Common learning
issues
MOSBY’S
Cholesterol (166 – 170)
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Normal Findings:
Adult: <200 mg/dL
Child: 120-200 mg/dL
Newborn: 53-135 mg/dL
-Needed for production of steroids, sex hormones, bile acids, and cellular membranes
-The main lipid associated with arteriosclerotic disease
-Metabolized by the liver
-75% bound inside LDL and 25% is in HDL
- Main component of LDL (minimal in HDL and VLDL)
- Testing is typically part of a lipid profile (by itself is not an accurate predictor of heart disease)
- Individual cholesterol levels can vary daily by 15%
-Positional changes affect levels (15% decrease seen in lateral recumbent position, often seen in hospitalized patients)
-Repeat tests should be done for abnormal values and an average will be established
-Used to predict risk of CHD within the Framingham Coronary Prediction algorithm (determines overall risk of ischemic event)
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Increased levels: liver disease, pregnancy, oorophorectomy, postmenopausal status, familial hyperlipidemias or hypercholesterolemias,
hypothyroidism, uncontrolled diabetes mellitus, nephrotic syndrome, xanthomatosis, hypertension, atherosclerosis, biliary cirrhosis,
stress
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Drugs that increase levels: adrenocorticotropic hormone, anabolic steroids, beta-adrenergic blocking agents, corticosteroids,
cyclosporine, epinephrine, oral contraceptives, phenytoin, sulfonamides, thiazide diuretics, and vit D
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Decreased levels: liver disease, malabsorption, malnutrition, acute myocardial infarction (6-8 weeks following), advanced cancer,
hyperthyroidism, cholesterol-lowering medication, pernicious anemia, hemolytic anemia, sepsis, stress,
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Drugs that decrease levels: allopurinol, androgens, bile salt-binding agents, captopril, chlorpropamide, clofibrate, colchicine, colestipol,
erythromycin, isoniazid, liothyronine, MAO inhibitors, niacin, nitrates, and statins
C – Reactive Protein (197 – 199)
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Average: 1.0 - 3.0 mg/dL
Normal <10 mg/L
Low <1.0 mg/L
High >10 mg/L
-Nonspecific protein produced primarily by the liver during an acute inflammatory process and other diseases
-Positive test result indicates the presence, but not the cause of disease
-Synthesis is initiated by antigen-immune complexes, bacteria, fungi, and trauma
-Used to diagnose bacterial infectious disease and inflammatory disorders, such as acute rheumatic fever and
rheumatoid arthritis
-Will disappear with recovery or use of anti-inflammatory agents, salicylates, or steroids
-In an acute MI, CRP will peak 18-72 hours after CK-MB, and failure to normalize may indicate ongoing heart
damage (levels will not be elevated in angina)
-CRP levels may be a good predictor of cardiovascular events, especially in conjunction with a lipid profile
-more sensitive and rapidly responding than ESR; would also normalize faster than ESR with recovery
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Increased levels: bacterial infection (UTI, TB, postoperative wound), risk of ischemic events, inflammatory
reactions (acute rheumatic fever, Reiter syndrome, Crohn disease), collagen vascular disease (vasculitis, lupus
erythrematosus), tissue infarction (acute MI, pulmonary infarction), cigarette smoking, estrogens, progesterones
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Decreased levels: moderate alcohol consumption, weight loss, increased activity or endurance exercise, fibrates,
niacin, and statins
Erythrocyte Sedimentation
Rate (234 – 236)
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Westergren Method
Male: up to 15mm/hr
Female: up to 20mm/hr
Child: up to 10mm/hr
Newborn: 0-2mm/hr
- Measurement of the rate at which the RBCs settle in saline solution or plasma over a specified time
-nonspecific (not diagnostic),
-detects illnesses associated with acute and chronic infection, inflammation, advanced neoplasm, and tissue necrosis or infarction
-the above illnesses increase the protein (mostly fibrinogen) content of plasma causing the RBCs to stack on one another and be
weighted down in solution faster (increased ESR)
-a fairly reliable indicator of the course of the disease and can be used to monitor disease therapy
-can occasionally be useful in differentiating diseases (ex. pt with chest pain will have increased ESR for MI, but normal for angina)
-Limitations: nonspecific, sometimes not elevated in active disease, many factors play into the results
-ESR elevation may be late to appear in early disease (compared with other markers or indicators), but may also remain longer
-Artificial results can occur if sample is allowed to stand for >3hrs
Increased ESR: pregnancy, menstruation, B12 or iron deficient anemias, diseases associated with elevated proteins (macroglobulinemia),
chronic renal failure, malignant diseases, bacterial infection, inflammatory diseases, necrotic diseases,
Drugs that increase ESR: dextran, methyldopa, oral contraceptives, penicillamine, procainamide, theophylline, and vit A
Decreased ESR: sickle cell anemia, spherocytosis, diseases associated with decreased proteins (hypofibrinogenemia), polycythemia
(increased cells will inhibit sedimentation rate)
Drugs that decrease ESR: aspirin, cortisone, and quinone
Lipoproteins (incomplete 356
– 360)
• Lipoproteins- accurate predictor of heart disease
• -Proteins in the blood whose main purpose is to transport
cholesterol, triglycerides, and other insoluble fats
• -Used as markers to indicate the levels of lipids
Serum Osmolality (391 – 392)
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Adult: 285-295 mOsm/kg H2O
Child: 275-290 mOsm/kg H2O
Critical Value: <256 or >320 mOsm/kg H2O
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-Test used to learn about fluid status and electrolyte imbalance
-Measure the concentration of dissolved particles in blood
-Increased water and/or decreased particles will cause decreased osmolality
-Decreased water and/or increased particles will cause increased osmolality
-A high osmolality will stimulate ADH release to increase H2O reabsorption in the kidney (result in more concentrated urine and
less concentrated serum)
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-Osmolol Gap: this represents the difference between what the osmolality should be based on calculations of serum sodium,
glucose, and BUN (the 3 most important solutes in the blood) and what the osmolality actually is measured.
-A large gap indicates that solutes such as organic acids (ketones), sugars, or ethanol by products are suspected to be present
-Plays an important role in toxicology and workups for coma patients (grand mal seizures can occur between 400 -420 mOsm/ kg
H2O)
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Increased levels: hypernatremia, hyperglycemia, hyperosmolar nonketotic hyperglycemia, ketosis, azotemia, dehydration,
mannitol therapy, ingestion of ethanol, methanol, or ethylene glycol, uremia, diabetes insipidus, renal tubular necrosis, severe
pyelonephritis
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Decreased levels: overhydration, SIADH, paraneoplastic syndromes associated with carcinoma
Adult: 285-295 mOsm/kg H2O
Child: 275-290 mOsm/kg H2O
Critical Value: <256 or >320 mOsm/kg H2O
Plasma renin assay (463 –
467 )
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Adult/Ederly:
Upright position, sodium depleted (sodium restricted diet)
Age 20-39 yrs: 2.9-24 ng/ mL/ hr
>40 yrs: 2.9- 10.8 ng/mL/hr
Upright position, sodium replaced (normal sodium diet)
Age 20-39 yrs: 0.1-4.3 ng/mL/hr
>40 yrs: 0.1-3 ng/mL/hr
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-Renin is an enzyme released by the kidney in response to hyperkalemia, sodium depletion, decreased renal blood perfusion, or hypovolemia
-Renin is activated in the renin-angiotensin system to eventually produce angiotensin II (powerful vasoconstrictor that also stimulates aldosterone production)
-Angiotensin and aldosterone increase the blood volume, blood pressure, and serum sodium
-Renin is not actually measured; the test actually measures the rate of angiotensin I generation per unit time through a radioimmunoassay
-a determination of the PRA and a measurement of the plasma aldosterone levels are used in the differential diagnoses of primary vs secondary hyperaldosteronism
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-Renal vein assays are performed to diagnose renovascular hypertension (HTN as a result of high renin from a diseased or hypoperfused kidney)
- Renal vein assays will produce a renal vein renin level 1.4 times or greater than that of the unaffected kidney (levels of the same value or a smaller difference indicate the HTN is not of a
renovascular cause)
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-Renin Stimulation Test: used to distinguish primary from secondary hyperaldosteronism
PRA is obtained from the recumbent position of pt on a low salt diet
PRA is then repeated with pt standing erect
If renin levels increase, it is secondary hyperaldosteronism- decreased renal perfusion while standing will cause increase in renin production
If levels remain the same, the cause is primary
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-Captopril Test: Pts with renovascular HTN will have greater drops in blood pressure and increases in PRA after administration of an ACE inhibitor than those with essential HTN (take baseline
measurements, administer captopril, and reasses PRA at 60 mins)
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-Renin levels are higher in the morning and when taken from a patient in the upright position for 2 hrs prior (this should be when and how the sample is collected) due to the decrease in renal
perfusion which stimulates renin production
-Decreased levels are seen in the recumbent position
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Increased levels: pregnancy, reduced salt intake, essential HTN, Malignant HTN, Renovascular HTN, Chronic Renal failure, Salt-losing GI disease (vomiting or diarrhea), Addison disease, Reninproducing renal tumor, Bartter syndrome Cirrhosis, Hyperkalemia, Hemorrhage
Drugs that increase levels: ACE inhibitors, antihypertensives, diuretics, estrogens, oral contraceptives, and vasodilators
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Decreased levels: Primary hyperaldosteronism, steroid therapy, congenital adrenal hyperplasia, ingestion of large amounts of licorice
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Drugs that decrease levels: beta blockers, clonidine, potassium, and reserpine
Blood Sodium (479 – 482)
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Blood Sodium
Adult/Ederly: 136-145 mEq/L or 136-145 mmol/L
Children, Infant, and Newborn: roughly 134-150 mmol/L
Critical: <120 or >160 mEq/L
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-Major cation of the extracellular space (values as above; intracellular value of only 5 mEq/L)
-Aldosterone causes conservation of sodium through reabsorption in the kidneys
-Natriuretic hormone is stimulated by high sodium levels and decreases renal absorption
-ADH controls the reasborption of sodium at the distal tubules of the kidney
-the 1st symptom of hyponatremia is weakness and may then progress to confusion, lethargy, stupor, or even coma
-Hypernatremia includes symptoms of dry mucous membranes, thirst, agitation, restlessness, hyperreflexia, mania, and convulsions
-recent trauma, surgery, or shock may cause increased levels because renal blood flow is decreased
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Causes of Hypernatremia: increased sodium intake, decreased sodium loss (Cushing syndrome, Hyperaldosteronism), excessive free
body water loss (excessive sweating, thermal burns, diabetes insipidus, osmotic diuresis)
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Drugs that may increase levels: anabolic steroids, antibiotics, carbenicillin, clonidine, corticosteroids, cough medicine, estrogens,
laxatives, methyldopa, and oral contraceptives
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Cause of Hyponatremia: decreased sodium intake, increased sodium loss (Addison disease, diarrhea, vomiting, or nasogastric aspiration,
intraluminal bowel loss, diuretic administration, chronic renal insufficiency), increased free body water (excessive oral or IV H2O intake,
hyperglycemia, congestive heart failure, peripheral edema, ascites, intraluminal bowel loss, oversecretion of ADH)
- Treatment of Hyponatremia: water restriction
Drugs that may decrease levels: ACE inhibitors, captopril, carbamazapine, diuretics, haloperidol, heparin, NSAIDs, sodium free IV fluids,
sulfonylureas, triamterene, tricyclic antidepressants, and vasopressin
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Triglycerides (521 – 522)
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Adult: Male 40-160 mg/dL
Female 35-135 mg/dL
Critical: >400 mg/dL
-Produced in the liver using fatty acids and glycerol
-Transported by VLDL and LDL
-When levels are high, triglycerides are deposited in fatty tissues
-Constitute most of the fat of the body
-Measured as part of a lipid profile
• Increased levels: ingestion of fatty meals, alcohol, pregnancy, glycogen storage disease,
apoprotein CII deficiency, hyperlipidemias, hypothyroidism, high carb diet, nephrotic
syndrome, chronic renal failure
• Drugs that may increase levels: cholestyramine, estrogens, and oral contraceptives
• Decreased levels: malabsorption, malnutrition, abetalipoproteinemia, hyperthyroidism
• Drugs that may decrease levels: ascorbic acid, asparaginase, clofibrate, colestipol, fibrates,
and statins
Electroencephalography (573-577)
• -EEG is a graphic recording of the electrical activity of the brain
• -Performed to identify and evaluate patients with seizures, detection of pathologic conditions of
the brain cortex (tumors, infarction), evaluate trauma or drug intoxication, and determination of
brain death
• -In epileptic states the seizure activity is characterized by rapid, spiky waves on the graph
• -Can be used to monitor blood flow during surgery as an early detection of ischemia
• -Electrocorticography (ECoG) is a form of EEG in which the electrodes are placed directly on the
exposed surface of the brain (this is the "gold standard" for defining epileptogenic zones)
• - A less invasive technique for localizing pathology or defining sites of epileptic activity is the
magnetoencephalography (MEG)
• -MEG measures the magnetic fields produced by brain electrical activity using a sensitive device
called a superconducting quantum interference device (SQID)
• -Sleep may need to be shortened the night before
• -16 or more electrodes are applied to the scalp with electrode paste in a specified pattern over
both sides of the head, covering the prefrontal, frontal, temporal, parietal, and occipital areas
• -The procedure take 45 minutes to 2 hours
• -A sleep EEG can be performed after oral administration of a sedative or hypnotic
• Factors that may affect test results: hypoglycemia, caffeine, body and eye movements during the
exam, lights, drugs (sedatives)
• Clinical Significance: Seizure disorders, Brain tumor, Brain abscess, Intracranial hemorrhage,
Cerebral infarct, Cerebral death, Encephalitis, Narcolepsy, Metabolic encephalopathy
Evoked Potentials (589-593)
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Normal: No neural conduction delay
-Indicated in patients with a suspected sensory deficit, but are unable to indicate or are unreliable in indicating
recognition of a stimulus (such as infants, comatose pts, or those unable to communicate)
-EP studies focus on changes and responses in brain waves that are evoked from stimulation of a sensory
pathway
-While the EEG measures spontaneous activity, the sensory EP study measures minute voltage changes produced
in response to a specific stimulus, such as light pattern, an audible click, or a shock
-EP studies measure and assess the entire sensory pathway from the peripheral sensory organ to the brain
cortex
-Clinical abnormalities are detected by an increase in latency, which is a delay between the stimulus and wave
response
-Visual-evoked response (VER)occurs in the occipital area and is usually stimulated by a strobe light flash,
reversible checkerboard pattern, or retinal stimuli
-90% of MS patients show abnormal latencies in VERs
-Auditory brainstem evoked potentials (ABEPs) are typically stimulated by clicking sounds to evaluate the temporal
lobe and central auditory pathways of the brainstem
-One of the most successful applications of ABEPs has been screening low birth weight newborns for hearing
disorders
-Somatosensory evoked potentials (SERs) are initiated by sensory stimulus to an area of the body to evaluate
patients with spinal cord injuries and to monitor spinal cord functioning during spinal surgery
-A main benefit of EPs is their objectivity because voluntary patient response is not necessary
Prolonged latency for VERs: Parkinson disease, demyelinating disease, optic nerve damage, ocular disease,
blindness, optic tract disease, occipital lobe tumor, CVA, absence of binocularity, visual field defects
Prolonged latency for ABEPs: demyelinating diseases, acoustic neuroma, CVA, auditory nerve damage, deafness
Abnormal latency for SERs: spinal cord injury, cervical disk disease, spinal cord demyelinating disease, peripheral
nerve injury, parietal cortical tumor
Lumbar Puncture and CSF
Examination (682-690)
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Indications: Assist in diagnoses of primary or metastatic brain or spinal cord neoplasm, cerebral hemorrhage, meningitis, encephalitis, degenerative
brain disease, autoimmune diseases of the CNS, neurosyphilis, and demyelinating disorders. Also used to measure the pressure of the subarachnoid
space, to reduce intracranial pressure in those with normal pressure hydrocephalus with pseudotumor cerebri, or to inject therapeutic or diagnostic
agents.
Contraindications: Increased intracranial pressure (LP may induce cerebral or cerebellar herniation), degenerative vertebral joint disease, infection
near LP site, anticoagulation drugs (may cause epidural hematoma)
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*If blockage in CSF circulation is suspected, a Queckenstedt-Stookey test is performed through occlusion of the jugular vein. Within 10 seconds, the CSF pressure should increase 15-40 cm
H2O and then return to normal after release of pressure. A sluggish rise or fall of CSF pressure suggests partial blockage and no rise suggests a complete obstruction
Pressure
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-Pressure is measured through the attachment of a sterile manometer to the LP needle at the beginning and end of the procedure (a significant
difference btwn the two is could indicate a spinal cord obstruction such as a tumor or hydrocephalus)
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-A pressure of 20 cm H2O or greater is considered abnormal and indicative of increased intracranial pressure
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-Because the cranial venous sinuses are connected to the jugular veins, obstruction of the veins or of the superior vena cava will increase intracranial
pressure
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-Decreased pressure is associated with hypovolemia, chronic leakage of CSF, or a nasal sinus fracture with a dura tear
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-If high opening pressures are noted, normal volumes of CSF should not be removed to prevent risk of cerebellar herniation
Color
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-Normal is clear and colorless
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-Xanthochromia means an abnormal color (usually refers to a yellow tinge)
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-Color differences occur in hyperbilirubinemia, hyercarotenemia, melanoma, or elevated protein
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-Cloudy appearance may indicate increased WBCs or protein
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-Red tinge indicates blood (may be present from the LP needle)
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-Blood in the CSF will clot in a traumatic puncture, but not in a subarachnoid hemorrhage
Cells
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-WBCs and RBCs should not be present in normal CSF (except for a few lymphocytes)
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-Polymorphonuclear leukocytes is indicative of bacterial meningitis or cerebral abscess
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-Mononuclear leukocytes indicate viral or tubercular meningitis or encephalitis
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-Leukemia or tumors may increase WBCs
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-WBCs may appear in the CSF due to a "traumatic tap", but more than 1 WBC per 500 RBCs is considered pathologic and may indicate meningitis
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-Pleocytosis is used to describe turbidity of CSF because of an increased number of cells in the fluid
Lumbar Puncture and CSF
Examination (682-690)
Culture
• -Organisms in the CSF can be cultured and identified
• -A gram stain can also be used, which allows appropriate antibiotic therapy before the results of the culture return
• -The most common cause of meningitis is Haemophilus influenzae in children and Neisseria and Steptococcus in adults
Protein
• -Normally little protein is found in the CSF as the large molecules cannot cross the BBB
• -Proportion of albumin to globulin is higher than in blood plasma because of the small size of the albumin
• -Because albumin is not made in the CNS, increased levels of these proteins indicate increased permeability of the BBB
• -The permeability can be altered by infectious or inflammatory disease processes such as meningitis, encephalitis, or myelitis
• -CNS tumors may also produce and secrete protein
• -CSF protein electrophoresis is important is diagnoses
• -An increase in CSF immunoglobin G and the detection of oligoclonal gamma globulin bands are highly suggestive of inflammatory and
autoimmune diseases, especially MS
Glucose
• -Glucose levels are decreased when bacteria, inflammatory cells, or tumor cells are present
• -A blood sample is usually drawn prior to the spinal tap (compare CSF glucose to blood glucose. Significant if CSF lvls are 2/3 that of blood
lvls)
Chloride
• -Not normally tested in CSF, but can be requested
• -Levels can be decreased in patients with meningeal infections, tubercular meningitis, and conditions of low blood chloride
• -Increased levels are not neurologically significant; it correlates with blood levels
Lactic Dehydrogenase
• -Elevated levels are associated with infection or inflammation
• -Source of LDH may be the neutrophils fighting the invading bacteria
• -Nerve tissue in the CNS is also high in LDH, meaning that diseases directly affecting the brain or spinal cord are correlated with high
levels
Lactic Acid
• -Elevated levels indicate anaerobic metabolism associated with decreased oxygenation of the brain
• -Lactic acid cannot cross the BBB, therefore the blood levels do not affect the CSF level
• -Levels are increased in bacterial and fungal meningitis, but not viral
• -Also elevated levels are seen in patients with mitochondrial diseases that affect the CNS
Lumbar Puncture and CSF
Examination (682-690)
Cytology
• -Examination of cells in the CSF can determine if they are malignant (Ex. tumor cells)
Tumor Markers
• -Carcinoembryonic antigen, alphafetoprotein, or human chorionic gonadotropin may indicate metastatic tumor
Serology of Syphilis
• -Latent syphilis is detected with serologic testing of the CSF including:
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The Wassermann test
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The Venereal Disease Research Laboratory (VDRL)
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The flourescent treponemal antibody (FTA) test- most sensitive and specific
Glutamine
• -Made by increased levels of ammonia, which are commonly associated with liver failure
• -May detect and evaluate hepatic encephalopathy and hepatic coma
• -Also increased in patients with Reye syndrome
C-Reactive Protein
• -nonspecific, acute-phase reactant used in the diagnosis of bacterial infections and inflammatory disorders
• -Failure to find elevated levels of CRP in CSF is strong evidence against bacterial meningitis
• -Valuable in distinguishing bacterial meningitis from viral or tuberculosis meningitis, febrile convulsions, and other CNS disorders
Potential Complications
• -Persistant CSF leak
• -Introduction of bacteria into the CSF
• -Herniation of the brain
• -Inadvertent puncture of the spinal cord
• -Puncture of the aorta or vena cava
• -Transient back pain
• -Pain or paresthesia of the legs
• -Transient postural headache
Patient is usually placed in the lateral decubitus (fetal) position
Sweat electrolytes (711-713)
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Children: sodium: <70 mEq/L (abnormal >90)
chloride: <50 mEq/L (abnormal >60)
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-sensitive and specific test used to diagnose Cystic Fibrosis
-does not measure the severity of the disease
-test is indicated in children with recurrent respiratory tract infections, chronic cough, early onset asthma,
malabsorption issues, late passage of meconuim stool, or failure to thrive
-CF patients will have increased sodium and chloride contents in their sweat
-Sweat, induced by electrical current (pilocarpine iontophoresis), is collected, and the sodium and chloride
contents are measured
-In normal individuals, sweat produced at the bottom of a sweat duct is rich in sodium and chloride, but as it
moves through the duct, the chloride (followed by sodium) is transported through the lining cells out of the
sweat. This leaves behind water.
-In CF patients, the epithelial lining cells in the sweat ducts fail to take up the electrolytes, leaving a high sodium
and chloride content
-a small electrical current is felt during this test, but no pain or discomfort should be felt
-the positive electrode is saturated with pilocarpine hydrochloride, a drug that induces sweating
-the negative electrode is saturated with a bicarbonate solution
-the electrical current flows for 5-12 mins
-then paper disks with a paraffin airtight seal are placed over the test site to 1 hr
-a screening test to detect chloride levels is done by pressing paper containing silver nitrate against the child's
hand for several seconds. A positive test occurs when the child leaves a white powder, "heavy" handprint on the
paper
-dehydration may affect results
Test MUST be done multiple times to be useful as a diagnostic tool
Urine Osmolality (980-981)
Urine Osmolality
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12-14 hr fluid restriction: >850 mOsm/ kg H2O
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Random specimen: 50-1200 mOsm/ kg H2O (depending on fluid intake)
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-This test is an accurate determination of the kidney's concentration capabilities
-Also used to evaluate ADH abnormalities and fluid and electrolyte balance
-Measures the number of dissolved particles in the urine
-Most commonly measured by determining the freezing point
-Osmolality is more accurate and measured over a wider range than specific gravity
-More exact measurement of urine concentration than specific gravity, because specific
gravity depends on the weight and density of particles, temperature, and requires
correction for presence of glucose or protein
• -osmolality is more easily interpreted when the serum osmolality is simultaneously
measured with a normal ratio of urine to serum osmolality of 1:3
• Increased levels: SIADH, shock, hepatic cirrhosis, CHF, paraneoplastic syndromes associated
with carcinoma
• Decreased levels: Diabetes insipidus, excess fluid intake, renal tubular necrosis, severe
pyelonephritis,
DRUGS TO KNOW
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Albuterol
Pg 834
Class: Selective Beta2adrenergic agonist
Mech: agonist at beta
adrenergic receptors on
airway smooth muscle; act
on Gs to cause smooth
muscle relaxation
Indications:
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Asthma
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COPD
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Tachyarrhythmia
Palpitations
Restlessness
Dizziness
Headache
Tremor
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Cardiac effects
lessened compared
to non-selective
adrenergic agonists
Atorvastatin
Pg 330
Class: Inhibitor of cholesterol
synthesis (Statin)
Mech: inhibits HMG-CoA
reductase
Indications:
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Hypercholesterolemia
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Familial
hypercholesterolemia
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Coronary
atherosclerosis
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Prophylaxis for coronary
aterosclerosis
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Myopathy-increased
risk
Rhabdomyolysis
Hepatotoxicity
Abdominal pain
(constipation,
diarrhea, nausea)
Headache
• Active liver disease
• Pregnancy and lactation
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Up to 60% dec. in LDL
10% HDL increase
40% Triglyceride dec.
Drug of choice for
lowering LDL, one of
the most potent
Metabolism by P450
3A4
Combo with bile acid
sequestrant yields
lower LDL
Co-admin with Niacin->
inc. risk of myopathy
Co-admin with
gemfibrozil can induce
rhabdomyolysis
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hypersensitivity
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Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Captopril
Pg 349
Class: ACE inhibitor
Mech: decreases conversion
of AT I to AT II decreasing
arteriolar vasoconstriction,
aldosterone synth, renal
proximal tubule NaCl
reabsorp. and ADH release.
Also inhibit degradation of
the vasodilator, Bradykinin
Indications:
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Hypertension
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Heart failure
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Diabetic Nephropathy
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Myocardial Infarction
• Angioedema (more
frequent in black
patients)
• Agranulocytosis
• Neutropenia
• Cough
• Edema
• Hypotension
• Rash
• Gynecomastia
• hyperkalemia
• History of angioedema
• Bilateral renal artery
stenosis
• Renal failure
• pregnancy
• Given as active drug
and processed to
active metabolite
• Cough and
angioedema caused by
bradykinin action
• Hyperkalemia risk
increased when used
with potassiumsparing diuretics
• First-dose hypotension
more common in
patients with bilateral
renal stenosis
Furosemide
Pg 351
Class: Loop diuretic
Mech: reversibly and
competitively inhibit
Na+/K+/Cl- co-transporter in
apical membrane of thick
ascending limb
Indication:
• Hypertension
• Acute pulmonary edema
• Edema from heart failure,
hepatic cirrhosis, or renal
dysfunction
• Hypercalcemia
• Hyperkalemia
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• Co-admin with
aminoglycosides increases
ototoxicity and
nephrotoxictiy
• Sulfonamide derivative
• Front-line therapy for
listed indications
• Can counteract
hypercalcemic and
hyperkalemic states
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Hypotension
Pancreatitis
leukopenia
Volume contraction
alkalosis
Hypokalemia
Hyperuricemia
Hypomagnesemia
Hyperglycemia
Glycouria
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Nifedipine
Pg 369
Class : Calcium channel
blocker; Dihydropyridine
Mech: block voltage-gated
L-type Ca++ channels and
prevent the influx of Ca++
that promotes actin-myosin
cross-bridge formation
Indication:
• Hypertension
• Exertional/unstable
Angina
• Coronary spasm
• Hypertrophic
cardiomyopathy
• Pre-eclampsia
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Increased angina
Rare MI
Palpitations
Edema
Flushing
Constipation, heartburn
Dizziness
• Preexisting hypotension
• Very fast onset can
cause hypotensive
episode with reflex
tachycardia which
causes worsening
ischemia
• Arteriolar dilation
greater than venous
• High vascular-tocardiac selectivity
• Binds to “N” binding
site of Ca++ channel
Clonidine
Pg 144
Class: alpha2 adrenergic
agonist
Mech: selectively activate
central alpha2-adrenergic
auto-receptors to inhibit
sympathetic outflow from
CNS
Indication:
• Hypertension
• Opioid withdrawal
• Cancer pain
•
•
•
•
•
Bradycardia
Hypotension
Heart failure
Hepatotoxicity
(side effects related to
depressed sympathetics
and increased vagal
response)
• Not listed
• Used for HTN and
symptoms of opioid
withdrawal
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Potassium
Chloride
Class: Supplement
Indications:
Treatment for Hypokalemia
(stated by faculty as the only
thing we needed to know
about this drug for this unit)
• Not in our pharm book
• Not in our pharm book
• Not in our pharm book
Cisplatin
Pg 696
Class: Directly modify DNA
structure
Mech: Platinum compound
that cross-links intrastrand
guanine bases
Indications:
• Genitourinary and lung
cancer
•
•
•
•
•
Nephrotoxicity
Myelosuppression
Peripheral neuropathy
Ototoxicity
Electrolyte imbalance
• Severe bone marrow
depression
• Renal or hearing
impairment
• Can be injected
intraperitoneally for
treatment of ovarian
cancer
• Co-administration of
amifostine can limit
nephrotoxicity
Etoposide
aka VP-16
Pg 691 & 697
Class: Antineoplastic agent:
Topoisomerase inhibitor
Mech: bind topoisomerase II
and DNA, trapping the
complex in its cleavable state
Indications:
•
Lung cancer
•
Testicular cancer
•
Leukemia
•
•
•
•
•
Heart failure
Myelosuppression
Alopecia (hair loss)
Rash
GI disturbance
• hypersensitivity
• Class breakdown:
• Antineoplastic->
topoisomerase
inhibitors->
epipodophyllotoxin
• Action is specific to
late S and G phases of
cell cycle
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Avonex
Refib
aka: Interferon
Beta-1a
Pg 903
Class: Protein used to
augment an existing
pathways (Group Ib)
Mech: Unknown; Anti-viral
and immune regulator
Indication:
• Multiple Sclerosis
• Not listed
• Not listed
• Recombinant
Interferon Beta
• Reduce frequency of
relapses in MS
Betaseron
aka: Interferon
beta-1b
Pg 903
Class: Protein used to
augment an existing
pathways (Group Ib)
Mech: Unknown; antiviral
and immunoregulator
Indications:
•
Multiple Sclerosis
•
•
• Recombinant
Interferon Beta
• Reduce frequency of
relapses in MS
Copaxone
aka Glatiramer
acetate
Not in our pharm book
• Not in our pharm book
Indications:
•
Multiple Sclerosis
Not listed
Not listed
• Not in our pharm book
• Not in our pharm book
• Reduce frequency of
relapses in MS
• injection
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Dexamethasone
Pg 503
Class: Glucocorticoid
receptor agonist
Mech: Mimic cortisol
function by acting as
agonists at glucocorticoid
receptor
Indications:
•
Inflammatory
conditions in many
different organs
•
Autoimmune diseases
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Prednisone
Pg 503
Class: Glucocorticoid
receptor agonist
Mech: mimic cortisol
function function by acting
as agonists at glucocorticoid
receptor
Indications:
• Inflammatory conditions
• Autoimmune diseases
Immunosupression
Cataracts
Hyperglycemia
Hypercortisolism
Depression
Euphoria
Osteoporosis
Growth retardation in
kids
Muscle atrophy
Impaired wound
healing
Hypertension
Fluid retention
Inhaled may cause
oropharyngeal
candidiasis and
dysphonia
Topical causes skin
atrophy
• Same as above
Systemic fungal infection
•
•
•
• Same as above
Doesn’t correct
underlying etiology
just limits
inflammation
Should be tapered
when given
chronically to avoid
withdrawal and acute
adrenal insufficiency
Intranasal and
inhaled greatly
reduce systemic
adverse effects
5-6x more potent
than cortisol
• Same as above
• Equally as potent as
cortisol
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Phenytoin
aka: Dilantin
Pg 236
Class: Sodium channel
inhibitor
Mech: inhibit electrical
neurotransmission by usedependent block of
neuronal voltage-gated
Na+ channel
Indication:
• Focal and tonic-clonic
seizures, status
epilepticus, nonepileptic
seizures
• Neuralgia
• Ventricular arrhythmias
•
•
•
•
•
•
•
•
•
•
•
Ataxia
Nystagmus
Inncoordination
Confusion
Hirsutism
Agranulocytosis
Leukopenia
Pancytopenia
Megaloblastic anemia
Hepatitis
Stevens-Johnson
syndrome
• Toxic epidermal
necrolysis
• Hydantoin
hypersensitivity
• Sinus bradycardia
• SA node block
• 2nd or 3rd degress AV
block
• Stockes-Adams syndrome
• Interacts with many drugs
due to P450 2C9/10 and
P450 2C19 metabolism
• Phenytoin levels are
increased by cimetidine,
felbamate, isoniazid
• Phenytoin decreases levels of
warfarin, carbamazepine,
cyclosporine, levodopa,
lamotrigine, doxycycline, oral
contraceptives, methadone,
and quinidine
• At high doses, phenytoin
saturates the P450 system so
that small dose changes
cause large serum
concentration changes
Ciprofloxacin
pg596
Class: Quinolones:
inhibitor of topoisomerase
Mech: inhibit bacterial
type II topoisomerases;
causing dissociate of Top II
(DNA gyrase) from cleaved
DNA, leading to double
stranded breaksand cell
death
Indication:
• Gram (-) infections
• Common Upper Resp
Infections
• UTI
•
•
•
•
• Co-admin with tizanidine
• Hypersensitivity
• Resistance: thru
chromosonal mutations in
genes that encode type II
tops, or thru alterations in
expression of membrane
porins and efflux pumps that
determine drug lvls in
bacteria
• Bacteriostatic at low conc.
• Bactericidal at high conc.
•
•
•
•
Cartilage damage
Tendon rupture
Periph. Neuropathy
Increased Intracranial
pressure
Seizure
Severe hypersensitivity
reaction
Rash
GI disturbance
(Nausea/ Vomiting,
diarrhea)
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Trimethoprim
Pg 579
•
“Bactrim” =
Trimethoprim
/Sulfametho
xazole
Class: Antimicrobial
dihydrofolate reductase
inhibitor
Mech: folate analogue;
competitively binds
microbial DHFR to prevent
regeneration of
tetrahydrofolate from
dihydrofolate
Indications:
• Urinary Tract Infection
• Stevens-Johnson
syndrome
• Leukopenia
• Megaloblastic anemia
• Rash
• pruritus
• Megaloblastic anemia due
to folate deficiency
• Used with medication
below to limit
resistance
development
•
Excreted unchanged
into urine
Sulfamethoxazol
e
Pg 579
Class: Antimircrobial
dihydropteroate synthase
inhibitor
Mech: PABA analogue that
competitively inhibit
microbial dihydropteroate
synthase and thereby
prevent the synthesis of folic
acid
Indications:
•
Pneumocystis carinii
pneumonia
•
Shigellosis
•
Traveler’s diarrhea
•
UTI
•
Granuloma inguinale
•
Acute otitis media
•
• Infants less than 2 months
old
• Pregnant women at term
• Breastfeeding
• Megaloblastic anemia due
to folate deficiency
• Co-administration with
PABA
• Used with medication
above to limit
resistance
development
• Indications listed are
those
Sulfamethoxazole/Trim
ethoprim used
together
• Compete with bilirubin
for binding sites on
serum albumin and can
cause kernicterus in
newborns; can also
cause brain damage
•
“Bactrim” =
Trimethoprim/
Sulfamethox
azole
•
•
•
•
•
•
•
•
Kernicterus in
newborns
Brain damage in
newborns
Crystalluria
Stevens-Johnson
syndrome
Agranulocytosis
Aplastic anemia
Hepatic failure
GI disturbance
rash
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Vancomycin
pg614
Class: Inhibitor of murein
polymer synthesis
Mech: Bind to D-Ala-D-Ala
terminus of the murein
monomer and inhibit PGT
preventing addition of
murein units to the growing
chain
Indication:
• MRSA (IV admin)
• Serious skin infections
involving staph or strep
(IV admin)
• C. Difficile
enterocolitis(oral)
•
•
•
•
•
Neutropenia
Ototoxicity
Nephrotoxicity
Anaphylaxis
“Red-man syndrome”
(flushing and
erythroderma)
• Drug fever
• Hypersensitivity rash
• Co-admin with Gentamycin
• Solutions containing
dextrose in patients with
known corn allergy
• Increased nephrotox
with aminoglycosides
• “red-man syndrome”
can be avoided by
slowing infusion rate or
preadministering
antihistamines
• Resistance: arises thru
acquisition of DNA
encoding enzymes that
catalyze formation of
D-Ala-D-lactate
• Used for Gram (+) rods
and cocci
• Gram(-) rods are
resistant
Methicillin
Pg 615
Class: Penicillins: inhibitors
of polymer cross-linking
Mech: Beta-Lactams inhibit
transpeptidase by forming a
covalent (“dead-end”) acyl
enzyme intermediate
Indication:
• Skin and soft tissue
infections or systemic
infection with Blactamase- producing
methicillin-senstive S.
aureus
• All side effects listed are
for the other drugs in
this class
• Hypersensitivity to
penicillins
• Beta-lactamase
resistant
(staphlococcal)
• Narrow-spectrum
antibacterial activity
• Gram (+) only
• Is a hydrophobic
substance
• Penicillins have a 5membered ring
attached to the betalactam ring
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Ceftriaxone
Pg 616
Class: Cephalosporin:
inhibitor of polymer crosslinking
Mech: Beta-Lactams inhibit
transpeptidase by forming a
covalent (“dead-end”) acyl
enzyme intermediate
Indication:
• N. gonorrhoeae
• Borrelia burgdorferi
• H. Influenzae
• Most Enterobacteriaceae
• Lower resp infections
• Community-acquired
meningitis
• Culture negative
endocarditis
• Cholestatic hepatitis
(rare)
• Pseudomembranous
enterocolitis
• Leukopenia
• Thrombocytopenia
• Hepatotoxicity
• Nausea
• Vomiting
• Diarrhea
• rash
• Hypersensitivity to
cephalosporins
• Rarely cross-react with
penicillins
• Can give to patients with
penicillin allergy unless
their reaction was
anaphylaxis
• 3rd generatioin
cephalosporin
• Highest CNS
penetration of this
class
• Resistant to many betalactamases
• Highly active against
Enterobacteriaceae
• Less active against
Gram (+) than are 1stgeneration
cephalosporins
• Active against S.
pneumonea
• Cephalosporins have a
6-membered ring
attached to the betalactam ring
BATES
Marcus Gunn Pupil (pg 244)
Cause: Afferent pupillary defect from damage to optic nerve.
• Observed during swinging light test.
• Light in unaffected eye: Both direct and consensual pupil
dilation present.
• Light in affected eye: Partial dilation of both pupils.
• The afferent stimulus to the affected eye is reduced, thus the
efferent signals to both pupils will also be reduced and a net
dilation will occur, but less than that compared to the
unaffected eye response.
Cranial Nerves (pg 659)
Air and Bone Conduction (pg 226-27)
• Tests used for distinguishing conductive from sensorineural hearing loss.
• NEED: Quiet room and tuning fork (preferably 512 Hz or possibly 1024 Hz; these fall within range
of human speech).
• Weber Test:
•
•
•
•
•
•
•
•
Tests for Lateralization
Place base of lightly vibrating tuning fork firmly on top of pt’s head or on mid-forehead.
Ask pt where they hear it; one side or both?
Normal: Sound heard midline or equally in both ears.
If nothing is heard, try again pressing the fork more firmly on head.
Because pt’s with normal hearing may lateralize, this test should be restricted to those with hearing
loss.
Unilateral Conductive Hearing Loss: Sound is louder in impaired ear.
Unilateral Sensorineural Hearing Loss: Sound is louder in good ear.
• Rinne Test:
•
•
•
•
•
•
Comparing air conduction (AC) and bone conduction (BC).
BC: Place base of lightly vibrating fork on Mastoid Process, behind the ear and lvl with the canal.
AC: When the pt can no longer hear the sound, quickly place the fork close to the ear canal (U part
of fork pointed toward ear) and ask if the sound can be heard again.
Normal: Sound heard longer through air than bone (AC > BC)
Conductive Hearing Loss: Sound through bone is as long or longer than air (BC = AC or BC > AC)
Sensorineural Hearing Loss: Sound is heard longer through air (AC > BC). Yes, this is the same as a
normal finding.
Mietzner guide to
bacterial tests
Directly from his powerpoint
Catalase Test
Differentiates
-Streptococci (-) from Staphylococci (+)
-Clostridia (-) from Bacillus (+)
4/16/2013
• Detects the presence of catalase, and enzyme the converts
hydrogen peroxide to water and oxygen. The liberated oxygen
causing bubbles.
Catalase Test
Cocci
4/16/2013
Gram Positive
Rod
Catalase Test
Positive
Negative
Staphylococcus
Positive
Negative
Bacillus
Streptococcus
Clostridia
COAGGULASE Test
4/16/2013
• Detects the presence of coagulase. This enzyme acts with a
plasma factor to convert fibrinogen to a fibrin clot
• Used to differentiate Staphylococcus aureus (pos) from
Staphylococcus epidermidis (neg)