john Shared "Copy of Collaboration for 100% First Aid coverage" - 61 Picmonics
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First Generation Antipsychotics [FGAs] (Also called conventional, typical, or traditional antipsychotics).
Therapuetic effect: in the mesolimbic pathwayD2 blockade reduces active psychotic features. This may take up to 6 weeks to appear)$.
# Antidopaminergic S/E; 1. In Nigrostriatal tract >>> EPSE (because of the resulting hypercholinergic effect, which manifests in skeletal muscle spasms
Extra-Pyramidal Side Effects (EPSE)
- Acute dystonia: appears within days after Rx. Severe painful spasm of neck muscles (torticollis), ocular muscles (oculogyric crisis) muscles of the back (opisthotonus) and tongue protrusion.
Parkinsonism: appears within weeks after treatment, its features: stooped posture, akinesia, muscle rigidity, masked face, and coarse tremor. Treated with anticholinergic drugs (e.g. procyclidine)
Rabbit Syndrome Rapid perioral tremor.
cont Super-sensitivity of dopamine receptors. No specific treatment, the only agreed treatment is to discontinue the antipsychotic drug when the patient’s state allows this.
cont Thus, antidopaminergics induce excessive prolactin secretion, which lead to gynecomastia and amenorrhea. Some gynecologists prescribe dopaminergic medications (e.g. bromocriptine) to reverse amenorrhea in psychotic females, which may aggravate their
# Anticholinergic S/E; dry mouth, constipation, urinary retention, poor erection, blurred vision, and precipitation of closed-angle glaucoma.
Haloperidol (Haldol) 10 mg high potency s-e sezure prolonged qt
Second Generation Antipsychotics [SGAs] (Also called novel or atypical antipsychotics, serotoninA 2-dopamine antagonists). ;
Therapeutic effects; More specific for the mesolimbic than nigrostriatal dopamine system >>> less EPSE.
> improve negative symptoms of psychosis: low initiation, lack of motivation, and restricted affect. They improve both positive and negative symptoms of psychosis and can help some resistant cases.
Adverse effects; Less EPSE, antiadrenergic, anticholinergic S/E. but there is a high risk of metabolic syndrome ( see below).
Olanzapin Advantage Effective on negative features
Clozapin se Agranulocytosis Metabolic syndrome + Agranulocytosis (check WBCs). + High risk of seizures
Quetiapin se Metabolic syndrome
Third Generation Antipsychotics Dopamine System Stabilizers [DSS].
DEPOT (SLOW RELEASE) ANTIPSYCHOTICS: These are long-acting antipsychotic drugs, given as deep intramuscular injections to patients who improve with drugs but cant take it orrally
(¼ - ½ the dose) to check patient’s tolerability. Depot injections are released slowly in 1 – 8 weeks - Risperdal consta:25-50 mg./2weeks. -Zuclopenthixol decanoate ( Clopixol ) : 200 – 600 mg. /month.
-
Toxic Effect: Neuroleptic Malignant Syndrome (NMS) , Recent memory: loss ( early) dementia but may occur in normal elderly and because of medications side effect
Delirium Control mental and physical disturbance
contraindicated in Lewy Body Disease
SLE, MS) is associated with predominance of manic episodes and frequent psychotic symptoms. Antipsychotics (e.g. olanzapine 10mg) can be given to control such complications.
CNS Stimulants tr Symptomatic use of an antipsychotic medication e.g. olanzapine
side effect Depression ,,,, . LITHIUm may potentiate extrapyramidal side effect
clozapine side effect hypersalvation , myocarditis , ileus
INCREASED SLEEP (Bio)\ DECREASED SLEEP (Bio)= EMW (Bio)=earlymorning waking=g (terminal) insomnia waking 2 - 3 hours before the usual time, this is usually associated with severe
Obsessional symptom
Constipation -
ATYPICAL OR MASKED OR DEPRESSIVE NEUROSES
:hypersomnia2 -Increased appetite or significant weight gain3-leaden paralysis or sensitivities of the legs that extend far beyond the mood disturbance episodes
interpersonal rejection sensitivity that extends far beyond the mood disturbance episodes
≥ 2 years history of chronic low mood. No remission periods more than two months. During low mood there should be ≥ 2 out of the
dysthymic disorder complicated by major depressive episodes (double depression)
insidious onset before age 25; the course is chronic. Some patients may consider early onset dysthymic disorder as part of life.
postpartum depression
10 - 15 % recently delivered women develop disabling depression within 6 weeks of childbirth - if not treated may continue for six months or more
Major Depressive Episode ( MDE ) is spontaneously
discrete periods of abnormal mood; low, ≥ 2 weeks of low mood/loss of interest
MDD is marked by chronic depression with symptoms lasting for as much as the whole life of the person. Additionally, MMD frequently occurs with other psychiatric problems, such as Bipolar Disorder or Anxiety Disorder. Those with MDD is with heart diseas
Diagnostic Criteria for Major Depressive Disorder (MDD)
A. Presence of major depressive episode (s). B. Not better accounted for by schizoaffective disorder and is not superimposed on schizophrenia,
C. There has never been a manic episode, a mixed episode, or a hypomanic episode.
-
: Delusion that a patient has done something sinful, with excessive pathological feeling of remorse and guilt seen in severe depression.
Pseudo-dementia (Depression in the elderly): which is rapid onset after depression
Poverty of Speech -assment Poverty of thought
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Delusion of poverty and impoverishment. 4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
Epidemiology of mdd: (more in women like any mood disorder). Lifetime risk is in the range of 10 - 15 %. Lifetime prevalence is in the range of 15 - 25 %. The mean age of onset is about 40 years (25 - 50 years)
in children
in children
in children
in children
in children
in children
in children
in children
in children
in children
in children
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
not uncommon. Child may not express his low mood verbally. so look for
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
usually self-limiting, but may become chronic or recurrent. Masked depression may present as a behavior disorder.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Poor outcomes of the medical illness Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non- depressed patients with no GMC
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
Behavioural: Physical inactivity. Smoking. High carbohydrate & high fat diet.
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
mdd “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression)
11 secs
Serum serology of hbv
Antigens
HbsAg: ➔ Appears in serum 2 to 10 weeks. ➔ Persistence of HBsAg for >6 months implies progression to chronic=presistent carrier HBV infection. ➔ In self-limited acute hepatitis, HBsAg usually becomes undetectable after 4-6 months. ➔( The disappearance of
HBsAg → infection (carrier): surface antigen' -whern its disappear = non invective
HBeAg → viral replication
Viral load: HBV DNA → viral replication QUANTITATIV: - measured by PCR; if it persists > 6 weeks, patient is likely to develop chronic disease
Antibodies
Anti-HBs → immunity: n or after clearance of HBsAg, usually detectable 1 to 3 months after infection.
Anti-HBe → seroconversion= low infecctivity
. Anti-HBc (Hepatitis B core antibody) 1st ab → exposure to actual virus (IgM = acute): - Assay of IgM & IgG combined. - Useful because it may be the only serologic marker of HBV infection during the “window peek” in which HBsAg is disappearing,
The accurate diagnosis of acute hepatitis B require testing with immunoglobulin (Ig) M antibody to hepatitis B core antigen (HBcAg) (IgM anti-HBc)$
Coexistence of HBsAg and anti-HBs in serum has been reported in approximately 25% of HBsAg-positive persons and occurs more commonly in persons with chronic hepatitis B than in those with acute hepatitis B.
IgM class is usually detectable for 4 to 6 months after an acute episode of hepatitis or during exacerbation of chronic hepatitis B and rarely for up to two years.
antibody to HBeAg (anti-HBe)-=low infectivity
HbeAg ➔ Persistence of HBeAg three or more months after the onset of illness indicates a high likelihood of transition to chronic HBV infection.
80% of HBsAg-positive mothers who are HBeAg -positive transmit the disease to their offspring$$
after serology LFT, U/S liver, PCR,
how to deal with hbv patient? Measure for Family Contacts, screen and vaccinate the negative ones Referral to hepatologist, No blood donation
people who are HBsAg +ve can have sexual intercourse with their partners. normally if partner is vaccined
-the partner should receive a hepatitis B vaccination series (3 doses at 0, 1 month, & 6 months), then 1-2 months after finishing the series he/she should be tested for immunity against Hep B, if immune they can have intercourse without condom.
if hb core ab + but others nigative : Interpret the results: • H/O chronic exposure to HB virus
2- May be distantly immune and test is not sensitive enough to detect very low level of anti-HBs in serum.
4- May be a false positive anti-HBc.
Diagnosis: Hepatitis B surface antigen (HBsAg) o There is a good chance that the body will get rid of hepatitis B virus on its own within 6 months.
the infection. They will also have total antiHBc antibodies which means that this person was exposed to the virus; so he is immune by previous infection. (If HBc is not there and the patient is immune, it means he is immune by vaccination). , HBe
• Newborn of HBsAg-positive mothers (MCQ): This will protect 95% of the kids$
Hepatitis B Immunoglobulins passive (within 12 hours of birth)
Vaccine
Older children: antiviral medications however most of these drugs are not effective and the hepatitis B stays with them until adulthood. So, Wait & observe (spontaneous recovery, new better antiviral medications)
core
anti hbc and hbs =history
acte HBsAg Anti-HBc igm , maybe HBV DNA
low level anti hbc positice =chronic
anti hbc only resolve most common2- fp 3- low level chronic
Inactive chronic infection
lazy
specific
, , E.g. of passive vaccine: if a pregnant mother is + ve for Hepatitis B, we give the newborn baby immunoglobulins (because the active vaccine takes time + already the mother's ,vaccine Interference with Immunoglobulins bc active , Hepatiti
Acute hepatitis, supporative
,, 89. An 11 month old infant recently arrived from an asian country, his status is unknown. Mother is positive hepatitis b surface antigen. What is the most appropriate vaccine infant should receive? B. HBIG (1 dose) and hepatitis b vaccine (3 dose withi
Note: Hepatits B virus is NOT a contraindication of brestfeeding because the babies are given immunoglobulin and vaccinations directly after birth if the mother is HBsAg positive.$ ,.
110- A pregnant lady Hip B: B. give immunolobunolin and Hep b vaccine in first 12 hours ,, - HepB +ve mom gave birth the child should receive: (1 answer) A. HBIG and vaccine at birth
acute and window ↑ (ALT > AST)
“Window period”maybe Anti-HBe
igm first then igg
HBV DNA window maybe
history Anti-HBe , igg
Active chronic infection hbsag , hbeag , igg , dna >2000 iu ml , alt >ast maybe
Active chronic infection hbsag , hbeag , igg , dna >2000 iu ml , alt >ast maybe
dna >2000 iu ml , alt >ast maybe
Inactive chronic infection hbsag , anti hbe , igg , hbv dna less or = 2000
,
Anti‑HBe Indicates long-term clearance of HBV
Screening: HBsAg (detectable 1–5 months after infection)
isolation
maybe
cirrhosis, cellular dysplasia → HCC
start
infectious
common
,
acute
,
,
,
,
,
normal child at birth , 2 , 4 , 6 passive
core
,
wand
antibody
Management of Hypertension
nice guidelines hypertension
less120-80 reasses after1 year
Treatment of hypertension depend on the type of hypertension, comorbidity, the cause and the age of pt
120-129-less80 : lifestyle if they didn’t treat, within 0.5 - 2 years they will develop hypertension.
High normal (SBP >130–139 mmHg, DBP 85–89 mmHg) reasses after6 month
if there is no Atherosclerotic Cardiovascular Disease or 10yr cvd risk }Lifestyle Intervention In high risk patients ..if yes two in the begining tr like more140
Regular physical exercise : 30 min of moderate-intensity aerobic exercise 5-7 days/week
over 55yr or african amercan = ccb or thiazide like drugs= indapamide sr
under 55 yr: acei or arb
BP (more than 140/90) srage 1 htn
lifestyle and medication - reasses after 1month..these bellow are best initial
(BP > 160) stage2 htn
acei+ccb+thiazide in one pill
resistant hypertension
arb or acei)+ccb+thaiazide all in one --+ further duiritics or alpha or beta blockers
Hypertensive Emergency:Admitted to ICU and treat with IV administration.
Malignant (accelerated) hypertension : Need for ICU and treat with IV
55% of participants on medication for hypertension had their blood pressure uncontrolled.
Diabetes Mellitus proteinuria : (ACEi,or ARB same effect ),NO
Chronic kidney disease : ACEi, ARBs, Thiazide
Benefits of Lowering BP:
Stroke incidence will reduce 35 to 40% ● Myocardial infarction will reduce 20 to 25% ● Heart failure will reduce 50% ● Renal failure will reduce 35 to 50%
jnc9 2014 guidline applicaple for pt without other disease
dult aged ≥18 years with hypertension t lifestyle interventions (continue throughout management).
General population (no diabetes or CKD)
Age ≥60 years Blood pressure goal SBP <150 mm Hg (or)DBP <90 mm Hg
Nonblack Initiate thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination.a
all ages CKD present with or without diabetes Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg
all above
Select a drug treatment titration strategy A. Maximize first medication before adding second or B. Add second medication before reaching maximum dose of first medication or
if At goal blood pressure? Continue current treatment and
if not Reinforce medication and lifestyle adherence. For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB).
if not goal Reinforce medication and lifestyle adherence. Add and titrate thiazide-type diuretic or ACEI or ARB or CCB
not At goal blood pressure?
-
Up to 65% of Americans with hypertension do not achieve adequate blood pressure control.
All Anti hypertensives are taken at night to prevent non dipping except diuretics which are taken in the morning
gestational htn hydralazine , dihydropyridine
dm In Microalbuminuria and Nephropathy (Renal damage) lower BP to ≤ 130/80
Initial Drug Choice
e Isolated Systolic • Thiazides , ccb
ifestyle changes “weight loss is the most effective” and any modifiable risk factors, such as obesity or smoking, should be controlled)
Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat. , reduce 8-14 mmHg in sbp
Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day. most days of the week). 4-9 mmhg red in sbp
The amount of blood pressure reduction is the major determinant of reduction in cardiovascular risk
diabetes management
to improve symptoms of hyperglycemia and to minimize the risks of long-term microvascular and macrovascular complications
education - Self-assessment USE DSMES GLUCOMETER , CGM , REVIEW INSULIN PUMP SETTING of glycaemic control: Insulin-treated patients should be taught to monitor blood glucose using capillary blood glucose meters, and to use the results to guide insulin do
Therapeutic goal $ : The target HbA1c depends on the patient. Early on in diabetes (i.e.patients managed by diet or one or two oral agents), a target of 48 mmol/mol (6.5%) or less may be appropriate,(7.5%) may be more appropriate in older patients with pr
In new cases of diabetes, adequate glycemic control can be obtained by diet and lifestyle advice alone in approximately 50%
Diet and lifestyle
reducing alcohol consumption and stopping smoking, are important but difficult for many to sustain first line
Drugs to reduce hyperglycemia (you have more than 1500 combination choice)
(first-line) drug therapy is with oral Metformin
Sulfonylureas
Thiazolidinediones provide no clear benefit over the other hypoglycemic medications
Nateglinide and repaglinid are stimulators of insulin release in a similar manner to sulfonylureas, but do not contain sulfa. They do not add any therapeutic benefit to sulfonylureas
Alpha glucosidase inhibitors (acarbose, miglitol)
Incretins
Insulin is added if the patient is not controlled with oral hypoglycemic agents -( First drug to give if patient came with HBA1c >10% is premixed insulin. $$
Prevent Complications
-
Patients with prediabetes (A1C 5.7% [39 mmol/moll, IGT, or IFG) should be tested yearly. 3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years.
Prevention Or Delay Of Type 2 Diabetes Recommendation: At least annual monitoring for the development of type 2 diabetes in those with prediabetes is suggested. - Lifestyle Interventions
Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI ≥35 kg/m2, those aged <60 years, and women with prior GDM.
or more of moderate-tovigorous intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 min/week) of vigorous- intensity or interval training may be enough
A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). , quarterly in patients whose therapy has changed or who are not meeting glycemic goal
less than 6.5 Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease.
cont complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents inclu
Blood pressure should be measured at every routine clinical visit. Patients found to have elevated blood pressure (≥140/90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertensi
In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes if ASCVD risk factors are treated. Consider investigations for coronary artery disease in the presence of any of the following: atyp
Consider aspirin therapy (75–162 mg/day) C
n patients with diabetes <50 years of age with multiple other risk factors (e.g., 10-year risk 5–10%), clinical judgment is required
Statin without adding anything else , At least once a year, assess urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and eGFR in patients with type 1 diabetes with duration of ≥5 years, in all patients with type 2 diabetes, and in all pat
cont The screening is done by using a camera “non mydriatic fundus camera”. The camera will take a picture and the picture will be sent to computer and the doctor will look
cont If the retina is ok then the screening is done every year. If mild non PDR → done after 6 months. If it’s severe non PDR, PDR or macular edema → refer to laser.
If there is no evidence of retinopathy for one or more annual eye exam and glycemia is well controlled, then exams every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeat
Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy.
All patients should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter.
Refer patients who smoke or who have histories of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or peripheral arterial disease to foot care specialists for ongoing preventive care and lifelong surveillance.
ada 2019
DM pt on Metformin with HbA1c above target, Establieshed ASCVD or CKD. • Without established ASCVD or CKD: • To minimize hypoglycemia • To promote weight loss or minimize weight gain • Cost is a major issue
without established ascvd or ckd1- to reduce weight : GLP 1 OR SGLT2 , if not target add the other drug i
to minimize hypoglycemia ddp-4 or glp1 ra or sglt2i or tzd if note target add other from above
ascvd predominant glp1 or sglt all with proven reduce cvd if
hf or ckd: PREFERABLY SGLT2I if not tolerated or egfr less than adequate (ADD)glp1 ra , all proven ckd or cvd benifit
If HbA1c still above target despite dual/triple therapy, What to do? Consider GLP-1 RA in most prior to insulin. •
If HbA1c still above target despite dual/triple therapy, What to do? Consider GLP-1 RA in most prior to insulin. •
If HbA1c still above target despite dual/triple therapy, What to do? Consider GLP-1 RA in most prior to insulin. •
If HbA1c still above target despite dual/triple therapy, What to do? Consider GLP-1 RA in most prior to insulin. •
dont mix dpp4 with glp1 , HbA1c still above target despite adequately titrated basal insulin OR once basal insulin > .7 – 1.0 IU/kg OR FPG at target, What to do?
dont mix dpp4 with glp1 , HbA1c still above target despite adequately titrated basal insulin OR once basal insulin > .7 – 1.0 IU/kg OR FPG at target, What to do?
dont mix dpp4 with glp1 , HbA1c still above target despite adequately titrated basal insulin OR once basal insulin > .7 – 1.0 IU/kg OR FPG at target, What to do?
dont mix dpp4 with glp1 , HbA1c still above target despite adequately titrated basal insulin OR once basal insulin > .7 – 1.0 IU/kg OR FPG at target, What to do?
Xeroderma Pigmentosum
Pathophysiology
Defective Nucleotide Excision Repair
Complications
Extreme Light Sensitivity
Dark Freckles on Skin
Pale, Dry Skin
Susceptible to UV Rays A and B
Corneal Ulcers
Increased Risk of Skin Cancer
Some Patients Present Progressive Neurodegeneration
2 mins
Hyperchylomicronemia (Type I Familial Dyslipidemia)
Dysbetalipoproteinemia (Type III Familial Dyslipidemia)
INHERITANCE
Autosomal Recessive
PATHOGENESIS
Defective Apolipoprotein E (Apo E)
Lab Findings
Increased Chylomicrons
Increased VLDL
Symptoms/Findings
Premature atherosclerosis
Tuberoeruptive xanthomas
Palmar xanthomas
3 mins
Hypertriglyceridemia (Type IV Familial Dyslipidemia)
INHERITANCE
Autosomal Dominant
pathogenesis
Hepatic Overproduction of VLDL
Related to Insulin Resistance
Lab Findings
Increased VLDL
Increased Triglycerides (> 1000 mg/dL)
Symptoms/Findings
Acute Pancreatitis
Eruptive Xanthomas
Increased Risk for Coronary Artery Disease (CAD)
Increased Risk of Peripheral Vascular Disease
3 mins
Live Vaccines
Vaccines
Varicella Zoster Virus (VZV)
Sabin Polio (Oral)
Smallpox
Yellow Fever
Influenza Intranasal
MMR
MMR: Only Live Attenuated Vaccine That Can Be Given To AIDS Patients
General Characteristics
Induce Humoral And Cell Mediated Immunity
May Revert To Virulent Form
Do Not Require Boosters
4 mins
Killed Vaccines
Induce Humoral Immunity
Require Booster Shots
Influenza (Injected)
Salk Polio (Injected)
Hepatitis A
Rabies
3 mins
Subunit Vaccines
Consist of Specific Parts of a Pathogen
Hepatitis B Antigen
Human Papillomavirus (HPV)
Pneumococcal Vaccine
May Require Boosters
Safe in Immunocompromised Patients
1 min
Toxoid Vaccines
Consist of Toxins Released From a Pathogen
May Require Boosters
Safe In Immunocompromised Patients
Corynebacterium Diphtheriae Vaccine
Tetanus Vaccine
Bordetella Pertussis Vaccine
2 mins
Streptococcus Bovis
Group D Strep
Catalase-Negative
Gram Positive Cocci
Won't Grow in 6.5% Salt
Grows In Bile
Clinical Features
Endocarditis
Bacteremia Associated With Liver Disease
Bacteremia Associated With Colon Cancer
3 mins
Leptospirosis and Weil's disease
Epidemiology
Prevalent Among Surfers In Tropics
Characteristics
Leptospira interrogans
Spirochete
Hooked Shaped Ends
Water Contaminated With Animal Urine
Signs and Symptoms
Myalgias, Especially Of Calves
Flu-like Symptoms
Photophobia
Conjunctival Suffusion
Weils disease
Liver And Kidney Dysfunction
Jaundice
Hemorrhage
Anemia
3 mins
Trichinella spiralis
Characteristics
Nematode
Mode of transmission
Undercooked Meat (Especially Pork)
Signs and Symptoms
Larvae Enter Bloodstream And Encyst In Striated Muscle
Nause And Vomiting
Myalgia
Fever
Eosinophilia
Periorbital Edema
Treatments
Albendazole And Prenidonse
2 mins
AV Heart Blocks
First Degree
First Degree: PR> 200 Milliseconds
No Treatment Needed
Second Degree
Mobitz I (Wenkebach): Progressive Lengthening of PR Intervals Leading to Dropped Beat
Exercise Improves, Vagal Maneuvers Worsen
Mobitz II: Dropped Beats With No Preceding PR Prolongation
Atropine
Electrical pacing
Third Degree
Third Degree (complete): P Waves and QRS Beat Independently
Treated With Pacing
Lyme Disease Can Cause 3rd Degree Block
2 mins
Brugada Syndrome
Defective Myocardial Sodium Channels
Predominance in Asian Males
Autosomal Dominant
Pseudo-Right Bundle Branch Block Pattern
Persistent ST Elevations in Leads V1-V2
Risk of VTACH and Sudden Cardiac Death
Syncope
Management
ICD
Antiarrhythmics
3 mins
Foregut Blood Supply and Innervation
Foregut Structures
Pharynx
Lower Esophagus
Proximal Duodenum
Liver
Gallbladder
Pancreas
Spleen
Supply
Vagus Nerve
Celiac Artery
3 mins
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