8 Flashcards
Patients receiving parenteral nutrition through central venous catheter are at a high risk for
Candidemia (pseudohyphae with blastoconidia)
Low testosterone with decreased FSH and LH
Hypogonadotropic hypogonadism (Kallman Syndrome) just one example
LOS is like LPS but lacks
repeating O antigent (amount of LOS correlates to NM disease severity)
LOS of N. meningitidis causes sepsis via what cytokines?
TNF-alpha, IL-1b, IL-6, IL-8 due to interaction with toll like receptor 4
Causes of Asherman syndrome
Postpartum endometritis and dilation/curettage
MDD: SIG E CAPS (5+ present for longer than 2 weeks)
Dont forget:
Depressed mood
S- Sleep disorder I-Interest deficit (anhedonia) G- Guilt (worthlessness, hopelessness, regret) E- Energy deficit C-concentration A- Appetite disorder P- psychomotor retardation or agitation S- Suicidality
Adenomyosis is common in what age group
middle aged parous females
Heavy menstrual bleeding, dysmenorrhea, and on exam a UNIFORMLY enlarged uterus (from hormonal stimulation of endometrial glandular tissue in myometrium)
Adenomyosis
Fibroids
Leiomyomas caused by proliferation of myometrial smooth muscle cells. IRREGULARLY enlarged uterus and heavy menstrual bleeding
Hyperplastic growth of endometrial glands and stroma leading to a benign projections of uterine lining. Do not cause uterine enlargement
Endometrial polyps
During first few weeks of embryogenesis Hb is synthesized by _______
Yolk sac (zeta or epsilon)
Hb F begins around 8 weeks gestation and replaces embryonic Hb by 14 weeks. Where is it made?
Spleen and liver (by 14 weeks erythropoiesis is taking place here
Hb H (3 deletions of alpha gene) manifest as
chronic hemolytic anemia (note: Hb Barts- gamma4 is not compatible with life- hydrops fetalis
Sources of ALK phos other that osteoblast
Placenta during pregnancy, liver, and intestine
Difference btw liver and bone alk phos
Bone= boil (easily denatured). Electrophoresis can be used and so can monoclonal antibodies
Osteoclast produce: It is tartrate-resistant and is unstable in frozen serum samples
Acid phosphatase
Measurement of osteoClastic activity?
1) Urine deoxypryridinoline (pryridinoline covalently cross links collagen fibers)
2) Tartrate resistance
3) hydroxyproline could be used but can be fasely high in urine due to meat products (shitty)
Ipratropium
Anti-muscarinic (bronchodilation) + blocks the parasympathetic stimulation of tracheobronchial submucosal glands in the lungs (great add benefit for asthma and COPD)
Inhaled glucocorticoid used for the prophylactic treatment of bronchial asthma
Flunisolide
How does Nifedipine cause bronchodilation
By blocking calcium influx into bronchial smooth muscle
Bronchodilation by blocking PDE activity–> increasing intracellular cAMP
Methylxanthines (theophylline and aminophylline)
Inhibitor of lipoxygenase pathway for prophylactic asthma therapy
Zileuton
benign nerve sheath neoplasms predominantly comprised of SCHWANN CELLS (derived from neural crest cells)
Cutaneous Neurofibromas
spontaneous episodes of rest and nighttime angina with transient ST elevation
Vasospastic or variant (prinzmetal) angina
Drug causes of vasospactic angina?
Dihydroergotamine, cig smoking, cocaine/amphetamines, triptans
What can be used to treat vasospastic angina?
Nitroglycerine to treat acute. Prophylactic Ca++ channel blockers (don’t forget smoking cessation)
Acts as vasodilator reducing SVR and increases venous capacitance. Also sympatholytic effects on cardiovascular system. Can be used for severe pain in acute MI
Morphine
Decrease left ventricular volume and stress via VENO>arterial dilation
Nitrates
Vitamin D toxicity
Hypercalcemia–> impaired depolarizatins of neuromuscular membranes (muscle weakness, constipation and mental status change) and impaired concentration of urine at distal tubule (polyuria, polydipsia). Dehydration
Note: hypercalciuria also seen
PTH-independent conversion of 25-hydroxyvitamin D to 1,25 dihydroxyvitamin D (calcitriol) by 1-alpha-hydroxylase (expressed in activated macrophages)
Seen in granulomatous diseases (sarcoidosis, tuberculosis)
-Increased intestinal absorption of calcium
Can also be seen in Hodgkin Disease and some non-Hodgkin lymphomas
Biliary obstruction alters lipid absorption and can lead to
FAT soluble vitamin deficiencies
Carcinoid Syndrome can have pallegra (niacin def.)
Tryptophan—> Serotonin (all shunts this way). Niacin hardly produced
Impaired incorportation of copper into ceruoplasmin and defective excretion of excess copper into bile (elevated free copper and deposition in the liver and other organs)
Wilsons Disease: ATPB7 gene Chromosome 13
Autosomal Recessive
TX: chelation w/ penicillamine or trientine, oral zinc
Mental status changes, muscle weakness, constipation, polyuria/polydipsia, and dehydration
Hypercalcemia presentation
Superficial branching nests of distended capillaries
telangiectasias
Ataxia-telangiectasia predisposes to…
Note: deficiency in both cell-mediated and humor dysfunction
Increased risk of hematologic malignancies
Hypersensitivity to X-ray radiation that causes multiple chromosomal breaks. ATM gene mutated responsible for DNA break repair. AR
Ataxia- Telangiectasia
Choreoathetoid movement and spasticity also seen in Lesch-Nyhan. Inheritance?
HGPRT nemonic
X-Recessive
Immunodeficiency resulting from a defect in expression of HLA-II antigens on surfaces of APCs. Note: MHC class II present foreign antigen to T cells to elicit a cell mediated AND humoral response (because T cells must first activate B cells to mature and undergo class switching)
Bare Lymphocyte syndrome
HSM, anemia, motor neuropathy–>hypotonia and areflexia, and cherry red spot on mucula
Niemann-Pick disease (AR)
Defect in sphingomyelinase–> shingomyelin accumulates within monocytic cells (early death in child hood)
Wide, fixed splitting of S2 that does not vary with respiration
ASD
ASD–>L-R shunt–>P.HTN via laminated medial hypertrophy–>Pulm vascular resistance > total SVR–> Eisenmenger syndrome ensues (due to pulmonary HTN). What will the pulmonary valve show over time?
Closure of ASD may be required to prevent IRREVERSIBLE pulmonary sclerosis and a permanent Eisenmenger syndrome
Pulmonary edema due to HTN emergency. Give Nitroglycerine, Nitroprusside. Used to improve acute heart failure by reducing
Afterload
Nitrates (NO) –> activate sGC–> Increased cGMP in endothelium decreases INTRACELLULAR CALCIUM–> decrease myosin light-chain kinase–> leading to myosin light chain dephosphorylation and _______
vascular smooth muscle relaxation
Check for association btw 2 CATEGORICAL (%) variables
Chi-square
Ex: determine if the distribution of gender and smoking status is random or if there is a difference between the sexes regarding smoking status.
Used to compare the difference between the means of 2 groups
t-test
Compares the difference between the means of 2 or more groups
ANOVA
Studies assessing the effects of aspirin on certain cardiovascular events may be inconclusive. However, analysis of data compiled from multiple clinical trials may reveal significant benefit.
Meta-analysis
“pooling data from several studies to perform an analysis having greater statistical power than individual studies themselves”
Model the linear relationship btw dependent variable and 2 or more independent variables.
Multiple linear regression
Ex: quantify the effects of alcohol use, tobacco smoking and charred food consumption on the incidence of gastric cancer.
measure of the strength and direction of a linear relationship btw 2 variables
Pearson correlation coefficient
Ex: Average blood glucose levels and HbA1c
Treatment for pufferfish tetrodotoxin (voltage Na sodium block)
Gut lavage and charcoal
Originate above the dentate line and are covered by columnar epithelium. Autonomic innervation from the inferior hyogastric plexus (sensitive to stretch not pain, temp, or touch)
Internal Hemorrhoids
External hemorrhoids (painful if thrombose) originate below the dentate line and are covered by _________ epithelium and have cutaneous (somatic) innervation from ________
1) modified squamous
2) Inferior rectal nerve (branch of pudendal nerve)
Supply the perineum and external genitalia in males and females are very sensitive to touch, temp, and pain
Branches of pudendal nerve
Derived from L1, carries sensation from:
- skin of the upper and medial part of the thigh
- root of the penis and upper part of the scrotum
- mons pubis and labia majora (females)
Ilioinguinal nerve
Inferior gluteal nerve? Branches? Innervation?
L5,S1-S2
Motor to gluteus maximus
sympathetic and parasympathetic components (innervates the internal pelvic viscera but not the external perirectal area
inferior hypogastric plexus
derived from S2,S3, and S4 and provide parasympathetic innervation to the pelvic and genital organs
pelvic splanchnic nerves
Continuation of hypogastric nerve with additional input from the pelvic and sacral splanchnic nerves. Gives rise to prostatic plexus (w/in fascia of prostate)
Inferior hypogastric plexus
________ and _______ ________ _______ arise from the prostatic plexus and pass beneath the pubic arch to innervate the corpa cavernosa of the penis and urethra
Greater and lesser cavernous nerves: carry post ganglionic parasympathetic fibers—> facilitate erection
Prostatectomy or injury to prostatic plexus can cause
ERECTILE dysfunction–> thus surgeons try to preserve integrity of prostatic fascial shell during surgery.
Detrusor muscles are controlled by what nerves? Overactivity can lead to what?
1) Parasympathetic fibers from pelvic splanchnic nerves and inferior hypogastric plexus.
2) Urge incontinence (women>men)
Innervation of external urethral and anal sphincters. Sensory to external genitalia.
Branches of pudendal nerve
Fecal incontinence, decreased penile sensation, or external urethral sphincter paralysis due to injury to what nerve?
Pudendal nerve
Cremasteric reflex
Genitofemoral nerve (L1-L2 spinal nerves origin) Loss of reflex is seen is testicular torsion or L1-L2 spinal injury
Tracheobronchitis
Mycoplasma pneumonia
Can lead to complement mediated, intravascular hemolytic anemia due to similarity between antigens in the cell membrane of ________ and the cell membrane of erythrocytes (I-antigen)
M. pneumoniae
Extrapulmonary manifestations of M.pneumoniae
SJS, joint pains, encephalitis, cardiac rhythm, bullos myringitis
Lack of cell wall facilitates resistance (stripped down genome that can not perfom metabolic function (peptidoglycan cell wall and synthesis of purines)
M. pneumoniae (no bacterial cell wall antigen; phospholipid bilayer cell membrane only)
Enzyme deficiencies that cause anemia
G6PD and pyruvate kinase
- AR
- RBCs most effected (no mito thus anaerobic respiration)
- Loss of ATP
- Membrane failure–> phagocytosis in spleen (extravascular hemolysis)
- New born with anemia and spleenomegaly (severe)
Pryuvite Kinase deficiency
Increases amino acid transport and ribosomal translation efficiency in muscle, adipose and liver tissue
Insulin
Lack of insulin induces catabolic state, and patients typically lose weight despite normal or increased appetite
New-onset DM1
Stimulates glucagon release
Increases release of glucose from the liver
Decreases peripheral uptake of glucose
Epinephrine
increases renal absorption of sodium, leading to increased blood volume and blood pressure
Insulin (glucose reuptake is INDEPENDENT OF INSULIN)
Most common congenital breast anomalies in women and men are
accessory nipples (polythelia, supernumerary nipple)
Cause of polythelia/supernumerary nipple (asymptomatic but may swell or become tender during menses, pregnancy, and lactation)
failure of involution of mammary ride
Hyperpigmentation, epidermal thickening, pilosebaceous structure of Montgomery areolar tubercles, smooth muscle bundles (areola) and possible mammy glands and multiple ducts
Accessory nipple histo (similar to normal nipple)
Clonal proliferation of benign melanocytes in utero. Can be raised are hyperpigmented
Congenital melanocytic nevi
Increased melanin production on sun-exposed areas
Ephelides (freckles)
Increased proliferation of melanocytes! Larger than freckles also flat) and are seen in adults
solar lentigines
Skin tags, benign, pedunculated outgrowths of normal skin. In locations of friction (below breast or axillae)
Acrochorda
Sudden onset of heart failure in 10% of people with severe aortic stenosis
Atrial fibrillation
decrease preload to LV (hypotension) and pulmonary edema (increase pulm. venous pressure
Scurvy in children is more severe than the normal easy bruising, periodontal disease, poor wound healing, and hyperkeratotic follicles
Children= hemorrhages, bony deformities, and subperiosteal and joint hematomas
Hydroxyproline and hydroxylysine are essential for cross-linking collagen molecules. Failure to hydroxylation is due to
prolyl and lysyl hydroxylases not having vitamin C to function as reducing agent. Results in decreased tensile strength of collagen
Hesselbach’s triangle (direct hernia goes through). Boarders?
Inferior: Inguinal ligament
Lateral: Inferior epigastric
Medial: Rectus abdominus muscle
Floor: Trasnversalis fascia (weakness can lead to protrusion of abdominal contents through triangle into inguinal canal)
Direct vs. indirect coverings
Indirect (thru deep inguinal ring): all three spermatic fascial layers)
Direct (superficial ring): external spermatic fascia only
Due to failure of processus vaginalis to obliterate and the internal inguinal ring to close.
Indirect inguinal hernias (most common type of hernia)
Protrude lateral to inferior epigastric artery
If pertechnetate or perchlorate are present, uptake of iodine isotypes will decrease due to competitive inhibiton
NIS (sodium-iodide symporter) located on basolateral membrane transports perchlorate, pertechnetate, and iodide into thyroid follicular cell
______ treatment can cause a transient worsening of hyperthyroidism (elerdly or severe disease) are started initially on anti-thionamides (propylthiouracil, methimazole)
Radioiodine
Hyperthyroidism–>Increased sympathetic activity
Beta-blockers can provide initially sympathetic relief and are often continued during radioactive iodine tx
Contains factors VIII, XIII, vWF, and fibrinogen (precipitate obtained from FFP by centrifugation/thawing)
Cryoprecipitate
Brodifacoum, a long-acting 4-hydroxycoumarin derivative
Rodenticides. Tx: FFP in addition to vitamin K (IM)
Distal tubule sodium sensor
macula densa
Beta-adrenergic antagonist inhibit _____ release via B1 receptors on Juxtaglomerular cells
Renin
Inhibits sacral micturition center
Cerebral cortex
Located in the pontine reticular formation. Coordinates relaxation of external urethral sphincter with bladder contraction during voiding
Pontine micturition center
Located at S2-S4 level and responsible for bladder contraction. Parasympathetic fibers travel from S2-S4 ventral white matter within pelvic nerves and stimulate cholinergic receptors in the bladder wall
Sacral micturition center
Normal pressure hydrocephalus–>decreased CSF absorption–>ventricular enlargment–> traction on cortical efferent and afferent fibers (corona radiata). Traction disrupts periventricular pathways that transmit impulses from the cortex to the sacral micturition center. Later in disease, lack of cerebral cortex inhibition to sacral micturition center leads to
Urge incontinence (uncontrolled and frequent micturition) Bladder fills with urine and empties reflexively when full. Patient has no control over bladder function or sensation. Voluntary relaxation of urethral sphincter remains intact
APML (M3 variant)
Risk for DIC
t(15;17)
PML gene on 15 and RARA on 17
Codes for abnormal retinoic acid receptor, which then inhibits myeloblast differentiation.
Smear of APML
Abnormal promyelocytes and aeur rodes
Anemia (fatigue, pallor), thrombocytopenia (petechiae, hemmorrhages) and neutropenia (fever, opportunistic infections, result from marrow replacement by leukemic cells
AML manifestations clincally
Defective PDGF receptor plays a role in pathogenesis of several cancers. Name one?
Ovarian
Two most common causes of SVC syndrome
Lung cancer> non-Hodgkin lymphoma
Dyspnea, distended neck veins, distal heart sounds and pulsus paradoxus (decrease in systolic pressure >10mmHg during inspiration)
Pericardial effusion
Arise at lung apex. Shoulder pain (brachial plexus). Horners syndrome (cervical sympathetic plexus).
VERY VERY rarely SVC syndrome
Superior sulcus tumors (Pancoast tumors)
most selective determinant of particle size penetrance (renal)
GBM and slit diaphragms (btw foot processes of epithelial cells)
Charge selectivity is provided by (renal)
Negatively charged anions (heparan sulfate and other proteoglycans).
Located on endothelial cells in GBM
*Reason for albumin leak in MCD (loss of molecules)
Tubular proteinuria: presence of low molecular weight proteins ( such as…..) that are normally filtered and reabsorbed in PCT. Appear in urine with PCT function in disrupted as in tubulointerstitial nephritis (P’s)
B2-microglobulin, immunoglobulin light chains (multiple myeloma), AAs, and retinol-binding protein
Functional proteinuria
Caused by change in blood flow through glomerulus
Excercise, high fever, stress, or cold exposure
Common in young adults with normal renal function. Disappears on repeated testing
Orthostatic Proteinuria
Older, tall, thin adolescents
increased protein excretion in upright position, but normal when supine/sleeping
Normal renal function (albuminuria less than 1g a day and normal at night )
Highly selective proteinuria: mostly low-molecular weight proteins such as albumin and transferrin excreted
MCD
Bloody diarrhea with or without abdominal pain is the hallmark of
Ulcerative colitis (in Crohn’s disease there may also be bloody diarrhea but abdominal pain is virtually always present
Complications of UC
Toxic megacolon (most dangerous) can lead to perforation. UC increases risk for adenocarcinoma of colon.
