Blocks 37, 38 Flashcards
Enterococcus is a component of normal flora where in the body?
Colonic flora
Urogenital Flora
Enterococcal endocarditis usually occurs in elderly men who have recently undergone what procedures?
Genitourinary (cystoscopy)
Gastrointestinal (colonoscopy)
Obstetric procedures (in women)
Postitive VDRL of the spinal fluid indicates what?
Neurosyphillis
Lancinating pains, parasthesias, loss of vibratory and position sensation. Loss of proprioception is usually compensated for by visual clues, but sensory ataxia prevails in the dark. Areflexia and loss of bladder function can also occur. Possibly Argyll Robertson pupils and +Romberg sign.
Tabes Dorsalis as a result of neurosyphillis
Damage to dorsal roots in dorsal columns
Progressive signs and symptoms like bleeding from thrombocytopenia (epistaxis, bruising), pallor and fatigue from anemia, and bacterial infections from leukopenia/neutropenia. Splenomegaly is ABSENT due to a lack of available hematopoietic progenitor cells and therefore a lack of extramedullary hematopoiesis.
Aplastic anemia
Pancytopenia with bone marrow hypocellularity
What is the pathogenesis of muscular dystrophy?
Deletions of dystrophin gene that encodes the dystrophin protein on X chromosome p21.
Loss of dystrophin leads to cellular injury (myonecrosis)
X linked recessive
What is given to patients with moderate to severe allergic asthma that is uncontrolled?
Oral glucocorticoids
Omalizumab (Anti-IgE antibodies) - to reduce dependency on both oral and inhaled steroids
Approximately 90% of left atrial thrombi are found within what area in patients with nonvalvular atrial fibrillation?
Left Atrial Appendage - a small saclike structure in the left atrium
What are the 3 most important predisposing factors for hypoglycemia in patients with type 1 diabetes?
- Excessive Insulin Dose
- Inadequate food intake
- Physical activity/exercise
What gives rise to the collecting system of the kidney? (collecting tubules and ducts, major and minor calyces, renal pelvis, ureters)
Ureteric Bud
What gives rise to the glomeruli, Bowman’s space, proximal tubules, loop of Henle, and distal convoluted tubules?
Metanephric Mesoderm (blastema)
What is the Reid Index?
Ratio of thickness of the mucous gland layer in the bronchial wall submucosa to the thickness of the bronchial wall between the respiratory epithelium and bronchial cartilage.
*sensitive measurement of mucous gland enlargement
*Elevations of the RI above the normal value of 40% = duration and severity of chronic bronchitis
Severe fatigue, splenomegaly (often causing early satiety/abdominal discomfort), hepatomegaly, anemia and bone marrow fibrosis
Primary Myelofibrosis
Atypical megakaryocytic hyperplasia (stimulates fibroblast proliferation) resulting in replacement of marrow space by extensive collagen deposition.
Peripheral smear = teardrop-shaped red blood cells (dacrocytes) and nucleated RBCs
GOF mutation of a non-receptor tyrosine kinase protein in hematopoietic cells, leading to persisten activation of signal transducers and activators of transcription (STAT) proteins. (JAK2)
Repetitive, rhythmic, involuntary movements of the tongue, lips, face, trunk, and extremeties
Orofacial dyskinesias (facial grimacing, lip smacking) are most common, but choreoathetoid movements of the trunk and limbs can also occur.
Tardive Dyskinesia
Chronic use of antipsychotic medications
What is the most common gastrointestinal abnormality associated with Down Syndrome?
Duodenal atresia - failure of recanalization of the duodenum; Bilious emesis and double bubble sign in first few days of life
Also, imperforate anus, hirshsprung disease, tracheoesophageal fistula, celiac disease
What is the equation for Filtration Fraction?
GFR/RPF
Unilateral facial pain that worsens with jaw movement, headache, ear discomfort (pain and muffled hearing in that ear)
Temporomandibular Disorder (TMD)
Mandibular nerve (trigeminal) causes the jaw pain and otologic symptoms
Prolactinomas cause what symptoms in women?
Amenorrhea and galactorrhea
Hypogonadism, anovulation, amenorrhea
Decreased estrongen:
Accelerated bone loss (high risk for pathological fractures)
Vaginal dryness
Digital clubbing, a thickening of the distal phalanges is a sign of what?
Fingers have a drumstick appearance, flattening of the nail folds, shininess of nail and distal portion of the finger.
HYPOXIA
Lung diseases: bronchiectasis, pulm HTN, lung cancer, TB, empyema
Heart: cyanotic congenital heart diseases, bacterial endocarditis
Other: IBD, hyperthyroidism, malabsorption
If the AV node is bypassed, what part of the ECG will be affected?
Wolff-Parkinson White Triad:
PR interval will be shortened
Widened QRS
Delta wave
1 month old with a history of persistent jaundice now having muscle rigidity, lethargy, and seizures. What is causing the hyperbilirubinemia?
Crigler Najjar - AR
Genetic lack of UGT needed to catalyze bile glucuronidation
Adverse drug reaction that occurs due to known pharmacologic actions of a drug but at a lower dose than expected.
Exaggerated Drug Sensitivity
Unpredictable reaction to a drug due to genetic differences or complex metabolic interactions in certain patients
Idiosyncratic Drug Reaction
Ex: G6PD pt given primaquine –> oxidative cellular injury and nonimmune hemolytic anemia
Low doses of Dopamine vs. high doses of Dopamine have what effets on renal blood flow and cardiac output?
Low: Vasodilation; Increased renal blood flow, increased cardiac contractility (increased CO)
High: Vasoconstriction; decreased renal blood flow, decreased CO (increased afterload)
Flushed skin and mydriasis are symptoms from what type of blockade?
Muscarinic Receptor Blockade
Medications with Antimuscarinic effects
Atropine
TCAs
H1 receptor antagonists (diphenhydramine)
Neuroleptics
Antiparkinsonian drugs
Slowly progressive exertional dyspnea, dry cough, restrictive profile on pulmonary function testing (FVC 40% of the predicted value and a FEV1/FVC of 87%), interstitial fibrosis with cystic air space enlargement
Idiopathic Pulmonary Fibrosis
Patchy involvement with dense fibrosis
Alveolar wall collaps leads to honeycombing lined by hyperplastic type 2 pneumocytes or bronchiolar epithelium
*Predominant in the subpleural and paraseptal spaces
Microcytic anemia, constipation, mental status changes in the setting of construction work
Lead poisoning
Lead lines at gum-tooth line
Wrist drop or foot drop to peripheral neuropathy
Basophilic stippling on peripheral blood smear
Administration of what drug type will cause an increase in systolic and diastolic blood pressures and a reflexive (delayed) decrease in HR
Selective alpha 1 adrenergic agonist (phenylephrine, methoxamine)
Diagnostic criteria for Kawasaki Disease
Asian child under 5 y/o
Fever for at least 5 days plus 4 of the following:
Bilateral non-exudative conjunctival injection (erythema)
Cervical LAD
Mucositis: strawberry tongue, cracked lips, red throat
Extremity changes: edema of hands/feet, erythema of palms/soles, desquamation of fingertips
Rash: polymorphous (itchy) erythematous rash on extremities that spreads to the trunk
Patient with SLE plus prolonged activated partial thromboplastin time (aPTT) and false-positive rapid plasma reagin (RPR) test suggest what?
circulated antiphospholipid antibodies
Antiphospholipid antibody syndrome causes what adverse pregnancy outcomes?
Unexplained fetal loss
Preamture birth due to placental insufficiency or preeclampsia
What type of test is commonly used to determine if the means of 2 populations are equal?
Two-sample T test
Infant with normal development for a few months followed by progressive neurologic deterioration: weakness, hypotonia, developmental regression, seizures, blindness, and spasticity. PE shows macrocephaly and an abnormal startle reflex with acoustic stimuli. Cherry-red macula spot surrounded by a white macula (halo)
Tay-Sachs Disease
AR
Beta-hexosaminidase A deficiency resulting in the accumulation of GM2 ganglioside within lysosomes.
What is the initial insult in an aortic dissection?
Tear in the aortic intima that typically extends 1-5 cm in a transverse or oblique direction.
Bump below normal breast line that may swell or become tender similar to normal breast tissue before or during menses, pregnancy, and lactation. Hyperpigmentation, epidermal thickening
Accessory nipple
Failure of involution of the mammary ridge
Severe pruritus that slowly progresses over time. Especially prominant over palms and soles that may be unbearable at night. Fatigue. High direct bilirubin, Alk phos, and AST.
Primary Biliary Cirrhosis (PBC) - autoimmune destruction of the intrahepatic bile ducts and cholestasis
Later: Hepatosplemomagaly, xanthomatous lesions in skin (eyelids), jaundice, steatorrhea, portal HTN, and osteopenia
Associated with Sjogren’s syndrome, raynaud, scleroderma, autoimmune thyroid disease, hypothyroidism, celiac disease
Infant with a one sided scrotal enlargement that increases when he cries/strains. Present since birth. US shows a fluid collection around the testis. What is defective and what can happen as a result?
Failure of obliteration of the processus vaginalis leading to a persisten connection between the scrotum and the peritoneal cavity through the inguinal canal.
Can lead to an indirect inguinal hernia if the opening is large enough.
What are the 2 arrest points in female gametogenesis?
Prophase 1 of Meiosis 1 - primary oocytes prior to becoming a follicle for ovulation
Metaphase of Meiosis 2 - secondary oocytes prior to fertilization
Episodic sudden onset headache, tachycardia, diaphoresis, apprehensiveness, fine tremor. Severe HTN that may be paroxysmal or persistent. Symptoms resolve in a matter of moments but will occur again.
Pheochromocytoma
Symptoms from increased catecholamine secretion
Arise from neuroendocrine cells in adrenal medulla
What should be watched for when initiating an ACEI for the first time?
First-dose hypotension
Abrupt removal of the vasoconstrictive effects of angiotensin 2, resulting in decreased peripheral vascular tone and a precipitous drop in BP.
More likely in pts with high plasma renin activity like volume depletion or heart failure.
Ion pump failure due to ATP deficiency during cardiac ischemia causes what to happen intracellularly?
Accumulation of Na+ and Ca2+ intracellularly –> free water drawn into the cell –> cellular and mitochondrial swelling
What structures are penetrated when a suprapubic cystostomy is preformed?
Aponeurosis of abdominal wall muscles
Layers of superficial fascia, transversalis fascia, extraperitoneal fat
African American female with hilar adenopathy and pulmonary infiltrates + non-caseating granulomas on lung biopsy
Sarcoidosis
Granuloma formation is a manifestation of cell-mediated immunity driven by products of what?
Th1 type CD4 –> IL-2, and IFN-gamma –> stimulate Th1 type cell proliferation (IL-2) and macrophage activation (IFN-gamma)
Beta globin mutation resulting in a reduced binding of 2,3-bisphosphoglycerate
Familial Erythrocytosis
Lysine –> Methionine base substitution
Decreased + charge of the binding side for 2,3-BPG increases hemoglobin oxygen affinity.
Resembles Hemoglobin F
Pt. with DKA, or underlying immunosuppression with facial and periorbital pain, headache, and purulent nasal discharge. Black eschar (necrotic tissue) may be seen on the palate or nasal turbinates.
Mucormycosis
Mucor, Rhizopus, Absidia species
Broad, nonseptate hyphae that branch at wide 90 degree angles
What is the acute phase reactant synthesized by the liver that acts as the central regulator of iron homeostasis?
Hepcidin
Low hepcidin levels increase intestinal iron absorption and stimulate iron release by macrophages.
Numbness and tingling in both legs and difficulty walking for several months. Tires more easily with physical activity. Mucosal pallor and loss of vibration and position sensation in the bilateral lower extremeties with associated gait ataxia. What is lacking?
Vitamin B12 deficiency
Only happens after complete absence for intake for 4-5 years.
Subacute combined degeneration of the spinal cord - from impaired myelin synthesis, specifically in the dorsal and lateral columns
What class of medication binds to PPAR-gamma and what effect do they have on insulin?
Thiazolidinedione (TZD) like pioglitazone
Decrease insulin resistance
How do you distinguish between acute stress disorder and PTSD?
PTSD = at least 1 month
Acute stress disorder = 3 days to 1 month
Tamoxifen can be used in males for what purpose?
Prevention and treatment of gynecomastia in patients on androgen deprivation therapy (for prostate cancer).
Selective estrogen receptor modulator
Patient who complains of difficulty with stairs and frequent falling secondary to “knee buckling”. Patellar reflex diminished.
Femoral Nerve Neuropathy
Also will have weak quadricep muscle, and loss of sensation over the anterior and medial thigh and medial leg
After a transplant: diffuse maculopapular rash that has a predilection for palms and soles and may desquamate, diarrhea, intestinal bleeding, abdominal pain.
Approx a week after the transplant
Graft vs. Host Disease
Donor T cells against host MHC antigens
A vertical midline episiotomy will cut through what structure?
Perineal Body
What is the pathogenesis of type 2 diabetes?
Insulin resistance and relative insulin deficiency
Chronically elevated free fatty acid levels contribute to the insulin resistance by impairing insulin-dependent glucose uptake and increasing heptatic gluconeogenesis.
Symmetrical proximal muscle weakness, increasing difficulty climbing stairs, getting up from a chair, carrying heavy objects. Biopsy shows endomysial mononuclear inflammatory infiltrate and patchy muscle fiber necrosis.
Polymyositis
+ ANA, anti-jo-1, anti-histidyl-tRNA synthetase
Elevated muscle enzymes (CK, aldolase)
Associated with interstitial lung disease, myocarditis
Thoracentesis is preformed in what 3 areas?
6-8th rib midclavicular
8-10th midaxillary
10-12th paravertebral
*If needle is inserted higher, there is a risk of lung injury
What is the most common cause of sudden cardiac death (abrupt cessation of organized cardiac activity with hemodynamic collapse, causing an inability to maintain adequate tissue perfusion) in the first 48 hours after acute MI?
Ventricular Fibrillation - due to electrical instability due to a lack of perfusion in the ischemic myocardium
What are P bodies?
Distinct foci foudn within eukaryotic cells that are invovled in mRNA regulation and turnover.
They play a fundamental role in translation repression and RNA decay, and contain numerous proteins including RNA exonucleases, mRNA decapping enzymes, and constituents incolced in mRNA quality control and microRNA-induced mRNA silencing.
They also function as a form of mRNA storage, as certain mRNAs are incorporated into P bodies to be later released and utilized for protein translation.
What drug is ideal for prevention of breast cancer AND osteoporosis without increasing the risk of endometrial cancer?
Raloxifene
Estrogen antagonistic activity on breast and uterus + estrogen agonist activity on bone (decreases bone resportion and improves bone mineral density)
Patients are encouraged to rinse out their mouth after using daily inhaled glucocorticoids for what reason?
Deposition of the medication in oral mucous membranes can lead to oral candidiasis.
Aortic regurgitation with mediastinal widening, suggesting an aortic aneurysm that has dilated the aortic annulus with a postitive serology for syphilis = what type of syphilis?
Tertiary syphilis
Vasa vasorum endarteritis and obliteration, resulting in inflammation, ischemia, and weakening of the adventitia. Aneurysmal dilation of the thoracic aorta results and can extend to involve the aortic valve ring.
What explains the 2 most common complications of Crohn’s disease: strictures and fistulas?
Transmural inflammation
Loud, blowing holosystolic murmur at the mid to lower left sternal border with no symptoms inititially = what congenital heart lesion? When can this be heard?
Ventricular Septal Defect (VSD)
*most common congenital heart lesion*
Will not be heard until 4-10 days after birth when pulmonary vascular resistance declines, enabling L-R shunting
What are the 4 characteristics of Ulcerative Colitis?
- The rectum is always involved.
- Inflammation is limited to mucosal and submucosa
- Mucosal damage is continuous
- Hallmark = bloody diarrhea, with or without pain
Liver disease with hepatomegaly, abdominal pain, skin hyperpigmentation (in sun-exposed areas), diabetes mellitus secondary to pancreatic islet destruction, impotence, arthropathy, and cardiac dysfunction/enlargement.
Hemochromatosis
AR
Abnormally high iron GI absorption
What are the 2 mechanisms for development of diabetic neuropathy?
- Non-enzymatic glycosylation of proteins leading to increased thickness, hyalinization, and narrowing of the walls of arteries.
- Intracellular hyperglycemia in peripheral nerves. Accumulating glucose is converted to sorbitol and fructose by aldose reductase. Sorbitol increases water influx into cell –> osmotic damage to axons and schwann cells.
