Diabetic Hypoglycemia and Hypoglycemic Crisis

Profuse sweating as body uses endogenous Epi to try to raise blood glucose levels.

Hepatitis B Serology Interpretation

Unfortunately the last row cut out anti-HBc and anti-HBs under HBsAg.

In general, it's unusual for anti-HBc to be positive without anti-HBs also being so.

FORD the c: F: false positive, O: occult infection, R: recovering from acute, D: distant resolved, most often. (Anti-HBses now too low to detect).

7 Teratogens and their Side Effects

7 Well known Teratogens and their Birth Defects follow.

Phenytoin: Mech: unknown. SE: Neural tube defects, orofacial clefts, microcephaly, nail, digit hypoplasia (In adults, gingival hyperplasia d/t increased PDGF after 3-4 mo of tx).

Lithium: Mech: displaces Sodium. SE: Ebstein anomaly=atrialization of the R ventricle, nephrogenic DI, hypothyroidism

Valproate: Mech: blocks voltage sodium channels in cortex. SE: Neural tube defects

Isotretinoin: Mech: Compet. Inhib of Testosterone enzyme. Vit A stimulates skin, nail growth. SE: Microcephaly, Thymic Hypoplasia, small ears, hydrocephalus

Methotrexate: Mech: Inhibits Dihydrofolate reductase, prevents folate cofactor to dUMP to dTMP reaction. Results in messed up DNA transcription. SE: Limb, craniofacial abnormalities, neural tube defects, abortion

ACE Inhibs and ARBs: Mech: blocks renal efferent dilation by decreasing Ang. II/blocking its receptors. SE: Renal dysgenesis, oligohydramnios

Warfarin: Mech: prevents regen of Vit. K (affects Prot C anticoag first, so bridge w Heparin). SE: Nasal hypoplasia, stippled epiphysis

Non-teratogen but Dangerous:
Aspirin: Mech: COX inhib, will cause baby and mother to bleed.

The 3 Contraceptive Modalities

Systemic Progestins
-Combined Estradiol+Progesterone (pill, transderm patch, vag ring)
-Progesterone implant/injection
Mechanism: Suppress GnRH and by extension LH inhibiting ovulation, and FSH preventing the follicular phase (stroma/gland < 1:1) leading up to ovulation.

Locally-acting Progestins
-Progesterone-analog ONLY pill (norethindrone)
-Levonorgestrel IUD
Mechanism: Thicken cervical mucus, impair sperm penetration

Copper IUD
-chronic cytotoxic environment
-inflamm. response in uterus, impairing sperm migration.

Testing trick: IUDs proportionally increase ectopic/tubal pregnancies, but numerically decrease ectopic/tubal pregnancies.

SERM effects

Tamoxifen: Inhibits breast tissue estrogen receptors, stimulates endometrial, stimulates bone. Endometrial hyperplasia side effect. Lowers total and LDL cholesterol, no effect on HDL. Used for premenopausal women.

Raloxifene: Inhibits breast tissue, inhibits endometrial, stimulates bone. No endometrial hyperplasia side effect. (So Relax!) used for postmenopausal women.

Breakdown of Infectious Vaginitis

Vaginitis: 3 Infectious Causes

Gardnerella
Bacterial
Exam: Thin, off-white discharge, fishy odor, no inflammation
Lab: pH > 4.5, Clue cells, Positive Whiff test using KOH to react w amines
Treatment: Metronidazole: reduced metronidazole in anaerobic environments disrupts DNA synth by an incompletely understood mechanism. OR Clindamycin: Inhibits 50S rRNA.

Trichomonas
Protozoan
Exam: Thin, yellow/green, VERY malodorous, frothy discharge. Strawberry cervicitis, vaginal inflammation.
Lab: pH > 4.5, motal trichomonads via saline microscopy.
Treatment: treat the partner too! (yeah, grow that practice!) w Metronidazole

Candida vaginalis
Fungus
Exam: Thick, cottage-cheese discharge, Vaginal inflammation. (often Hx of antibiotic use, Gr+ Lactobacilli are protective)
Lab: Normal pH, pseudohyphae
Treatment: Fluconazole-inhibits fungal P450 enzyme, prevents ergosterol formation

Plus: does she wash her vagina? May simply be d/t harsh cleansing agents. Tx: Discontinue.

Note: N. gonnorrhoea is an enflamed cervix, not vagina, with vaginal discharge. Vaginal vesicles? HSV2 > HSV1. Tx: Acyclovir 5x daily (water sol.).

Urinary Incontinence: All you ever didn't want to know

3 Physiologic Types: Stress, Urge, Overflow, (also Psychogenic, Functional due to inability to move oneself to toilet, are non-physiologic causes. Mixed also possible of course)

Stress 
Cause: Loss of urethral support may cause, or intra-abdominal pressure exceeds (e.g. in pregnancy), urethral sphincter pressure.
Symptoms: Leaking with cough, sneeze, laugh or lifting heavy objects.
Treatment: Kegel exercises to strengthen sphincter muscle, surgery to increase urethral support and thereby decrease pressure on sphincter.

Urge
Cause: Detrusor overactivity, possibly due to M3 overactivity.
Symptoms: Sudden, overwhelming frequent need to empty bladder. Peeing on way to toilet.
Treatment: Phenylephrine, Pseudoephedrine, Adrenergic agonists to counteract muscarinic overactivity.

Overflow
Cause: Impaired detrusor contractility or bladder outlet obstruction due e.g. to BPH.
Symptoms:Constant involuntary dribbling, incomplete emptying.
Treatment: remove the obstruction, increase detrusor contractility with M3 agonists like Bethanechol.

Cardiology GI Nephro Quiz