Situations in which parental consent is usually not required: Sex (contraception, STIs, prenatal care— usually not abortion),
Drugs (substance use
disorder treatment), Rock and roll (emergency/trauma)
Goals - Specific, Measurable, Achievable, Relevant, and Time bound (SMART).
Patient-centered interviewing techniques (VR-FAIR / IAR-VRF) - Introduction Agenda Reflection Validation Recapitulation Facilitation
Expressing empathy PEARLS - Partnership Empathy Apology Respect Legitimization Support
Delivering bad news SPIKES - Setting Perception Invitation Knowledge Emotions Strategy
Cholinomimetic agents - Watch for exacerbation of COPD, asthma, and peptic ulcers in susceptible patients. Direct agonists-
Bethanechol - Rx Urinary retention.
Carbachol - Rx Constricts pupil and relieves intraocular pressure in open-angle glaucoma.
Methacholine - Rx Challenge test for diagnosis of asthma.
Pilocarpine - Rx Potent stimulator of sweat, tears, and saliva. Open-angle and closed-angle glaucoma, xerostomia (Sjögren syndrome).
Indirect agonists (anticholinesterases)-
Donepezil, rivastigmine, galantamine - Rx 1st line for Alzheimer disease.
Edrophonium - Rx Historically used to diagnose myasthenia gravis; replaced by anti-AChR Ab (anti-acetylcholine receptor antibody) test.
Neostigmine - Rx Postoperative and neurogenic ileus and urinary retention, myasthenia gravis, reversal of neuromuscular junction blockade
(postoperative).
Pyridostigmine - Used with glycopyrrolate, hyoscyamine, or propantheline to control pyridostigmine side effects. Rx Myasthenia gravis (long acting);
does not penetrate CNS (quaternary amine). Physostigmine - Crosses blood-brain barrier as not charged > CNS (tertiary amine). Rx Antidote for
anticholinergic toxicity; physostigmine “phyxes” atropine overdose.
Anticholinesterase poisoning - Muscarinic effects - Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Emesis, Lacrimation, Sweating,
Salivation. (DUMBBELSS). Reversed by atropine, a competitive inhibitor. Atropine can cross BBB to relieve CNS symptoms. Nicotinic effects -
Neuromuscular blockade (mechanism similar to succinylcholine). Reversed by pralidoxime, regenerates AChE via dephosphorylation if given early.
Pralidoxime (quaternary amine) does not readily cross BBB.
Muscarinic antagonists-
Atropine, homatropine, tropicamide - Eye - Produce mydriasis and cycloplegia
Benztropine, trihexyphenidyl - CNS - Parkinson disease (“park my Benz”). Acute dystonia.
Glycopyrrolate - GI, respiratory - Parenteral: preoperative use to reduce airway secretions Oral: reduces drooling, peptic ulcer.
Hyoscyamine, dicyclomine - GI - Antispasmodics for irritable bowel syndrome
Ipratropium, tiotropium - Respiratory - COPD, asthma. Duration: tiotropium > ipratropium
Solifenacin, Oxybutynin, Flavoxate, Tolterodine - Genitourinary - Reduce bladder spasms and urge urinary incontinence (overactive bladder). Make
bladder SOFT.
Scopolamine - CNS - Motion sickness
Atropine - Blocks muscarinic effects (DUMBBELSS) of anticholinesterases, but not the nicotinic effects. ADVERSE EFFECTS inc body temperature
(due to dec sweating); inc HR; dry mouth; dry, fushed skin; cycloplegia; constipation; disorientation. Can cause acute angle-closure glaucoma in
elderly (due to mydriasis), urinary retention in men with prostatic hyperplasia, and hyperthermia in infants. Side effects:Hot as a hare Fast as a fiddle
Dry as a bone Red as a beet Blind as a bat Mad as a hatter Full as a flask.
(Anticholinergic) Jimson weed (Datura) > gardener’s pupil (mydriasis due to plant alkaloids).
Sympathomimetics-
Direct sympathomimetics-
Albuterol, salmeterol, terbutaline - Rx Albuterol for acute asthma/COPD. Salmeterol for serial (long-term) asthma/COPD. Terbutaline for acute
bronchospasm in asthma and tocolysis.
Dobutamine - Rx Cardiac stress testing, acute decompensated heart failure (HF) with cardiogenic shock (inotrope).
Dopamine - Rx Unstable bradycardia, shock; inotropic and chronotropic effects at lower doses via β effects; vasoconstriction at high doses via α
effects.
Epinephrine- Rx Anaphylaxis, asthma, shock, open-angle glaucoma; α effects predominate at high doses. Stronger effect at β2-receptor than
norepinephrine.
Fenoldopam- Rx Postoperative hypertension, hypertensive crisis. Vasodilator (coronary, peripheral, renal, and splanchnic). Promotes natriuresis. Can
cause hypotension, tachycardia, fushing, headache.
Isoproterenol Rx Electrophysiologic evaluation of tachyarrhythmias. Can worsen ischemia. Has negligible α effect.
Midodrine (α1) - Rx Autonomic insuffciency and postural hypotension. May exacerbate supine hypertension.
Mirabegron - Rx Urinary urgency or incontinence or overactive bladder.
Norepinephrine Rx Hypotension, septic shock.
Phenylephrine- Rx Hypotension (vasoconstrictor), ocular procedures (mydriatic), rhinitis (decongestant), ischemic priapism.
Indirect sympathomimetics-
Amphetamine - Rx Narcolepsy, obesity, ADHD.
Cocaine - Rx Causes mydriasis in eyes with intact sympathetic innervation > used to confirm Horner syndrome.
Ephedrine - Rx Nasal decongestion (pseudoephedrine), urinary incontinence, hypotension.
Sympatholytics (α2-agonists) -
Clonidine, guanfacine - Rx Hypertensive urgency (limited situations), ADHD, Tourette syndrome, symptom control in opioid withdrawal. SE - CNS
depression, bradycardia, hypotension, respiratory depression, miosis, rebound hypertension with abrupt cessation.
α-methyldopa - Rx Hypertension in pregnancy. SE - Direct Coombs ⊕ hemolysis, drug-induced lupus, hyperprolactinemia.
Tizanidine - Relief of spasticity - Hypotension, weakness, xerostomia.
α-blockers-
Nonselective -
Phenoxybenzamine - Irreversible. Rx Pheochromocytoma (used preoperatively) to prevent catecholamine (hypertensive) crisis. SE - Orthostatic
hypotension, reflex tachycardia.
Phentolamine - Reversible. Rx Given to patients on MAO inhibitors who eat tyramine-containing foods and for severe cocaine-induced hypertension
(2nd line). Also used to treat norepinephrine extravasation. SE - Orthostatic hypotension, reflex tachycardia.
α1 selective (-osin ending) - Prazosin, terazosin, doxazosin, tamsulosin- Urinary symptoms of BPH; PTSD (prazosin); hypertension (except
tamsulosin). SE - 1st-dose orthostatic hypotension, dizziness, headache.
α2 selective - Mirtazapine - Rx Depression. SE - Sedation, inc serum cholesterol, inc appetite.
β-blockers - Angina pectoris, Glaucoma-Rx Timolol, Heart failure (BMC) Rx Bisoprolol, carvedilol, metoprolol (β-blockers curb mortality),
Hypertension, Hyperthyroidism/thyroid storm Rx Propranolol, Hypertrophic cardiomyopathy, Myocardial infarction, Supraventricular tachycardia
(ME) Rx Metoprolol, esmolol, Variceal bleeding (PNC) Rx Nadolol, propranolol, carvedilol. ADVERSE EFFECTS Erectile dysfunction,
cardiovascular (bradycardia, AV block, HF), CNS (seizures, sleep alterations), dyslipidemia (metoprolol), masked hypoglycemia, asthma/COPD
exacerbations. Use of β-blockers for acute cocaine-associated chest pain remains controversial due to unsubstantiated concern for unopposed α-
adrenergic stimulation.
Nonspecifc PDE inhibitor - Theophylline Rx COPD/asthma (rarely used). SE - Cardiotoxicity (eg, tachycardia, arrhythmia), neurotoxicity (eg, seizures,
headache), abdominal pain.
PDE-5 inhibitors - Sildenafl, vardenafl, tadalafl, avanafl - Rx Erectile dysfunction, Pulmonary hypertension, Benign prostatic hyperplasia (tadalafl
only). SE - Facial fushing, headache, dyspepsia, hypotension in patients taking nitrates; “hot and sweaty,” then headache, heartburn, hypotension.
Sildenafl only: cyanopia (blue-tinted vision) via inhibition of PDE-6 (six) in retina.
PDE-4 inhibitor - Rofumilast - Rx Severe COPD. SE - Abdominal pain, weight loss, depression, anxiety, insomnia.
PDE-3 inhibitor - Milrinone - Rx - Acute decompensated HF with cardiogenic shock (inotrope). SE - Tachycardia, ventricular arrhythmias,
hypotension.
“Platelet inhibitors” Cilostazol, Dipyridamole - Rx - Intermittent claudication, Stroke or TIA prevention (with aspirin), Cardiac stress testing
(dipyridamole only, due to coronary vasodilation). Prevention of coronary stent restenosis. SE - Nausea, headache, facial flushing, hypotension,
abdominal pain.
Ingested seafood toxins -
(BMMT) Histamine (scombroid poisoning) - Spoiled dark-meat fish such as tuna, mahi-mahi, mackerel, and bonito. Bacterial histidine decarboxylase
converts histidine to histamine Frequently misdiagnosed as fish allergy. Mimics anaphylaxis: oral burning sensation, facial flushing, erythema, urticaria,
itching; may progress to bronchospasm, angioedema, hypotension. Rx Antihistamines, Albuterol +/– epinephrine.
Tetrodotoxin - Pufferfish - Binds fast voltage-gated Na+ channels in nerve tissue, preventing depolarization. Nausea, diarrhea, paresthesias, weakness,
dizziness, loss of reflexes. Rx Supportive. (BMS) Ciguatoxin - Reef fish such as barracuda, snapper, and moray eel. Opens Na+ channels, causing
depolarization. Nausea, vomiting, diarrhea; perioral numbness; reversal of hot and cold sensations; bradycardia, heart block, hypotension. Rx
Supportive.
Common causes of pneumonia
NEONATES(< 4 WK) - Group B streptococci, E coli
CHILDREN (4 WK–18 YR) - Viruses (RSV), Mycoplasma, C trachomatis (infants–3 yr), C pneumoniae (schoolaged children), S pneumoniae. Runts
May Cough Chunky Sputum.
ADULTS(18–40 YR) - Mycoplasma, C pneumoniae, S pneumoniae, Viruses (eg, influenza)
ADULTS(40–65 YR) - S pneumoniae, H influenzae, Anaerobes, Viruses, Mycoplasma
ELDERLY - S pneumoniae, Influenza virus, Anaerobes, H influenzae, Gram ⊖ rods
Special groups-
Alcohol overuse - Klebsiella, anaerobes usually due to aspiration (eg, Peptostreptococcus, Fusobacterium, Prevotella, Bacteroides)
IV drug use - S pneumoniae, S aureus
Aspiration - Anaerobes
Atypical - Mycoplasma, Chlamydophila, Legionella, viruses (RSV, CMV, influenza, adenovirus)
Cystic fibrosis - Pseudomonas, S aureus, S pneumoniae, Burkholderia cepacia
Immunocompromised - S aureus, enteric gram ⊖ rods, fungi, viruses, P jirovecii (with HIV)
Nosocomial - S aureus, Pseudomonas, other enteric gram ⊖ rods
