Course Instructors: Dr. Francis, Dr. Wolf and Dr. Bautista
Hemostasis Lymphoma & Leukemia 251 Amino Acids Biochemistry Endocrinology Neurophysiology Hematology Vitamins, Minerals, Trace Elements Cellular Physiology Membrane Physiology 244 Low Energy State Inflamation Nephritic-Nephrotic 254 248 218 Reproductive Endocrinology Renal Physiology 76 159 171 192 220 Gastrointestinal Physiology (GI) 135 5 45 53 55 80 87 64 71 105 116 125
Electrolyte Physiology Pulmonary Physiology Neuromuscular Physiology Vascular Physiology Cardiac Physiology Page Lecture Note Pages Welcome to the Program Rheumatology 238 PASS PROGRAM USMLE REVIEW STEPS 1, 2 AND 3 Course Instructors: Dr. Francis, Dr. Wolfe & Dr. Bautista 184 1 Anabolic Pathways Cancers Immunodeficiencies Lymphocytes Leukocytes Immunology Catabolic Pathways Protein Structure and Function Enzymes Microbiology Antibiotics Granulocytes Biochemistry, Glycolysis, Gluconeogenesis & TCA Viruses 497 515 Antibiotics (Dr. Cordova) Surgery & Trauma (Dr. Cordova) 413 453 477
408 292 303 329 335 344 371 262 277 282 351 358 369 Obstectrics and Gynecology Note Pages The Four Hypersensitivities 366 2 PASS PROGRAM USMLE REVIEW STEPS 1, 2 and 3 Week 1 Monday Tuesday Wednesday Thursday Friday Introduction Behavioral science Test taking/Time mgt. Membrane Phys Cardio Patho logy 7:15-9:009:00 am Low Energy State EKG Phys Cardiac Phys 7:15 am Low Energy State EKG Phys Cardiac Phys 1 hr break Vitamins Psychiatry Arrhythmias Murmurs 10:00-12:00 Minerals Endocrine Phys Trace elements Endo Path LUNCH 1:30-4:00pm Cellular Phys Psych Endo Neuromuscular Cardio Vascular Phys Week 2 Monday Tuesday Wednesday Thursday Friday Gastrointestinal Surgery Principals Pulmonary phys Renal Phys Neuro Phys 7:15-9:00 Physiology 1 hr break Trauma Pulm Path Renal Path Neuro Path 10:00-12:00 GI Path LUNCH LUNCH 1:30-4:00pm GI Ansthesia Pulm Renal Neurology Week 3 Monday Tuesday Wednesday Thursday Friday Amino Acids OB Glycolysis Ketogenesis Nucleotides 7:15-9:00 Protein structure Gluconeogenesis GlycogenGlycogen 7:15 9:00 Protein s tructure Gluconeogenesis 1 hr break Protein function GYN Fructose/Galactose Pentose Pathway 10:00-12:00 OB/GYN Pharm Pyruvate metab. LUNCH 1:30-4:00 pm Quaternary protein Reproductive TCA cycle Amino acids DNA Repro Pharm Lipolysis Fatty acid synth.
Week 4 Monday Tuesday Wednesday Thursday Friday Oncology Pediatricts Leukocytosis Rheumatology Myobacteria, Spiro. 7:15-9:00 Development Leukemia's Rickettsia 1 hr break Myelodysplasia Normal Flora Virus 10:00-12:00 Pediatricts Pharm Gram+/LUNCH Oncology l Immunology l Granulocytes l t Fungus O I G F 1:30-4:00pm Imm. Deficiency Hypersensitivities Parasites Closing remarks!!! Transplantation Protozoa Dr. Francis ·CellularCellular physiology Dr. Wolf ·TimeTime management Teaching Associates ·Antibiotics-Antibiotics ·Antibiotics-Antibioti cs Dr Cordova (datee TBA) · physiology ·Behavioral ·Cardiology ·Pulmonary ·Biochemistry ·Reproductive ·Immunology ·Pediatricts ·Oncology · management ·Endocrine ·Rheumatology ·Gastrointestinal ·Renal ·Neurology · Microbiology/Antibiotics ·OB/GYN Dr Cordova (dat TBA) ·Surgery/Ansthesia- Dr Cordova ·Hematology- Dr Qi (date TBA) ·Statistics- Dr Qi (date TBA) ·DNA/RNA- Dr Bautista ·Biochem pathways- Dr Lee 3 4 5 5 6 6 7 7 8 8
9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 23 23 24 24 25 25 26 26 27 27 28 28 29 29 30 30 31 31 32 32 33 33 34 34 35 35 36 36 37 37 38 38
39 39 40 40 41 41 42 42 43 43 44 44 4/30/2008 1 Making the most out of your time here at the PASS program !!! Making the most out of your time here at the PASS program !!! Study smart not hard Study smart not hard Power is in knowledgegegg ! Power is in knowled ! NBME-NBME- National Board of Medical Examiners National Board of Medical Examiners For For profit company NBME-NBME- National Board of Medical Examiners National Board of Medical Examiners · Shortage of family doctors throughout US · Shortage of OB/GYN physicianshysicians in Fl, · Shortage of family doctors throughout US
· Shortage of OB/GYN p in Fl, py Texas, California, and Michigan · Cutoff for USMLE Step's were raised from 182 to 185? py Texas, California, and Michigan · Cutoff for USMLE Step's were raised from 182 to 185? · You're the next cutting edge physician · 20,000 new residents · Your pay?ay? · You're the next cutting edge physician · 20,000 new residents · Your p What do you want to do when you finish medical school? What do you want to do when you finish medical school? py · Radiology, Dermatology, Ortho. · Those making decisions,, control how many come across the bridgeridge py · Radiology, Dermatology, Ortho. · Those making decisions control how many come across the b 45 4/30/2008 2 Why do so many fail the test? Why do so many fail the test? ZOO
THEORY THEORY · A physician sits and writes a question based offf of the disciplineiscipline theyy wantt to testst you on A hhologistshologists l i t dss thee titiontion thee · A physician sits and writes a question based of of the d the wan to te you on A h l i t d th ti th How do they comprise a test that is written for you to fail? How do they comprise a test that is written for you to fail? ·· A psyc rewordd th ques th way your mind thinks¼ ± This is why the wrong answers always look good A psyc rewor th ques th way your mind thinks¼ ± This is why the wrong answers always look good 5 PASS rules in answering question 5 PASS rules in answering question · 1. Cover the answers · 2. Read the lastast sentence and decidede iff it is a clue or concept · 1. Cover the answers · 2. Read the l sentence and deci i it is a clue or concept 5 PASS rules in answering question 5 PASS rules in answering question · 1. Cover thehe answers · 2. Read thehe last sentenceence and decideide if it is a clue or concept question · 1. Cover t answers · 2. Read t last sent and dec if it is a clue or concept question it is a clue or concept question · 3. Read the vignette, and isolate the facts of the vignette · 4. Compriseprise a thought process · 5. Look down, click and move !!!!!!! it is a clue or concept
question · 3. Read the vignette, and isolate the facts of the vignette · 4. Com a thought process · 5. Look down, click and move !!!!!!! · 3. Readad the vignette,ignette, andd isolateolate the factsacts of the vignetteignette · 4. Comprise a thought process · 5. Look down, click and move !!!!!!! · 3. Re the v an is the f of the v · 4. Comprise a thought process · 5. Look down, click and move !!!!!!! A 38 y/o woman has congestive heart failure, premature ventricular contractions and repeated episodes of ventricular tachycardia. Her blood pressure is normal and there are no murmurs. Her heart is markedly enlarged. A 38 y/o woman has congestive heart failure, premature ventricular contractions and repeated episodes of ventricular tachycardia. Her blood pressure is normal and there are no murmurs. Her heart is markedly enlarged. Coronaryy angiographygiography shows no abnormalities.ities. Whichh of the followingollowing is the most likelyly diagnosisgnosis ? Coronar an shows no abnormal Whic of the f is the most like dia ? A.Acute rheumatic fever B.Congenital fibroelastosis C.Constrictive pericarditis D.Myocardial infarction A.Acute rheumatic fever B.Congenital fibroelastosis C.Constrictive pericarditis D.Myocardial infarction E.Primary cardiomyopathy E.Primary cardiomyopathy A.Acute rheumatic fever B.Congenital fibroelastosis C.Constrictive pericarditis D.Myocardial infarction A.Acute rheumatic fever B.Congenital fibroelastosis C.Constrictive pericarditis D.Myocardial infarction E.Primary cardiomyopathy E.Primary cardiomyopathy 46
4/30/2008 3 USMLE Step 2 and Step 3 approach USMLE Step 2 and Step 3 approach Whathat is the next best step in management? Is the patientnt stable?table? (basedbased on hemodynamics)modynamics) -Unstable:nstable: ABC'sBC's - Stable:: readead the vignetteignette W is the next best step in management? Is the patie s ( on he -U A - Stable r the v Do you have enough information to make a definitive diagnosis? -Yes- treat - No- order a test (BLIS) blood/labs/image/surgery Do you have enough information to make a definitive diagnosis? -Yes- treat - No- order a test (BLIS) blood/labs/image/surgery A 23 y/o man who is HIV positive has a 2 week history of midsternal chest pain that is aggravated by eating spicy foods; the pain is unrelated to exertion or position and he reports no dysphagia. Treatment with H2 receptor blocking agents has provided no relief. He takes clotrimazole for thrush and zidovudine (AZT).AZT).)) He has a CD4+ T A 23 y/o man who is HIV positive has a 2 week history of midsternal chest pain that is aggravated by eating spicy foods; the pain is unrelated to exertion or position and he reports no dysphagia. Treatment with H2 receptor blocking agents has provided no relief. He takes clotrimazole for thrush and zidovudine ( He has a CD4+ T ( lymphocytecyte count of 220/mm3mm3 (N>500).). Which of the following is the most appropriateopriate next stepep inn management?gement? ( lympho count of 220/ (N>500 Which of the following is the most appr next st i mana A.Therapeutic trial of acyclovir B.24 Hour pH probe
C.Acid perfusion test D.Esophageal manometry A.Therapeutic trial of acyclovir B.24 Hour pH probe C.Acid perfusion test D.Esophageal manometry E.Esophagoscopy E.Esophagoscopy A.Therapeutic trial of acyclovir B.24 Hour pH probe C.Acid perfusion test D.Esophageal manometry A.Therapeutic trial of acyclovir B.24 Hour pH probe C.Acid perfusion test D.Esophageal manometry E.Esophagoscopy E.Esophagoscopy Procrastination in doing questions Procrastination in doing questions · How many read before doing questions? Whatat t testingesting ti ? · How many read before doing questions? Wh t t ti ? Wh are you t ? 2 weeks later, what happens? Wh are you t ? 2 weeks later, what happens? Procrastination in doing questions Procrastination in doing questions · How many read all the choices in the explanation? futureuture · How many read all the choices in the explanation? f ± Prior exposure to f questions ± I have a lot of details in my head ± Prior exposure to f questions ± I have a lot of details in my head 47
4/30/2008 4 Procrastination in doing questions Procrastination in doing questions · How many do the questions in tutor mode? · How many do the questions in tutor mode? ±Driving a car and lost ±Driving a car and lost It's ok to be wrong !!!! It's ok to be wrong !!!! · Block of 50 question and get 45/50 correct, are you any more prepared for the boards from the moment you started that test? · Block of 50 question and get 45/50 correct, are you any more prepared for the boards from the moment you started that test? · If you get 30 /50 wrong, you will not be very happy · Found a hole, that can be fixed · Remember every time you fall · If you get 30 /50 wrong, you will not be very happy · Found a hole, that can be fixed · Remember every time you fall Why do we not listen to our first thought? Why do we not listen to our first thought? · We are scared of being wrong · We are scared of being wrong · We do average · We do average
not want our over all to be lower than the meanean not want our over all to be lower than the m
My friends told me to do as many questions as I can before I take the test¼
My friends told me to do as many questions as I can before I take the test¼ · 6000 questions · Multiple banks · You are doing questions to learn from them · Do we order test to learn about a pathology (i.e. Hypothyroidism ± TSH panel) · 6000 questions · Multiple banks · You are doing questions to learn from them · Do we order test to learn about a pathology (i.e. Hypothyroidism ± TSH panel) 3 steps to studying:: 1. Obtain the information 2. Questions 3. Results of the bank 3 steps to studying 1. Obtain the information 2. Questions 3. Results of the bank · Questions: Organ system based ± 50 question · Questions: Organ system based ± 50 question ± Do they ask youou 50 new things? ± Pathologicalogical presentation doesoes not change, just the story lineine (cluesues are so important) ± Willill youou see the pattern in mixed blocks?ocks? ± Do they ask y 50 new things? ± Pathol presentation d not change, just the story l (cl are so important) ± W y see the pattern in mixed bl What bank to use? What bank to use? Q-BankQ-Bank USMLEUSMLE Rx. USMLEworldUSMLEworld Rx. Do you see a pattern? At the end of your first week, you will be evaluated by several
tutors to determine which is the best test bank for you to use. Do you see a pattern? At the end of your first week, you will be evaluated by several tutors to determine which is the best test bank for you to use. 48 4/30/2008 5 What should I results of my What should I results of my
do, with question do, with question
the bank? the bank?
· 50 questionsuestions completed (what is right or wrong) Example: Polyhydramnios:ramnios:ramnios:ramnios: Downownwnwn syndromeyndromendro mendrome · 50 q completed (what is right or wrong) Example: Polyhyd D s Example: Polyhyd Do sy What is the mostst commonmmon cardiac abnormality? · Write the subject matter · Look for patterns in the question · This is what you will read about Example: Polyhyd Do sy What is the mo co cardiac abnormality? · Write the subject matter · Look for patterns in the question · This is what you will read about What do most students do¼ What do most students do¼ · Vignette¼..gnette¼.. Downs syndromee ± Answer: Endocardialal cushionon defect · Read about it from the author · Transcriberanscribeee to noteoteee cardsdsss onn ECDCD · Vi Downs syndrom ± Answer: Endocardi cushi defect · Read about it from the author · T to n car o E Transcrib to not card on ECD · Readad the notesotes about ECD
· Read the CMDT about ECD · ªHarrisonsº and read about ECD Are you any more prepared for Downs syndrome on thehe boards?oards? Transcrib to not card on ECD · Re the n about ECD · Read the CMDT about ECD · ªHarrisonsº and read about ECD Are you any more prepared for Downs syndrome on t b NBME practice exam¼ NBME practice exam¼ · On line at http://www.NBME.org ± Step 1 ± 5 forms (do not take form 3) ± Step 2 ± 3 forms · ± ± ±
On line at Step 1 ± 5 Step 2 ± 3 Step 3 ± 1
http://www.NBME.org forms (do not take form 3) forms form
· When should I take may NBME ? ± Step 3 ± 1 form · When should I take may NBME ? Not enough time in the day !!!!!!! - Exercise - 210 score - Proper sleep hygiene - Proper sleep hygiene -Take time out to reward yourself PASS program clues vs. class notes PASS program clues vs. class notes · You should drill the PP-clues with a partner for at least 1 hour a night. ( ½ hour new, ½ hour random review) · You should drill the PP-clues with a partner for at least 1 hour a night. ( ½ hour new, ½ hour random review) · ± · ±
Caution Teacher Caution Teacher
inn drillinglling classass notes: vs. Student i dri cl notes: vs. Student
Tutoring:: Tutoring · This is your time to ask questions that you may have with the material · Doo questionstionstionstions with your tutor (rememberremember
· This is your time to ask questions that you may have with the material · D ques with your tutor ( Do ques with your tutor (remember its ok to be wrong)ong) · Yourr tutortor is there to help you find and fix your weaknesss Do ques with your tutor (remember its ok to be wr · You tu is there to help you find and fix your weaknes 49 4/30/2008 6 Tutoring cont. Tutoring cont. · Try several tutors to find the chemistry that works for you · If you can not make it to your secession,, please inform your tutor, so theyey can fill the spot with another studentdent · Try several tutors to find the chemistry that works for you · If you can not make it to your secession please inform your tutor, so th can fill the spot with another stu · Once you are comfortable with a couple of tutors, there is a request book in the back. (The key word, just a ªrequest bookº) · Once you are comfortable with a couple of tutors, there is a request book in the back. (The key word, just a ªrequest bookº) 50 Physiology: Weeks One & Two 51 51 52 52 1
INTRODUCTION: THE MOST POWERFUL CONCEPT IN MEDICINE THE LOW ENERGY STATE WHO USES ENERGY? · · · · ·
BRAIN MUSCLES PRIMARY ACTIVE TRANSPORT HEART MEMBRANE MOVEMENT
· RAPIDLY DIVIDING CELLS ± SKIN ±HAIR ±GI ± RESPIRATORY ± RENAL(PCT) ± BLADDER ± ENDOMETRIUM ± ENDOTHELIUM ± BREASTS ± SPERM ±GERM CELLS ± CUTICLES ± BONE MARROW · RED BLOOD CELLS · WHITE BLOOD CELLS · PLATELETS PRESENTATION OF A DISEASE · When it bothers the patient enough, he or she will see the doctor as soon as possible ± Weakness so that the patient can not go to work ± Shortness of breath scares people; they think they might die SIGNS OF DISEASE: WHAT YOU CAN SEE · TACHYPNEA and DYSPNEA SYMPTOMS: THE PATIENT'S COMPLAINTS · WEAKNESS · SHORTNESS OF BREATH MOST COMMON INFECTIONS · PULMONARY INFECTIONS · URINARY TRACT INFECTIONS 53 53 2 OTHER COMPLICATIONS
·Dry skin · Hair dry and brittle ·Nails brittle · Bone marrow suppressed ± Anemia ± Leukopenia ± Thrombocytopenia COMPLICATIONS, cont · Endothelium ± atrophic · Endometrium ± atrophic · Breasts ± atrophic ·Sperm count ±low ·GI ± nausea, vomiting and diarrhea · Renal- PCT shuts down · Bladder ± atrophic; leads to UTIs · Respiratory ±weak cough > infections · Germ cells ± unable to replicate > leads to skin and GI cancers ·CNS: MR (children) and dementia (adults) ·CV ± heart failure MOST COMMON CAUSE OF DEATH? HEART FAILURE!!! ANYTIME YOU CAN CONNECT TO THE LOW ENERGY STATE ¼ · APPLY THE ENTIRE CONCEPT · THIS ACCOUNTS FOR APPROXIMATELY 98% OF ILLNESSES · WHENEVER IN DOUBT > ASSUME IT IS A LOW ENERGY STATE STOP GUESSING!!! 54 54 VITAMINS, MINERALS and TRACE ELEMENTS THE BEGINNING Vitamin A · A cofactor for PTH · Necessary for CSF production · Used for epithelial maturation, especially hair, skin, and eyes · Most unique function is night vision · A mild antioxidant
Vitamin A deficiency · · · ·
Poor night vision Decreased CSF production: asymptomatic Hypoparathyroidism Epithelial cells fail to mature
Vitamin A excess · Pseudotumor cerebri: excess CSF production · Hyperparathyroidism: moans, groans,bones and stones Pseudotumor Cerebri · Sign: papilledema · Symptom: headache · Evaluation: CT scan ( shows enlarged ventricles) · Treatment: d/c vitamin A; serial LPs (30cc at a time) · Main complication: blindness · This is the only cause of increased ICP where you don't have to worry about herniation Vitamin B1: Thiamine · ± ± ± ±
Necessary for four important enzymes: Pyruvate dehydrogenase Alpha-ketogluterate dehydrogenase Branched chain amino acid dehydrogenase Transketolase
55 55 Thiamine Deficiency · Beriberi ± Dry beriberi ± Wet beriberi · Wernicke's Encephalopathy ± Receptive aphasia · Wernicke-Korsakoff syndrome ± Mamillary bodies now also involved ± Confabulation ± Inability to move short-term memory to long-term memory Vitamin B2: Riboflavin · Used in cofactors ( FAD) · Best source is milk · Sunlight breaks riboflavin down Riboflavin deficiency · Angular Cheilosis
Vitamin B3: Niacin · Necessary for cofactors ( NAD, NADH, NADP, NADPH) · Needed by pyruvate dehydrogenase, alpha-ketogluterate dehydrogenase, and branched chain amino acid dehydrogenase Niacin deficiency · Pallegra : 4 D's diarrhea, dermatitis, dimentia and death · Hatnup's disease: presents just like pallegra ± Defective renal transport of tryptophan Vitamin B4: Lipoic acid · Needed by pyruvate dehydrogenase, alpha-ketogluterate dehydrogenase, and branched chain amino acid dehydrogenase · No deficiency state 56 56 Vitamin B5: Panthotenic Acid · Needed by pyruvate dehydrogenase, dehydrogenase, alpha-ketogluterate dehydrogenase, and branched chain amino acid dehydrogenase · No deficiency state Vitamin B6: Pyridoxine · Needed by all transaminases · INH pulls pyridoxine out of the body · Forms the cofactor pyridoxalphosphate Pyridoxine deficiency ·neuropathy Vitamin B9: Folate · The first vitamin to run out whenever you have rapidly dividing cells · Used to make tetrahydrofolate (THF) from which you make nucleotides Folate deficiency · · · ·
Megaloblastic anemia Hypersegmented neutrophils Neural tube defects in fetuses Mcc: overcooked vegetables
Vitamin B12: Cyanocobalamin · Needed by two enzymes: ± Homocysteine methyltransferase ± Methylmalonyl-CoA mutase · Used to make tetrahydrofolate · Used to recycle odd-numbered carbon fatty acids 57 57 Vitamin B12 deficiency · Megaloblastic anemia · Hypersegmented neutrophils ·Neuropathy, especially involving the dorsal column pathways and corticospinal tracts · Mcc: pernicious anemia (type A gastritis) Vitamin C · Used for hydroxylation · Hydroxylates proline and lysine in collagen and elastin · Main antioxidant in the GI system Vitamin C deficiency ·Scurvy · Bleeding from hair follicles and gums Vitamin D · Necessary for bone and teeth formation · Stimulates osteoblastic activity · Stimulates calcium AND phosphorous absorption and reabsorption · Mineralizes bones and teeth Vitamin D deficiency · Rickets: in children · Lateral bowing of the legs · Osteomalacia: in adults · Vitamin D resistant rickets ± Defective renal reabsorption of phosphorous ± As phosphorous leaks out, it pulls calcium with it Vitamin E · The main antioxidant in your blood · Absorbs free radicals 58 58 Diseases involving oxidation
· · · ·
Cancer Alzheimer's disease Coronary artery disease Hemolytic anemia ( esp. G6PD)
Antioxidants · · · ·
Vitamin E: in blood Vitamin C: in GI tract Vitamin A Beta-Carotene
Biotin · Necessary for carboxylation Biotin deficiency · Many carboxylases would lose their function Vitamin K · Needed for gamma-carboxylation · Adds a third (gamma) carboxyl group to the vitamin k dependent clotting factors ± Clotting factors II, VII, IX, X, Protein C & Protein S ± Protein C has shortest half life, followed by factor VII Warfarin · · · · · · ·
Competitive inhibitor of vitamin K Given orally Always give heparin first Crosses the placenta Teratogenic Follow PT ( prothrombin time ) INR 2 to 3x normal
59 59 Heparin · Acts as a cofactor for antithrombin III · Blocks thrombin, as well as clotting factors IX, X, XI, and XII ± Follow by measuring PTT ( INR 2 ± 3X NL) ± To reverse the action: protamine sulphate ± If patient acutely bleeding: give FFP to reverse immediately What are germs good for? Vitamins related to gut flora · They make: 90% of vitamin K ±Biotin ± Folate
± Panthotenic acid · They help absorb ± Vitamin B12 MINERALS Minerals ·Calcium ·Magnesium ·Zinc · Copper ·Iron Calcium · Intracellular calcium needed for all muscle contraction · Smooth muscle uses extracellular calcium for second messenger systems · Atrium is ONLY membrane that uses calcium to depolarize · Cardiac ventricle depends on extracellular calcium to trigger off its intracellular calcium release 60 60 Calcium, cont · Used for axonal transport · Presynaptic influx of calcium necessary for release of ALL neurotransmitters · Needed for normal bone and teeth development Magnesium · A cofactor for ALL kinases · A cofactor for PTH · Interacts with potassium as well, but location currently unknown Zinc · Needed by hair, skin, sperm and taste buds · Zinc deficiency: dysguisia Copper · Needed by lysine hydroxylase in the formation of collagen · Also needed by complex IV of electron transport system Copper excess · Wilson's disease ± Autosomal recessive
± Ceruloplasmin deficiency ± Copper deposition in lenticular nucleus (basal ganglia), iris (Kayser-Fleischer rings) and in the liver (causing cirrhosis) ± Tx: penicillamine Movement disorder in a middleaged person · HUNTINGTON'S DISEASE (90%) ± Autosomal dominant ± Trinucleotide repeats ± Involves caudate nucleus ± Has anticipation ± Treat with antipsychotics ± Mcc of death: suicide · WILSON'S DISEASE ± Autosomal recessive ± Ceruloplasmin def ± Copper deposition in lenticular nucleus, liver and iris ± Treat: penicillamine 61 61 Trinucleotide repeats · · · · ·
Huntington's disease Fragile X Fredrieck's ataxia Prader Willi syndrome Myotonic dystrophy
Iron · Needed for formation of heme and hemoglobin · Ferrous iron binds oxygen · Needed by complex III and IV of electron transport system And finally¼ the trace elements Trace Elements ·Chromium · Selenium · Molebdenum ·Manganese ·Tin · Flouride Chromium · Enhances insulin action · Def: causes diabetes Selenium
· Needed primarily by the heart · Excess: breath smells like garlic ( arsenic as well) · Def: dilated cardiomyopathy 62 62 Molebdenum and Manganese · Needed by many enzymes in glycolysis · Xanthine oxidase: needs both elements Tin · Needed for hair growth Flouride · Needed for teeth and bone growth · Excess: blocks enolase of glycolysis THE END BUT, it is really the beginning¼ 63 63 CELLULAR PHYSIOLOGY · CELL ORGANELLS IRREVERSIBLE CELLULAR INJURY · APOPTOSIS ± CELL MEMBRANE DISSOLVES FIRST ± PROGRAMMED CELL DEATH ± NONINFLAMMATORY ± PYKNOSIS ± KARYORHEXXIS ± KARYOLYSIS · NECROSIS ± NUCLEUS DISSOLVES FIRST ± UNEXPECTED ± INVOLVES INFLAMMATION ± PYKNOSIS ± KARYORHEXXIS ± KARYOLYSIS NECROSIS ·ISCHEMIC (COAGULATIVE) · PURULENT · GRANULOMATOUS ·FIBRINOUS ·CASEOUS
·FAT · HEMORRHAGIC · LIQUEFACTIVE NECROSIS ·ISCHEMIC (COAGULATIVE) · PURULENT · GRANULOMATOUS ·FIBRINOUS ·CASEOUS ·FAT · HEMORRHAGIC · LIQUEFACTIVE NECROSIS ·ISCHEMIC (COAGULATIVE) · PURULENT · GRANULOMATOUS ·FIBRINOUS ·CASEOUS ·FAT · HEMORRHAGIC · LIQUEFACTIVE 64 64 NECROSIS ·ISCHEMIC (COAGULATIVE) · PURULENT · GRANULOMATOUS ·FIBRINOUS ·CASEOUS ·FAT · HEMORRHAGIC · LIQUEFACTIVE NECROSIS ·ISCHEMIC (COAGULATIVE) · PURULENT · GRANULOMATOUS ·FIBRINOUS ·CASEOUS ·FAT · HEMORRHAGIC · LIQUEFACTIVE NECROSIS ·ISCHEMIC (COAGULATIVE) · PURULENT · GRANULOMATOUS ·FIBRINOUS ·CASEOUS ·FAT · HEMORRHAGIC · LIQUEFACTIVE NECROSIS ·ISCHEMIC (COAGULATIVE) · PURULENT · GRANULOMATOUS
·FIBRINOUS ·CASEOUS ·FAT · HEMORRHAGIC · LIQUEFACTIVE NECROSIS ·ISCHEMIC (COAGULATIVE) · PURULENT · GRANULOMATOUS ·FIBRINOUS ·CASEOUS ·FAT · HEMORRHAGIC · LIQUEFACTIVE MESS WITH THE CHROMOSOMES · MONOSOMIES: DIE! DIE! DIE! ± MCC: NONDISJUNCTION · 90% IN DAD, USUALLY IN MEIOSIS 1; BUT SPERM DIE ON A DAILY BASIS · FEWER OCCUR IN MOM; BUT MOM KEEPS HER EGGS FOR LIFE AND IS THEREFORE MORE LIKELY TO TRANSMIT HERS · IF ONE WERE TO SURVIVE TO BE BORN, IN THE LEAST, THINGS WILL NOT GROW 65 65 TURNER SYNDROME · · · · ·
WEBBED NECK CYSTIC HYGROMA GONADAL STREAKS SHIELD-SHAPED CHEST COARCTATION OF AORTA
TRISOMIES ·DIE! DIE! ·FEW LIVE · TRISOMIE 13: PATAU SYNDROME ±POLYDACTYLY ± PALATE IS HIGH-ARCHED ± PEE-ING SYSTEM ABNORMALITY TRISOMIES · TRISOMIE 18: EDWARDS SYNDROME ± ROCKERBOTTOM FEET (IN 95%) TRISOMIES · TRISOMIE 21: DOWNS SYNDROME ± MCC: NONDISJUNCTION ± ROBERTSONIAN TRANSLOCATION: HIGHEST INCIDENCE (33% OF OFFSPRING) ± HAS MANY THINGS TO CONSIDER
DOWN'S SYNDROME · MENTAL RETARDATION ± 100% ± IQ: AVERAGE IS 85 TO 100 WITH A STANDARD DEVIATION OF 15 ± SUPERIOR INTELLIGENCE: IQ > 130 ± MILD MR: IQ < 70 ± MODERATE MR: IQ < 55 ± SEVERE MR: IQ < 40 ± PROFOUND MR: IQ < 25 ± NEEDS 24HR CARE ± MILD TO MODERATE MR CAN BE TAUGHT BASIC ADLS 66 66 DOWN'S SYNDROME · EARLY-ONSET ALZHEIMER DISEASE · HIGHER FREQUENCY OF AML;BUT ALL IS THE MOST COMMON LEUKEMIA · 20 TO 40% HAVE congenital heart DISEASE · -ENDOCARDIAL CUSHION DEFECTS ± VSD and ASD ± VSD ± ASD DOWN'S SYNDROME ·CYANOTIC CONGENITAL HEART DISEASE ± TRANSPOSITION OF GREAT ARTERIES ± TETROLOGY OF FALOT DOWN'S SYNDROME · 50% HAVE HYPOTHYROIDISM · WIDELY-PACED CRANIAL SUTURES · MACROGLOSSIA ·DUODENAL ATRESIA · HIRSCHSPRUNG'S DISEASE · CLUES: ± MONGLIAN SLANT TO EYES ± WIDELY SPACED FIRST AND SECOND TOES ± SIMIAN CREASE TRISOMIES · XXX: Normal female; has two barr bodies · XXY: Klinefelter's syndrome. Tall male with gynecomastia, small penis and testicles · X- Fragile X syndrome ± Mcc of chromosomal induced MR ± Short stature; macrochordism ± Collagen disorder (increased risk of MVP) ± Isolated using the drug METHOTREXATE Chemotherapy
67 67 CHEMOTHERAPY · · · · ·
Stops rapidly dividing cells Attacks the nucleus in some way Causes irreversible cellular death WILL kill some patients No such thing as safe chemo
ANTIMETABOLITES ·ARA-A ·ARA-C · 5-FU: blocks thymidylate synthetase · 6-MERCAPTOPURINE: promotes gout; recognized by xanthine oxidase · THIOGUANINE · METHOTREXATE: inhibits dihydrofolate reductase(as does TRIMETHOPRIM and PYREMETHAMINE) ± Most commonly used antimetabolite ± Used to treat molar pregnancies ± Used to treat STEROID RESISTANT disease( followed by AZOTHIOPRINE and CYCLOSPORINE) ANTIMETABOLITES · METHOTREXATE ± Causes folate deficiency and megaloblastic anemia ± Give LEUCOVORIN > FOLINIC ACID to prevent the anemia ANTIMETABOLITES · AZOTHIOPRINE ± Used for steroid resistant diseases( behind METHOTREXATE and before CYCLOSPORINE) ALKYLATING AGENTS · Bind to double stranded DNA · Used primarily for slow growing cancers · Cause the most nausea and vomiting ±ONDANSETRON: serotonin blocker used to treat nausea and vomiting in chemotherapy ALKYLATING AGENTS · Bleomycin · Busulphan ·Adriamycin · Cisplatnin · Cyclophosphamide · Isophosphamide ·Mitomycin · Antimycin · Acridine dyes
· · · · · ·
Hydroxyurea Melphalan Mechlorethamine Procarbazine Dacarbazine Chlorambucil
· FOR RESCUES · Desroxzasane ·Mesna 68 68 MICROTUBULE INHIBITORS · Vinblastine · Vincristine · Paclitaxel NUTRIENT DEPLETION · L-ASPARAGINASE IMMUNEMODULATORS · LEVAMISOLE IRREVERSIBLE CELLULAR DEATH · NUCLEAR DAMAGE · LYSOSOMAL DAMAGE · MITOCHONDRIAL DAMAGE · OCCURS IN 6 HOURS in all tissues 69 69 IRREVERSIBLE CELLULAR DEATH · NUCLEAR DAMAGE · LYSOSOMAL DAMAGE · MITOCHONDRIAL DAMAGE · OCCURS IN 6 HOURS in all tissues except the brain IRREVERSIBLE CELLULAR DEATH · OCCURS IN 20 MINUTES IN THE BRAIN The End? To Be Continued¼ 70 70 MEMBRANE PHYSIOLOGY
A MEMBRANE'S JOB IS NEVER DONE WHAT A MEMBRANE DOES · PROVIDE SHAPE ·AMPHIPATHIC ± HYDROPHILIC and HYDROPHOBIC ± WATER SOLUBLE and FAT SOLUBLE ±HYDROPHOBIC wants to be INSIDE away from water ± HYDROPHILIC wants to be OUTSIDE in contact with water FAT SOLUBLE COMPOUNDS · DO NOT interact with the outer cell membrane. They go right through and head for the nucleus · HAVE NUCLEAR MEMBRANE RECEPTORS · Concentration gradient is only limiting factor STEROID HORMONES · MADE FROM CHOLESTEROL · FAT SOLUBLE( hydrophobic) · Do NOT interact with cell membrane · ALL have a nuclear membrane receptor except CORTISOL · CORTISOL has a cytoplasmic receptor; but it still translocates to the nuclear membrane 71 71 WATER SOLUBLE HORMONES · HYDROPHILIC · CAN NOT simply go through a fat soluble membrane · Must bind to the outside membrane to a receptor · Requires a SECOND MESSENGER · But first, what about ANY water soluble compound? WATER SOLUBLE COMPOUNDS Factors affecting diffusion · CONCENTRATION GRADIENT · SIZE of molecule · Net charge on molecule · pH (affects the net charge of a molecule) · THICKNESS of membrane · SURFACE AREA of membrane · FLUX (dx/dt) · REFLECTION COEFFICIENT ± NUMBER OF PARTICLES RETURNED / NUMBER OF PARTICLES SENT TO MEMBRANE
FICK'S EQUATION · Factors that FAVOR diffusion go in the NUMERATOR · Factors that NEGATIVELY affect diffusion go in the DENOMINATOR OTHER FUNCTIONS OF A MEMBRANE · CREATE and MAINTAIN concentration gradients · SELECTIVE permeability · Has SATURATED fats( no double bonds) · Has UNSATURATED fats( double bonds) ± Easier to break down ± Better temperature regulation ± More fluidity of movement, especially lateral ESSENTIAL FATS · Can get them ONLY through the diet · LINOLENIC · LINOLEIC ± Used to make ARACHADONIC ACID ± Arachadonic acid becomes essential if linoleic acid is missing from the diet OTHER MEMBRANE FUNCTIONS · PHAGOCYTOSIS: requires energy ± ENDOCYTOSIS: primarily for nutrition ± EXOCYTOSIS: primarily for getting rid of waste products ( i.e. lipofuscin ) ± PINOCYTOSIS: for movement of fluids and electrolytes · SKIN is only organ that does this process 72 72 OTHER MEMBRANE FUNCTIONS · TEMPERATURE REGULATION ± RADIATION > concentration gradient ± CONDUCTION > requires contact ± CONVECTION > movement of environment drags heat out of the body OTHER MEMBRANE FUNCTIONS · ALL membranes can depolarize · Resting membrane potentials ELECTROLYTE MOVEMENT · · · · ·
CONCENTRATION GRADIENT ELECTRICAL GRADIENT DRIVING FORCE NERNST NUMBER (E-ion) CONDUCTANCE (G-ion)
· ± ± ±
PERMEABILITY CHANNELS: small ions PORES: medium-sized molecules (sweat) TRANSPORT PROTEINS
TRANSPORT PROTEINS · PRIMARY ACTIVE TRANSPORT >requires an ATPase. Going against a gradient · SECONDARY ACTIVE TRANSPORT ± Requires sodium's gradient ± SYNPORT or COTRANSPORT >moving in the same direction as sodium ± ANTIPORT > movement in opposite direction as sodium SECOND MESSENGERS · C-amp > most common second messenger 73 73 PHOSPHODIESTERASE INHIBITORS · CAFFIENE · THEOPHYLLINE ·SILDENAFIL · VARDENAFIL · TADALAFIL SECOND MESSENGERS, cont · IP3 -DAG IP3-DAG SYSTEM · All HYPOTHALAMIC HORMONES, except CRH · All SMOOOTH MUSCLE CONTRACTION by hormone or neurotransmitter CALCIUM ±CALMODULIN SYSTEM · 4 calcium molecules: 1 calmodulin · All SMOOTH MUSCLE CONTRACTION by DISTENTION CALCIUM · Used as a second messenger by GASTRIN only TYROSINE KINASE · INSULIN and all GROWTH FACTORS 74 74 NITRIC OXIDE
· NITRIC OXIDE > GUANYLATE CYCLASE > elevates c-GMP ·NITRATES · ENDOTOXIN ·ANP NITRATES · VASODILATORS · TACHYPHYLAXIS; rapid tolerance · Nitroglycerin · Dinilatrate · Sodium Nitroprusside The End Insane in the membrane 75 75 INFLAMMATION SHUTTING DOWN THE Na-K ATPase · Potassium still leaks out · Cell becomes more negative > less likely to depolarize SHUTTING DOWN THE Na-K ATPase, cont · With Na trapped within the cell, calcium also gets trapped within the cell ± This increases contractility · DIGITALIS · DIGITOXIN ·OUBAIN EKG CHANGES · Na-K ATPase shuts down when a vessel is 70% stenosed · Potassium leaks out, making cells more negative · This is why you get ST-wave DEPRESSION ST-WAVE DEPRESSION · Early ischemia · 70% stenosis · SYMPTOMS BEGIN · Subendocardial ischemia · STABLE ANGINA ± Comes on with exertion; goes away with rest ± 30% flow is enough at rest, but not on exertion ± TX: VASODILATORS > increase radius increases flow FOLLOW-UP FOR ANGINA
· ± ± ± ± ± · ±
PAIN GOES AWAY Hospitalize for 24hours Do serial EKGs and CIEs (Q6h x 24h) If negative workup, then discharge home Do a regular STRESS TEST in 6 weeks Do STRESS THALLIUM test in 6 weeks Thallium flows through the coronary arteries Look for COLD AREAS: NO FLOW( ISCHEMIC)
76 76 FOLLOW-UP FOR ANGINA, cont · If you think they might have had an MI, then do a Ca-PYROPHOSPHATE scan ± Cells that die calcify ± Dead cells will take up the CaPYROPHOSPHATE · Look for a HOT SPOT FOLLOW-UP FOR ANGINA, cont · IF PATIENT UNABLE TO PERFORM THE STRESS TEST: ± DOBUTAMINE STRESS TEST ± DIPYRIDAMOLE STRESS TEST EKG CHANGES · Na gets trapped within a cell when there is at least 90% stenosis · Cells become more POSITIVE UNSTABLE ANGINA · 90% stenosis · EVENTS OCCUR · PLAQUE RUPTURED, and platelets are closing off the rest of the lumen · TX: Aspirin > Nitrates> Oxygen > Heparin > tPa > Morphine > B-blockers > Take to CATH LAB for angiogram ANGIOGRAM FINDINGS · LEFT MAIN CORONARY ARTERY OCCLUSION ( 70% stenosis or more) · THREE OR MORE VESSELL DISEASE · TX: GO STRAIGHT TO SURGERY ANGIOGRAM FINDINGS, cont · ANY SINGLE OR DOUBLE VESSELL DISEASE · TX: PTCA with STENT placement coated with CLOPIDOGREL
77 77 CELLS ARE MORE LIKELY TO DEPOLARIZE WHEN ISCHEMIC · After a stroke: SEIZURES · After an MI: ARRYTHMIAS · After ischemic bowel: BLOODY DIARREA · After a DVT: CRAMPS WITH Na and Ca trapped within the cell · Since atria use Ca to depolarize, the trapped Ca may cause atrial arrythmias · Contractility of muscles increases WITH CELL DYING, · Sodium continues to accumulate inside cell · Chloride will follow · WATER will follow next · SWELLING is therefore the FIRST visible change of cellular injury SWELLING · · · · ·
Cerebral edema Papilledema Hydropic changes Dilated lymphatics Third spacing
INFLAMMATION TIME LINE · < 24 hours: SWELLING · AT 24 hours: NEUTROPHILS show up and peak at 3 days · T-cells and MACROPHAGES: show up at day 4 and peak at day 7 · FIBROBLASTS: show up at day 7, peak at day 30, and take 3 to 6 months to complete their work ( chronic inflammation) WHEN TOO MUCH SODIUM INSIDE CELL¼. · Sodium begins to leak OUT of the cell now that concentration gradient is reversed · The only way for sodium to get out is to use the Na-Ca exchange protein which is concentration driven 78 78 IF BLOOD SUPPLY NEVER RETURNS TO THE CELL · The sodium can pull ALL the calcium into the cell · WHILE calcium is moving into cell, more atrial arrythmias may develop
WHEN ALL CALCIUM NOW TRAPPED WITHIN THE CELL · Cells that depend on EXTRACELLULAR calcium will lose function ± SMOOTH MUSCLE ±ATRIUM ± VENTRICLE SIGN OF CHRONIC DISEASE · ON BIOPSY: you see evidence of fibrosis · ON X-RAY: you see calcifications ALL inflammatory processes¼ DONE!!! 79 79 Electrolyte Physiology Something in the way she moves me¼ Electrolyte Movement · · · · · · ± ± ±
CONCENTRATION GRADIENT ELECTRICAL GRADIENT DRIVING FORCE NERNST NUMBER (E-ion) CONDUCTANCE (G-ion) PERMEABILITY CHANNELS: small ions PORES: medium-sized molecules (sweat) TRANSPORT PROTEINS
Electrolyte Movement · · · · · · ± ± ±
CONCENTRATION GRADIENT ELECTRICAL GRADIENT DRIVING FORCE NERNST NUMBER (E-ion) CONDUCTANCE (G-ion) PERMEABILITY CHANNELS: small ions PORES: medium-sized molecules (sweat) TRANSPORT PROTEINS
Electrolyte Movement · CONCENTRATION GRADIENT · ELECTRICAL GRADIENT ·DRIVING FORCE · NERNST NUMBER (E-ion) · CONDUCTANCE (G-ion) · PERMEABILITY ± CHANNELS: small ions ± PORES: medium-sized molecules (sweat) ± TRANSPORT PROTEINS Electrolyte Movement
· · · · · · ± ± ±
CONCENTRATION GRADIENT ELECTRICAL GRADIENT DRIVING FORCE NERNST NUMBER (E-ion) CONDUCTANCE (G-ion) PERMEABILITY CHANNELS: small ions PORES: medium-sized molecules (sweat) TRANSPORT PROTEINS
Electrolyte Movement · · · · · · ± ± ±
CONCENTRATION GRADIENT ELECTRICAL GRADIENT DRIVING FORCE NERNST NUMBER (E-ion) CONDUCTANCE (G-ion) PERMEABILITY CHANNELS: small ions PORES: medium-sized molecules (sweat) TRANSPORT PROTEINS
80 80 Electrolyte Movement · · · · · · ± ± ±
CONCENTRATION GRADIENT ELECTRICAL GRADIENT DRIVING FORCE NERNST NUMBER (E-ion) CONDUCTANCE (G-ion) PERMEABILITY CHANNELS: small ions PORES: medium-sized molecules (sweat) TRANSPORT PROTEINS
Electrolyte Movement ·Depolarize: to become positive from baseline · Overshoot: more positive than the threshold potential · Repolarization: to become negative from a positive potential · Hyperpolarization ( or undershoot): to become more negative than baseline potential Sodium Channels 81 81 HEART BLOCKS · NORMAL PR-interval : <0.2sec · FIRST DEGREE HEART BLOCK: fixed and prolonged PR-interval ± Problem is AT the SA node or BETWEEN the SA node and the AV node ± NO treatment necessary ± Speeding up the heart rate( exercise) will
make the block disappear HEART BLOCKS, cont · SECOND DEGREE HEART BLOCK · MOBITZ 1: progressive lengthening of PRinterval until QRS is dropped ± Early ischemia at the AV node ± Also called WENCKEBACK'S ± Put in pacemaker if symptomatic; do nothing if asymptomatic HEART BLOCKS, cont · MOBITZ II: PR-interval is normal; QRS complexes are dropped erratically ± Late ischemia at the AV node ± Some cells are negative; some cells are positive ± ALL must have a pacemaker 82 82 HEART BLOCKS, cont · THIRD DEGREE HEART BLOCK ± COMPLETE AV DISSOCIATION ± AV-node has INFARCTED ± P-waves and QRS complexes have NO relationship ± ALL must have a pacemaker QRS COMPLEXES · Premature ventricular complex (PVC) ± No P- wave; wide QRS complex; a pause following the QRS complex ± BIGEMINY: A PVC every other beat ± TRIGEMINY: A PVC every third beat ± VENTRICULAR TACHYCARDIA: three or more consecutive PVCs with a minimum heart rate of 150 ± VENTRICULAR FIBRILLATION: NO recognizable QRS complexes VENTRICULAR TACHYCARDIA · IF PATIENT STABLE: treat with medication · IF PATIENT UNSTABLE: ± SHOCK with 200joules ± SHOCK with 300joules ± SHOCK with 360(max)joules ±LIDOCAINE ± SHOCK ± BRETYLIUM or AMIODORONE VENTRICULAR FIBRILLATION · EPINEPHRINE · TREAT LIKE VENTRICULAR
TACHYCARDIA ATRIAL ARRHYTHMIAS · · · · · ± ± ± ±
Premature atrial contraction (PAC) Multifocal atrial tachycardia Paroxysmal supraventricular tachcardia Atrial flutter Atrial fibrillation If ACUTE and STABLE: treat with medication If ACUTE and UNSTABLE: DEFIBRILLATE If CHRONIC: treat medically; put on coumadin May defibrillate after minimum 2 weeks on coumadin
· TX: use synchronized button ELECTROLYTES AFFECT DEPOLARIZATIONS · FOUR SPECIALIZED MEMBRANES ± NEURONS ± SKELETAL MUSCLES ± SMOOTH MUSCLES ± CARDIAC MUSCLE · ATRIUM: uses calcium to depolarize · VENTRICLE: uses sodium to depolarize; uses intracellular calcium to contract; depends on extracellular calcium to trigger off intracellular calcium release 83 83 HYPERMAGNESEMIA · · · ·
LESS LIKELY TO DEPOLARIZE AFFECTS CALCIUM AND POTASSIUM GETS IN THE WAY OF SODIUM TX: IV normal saline; loop diuretic
HYPOMAGNESEMIA · · · ·
MORE LIKELY TO DEPOLARIZE AFFECTS CALCIUM and POTASSIUM AFFECTS all KINASES TX: magnesium sulphate
HYPERCALCEMIA · LESS LIKELY TO DEPOLARIZE everywhere except the atrium( more likely) · SMOOTH MUSCLE: initially less likely (blocks nerve) to depolarize, then more likely to CONTRACT (due to second messenger systems) · TX: IV normal saline; loop diuretics HYPOCALCEMIA · MORE LIKELY TO DEPOLARIZE everywhere except the atrium( less likely) · WILL AFFECT SECOND MESSENGER
SYSTEMS · SMOOTH MUSCLE: initially more likely to depolarize( nerve fires more) followed by less likely to CONTRACT (affects second messenger systems) HYPERKALEMIA · Initially MORE LIKELY TO DEPOLARIZE · Potassium will flow into the cell, taking the membrane potential closer to threshold · Potassium gets trapped INSIDE the cell during repolarization; repolarization therefore takes longer > LESS LIKELY TO DEPOLARIZE ± Peaked T waves ± Widened T waves ± Prolonged QT interval · Predisposes to arrythmias HYPOKALEMIA · LESS LIKELY TO DEPOLARIZE · Potassium will rush out of the cells, making them more negative ± Cells repolarize even faster ± Cells repolarize too much ·Narrow T waves ·Flat T waves · Flipped and inverted T wave · The U wave( exaggerated flipped T wave) 84 84 HYPERNATREMIA · MORE LIKELY TO DEPOLARIZE · SODIUM rushes into the cells, making them more positive · After sometime, the NA-K ATP-ase kicks Into high gear, making the cells more negative( less likely to depolarize) · TX: IV normal saline; correct slowly HYPONATREMIA · MORE LIKELY TO DEPOLARIZE · SODIUM will now leak out of a cell by Na-K exchange · When calcium leaks INTO cell in exchange for sodium leaking OUT, cells become more positive · TX: IV normal saline; correct slowly ± Use 3% saline if sodium under 120 with symptoms ± Use fluid restriction if hyponatremia due to SIADH Hyponatremia The End: Turn off the lytes Antiarrhythmics Class 1: Na channel blockers
·1a ± Quinidine ± Procainamide ± Disepyramide ·1b ± Lidocaine ± Tocainide ± Mixelitine ± Phenytoin ·1c ± Encainide ± Flecainide ± propofenone 85 85 Class II: Beta Blockers · All end in ±lol · Specific beta 1: begins with A thru M, but NOT L or C · Nonspecific: begins with N thru Z, including L and C Class II: Beta Blockers · · · · · · ·
Propanolol Acebutalol Esmalol Atenalol Sotalol Pindalol Timalol Butexalol Labetalol Carvedilol
Class III: K Channel blockers · · · ·
Napa ( from procainamide) Sotalol Bretylium Amiodorone
Class IV: Ca Channel blocker · · · · · · ·
Verapamil Quinidine Diltiazem Procainamide Nifedipine Phenytoin Nicardipine Nimodipine Femlodipine Amlodipine
IF YOU PLAY WITH LYTES¼ You may go down IN FLAMES 86 86 PULMONARY PHYSIOLOGY TAKING A DEEP BREATH PULMONARY PHYSIOLOGY
