Anatomy Flashcards
Order of neurovasculature in femoral triangle
vein, artery, nerve (medial to lateral)
location of cricothyroid membrane (for cricothyroidotomy if someone is choking)
superior to cricoid cartilage inferior to thyroid cartilage (vignettes 22)
paraesophageal hernia
Fundus protrudes into thoracic cavity. GEJ remains fixed below diagram unlike in sliding hiatal hernia.
Femoral nerve palsy: 1) common scenario 2) dysfunction
1) Pelvic fracture
2) weakness in right leg and lack of sensation in anterior area of thigh + weakness with extension of right knee + weak hip flexion
klumpke vs erb palsy
klumpke is an abduction injury; Erb palsy is an adduction injury
Jugular foramen (Vernet) syndrome
lesion to jugular foramen, thus CN 9, 10, 11 affected
Jugular foramen (Vernet) syndrome presentation
dysphagia + hoarseness + dysarthria + loss of gag reflex on ipsilateral side + deviation of uvula toward normal side + atrophy of sternocleidomastoid muscle and trapezius.
unhappy triad
ACL + MCL + medial meniscus
compartment syndrome presentation
Persistent leg pain + swollen, tense, and warm region + decreased anterior tibial pulse.
causes of compartment syndrome
crush injury + fracture + chronic vigorous exercise
FDS vs. FDP
- FDS wraps around PIP.
- FDP goes all the way to the end and flexes wrist + MCP + interphalangeal joints.
ACL location
lateral femoral condyle –> anterior tibia.
PCL location
medial femoral condyle –> posterior tibia.
Lachman test
Tests for ACL injury, at 30 degree angle
valgus/varus
lateral force/medial force
McMurray test
1) pain, “popping” on external rotation –> medial meniscal tear.
2) pain, “popping” on internal rotation –> lateral meniscal tear.
Baker cyst
Popliteal fluid collection in gastrocnemius-semimembranous bursa, commonly communicating with synovial space and related to chronic joint disease.
most common rotator cuff injury?
supraspinatus
test for supraspinatus tear?
“empty/full can” test.
infranspinatus innervation
suprascapular nerve
Most common pitching injury
infraspinatus
teres minor innervation
axillary
subscapularis innervation
upper and lower subscapular nerves
SITS muscle innervated by
C5-C6
bone palpated in anatomic snuff box
scaphoid
lunate dislocation
Can cause carpal tunnel syndrome
damage to hook of hamate
ulnar nerve injury (common with fall on outstretched hand).
axillary innervation
C5-C6
musculocutaneous innervation
C5-C7
loss of supination suggests…
musculocutaneous damage
decreased grip strength suggests
radial nerve injury (wrist extension necessary for maximal action of flexors)
Median innervation
C5-T1
supracondylar fracture of humerus damages
median
location of radial nerve deep branch
supinator canal, where it can be injured with repetitive pronation/supination (such as using a screwdriver).
ulnar innervation
C8-T1
radial deviation of wrist upon flexion indicates…
ulnar injury
Nerve responsible for abduction and adduction of fingers
Interossei muscle, innervated by ulnar.
recurrent branch of median nerve innervation
C5-T1
recurrent branch of median nerve 1) scenario 2) presentation
1) superficial laceration of palm
2) “ape hand”, loss of thenar muscle group: oppostion, abduction, and flexion of thumb. *no loss of sensation
medial antebrachial cutaneous nerve distribution
FA 442
Damage to posterior cord causes…
Wrist drop
erb palsy muscle deficit
deltoid, supraspinatus, infraspinatus, biceps brachii
klumpke palsy nerve damage
C8-T1
lumbricals function
Flex MCP joints, extend DIP and PIP joints.
klumpke palsy muscle deficit
intrinsic hand muscles; lumbricals, interossei, thenar, hypothenar
TOS functional deficit
atrophy of instrinsic hand muscles; ischemia, pain, and edema due to vascular compression.
pope’s blessing seen with
proximal median nerve injury
hand presentation for proximal ulnar nerve injury
“OK gesture” (digits 1-3 flexed)
dorsal vs. palmar interossei
Dorsal abduct fingers, palmars adduct (DAB PAD)
Obturator innervation
L2-L4
Pelvic surgery nerve at risk
obturator
femoral innervation
L2-L4
Nerve at risk with pelvic fracture
femoral
femoral injury presentation
decreased thigh flexion and leg extension
common peroneal roots
L4-S2
tibial roots
L4-S3
tarsal tunnel syndrome
distal lesion to tibial nerve
tibial nerve damage presentation
Inability to curl toes and loss of sensation on sole of foot.
tibial nerve proximal lesion
Foot everted at rest with loss of inversion and plantarflexion.
superior gluteal nerve roots
L4-S1
localizing trendelenburg
lesion is contralateral to side of hip that drops, ipsilateral to extremity on which patient stands
Inferior gluteal roots
L5-S2
nerve at risk with posterior hip dislocation
inferior gluteal
inferior gluteal lesion presentation
difficulty climbing stairs + rising from seated position + loss of hip extension
superior gluteal innervates..
gluteus medius, minimus + tensor fascia latae.
inferior gluteal nerve innervates…
gluteus maximus
sciatic nerve roots
L4-S3
sciatic path and innervation
innervates posterior thigh, splits into common peroneal and tibial nerves.
pudendal roots
S2-S4
Best location for IM gluteal injection
superolateral quadrant
Presentation of L3-L4 herniation
Weakness of knee extension, decreased patellar reflex.
Presentation of L4-L5 herniation
weakness of dorsiflexion, difficulty in heel-walking
Presentation of L5-S1 herniation
weakness of plantarflexion, difficulty in toe-walking + decreased achilles reflex
long thoracic nerve travels with…
lateral thoracic artery
axillary nerve travels with
posterior circumflex artery
radial nerve travels with
deep brachial artery
median nerve location
distal humerus/cubital fossa
median nerve travels with
brachial artery
tibial nerve travels with
popliteal artery
distal tibial nerve location
posterior to medial malleolus
tibial nerve travels with
posterior tibial artery
skeletal muscle triad
1 T-tubule + 2 terminal cisternae
cardiac muscle dyad
1 T-tubule + 1 terminal cisterna
release Ca effect in muscle cell physiology…
Binds to TROPONIN C, causing conformational change that moves tropomyosin out of the myosin-binding groove on actin filaments.
Muscle cell physiology
tropomysin complex mooves out of myosin-binding groove —> myosin releases bound ADP and Pi –> displacement of myosin on actin filament (power stroke) –> contraction results in shortening of H and I bands between Z lines but A band remains the same (A band Always same length).
Next step after contraction in muscle cell?
Binding of a new ATP molecule causes detachment of myosin head from actin filament. Hydrolysis of bound ATP –> ADP, myosin head adopts high-energy cocked position for the next contraction cycle.
Type 1 vs type II muscle fibers
codebook
NO synthase
activates L-arginine to nitric oxide
smooth muscle relaxation pathway
agonist binds to receptor –> calcium released –> calcium activates NO synthase –> NO diffuse through endothelial cell and into smooth muscle cell –> NO activates GTP to cGMP –> cGMP activates myosin-light-chain phosphatase (MLCP) –> MLCP dephosphorylates myosin II causing relaxation.
myosin-light-chain phosphatase (MLCP)
Enzyme that initiates smooth muscle cell relaxation
smooth muscle contraction pathway
Membrane depolarization –> Ca enters through L-type voltage gated channels –> forms calcium-calmodulin complex –> activates myosin-light-chain-kinase (MLCK) –> phosphorylates Myosin
endochondral ossification bones
codebook
defective process in achondrplasia
endochondral ossification
intramembranous ossification bones
codebook
endochondral ossification process
cartilaginous model –> woven bone –> lamellar bone
woven bone found in…
1) fractures
2) Paget disease
membranous ossification process
woven bone formed directly –> lamellar bone
origin of osteoblasts
differentiate from mesenchymal stem cells in periosteum
osteoclast mechanism
dissolves bone by secreting H+ and collagenases
osteoclast origin
Differentiates from a fusion of monocyte/macrophage lineage precursor.
PTH action
1) At low, intermittent levels, exerts anabolic effects (builds bone) through indirect mechanism.
2) chronic high PTH levels cause catabolic effects (osteitis fibrosa cystica)
osteitis fibrosa cystica
Presentation of primary hyperparathyroidism. Characteristic findings = subperiosteal erosions/thinning of phalanges + granular “salt-and-pepper” skull + osteolytic cysts in long bones.
estrogen mechanism in relation to bone.
Inhibits apoptosis in bone-forming osteoblasts and induces apoptosis in bone resorbing osteoclasts.
estrogen deficiency in relation to osteoporosis
Causes excess cycles of remodeling. Bone resoprtion leads to osteoporosis.
achondroplasia mechanism
Constitutive activation of fibroblast growth factor receptor (FGFR3) inhibits chondrocyte proliferation. So it’s actually a gain of function mutation.
achondroplasia genetics
> 85% occur sporadically; autosomal dominant with full penetrance (homozygosity is lethal).
trabeuclar bone
spongy bone
osteoporosis bone pathophys
There’s normal mineralization and lab values but trabecular and cortical bone lose mass and interconnections.
levothyroxine SE
osteoporosis
osteoporosis diagnosis
Bone mineral density scan (dual energy x-ray absorptiometry) with a T-score of less than or equal to -2.5 OR fragility fracture of hip or vertebra.
osteoporosis treatment
Bisphosphonates + teriparatide + SERMS + rarely calcitonin + denosumab.
Colles fracture
Fracture of distal radius; classic sign of osteoporosis.
Osteopetrosis
1) etiology
2) presentation
3) treatment
o Coded character: walls made out of sponges/persistence of the primary spongiosa in the medullary cavity with no mature trabeculae. Dead zombies lining perimeter + page is weaving + woven bones all along back wall/caused by defective osteoclastic bone resorption, which results in accumulation of woven bone and diffuse skeletal thickening. /autosomal recessive and dominant forms. Skeleton with really thick bones on couch + covered in casts/causes thickened and dense bones that are prone to fracture. Skeletons bones look like below + big Erlenmeyer flasks on table/ends of long bones are misshapen and bulbous (“Erlenmeyer flask deformity”). Casts all over skeleton/although bone turnover is decreased, tissue becomes weak and predisposed to fractures. /cranial foramen decrease in size, leading to CN palsies. Huge spleen to the left of the couch + huge hippo on couch/hepatosplenomegaly. He has a pan on top of his head/bone fills marrow space pancytopenia + extramedullary hematopoiesis. /mutations (eg carbonic anhydrase II) impair ability of osteoclast to generate acidic environment necessary for bone resorption. Big pile of bones on top with Jo-Jo sitting on top/treatment = bone marrow transplant (osteoclasts derived from monocytes).
osteoid
unmineralized, organic portion of bone matrix that forms prior to maturation (mineralization) of bone.
lab profile in osteomalacia/rickets
lab profile = low levels of vitamin D and phosphate + low or normal level of calcium + elevated alkaline phosphatase
“looser zones”
pseudofractures, found in osteomalacia.
lab profile in paget’s
normal Ca, phosphorus, PTH, + increased ALP.
fractures in paget’s
long bone chalk-stick fractures
stages of paget’s
lytic (osteoclasts) –> mixed (osteoclasts + osteoblasts) –> sclerotic (osteoblasts) –> queiescent (minimal osteoclast or blast activity)
causes of avascular necrosis
1) corticosteroids
2) alcoholism
3) sickle cell disease
4) trauma
5) the bends “caisson/decompression disease)
6) Legg-Calve-Perthes disease (idiopathic)
7) Gaucher disease
8) Slipped capital femoral epiphysis
Osteopetrosis lab values
everything normal except low/normal serum Calcium
Paget lab values
everything normal except increased ALP
“Brown tumors”
characteristic finding in osteitis fibrosa cystica due to fibrous replacement of bone, subperiosteal thinning.
Primary hyperparathyroidism lab values
calcium, ALP, PTH up, phosphate down
secondary hyperparathyroidism lab values
decreased serum calcium, increased phosphate, ALP, PTH
Hyperphosphatemia in secondary hyperparathyroidism pathophys
pathophys = phosphate clearance declines due to fall in GFR increased phosphate binds free serum Ca2+, further exacerbating hypocalcemia.
lab profile in osteomalacia/ricktes
low serum ca + phosphate, high ALP, high PTH
Causes of hypervitaminosis D
1) Oversupplementation
2) Granulomatous disease (eg sarcoidosis)
lab profile in hypervitaminosis D
High serum calcium and phosphate, normal ALP, high PTH.
osteochondroma epidemiology
Most common benign bone tumor. Males
osteochondroma characteristics
Bony exostosis with cartilaginous (chondroid cap). rarely transforms to chondrosarcoma.
Giant cell tumor epidemiology, location, other name
20-40 years old, epiphyseal end of long bones, often around knee, “osteoclastoma.” Locally aggressive benign tumor.
osteosarcoma –> epidemiology, RF’s, location, management, characteristic findings
o Code: Evan Olmstead/Bimodal distribution: Peak incidence between 13 and 16, greater than 65 years old. Evil Dr. Hink in suit along wall + evil page/Rb + SIS oncogenes. Taryn with parrot on her shoulders slacklining above/teriparatide is a risk factor. Big devil behind Evan/malignant mesenchymal neoplasm of bone origin (osteoblasts). Aggressive. /second peak of incidence occurs in older adults + is associated with Paget + bone infarcts + ionizing radiation. Masses on his knees + femor/usually arise around knee + distal femur or proximal tibia. Bone stuck in ground with arrow through metaphyseal region/metaphyseal region. Tumors on shoulder + jaw/may also arise in shoulder + proximal femur + jaw. Evil anna petroveks attacking him/histology = anaplastic cells forming osteoid matrix. Below pattern as wallpaper/x-ray = “sunburst” pattern. Codman’s triangle in front of door/Codman’s triangle. /Other predisposing factor = bone infarcts. Surgeon cutting out evan’s back + he’s in a chemo chair/Treat with surgical en bloc resection (with limb salvage) + chemotherapy.
Fusion protein in Ewing’s
EWS-FLI i
Giant cell tumor location
Epiphysis
osteoarthritis presentation/symmetry
- asymmetric
- knee cartilage loss begins medially (“bowlegged”)
synovial fluid in osteoarthritis
non-inflammatory (WBC
joints involved in osteoarthritis
DIP, PIP, 1st CMC, NOT MCP.
osteoarthritis treatment
acetaminophen + NSAIDs + intra-articular glucocorticoids
pannus
proliferative granulation tissue seen in RA
RA RF’s
smoking + silica exposure + female + HLA-DR4
DMARDS
methotrexate, sulfasalazine, hydroxychloroquine, leflunomide
Joint findings in RA
Bone and cartilage erosions + juxtaarticular osteopenia + joint space narrowing + soft tissue swelling + subchondral cysts + pannus formation + increased synovial fluid.
synovial fluid in RA
inflammatory (WBC>2000)
fibrinoid necrosis
necrosis arising from immune complex deposition.
fibrinoid necrosis occurs in..
polyarteritis nodosa, malignant hypertension, preeclampsia, hyperacute transplant rejection
rheumatoid nodule histology description
fibrinoid necrosis with palisading histiocytes. Occurs in subcutaneous tissue.
extraarticular manifestations of RA
ILD, pleuritis, pericarditis, anemia of chronic disease, neutropenia, splenomegaly, amyloidosis, Sjogren’s, scleritis, carpal tunnel syndrome.
Felty syndrome
splenomegaly + RA
Joint findings in OA
thickened capsule + slight synovial hypertrophy + osteophytes + ulcerated cartilage + sclerotic bone + joint space narrowing + subchondral bone cyst
RA deformities
Deformities include subluxation, fingers with ulnar deviation, swan neck, boutonniere’s.
what mediates degradation and inadequate repair in OA?
chondrocytes
Gouty nephropathy pathophys
Urate crystals are deposited in the renal medullary interstitium where they can form intratubular precipitates, inflammatory tophi, or uric acid renal stones. Tubular obstruction leads to cortical atrophy and scarring, so 20% of people with chronic gout eventually die of renal failure
Hyperuricemia in gout epidemiology and pathophys
1) 90% caused by underexcretion of uric acid–largely idiopathic; can be exacerbated by meds.
2) overproduction of uric acid (10% of patients)–Lesch-Nyhan, PRPP excess, increased cell turnover (tumor lysis syndrome), von Gierke’s.
Tophi, etiology and location
Gout –> Accumulation of crystals in soft tissues), most commonly on external ears. Also olecranon bursa + achilles tendon.
What precipitates gout?
Alcohol consumption or large meal.
alcohol and gout pathophys
alcohol metabolites compete for same excretion sites in kidney as uric acid leading to decreased uric acid secretion.
Other name for pseudogout
calcium pyrophosphate deposition disease.
pseudogout associations
1) hemochromatosis
2) hyperparathyroidism
3) joint trauma
most commonly affected joint in calcium pyrophosphate deposition
knee
x-ray findings for calcium pyrophosphate deposition disease
chondrocalcinosis (cartilage calcification)
prophylaxis for calcium pyrophosphate deposition
colchicine
calcium pyrophosphate deposition acute treatment
same as gout: NSAIDs, colchicine, GC’s
keratomalacia
eye disorder resulting from vitamin A deficiency
eye finding in sjogren’s
keratoconjunctivitis sicca (decreased tear production and subsequent corneal damage)
xerostomia
decreased saliva production
sjogren’s can be secondary to…
RA, SLE, systemic sclerosis
MALT presentation
parotid enlargement, can be complication of sjogren’s
common causes of septic arthritis
S. aureus + streptococcus + neisseria gonorrhea
synovial fluid in septic arthritis
purulent (WBC>50,000/mm3)
gonococcal arthritis
STI presenting either as purulent arthritis or triad of polyarthralgias + tenosynotivis (eg, hand) + dermatitis
commonalities among seronegative spondylarthritis
inflammatory back pain (morning stiffness improving with exercise) + periphral arthritis + enthesitis + dactylitis + uveitis
enthesitis
Inflamed insertion sites of tendons (eg achilles)
reactive arthritis post…
shigella + salmonella + yersinia + campylobacter + chlamydia
anti-smith antibodies
antibodies to spliceosomal snRNPs
lupus antibodies
anti-nuclear antibody (ANA) + anti-DNA antibodies + anti-phospholipid + **anti-smith (anti-SM) antibodies (specific) + anticardiolipin
lupus HLA associations
DR2 and DR3
libman sacks vegetation locations
usually on mitral or aortic valves
lupus nephritis
glomerular deposition of anti-DNA immune complexes
Most common and severe type of lupus nephritis
Diffuse proliferative
other finding in lupus I don’t often think of…
serositis (inflammation of serous tissue)
Antinuclear antibodies in lupus sensitivity/specifity
sensitive, not specific
Anti-dsDNA antibodies in lupus sensitivity/specifity
specific, poor prognosis (renal disease)
Anti-Smith antibodies in lupus sensitivity/specifity
Specific, not prognostic (directed against snRNPs)
Antihistone antibodies in lupus sensitivity/specifity
sensitive for drug-indcued lupus (eg, hydralazine, procainamide).
complement deficiency in lupus
C3, C4, CH50
lupus treatment
NSAIDS, steroids, immunosuppressants, hydroxychloroquine
Lab findings in APA syndrome
lupus anticoagulant + anticardiolipin + antiB2 glycoprotein antibodies
treatment for APA syndrome
systemic anticoagulation
false positives on VDRL
viral infection (mono, hepatitis) + drugs (chlorpromazine; procainamide) + rheumatic fever + lupus + leprosy + anticardiolipin antibodies (APA syndrome).
speckled ANA
anti-U1 RNP antibodies
hypercalcemia in sarcoidosis pathophys
expression of 1-alpha-hydroxylase by activated macrophages.
fibrosis affect on lung function
INCREASED elasticity + decreased compliance
sarcoidosis on ECG
shortened QT interval (hypercalcemic)
sarcoidosis pathophys
pathophys = interactions between macrophages and Th1 CD4+ cells via MHC class II result in production of cytokines that favor the production of granulomas. Th1 cells secrete IL-2 + interferon-gamma (IFN-gamma).
lavage fluid findings in sarcoidosis
elevated ACE + elevated CD4/CD8 ratio.
common presentation of sarcoidosis
asymptomatic except for enlarged lymph nodes. No need to treat if not symptomatic!
lupus pernio
skin lesions of face resembling lupus (characteristic of sarcoidosis)
granulomas in sarcoidosis
epithelioid granulomas containing microscopic schaumann and asteroid bodies
lab findings in polymyalgia rheumatica
elevated ESR + elevated CRP + normal CK
fibromyalgia treatment
gradual, incremental aerobic exercise. Antidepressants (TCA’s + SNRI’s) + anticonvulsants in more severe cases.
proposed mechanism for fibromyalgia
abnormal central processing of painful stimuli
Lab findings in polymyositis/dermatomysitis
Increased CK + positive ANA + positive anti-Jo-1 + positive anti-SRP + anti-MI-2 antibodies
treatment for polymyositis/dermatomysitis
steroids followed by long-term immunosuppressant therapy (methotrexate)
most common site of involvement of polymyositis
shoulders
other findings in dermatomyositis
malar rash (like SLE) + gottron papules + heliotrope (erythematous periorbital rash) + shawl and face rash + mechanic’s hands.
Inflammatory differences between poly and dermatomyositis
polymyositis –> endomysial inflammation w/ CD8+ T cells.
Dermatomyositis –> perimysial inflammation and atrophy with CD4+ T cells.
potential sequela of dermatomyositis
risk of occult malignancy
MG diagnosis
edrophonium
MG treatment
pyridostigmine
which improves and which worsens with muscle use
MG worsens with muscle use, LEMS improves.
Frequency of MG vs LEMS
MG common, LEMS rare.
LEMs etiology
autoantibodies to presynaptic Ca2+ channel, leads to decrease ACh release.
Treatment for LEMS
can’t do much, not in FA at least
LEMS presentation
proximal muscle weakness + autonomic symptoms (dry mouth, impotence)
suspicious mass at site of previous trauma suggests…
myositis ossificans
scleroderma (systemic sclerosis)
Triad of autoimmunity + noninflammatory vasculopathy + collagen deposition with fibrosis. Includes both diffuse scleroderma and limited scleroderma.
Limited scleroderma
Limited skin involvement confined to fingers and face. This is the type that occurs with CREST syndrome
derm findings in scleroderma
puffy, taut skin WITHOUT wrinkles + fingertip pitting.
scleroderma epidemiology
75% female
CREST acronym
calcinosis, Raynauds, esophageal dysmotility, sclerodactyly, telangiectasia
Color transition in raynaud’s
white (ischemia) –> blue (hypoxia) –> red (reperfusion)
Raynaud’s pathophys
decreased blood flow to skin due to arteriolar vasospasm in response to cold or stress.
Raynaud disease vs. raynaud syndrome
disease = primary (idiopathic) syndrome = secondary
digital ulceration
critical ischemia seen in secondary raynaud’s (raynaud syndrome)
Other names for subcutaneous fat
hypodermis, subcutis
Epidermis layers from surface to base
Corneum –> Lucidum –> Granulosum –> spinosum –> basale (californians like girls in string bikinis)
where is keratin found?
stratum corneum (uppermost layer)
where are desmosomes found?
stratum spinosum
stem cell site
stratum basale
zonula occludens
area of tight junction
composition of tight junctions
claudins + occludins
function of tight junctions
prevent paracellular movement of solutes
adherens junction
1) location
2) function
1) below tight junction
2) forms belt connecting actin cytoskeletons of adjacent cells with cadherins
CADherins
Ca2+-dependent adhesion proteins.
clinical significance of loss of E-cadherin expression
promotes metastasis
zonula adherens
adherens junction
macula adherens
desmosome
desmosome
1) function
2) protein composition
1) structural support via intermediate filament interactions.
2) cytokeratin + desmoplakin
gap junction
composed of channel proteins called connexons that permit electrical and chemical communication between cells
hemidesome function
connects keratin in basal cells to underlying basement membrane
Integrins
Membrane proteins that maintain integrity of basolateral membrane by binding to collagen and laminin in basement membrane.
macule
flat lesion with well-circumscribed change in skin color
patch
macule > 1 cm (eg congenital nevus/birthmark)
papule
elevated solid skin lesion
plaque
papule > 1 cm (psoriasis)
vesicle
small fluid-containing blister
bulla
large fluid-containing blister >1 cm (bullous pemphigoid)
pustule
vesicle containing pus (pustular psoriasis)
wheal
transient smooth papule or plaque (Hives)
scale
flaking off of stratum corneum (eczema, psoriasis, SCC)
crust
dry exudate (impetigo)
psoriasis can be pustular
ok
hyperkeratosis
1) characteristics
2) examples
1) increased thickness of stratum corneum
2) psoriasis, calluses
parakeratosis
1) characteristics
2) examples
1) hyperkeratosis with retention of nuclei in stratum corneum
2) psoriasis
Hypergranulosis
1) characteristics
2) examples
1) increased thickness of stratum granulosum
2) lichen planus
spongiosis
1) characteristics
2) examples
1) epidermal accumulation of edematous fluid in intercellular spaces
2) eczematous dermatitis
acantholysis
1) characteristics
2) examples
1) separation of epidermal cells
2) pemphigus vulgaris
acanthosis
1) characteristics
2) examples
1) epidermal hyperplasia (increased thickness of spinosum)
2) acanthosis nigricans
albinism etiology
normal melanocyte number, decreased melanin production
chloasma
melasma
vitiligo etiology
autoimmune destruction of melanocytes. Complete absence of melanocytes.
acne description
pilosebaceous follicles with increased sebum, eratin.
acne treatment
retinoids + benzoyl peroxide + antibiotics
location of atopic dermatitis
flexural surface
lab findings in atopic dermatitis
increased IgE
presentation of atopic dermatitis in infancy
appears on face and then antecubital fossa
common triggers of ACD
nickel, poison ivy, neomycin
medical term for common mole
melanocytic nevus
difference between intradermal nevi and junctional nevi
intradermal = papular junctional = flat
derm findings in psoriasis
1) acanthosis with parakeratotic scaling (nuclei still in stratum corneum)
2) Munro microabscesses
3) increased stratum spinosum
4) decreased stratum graunlosum
5) Auspitz sign – pinpoint bleeding spots from exposure of dermal papillae when scales are scraped off.
6) can be associated with nail pitting
rhinophyma ssociated with..
phymatous rosacea
rosacea description
erythematous papules and pustules
horn cysts
keratin-filled cysts, found in seborrheic keratosis
leser-trelat associated with
GI + lymphoid malignancy
characteristics of verrucae
epidermal hyperplasia + hyperkeratosis + koilocytosis
condylomata acuminata
verrucae on genitals
feature differentiating bacillary angiomatosis from kaposi’s
neutrophilic infiltrate in bacillary
glomus tumor
Mom: big globe hanging from ceiling above her/glomus tumor. she has super long nails and a red-blue tumor under them/benign, painful, red-blue tumor under fingernails. Globe is a thermostat + wrapped in smooth muscle/arises from modified smooth muscle cells of the thermoregulatory glomus body.
infiltrate in kaposi sarcoma
lymphocytic
pyogenic granuloma
Big hole in ground with a massive pie in it/pyogenic granuloma. Page’s finger looks like below/polypoid capillary hemangioma that can ulcerate and bleed. Page on the couch, pregnant + being hit by Toby with a bat/associated with trauma + pregnancy.
pyogenic granuloma description
polypoid lobulated capillary hemangioma.
kaposi’s
Neoplastic growth associated with HIV. Can also be caused by HHV-8.
strawberry hemangioma epidemiology
1/200
strawberry hemangioma timeline
Initial rapid growth then regress spontaneously by 5-8 yo
cystic hygroma
cavernous lymphangioma
bullous impetigo causative organism
s aureus
erysipelas
1) area of location
2) organism
3) presentation
1) upper dermis and superficial lymphatics
2) s pyogenes
3) well-defined demarcation between infected and normal skin
cellulitis causative organisms
s pyogenes + s aureus
cellulitis area of involvement
deeper dermis + subcutaneous tissues
staphylococcal scalded skin syndrome pathophys
exotoxin destroys keratinocyte attachments in stratum granulosm only (vs. toxic epidermal necrolysis, which destroys epidermal-dermal junction).
staphylococcal scalded skin syndrome
1) presentation
2) prognosis
3) epidemiology
1) fever + generalized erythematous rash with sloughing of upper layers of epidermis.
2) heals completely
3) newborns and childrens + adults with renal insufficiency
hairy leukoplakia vs. leukoplakia
leukoplakia is cancerous.
zinc derm presentation
acrodermatitis enteropathica
acanthosis nigricans etiology
epidermal hyperplasia causing symmetric hyperpigmentation
acanthosis nigricans associations
diabetes, obesity, Cushing syndrome, gastric adenocarcinoma
erythema nodosum
painful inflammatory lesions of subcutaneous fat, usually on shins
erythema nodosum associations
sarcoidosis, coccidioidomycosis, histoplasmosis, TB, streptococcal infections, leprosy, IBD
wickham striae
reticular white lines. manifestation of lichen planus
underlying condition in lichen planus
sawtooth infiltrate of lymphocytes at dermal epidermal junction
lichen planus association
hep c
pityriasis rosea prognosis
self resolves in about 6 weeks
UVA
tanning and photoaging
UVB
sunburn
sunburn pathophys
causes DNA mutations, inducing apoptosis of keratinocytes
BCC characteristic behavior
locally invasive, but rarely metastasizes.
BCC presentations
1) pink, pearly nodules with telangiectasias, rolled borders, central ulcerations or cursting
2) nonhealing ulcers with infiltrating growth
3) scaling plaque
SCC RF’s
aresnic, immunosuppression, sunlight
SCC locations
face, lower lip, ears, hands
SCC characteristic behavior
locally invasive, may spread to lymph nodes. Rarely metastasize.
SCC presentation
ulcerative red lesions with frequent scale.
SCC presentation
chronic draining sinuses.
keratoacanthoma
variant of SCC that grows rapidly (4-6 weeks) and may regress spontaneously over months.
diameter cutoff for melanoma
6 mm
different types of melanoma
1) Superficial spreading
2) nodular
3) lentigo maligna
4) acral lentiginous
melanoma treatment
resection with appropriately wide margins
vemurafenib used in..
metastatic or unresectable melanoma in patients with BRAF V600E mutation
LTB4, leukotriene B4
neutrophil chemotactic agent
PGI2
Platelet-gathering Inhibitor. Inhibits platelet aggregation and promotes vasodilation
acetaminophen MOA
reversibly inhibits cyclooxygenase, mostly in CNS, inactivated peripherally
aspirins effect on coagulation
increased bleeding time. Effect lasts until new platelets are produced.
aspirin clinical use
low dose (less than 300 mg/day): decreases platelet aggregation. Intermediate dose (300-2400 mg/day): antipyretic and analgesic High dose (2400-4000 mg/day): anti-inflammatory.
aspirin AE’s
gastric ulceration + tinnitus. chronic use can lead to ARF, interstitial nephritis, GI bleeding.
good things about celecoxib
spares gastric mucosa + spares platelet function (TXA2 production depends on Cox-1
meloxicam
NSAID
piroxicam
NSAID
NSAID clinical use
antipyretic, analgesic, anti-inflammatory
NSAIDs AEs
interstitial nephritis + gastric ulcer + renal ischemia
leflunomide MOA
reversibly inhibits dihydroorotate dehydrogenase, preventing pyrimidine synthesis. Suppresses T-cell proliferation
leflunomide AE’s
diarrhea + HTN + hepatotoxic + teratogenicity
bisphosphonates MOA
pyrophosphate analogs, bind hydroxyapatite in bone, inhibiting osteoclast activity
bisphosphonates clinical use
osteoporosis, hypercalcemia, paget’s, metastatic bone disease, OI
bisphosphonates AE’s
esophagitis + osteonecrosis of jaw + atypical stress fractures
guidelines for oral bisphosphonates
take with water + remain upright for 30 minutes
teriparatide MOA
recombinant PTH analog that increases osteoblastic activity
teriparatide route
given subcutaneously daily
teriparatide clinical use
osteoporosis, unlike antiresorptive therapies, it causes increased bone growth.
allopurinol MOA
competitive inhibitor of xanthine oxidase, decreases covnersion of hypoxanthine and xanthine to urate. Increases concentrations of azathioprine and 6-MP (both normally metabolized by xanthine oxidase).
pegloticase MOA
recombinant uricase that catalyzes metabolism of uric acid to allantoin (more water-solube product)
probenecid MOA
inhibits reabsorption of uric acid in PCT.
probenecid caveats
1) Inhibits secretion of penicillin.
2) can precipitate uric acid calculi
NSAIDs to give for gout and caveat
naproxen + indomethacin. Don’t give salicylates.
gout prophylaxis
colchicine
colchicine MOA
binds and stabilizes tubulin to inhibit microtubule polymerization, impairing neutrohil chemotaxis and degranulation.
Problem with TNF-alpha inhibitors and pathophys
Predispose to infection, including reactivation of latent TB, since TNF is important in granuloma formation and stabilization.
etanercept mechanism
fusion protein (receptor for TNF-alpha + IgG1 Fc) produced by recombinant DNA. Decoy receptor.
etanercept clinical uses
RA, psoriasis, ankylosing spondylitis
adalimumab
anti-TNF-alpha monoclonal antibody
infliximab, adalimumab clinical uses
IBD, RA, ankylosing spondylitis, psoriasis
rasburicase MOA
recombinant uricase that catalyzes metabolism of uric acid to allantoin.
Xanthine oxidase
catalyze hypoxanthine to xanthine, and then xanthine to plasma uric acid
Purine metabolism pathway
purine –> hypoxanthine –> xanthine –> plasma uric acid
drainage area of superficial lymph nodes
tumors of penis + skin of vagina + anal canal BELOW the dentate line drain to the superficial inguinal lymph nodes. /superficial inguinal lymph nodes also drain the lower extremity + gluteal region + skin below the umbilicus.
lymphatic drainage of legs
• /generally follows the course of the superficial veins (see below). /most venous drainage is to great saphenous vein. Accompanying lymphatics drain into the superficial group of the inguinal lymph nodes. Paint the lateral foot and back of leg green/however, skin drained by small saphenous vein, including lateral aspect of dorsum of foot is an exception to this rule. Lymphatic fluid from this area drains into lymphatics accompanying the small saphenous vein, then drains into lymph nodes behind the knee in the popliteal fossa.
pouch of douglas
rectouterin pouch
leg compartments
Lateral – superficial peroneal nerve
Anterior – anterior tibial
Deep posterior – Posterior tibial nerve + posterior tibial artery
Jaw muscle anatomy
lateral pterygoid function = pulls mandible forward in the process of opening the jaw against resistance + protracts mandible + pulls mandible side to side. /unilateral action of the lateral pterygoid results in deviation of the mandible to the opposite side. /all other jaw muscles (masseter + medial pterygoid + temporalis) act to CLOSE THE JAW.
gastrocolic ligament and what it contains
portion of the greater omentum between the greater curvature of the stomach and the transverse colon. Contains the gastroepiploic vessels.
gastrohepatic ligament and what it contains
portion of the lesser omentum between the liver and lesser curvature of the stomach. Contains the right and left gastric vessels.
splenorenal ligament and what it contains
mesentery that connects the spleen to the posterior abdominal wall. Contains the splenic artery and splenic vein + tail of the pancreas.
Salivary gland anatomy
sublingual gland full of mucous/as you move from the midline laterally, acini in sublingual gland are almost pure mucous cells serous blacks cut in half/acini in submandibular gland contain a mixture of serous and mucous cells. Serous blacks in all acini of parotid gland/acini in parotid gland are mostly pure serous cells.
Sensory supply of ear
Massive ear on back wall of anatomy lab. /vestibulocochlear = hearing and motion sense. Small oxe nailed to top of auricle/lesser occipital = upper part of the auricle. Giant orating at base/greater auricular = lower part of the auricle. Ears stuck to clocks on anterior half of canal/auriculotemporal = anterior half of external ear canal. Vagus signs lighting up posterior half of canal/auricular branch of vagus nerve = posterior half of the external ear canal.
esophageal histology
Indians in chains lining esophagus/nonkeratinized stratified squamous epithelium. /striated muscle in upper 1/3, smooth muscle in bottom 2/3.
Epithelia of rectum
columns above dentate line/mucosa above dentate (pectinate) line = simple columnar epithelium. Indians covered in poop below dentate line/below dentate line = squamous.
Epithelia of respiratory tract
o nose and nasopharynx lined with columns/nose, paranasal sinuses, nasopharnyx, most of larynx, and tracheobronchial tree = pseudostratified columnar, mucus-secreting. Oropharynx and below lined with Indians + Indians in chains singing and standing around vocal folds + lining anterior and posterior epiglottis/oropharynx + laryngopharynx + anterior epiglottis + upper half of posterior epiglottis + vocal folds (true vocal cords) = stratified squamous epithelium. This is to protect it from abrasive swallowing of food. /So it’s pretty much all pseudostratifeid columnar except oropharynx/laryngopharynx area. Imagine alveoli and respiratory bronchioles lined with cubes/past the terminal bronchioles, in respiratory bronchioles and alveolar duct, epithelia transitions to cuboidal cells. Imagine Indians lining alveolar sacs/alveoli = simple squamous.
Epithelia of the female reproductive tract
imagine ovary lined with cubes/ovary = simple cuboidal (rapidly proliferate to repair ovulatory surface defects). Imagine fallopian tube lined with columns/fallopian tube = simple columnar. Imagine uterus lined with columns/uterus = simple columnar. ectocervix lined with a circle of native americans + circle of columns behind them/cervix = ectocervix = stratified, squamous non-keratinized, endocervix = simple columnar. Indians in chains lining vagina/vagina = stratified squamous non-keratinized. Imagine Hannah Mcdermotts in transformation zone/transformation zone = squamocolumnar junction (most common area for cervical cancer)
recurrent laryngeal supplies…
recurrent laryngeal nerves are branches of the vagus (X) and supply all intrinsic muscles of the larynx except the cricothyroid. /damage (such as in thyroid surgery) can cause hoarseness.
Musculocutaneous
jacked due from brachial plexus memory palace: he has super biceps + his lateral forearms are on fire/innervates major forearm flexors (biceps, brachialis) and coracobrachialis + provides sensory innervation to the lateral forearm. He’s a baseball player/often injured by trauma or strenuous upper extremity exercise (baseball).
Distal location of median nerve
before the median nerve enters the carpal tunnel, it lies between the tendons of the palmaris longus + flexor carpi radialis. Local anesthetic may be injected at this point to achieve anesthesia in the cutaneous region supplied by the median nerve.
phrenic nerve innervation and damage
panicky method with a ham bone + it’s hailing/arises from C3-C5 segments of the spinal cord and innervates the Ipsilateral hemidiaphragm. He has wings on + is hiccupping intensely/damage causes hiccups + diaphragmatic paralysis with dyspnea + referred pain to the shoulder. /affected hemidiaphragm will be elevated on CXR.
recurrent laryngeal location
left recurrent laryngeal arises from the vagus as the vagus crosses in front of the arch of the aorta. /right recurrent laryngeal nerve arises from right vagus nerve as it crosses anterior to the right subclavian artery.
Layers of anterior abdominal wall
1) skin. Bunch of people camping in front with fat everywhere/2) superficial fascia of Camper (fatty layer). Climbers climbing up tunnel after them/3) superficial fasca of Scarpa (membranous layer). External oblique muscle (angled up and down)/4) external oblique muscle/aponeurosis. Internal oblique muscle (angle up and down but opposite to external)/5) internal oblique muscle/aponeurosis. Tranny stretched out across tunnel with a jacked 6 pack (it’s transverse/horizontal stretching out across tunnel)/6) transversus abdominis muscle/aponeurosis. Then a thick layer of fascia/7) fascia transversalis. Then a thick layer of fat/8) extraperitoneal fatty tissue. Into the north/9) peritoneum.
Temporomandibular disorder (TMD):
o /arises from problems involving the temporomandibular joint, the muscles of mastication, and the nerves that supply the jaw. He has a trident stuck into his jaw/affected nerve = mandibular division of the trigeminal nerve. Wearing headphones + axe in his jaw + screw through his head/presentation = otologic symptoms (ear discomfort) + jaw pain + unilateral facial pain worsening with jaw movement + headache.
Vagus nerve respiratory action
main efferent action is bronchoconstriction and increased bronchial mucus secretion.
Cranial nerves and locations of exit through the skull.
o big hole in ceiling and gram taking a duce through it + playing crocae + Dr. Soohoo peaking his head over + huge eye with motor dangling from it/oculomotor (CN III) + ophthalmic nerve (CNV1) + trochlear (CN IV) + abducens (CN VI) enter the orbit via the superior orbital fissure. Blue blood vessel attached to hanging eye/superior ophthalmic vein also passes through the superior orbital fissure to enter the orbit. Really fat Max in far right corner/foramen rotundum transmits the maxillary division of the trigeminal nerve (CN V2). Big oval hole in back wall with mandible hanging in it and trident stuck into it/foramen ovale transmits mandibular branch of the trigeminal nerve (V3). Huge nose stuck on wall to right with plate through it midway/CN 1 olfactory bundles traverse cribriform plate. /foramen spinosum = middle meningeal artery + vein. Huge jacked magnus bench pressing in middle covered in shiny accessories/foramen magnum = spinal roots of CN XI (enter brain through foramen magnum) + brain stem + vertebral arteries. Big jug of milk in far left corner + vegas sign above it + Kelsey fitzgibbons sucking dick + milk jug covered in shiny accessories/jugular foramen = CN IX + X + XI (leaves through jugular foramen) + jugular vein. Ears on face with chunks meat stuck to them/internal auditory meatus = CN VII + VIII.
eye muscles + innervation
/remember that oculomotor also innervates skeletal muscle found in the levator palpebrae superioris.
/from the abducted position, the superior rectus is the only muscle that can elevate the eye.
/inferior oblique is only muscle that can elevate the eye in the adducted position.
location of IVC
L4/L5
Lungs anatomic location
Picture nasty hair filling horizontal fissure/Horizontal fissure of right lung lies at the level of the 4th rib. Ivy on midaxial/lower border at midaxillary line located at rib 8. Hash block stuck into bottom/lower border along midclavicular located at rib 6. Tie hanging off backside at paravertebral line/lower border at 10th rib on paravertebral line.
functions that occur in the cytoplasm
Big pool in entryway: machine spitting out bacon + cholesterol eggs + steak/glycolysis + fatty acid synthesis + protein synthesis (RER) + steroid synthesis (SER) + cholesterol synthesis.
Vesicular trafficking proteins
COP with a sombrero forcing traffic backwards/COPI: Golgi golgi (retrograde) + cis-golgi ER. Cop in chicken suit forcing traffic forward/COPII: ER cis-Golgi (anterograde). Kate throws steak intos into the lysosome hottub + circle of trannies around her/Clathrin: trans-Golgi lysosomes.
cerebellar anatomy and lesions
/neocerebellum/cerebrocerebellum rests is responsible for fine movements of the hand and face. Lesions would cause dysdiadochokinesis (impairment in rapidly alternating hand movements) and intention tremor. /acute lesion to the cerebellar vermis causes truncal + gait ataxia. Put horns on flocculonodular lobe/involvement of the flocculonodular lobe causes vertigo/nystagmus due to dysregulation of the vestibular nuclear complex.
sertoli cell functions
White guys from star wars shooting up a fish/produce Inhibin B, which downregualtes FSH synthesis and inhibits FSH secretion. they’re shooting up a uterus hanging from the ceiling/secrete Mullerian inhibiting factor. They’re covered in roses/testosterone is aromatized in sertoli cells to produce estrogen. /secrete androgen binding protein. /nurture developing sperm.
2 cell hypothesis
/theca cells are stimulated by LH to secrete androgens androstenedione and testosterone these diffuse into the granulosa cells where they are aromatized to estrogens. This conversion is stimulated by FSH action on granulosa cells.
granulosa cell functions
pile of grains on either side of entrance to Ben’s house/female equivalent of sertoli cells. Anna covered in floors on top/produce estrogen. /FSH stimulates aromatase in granulosa cells to synthesize estrogen. Big egg on top of the area with chicken bursting out/as the follicle approaches ovulation, LH receptors begin to be expressed by granulosa cells. Response of granulosa cells to LH, which favors progesterone production is required for maturation of the dominant follicle, ovulation, and then luteinization.
estrogen types
o Estradiol: huge pile of grains by window/synthesized by granulosa cells. Arnold Schwarzenegger standing in middle of the room/precursor = testosterone. o Estrone (aka estradione): tons of really fat people walking around and big stones everywhere/synthesized by adipocytes. Andrew black standing in middle/precursor = androstenedione. Old granny at counter/only estrogen still detectable in menopausal women since it’s synthesized in peripheral adipocytes. o Estriol (E3): huge placenta on floor/synthesized by placenta. Tosh.0 dressed as a military commander screaming and yelling at the class/precursor = 16-alpha-OH-DHEAS.
androgen synthesis in females
o Picture the follicle and then islands of flowers within huge granular mounds of sands/LH stimulates the theca interna cells of the ovarian follicle to produce androgens. aromatase within the follicle’s granulosa cells subsequently converts these androgens to estradiol under FSH stimulation.
Marker for osteoclast activity
Hydroxyproline
osteitis deformans
Paget’s
Juvenile Idiopathic Arthritis (JIA) AKA Juvenile Rheumatoid Arthritis (JRA)
o Coded character: Kiya (Sarah’s daughter)/more common in females and usually in kids under 16. She’s in a wheelchair + 1920s wagon full of kids covered in a rash/presentation = joint pain + joint swelling + migratory rash. Newts crawling around everywhere and walls made of sand/labs = elevated ESR + neutrophils. she has motorcycle goggles on/uveitis that may lead to blindness can be a serious complication.
o Location: Grassy area at AZ hotel
Vertebral subluxation:
o Code: Two EMT’s holding Cam + he has a c spine collar on/severe chronic RA can involve the cervical spine and cause joint destruction with vertebral malalignment (subluxation). Huge globe on a car axis/the atlantoaxial joint is often involved and more prone to subluxation because the atlas (C1) has a high degree of mobility relative to the axis. IV pole next to him + he’s paralyzed + axe in his neck/anterior movement of the atlas can cause spinal cord compression, presenting with neck pain + stiffness + radicular pain + paralysis with decreased or absent reflexes beleververtow the level of the compression (areflexic paralysis) + hypotension (due to loss of sympathetic tone) + and/or sudden death.
o Location: Entrence of Res dinner
osteoporosis risk factors
1) Age
2) Gender. **NBME answer for greatest RF. Women are at much higher risk of osteoporosis than men.
3) Smoking
4) ethnicity
Genitofemoral supplie
sensation to upper anterior thigh + skin of anterior scrotum + mons pubis
pudendal nerve
Carries sensation from the external genitalia of both sexes + skin around anus and perineum.
Name the spinal ligaments.
…
p53 actions
1) Inhibits apoptosis
2) Inhibits progression from G1–>S
3) Stimulates cell-cycle repair
Proteinase 3
epitope of anti-neutrophil cytoplasmic antibodies of c-ANA so relevance = Wegener’s granulomatosis
Prader willi other mechanism of inheritance
MATERNAL uniparental disomy
