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By: H. Tuwas, MD
Program Director, Liberty University College of Osteopathic Medicine (LUCOM)
The side effect of severe depres- mission medicine 8 capital rocka cheap 300 mg retrovir fast delivery, a condition that can be caused either by a reduction sion in patients treated with reserpine provided an early clue in neurotransmitter release or by long-term receptor antago- that neurotransmitter levels may be inadequate in persons nism medications 101 cheapest retrovir. For example 94 medications that can cause glaucoma generic 100 mg retrovir otc, daily administration of haloperidol, a with this type of affective disorder (see Chapter 22). Drugs dopamine receptor antagonist, in a schizophrenic patient can can cause non-exocytotic release of neurotransmitter by lead to up-regulation of D2 receptors. These six broad areas of functional pro- by blocking the reuptake of dopamine, norepinephrine, or cessing, however, provide an introduction to the neuroanat- serotonin. Cognitive processing occurs in prefrontal cortical struc- tures, where sensory information is integrated with past Receptor Activation or Blockade experience and interpreted in a manner that can result in Postsynaptic receptors are activated or blocked by thoughts and behavioral action. For example, bromocriptine, a involved in cognitive processing include association fbers drug used in the treatment of parkinsonism, acts as an that arise from areas throughout the brain and converge on agonist at dopamine receptors, whereas antipsychotic the anteromedial frontal, orbital frontal, and cingulate areas drugs act as antagonists at dopamine and serotonin of the prefrontal cortex. Cognitive processing uses memory and is infuenced by Presynaptic receptors are involved in feedback inhibi- emotions. Cognitive processing tors when they are activated by the same neurotransmitter also encompasses abstract reasoning and forethought, which that is released by the neuron and heteroreceptors when are processes that do not necessarily result in motor expres- they are activated by a different neurotransmitter. Memory hot stove is painful may keep a child from playing near the Memory is the ability to recall events and integrate them stove in the future, and remembering that a family mem- into cognitive processing, emotional processing, and ber’s birthday is approaching may trigger activities such as ongoing motor activities. Declarative memory involves neu- procedural memory, is used to recall a set of practiced ronal tracts in the hippocampus, amygdala, thalamus, motor actions (e. The involvement of form of memory, called declarative memory, involves the basal ganglia in procedural memory may explain why thoughts and associations that may be used to determine some patients with Parkinson disease have diffculties with future actions. Emotional Processing Emotional processing is responsible for the generation of Autonomic Processing emotions such as anger, anxiety, fear, happiness, love, and Autonomic processing involves areas of the brain that sadness. These emotions represent the conscious perception integrate the activities of the peripheral autonomic of neuronal activity originating in the limbic system, includ- nervous system (see Chapter 5). These areas include the ing the hypothalamus, amygdala, septum, hippocampus, and hypothalamus and portions of the brain stem, such as the mammillary bodies, as well as the cingulate and entorhinal vasomotor center and the cranial nuclei of parasympathetic portions of the frontal lobe cortex. For example, anxiety contributes to a state of height- hypotension and postural tachycardia syndrome. The drugs that affect autonomic processing Drugs that affect emotional processing in the limbic include antidepressants, antiparkinsonian drugs, antipsy- system include anxiolytic (antianxiety) drugs, antidepres- chotics, and drugs used to treat Alzheimer disease. Up- to the thalamus, which projects this information to the regulation is evoked by receptor antagonists, whereas cortex. The brain stem region known as the reticular for- down-regulation is evoked by receptor agonists or mation plays a signifcant role in fltering sensory informa- reuptake inhibitors. Which of the following terms best describes a receptor receptor, is a type of presynaptic receptor in which the located on a neuronal terminal that binds a neurotrans- binding of the same neurotransmitter released from the mitter released from another neuron and decreases release neuronal terminal decreases further release of that neu- of neurotransmitter from the neuronal terminal? Answer E, ionotropic receptor, is the term (A) presynaptic receptor for a receptor associated with an ion channel and could (B) heteroreceptor be located on either the presynaptic or postsynaptic (C) postsynaptic receptor membrane. Fusion of the neurotrans- mitter vesicle is triggered with an infux of Ca2+ into the (E) ionotropic receptor 2. What Answer A, apoptosis, is incorrect as this means pro- name is given to this process? Answer B, phagocytosis, means the (A) apoptosis engulfng of cellular debris or bacteria by another cell, (B) phagocytosis usually a macrophage. Answer C, endocytosis, is the (C) endocytosis process whereby receptors and other membrane proteins (D) pinocytosis are recycled back into the neuron.
Pathological: • Renal: any primary renal disease (nephrotic syndrome symptoms insulin resistance order 300 mg retrovir overnight delivery, acute glomerulonephritis treatment 101 generic 100mg retrovir with visa, chronic Glomerulonephritis treatment internal hemorrhoids cheap retrovir 300 mg with visa, IgA nephropathy, pyelonephritis, renal tubular acidosis, tubulo- interstitial nephropathy, renal tumour). A: When proteinuria occurs during prolonged standing but not on recumbent position. A: As follows: • Selective proteinuria: infltration of low molecular weight protein like albumin through the glomerular membrane. However, these cases are probably the most straightforward in terms of diagnosis and defning the site of lesion. To attain effciency and skill, a good deal of practice is required that will suffce to score highly. The signs need to be elicited carefully for exact anatomical localization of any lesion. Occasionally, examiner may ask, ‘Examine the legs or lower limbs’ (In such case, examine the legs thoroughly, also perform neurological examination). Hence, never forget the non-neurological cases and examine prop- erly, keeping these in mind. Even if asked to perform neurological examination, quickly look carefully to exclude the above diseases. After good visual survey, if nothing is obvious, proceed for the neurological examination. Proceed as follows: Introduce yourself, ensure that lower limbs are well exposed (with permission), patient lying in supine position. Inspection: • Wasting (mention whether of right, left or both, involving thigh or leg). Bulk of the muscles (measure with tape from a particular point): • Unilateral wasting (in old poliomyelitis). To test, ask the patient to follow your instructions as follows: • Hip fexion: ‘Raise your leg straight, do not let me push it down’. Mention your fnding, ‘Plantar is extensor or fexor or equivocal or cannot be elicited’. Ask the patient to pull his or her clasped hands outwards (Jendrassik’s manoeuvre), or clench the teeth and then see the refex again. There will be extensor plantar response, if the signs are positive (indicates extensive pyramidal lesion). Superfcial refexes: • Abdominal refex (T6 to T11): Elicited by lightly stroking the abdominal wall diagonally towards umbilicus in each of the four quadrants of abdomen. It is absent in upper motor neuron lesion (early loss is found in multiple sclerosis). Normally, contraction of cremasteric muscles pulls up the scrotum and testis on the side stroked. Sensory test: Explain to the patient with light touch by cotton-wool in normal area such as forehead. If no, continue to touch above, until the patient can feel to fnd out the level of sensory loss. Perform the test according to the nerve distribution: • Outer thigh L2 (upper thigh). Now, test is done placing the vibrating fork on bony prominence such as side of great toe, medial malleolus. Test for proximal myopathy: ask the patient to stand up from sitting without support.
The distal femur forms two large knuckle-like lateral and medial condyles symptoms 9 weeks pregnancy purchase genuine retrovir, which articulate with lateral and medial tibial condyles medications 1 gram generic retrovir 300 mg with amex. The superior surfaces of the tibial condyles are flattened to form the tibial plateau symptoms 0f gallbladder problems discount retrovir american express. An intercondylar eminence fits between the femoral condyles, and the proximal fibula articulates with the lateral tibial condyle but is not a part of the knee joint. The flat tibial condylar surfaces are modified to accommodate the femoral condyles by the c-shaped lateral and medial menisci. These fibrocartilaginous structures are wedge-shaped in cross section; they are thick peripherally but thin internally, are firmly attached to the tibial condyles, and serve as shock absorbers. The lateral meniscus is the smaller of the two, and is somewhat circular, whereas the medial meniscus is c-shaped. The femoral and remaining portions of the tibial condyles are covered with articular cartilage (Figure 7-1). The knee joint is surrounded by a capsule, lined with synovial membrane, and reinforced by several ligamentous thickenings. Anteriorly, the patella is embedded within the tendon of the quadriceps femoris muscle group. Inferior to the patella, the tendon becomes the patellar ligament, which inserts into the tibial tuberosity. Laterally, the capsule is thickened to form the fibular (lateral) collateral ligament from the lateral femoral epicondyle to the fibular head. The fibular collateral liga- ment remains separated from the lateral meniscus by the tendon of the popliteus muscle. The tibial (medial) collateral ligament extends from the medial femoral epicondyle to the medial tibial condyle. The deep aspect of this ligament is firmly attached to the margin of the medial meniscus. Posteriorly, the capsule is reinforced by oblique and arcuate popliteal ligaments. The knee is unique because of the presence of two intraarticular ligaments: the acl and the posterior cruciate ligament (Pcl). The cruciate liga- ments are covered by synovial membrane and thus are external to the synovial cavity and are named for their attachment to the tibia. It limits anterior displacement of the tibial in relation to the femur and limits hyperextension. The Pcl extends from the posterior aspect of the tibial plateau to the anterolateral aspect of the medial femoral condyle. The Pcl limits posterior displacement of the tibia on the femur and limits hyperflexion. A dozen or so bursae are associated with the knee joint, and four of these commu- nicate with the synovial cavity of the joint: suprapatellar, popliteus, anserine, and gastrocnemius. Thus, inflammation of any of these bursae (bursitis) will likely result in swelling of the entire knee joint. The knee joint is richly supplied by several genic- ular and recurrent arteries from the femoral, popliteal, and anterior tibial arteries. Additional strength and stability to the knee joint are provided by the muscles that cross and produce movement at the joint. Because the medial meniscus is firmly attached to the deep surface of the tibial collateral ligament, it also is frequently damaged. Forces applied to the medial aspect of the knee can damage the fibular (lateral) collateral ligament in a similar manner. The acl is most often dam- aged when forces or activities produce hyperextension of the knee.
In the past medicine 2 purchase retrovir 100mg otc, dextromethorphan was considered devoid of analgesic actions; however symptoms wheat allergy buy retrovir 300mg overnight delivery, it now appears the drug can reduce pain medications prescribed for ptsd buy retrovir online pills. Although dextromethorphan has minimal analgesic effects when used alone, it can enhance analgesic effects of the opioids. For example, we can double the analgesic response to 30 mg of morphine by combining the morphine with 30 mg of dextromethorphan. Other Nonopioid Antitussives Diphenhydramine is an antihistamine with the ability to suppress cough. Like other antihistamines, diphenhydramine has sedative and anticholinergic properties. Benzonatate [Tessalon, Zonatuss] is a structural analog of two local anesthetics: tetracaine and procaine. The drug suppresses cough by decreasing the sensitivity of respiratory tract stretch receptors (components of the cough- reflex pathway). In children younger than 2 years, accidental ingestion of just one or two capsules has been fatal. In older children and adults, overdose can cause seizures, dysrhythmia, and death. Smaller doses can cause confusion, chest numbness, visual hallucinations, and a burning sensation in the eyes. If the capsules are sucked or chewed, rather than swallowed, the drug can cause laryngospasm, bronchospasm, and circulatory collapse. Expectorants and Mucolytics Expectorants An expectorant is a drug that renders cough more productive by stimulating the flow of respiratory tract secretions. However, for this drug to be effective, doses higher than those normally employed may be needed. Mucolytics A mucolytic is a drug that reacts directly with mucus to make it more watery. Two preparations— hypertonic saline and acetylcysteine—are employed for their mucolytic actions. Because of its sulfur content, acetylcysteine has the additional drawback of smelling like rotten eggs. Cold Remedies: Combination Preparations Basic Considerations The common cold is an acute upper respiratory infection of viral origin. Between 50% and 80% of colds are caused by the human rhinovirus, which can also cause serious infection of the lower respiratory tract. Characteristic symptoms of the common cold are rhinorrhea, nasal congestion, cough, sneezing, sore throat, hoarseness, headache, malaise, and myalgia; fever is common in children but rare in adults. Persistence or worsening of symptoms suggests development of a secondary bacterial infection. In the United States the economic burden of the cold is estimated at more than $60 billion a year. Because colds are caused by viruses, there is no justification for the routine use of antibiotics. Because no single drug can relieve all symptoms of a cold, the pharmaceutical industry has formulated a vast number of cold remedies that contain a mixture of ingredients. These combination cold remedies should be reserved for patients with multiple symptoms. In addition, the combination chosen should contain only those agents that are appropriate for the symptoms at hand. Combination cold remedies frequently contain two or more of the following: (1) a nasal decongestant, (2) an antitussive, (3) an analgesic, (4) an antihistamine, and (5) caffeine.
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