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Transcript
ANS practice problems Reading assignments: Kaplan Pharmacology USMLE Step1 , Lecture notes;2009,p53-67 ; 2 types of ANS practice problems asked by NBME 1.Classic presentation :In the body of Q. you will see a graph/tracing showing effect/s of an unknown drug alone or in combination with other drugs. By looking at the response you will have to identify that unknown drug. 2.Other Qs : Effect of unknown drug/s are shown in non graphical pattern (in bars or charts or as pictogram or others).Few working examples are given in practice problem in this PP. Effect of an unknown drug on Heart rate and blood pressure Control drug effect Increased diastolic Decreased diastolic Increased Heart rate Decreased Heart rate Increased pulse pressure Increased TPR (Increased α1) decreased TPR (increased β2, decreased α1, directly acting vasodilators and cholinomimetics. increased β1 (May be reflex *) Increased Cholinergic (May be a reflex) increased β1 (increased inotropic activity) Effect of α1 activators on Heart rate and blood pressure •Systemically , increase mean blood pressure via vasoconstriction. •Increased BP may elicit a reflex bradycardia. •Cardiac output may be decreased but also offset by increased venous return. •No change in pulse pressure. Effect of β activators on Heart rate and blood pressure •Systemically, decrease mean BP via vasodilation (β2) and increased HR (β1) •Increased Pulse pressure. Effect of Norepinephrine on Heart rate and blood pressure Exercise: Effect of norepinephrine after pre-tretment with atropine. Effect of Epinephrine on Heart rate and blood pressure Dose dependent effects Low dose: β1 ,β2 stimulation. High dose: α1, β1 (β2). Β2 specific effects: Smooth muscle relaxation. Metabolic effects: Increased glycogenolysis Increased gluconeogenesis Increased mobilization and use of fat. Exercise: Effect of epinephrine after pretreatment with α1 blocker. Effect of an unknown drug (R) on Heart rate and blood pressure NBME Step1: Go to working section and write Receptor affections for each of drugs given in the choices ---interpret as the drug R will essentially work by using any of those receptors Step2 :What does the drug R do in BP &HR in control tracing? ------Match those effects with the drug from working section in lite of their receptor affection--------if more than 1 option looks correct move on to next experiment. Step3:Visit each experiment (R + Blocker) and ask 2 Qs. 1.Does the blocker changes drug response in anyway? (compare with control) interpret as if R + Blocker blocks a response caused by drug R meaning that drug R when given alone will produce that response (blocker can not produce any response by its own. It can only block an agonist response.) 2.In +ce of blocker can the drug still do some changes? (compare baseline/pre t/t vs drug effect in the same tracing) R is A. epinephrine B.norepinephrine C. phenylephrine D. isoproterenol E. terbutaline Effect of an unknown drug (U) on Heart rate and blood pressure NBME Effect of an unknown drug (S) on Heart rate and blood pressure NBME Effect of an unknown drug (H) on Heart rate and blood pressure NBME Effect of an unknown drug (R) on Heart rate and blood pressure NBME Effect of an unknown drug (R) on Heart rate and blood pressure NBME Drug H is Isoprotenol Epinephrine. Norepinephrine Phenylephrine Tyramine Effect of an unknown drug (R) on multiple body parameters Drug X and Y are, respectively Isoproterenol and propranolol Epinephrine and phenoxybenzamine Norepinephrine and phentolamine Terbutaline and phenylephrine. Acetylcholine and hexamethonium NBME Effect Effectofofananunknown unknowndrug drug(R) (R)ononHeart multiple rate body and blood parameters pressure NBME Effect of unknown drugs on Heart rate and blood pressure in vitro NBME NBME Horner's syndrome is a clinical syndrome caused by damage to the sympathetic nervous system. PAMELa" for Ptosis, Anhidrosis, Miosis, Enophthalmos and Loss of ciliospinal reflex. Lesions First-order neuron disorder: Central lesions that involve the hypothalamospinal pathway (e.g. transection of the cervical spinal cord). Second-order neuron disorder: Preganglionic lesions (e.g. compression of the sympathetic chain by a lung tumor). Third-order neuron disorder: Postganglionic lesions at the level of the internal carotid artery (e.g. a tumor in the cavernous sinus). lesion of the post-ganglionic sympathetic innervation of the right eye. 1. Alpha 1 agonist 2. Releaser / indirectly acting drug 3. Muscarinic receptor blocker 4. Alpha receptor blocker Baroreceptor Reflex BP = SNS; PSNS BP = SNS; PSNS Pretreatment with which drug will amplify the tachycardia produced by the baroreflex arc illustrated in the previous slide when an experimental subject is given an intravenous injection of histamine? A. Botulinum toxin B. Diphenydramine C. Hexamethonium D. Metoprolol E. Physostigmine Answer: E Amplifies response at ganglia Baroreceptor Reflex Phenylephrine Histamine BP (mmHg) SNA (Units) PSNA (Units) HR (bpm) Time (minutes) NBME Pretreatment with which of the following will block the decrease in heart rate shown in the preceding slide when an intravenous injection of phenylephrine is given to an experimental subject? A. Metoprolol B. Phenelzine C. Physostigmine D. Prazosin E. Reserpine Answer: D Blocks alpha-1 receptors Predicting Responses β1 & β2 Epi reversal β 1, β 2, & α 1 β 1, & α1 NBME Stimulation of which receptor is responsible for the slight pressor response seen on the preceding slide when norepinephrine is injected intravenously into an experimental subject pretreated with an alpha blocker? A. Alpha1 B. Alpha2 C. Beta1 D. Beta2 E. NicotinicN Answer: C Increases cardiac output NBME Heart Rate Low dose Blood Pressure Look at BP 1st ACH (2 mg) ACH (50 mg) Intermediate dose (Atropine: Muscarinic Receptor Antagonist) ACH (50 mg) ACH (5 mg) High dose (Hexamethonium: Neuronal Nicotinic Receptor Antagonist) ACH (5 mg) Which drug will block the pressor response illustrated on the preceding slide when 5 mg of ACh was given to an experimental subjects pretreated with atropine? A. Butoxamine B. Cocaine C. Metoprolol D. Physostigmine E. Prazosin Answer: E Blocks alpha-1 receptors