Week 17 - Medical School; Semester 1

Tracts

-DCML (sensory) decussates in ROS trial medulla -spinothalamic (sensory) decussationS are in the spinal cord -corticospinal crosses below DCML

Sensory laminae of Rexed

-Lamina I: marginal zone -lamina II: substantia gelatinosa ---interneurons that modify the perception of pain -laminae III and IV: nucleus proprius ---gives rise to spinothalamic tract -laminae VI and VII: nucleus dorsalis of Clarke ---gives rise to dorsal spinocerebellar tract

Physiochemical properties of molecules

-Lipophilic molecules are more likely to penetrate across endothelial and epithelial membranes -charged are less likely to penetrate -hydrophilics tend to concentrate in aqueous compartments

Motor signs of unilateral cranial nerve injuries

-V: jaw moves toward injury -VII: cant move ipsilateral face -X: uvula points away from injury -XI: cant turn head away from injury; cant lift ipsilateral shoulder -XII: tongue points toward injury

Tracts

-ascending conveys sensory info from body to brain -descending conveys motor information from brain to body -axons that decussate do so in ventral white commissure

Corticospinal/pyramidal tract (CST) (descending/motor)

-fibres originate in cerebral cortex (conveys voluntary motor info from cerebral cortex to limbs) -most fibres decussate in the caudal medulla forming the the Lateral Corticospinal tract (80%) -the uncrossed fibres (20%) form the ventral coritospinal tract -axonds descend through the cord and synpase on neurons in the intermediate zone and ventral horn for motor action AD PIC

Classification of ankle sprains

-grade I: a ligament is stretched but no instability or opening of the joint on stress maneuvers -grade II: a partial tract to the ligament with some instability inducted by partial opening of joint on stress maneuvers -grade III: a complete tear with complete opening joint of stress

Clinical pearsl

-if abrupt onset of M or S deficits, think TIA or CVA -if progressive, subacute onset of lower distal extremity weakness think Gillian Barre syndrome -if chronic, gradual onset of extremity weakness metastatic cord lesions and lumbar disc disease -focal or asymmetric weakness - think central -myositis - rate condition with idiopathic muscle inflammation - weakness but no pain

Dorsal Column Medial Leminiscus Pathway (ascending/sensory tract)

-in dorsal funinculus of white matter -touch, proprioception, position, vibration, pressure -first order neurons travel through the dorsal root ganglion -all first order neurons release glutamate (excitatory) -does NOT decussate at spinal cord -synapse on second order neurons in medulla (gracile and cuneate nuclei) -destined for cerebral cortex -Fasiculus Gracilis: medial; info from lower body -Fasiculus Cuneatus: lateral (above T7); info from upper body

Anterolateral system (ascending/sensory tract)

-in ventral and lateral funiculi of white matter -input from free nerve endings (pain, temp, ache, itch) -first order neuron travel through dorsal root ganglion -synapse on second order neurons in dorsal horn -second order neurons decussate at ventral white commissure -fibres ascend contralaterally in ventral and lateral funiculi Destined for cerebral cortex

Gastric motility

-metoclopramide > higher rate of absorption -atropine > low rate of absportion

Meningitis assessment

-neck mobility: supine, hands behind patients neck and flex forward until chin touches chest (normal: supple neck) -Brudzinski's sign: flex patients neck, watch hips and knees in reaction (relaxed= normal; positive=flexion of hips and knees) -kernig's sign: flex patients hip at knee and then straighten knee (positive = pain and increase resistance to knee extension)

Sensory screening

-reflex -conscious sensation -body position calibration -regulating internal autonomic functions -BP, heart rate, respiration -reach sensory cortex via spinothalamic tract or posterior columns -pain and temp: post horn and synapse with secondary sensory neurons -crude touch - perceived as light touch without accurate localization; passes into posterior horn synapsing with secondary sensory neurons -position and vibration : directly into posterior columns and travel ip to the medulla along with fibres transmitting fine touch -fine touch: accurately localized and finely discriminating touch

Induction or inhibition of P-glycoprotein:

-rifampin + fexofendine > low fexofendine levels (induction of P-glycoprotein) -verapamil + digoxin > high digoxin level (inhibition of P-glycoprotein)

Romberg test

-stand with feet together, eyes closed, for 30 sec with no support -stand behind patients during exam Tests proprioception or vestibular dysfunction

Motor testing

-tests of dexterity and coordination are most sensitive to notice upper neuron and cerebellar problems -tests of strength are more sensitive to lower motor neuron dysfunction

Spinocerebellar tracts (sensory)

-unconscious proprioception, coordination, and posture -in lateral funinculus -destined for cerebellar cortex -2 subdivisions with diff pathways -1. Dorsal: ispilateral -input from muscle spindles, golgi tendon organs, and skin receptors -first order neurons: dorsal root ganglia -enter gray matter of cord and synapse in nucleus dorsalis of Clarke (lamina VI-VII) -axons ascend in lateral funinculus) -2. Ventral: contralateral -input from muscle spindles, golgi tendon organs and skin receptors -first order neurons: dorsal root ganglia -enter gray matter and synpase on spinal border cells (laminae VII-IX) - second order neurons -axons decussate in ventral white commissure -neuron ascend in lateral funinculus

Lamina of Rexed overview

-vertical columns of neurons -corresponds to functional differences -Laminae I-VI: dorsal horn (sensory) -Lamina VII: intermediate zone (interneuron) and lateral horn (viscerosensory) -laminae VIII-IX: ventral horn (motor) -lamina X: surrounding central canal

Motor screening

-wasting and movement -muscle tone -muscle strength -fine finger movements -pronator drift -reflexes -sensation -pinprick or temp in hands and feet -vibration or joint position in toes and fingers -assess coordination (finger nose finger and hell knee shin)

Regional anatomic differences

-white matter increases from caudal to ROS trial -gray matter enlarges in cervical (C4-T1) and lumbar (L2-S3) -thoracic segments have a small lateral horn

CYP3A4 inhibitors (MEMORIZE)

1, cimetidine (tagamat (???)) 2. Erythromycin and clarithromycin 3. Ketoconazole and itraconazole 4. Ritonavir 5. Atrazanavir 6. Grapefruit juice These drugs are substrates and competitive inhibitors of P-glycoprotein

Antimicrobial stewardship

1, promotes the appropriate use of antibiotics and microbials 2. Improves patient outcomes 3. Reduces micrbial resistance 4. Decreases spread of infections caused by multi-drug resistant organisms

Mechanisms of pharmacodynamic drug interactions

1. Additive : sum of the effect of each agent given alone -i.e.: diphenhydramine [benadryl] + zolpidem (Ambien [sleeping pill]) > CNS depression 2. Synergy: exceeds the sum of the effects of each agent given alone -i.e.: methadone (opiod to manage withdrawal of drugs) + alprazolam + alcohol > CNS depression, coma, death 3. Potentiation: enhanced effect caused by one drug due to the presence of another drug -i.e.: cyclosporine +sirolimus (both suppress immune system after transplant; neither toxic alone) > enhanced nephrotoxicity (can be therapeutic or toxic) 4. Antagonism: interference of one drug with with the action of another -i.e.: morphine + halo one > treatment of opioid overdose

Lesions superior to pathway decussations will cause ________

1. Afferent (sensory): receive other axons/signals from periphery 2. Efferent (motor): project own axons/signals to periphery Paired and bilateral

cranial nerve nuclei and brainstem position (medial and lateral)

1. Afferent (sensory): receive other axons/signals from periphery 2. Efferent (motor): project own axons/signals to periphery Paired and bilateral

Absorption interactions

1. Alter gastric pH: 2. Sequestration in GI tract: 3. Gastric motility: 4. Induction or inhibition of P-glycoprotein:

Alteration of therapeutic action

1. Aspirin + heparin > higher risk of bleeding (antiplatelet and anticoagulant) 2, nitroglycerin (vasodilation) + slidenafil (viagra) > profound and potentially catastrophic hypotension (NO increases cGMP +slidenafil inhibits cGMP degradation)

Alteration of receptor binding

1. Atropine + nerve agent > treatment of cholinergic poisoning (anticholinergic and acetylcoinesterase inhibitor) 2, buprenorphine + narcotic drugs of abuse > treatment of narcotic drug abuse (bupreorphine has high affinity for the mu opiod receptor)

Harmful effects on cells and organs

1. Cells: apoptosis, necrosis, mutagenesis, carcinogenesis 2. Liver: hepatitis, hepatitc necrosis, cirrhosis 3. Kidney: glomerular nephropathy, tubular necrosis, interstitial nephritis 4. Nerves: neuropathy, seizures, coma

Corticopontine tract and pontocerebellar tract

1. Corticopontine tract: cortical motor command copy to pontine nuclei 2. Pontocerebellar tract: cortical motor command copy to middle peduncle

3 motor pathways that impinge on anterior horn cells (lower motor neuron cell bodies)

1. Corticospinal tract: voluntary movement, integrate skilled, complicated delicate movements, inhibit muscle tone 2. Basal ganglia system: maintains muscle tone and control body movements (walking) 3. Cerebellar system - coordinates motor, equilibrium, posture -Upper lesions: muscle tone increased, clonus spasticity, babinski sign, DTRs exaggerated -lower lestions: ipsilateral weakness and paralysis, muscle tone decreased, DTRs are decreased or absent, atrophy, fasciculations

Most common causes of sensory deficits

1. Diabetes mellitus 2. Thiamine deficiency 3. Neurotoxin damage (insecticides)

Distribution interactions

1. Displacement from plasma protein binding sites -i.e.: methotrexate + sulfonamide > enhanced toxicity of the methotrexate effect 2. Inhibition of transport proteins -simvastatin + gemfibrozil > gemfibrozil blocks OATP1B1 mediated uptake into hepatocyte > high systemic exposure to simvastatin > high simvastatin toxicity -quinidine + loperamide > high CNS exposure to loperamide

3 major divisions of spinal cord white matter

1. Dorsal fununculus - sensory axons -bounded by tract of Lissauer 2. Lateral funiculi (S and M axons) 3. Ventral funiculus (M and S axons)

Spinal cord gray matter 4 divisions

1. Dorsal/posterior horns - sensory 2. Ventral/anterior horns - motor 3. Intermediate zone - interneurons for local circuits 4. Lateral horns - preganglionic sympathetic neurons -only in thoracic and upper lumbar segments

Mechanisms of resistance

1. Drug does not reach target 2, drug inactivation 3. Target alteration 4. Organisms expresses alternate metabolic pathways

Harmful effects to fetus

1. Fetotoxicity: injury to fetus from a substance that enters the maternal and placental circulation 2. Teratogen: any substance that acts during embryonic or fetal development to produce a permanent chance of form or function 3. Neonatal abstinence syndrome: symptoms of withdrawal that babies can develop after birth if their mothers ahcev taken medications or drugs during their pregnancy that can be addictive

Rules of ottawa

1. Foot -pain in mid foot and base of 5th metatarsal -pain in mid foot and navicular -inability to bear weight for 4 steps immediately and in ER 2. Ankle -pain an m malleolus or along distal 6 cm of posterior/medial tibia -pain at l malleolus or along distal 6 cm of posterior fibula -inability to bear wirght immmediately and for 4 steps in ER

Simple stretch reflex

1. Hammer strike stretches muscle > muscle spindle excited > sensory info conveyed to spinal cord > excites motor neurons of agonist (and synergist) > agonist (and synergist) contract and shorten 2. Reciprocal inhibition of motor neurons for antagonist 3. Neurotransmitters: Glu, Ach, Gly,

Effect of resistance on IC50 and Emax

1. Intermediate resistance: -high IC50 > much higher concentrations needs to achieve a particular effect (same Emax) 2. Resistance: -decreases in Emax: higher dose would not increase the effect beyond a certain point -high IC50 > very high dose to kill microbe but intolerable toxicity -eradication of the microbe by that drug will never happen

Intrinsic and extrinsic resistance

1. Intrinsic: microorganism has features that make it inherently resistant 2. Acquired: normally responsive organisms acquires: -spontaneous and random chromosomal mutations -transfer off resistance genes from other bacteris

Motor laminae Rexed

1. Lamina IX: spinal accessory nucleus -extends from C1-C6 -gives rise to the spinal root of CN XI, innervates trap and sternocleidomastoid m 2. Lamina IX: phrenic nucleus -extends from C3-5 -innervates diaphragm

Lesion level and position

1. Level: indicated no involvement of cranial nerves and their nuclei 2. Position: indicate by disordered function of ascending or descending tracts

Spinal cord injury

1. Lower motor neuron lesion: from damage to motor neurons of ventral horn which interrupts the connection between the nerve and muscle leading to weakness 2. Upper motor neuron lesion: results from damage to neurons in the cerebral cortex that contribute to the CST > spasticity

Longitudinal arches

1. Medial: -calcaneous, talus, navicular, all cuneiforms, 1-3 metatarsals -maintained by plantar ligaments, plantar fascia, tibialis posterior, flexor digitorum longus, flexor hallucis longus, and intrinsic muscles of foot 2. Lateral: -calcaneous, cuboid, 4 +5 metatarsals -limited mobility; designed to transmit weight and thrust to the ground -major articulation is calcaneocuboid: stress through this arch can cause a typical cuboid SD

Microbicidal vs microbiostatic

1. Microbicidal: kills infective organism; should be used when host defenses are impaired (immunocompromised, meningitis, endocarditis, osteomyelitis) -infections in anatomical sites where the immune function is reduced 2. Microbiotatic: inhibits microbial growth and replication, does not kill it -intact immune system required to remove the microorganisms from the body

Pharmacodynamic drug interactions

1. Modification of drug target: The pharmacodynamics of chemicals can be altered by competition at the intended and/or the unintended receptor 2. Non receptor pharmacodynamic interactions: Drugs having different mechanisms of action can lead to a greater or lesser response than the sum of effects

Narrow vs broad spectrum antimicrobials

1. Narrow: drugs effective against a limited group of microorganisms 2. Broad: drugs effecting against a wide variety of microbial species It is good to use the most selective drug that produces the fewest adverse effects

Administration of drugs

1. Oral: mild to moderate infections and outpatients -pH of stomach destroys some drugs and reduces the bioavailability of others -systemic concentration may be lower with oral than parental due to first pass metabolism 2. IV: moderate to severe infections when rapid onset and higher concentration in blood are required 3. Intramuscular: poor venous access; when therapeutic blood levels can be maintained with workout or monthly injections 4. Topical: superficial cutaneous infections -local application of poorly absorbed drugs on surface wounds or mucous membranes permits highly effective local concentrations without toxic side effects

Predictors of bacterial eradication

1. Peak/MIC: rate and extend of killing increases progressively with higher antibacterial concentrations (peak concentration to MIC ratios) -values greater than 8:10 are effective; resistance is hen values fall below 3:1 -persistent suppression of microbial growth that occurs after antibiotic levels fall 2. T>MIC: microbes are killed at. The same rate and the the same extent once the threshold concentration is reached (increases concentration above 4-6X MIC is pointless -efficacy correlates with duration of exposure -no persistent effect 3, 24h-AUC/MIC: efficacy correlates with total amount of drug -total drug exposure to MIC ratio determines the rate and extent of kill for some drugs -ideal dosing maximizes the amount of drug in a 24 h period -time dependent and prolonged effects

Pharmacogenetics vs pharmacogenomics

1. Pharmacogenetics: the study of inherited genetic differences (single nucleotide polymorphism) that affect drug metabolism, distribution, receptor targets, and biological effect 2. Pharmacogenomics: study of acquired and inherited genetic differences in relation to drug response and drug behaviour through systematic examination of genes, gene products, and inter and intra individual variation in gene expression and function

Mechanisms of drug toxicity

1. Pharmacologic: Predictable, concentration-dependent -I.e.: sedative-hypnotics: anxiolytic > sedation > somnolence > coma 2. Pathologic: generation of toxic metabolites -direct organ damage such as haptatic necrosis, interstitial nephritis, or pulmonary fibrosis 3. Genotoxic: DNA injury > mutations or cancer -cancer chemotherapise -onset may be delayed for several years

Antimicrobial agents must penetrate into the infected compartment with enough concentration to inhibit/prevent the growth of the organism

1. Physiochemical: lipophilic, hydrophilic, polar 2. Tissue penetration: anatomic and vascular barriers like BBB 3. Active efflux: p-glycoprotein and other efflux pumps 4. Intracellular penetration: some organisms hide in host cells 5. Endocardium vegetation: deposition of platelets, fibrin, microbes, inflammatory cells on endocardial tissue 6. Biofilm: colonies of slow growing microbes that adhere to prosthetic devices

Physiological vs chemical interactions

1. Physiological: agonist and antagonist acting at two different sites and inducing independent but opposite effects (insulin + glucagon) 2. Chemical: a compound that directly interacts with the agonist, modifying or sequestering it so that the agonist is no longer capable of binding to and activating the receptor -ie heparin (acidic) and protamine (basic antidote) > neutralizes heparin

Gene varieties affecting pharmacokinetics

1. Poor metabolizers: two alleles encoding for a nonfunctional protein 2. Intermediate metabolizers: one functionoal allele (phenotype can be similar to EM) 3. Extensive metabolizers: 2 functional alleles 4, ultra rapid metabolizers: very high enzymatic activity, sometimes due to gene duplication 5. Other gene variants: polymorphisms in genes transporters

Inversion stress test

1. Purpose: assess joint laxity in inversion to test the continuity of the ATFL and CFL 2. How: patient's foot in neutral position with forefoot and heel grasped by examiner > inversion force applied to gap the calcaneous away from lateral malleolus 3. Positive test: excessive laxity - excessive inversion of foot medially

Eversion stress test

1. Purpose: assess joint laxity to these the continuity of the medial ankle ligament complex 2. How: patient's foot in neutral position with forefoot and heel grasped by examiner > eversion force applied to gap the calcaneous away from medial malleolus 3. Positive test: excessive laxity - excessive inversion of foot laterally

Anterior Draw Test

1. Purpose: detects excessive anterior displacement of the talus on the tibia 2. How: patient's foot in neutral position (slightly plantar flexed and inverted) while physician stabilizes the lower leg and grasps heel > apply gentle and steady anterior force while holding distal anterior leg fixed 3. positive test: excessive laxity - excessive anterior translation of the foot anterior, may feel a clunk

6 goals of antibiotic stewardship programs

1. Reduce antibiotic consumption and inappropriate use 2, reduce clostridium difficult infections 3, improve patient outcomes 4, increase adherence and utilization of treatment guidelines 5, reduce adverse drug events 6, decrease or limit antibiotic resistance -best for healthcare associated gram negative organisms

Lesions in sensory pathway

1. Sensory cortex lesion: -impairs finer discrimination -unable to appreciate size, shape, or texture of an object by feeling it (cant identify it) 2. Posterior column disease: -loss of position and vibration sense but others are ok -dermatome knowledge helps localize lesion to a specific spinal cord segment

Squeeze test

1. Test: squeeze the proximal tibia-fibula to compress the bones proximally and cause a gapping of the distal tibiofibular syndesmosis 2. Positive test: pain at the distal tibiofibular joint indicates injury in this area (high ankle sprain)

Classifications of adverse drug events

1. Type A: common and predictable -overdose -side effects -secondary effects (superinfection) -indirect effects (phototoxicity) -drug interactions 2. Type B: rare and unpredictable -intolerance -idiosyncracy (not attributable to pharmacological properties) -immunologic drug reaction (allergy)

Brainstem lesions

1. Unilateral brainstem lesions would have ipsilateral lower branch symptoms and contralateral upper branch symptoms 2. Unilateral CN lesions would have all ipsilateral symptoms

White/gray matter

1. White: tracks of myelinated axons -located on periphery of cord 2. Gray: cell bodies -within the spinal cord (H-shaped)

Diffusion susceptibility test

A. Disk diffusion 2. E test

Pronation

ABduction, eversion, dorsiflexion

Examples of toxicities

ADD PCI

General locations of nuclei

ADD PCI

Supination

ADduction, inversion, plantar flexion

Conjugate lateral gaze

Abducens which then occuolomotor

Graphesthesia

Ability to identify a number drawn on palm of hand

Stereognisis

Ability to identify an object by feeling it

MLF syndrome

Affects medial movement in context of conjugate Horizonte gaze Same side

Contralateral CNs

All CNs are ispilateral except CN III and IV

Paresthesia

Altered sensation

Pharmacokinetic interactions (modifying ADME properties [absorption, distribution, mechanism, excretion)

Altered: -rates of absorption (calcium binds with tetracycline in gut so its not absorbed) -biotransformation -protein binding -excretion This heightens or decrease the concentration of the active drug in blood > high or low concentration of active drug delivered to site of action

Symptoms of spinothalamic tract injury

Analgesia (loss of pain) Theroanesthesia (loss of temp sense)

Navicular tubercle

Articulates with 5 bones: talar head, 3 cuneiforms, and cuboid -aseptic necrosis of navicular can be noted by local tenderness and a limping gait (children mostly)

Shallow knee bend

Assess for proximal weaknes

Ataxia

Associated with cerebellar function Lesion in: -red nucleus: contralateral to ataxia -lateral pons and medulla: ipsilateral to ataxia

Cortex

Associated with contralateral control and sensation

Palsy

Associated with cortical function lesion in: -ventral-lateral midbrain -ventral pons -ventral-medial medulla Above motor decussation Contralateral to palsy

Cerebellum

Associated with ipsilateral control and sensation and contralateral cortex

Medial malleolus

At the medial aspect of the talus -add bony ability to the ankle joint

Symptoms of cerebellar pathway injsury

Ataxia - nucoordinated movement -dysmetria - undershoot or overshoots -tremor -hypotonia -hyporeflexia

Common inducers (MEMORIZE)

CYP3A4 and P-gp -phenytoin -carbamazepine -phenobarbital -Rifampin -St. John's wort These drugs also affect other CYP's CYP1A family -cigarette smoking ---CYP1A1 and CYP1A2 can metabolically activate chemical carcinogens ----many of these substances are inert unless metabolized by CYPs

Multiple sclerosis

Cause numbness in any extremity

Posterior tarsal tunnel

Characterized by pain, numbness, and paresthias of sole of foot

Olivocerebellar tract

Climbing fibres > inferior peduncle -cerebellar motor copy + vestibular > inferior peduncle

Diabetes mellitus

Common cause of lower extremity numbness

Rubrospinal tract

Control of distal limb muscles (crossed)

Reticluospinal tract (motor)

Controls unconscious movement/posture (bilateral)

Cuneocerebellar tract (sensory)

Conveys unconscious proprioceptive info from upper extremities (analogue of DSCT)

Identifying axons

Dark area in myelin stained bodies -tract: axons surrounded by other nervous tissue -nerve: axons not surrounded by other nervous tissue -nerve root: axons giving rise to nerves; surrounded by other nervous tissue

5 D's of antibiotic stewardship

Diagnosis Drug Dosing Duration De-escalation when appropriate

Dysthesia

Distorted sensation (light touch or pinprick feels like burning or irritating sensation)

Inhibition of enzymes

Drugs or reactive intermediates that bind to drug-metabolizing enzymes > low catalytic activity of enzyme 1. Competitive inhibition at the CYP heme iron 2. Noncompetitive binding to allosteric site preventing the subrstrate from binding 3. Suicide inhibition: substrate irreversibly inhibits CYPs by: -covalent binding with heme moiety -covalent binding with protein part of enzyme -cause heme fragmentation

Anal reflex

Dull object to strok outward in 4 quadrants of anus -look for contraction

FOR BRAINSTEM INTERNAL ANATOMY - PLEASE USE LECTURE SLIDES

FOR BRAINSTEM INTERNAL ANATOMY - PLEASE USE LECTURE SLIDES

Dome of talus

Felt in inversion and plantar flexion -better palpated laterally than medially

Thompson test

For achilles tendon continuity

Tinel's sign

For anterior tarsal tunnel

Suppressive

For immunosuppressed individuals when the original infection is not completely eradicated by the initial therapy

Spinoreticular tract (sensory)

Forms part of the reticular activating system (involved perception of visceral pain) and in postural control and orientation

Anterior and posterior metatarsal arch

Head of the metatarsal bones (2nd metatarsal head in the apex) 1. Posterior: bases of the metatarsal bones 2. Anterior: navicular, all cuneiforms, cuboid -key stone is in 2nd cuneiform

Spinotectal tract (sensory)

Helps orient eyes and head to a stimulus

Anterior talofibular ligament

High incidence of sprain

Abducens nerve issues

Horizantle diplopia

Empiric

Immediate broad spectrum antimicrobial therapy when a delay in initiative antibiotic therapy could cause significant morbidity or fatality

P-glycoproteins

Inhibition of P-glycoprotein transporters increases CNS exposure to the drugs b

High ankle sprain

Injury to tibiofibular syndesmosis ligaments (anterior inferior tibiofibular ligament, posterior inferior tibiofibulra ligament, or interosseus membrane -mechanism of injury is excessive dorsiflexion and eversion of ankle joint, mainly lateral rotation of the foot with internal rotation of tibia -tested by squeeze test

Sustentaculum tali

Just inferior to the distal end of the medial malleolus -may not be palpable -supports the talus and serves as an attachment for the spring ligament

Foville's

Knocks out abducens Impaired lateral eye movement toward side of lesion in both eyes

Knee/patella tendon reflex

L2-4 nerve root -seated with leg dangling or supine > tap patellar tendon just below patella -normal: contraction of quads and knee extension

Plantar response

L5, S1 Stroke lateral aspect of sole curving medially across ball -big toe plantar flexes (normal, no babinksi)

LOOK UP LANDMARKS

LOOK UP LANDMARKS

Lactation labeling rule

Labels have a list of risks of using a drug during pregnancy and lactation, a disscussion of data supporting that summary, and relevant info to help health care providers. In prescribing decisions and counsel Labeling include info about pregnancy, testing, contraception, and infertility for physicians

Interneuron lamina rexed

Lamina VII: Sacral Autonomic Nucleus -extends from S2-4 -gives rise to preganglionic parasympathetic fibres -innervates pelvic viscera via pelvic nerve

Identifying nuclei

Light area in myelin stained slides -nucleus: cell bodies surrounded by other nervous tissue (in CNS) -ganglion: cell bodies NOT surrounded by other nervous tissue (outside CNS)

Spinothalamic tract and posterior columns

Light touch

Sinus tarsi area

Located just anterior to the lateral malleolus -palapted as soft tissue depression which is filled with extensor digitorum bare is and pad of fat

Dysmetria

Loss of ability to control and judge distance, speed, and power of a motor act

Minimum inhibitory concentration

Lowest concentration of an antibacterial agent that inhibits visible growth

Minimum bactericidal concentration

Lowest concentration of antibacterial agent that either totally prevents growth or >99.9% decrease in the initial inoculum

Head of talus

Medial side of talar head is immediately proximal to the navicular -inverting and everything the forefoot creates palpable motion between the talus and navicular

Vestibulospinal tract (motor)

Mediates equilibrium by coordinating the vestibular apparatus in the inner ear with axial muscles and limbs (uncrossed)

Polypharmacy

Meds/OTC/herbal Prescribing cascade

Rubrospinal tract

Motor Superior peduncle to red nucleus Meets corticospinal tract in spinal cord

Biceps tendon reflex

Musculocutaneous nerve: C5, C6 -flex arm at pronation > strike biceps tendon -normal: flexion at elbow and contraction of bicepts

2 point discrimination

Normal space to discriminate is <5mm on finger pads

Sesamoid bones

On 1st metatarsal within flexor hallucis brevis tendon -allows for distribution of somebody weight and creates mechanical advantage to flexor tendon of the great toe during toe-off

5th metatarsal and metatarsophalangeal joint

On lateral side of ball of foot -proximally along lateral shaft o 5th metatarsal -styloid process can be palapted -peroneus brevis inserts into the process

Medial tubercle of calcaneous

On medial plantar surface of calcaneous -attachment for aBductor hallucis medially and flexor digitory brevis and plantar aponeuronis anteriorly -weight bearing

Trochlear nerve

Only nerve leaving brainstem dorsally and projecting contralaterally -nucleus in floor of midbrain (tegmentum) -vertical diplopia can occur

Raymonds

Only one lateral gaze (same side) Abducens nerve

Spinothalamic tract

Pain and temp

Crossed extensor reflex

Painful stimuli on R leg > pain sensor excited > sensory info to spinal cord > excited flexor motor neurons of R leg withdrawing it from stimulus -excites extensor motor neurons of L leg to support shift in body weight -interneurons help in feedback control

Flexor withdrawal reflex

Painful stimulus on hand > pain sensor excited > sensory info conveyed to spinal cord > excited flexor motor neurons of arm> limb withdrawn from stimulus

Quadriplegia

Paralysis of all 4 limbs

Paraplegia

Paralysis of legs

Hemiplegia

Paralysis of one half of body

Symptoms of DCML injuryt

Paresthesia (loss of touch and proprioception -ataxia and cerebellum injury type symptoms

Most common ankle sprain

Plantar flexion and inversion

Posterior Columns

Position and vibration

Anterior tarsal tunnel

Presents as deep, aching pain in the dorsum of foot, weakness of extensor digitorum brevis, and numbness in the distribution of the deep peroneal nerve

Brachioradialis tendon reflx

Radial nerve (C5,C6) -hand resting and pronated > strike radius 1-2" above wrist -Normal: flexion and supination of forearm

Triceps tendon reflex

Radial nerve (roots: C6, C7) -upper arm raised forming a right ankle at shoulder -tap triceps tendon -normal: extension of elbow and triceps contraction

Resistance contributors

Random events > mutations > when drug present these mutations may conger a survival advantage to the organisms > survival of the fittest -increased exposure to the drug increases selection pressure for the mutation Frequent or long term use of a drug increases the chance that microbial mutations produce resistance to drug

Proximal weakness

Related to muscle disease -difficulty with movement -weakness greatest at hip and shoulder girdle -may have difficulty standing out of chair without arm help, trouble combing hair, getting out of cars...

Distal weakness

Related to neurological disease -hand movements -difficulty opening a jar, using scissors or a screwdriver -trip when walk

Clonus

Relax patient, sharply dorsiflex, look for rhythmic oscillations between Dorsi flexion and plantar flexion

Ankle/achilles tendon refelx

S1 -seated and dorsiflexed > strike achilles tendon -normal: plantar flexion

Trigeminal issues

Selective anesthesia Suicide disease No longer can blink Herpes zoster Jaw deviates to one side Wallenberg syndrome - pain/temp

Definiitvw

Specific, narrow spectrum antimicrobial agent when's then microorganism and its susceptibility to specific antibiotics are identified

Pronator drift

Stand with eyes closed and palms upward for 30 secs Tests upper extremity weakness

Lumbar radiculopathy test

Straight leg raise

Plegia

Strength absent

Paresisq

Strength imparied

Abdominal reflex

Stroke each side of abdomen -contraction of abs and deviation of umbilicus towards stimulus -T8-10 above umbilicus -T10-12 below

Preemptive

The prevent development of a potential dangerous disease in those who already have evidence of infection I.e. Cytomegalovirus after hematopoietic stem cell transplantation and solid organ transplantation

Combination

To broaden antibiotic spectrum or synergism or additative effects Not a first choice but recommended in: -empiric therapy to extend the spectrum -preventing resistance to mono therapy -accelerating therapeutic efficacy of microbial kill -enhancing therapeutic efficacy (synergism) -additive effects to reduce dose and bad effects of a particular agent

Prophylactic

To prevent infection in high risk patients I.e. Surgery, immunosuppression, endocarditis

Medial medullary syndrome

V Jaw moves towards injury

Wallenberg's syndrome

VII Cant move ipsilateral face

Benedikt's/ Weber's syndrome

VIII Falling towards injured side

Peduncles

Very large tracts (dark areas in myelin stained slides) connecting to the cerebellum and cerebrum 1. Superior cerebellar peduncle: runs to and from midbrain 2. Middle cerebellar peduncle: runs to and from pons 3. Inferior cerebellar peduncle: runs to and from the medulla 4. Cerebral peduncles (aka basis pedunculi/crux cerebri): runs from cerebrum through midbrain

Rubro-olivary tract

Via central tegmentum - cerebellar motor command copay to inferior olivary nuclei

Symptoms of corticospinal tract injury

Weakness Palsy Paresis Hemiparesis Hemiplesia Paraplegia Paralysis: total loss of voluntary movement

Hemiparesis

Weakness of one half of body

Avellis' syndrome

X Uvula points away from injury

Millard-Gubler syndrome

XI Cant lift ipsilateral shoulder

Raymond's syndrome

XI Cant turn head away from injury

Foville's syndrome

XII Tongue points toward injury

Alter gastric pH

omeprazole + ketoconzaole > low absorption of ketoconzaole (omeprazole = proton pump inhibitor [antacidf] and ketocondazole = antifungal agent)

Sequestering in GI tract

tetracycline + antacid > low absorption of tetracycline -cholestyramine (binds many things in gut) + many drugs > low absorption of drugs -bulk laxatives + some drugs > less aborption