Asthma Treatments

	Period: Day	Period: Night	Lung Function	Treatment
Intermittent	<= 2 Days a Week	<= 2 Nights a Month	Normal predicted FEV1, normal FEV1/FVC	SABA
Mild Persistent	> 2 Days a Week, not daily	3-4 Nights a Month	80% predicted FEV1, normal FEV1/FVC	SABA + low dose IGC
Moderate Persistent	Daily	> once a week, not nightly	61-79% predicted FEV1, FEV1/FVC reduced 5%	SABA + low dose IGC + LABA
Severe Persistent	All.The.Time.	Often every night	60% or less predicted FEV1, FEV1/FVC reduced >5%	SABA + high dose IGC + LABA

Asthma is defined by a triad that includes airway inflammation, airway hyperresponsiveness, and reversible airflow obstruction. It can occur at any age. COPD and Asthma may be differentiated because when placed under bronchodilator challenge, FEV1 is increased with Asthma but remains the same in COPD. FEV1/FVC are decreased in both severe asthma and COPD, as with all obstructive lung diseases.

Leukotriene-modifying agents include zafirlukast, montelukast, and zileuton. These agents can be helpful in patients who may be less sensitive to inhaled glucocorticoids (because of a smoking history) or those with exercise or aspirin-induced asthma.

On Airs Waters and Places, Part One- Hippocrates

Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces for they are not at all alike, but differ much from themselves in regard to their changes. (1) Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality. We must also consider the qualities of the waters, for as they differ from one another in taste and weight, so also do they differ much in their qualities. (2) In the same manner, when one comes into a city to which he is a stranger, he ought to consider its situation, how it lies as to the winds and the rising of the sun; for its influence is not the same whether it lies to the north or the south, to the rising or to the setting sun. These things one ought to consider most attentively, and concerning the waters which the inhabitants use, whether they be marshy and soft, or hard, and running from elevated and rocky situations, and then if saltish and unfit for cooking; and the ground, whether it be naked and deficient in water, or wooded and well watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labor, and not given to excess in eating and drinking. 

Source: http://classics.mit.edu/Hippocrates/airwatpl.1.1.html

(1) In Winter, people tend to remain inside together for longer periods. During this period therefore the Influenza viruses A and B tend to afflict Americans, which is why seasonal vaccinations are advised between September and October. Treatment includes Rest, Acetaminophen and Hydration, or if the symptoms have been going less than 48 hours, Oseltamavir.

(2) Fluoride-fortified water has been shown to reduce childhood dental disease. Some of the waterborne-only human diseases in untreated water include:

Bacteria: Vibrio cholera, Leptospira (contaminated with animal urine)
Viruses: Adenovirus, Hepatitis A, Hepatitis E, Poliovirus
Parasites: Giardia lamblia, Entamoeba histolytica (in immunocompromised), Cryptosporidium, Naegleria fowleri (warm fresh water brain amoeba),
Nematodes: Enterobius vermicularis, Ascaris lumbricoides
Dracunculensis medininsis,
Trematodes (Flukes): Chlonorchis sinensis (Chinese liver flukes), Schistosoma haematobium (swimmers at risk), Schistosoma japonicum, Schistosoma mansoni

BMI

Calculated in weight (kg) divided by (height (meters) squared).

30+ Obesity
25+ Overweight
18.5+ Normal
Less than 18.5 Underweight

Celiac Disease

Primary Histology:
-Mucosal Inflammation
-Villous Atrophy
-Crypt Hyperplasia

Primary Symptoms:
unexplained continued
-diarrhea with
-foul smelling floating stools d/t steatorrhea.
-malabsorption
-weight loss
-bloating

or with unexplained
-iron def. anemia
-folate (B9) def.
-B12 def.
-elevated aminotransferases

Diff Dx: lactose intolerance, IBS
Dx: Primarily the symptoms, be sure to test IgA anti-TTG (tissue transglutaminase)
Then upper endoscopy with small bowel bx. Also IgA EMA (endomysial antibody), IgA/IgG anti-TTG and IgA/IgG DGA (deaminated gliadin antibody).
Tx: Remove Gluten from diet

Diff Dx:
Whipple's Disease: periodic PAS Acid-Schiff positive macrophages in the duodenum, with dementia, AMS, apathy, myoclonus, cranial nerve involvement. ID of Topherema whipplei by DNA PCR. IgA tests above should be negative.

Tropical sprue: poorly understood etiology. Lipid and folate malabsorption common on chronic diarrhea. More eosinophils compared with celiac disease.

Crohn's Disease: IgA tests above should be negative. p-ANCA is highly specific for Crohn's and distinguishes from Ulcerative Colitis, the other kind of Inflammatory Bowel Disease.

GERD

Upper endoscopy is indicated if patient has GERD symptoms along with one or more of the 3"ALARM" symptoms:

-Dysphagia
-Bleeding
-Weight Loss

Blindness [working]

Macular Degeneration:
-Dry 80%
-Wet 20% of cases
-most common cause of vision loss in developed countries

...

Stapholococcus aureus

• Coagulase Positive: converts fibrinogen to fibrin (red sea clotted)
• Protein A on S. aureus cell wall binds Fc portion of antibodies
• Catalase Positive (cat) (watch out in Chronic Granulomatous Disease where O2 dependent killing is defective)
• Beta-hemolytic (red bulb)
• Dx: Grows on Mannitol salt agar, ferments mannitol turning agar yellow
• Colonizes the nares of the nose
• Inflammatory Diseases
• Pneumonia (patchy infiltrate)
• Often secondary post-viral infection
• Septic arthritis, most common cause
• Abscesses
• Rapid onset, acute endocarditis, often IV drug abusers, R side heart problems: Tricuspid
• Toxin-mediated diseases
• Scalded-skin diseases (exfoliative toxin, protease)
• Toxic shock syndrome d/t toxic shock super-antigen (superhero cape)
• Food poisoning, rapid onset in 1-8 hrs after ingestion: mayo and unrefrigerated meats, more vomit than diarrhea
• MRSA: penicillin-resistant, alters penicillin binding proteins, Rx: vancomycin
• If Methicillin sensitive, may use Rx: Nafcillin "Naf for Staph"
• or for Cellulitis, Doxycycline (if not child or nursing)

Other sources:
http://www.emedicinehealth.com/slideshow_mrsa_pictures/article_em.htm
Commonly called Staph aureus.

Causes of Rectal Bleeding

Celiac Disease: Loose stools, Flatulence, increased anti-transglutamine IgA, increased endomysial Abs Diverticulitis: (Sometimes Massive) rectal bleeding, Fever, most frequently Sigmoid, often in Elderly, Diarrhea/Constipation, Fistula, LLQ pain IBS: Non-inflammatory implies no fistulae, Diarrhea and Constipation, Pain Irritable Bowel Disease, contains: Ulcerative Colitis: Colon mucosal inflammation, non-transmural so no fistuae, Gross blood in stool, Continuous from the rectum proximally. Crohn's Disease: Fistulae, most frequently Ileal, Skip Lesions, Surgery usually for complications.

Onco and Anti-oncogenes

Gene	Function	Syndrome/Disease
n-myc	oncogene	neuroblastoma, small cell carcinoma of lung
L-myc	oncogene	Small Cell Lung Cancer
c-myc	oncogene	Burkitt's Lymphoma (Chromosome 8)
ABL	oncogene	CML and ALL
BCR-ABL t(9;22)	oncogene	CML or ALL
BRAF	oncogene	Melanoma
BCL-2	oncogene	Follicular Lymphoma with t(14;18)
SIS	oncogene	Astrocytoma, Hepatocellular Carcinoma
HER-1	oncogene	Squamous Cell Carcinoma
HER-2	oncogene	Breast Cancer, Ovarian Cancer
KRAS	oncogene	Lung Cancer, Colon Cancer, Pancreatic Cancer
HRAS	oncogene	Renal Cell Cancer, Bladder Cancer
TGFA SIS	oncogene	Astrocytoma, Hepatocellular Carcinoma
APC/β Catenin	anti-oncogene	Stomach Cancer, Colon, Pancreatic Cancer, Familial Adenomatous Polyposis
DCC	anti-oncogene	Colon Cancer
NF1	anti-oncogene	Neuroblastoma, Neurofibromatosis Type 1, Sarcoma
VHL	anti-oncogene	Von Hippel Lindau Syndrome, Renal Cell Cancer
WT-1	anti-oncogene	Wilms Tumor
BRCA1, BRCA2	anti-oncogene	Breast Cancer, Ovarian Cancer
RB	anti-oncogene, suppresses G1 to S	inactivated in many cancers
TP53	anti-oncogene p53 "guardian of the cell"	inactivated in many cancers

Screening and Vax Guidelines

Screening is recommended by the United States Preventive Screening Task Force for

Adults
Age 18+  by asking about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to adults who use tobacco (includes pregnant women).

Age 18+ for Obesity: BMI > 30. Initiate "intensive, multicomponent behavioral interventions." if positive.

Age 18+ for High BP.

for Syphilis infection in persons who are at increased risk for infection.

Age 40-70 and Overweight for Diabetes with fasting blood glucose test.

Colonoscopy:
Every 3-10 years age 50-75 depending on findings of colonoscopy.
Start at age 40 if a 1st degree relative had colon cancer after age 50. Start ten years earlier than diagnosis if 1st degree relative had colon cancer earlier than age 50.
Older than 75 to 85 is at individual discretion. More likely to benefit if never before screened.

All adults 

Adult Smokers
AAA:
One time Abdominal US Screening between age 65 and 75 in men who have ever smoked.

Lung cancer screening with Low Dose Computed Tomography (LDCT) in age 55-80 if smoked (>30 pack-years) and quit less than 15 years ago. Discontinue after 15 years abstinence or if unwilling to do surgery if positive.



Alcohol misuse:
Screen those 18+

Initiate low dose ASA preventive medication against CVD and C/R cancer
for those 50-59 with a 10%+ 10 year risk. Evidence is only grade C for those 60-69.

Depression Screening 19 and up, for MDD age 12-18.

Vit D supplementation and exercise for community dwelling older adults 65+ at risk for fall.

If overweight or obese, refer for or perform intensive behavioral intervention. Counselling shows small benefit in ordinary patients.

Latent TB in those at high risk: PPD test

Test Hep B in those at high risk.

Test Hep C in those at high risk and those born between 1945 and 1965.

Selectively offer AAA US screening between 65-75 in non-smokers.

Vaccinations:
Pneumonia Vax (Antigen)
For naive immunocompetent: 19-64yo: give one dose of PPSV23 (and no more for a year if 64yo).
     65 and older: Prevnar (PCV13) then Pneumovax (PPSV23) a year later and at least 5 years after          most recent PPSV23.
     If received dose of PPSV23 already, give Prevnar (PCV13) a year later.
For non-competent: Give Prevnar (PCV13) between 19-64. 

Tetanus Vax (Tdap antigen). Every 10 years. Repeat if more than 5 years and unsure.

Flu Vax: Annual (Killed)

Women
Childbearing-age women take 0.4 to 0.8 mg Folate (if preg possible)
and Screen for intimate partner abuse.
Pregnant:
The USPSTF recommends that clinicians screen all pregnant women for syphilis infection. 
Hep B: first prenatal visit.
Rh(D) blood typing and antibody testing: first prenatal visit.
Asymptomatic Bacteriuria:
between 12 and 16 weeks.


Gestational Diabetes after 24 weeks.
The USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks' gestation, unless the biological father is known to be Rh(D)-negative.
For women at high risk for pre-eclampsia: 81 mg/d ASA after 12 weeks.

Pap Smear
Age 21-29: Every 3 years get a pap smear for screening cervical cancer
30-65: Combined cytology, HPV and pap smear every 5 years

Mammography:
age 40-49: less clear cut evidence for biennial screening. Family history could justify.
Biennially age 50-74. American college of surgeons say annually is justified. And insurance will pay for annual even from age 40.

BRCA-related cancers (breast, ovarian, tubal or peritoneal) in 1st degree relative should be screened for gene.

Women at high risk for breast cancer:
should be offered tamoxifen or raloxifene to mitigate risk.

Ghonnorrhea and Chlamydia Screening
For sexually active women under age of 24 and "at risk" older women.

Lipid levels age 20 and older if at increased risk for coronary artery disease.

Osteoporosis: Age 65 and older and those women with equivalent risk. DEXA. -1 and less: osteopenic. -2.5 SD and less osteoporotic.

Men
PSA:
Start talking about it at age 50. Rectal exam poor evidence. Give it to them if they ask.

Lipid levels starting at age 35, age 20-35 if at increased risk for coronary artery disease.
Children
Newborns: "The USPSTF recommends prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum. "
Oral fluoride supplementation and lining for those without fortified water or abscess resp.

The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. 

Screen age 6 and up for obesity.

Sexually active adolescents: The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).

Fair skinned adolescents: counsel avoiding direct sun exposure, using sunblock.
Source

Smokers: The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents.

*according to the USPSTF (United States Preventive Screening Task Force)

Variant words: Abdominal U/S Abdominal Ultrasound

Hep C

Treatment:

Harvoni (combo drug between ledipasvir and sofosbuvir).

Sea-sickness, Dizziness

Tx:
Diphenhydramine: with significant drowsiness side effect
Scopolamine (Hyoscine hydrobromide)
Dimenhydrinate (marketed as Dramamine, Gravol) also as antiemetic and sedative in housepets.

Dry, itchy eyes

Tx: Alloway, and if not improved, Claritin (Loratidine), and Zyrtec (Cetirizine). 

Hematuria Differential

IgA Nephropathy
-especially in elderly
Cystitis
-pelvic tenderness? fever?
Plan: CRP, creatinine, ESR,
Pyelonephritis
Glomerulonephritis
Prostate Cancer or Prostatic Hyperplasia
-check PSA, will be elevated.
Penile Carcinoma -pretty much only in uncircumcised
Kidney neoplasm
Idiopathic Hypercalcuria
Trauma
Nephrolithiasis
-most common stone is
plan: retroperitoneal U/S

Microscopic
workup: recent exercise, sexual hx, menstruation, UTI hx? lab workup: ESR, creatinine, CRP, coags.

Gross Hematuria defined as > 1mL blood per L of urine.
-blood clots may be painful to pass
-after lithotripsy, gross hematuria is to be expected. Pt may be d/ced as long as no clots.

Psychiatry pimp fest

What 3 conditions do antipsych drugs  = neuroleptics treat?

Psychosis
Schizophrenia
Hallucinations

What receptors do antipsych drugs inhibit?

Central Dopamine D2 receptors

What is the drug of choice for refractive schizophrenia?

Clozapine (Clozaril)

What class of drug is Clozapine (Clozaril)?

A dibenzodiazapine, an atypical agent.

Why is it atypical?

it has different side effect profile: agranulocytosis?

What receptors does clozapine work on, unlike all other neuroleptics that work on D2 receptors?

D1 or serotonin

What group of schizo symptoms does clozapine treat?

Negative symptoms including flat affect, avolition, poverty of speech,

What long acting neuroleptics work on treating non-compliant schizo patients?

Haloperidol (Haldol) and Fluphenyzine (Prolixin)

In addition to long action what makes them useful?

IM injection availability

What extrapyramidal side effects do high potency neuroleptics cause?

Acute dystonia (sustained muscle contractions in the head and neck region)

5 muscle spasms that commonly occur with acute dystonia in the head and neck region?

Eye, tongue, jaw, neck, laryngeal (can cause airway obstruction (treat with Dyphenhydromine (Benadryl) or Benztropine (Cogentin) both anticholinergics.)

What 2 categories do neuroleptic drugs fall into?

High potency and low potency

What is time of onset of side effects of low potency antipsychotics?

Immediate, right away

What are the three classes of side effects of low potency antipsychotics?

Anticholinergic, Antihistaminergic, Antiadrenergic (usually not a problem except in overdose)

What are anticholinergic side effects?

Anticholergic is anti-cool: No water, sunglasses, no hat, alone: you become: hot, dry, red, blind, crazy.

Which are due to peripheral effect? Hot, dry, red, blind.

What are due to central effect? crazy

What causes hot and dry? suppression of cholinergic sweat glands.

What is covered under "dry"? Dry skin, mouth, nose, eyes, urine retension, no intestinal secretion, or motion?

What causes retension of urine in bladder? Lack of irritability of the detrussor muscle.

What causes red?

cutaneous flushing

What happens to eyes with anticholinergic action?

Pupils dilate: dilation wins.

What are 4 examples of ways antichol toxicity can affect CNS?

Disorientation, hallucination, seizure, coma

What are two examples of antihistaminergic side effects of low potency neuroleptics?

Sedation, weight gain

What are the two main adrenergic side effects of low potency neuroleptics?

Hypotension and reflex tachycardia

What are 4 low potency antipsychotics with high potential for side effects? 

Chlorpromazine (Thorazine) (not used much d/t high side effect profile) , Clozapine (Clozaril), Thioradazine (Melaril), Risperidone (Risperdal)

How often does Clozapine (Clozaril) induce fatal agranulocytosis?

1% of patients

How often must physicians monitor WBC blood levels of Clozapine (Clozaril) patients?

Weekly

Which is used at same dosage as Chlorpromazine (Thorazine) but much lower risk side effect profile, mainly anticholinergic? Thioradazine (Melaril)

Which has by far lowest dosage required but has low potency profile, mainly anticholinergic?

Risperidone (Risperal)

What toxicity syndrome resembles that of low potency antipsychotics?

Sympathomimetic toxicity, adrenergic overstimulation

What two drugs cause sympathomimetic toxicity?

Cocaine and amphetamines

What signs?

Hot, red, blind, crazy (NOT dry, except for urinary retension).

Which two are likely to be different with mild intoxication?

May be cool and pale.

What will the different findings be?

Eyes and skin wet, BS hyperactive = diarrhea in sympathomimetic. (mouth and nose variable).

High potency neuroleptics have 3 side effect groups. What are they?

Extrapyramidal side effects, tardive dyskinesia, NMS


Extrapyramidal: Actute dystonia, Drug-induced Parkinsonian syndrome, Akathesia

What is akathesia?

Strong feelings of inner restlessness, difficulty being still

Tardive dyskinesia symptoms?
Involuntary Tongue, mouth fingers, toes movements. Facial grimaces.

Almost any of the antipsychotics can cause tardive dyskinesia?

All of them. High potency much higher. Risperidone (Risperdal) much lower chance of this.

All may produce neuroleptic malignant syndrome except?

Clozapine (Clozaril)

Symptoms of NMS?

Severe muscle rigidity, fever, AMS, autonomic instability.

What three high potency antipych meds have highest risk of side effects?
Haloperidol (Haldol), Fluphenazine (Prolixin), Thiothixine (Navane)

What 3 abnormalities in women will prolactinemia (a common antipsych side effect) cause?

Galactorrhea, Gynecomastia, Menstrual dysfunction

What are the side effects in men?

ED, retrograde ejaculation, inhibition of orgasm,

(Non-psych questions)How to treat severe headaches with orgasm?

First need to check for subarachnoid hemorrhage. If none, treat with indomethacin 50mg PO, prior to intercourse.

What do you treat Wilson's disease with?

Penacillamine, a Copper chelator. Protecting brain, liver, kidney, cornea.

What is the general trend of cephalosporins from generation to generation?
The lower the Gen of Cephalosporin the better it works against Gram positive vs. Gram negative.

Key difference between second and third gen Cephalosporins? Third treat PSA.

Soy and tofu do not have feminizing effects in men

http://www.fertstert.org/article/S0015-0282(10)00368-7/abstract

Pimping questions and answers

Most common causes of pancreatitis: gallstone, EtOH big ones. 80%. The rest are ERCP End stage renal dz, scorpion bites, hypertriglyceridemia, hypercalcemia, etc.

Charcot's Triad: For ascending cholangitis: RUQ pain, fever, jaundice.

Reynold's Pentad: For ascending cholangitis: Charcot's triad + Hypotension and confusion.

Diuretic class that can induce hyperglycemia and diabetes: Thiazides