Condet

Chi Chiung Grace Chen, MD

• Assistant Professor, Department of Gynecology and Obstetrics, Johns Hopkins
• Bayview Medical Center, Baltimore, Maryland

Which of the following is a tyrosine kinase enzyme inhibitor that is used to treat chronic myelogenous leukemia Sputum is scant and nonpurulent erectile dysfunction drugs don't work discount levitra extra dosage 40mg with visa, and a Gram stain reveals many white cells but no organisms erectile dysfunction doctor san diego generic 40 mg levitra extra dosage otc. Because this otherwise healthy patient appears to have a community-acquired pneumonia erectile dysfunction after radical prostatectomy treatment options 40 mg levitra extra dosage visa, you should initiate treatment with (A) Azithromycin (B) Clindamycin (C) Tetracycline (D) Metronidazole (E) Quinupristin-dalfopristin 91 erectile dysfunction 24 buy levitra extra dosage 100 mg line. Relative to ciprofloxacin, levofloxacin has improved activity against (A) Bacteroides fragilis (B) Escherichia coli (C) Haemophilus influenzae (D) Mycoplasma pneumoniae (E) Streptococcus pneumoniae 92. Which of the following is the drug of choice for the management of osteoporosis caused by high-dose use of glucocorticoids A 45-year-old man who received an allogenic liver transplant received an immunosuppressive regimen containing prednisone, azathioprine, and cyclosporine. Which of the following most accurately describes the mechanism of antiinflammatory activity of cyclosporine Which one of the following drugs is appropriate for treating a patient with moderate-to-severe rheumatoid arthritis but is not appropriate for treating a patient with moderate-to-severe osteoarthritis An anesthetized subject was given an intravenous bolus dose of a drug (Drug 1) while the systolic and diastolic blood pressures (blue) and the heart rate were recorded, as shown on the left side of the graph below. Questioning reveals that the patient has had only 4 menstrual periods in the last year and that she sometimes notices breast nipple discharge. A serum prolactin measurement reveals a concentration of 90 ng/mL (normal for a nonpregnant woman is <25 ng/mL). A 34-year-old woman seeks advice because she has been trying to get pregnant for 2 yr. Before initiating therapy, it is important to confirm that the patient has normal renal function because patients with unrecognized renal insufficiency who take normal doses of metformin are at increased risk of which of the following Identify Drug 1 from the following list (A) Atropine (B) Diphenhydramine (C) Echothiophate (D) Endothelin (E) Epinephrine (F) Histamine (G) Isoproterenol (H) Norepinephrine (I) Phentolamine (J) Phenylephrine (K) Terbutaline 96. C (1) Phase 3 trials are carried out under the conditions of proposed use in (usually) several thousand patients. B (1) According to the Henderson-Hasselbalch principle (Chapter 1), weak acids are less protonated (and more charged) in alkaline media, and weak bases are more protonated (and more charged) in acidic media. Since the clearance of the unknown drug is greater in alkaline urine, the drug must be a weak acid. Sucralfate forms a protective coating over an ulcer bed, and cimetidine inhibits H2 histamine receptors. Thiazides, loop diuretics, and even carbonic anhydrase inhibitors can reduce serum potassium levels because they present more sodium to the cortical collecting tubules, which attempt to compensate by wasting potassium in exchange for sodium. B (7) the appropriate treatment for myasthenic crisis is an indirect-acting cholinomimetic, the same medication used for chronic therapy of this condition. D (8, 58) the patient has characteristic signs of antimuscarinic (also known as anticholinergic) toxicity, caused by drugs such as atropine. Children are especially susceptible to the hyperthermia caused by antimuscarinic drug overdose. C (3) Two hours after an overdose of a drug with a 40-hr half-life, the plasma concentration will approximate that immediately after a loading dose. C (27) A drug that antagonizes nicotinic receptors at skeletal neuromuscular junctions (pancuronium) is required to inhibit spontaneous respiratory movements. Succinylcholine is not appropriate partly because it may initially stimulate N-receptors and also because its duration of action is very short. By interfering with accommodation in the dominant eye, atropine can sometimes prevent amblyopia. Timolol has no significant effect on accommodation, whereas the other drugs listed cause miosis and cyclospasm. Colchicine exerts its anti-inflammatory effects by prevention of tubulin polymerization, and it is used predominantly in acute gout attacks.

Syndromes

• Headache
• Cough with phlegm (sputum)
• Are suicidal
• Nephrotic syndrome
• Fever, muscle aches, headaches, and weight loss
• Scurvy

The drug should be avoided in patients with a history of cardiac conduction defects erectile dysfunction trimix generic levitra extra dosage 60mg without a prescription, psychiatric disorders erectile dysfunction treatment testosterone replacement discount 100 mg levitra extra dosage visa, or seizures erectile dysfunction journal discount levitra extra dosage 60 mg line. Miscellaneous Agents Other alternative drug regimens for the treatment of pneumocystis pneumonia include trimethoprim plus dapsone erectile dysfunction rates discount 100mg levitra extra dosage with amex, primaquine plus clindamycin, and trimetrexate plus leucovorin. Pentamidine Pentamidine is commonly used in the hemolymphatic stages of disease caused by Trypanosoma gambiense and T rhodesiense. Because it does not cross the blood-brain barrier, pentamidine is not used in later stages of trypanosomiasis. Melarsoprol this drug is an organic arsenical that inhibits enzyme sulfhydryl groups. Melarsoprol is given parenterally because it causes gastrointestinal irritation; it may also cause a reactive encephalopathy that can be fatal. Nifurtimox this drug is a nitrofurazone derivative that inhibits the parasiteunique enzyme trypanothione reductase. Nifurtimox is the drug of choice in American trypanosomiasis, an alternative agent in African forms of the disease, and has also been effective in mucocutaneous leishmaniasis. It is also an alternative to ivermectin in the treatment of onchocerciasis (see Chapter 53). Suramin is used parenterally and causes skin rashes, gastrointestinal distress, and neurologic complications. Eflornithine this agent, a suicide substrate of ornithine decarboxylase, is effective in some forms of African trypanosomiasis. It causes gastrointestinal irritation and hematotoxicity; seizures have occurred in overdose. A traveler in a geographical region where chloroquine-resistant P falciparum is endemic used a drug for prophylaxis but nevertheless developed a severe attack of P vivax malaria. The drug used for prophylaxis was probably (A) Atovaquone (B) Iodoquinol (C) Mefloquine (D) Proguanil (E) Tetracycline 4. Which drug should be used for oral treatment of the acute attack of P vivax malaria but does not eradicate exoerythrocytic forms of the parasite A male patient presents with lower abdominal discomfort, flatulence, and occasional diarrhea. A diagnosis of intestinal amebiasis is made, and E histolytica is identified in his diarrheal stools. Later he presents with severe dysentery, right upper quadrant pain, weight loss, fever, and an enlarged liver. Sodium stibogluconate (pentavalent antimony), the primary drug in all forms of the disease, appears to kill the parasite by inhibition of glycolysis or effects on nucleic acid metabolism. Alternative agents include pentamidine, paromomycin, or miltefosine (for visceral leishmaniasis), fluconazole or metronidazole (for cutaneous lesions), and amphotericin B (for mucocutaneous leishmaniasis). The drug regimen most likely to be effective in treating severe extraintestinal disease in this patient is (A) Chloroquine (B) Diloxanide furoate plus iodoquinol (C) Emetine plus diloxanide furoate plus chloroquine (D) Pentamidine followed by mefloquine (E) Tinidazole plus diloxanide furoate 8. He acknowledges drinking stream water without purification, and you suspect he is showing symptoms of giardiasis. Metronidazole is not effective in the treatment of (A) Amebiasis (B) Infections due to Bacteroides fragilis (C) Infections due to Pneumocystis jiroveci (D) Pseudomembranous colitis (E) Trichomoniasis 3. Primaquine (not mefloquine) is the drug that destroys secondary exoerythrocytic schizonts. Resistance to chloroquine in P falciparum can result from decreased accumulation of the drug in the food vacuole 9. Mefloquine is a recommended drug for prophylaxis in regions of the world where chloroquine-resistant P falciparum is endemic. One dose of mefloquine weekly starting before travel and continuing until 4 wk after leaving the region is the preferred regimen. Doxycycline (not tetracycline) is an alternative drug for this indication, as is atovaquone plus proguanil (Malarone). Chloroquine is the drug of choice for the oral treatment of an acute attack of malaria caused by P vivax but will not eradicate exoerythrocytic forms of the parasite. Primaquine is the only antimalarial drug that reliably acts on tissue schizonts in liver cells. Quinine is a highly effective blood shizonticide against all 4 species of human malaria parasites, but it is not active against liver stages.

Pressure in the ventricle falls below the pressure in the atria and this causes the opening of atrioventricular valves erectile dysfunction treatment by acupuncture safe 100mg levitra extra dosage. It is essential for the circulation of blood erectile dysfunction facts and figures buy levitra extra dosage 100 mg fast delivery, because the flow of blood through systemic and pulmonary circulation depends upon the pressure at which the blood is pumped out of ventricles erectile dysfunction boyfriend cheap levitra extra dosage 60mg with mastercard. Because of continuous relaxation of ventricles during slow filling period erectile dysfunction doctors albany ny generic 40 mg levitra extra dosage visa, the ventricular pressure decreases further. It is because of the higher pressure in left ventricle than in the right ventricle. Minimum pressure in systemic aorta is much greater than the minimum pressure in the left ventricle. It is due to the presence of elastic tissues in the aorta, which enable the aorta to recoil and maintain the minimum pressure at a higher level. Chapter 91 t Cardiac Cycle 541 During diastole, it reduces gradually and reaches the minimum level. At the time of closure of semilunar valves, an incisura occurs due to back flow of some blood towards the ventricles. A small hole is made in the diaphragm, through which the ventricles of the animal are pushed. Cardiometer is connected to a recording device like Marey tambour (a small stainless steel capsule covered by rubber membrane) or polygraph, to record the volume changes. By Angiography Angiography is the radiographic study of heart and blood vessels using a radiopaque contrast medium. During angiography, it is possible to measure the ventricular dimensional area and thickness of ventricular wall. Maximum volume of blood in each ventricle after filling (enddiastolic volume) is 130 to 150 mL. Minimum volume of blood left in the ventricles at the end of ejection period (end of systolic volume) is 60 to 80 mL. Ejection Fraction Ejection fraction (Ef) is the stroke volume divided by enddiastolic volume, expressed in percentage. Actually, the ventricular Chapter 91 t Cardiac Cycle 543 volume is not altered during isometric contraction. It is because the heart thrusts itself into the cardiometer during isometric contraction. It is because of the entrance of blood into coronary artery from aorta during this period. Rapid rise in ventricular volume is due to sudden rush of blood after the opening of atrioventricular valves. Heart sounds are heard by placing the ear over the chest or by using a stethoscope or microphone. First and second heart sounds are called classical heart sounds and are heard by using the stethoscope. Third heart sound is a mild sound and it is not heard by using stethoscope in normal conditions. Four types of factors are responsible for the production of the first heart sound. Valvular factor Synchronous closure of atrioventricular valves set up the vibrations in the valvular leaflets and chordae tendineae. These vibrations are mainly responsible for the production of the first heart sound. Vascular factor Rush of blood from the ventricles into aorta and Applied Physiology 1. Reduplication of first heart sound Reduplication means splitting of the heart sound. First heart sound is split when the atrioventricular valves do not close simultaneously (asynchronous closure). Splitting of first heart sound in normal conditions (physiological splitting) is rare. Pathological splitting of first heart sound occurs in stenosis of atrioventricular valves and atrial septal defect. Soft first heart sound Heart sound becomes soft when the intensity of sound decreases. A soft first heart sound is heard in low blood pressure, severe heart failure, myocardial infarction and myxedema.

It is because of the discharge of impulses from the center even after stoppage of stimulus erectile dysfunction and causes cheap levitra extra dosage 60mg online. Internuncial neurons erectile dysfunction injection device levitra extra dosage 60mg for sale, which continue to transmit afferent impulses even after stoppage of stimulus are responsible for after discharge impotence jelly buy 60 mg levitra extra dosage with mastercard. But erectile dysfunction pills that work cheap levitra extra dosage 40mg, when the inhibition is suddenly removed, the reflex activity becomes more forceful than before inhibition. According to this law, the reciprocal inhibition is due to segmental arrangement of afferent and efferent connections in the spinal cord. Afferent nerve fibers, which evoke flexor reflex in a limb, have connections with motor neurons supplying flexors and the motor neurons supplying the extensors of same side. Simultaneously, it also inhibits the motor neurons supplying extensors through an interneuron. Accordingly, the flexor muscles contract and extensor muscles relax resulting in flexion of the limb. For example, while eliciting a flexor reflex activity in a limb, that limb is flexed. Usually, excitation of one group of muscles is associated with inhibition of another. For example, when a flexor reflex is elicited, the flexor muscles are excited (contracted) and the extensor muscles are inhibited (relaxed) in that side. It helps in the forward movement of one limb while causing the backward movement of the opposite limb. Flexors are excited and extensors are inhibited in this limb, but in the opposite limb, the flexors are inhibited and extensors are excited. It extends from foramen magnum where it is continuous with medulla oblongata, above and up to the lower border of first lumbar vertebra below. Coverings Spinal cord is covered by sheaths called meninges, which are membranous in nature. Enlargements Spinal cord has two spindle-shaped swellings, namely cervical and lumbar enlargements. A slender non-nervous filament called filum terminale extends from conus medullaris downward to the fundus of the dural sac at the level of second sacral vertebra. Appearance of the segment is by nerves arising from spinal cord, which are called spinal nerve. Spinal Nerves Segments of spinal cord correspond to 31 pairs of spinal nerves in a symmetrical manner. Cervical segments/Cervical spinal nerves Thoracic segments/Thoracic spinal nerves Lumbar segments/Lumbar spinal nerves Sacral segments/Sacral spinal nerves Coccygeal segment/Coccygeal spinal nerves Total = 8 = 12 = 5 = 5 = 1 = 31 of spinal cord innervate upper and lower extremities respectively. Conus Medullaris and Filum Terminale Below the lumbar enlargement, spinal cord rapidly narrows to a cone-shaped termination called conus Nerve Roots Each spinal nerve is formed by an anterior (ventral) root and a posterior (dorsal) root. Both the roots on 804 Section 10 t Nervous System either side leave the spinal cord and pass through the corresponding intervertebral foramina. The first cervical spinal nerves pass through a foramen between occipital bone and first vertebra, which is called atlas. Cervical and thoracic roots are shorter whereas, the lumbar and sacral roots are longer. Long nerves descend in dural sac to reach their respective intervertebral foramina. This bundle of descending roots surrounding the filum terminale resembles the tail of horse. Fissure and Sulci On the anterior surface of spinal cord, there is a deep furrow known as anterior median fissure. Lateral to the anterior median fissure on either side, there is a slight depression called the anterolateral sulcus. This sulcus is continuous with a thin glial partition called the posterior median septum. On either side, lateral to posterior median sulcus, there is posterior intermediate sulcus. It is continuous with posterior intermediate septum, which extends for about 3 mm into the spinal cord.

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