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Beta 3 Receptor

Increases Lipolysis

Skeletal muscle thermogenesis increase

Gs Protein Class

Increased CAMP

Atypical Antipsychotic Names

These are all second generation antipsychotics

Varied effects on 5-HT2 (antagonism), dopamine, and α- and H1-receptors

Aripiprazole (Abilify) - D2 partial agonist

Asenapine, Clozapine, Quetiapine, Olanzapine

-pine associated with metabolic syndrome (Weight gain, Diabetes, Hyperlipidemia, tracking fasting glucose and lipid profile)

Clozapine and olanzapine carry the greatest risk of metabolic syndrome side effects

U. Olanzapine can be used for acute mania and anorexia

Olanzapine has affinity for muscarinic receptor

Most common side effects of olanzapine are sedation and weight gain

Most common side effects are metabolic syndrome and sedation (histamine)

Iloperidone, lurasidone, paliperidone, risperidone, ziprasidone

Ziprasidone most associated with QT prolongontion

Risperidone most associated with elevated prolactin

Ziprasidone, lurasidone and aripiprazole all have lower incidence of metabolic syndrome

Quitiepine is sedating and is often used in insomnia (or bipolar with insomnia); has an oral dissolving form

O. Risperidone has higher likelihood of EPS, all the drugs cause QT prolongtion

Olanzapine has a IM long acting as well as a rapid acting IM version for emergencies

Hypo and Hypernatremia

Hypernatremia: Greater than 145, Irritability, stupor, coma, thirst

Hyponatremia: Less than 135, Nausea, malaise, stupor, coma, seizure

Hyper and Hypophosphatemia

Hyperphosphatemia: Renal stones, metastatic calcifications, hypocalcemia

Hypophosphatemia: Bone loess, osteomalacia (adults), Rickets (Children)

Muscle weakness and paralysis

Rhabdomyolysis, paresthesia, respiratory failure

Can be due to alcoholism

Critically ill frequent ly develop intracellular phosphate defic iencies due to poor oral phosphate intake

Clinically silent until caloric supplementation with intravenous dextrose, a component of total parenteral nutrition (TPN)

Critically ill patients initiated on TPN --> monitor serum phosphate so that phosphate can be administered if a deficiency deve lops

Manifestation of refeeding syndrome

Can cause seizures, rhabdomyolysis, life-threaten ing cardiovascular complications (eg, arrhythmia, CHF)

SIADH Causes and Treatment

Causes: Small Cell (Oat Cell) Carcinoma, CNS disorders/Trauma, Pulmonary disorders, cyclophosphamide

Treatment: Slowly correct sodium, Fluid Restriction, sodium tablets, IV hypertonic saline, diuretics, conivaptan, tolvaptan, demeclocycline

Tolvaptan And Conivaptan are ADH antagonists

CNS disturbance (eg, stroke, hemorrhage, trauma)

Medications (eg, carbamazepine, SSRls, NSAIDs)

Lung disease (eg, pneumonia )

Pain &/or nausea can be a cause

Treatment: Fluid restriction ± salt tablets

Hypertonic (3%) saline for severe hyponatrem ia

VAPTANS ARE NO LONGER EVER THE ANSWER

Unless there are neurologic symptoms arising from the hyponatremia , it should be corrected slowly with water restriction

Once water restriction is initiated , the plasma sodium concentration will slowly begin to normalize

An ideal rate of increase is 0.5 mEq/h

Patients must be simultaneously monitored for volume depletion as a sodium deficit may become apparent , requiring concomitant administration of salt

Demeclocycline (preferred) and lithium are indicated in patients with persistent severe hyponatremia

Valproic acid is another cause

Adrenoleukodystrophy

X linked recessive (usually affects males)

Disrupts very-long-chain fatty acids metabolism

Impaired ability to add coenzyme A to fatty acids

Fatty acid build up in nervouse system (especially white matter of the brain), adrenals, testes

Progressive disease that can lead to long-term coma/death

Can cause adrenal gland crisis

Multiple Sclerosis Interventions

Slow progression with disease modifying therapies: B-interferon, glatiramer, natalizumab

Acute flares: IV steroids

Neurogenic Bladder: Catheterization, muscarinic antagonists

Spasticity: Baclofen, GABA B agonist or tizanidine (alpha-2 adrenergic agonist)

Pain: Opioids

Acute attack and disabling --> high-dose IV glucocorticoids (eg, methylprednisolone), Plasma exchange in non responders

Chronic: can also use Fingolimod

Symptomatic: urine retention (Bethanechol), incontinence (Amitriptyline), neuropathic pain (gabapentin)

Disease-modifying (eg, beta-interferon, glatiramer) indicated for chronic maintenance in relapsing-remitting multiple sclerosis

Pregnancy: slightly increased C-section/assisted delivery (forceps) rates, treat exacerbations with IV corticosteroids

Lower disease activity during pregnancy and higher disease act ivity in the postpartum period, most MS drugs are safe during pregnancy

Teriflunomide and mitoxantrone are not safe during pregnancy

Sleep hygiene, regular exercise

Amantadine

Stimulants (eg, methylphenidate, modafinil)

Physical therapy & stretching

Massage therapy

Baclofen or tizanidine

SSRI/SNRI

Gabapentin or duloxetine

Timed voiding

Fluid restriction (<2 Uday)

Anticholinergic medication (eg, oxybutynin, tolterodine)

Pseudogout

Causes: Hemochromatosis, idiopathic, hyperparathyroidism and joint trauma

Pseudo-gout or pseudo-arthritis

Crystals (from synovial fluid) are rhomboid and are weakly birefringent under polarized light (blue when parallel)

Colchicine: Both treatment and prophylaxis

Synovial fluid analysis will show an inflammatory effusion

In addition to synovial fluid analysis, X-ray can also be useful to diagnose and typically reveals chondrocalcinosis

Intra-articular glucocorticoids

Synovial fluid analysis will show an inflammatory effusion (15,000-30,000 cells/mm3)

Urate gout will have up to 50,000 cells/mm3 and septic arthritis will have >50,000 cells/mm3, + organisms on Gram stain

Hyperparathyroidism with hypercalcemia

Beta Blocker Antidote and Side Effects

Antidote: Glucagon (causes increase in cAMP which causes calcium release --> cardiomyocite contraction), saline, atropine

Erectile dysfunction

Cardiovascular adverse effects (bradycardia, AV block, HF)

CNS adverse effects (seizures, sedation, sleep alterations)

Dyslipidemia (metoprolol)

Asthma/COPD exacerbations

Use with caution in cocaine users and pheochromocytoma due to risk of unopposed α-adrenergic receptor agonist activity

Except the nonselective α- and β-antagonists carvedilol and labetalol

Despite theoretical concern of masking hypoglycemia in diabetics, benefits likely outweigh risks; not contraindicated

Propranolol can exacerbate vasospasm in Prinzmetal angina

First steps in management are to secure the airway and give isotonic fluid boluses and intravenous (IV) atropine

In patients with refractory or profound hypotension , the next step is to administer IV glucagon

Not bold: Other therapies include IV calcium, vasopressors (epi/norepinephrine), high-dose insulin and glucose, IV lipid emulsion therapy

Embryonal Carcinoma

Malignant tumor

Large primitive cells

Aggressive with early metastasis

Stromal tumor

All same as above female characteristics

May produce glands

Hemorrhagic mass with necrosis

Hematogenous spread

Chemotherapy may cause differentiation into another germ cell tumor

Possible increase in B-hCG or when its mixed increased AFP

Painful

Often a "mixed" with other tumors

Prostatitis

Causes in young adult causes: Chlamydia Trachomatis, Neisseria Gonorrhoeae

Causes in older adults: E. Coli and Pseudomonas

Dysuria

Fever

Chills

Tender and boggy on digital rectal exam

Prostate secretions shows WBCs with bacteria

Dysuria with pelvic pain or low back pain

Prostate secretions have WBCs but culture negative

Either bacterial or nonbacterial (eg, 2° to previous infection, nerve problems, chemical irritation)

Possible slight PSA increase

U. (not sure acute or chronic) obstructive urinary symptoms,

purulent dyscharge, lower back/abdominal/pelvic pain, prostate may be boggy or nodular

Frequency; urgency; low back pain; warm/tender/enlarged prostate

Sertoli/Leydig Tumor

Sertoli tumor is comprised of tubules and is usually silent

Leydig Males: produces androgen or estrogen causing precocious puberty in children and gynecomastia in adults; golden brown in color

Resemble sex cord stromal tissue of testicle

Reinke crystals may be seen histologically

Golden brown color; contains Reinke crystals (eosinophilic cytoplasmic inclusions)

Leydig/Sertoli in females: May cause hirsutism or virulization (androblastoma of the ovary), clitoromegally, deep voice, young women usually

Hollow or solid tubules lined by round Sertoli cells and surrounded by a fibrous stroma

Benign

Rickettsia prowazekii and typhi

Rash travels outwards, spares the hands and feet

Commonly in POW camps and military camps

Caused by lice arthropod, defecates near feeding sites and the scratching that actually introduces it to the blood

Causes epidemic typhus; myalgia/arthralgia, pneumonia, encephalitis and coma

Causes endemic

Caused by flea

Chlamydia pneumoniae and Chlamydia psittaci

Causes atypical pneumonia

Most common in young adults

Causes atypical pneumonia

Transferred by birds, often parrots

Treatment: Azithromycin (favored due to single dose), Doxycycline

Aerosol trasmission

Reactive arthritis (triad of arthritis, uveitis and urethritis

Streptomycin

Aminoglycoside drug class

Interferes with 30S component of ribosome

Mycobacterium tuberculosis (2nd line)

IV only

Resistance in mycobacterium is via ribosomal alterations (as well as other aminoglycoside mechanisms of resistance)

Tinnitus

Vertigo

Ataxia

Nephrotoxicity especially with aminoglycosides

Penicillinase-resistant penicillins

Dicloxacillin, nafcillin, oxacillin (several more with oxacillin at the end)

Same as penicillin. Narrow spectrum

Penicillinase resistant because bulky R group blocks access of β-lactamase to β-lactam ring

Clinical use: S aureus (non MRSA)

Hypersensitivity reactions, interstitial nephritis

Bactericidal

Methcillin not used anymore do to several side effects

Same side effects as penicillin

Resistance occurs via altered PBPs

Oxazolidinones (Linezolid)

Inhibit protein synthesis by binding to 50S subunit and preventing formation of the initiation complex

Bacteriostatic

Indications: Gram ⊕ species including MRSA and VRE

Bone marrow suppression (especially thrombocytopenia)

Peripheral neuropathy (optic most common but also glove and stocking peripheral nephropathy)

Serotonin syndrome due to MAOI activity

Sideroblastic anemia

Point mutation of ribosomal RNA

Binds to the 23s portion

Dapsone

MOA: Similar to sulfonamides, but structurally distinct agent (Inhibit dihydropteroate synthase)

Leprosy (lepromatous and tuberculoid)

Pneumocystis jirovecii prophylaxis

Dermatitis herpetiformis (celiac disease)

Hemolysis if G6PD deficient

Fever, rash and methemogloinemia

Pigment changes

Daptomycin

MOA: Lipopeptide that disrupts cell membrane of gram ⊕ cocci; Bactericidal

S aureus skin infections (especially MRSA), bacteremia, endocarditis, VRE

Not used for pneumonia (avidly binds to and is inactivated by surfactant)

Depolarizes cellular membrane by creating transmembrane channels

Myopathy

Rhabdomyolysis

CPK elevation

Pyrazinamide

Mechanism uncertain

Pyrazinamide is a prodrug that is converted to the active compound pyrazinoic acid

Works best at acidic pH (eg, in host phagolysosomes)

Indications: Mycobacterium tuberculosis

Hyperuricemia (gout)

Hepatotoxicity (hepatitis)

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