutes, it is relieved by rest and/or nitroglycerin, and its pattern of symptoms have not changed substantially over >3 months.
Stable angina pectoris
This is manifested by precordial chest pain or tightness that occurs at rest and is not related to physical exertion. There are ST elevations on ECG during pain episodes, which are caused by coronary artery vasospasms. Underlying atherosclerosis is present in 60-80% of cases, and thrombosis/occlusion may result during one of these episodes.
Variant (Prinzmetal) angina
These are four direct thrombin inhibitors that can be used in acute coronary syndrome or for other conditions requiring anticoagulation.
Hirudin, bivalirudin, argatroban, dabigatran
These are three glycoprotein IIb/IIIa inhibitors that have been shown to reduce the risk of death and MI in patients with NSTEMI, as well as after coronary angioplasty and stenting. They prevent fibrinogen binding and platelet aggregation.
Tirofiban, abciximab, eptifibatide
This is manifested by respiratory distress, pinkish sputum or frank hemoptysis, coarse rales, expiratory wheezes, tachycardia, S3 gallop, diaphoresis, AMS.
CHF with left ventricular failure
This is manifested by elevated central venous pressure, pedal edema, hepatomegaly, cyanosis, and sometimes pleural effusion or ascites. It is oftentimes seen in long-standing CHF.
CHF with right ventricular failure
Use of this medication leads to corneal epithealial whorl-like microdeposits in nearlly all patients who use it for an extended time. Patients may report hazy vision or colored halos around lights. Patients may also get discoloration of periocular skin (slat-gray or blue color) due to photosensitivity. Rarely, a patient may have associated optic neuropathy.
Amiodarone
These medications may cause a keratoconjunctivitis sicca-like syndrome likely due to decreased lacrimation. They may also decreased IOP and cause certain visual disturbances and visual hallucinations.
Systemic beta blockers
This medication causes glare and disturbances of color vision, including decreased vision; blue-yellow pattern defects; a yellow, green, blue, or red tinge to objects; and colored halos (mainly blue) around lights. They may also have yellow or green flickering vision, colored borders around objects, glare phenomena, light flashes, scintillating scotomata, frosted appearance to objects, and formed visual hallucinations.
Digoxin
These medications may cause angioedema involving the eye and orbit due to disruption of bradykinin metabolism.
ACE inhibitors
This is the ischemic, but not infarcted, area of the brain in a stroke. It is dynamic, and earlier treatment can prevent infarction and permanent neurologic injury.
Penumbra
This can present with the classic triad of Horner’s syndrome, neck pain/HA, and neurologic signs and symptoms.
Carotid dissection
These are the annual stroke rates among patients with isolated transient monocular visual loss (TMVL), retinal infarct, or retinal TIA, respectively. Untreated, these patients have a 30% risk of MI and 18% risk of death at 5 years.
2%, 3%, and 8%
85% of these develop in the anterior part of the circle of Willis, most commonly at the origin of the PCA from the internal carotid artery. Presentation: HA, CN 3 palsy involving the pupil.
Congenital saccular (or “berry”) aneurysms
This is a group of reversible, obstructive airway diseases in which the airways are hyperresponsive and develop an inflammatory response with bronchospasm to various stimuli.
Asthma
This is a group of irreversible obstructive airways diseases in which forced expiratory flow is reduced in either a constant or a slowly progressive manner over months to years.
Chronic obstructive pulmonary disease (COPD: emphysema, chronic bronchitis, peripheral airway disease)
This is a diverse group of conditions that cause diffuse parenchymal damage to the lung, leading to a reduction in total lung volume, diffusing capacity, and vital capacity. It can also occasionally be seen in patients with disease of the chest wall, respiratory muscles, pleura, or spine.
Restrictive lung disease (fibrotic disease, granulomatous disease, collagen vascular diseases, etc)
What FEV1/FVC ratio suggests obstructive lung disease?
<70%
What total lung capacity suggests restrictive lung disease?
<70%
These are three eye findings associated with OSA.
Floppy eyelid syndrome, keratoconus, and nonarteritic anterior ischemic optic neuropathy (NAION)
Nasal CPAP for OSA can worsen these two eye conditions.
Glaucoma (can moderately increase IOP), DES
These are three short-acting beta-2 agonists used to treat bronchoconstriction.
Fenoterol, salbutamol, isoetharine
These are two long-acting beta-2 agonists used to treat bronchoconstriction.
Formoterol, salmeterol
This is a peptide hormone produced by the liver that inhibits iron transport across intestinal mucosa and out of macrophages (the site of iron storage and transport).
Hepcidin
In this condition, the incorporation of iron into heme is defective, and hemoglobin synthesis is reduced. Iron accumulates in mitochondria, and Prussian blue stain of bone marrow will show few granules of hemosiderin in the cytoplasm of erythroblasts. Causes: genetic, myelodysplastic syndromes, chronic alcoholism, lead poisoning.
Sideroblastic anemia
This is produced by gastroparietal cells and is required for the absorption of B12 in the terminal ileum.
Intrinsic factor
This is a humanized monoclonal antibody against complement component C5, which is used in the treatment of paroxysmal nocturnal hemoglobinuria. It can also be used to treat TTP.
Eculizumab
These are oxidized hemoglobin precipitants found in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency (x-linked recessive).
Heinz bodies
This is an autosomal dominant condition characterized by localized dilation of capillaries and venules of the skin and mucous membranes. These lesions increase in size and number over decades, often leading to profuse bleeding. Conjunctival lesions are common.
Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease)
This autosomal dominant condition is characterized by hyperplastic, fragile skin and hyperextensible joints. Easy bruising and hematomas are common. Ocular manifestations include microcornea, myopia, and angioid streaks. Retinal detachment and ectopia lentis have also been reported.
Ehlers-Danlos syndrome
This autosomal dominant condition is characterized by bone fractures and otosclerosis (leading to deafness). Easy bruising and hematomas are common. Blue sclerae are typical in this condition.
Osteogenesis imperfecta
This results from platelet injury by antiplatelet antibodies. The acute form usually occurs in children and young adults following a viral illness, and it commonly undergoes spontaneous remission. The chronic form is more common in adults and has mild manifestations but does not commonly remit spontaneously. Tx: corticosteroids, IVIG, anti-D immunoglobulin, rituximab, or mycophenolate mofetil, thrombopoietin agonists, splenectomy.
Idiopathic thrombocytopenic purpura (ITP)
These are 2 thrombopoietin agonists approved for the treatment of ITP.
Romiplostim, eltrombopag
This is characterized by thrombocytopenia, thrombotic occlusions of the microcirculation, and hemolytic anemia. Fever, neuro sxs, anemia, and renal dysfunction can occur abruptly with death within days to weeks of untreated cases. Tx: exchange plasmapheresis, antiplatelet drugs, corticosteroids, immunosuppressive agents, eculizumab.
Thrombotic thrombocytopenis purpura
How long can a single aspirin modestly prolong bleeding time?
48-72 hours
Most common inherited bleeding disorder. These patients are deficient in a factor that stabilizes factor VIII to prevent degradation and functions in platelet adhesion.
von Willebrand disease
Ophthalmic complications of this include retinal vein and artery occlusion, retinal vasculitis, choroidal infarction, and anterior ischemic optic neuropathy. Tests for patients with this syndrome include anticardiolipin antibodies and lupus anticoagulants.
Antiphospholipid antibody syndrome
These are two factor Xa inhibitors, which are novel oral anticoagulants.
Rivaroxaban (Xarelto), apixaban (Eliquis)
This disorder is characterized by an additive, symmetric, deforming, peripheral polyarthritis that primarily affects the small joints of the hands and feet. Boutonniere deformity (abnormally flexed PIP joint and extended DIP joint), swan-neck deformities, and ulnar deviation can be seen. Ocular manifestations include DES, scleritis, episcleritis, and marginal corneal ulcers.
Rheumatoid arthritis
These two antibodies are highly sensitive and specific for rheumatoid arthritis.
Anti-cyclic citrullinated peptide (anti-CCP) and anti-mutated citrullinated vimentin (anti-MCV)
This is the triad of rheumatoid arthritis, splenomegaly, and neutropenia. Patients may also have hyperpigmentation, chronic leg ulcers, and recurrent infections.
Felty syndrome
This refers to a spectrum of diseases that share a predilection for axial (spinal and sacroiliac joint) inflammation and HLA-B27 positivity. Enthesitis
(inflammation of the entheses, the sites where tendons or ligaments insert into bone) and dactylitis (painful inflammation of finger or toe) are commonly seen.
Spondyloarthropathies (undifferentiated, ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and IBD)
This is the primary ocular manifestation of ankylosing spondylitis, which does not correlate with the activity of the joint disease.
Nongranulomatous iridocyclitis
This is classically described as the triad of arthritis (episodic oligoarthritis of lower extremities), urethritis, and conjunctivitis (mild, bilateral, and mucopurulent). Precipitating agents include Chlamydia trachomatis (GU) and Salmonella, Shigella, Yersinia, or Campylobacter (GI).
Reactive arthritis
These are extraintestinal manifestations of IBD
Dermatitis, mucous membrane disease, ocular inflammation (iridocyclitis), arthritis
Uveitis in patients with this type of sponydloarthropathy tends to be more insidious in onset, smoldering, posterior, and bilateral.
Psoriatic arthritis
In this form of juvenile idiopathic arthritis, fewer than 5 joints are involved during the first 6 months of illness. Although the arthritis tends to remit, 10-50% of patients may develop chronic iridocyclitis.
Pauciarticular-onset (oligoarticular-onset)
This form of juvenile idiopathic arthritis presents with fever, rash, and arthritis of any number of joints. They may also have hepatosplenomegaly and lymphadenopathy. Ocular disease is generally not associated.
Systemic-onset (Still disease)
These two HLA types are associated with SLE.
DR2 and DR3
Presentation: malar rash, discoid lesions, vasculitic skin lesions, purpuric skin lesions, alopecia, mucosal lesions, photosensitivity, polyarthralgia, fatigue, fever, weight loss, nephritis, Raynaud’s, peri/myocarditis, Libman-Sacks endocarditis, pulmonary involvement, nausea, dyspepsia, HA, szs, psychosis, hemolytic anemia, etc.
Systemic lupus erythematosus (SLE)
These three antibodies are highly specific for SLE.
Anti-dsDNA, anti-Smith (anti-Sm), and antiphospholipid antibodies
These are three major ocular manifestations of SLE.
Discoid lesion of eyelids, keratitis sicca (secondary Sjogren syndrome), and retinal/choroidal microvascular lesions (cotton-wool spots, hemorrhages, vascular occlusions, neovascularizatino)
These three in vitro clotting assays are prolonged by lupus anticoagulants and can help diagnose antiphospholipid antibody syndrome.
Activated partial thromboplastin time (aPTT), dilute Russell viper venom time (dRVVT), and kaolin plasma clotting time (KCT)
This is the limited form of systemic sclerosis (formerly known as scleroderma), a connective tissue disease characterized by fibrous and degenerative changes in the viscera, skin, or both.
CREST syndrome (calcinosis, Raynaud phenomenon, esophageal involvement, sclerodactyly, telangiectasias)
These are three specific anti-nuclear antibodies that are helpful in defining systemic sclerosis and various syndromes that overlap with it.
Anticentromere, anti-topoisomerase I (anti-Scl-70), anti-RNA polymerase
This syndrome has characteristics of both SLE and myositis. It is characterized by a specific autoantibody directed at the U1-ribonucleoprotein complex.
Mixed connective tissue disease
Ocular manifestations of this disease include eyelid tightness and blepharophimosis (but only rarely corneal exposure), conjunctival vascular abnormalities (telangiectasias and vascular sludging), and keratoconjunctivitis sicca. There can be diffuse microvascular damage, leading to patchy choroidal nonperfusion seen on FA.
Systemic sclerosis (formerly known as scleroderma)
This may present as dry eyes, dry mouth, and parotid gland enlargement. It is characterized by lymphocytic infiltration of exocrine glands. Systemic manifestations may include upper-airway dryness, mucous plugs, purpuric vasculitis, hyperglobulinemia, CNS inflammation (mimicking MS or psych symptoms).
Sjogren syndrome
These are the antibodies often found in Sjogren syndrome.
Anti-SS-A (anti-Ro), anti-SS-B (anti-La)
These are the names of the erythematous to violaceous rash typical of dermatomyositis, present on the eyelids, chest, and extensor surfaces, respectively.
Heliotrope rash, V-neck sign, Gottron sign
This is an episodic autoimmune disorder characterized by widespread, potentially destructive inflammation of cartilage, the cardiovascular system, and organ of special sense (saddle-nose deformity, laryngeal collapse, aortic insufficiency, etc). 50% of patients of ocular manifestations: conjunctivitis, scleritis, uveitis, retinal vasculitis.
Relapsing polychondritis
This large-vessel arteritis affects older adults with potentially blinding, granulomatous inflammatory disease affecting the aorta and its branches.
Giant cell (temporal) arteritis
This large-vessel arteritis affects the aorta and its branches, mainly in children and young women It is common in Asia. S/S: fatigue, HA, weight loss, fever, vascular insufficiency.
Takayasu arteritis
This is a necrotizing medium-vessel vasculitis is characterized by segmental lesions, leading to aneurysms. S/S: mononeuritis multiplex (simultaneous or sequential damage to anatomically unrelated peripheral nerves), renal dz, GI dz. Mainly affects 40-50 y/o men. Ocular manifestations: HTN retinopathy, retinal vasculitis, visual field loss (CNS lesions), choroidal vasculitis, exudative retinal detachments.
Polyarteritis nodosa (PAN)
Infection with this virus is strongly linked to polyarteritis nodosa.
Hepatitis B
This medium-vessel vasculitis presents with high persistent fever, swollen lymph nodes, bilateral conjunctivitis, truncal rash, red/swollen tongue, coronary aneuryms, myocarditis, dysrhythmias in infants and young children.
Kawasaki disease
This small-vessel, c-ANCA-associated vasculitis presents with necrotizing granulomatous vasculitis of the upper and lower respiratory tract and focal segmental glomerulonephritis. It is treated with weekly rituximab with high dose corticosteroids. Bactrim may also be helpful.
Granulomatosis with polyangiitis (formerly known as Wegener granulomatosis)
This p-ANCA associated, small-vessel vasculitis is associated with necrotizing glomerulonephritis. It can also affect the lungs and cause arthralgia, rash, and neuropathy. More specific antibodies include MPO-ANCA. May present initial with peripheral ulcerative keratitis.
Microscopic polyangiitis
This p-ANCA associated, small-vessel vasculitis presents with asthma and granulomas with eosinophilic tissue infiltration of smaller vessels. It may also affect the kidneys, heart, skin, and GI tract. CNS involvement may lead to mononeuritis multiplex. Eyes: conjunctival granulomas, retinal vasculitis and occlusion, uveitis, cranial nerve palsies.
Eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss syndrome)
This multisystem vasculitis can affect vessels of any size, and it was initially described as oral ulcers, genital ulcers, and uveitis with hypopyon. It may also have skin involvement and pathergy (pustular response to skin injury). Most untreated patients lose all or part of their vision within 5 years of onset.
Behçet disease
This is characterized by inflammatory lesions of the eye and inner ear. Presentation: fatigue, fever, weight loss, uveitis, interstitial keratitis, scleritis, dizziness, hearing problems. Recurrence may lead to blindness and deafness.
Cogan syndrome
These drugs inhibit phospholipid breakdown to arachidonic acid, blocking production of inflammatory mediators (prostaglandins, leukotrienes). Other effects: gluconeogenesis, increasing circulating neutrophils, fat mobilization, mineralocorticoid activity, osteoporosis, adrenal suppression.
Glucocorticoids (hydrocortisone, cortisone, prednisone, prednisolone, methylprednisolone, triamcinolone, dexamethasone)
These drugs inhibit cyclooxygenase (COX), with analgesic, antipyretic, and anti-inflammatory functions. ADE: GI bleed, renal failure, HTN, heart failure, asthma, interference of platelet function. Rare ocular complications: blurred vision, diplopia, optic neuropathy, macular edema.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
This enzyme is present in most cells and appears to be involved in various aspects of cellular metabolism, including gastric cytoprotection, platelet aggregation, and renal function
COX-1
This enzyme is present in some tissues, such as brain and bone, but is also expressed in response to inflammation. Selective inhibitors of this enzyme may cause vasodilation and inhibit platelet aggregation, leading to increased prothrombotic activity; they can also cause conjunctivitis, temporary blindness, and vague vision blurring.
COX-2
This is a structural analogue of folic acids that interferes with purine and pyrimidine metabolism, increasing extracellular adenosine (which has intrinsic anti-inflammatory activity). All pts are supplemented with folic acid. ADE: GI upset, stomatitis, rash, hepatic fibrosis, interstitial lung dz, bone marrow toxicity, teratogenicity, sterility.
Methotrexate
This drug inhibits pyrimidine synthesis, targeting rapidly dividing cells such as activated lymphocytes to reduce inflammation. ADE: liver toxicity, neuropathy, birth defects. Can be combined with methotrexate when methotrexate alone is ineffective.
Leflunomide
This antimalarial drug is commonly used to treat rheumatologic diseases. It increases pH of cellular compartments, decreasing cytokine production and lymphocyte proliferation. ADE: GI upset, myopathy (rare), retinopathy (bull’s-eye maculopathy, although this is unusual).
Hydroxychloroquine
This drug is effective in treating rheumatoid arthritis, although its mechanism of action is unclear. ADE: hypersensitivity (skin reactions, aplastic anemia), dose-related effects (GI upset, HA). It can be used with other drugs such as hydroxychloroquine and methotrexate.
Sulfasalazine
This is a major proinflammatory cytokine involved in the pathogenesis of inflammatory disease (and five inhibitors used to treat those diseases). Inhibitors of this cytokine are expensive, and they are associated with: opportunistic infections (TB, mycobacteria), demyelinating dzs, lymphoma, cytopenias, heart failure, shingles, lupus-like syndrome, optic neuritis.
Tumor necrosis factor alpha (TNF-alpha); etanercept, adalimumab, infliximab, certolizumab pegol, golimumab
These are two interleukin-1 (IL-1) inhibitors that are used in the treatment of autoimmune diseases.
Anakinra, canakinumab
This is an anti-IL-6 receptor antibody recently approved for the treatment of rheumatoid arthritis and juvenile idiopathic arthritis. It works best when combined with other disease-modifying agents (such as methotrexate).
Tocilizumab
This drug blocks the T-cell receptor CD28, which is involved in T-cell activation, and it can be very effective in treating refractory rheumatoid arthritis.
Abatacept
This is a B-cell-depleting monoclonal antibody (anti-CD20) used primarily for chemotherapy but also in refractory rheumatoid arthritis.
Rituximab
This is a human monoclonal antibody that inhibits B-cell activation by binding to B-cell activating factor (BAFF). It is approved for the treatment of SLE, but it is not very effective and has a risk of infection and increased mortality.
Belimumab
This is a monoclonal antibody that binds to CD52, a protein on mature lymphocytes, that is used to treat CLL and has shown promise in autoimmune diseases.
Alemtuzumab
These are two alkylating agents that are very potent immunosuppressive drugs. They cross-link DNA to block replication. ADE are severe: infertility, BM suppression, infection, late malignancy.
Cyclophosphamide, chlorambucil
This is an antimetabolite that interferes with purine metabolism. ADE: GI upset, infection, BM suppression. Up to 10% of patients may have more pronounced BM suppression and toxicity due to reduced levels of thiopurine methyltransferase (TPMT).
Azathioprine
These two agents inhibit the transcription of IL-2 and other cytokines, primarily in helper T cells. They are primarily used to help prevent rejection in transplantation, but they can also be used to treat autoimmune diseases. ADE: nephrotoxicity, HTN, infection, nonmelanoma skin cancers.
Cyclosporine, tacrolimus
This drug inhibits the production of guanosine in lymphocytes and decreases cellular proliferation and antibody production. It was initially used in transplantation but is also used in patients with immunologic diseases. ADE: GI upset, BM suppression, infection.
Mycophenolate mofetil
These are the changes that occur in the eye due to aging.
Soft tissue atrophy (secondary ptosis due to dermatochalasis and levator dehiscence); DES (lacrimal gland, meibomian gland, and goblet cell dysfxn); conjunctival atrophy and reduced corneal sensitivity; miosis with decreased pupillary reactivity; increased incidence of presbyopia, cataract, glaucoma, AMD, diabetic retinopathy; decreased contrast and visual field sensitivity
Functional assessment of geriatric patients should include documentation of how vision loss affects these, including things such as reading, driving, taking medications properly, and using the telephone independently.
Instrumental activities of daily living (IADLs)
Major depressive disorder is characterized by episodes of at least 2 weeks of depressed mood or loss of interest or pleasure in activities with 4 or more of these symptoms.
Changes in appetite, weight loss/gain, sleep disturbance, agitation, diminished libido, retardation (slowing down), energy loss, feelings of worthlessness or guilt, difficulties in concentration and decision making, recurrent thoughts of suicide or death
These drugs are commonly prescribed for postmenopausal women to inhibit bone resorption. They may be associated with inflammatory disease of the eye (conjunctivitis, uveitis, episcleritis, and scleritis)
Bisphosphonates
This is the inability to understand instructions, integrate information, and perform tasks.
Executive function deficit
The hallmarks of this condition include hallucinations, delusions, disorganized thinking, and negative symptoms (emotional and cognitive blunting, social and occupational dysfunction).
Schizophrenia
This is the inability to experience pleasure, which is one of the hallmarks of MDD.
Anhedonia
This disorder is characterized by mania with or without depressive episodes.
Bipolar I disorder
This disorder is characterized by MDD and at least one mild manic episode (hypomania).
Bipolar II disorder
This type of personality disorder has a tendency to develop schizophrenia. It includes paranoid, schizotypal, and schizoid disorders.
Cluster A personality disorders
This type of personality disorder may display dramatic or irrational behavior and may be very disruptive. It includes antisocial, borderline, histrionic, and narcissistic.
Cluster B personality disorders
This type of personality disorder often stems from maladaptive attempts to control anxiety. It includes avoidant, dependent, and OCPD.
Cluster C personality disorders
Sedative or ethanol use can cause this type of nystagmus.
Sustained, horizontal gaze-evoked nystagmus
Ocular manifestations of this substance-induced congenital syndrome include blepharophimosis, telecanthus, ptosis, optic nerve hypoplasia or atrophy, and tortuosity of the retinal arteries and veins.
Fetal alcohol syndrome
This recreational drug causes a temporary (3-4 hour) lowering effect on intraocular pressure. However, the effect is transient and makes this drug clinically useless in ophthalmology.
Marijuana
Second generation antipsychotics (especially olanzapine, quetiapine, and clozapine) have these adverse effects that may affect the eye.
Diabetes mellitus (secondary refractive and retinal vascular changes), anticholinergic properties (DES, accomodative symptoms, precipitation of angle-closure glaucoma)
Animal studies suggest that quetiapine, a second generation antipsychotic, may increase the risk of this ophthalmic condition.
Cataracts
First generation antipsychotics (especially thioridazine) have these ocular adverse effects.
Corneal deposition, lens pigmentation, retinal pigmentary degeneration, blepharospasm (from EPS side effects)
This class of anti-depressant can cause nonspecific visual symptoms (such as blurred vision) in 2-10% of patients, “tracking” difficulties (more common in withdrawal), mydriasis (which rarely can cause angle-closure glaucoma)
SSRIs
This class of anti-depressant has a significant risk of hypertensive crisis and can interact with various drugs (vasopressors, decongestants) or foods high in tyramine (cheese, herring, liver, yeast, yogurt, red wine, and beer).
MAO inhibitors
This mood stabilizer has been reported to cause a Stevens-Johnson reaction.
Lamotrigine
The ocular adverse reactions of this mood stabilizer include blurred vision, irritation due to secretion in tears or changes in sodium transport, nystagmus (usually downbeat), and exophthalmos associated with changes in thyroid function.
Lithium
This is a catechol-O-methyltransferase inhibitor that can extend the duration of the levodopa effect and reduce the “off” time by inhibiting the methylation of levodopa and dopamine.
Entacapone
These are five dopamine agonists that stimulate dopamine receptors in the brain and may delay the need for levodopa.
Bromocriptine, pramipexole, ropinirole, rotigotine, apomorphine
This is a MAO B inhibitor that may modestly improve the symptoms of Parkinson disease.
Selegiline
These are two anticholinergic medications that can help control the tremor and rigidity of Parkinson’s disease; however, the adverse effects can be problematic.
Trihexyphenidyl, benztropine
This is an antiviral drug that is effective in the early stages of Parkinson’s disease, although the effectiveness may wear off after several months.
Amantadine
These are five eyelid disorders that can be seen in patients with Parkinson disease.
Seborrheic dermatitis/blepharitis, apraxia of eyelid opening, eyelid retraction, decreased blinking (secondary DES), and blepharospasm
These are six ocular motor abnormalities seen in patients with Parkinson disease.
Convergence insufficiency, upgaze limitation, hypometric saccades, saccadic pursuit, square-wave jerks, oculogyric crisis
This is a transient focal motor deficit that lasts for hours or, in rare cases, days after an epileptic convulsion. It may be related to either neuronal exhaustion or to active inhibition.
Postictal paresis (Todd paralysis)
This congenital syndrome caused by substance ingestion during pregnancy is characterized by hypertelorism, epicanthal folds, glaucoma, optic nerve hypoplasia, and retinal colobomas.
Fetal hydantoin syndrome
This anti-epileptic medication can cause saccadic eye movements and has been associated with isolated cases of downbeat nystagmus and oscillopsia. Blurred vision, diplopia, and nystagmus may also occur.
Carbamazepine
This anti-epileptic medication may cause acute angle-closure glaucoma, anterior chamber shallowing, acute myopia, and choroidal effusions (usually within first 2 weeks of use).
Topiramate
This anti-epileptic medication is approved for those who are unresponsive to other medications. Long-term exposure causes irreversible, concentric visual field loss. Central vision can also be affected. Because of this, the drug is available only through a special restricted distribution program.
Vigabatrin
This is the second most common form of neurodegenerative dementia, and it often presents with complex (or formed) visual hallucinations. With treatment, these can improve.
Lewy body dementia
This is the mnemonic of characteristics suggestive of melanoma.
ABCDE (asymmetric, borders irregular, color variability, diameter >6mm, evolving)
These chemotherapeutic drugs are derived from the periwinkle plant. They block the incorporation of orotic acid and thymidine into DNA and cause arrest and inhibition of mitosis.
Vinca alkaloids (vincristine, vinblastine)
These chemotherapeutics are semisynthetic plant derivatives that arrest cells in the G2 phase.
Podophyllin derivatives (etoposide, teniposide)
This chemotherapeutic was originally isolated from the bark of the Pacific yew tree. It is approved to treat breast, ovarian, and lung cancer as well as Kaposi sarcoma. It stops microtubules from breaking down, thus preventing cell growth and division.
Paclitaxel
This bacteria colonizes the anterior nares and other skin sites, and more than 25% are beta-lactam resistant. It causes furuncles, acne, bullous impetigo, paronychia, osteomyelitis, septic arthritis, deep-tissue abscesses, bacteremia, endocarditis, enterocolitis, pneumonia, wound infections, scalded skin syndrome, toxic shock, and food poisoning.
Staphylococcus aureus
This bacteria causes a variety of acute suppurative infections through droplet transmission. Infection is modulated by an opsonizing antibody, which provides a type-specific immunity that lasts for years. Infections include pharyngitis, impetigo, pneumonia, erysipelas, wound and burn infections, peureral infections, and scarlet fever.
Group A beta-hemolytic streptococci (Streptococcus pyogenes)
These are lancet-shaped diplococci that cause alpha-hemolysis on blood agar. Its virulence is determined by its complex polysaccharide capsule, of which there are more than 80 distinct serotypes. Infections include sinusitis, meningitis, otitis media, and peritonitis.
Streptococcus pneumoniae
This is an endemic anaerobic gram-positive bacillus that is part of the normal GI flora. It can cause fever and diarrhea that develops 1-14 days after the start of antibiotic therapy, causing a pseudomembranous enterocolitis. Tx: metronidazole x10 days
Clostridium difficile
This is a common upper respiratory bacteria with 6 serotypes based on differing capsular polysaccharide antigens. Encapsulated species protect it against phagocytosis. Infections include meningitis, epiglottitis, orbital cellulitis, arthritis, otitis media, bronchitis, pericarditis, sinusitis, and pneumonia.
Haemophilus influenzae
This is the most common cause of bacterial meningitis in children and young adults. Presentation: petechial or purpuric exanthem with meningitis. Tx: PCN, rifampin for chemoprophylaxis.
Neisseria meningitidis
This is a gram-negative bacillus found free-living in moist environments. It is one of the two most consistently antimicrobial-resistant pathogenic bacteria (the other is Serratia marcescens). Its virulence is related to extracellular toxins, endotoxins, and polysaccharide protection from phagocytosis.
Pseudomonas aeruginosa
This is the treatment of ocular syphilis, which is the same as for neurosyphilis.
IV PCN G, 2-4 million U, q4hrs x10 days
This is a large, microaerophilic, plasmid-containing spirochete that is transmitted through the bite of the Ixodes genus of ticks. It causes Lyme disease.
Borrelia burgdorferi
This is a small, obligate, intracellular parasite that can survive only briefly outside the body. Infections include trachoma, inclusion conjunctivitis, urethritis, epididymitis, mucopurulent cervicitis, proctitis, salpingitis, infant PNA syndrome, and lymphogranuloma venereum.
Chlamydia trachomatis
This is a unique bacterium that can cause pharyngitis, otitis media, tracheobronchitis, PNA, endocarditis, nephritis, encephalitis, meningitis, optic neuritis, and facial nerve palsy. It may play a role in chronic lung disorders (such as asthma). Tx: macrolide, tetracycline, or fluoroquinolone.
Mycoplasma pneumoniae
This includes a range of pathogenic and nonpathogenic species. It includes TB, which infects 2 billion persons worldwide (33% global prevalence) and causes ~1.4 million deaths each year. Other infections are more prevalent in the immunosuppressed, causing lymphadenitis, pulmonary infections, skin granulomas, prosthetic valve infections, and bacteremia.
Mycobacteria
These two drugs used to treat TB can cause optic neuritis in a small percentage of patients.
Isoniazid, ethambutol
This drug used to treat TB can cause pink-tinged tears and blepharoconjunctivitis
Rifampin
This protozoan parasite infects up to 1/3 of the world’s population. In pregnant women, it can be asymptomatic but cause severe fetal complications, including cognitive impairment, blindness, and epilepsy. Transmission: cat feces, water, soil, contaminated fruits/vegetables, undercooked or raw meat.
Toxoplasma gondii
This virus is associated with mucocutaneous infections of the pharynx, skin, oral cavity, vagina, eye, and brain. Ophthalmic infection most often manifests as coreal dendritic or stromal disease but may present as acute retinal necrosis. Tx: acyclovir, famciclovir, valacyclovir, cidofovir
Herpes simplex virus (types 1 and 2; type 2 is sexually transmitted)
This presents as a generalized vesicular rash + constitutional symptoms; reactivation can cause sensory nerve distribution pain followed by unilateral vesicular eruption over 1-3 dermatomic areas. Tx: famciclovir, valacyclovir, acyclovir.
Varicella-zoster virus (herpes zoster)
This is a ubiquitous human virus that affects 50% of adults in developed countries. Congenital disease carries a 20% incidence of hearing loss or cognitive impairment and 0.1% incidence of other congenital disorders (jaundice, HSM, anemia, microcephaly, chorioretinitis).
Cytomegalovirus (CMV)
Antibodies to this virus are found in 90-95% of all adults. It can cause infectious mononucleosis. It may lead to lymphoproliferative disorders in patients taking cyclosporine. It is associated with Burkitt lymphoma and nasopharyngeal carcinoma.
Epstein-Barr virus (EBV)
This is a highly prevalent infection associated with genital warts (condylomata), cervical intraepithelial neoplasia, and some cases of head and neck squamous cell carcinoma.
Human papillomavirus (HPV)
The use of these eyedrops (which is rare today) should be stopped 3 weeks prior to elective surgery. If it must be continued, succinylcholine cannot be used during intubation because of a drug interaction that would enhance succinylcholine’s effects, causing prolonged respiratory paralysis.
Echothiophate iodide
How long before surgery should warfarin be stopped?
5 days
How long before surgery should IV heparin be discontinued?
12 hours
This anxiolytic has a quick onset IV (2-3 minutes) and has a quick elimination half-life (2-4 hrs), making it ideal for outpatient surgeries.
Midazolam
This opioid has a peak onset within 1-2 minutes and lasts 10-20 minutes, making it an ideal agent for ophthalmic surgeries.
Alfentanil
This medication can reverse the effects of benzodiazepines.
Flumazenil
This drug produces rapid hypnosis. It has a tendency to produce bradycardia. It must be given in a large-bore vein or administered after a lidocaine flush as it causes burning upon administration. It is lipid-based and may support rapid bacterial growth at room temperature.
Propofol
This is a life-threatening complication of a retrobulbar block. It can be avoided by having the patient look straight ahead, using a needle <1.25” long, and using a less-sharp needle. It can also be avoided by using a peribulbar block.
Apnea (respiratory arrest due to inadvertent injection into subdural space)
This is an autosomal dominant disorder of hypermetabolism involving the skeletal muscles that is associated with mutations in either the ryanodine receptor 1 or the calcium channel A1S. Anesthetic triggers increases in intracellular calcium, stimulating muscle contracture. S/S: tachycardia, elevated ET CO2, labile BP, tachypnea, sweating, muscle rigidity, blotchy skin discoloration, cyanosis, dark urine, elevated temp (late sign). Ultimately, resp and metabolic acidosis, hyperkalemia, hypercalcemia, myoglobinuria, renal failure, DIC, and death can occur.
Malignant hyperthermia
This medication is used in the treatment of malignant hyperthermia. In addition, triggering agents should be stopped, patient should be hyperventilated with 100% O2, and patient should be actively cooled.
Dantrolene
