Cardio Flashcards
What are the 3 pacemaker structures in the heart?
SA node, AV node/bundle of His, and Purkinje cells
Which cells are the ‘native’ pacemakers of the heart. How fast do they beat?
SA node (60-100 bpm)
Which nerve root:Innervates part of hamstring via tibial protion of sciatic nerveIs responsible for the achilles tendon reflexHas a dermatome that includes the lateral part of the foot
S1
Which nerve root:Innervates part of hamstring via tibial protion of sciatic nerveIs responsible for the achilles tendon reflexHas a dermatome that includes the lateral part of the foot
S1
What is the automaticity of the AV node/bundle of his?
50-60 bpm
What are the nerve roots for the femoral nerve?
L2-L4
What are the nerve roots for the femoral nerve?
L2-L4
What is the automaticity of the purkinje cells?
30-40 bpm
What action does the femoral nerve perform?
Knee and hip extension
What action does the femoral nerve perform?
Knee and hip extension
What is first degree AV block?
Lengthened PR interval-more than .2 sec
What are the nerve roots for the obturator nerve?
L2-L4
What are the nerve roots for the obturator nerve?
L2-L4
What is 2nd degree AV block (Mobitz type I)?
Intermittent failure of AV conduction resulting in a progressively lengthened PR interval that eventually results in a P wave with no QRS.
What does the obturator nerve do?
Hip adduction
What does the obturator nerve do?
Hip adduction
What is 2nd degree AV block (Mobitz type II)?
Failure of AV conduction that occurs without the progressively lengthening PR interval. Spontaneous P waves with no QRS intervals.
What nerve root is responsible for the patellar reflex?
L4
What nerve root is responsible for the patellar reflex?
L4
What is 3rd degree AV block?
Atria and ventricles are completely electrically dissociated from each other.
What is the dermatome of L4?
Medial aspect of the foot
What is the dermatome of L4?
Medial aspect of the foot
How does 3rd degree AV block present?
Widened pulse pressure. Heart rate of 30-45 min.
What does the deep peroneal nerve do?
Dorsiflexion of the foot
What does the deep peroneal nerve do?
Dorsiflexion of the foot
What is a common presentation of a bicuspid aortic valve?
Usually asymptomatic but can have a systolic click or ejection murmur (aortic stenosis).
What is the root of the deep peroneal nerve
L4
What is the root of the deep peroneal nerve
L4
What changes does severe aortic stenosis cause? Name 3
Increased LVP and LV work Increased LV oxygen consumption Increased adenosine accumulation in cardiac tissue-acts as a vasodilator to increase blood flow through the coronary circulation
What vessels are torn in a subdural hematoma?
Cerebral bridging veins
What vessels are torn in a subdural hematoma?
Cerebral bridging veins
What is a common cause of acute bacterial endocarditis in IVDU?
S aureus
What are the radiographic findings of a subdural hematoma?
Crescent shapedDoesn’t cross midline but can involve the falxCrosses many suture lines
What are the radiographic findings of a subdural hematoma?
Crescent shapedDoesn’t cross midline but can involve the falxCrosses many suture lines
What does S aureus endocarditis look like on imaging?
Large, penetrating valvular lesions
What does meningeal vessel damage result in?
Epidural hemorrhage
What does meningeal vessel damage result in?
Epidural hemorrhage
What happens if bacterial vegetations from infected heart valves embolize to the brain?
Makes brain abscesses that appear as ring enhancing lesions on CT scan.
What are the radiographic findings of an epidural hemorrhage?
Biconvex appearance, never dips into the falx
What are the radiographic findings of an epidural hemorrhage?
Biconvex appearance, never dips into the falx
What is the truncus arteriosus?
A primitive tube consisting of the ascending aorta and pulmonary trunk. Normally by birth, a septum develops separating these structures.
What is the cushing reflex?
Hypertension and bradycardia in response to changes in cerebral perfusion pressure.CPP= MAP-ICP
What is the cushing reflex?
Hypertension and bradycardia in response to changes in cerebral perfusion pressure.CPP= MAP-ICP
What happens in the case of a persistent truncus arteriosus? What other defects would there be?
The truncus arteriosus receives blood from the right and left ventricules, leading to mixing of oxygenated and deoxygenated blood and cyanosis. There would also be a VSD, since the ventricular septum is formed by the same structure that is supposed to separate the ascending aorta from the pulmonary trunk.
What is Guillan Barre syndrome?
Acute idiopathic inflammatory polynueropathy that usually follows a URI or GI infection.
What is Guillan Barre syndrome?
Acute idiopathic inflammatory polynueropathy that usually follows a URI or GI infection.
What is the genetic defect in Marfan Syndrome? What is the pattern of inheritance?
Autosomal dominant from mutated fibrillin gene.
Describe the pathogenesis of Guillan Barre
Autoimmune attack of myelin in peripheral nerves
Describe the pathogenesis of Guillan Barre
Autoimmune attack of myelin in peripheral nerves
What are the clinical features of Marfan Syndrome? (3)
Mitral valve prolapse (mitral regurg)-midsystolic click followed by a murmur Increased risk of aortic dissection Dislocation of the lens
What does loss of the extensor plantar reflex indicate?
UMN lesion involving contralateral motor cortex or cortical spinal tract
What does loss of the extensor plantar reflex indicate?
UMN lesion involving contralateral motor cortex or cortical spinal tract
What type of heart disease can be seen in a patient with RA? What is the implicated factor?
Restrictive cardiomyopathy. Due to deposition of amyloid (from amyloid associated protein/AA) in the myocardium.
What does rupture of the MMA result in?
Epidural hematoma
What does rupture of the MMA result in?
Epidural hematoma
What is the pathophysiology of restrictive cardiomyopathy? How does this manifest clinically?
Decreased compliance and impaired diastolic filling leading to increased diastolic pressures resulting in: elevated systemic and pulmonary venous pressures–>JVD/hepatomegaly/peripheral edema
What can be a complication of MMA rupture and why?
Anisocoria since the MMA goes through the foramen spinosum, which is near where CNIII exits the skull in the middle cranial fossa.
What can be a complication of MMA rupture and why?
Anisocoria since the MMA goes through the foramen spinosum, which is near where CNIII exits the skull in the middle cranial fossa.
How do the carotid baroreceptors regulate BP?
Stretch of these baroreceptors leads to CN IX to send signals to the medulla that decreases blood pressure.
What are the cells and molecule primarily responsible for MS plaques? Are there axons left?
Demyelination but preservation of axons. Th1 cells that secrete interferon gamma cause the demylination by activating macrophages.
What are the cells and molecule primarily responsible for MS plaques? Are there axons left?
Demyelination but preservation of axons. Th1 cells that secrete interferon gamma cause the demylination by activating macrophages.
During carotid occlusion what happens?
The body thinks there is lower blood pressure (Less afferent CN IX activity to medulla). Results in increased sympathetic tone and decreased parasympathetic tone.
CNVII nuclei damage results in what?
Whole side of face drooping
CNVII nuclei damage results in what?
Whole side of face drooping
Where are M2 receptors and what do they do?
M2 parasympathetic receptors are only found in the heart. Stimulation decreases HR, contractility, conduction velocity and automaticity. Does not affect MAP!
Cortex damage controlling face expression results in what? Why?
Only lower side of face drooping since upper facial muscles can get signals from both hemispheres
Cortex damage controlling face expression results in what? Why?
Only lower side of face drooping since upper facial muscles can get signals from both hemispheres
What is the major risk factor for aortic dissection?
Systemic hypertension
What nucleii can be damaged in lateral medullary syndrome? What does this result in?
Vestibular and cochlear resulting in nausea and vomiting (Vestibular nuclei)Dysphagia from nucleus ambiguus (X)Loss of pain/temp in ipsilateral face (V)Loss of pain/temp in contralteral body (spinothalamic tract)Horner syndrome (loss of sympathetic innervation to the eye-miosis/ptosis)
What nucleii can be damaged in lateral medullary syndrome? What does this result in?
Vestibular and cochlear resulting in nausea and vomiting (Vestibular nuclei)Dysphagia from nucleus ambiguus (X)Loss of pain/temp in ipsilateral face (V)Loss of pain/temp in contralteral body (spinothalamic tract)Horner syndrome (loss of sympathetic innervation to the eye-miosis/ptosis)
What is the common presentation of an aortic dissection?
Acute chest pain that radiates to the back
What artery is frequently occluded to give lateral medullary syndrome?
PICA
What artery is frequently occluded to give lateral medullary syndrome?
PICA
What is the equation for TPR?
TPR=(mean arterial pressure - right atrial pressure)/cardica output. RAP assumed to be 0
Where does intraparenchymal hemorrhage often affect?
Basal ganglia/internal capsule
Where does intraparenchymal hemorrhage often affect?
Basal ganglia/internal capsule
What happens in transposition of the great vessels?
Aorta leaves RV, pulmonary artery leaves LV
What goes through the foramen ovale?
Mandibular nerve which is responsible for mastication
What goes through the foramen ovale?
Mandibular nerve which is responsible for mastication
How do you treat transposition of the great vessles?
With alprostadil, a PGE1 analog that maintains a patent ductus arteriosus (that connects pulmonary trunk and aorta) to allow for increased blood oxygenation in the aorta.
Where does the auriculotemporal nerve sense?
Anterior half of the external ear canal
Where does the auriculotemporal nerve sense?
Anterior half of the external ear canal
What is the most common cardiac tumor in children? How does it present?
Rhabdomyoma. Often presents with cardiac outlfow obstruction.
Where does the auricular branch of vagues sense?
Posterior half of external ear canal
Where does the auricular branch of vagues sense?
Posterior half of external ear canal
What are cardiac rhabdomyomas associated with?
Tuberous sclerosis
Where does the greater auricular nerve sense
Lower part of auricle
Where does the greater auricular nerve sense
Lower part of auricle
How does tuberous sclerosis present?
Neurocutaneous disorder with adenoma sebaceum (red papules on the face), epilepsy and mental retardation.
Where does the lesser occipital nerve sense on the ear?
Upper part of auricle
Where does the lesser occipital nerve sense on the ear?
Upper part of auricle
Aside from modulating cardiac contractility what else does digoxin do? What can digoxin be used for because of this?
Digoxin decreases conduction through the AV node, therefore it can be used for A fib with rapid ventricular rate
What are the 5 places that CN IX affects?
1) somatic sensation from posterior pharynx2) Taste/somatic sensation from posterior 1/3 of tongue3) Afferents from carotid body/sinus4) Motor efferents to stylopharyngeus5) Parasympathetic efferents to parotid gland
What are the 5 places that CN IX affects?
1) somatic sensation from posterior pharynx2) Taste/somatic sensation from posterior 1/3 of tongue3) Afferents from carotid body/sinus4) Motor efferents to stylopharyngeus5) Parasympathetic efferents to parotid gland
What is the treatment of choice for A fib in patients without heart failure?
Beta blockers (esmolol, metropolol) CCBs (verapamil, diltiazem)
Where does the olfactory bulb project to?
Piriform cortex
Where does the olfactory bulb project to?
Piriform cortex
What happens to coronary blood flow during systole? What condition is this exacerbated in?
Decreases because coronary blood vessels are compressed? Aortic stenosis exacerbates this.
What happens if the thyroglossal duct proximal end doesn’t regress?
Thyroid cyst lesion on midline of the neck
What happens if the thyroglossal duct proximal end doesn’t regress?
Thyroid cyst lesion on midline of the neck
What heart sound is heard with dilated cardiomyopathy?
S3
Pilocytic astrocytoma: kids or adults?
Kids/young adults
Pilocytic astrocytoma: kids or adults?
Kids/young adults
What chemotherapeutic is associated with an increased risk of developing dilated cardiomyopathy?
Doxorubicin
Pilocytic astrocytoma: location?
Posterior fossa
Pilocytic astrocytoma: location?
Posterior fossa
What heart murmur can develop as a consequence of aortic dissection?
Aortic insufficiency (a diastolic murmur)
Pilocytic astrocytoma: IHC
Rostenthal fibers, immunostaining with GFAP
Pilocytic astrocytoma: IHC
Rostenthal fibers, immunostaining with GFAP
What diseases have increased aortic pulse pressure?
Arteriosclerosis (because of high systolic BP), aortic regurgitation (because of low diastolic BP)
Sensory and motor fibers, wrist and elbow flexion, elbow extension, arm abduction. Sensation over deltoid and first 3 digits. Which nerve root?
C6
Sensory and motor fibers, wrist and elbow flexion, elbow extension, arm abduction. Sensation over deltoid and first 3 digits. Which nerve root?
C6
What diseases have decreased aortic pulse pressure?
Aortic stenosis (decreased systolic pressure), mitral stenosis (less volume in LV so less systolic pressure)
Lens opacification is seen in what disease process?
Cataracts
Lens opacification is seen in what disease process?
Cataracts
What disease has increased diastolic pressure in the aorta?
Mitral stenosis
Imipramine is what?
TCA that blocks serotonin, NE re-uptake
Imipramine is what?
TCA that blocks serotonin, NE re-uptake
What diseases have decreased diastolic pressure in the aorta?
Aortic regurgitatiion, PDA
HIV encephalitis shows what histologically?
Multi-nucleated giant cells
HIV encephalitis shows what histologically?
Multi-nucleated giant cells
What is one potentially fatal complication of an MI?
Ventricular wall rupture
What muscles do the superior gluteal nerve innervate?
Gluteus medius and minimus
What muscles do the superior gluteal nerve innervate?
Gluteus medius and minimus
What does ventricular rupture result in?
Cardiac tamponade which can present with Beck’s triad: hypotension, JVD and muffled heart sounds
Where does the superior gluteal nerve exit the greater sciatic foramen?
Upper border of the sciatic foramen
Where does the superior gluteal nerve exit the greater sciatic foramen?
Upper border of the sciatic foramen
What is coarctation of the aorta?
Narrowing of the aorta?
What muscle does the inferior gluteal nerve innervate?
Gluteus maximus
What muscle does the inferior gluteal nerve innervate?
Gluteus maximus
Describe preductal (infantile) coarctation of the aorta
Narrowing of the aorta proximal to the ductus arteriosus. Causes excessive flow in intercostal arteries, leading to rib notching PDA
Where does the inferior gluteal nerve exit the greater sciatic foramen?
Lower border of the sciatic foramen
Where does the inferior gluteal nerve exit the greater sciatic foramen?
Lower border of the sciatic foramen
Describe postductal (adult) coarctation of the aorta.
Narrowing of the aorta distal to the opening of the ductus arteriosus. Most survive into adulthood. Disparity in pressure between the upper and lower extremities
What does the pudendal nerve innervate?
The perineum
What does the pudendal nerve innervate?
The perineum
What is the clinical presentation of patients with HCM?
Younger individuals Dyspnea, chest pain. Postexertional syncope.
Where does the pudendal nerve exit the sciatic formaen?
The lower border.
Where does the pudendal nerve exit the sciatic formaen?
The lower border.
What is the primary problem in HCM?
Diastolic dysfunction
What does the sciatic nerve innervate?
The posterior compartment of the thigh and leg (hip and knee flexion), the plantar foot muscles.
What does the sciatic nerve innervate?
The posterior compartment of the thigh and leg (hip and knee flexion), the plantar foot muscles.
What would you expect to see with imaging/PE for HCM? (5)
Systolic murmur at left lower sternal border, accentuated by squatting/increased afterload S4 (due to stiffening of the ventricle walls. A (4) stiff (1) wall (2). ECG: anterior motion of the mitral valve Closing and reopening of the aortic valve LV hypertrophy
Where does the sciatic nerve exit the greater sciatic foramen?
The lower border.
Where does the sciatic nerve exit the greater sciatic foramen?
The lower border.
What is the treatment for HCM? Why?
Beta-blockers. Improve diastolic filling
What muscles does the obturator nerve innervate?
Adductors and medial rotators of the thigh.
What muscles does the obturator nerve innervate?
Adductors and medial rotators of the thigh.
Which drug can worsen re-entrant tachycardias? Why?
Re-entrant tachycardias are caused by accessory pathways between the atria and ventricles. Digoxin can worsen this by slowing conduction through the AV node.
Where does the obturator nerve exit the greater sciatic foramen?
It doesn’t, it exits via the obturator canal.
Where does the obturator nerve exit the greater sciatic foramen?
It doesn’t, it exits via the obturator canal.
Would one expect a VSD patient to be cyanotic?
No
What is the common presentation of retinoblastoma?
Mutlifocal or bilateral tumors in the eye.
What is the common presentation of retinoblastoma?
Mutlifocal or bilateral tumors in the eye.
What is the typical clinical presentation of VSD? (2)
Increased O2 sat in right ventricle Holosystolic murmur at left lower sternal border.
What is the genetic abnormality underlying familial retinoblastoma? What chromosome is it on? What other cancers is it associated with?
Loss of Rb tumor suppressor, which normally prevents the cells from exiting G1, allowing tumor growth. It’s located on chromosome 13. Also associated with osteosarcoma
What is the genetic abnormality underlying familial retinoblastoma? What chromosome is it on? What other cancers is it associated with?
Loss of Rb tumor suppressor, which normally prevents the cells from exiting G1, allowing tumor growth. It’s located on chromosome 13. Also associated with osteosarcoma
What can be a side effect of captopril (and other ACE inhibitors)?
Chronic cough
What would be the presentation of sporadic retinoblastoma?
Unilateral
What would be the presentation of sporadic retinoblastoma?
Unilateral
What is an alternative to an ACE inhibitor that doesn’t cause coughing?
Angiotensin II receptor antagonist, like losartan.
What is the IHC of retinoblastoma?
Neruoepithelial cells that form rosettes.
What is the IHC of retinoblastoma?
Neruoepithelial cells that form rosettes.
How does spironolactone work?
K+ sparing diuretic that blocks aldosterone receptors in the distal nephron.
What is the first step in catecholamine synthesis?
Conversion of tyrosine to dopa by tyrosine hydroxylase (rate limiting step)
What is the first step in catecholamine synthesis?
Conversion of tyrosine to dopa by tyrosine hydroxylase (rate limiting step)
What is a side-effect of spironolactone?
Gynecomastia in men, since it has an antiandrogenic effect.
How is dopa converted into dopamine?
By dopa decarboxylase
How is dopa converted into dopamine?
By dopa decarboxylase
What does bradykinin do?
Its a potent vasodilator
Where and how is dopamine converted into norepinepherine?
In terminal vesicles, dopamine beta-hydroxylase acts on dopamine to produce norepinepherine.
Where and how is dopamine converted into norepinepherine?
In terminal vesicles, dopamine beta-hydroxylase acts on dopamine to produce norepinepherine.
What are the two things that ACE inhibitors do?
Prevent bradykinin degradation (vasodilates) and angiotensin II formation.
How is epinepherine made?
NE is converted to epinepherine by the enzyme phenylethanolamine-N-methyltransferase (PNMT), which is induced by cortisol during periods of stress. SAM is the methyl donor. This enzyme exists in the cytoplasm and can act make epi if NE diffuses out of terminal vesicles. Epi can be repackaged into vesicles and then secreted.
How is epinepherine made?
NE is converted to epinepherine by the enzyme phenylethanolamine-N-methyltransferase (PNMT), which is induced by cortisol during periods of stress. SAM is the methyl donor. This enzyme exists in the cytoplasm and can act make epi if NE diffuses out of terminal vesicles. Epi can be repackaged into vesicles and then secreted.
What are the electrolyte imbalances caused by ACE inhibitors?
Primarily hyperkalemia, but sometimes mild hyponatremia.
You see apatient with difficulty extending the left thigh and flexing the knee. He aslo has pain in the posterior thigh, the lateral leg and foot. What does he have?
Compression of the sciatic nerve (sciatica).
You see apatient with difficulty extending the left thigh and flexing the knee. He aslo has pain in the posterior thigh, the lateral leg and foot. What does he have?
Compression of the sciatic nerve (sciatica).
What non-cardiac markers can signify an MI?
Elevation of AST and LDH
What are the clinical findings that differentiate diffuse lewy body disease from parkinsons? (name 3)
1) Dementia is more common with diffuse lewy body disease than in Parkinsons Disease (but PD patients can have dementia)2) Involvement of cortical regions is more common in diffuse Lewy Body disease3) Lewy Body disease has extrapyramidal symptoms and visual hallucinations.
What are the clinical findings that differentiate diffuse lewy body disease from parkinsons? (name 3)
1) Dementia is more common with diffuse lewy body disease than in Parkinsons Disease (but PD patients can have dementia)2) Involvement of cortical regions is more common in diffuse Lewy Body disease3) Lewy Body disease has extrapyramidal symptoms and visual hallucinations.
What vessels does fibromuscular dysplasia affect?
Renal arteries
What is the treatment of choice for OCD?
SSRIs (fluoxetine) are treatment of choice.Clomipramine is a TCA that also can be used to treat OCD
What is the treatment of choice for OCD?
SSRIs (fluoxetine) are treatment of choice.Clomipramine is a TCA that also can be used to treat OCD
What patient population does fibromuscular dysplasia usually affect?
Middle aged women
What are cells that derive from the neural crest (7)?
Pseudounipolar cells of spinal and cranial gangliaAutonomic gangliaSchwann cellsChromaffin cells of adrenal medullaOdontoblastsMelanocytesMeninges (pia and arachnoid)
What are cells that derive from the neural crest (7)?
Pseudounipolar cells of spinal and cranial gangliaAutonomic gangliaSchwann cellsChromaffin cells of adrenal medullaOdontoblastsMelanocytesMeninges (pia and arachnoid)
What are the imaging findings of fibromuscular dysplasia?
Sting of beads pattern
What is arnold chiari type I malformation?
Cerebellar tonsils herniate through the foramen magnum. Usually asymptomatic, but can have headache and neck pain
What is arnold chiari type I malformation?
Cerebellar tonsils herniate through the foramen magnum. Usually asymptomatic, but can have headache and neck pain
What is the common presentation of ASD?
Exercise intolerance
What is arnold chiari type II malformation?
Hindbrain, cerebellar vermis and fourth ventricle herniate into the foramen magnum.
What is arnold chiari type II malformation?
Hindbrain, cerebellar vermis and fourth ventricle herniate into the foramen magnum.
What are the physical findings of an ASD? (2)
Systolic ejection murmur (from large amount of blood exiting RV). Heard at left midsternal border. Wide, fixed splitting of S2, since more blood in the pulmonary artery
What other condition is associated with Arnold-Chiari type II?
MeningomyelocelesHydrocephalus (due to CSF obstruction)Brainstem dysfunction (poor swallowing
What other condition is associated with Arnold-Chiari type II?
MeningomyelocelesHydrocephalus (due to CSF obstruction)Brainstem dysfunction (poor swallowing
What is the equation for MAP?
MAP = XO * TPR
How does benign essential tremor usually present?
Progressive bilateral, postural tremor usually not associated with other neurologic symptoms.Usually a 6-12 Hz tremor primarily affecting the arms
How does benign essential tremor usually present?
Progressive bilateral, postural tremor usually not associated with other neurologic symptoms.Usually a 6-12 Hz tremor primarily affecting the arms
What class of drugs should be avoided in asthmatics? Why?
Beta-blockers. B2 blockers are in the lungs and would result in bronchoconstriction.
How do you treat benign essential tremor?
Antagonist of beta adrenergic receptors
How do you treat benign essential tremor?
Antagonist of beta adrenergic receptors
Where are beta-1 receptors?
In the heart
How do benzo’s work?
Increase the frequency of GABAa channel opening
How do benzo’s work?
Increase the frequency of GABAa channel opening
Which are the beta 1 specific beta blockers and which ones are non-specific?
Beta1: A-M Beta2: N-Z
What is status epilepticus? How does it present? What are the drugs of choice?
30 min + of continuous seizure activity or repetitive seizures while in a continuus unconscious state. Patient usually falls to the floor. Benzos are the drugs of choice for this.
What is status epilepticus? How does it present? What are the drugs of choice?
30 min + of continuous seizure activity or repetitive seizures while in a continuus unconscious state. Patient usually falls to the floor. Benzos are the drugs of choice for this.
What is the inheritance pattern for familial hypercholesterolemia?
Autosomal dominant
What is myasthenia gravis?
Autoantibodies against skeletal muscle nACh receptors
What is myasthenia gravis?
Autoantibodies against skeletal muscle nACh receptors
What is the genetic cause of familial hypercholesterolemia?
Mutations in the receptor for LDL
How is myasthenia gravis treated?
With Achesterase inhibitors (neostigmine and pyridostigmine) which act by carbamylating Achesterase.
How is myasthenia gravis treated?
With Achesterase inhibitors (neostigmine and pyridostigmine) which act by carbamylating Achesterase.
What is the clinical presentation of acute pericarditis?
Sharp, knife-like chest pains.
What is used to treat migraines? What is the molecular target of these drugs.
The triptans: 5-HT 1D/B agonists
What is used to treat migraines? What is the molecular target of these drugs.
The triptans: 5-HT 1D/B agonists
How do patients with acute pericarditis try to relieve their symptoms?
By leaning forward
What are the ECG findings for acute pericarditis?
Diffuse ST elevations with upright T waves.
What is a potential effect of over use of beta-1 selective blockers?
Varying degrees of heart block
What happens to arteries and arterioles in untreated hypertension? What happens to the wall-to-lumen ratio?
Hypertrophy of arteries and erterioles. Wall-to-lumen ratio increases, decreasing the diameter of the lumen
What is a cardiac condition associated with SLE?
Libman Sacks endocarditis
What is libman-sacks endocarditis?
Small granular vegetations develop on valve leaflets, resulting in a fibrotic process leading to insufficiency or stenosis of the valves.
What is the triad observed in Wegners granulomatosis?
Upper airway focal necrotizing vasculitis Upper/lower respiratory tract necrotizing granulomas Necrotizing glomerulitis with c-ANCA antibodies
What does the EKG of a patient with atrial fibrillation look like? Why?
No P waves because there is no synchronous depolarization. Irregularly irregular R-R intervals because action potentials arrive at the AV node at random intervals leading to an erratic ventricular rhythm.
What is used for long-term anti-coagulation for patients with high-risk Afib?
Warfarin
What parts of the heart does the Left circumflex coronary artery supply?
Lateral and posterior walls of left ventricle
What parts of the heart does the LAD supply?
Supplies anterior 2/3 of the interventricular septum, anterior papillary muscle and anterior surface of the left ventricle
What does the posterior descending artery supply in the heart?
The posterior half of the interventricular septum
What does left vs right dominant coronary circulation mean?
Determines whether posterior descending artery (that supplies the posterior half of the interventricular septum) arises from the RCA (80%) or the LCX (20%)
What pharmacologic agents inhibit cardiac remodeling in CHF?
ACE inhibitors such as captopril that block conversion of angiotensin I to angiotensin II
What is hyperplastic arteriolosclerosis?
Concentric and laminated onionskin arteriolar thickening with reduplicated basement membrane (proliferation of SMCs)
What causes hyperplastic arteriosclerosis?
Malignant hypertension
What class of drugs does isoproterenol belong to?
Beta agonist
What drug decreases VLDL, LDL and triglyceride levels while increasing HDL levels?
Niacin (vitamin B3
What are the side effects of niacin?
Facial flushing
What can be given to decrease the facial flushing symptoms seen with niacin treatment?
Aspirin
Where does mitral regurigitation radiate to?
Radiates to the axilla
What is responsible for the systolic ejection murmur observed in ASD?
Increased volume in the RV, leading to tubrulent flow past the pulmonic valve
What drug class is associated with exacerbation of heart failure?
CCBs like Verapamil
What is a cardiac myxoma? Who is it common in? Is it benign?
A primary cardiac neoplasm that is more common in females. It is benign as a cancer but can cause sudden cardiac death from mechanical obstruction.
Where do cardiac myxomas usually appear?
The left atrium
What is the histology of cardiac myxomas?
Stellate mesenchymal cells with a myxoid background (mucus like), inflammatory and endothelial cells
What vessel defect is maternal diabetes associated with?
Transposition of the great vessels
What is transposition of the great vessels?
Aorta comes from RV and pulmonary trunk comes from LV.
What cardiac abnormalities can anemia result in?
High output heart failure with a high EF (normal is 50-60)
How does anemia result in high output heart failure?
Decreased oxygen tension leads to compensatory dilation of arteries/arterioles, leading to increased venous return to the heart. This results in more output via the frank starling mechanism in an effort to get oxygen to oxygen starved tissues. Results in a higher than normal EF
What is the mechanism of nitroglycerin action?
Dilates both arteries and veins
What would nitroglycerin do the LVEDP and LVESP?
Decreased LVEDP because veins dilate, decreasing venous return LVESP decreases because there is less resistance to ejection
Which classes of anti-hypertensives can cause lipid abnormalities?
Metropolol and thiazides
What happens to LV EDV in premature ventricular contraction? Why?
Decreases, since atria didn’t fill ventricles.
What happens to atrial pressure in a premature ventricular contraction? Why?
Abnormally high atrial pressure since atria contract against closed AV valves.
What are three drugs used to treat chronic hypertension in pregnant women? (3)
Methyldopa Labetalol Nifedipine
How does methyldopa work? What is it used for?
Stimulates alpha 2 on pre-synaptic axon terminals. Used to decrease sympathetic outflow thus treat hypertension in pregnant women.
What is procainamide used for?
Treating ventricular arrythmias
How does procainamide work?
Stabilizes cardiac membranes and depresses action potential phase 0
What is a complication of procainamide administration?
Drug induced lupus
Review netter’s cards 1-68 through 1-71
x
What are the 3 lab/PE findings you would expect to see with aortic regurgitation? Where would you expect to hear the murmur?
Blowing diastolic murmur heard best at the left sternal border Very wide pulse pressure Large stroke volume
In a patient with pulmonary disease and Afib what drug class would you give? Name one example.
CCBs-verapamil
How can infantile form of aortic coarctation present? Why?
Cyanosis only in the lower body. This occurs because there is low BP past the coarctation and the PDA is open, leading to shunting of deoxygenated from PA into the distal part of the aorta-to the lower extremities resulting in cyanosis.
What is Churg-Strauss syndrome? What are the clinical (1) and lab (1) findings?
Necrotizing vasculitis affecting multiple organ systems. Asthma and eosinophilia
Fibrinous pericarditis: What precedes it? What is the clinical presentation (3)? What is the treatment?
Preceded by an MI (2 to 10 weeks prior) Fever, pleuritic chest pain and pericardial friction rub Treat with NSAIDs and steroids sometimes
What is minoxidil? How does it work?
Peripheral vasodilator that acts by opening potassium sensitive ATP channels to hyperpolarize SMCs
What is temporal/giant cell arteritis? What is a complication?
Focal granulomatous inflammation (with giant cells) that commonly involves branches of the carotid system. Complication: blindness from involvement of the opthalmic artery
What artery is frequently involved in paraxdoxical movement of the heart wall?
LAD
What is the amyloid protein deposited in the heart in patients with RA? Where does it come from?
AA from the liver
What is stable angina?
Angina that occurs with exertion.
What is the best enzyme to measure for an MI?
Troponins (T and I)
What is Loeffler endocarditis? What patient populations are susceptible?
Restrictive heart disease caused by endomyocardial fibrosis and associated with eosinophilia Associated with tropical climates
What happens to renin in polycystic kidney disease?
Goes up leading to hypertension
How can syphillis affect the aorta?
Obliterates the vasa vasorum leading to dilatation of the aorta, the aortic valve ring and wrinkling of the initmal surface.
What cardiac abnormalities are seen in Turner syndrome? (2)
Coarctation of the aorta Bicuspid aortic valve
What contributes to the webbed neck in turner syndrome?
Cystic hygromas
How does norepinepherine increase blood pressure?
Signals through Gq which causes PIP2 to make DAG and IP3. IP3 releases calcium which leads to smooth muscle contraction
When is ventricular rupture observed post-MI?
Between 5 and 10 days after the original MI.
When do arrythmias resulting from MIs occur?
2 days post MI
What is type I hypersensitivity?
IgE mediated mast cell histamine release
What is type II hypersensitivity?
Autoantibodies generated.
What is type III hypersensitivity?
Immune complex deposition
What is type IV hypersensitivity?
Mediated by T-lymphocytes, causing granuloma formation.
What is a normal stimulus for VEGF secretion?
Exercise
A woman has unilateral headache, visual changes, tenderness of the temples and an elevated ESR. What is her diagnosis?
Temporal/giant cell arteritis
What is the predominant cause of sudden cardiac death in older patients?
Ischemic heart disease
During ventricular fibrillation what will happen to the RA pressure?
Increase
What happes to pressure in the circulatory system following Vfib?
Pressures will equilibriate throughout the arterial and venous systems resulting in pressure become MSFP
What can PDA result in clinically?
Pulmonary hypertension (since increased blood volume in the pulmonary system.
Where do the umbilical arteries arise from?
From the internal iliac arteries
What do the umbilical arteries do?
Carry unoxygenated blood from fetus to the placenta
What happens to the umbilical arteries after birth? What do they become?
They are obliterated and become the medial umbilical ligaments
When does coronary blood flow drop the most?
During isovolumic contraction
What can acetazolamide cause in terms of electrolyte changes?
Hypokalemia, metabolic acidosis and an alkaline urine.
Where does the LDL receptor exist?
The liver
What class of drugs increases the risk of digoxin toxicity? Why?
Diuretics because they cause hypokalemia
What vavlular changes does one see in valves affected by rheumatic fever?
Fibrous bridging between thickened, calcified leaflets
What does CHF cause in the liver?
Venous stasis in central sinusoids leading to central hemorrhagic necrosis. Results in nutmeg liver.
What anti-hypertensive medication can blunt the effects of hypoglycemia? Why?
Beta blockers, since the adrenergic system signal a hypoglycemic state
What is amiodarone used to treat?
Supraventricular and ventricular tachycardia
What are the effects of amiodarone?
Blocks potassium channels Prolongs repolarization Widens the QRS Prolongs the QT interval
Can deposition of amyloid lead to enlargement of organs other than the heart?
Yes, it can lead to widespread organomegaly
What is the mineral compisition of deposits in calcific aortic stenosis? How do they look on H and E
Calcium phosphates. Acellular blue material.
What are the 3 changes seen in chronic severe hypertension?
Decreased numbers of arterioles Thick walled arterioles Increased TPR
What is digoxin toxticity? What exacerbates it?
Cardiac dysrthymia. Hypokalemia increases severity.
What history is usually seen for a subendocardial infarction? Why?
Severe hypotension, since the endocardium is the farthest from the arterial supply
What is the ECG findings in a subendocardial infarction?
Flat ST segments or ST depression on various leads.
What is the afferent nerve for the aortic arch baroreceptor reflex?
X
What is the afferent nerve for the carotid sinus baroreceptor reflex?
IX
What happens to the firing rate of nerves IX and X in response to increased blood pressure?
Increased firing rate
What is the predominant nervous input to the heart?
Parasympathetic
What is the major parasympathetic input to the heart that controls HR?
X
What is the relationship between velocity and cross sectional area of a blood vessel?
Inversely proportional. Blood moves slowest through capillaries since they have the largest cross sectional area.
What is the mechanism of action of digoxin?
Inhibits sodium potassium ATPase
What is digoxin used to treat? (2)
CHF and supraventricular tachycardia
What is long QT syndrome and what is the clinical sequelae of it?
Genetically acquired prolongation of the QT interval associated with syncope and sudden death
What drugs are contraindicated in long long QT syndrome?
Class IA and III
What drug should be given to control hypertension in patients with diabetes and hyperuricemia?
ACE inhibitors (like captopril) for patients with diabetes and renal disease
What cardiac problems are seen in down syndrome patients? What is the etiology?
Endocardial cushion defects due to failure of neural crest cells to migrate properly
What benzo’s are good to treat alcoholics going through withdrawal?
LOT: lorazepam, oxazepam, temazepam. Their excretion is not as affected by liver disease as the other benzo’s.
What is graft vascular disease?
A complication of heart transplantation. Characterized by intimal thickening of the coronary arteries.
What sign is seen in cardiac tamponade? What is this sign?
Pulsus paradoxus: Reduction of systolic pressure greater than 10 mm Hg with inspiration.
What happens to the LV in aortic coarctation?
Hypertrophy
When are inflammatory cells first seen following irreversible ischemic injury?
2-3 days.
Aside from diastolic dysfunction what other cardiac abnormalities would one observe in a patient with HCM? (1)
Increased EF
What is unstable angina?
Recurrent episodes of angina on minimal effort or at rest
What is the etiology of unstable angina?
Slow thrombosis of a coronary artery with or without an underlying atherosclerotic process
What does excessive nitric oxide administration result in?
Methemoglobinemia resulting in cyanosis.
What can be pharmacologically done for methemeoglobinemia?
Methylene blue.
What is a consequence of long-standing angina pectoris histologically? What is the etiology?
Loss of myocytes with fibrosis and vacuolization in the subendocardium. Due to sustained ischemia
What beta blocker is contra-indicated in patients with angina? Why?
Acebutolol/penputalol/pindolol, since they have intrinsic sympathomimetic activity and so do not decrease myocardial oxygen consumption significantly.
What is Monckeberg arteriosclerosis (medial calcific sclerosis)?
A benign condition in the elderly where the media of small to medium arteries calcify
What embryonic structure gives rise to the smooth part of the RA and coronary sinus?
Sinus venosus
What is the genetic basis Kartagener disease? What are the clinical sequelae?
Dynein genetic defect Impaired clearance of respiratory debris, sperm motility impaired and situs inversus resulting in dextrocardia
What is an ostium primum ASD? What is the embryonic structure implicated?
Malformations of AV vavles due to endocardial cushion defect.
What congenital disease is associated with ostium primum ASDs?
Down syndrome
What is a complication of MI that happens later (4-8 weeks post infarct)?
Ventricular aneurysm
What class of drugs can cause drug induced gout?
Thiazide diuretics
What are the class 1B anti-arrythmics?
Mexiletine, tocainide (PO) and lidocaine (IV)
What are the class 1A anti-arrythmics?
Quinidine, Proainamide, Disopyramide
What are the class 1C anti-arrythmics?
Flecainide, prpafenone
What do class 1 anti-arrythmics do?
Block sodium channels
What do class II anti-arrythmics do?
beta blockers
What do the class 3 anti-arrythmics do?
K+ channel blockers
What are the class 3 anti-arrythmics?
AIDS: amiodarone, Ibutilide, Dofetilide, Sotalol
What do the class IV anti-arrythmics do?
Block calcium channels
What are the class IV anti-arrythmics?
Cerapamil, diltiazem
What can iron overload result in cardio wise?
CHF
What is takaysu arteritis?
Granulomatous vasculitis involving aortic arch vessels (narrowing of the aortic arch)
What population does Takayasu arteritis commonly affect?
Young asian women
What is the pathognomic vascular finding in takayasu arteritis?
Absence of peripheral pulsess in the upper extremities
What can atherosclerotic disease in the carotid result in?
Microemboli to the ipsilateral eye resulting in transient, recurrent vision loss (amaurosis fugax.
What sized arteries does polyarteritis nodosa usually affect?
Small to medium sized arteries
What type of necrosis is seen in patients with polyarteritis nodosa?
Fibrinoid necrosis
What is Kawasaki disease?
Fever for at least 5 days Desquamative rash of fingers/toes Cervical adenopathy Bilateral conjunctivitis Strawberry tongue Oral lesions
What cardiac abnormalities are present in Kawasaki disease?
Coronary artery aneurysms
What is the genetic defect in type I hyperchylomicronemia?
Apoprotein CII
What does apoportein CII do?
Turns on lipoprotein lipase.
What does Apoporotein CII deficiency lead to?
Very high chylomicron levels
What drug can be used to ‘coat’ stress ulcers? What is its mechanism of action?
Sucralfate: polymerizes in the acidic environment
What is Crigler-Najjar syndrome? What is found lab wise?
Lack of glucuronyl transferase preventing the glucuronidation of bilirupin by hepatocytes. Leads to high levels of unconjugated bilirubin in the plasma.
What does MCAD deficiency result in?
Accumulation of C8-C10 acylcarnitines
What does MCAD do? What does this result in during a fasting state.
Beta oxidation of fatty acids. During a fasting state there are low ATP levels.
What is the consequence of having low ATP levels during fasting as a result of MCAD deficiency?
Urea cycle fails, leading to the accumulation of ammonia in the blood.
What 3 hormones have a trophic effect on the GI tract and exocrine pancreas?
Gastrin, CCK and secretin
What are the H2 blockers?
Cimetidine, ranitidine, famotidine, nizatidine
What do the H2 blockers do?
Decrease H+ secretion by parietal cells.
Which H2 blocker inhibits p450 and has anti-andriogenic effects?
Cimetidine
What is Menetrier disease?
Hyperplastic gastrophathy characterized by enlarged rugal folds. Protein losing enteropathy
What cells hyperproliferate in menetrier disease?
Mucus producing cells of the stomach causing the protein losing enetropathy.
What is ursodiol used to treat? What does ursodiol do?
Used to treat cholesterol gallstones. Acts by reducing cholesterol synthesis and secretion into bile.
What is the cause of chagas disases?
Trypansoma cruzi
What are 3 clinical features of chagas disase?
Cardiac failure, megaesophagus and megacolon.
What is Gilbert syndrome?
Mild defect in UDP-glucuronyltransferase. Leads to asymptomatic unconjugated hyperbilirubinemia.
What is the nerve responsible for the relaxation of the internal anal sphicnter?
Pelvic nerve
What is the nerve responsible for the sensation of needing to defecate?
Pelvic nerve
What innervates the external sphincter?
The pudendal nerve
What anti-microbial can produce disulfram like effects (nausea and vomiting etc with alcohol consumption
Metronidazole
What is the inferior rectal nerve a branch of?
The pudendal nerve
What is meconium ileus?
When abnormally viscous pancreatic secretions get stuck in the small bowel.
What does meconium ileus look like on imaging?
Air fluid levels in the small bowel.
What condition causes meconium ileus?
Cystic fibrosis.
What do hyperplastic polyps look like microscopically?
Sawtooth glandular epithelium composed of goblet cells and columnar epithelium.
How does diverticulitis present clinically?
peri-umbilical pain that later becomes RLQ pain.
What is pathognomic of a sliding hiatal hernia?
Gastroesophageal junction is found significantly above the esophageal hiatus of the diaphragm
What 2 veins are anastamosed to make a portosystemic shunt in patients with hypertension?
The splenic vein (which normally goes to the liver) is anastamosed to the left renal vein which drains directly into the IVC, thus bypassing portal circulation.
What vein produces external hemorrhoids when it is varicosed?
The inferior rectal vein
What vein produces internal hemorrhoids when it is varicosed?
The superior rectal vein
What provides circulation to the lower anal canal?
The inferior rectal artery and vein
What does cytotoxin A and B of C diff do?
A: attracts granulocytes B: cytopathic
What stimulates gastric acid secretion (3)?
Histamine Gastrin Vagal stimulation
What are the 2 biomarkers for carcinoid tumors?
5-HIAA Chromogranin A (CgA)
What is used to treat carcinoid tumors? How does it work?
Octreotide. Somatostatin analog that binds to receptors on carcinoid tumors and inhibits the synthesis and release of tumor hormones. Also slows the growth of the tumor.
Normally is there more conjugated or unconjugated bilirubin in the portal vein?
More unconjugated bilirubin.
What does CCK do? (3)
Stimulates gallbladder contraction and secretion of pancreatic enzymes Inhibits gastric acid secretion by promotion production of somatostatin
What is the pathogenesis of hepatic encephalopathy?
The liver doesn’t perform the urea cycle which is responsible for getting rid of ammonia. Ammonia increase causes encephalopathy.
What is used to treat hepatic encephalopathy? How does it work?
Lactulose. Reduces ammonia absorption from the GI tract.
How does annular pancreas present?
Bilious vomiting vomiting, and a double bubble sign on X ray. Also polyhydramnios as a fetus.
What is the etiology of annular pancreas?
Bifid ventral pancreatic bud wraps around and squeezes the duodenum.
What should you suspect if you see a child with painless rectal bleeding?
Meckel’s diverticulum
What does metoclopramide do? What is the clinical use of this?
Antagonizes dopamine receptors, used as an anti-emetic agent.
Review the blood supply of the GI system
x
What is Reye syndrome?
Life threatening condition with derangement of metabolism following a viral illness. Can be deadly.
What is the histology of the liver in Reye syndrome?
Microvesicular steatosis.
What is the arterial supply to the esophagus?
Esophageal branch of left gastric artery-a branch of the celiac trunk. Left inferior phrenic artery
What is the arterial supply of the lesser curvature of the stomach? What is it a branch of?
Anastamoses between right and left gastric arteries. Celiac
What is the arterial supply for the greater curvature of the stomach? What is it a branch of?
Anastamoses between the right and left gastro-omental artery. Celiac
What is the venus drainage of the lesser curvature of the stomach? Does it go into the portal circulation?
The left and right gastric veins which go into the portal circulation.
What is the venous drainage of the greater curvature of the stomach? Does it go into the portal circulation
The left and right gastro-omental veins. They drain into the portal circulation via the superior mesenteric vein.
What arteries supply the proximal portion of the duodenum? What is it a branch of?
The gastroduodenal artery and the superior pancreaticoduodenal artery, which is a branch off the gastroduodenal/gastroepiploic artery.
Celiac artery from the aorta gives rise to all of this
What arteries supply the distal part of the duodenum? What is it a branch of?
The inferior pancreatico-duodenal artery. SMA
What artery supplies the jejunum and ileum?
The SMA
What vein drains the jejunum and ileum?
The SMV
What artery supplies the cecum? What is it a branch of?
The ileocolic artery, a branch of the SMA
What artery supplies the transverse colon? What is it a branch of?
The middle colic artery, SMA
What arteries supplies the the descending and sigmoid colons?
The Left colic and sigmoid arteries, branches of the IMA
What arteries feed the pancreas? What is it a branch of?
Inferior and superior pancreaticoduodenal arteries, branches of the SMA.
What veins drain the pancreas?
Pancreatic veins that drain to the splenic vein.
What artery supplies the liver? What is it a branch of?
The hepatic artery, from the celiac.
What artery supplies the gallbladder? What is it a branch of?
The cystic artery, from the right hepatic artery.
How does necrotizing enterocolitis present?
Septic shock, with high leukocytes. Also with feeding intolerance, abdominal distension and bloody stools.
What would one see on laporotamy with necrotizing enterocolitis?
Gangrene of the terminal ileum and ascending colon.
How does bowel obstruction present?
High pitched, tinkling bowel sounds
What drugs are contraindicated in patients with bowel obstruction? Name one example
Pro-kinetics like metoclopramide
What is barret’s esophagus?
Metaplasia of the non-keratinized squamous epithelium of the esophagus to columnar epithelium characteristic of the stomach.
What causes barret’s esophagus?
Long-standing gastroesophageal reflux.
What is zollinger ellison syndrome?
Gastrinomas that form in the pancreas
What does ZES result in in the stomach?
Continuous HCl secretion
What is Boerhaave syndrome?
Esophageal rupture after sever retching
What are the clinical signs of boerhaave syndrome? (3)
Severe retrostenal pain Evidence of air in inappropriate locations in the chest. Tachypnea and tachycardia.
Where are the endocrine cells that produce GI hormones?
Scattered throughout the GI tract.
Where is the only GI hormone produced in the antrum of the stomach?
Gastrin
What are the 4 clinical features often observen in cirrhosis?
Ascites Jaundice Gynecomastia Cognitive deficiets.
Are the lesions in Crohns disease continuous or skipping?
Skipping
Are the lesions in ulcerative colitis continuous or skipping?
Continuous
What cell type would be increased in ZES? Why?
Parietal cells: gastrin has a hypertrophic effect.
What cell type would be decreased in ZES? Why?
G cells in the stomach since gastrin is being produced by the tumor cells.
What happens if scleroderma affects the esophagus? Why?
Lack of esophageal motility in the distal esophagus. Distal esophageal muscle is replaced with fibrotic tissue.
What metabolic disease predisposes to vaginal candadiasis?
Diabetes
What does ischemic bowel disease look like macrosopically?
Sharply demarcated, dark and hemorrhagic section of bowel.
What is an endocrine complication of chronic pancreatitis?
Diabetes
What is GI complication of Acariasis infection?
Obstruction of the small intestine.
What are the most frequent causes of traveler’s diarrhea? (3)
E coli, Shigella, C jejuni
What is traveler’s diarrhea treated with?
Fluoroquinolones
How is UC treated?
With the 5-aminosalicylates: mesalamine, olsalazine, sulfasalzine
What is the gene defective in hereditary nonpolyposis colorectal cancer (HNCC?)
hMSH2 and hMLH1, which are responsible for mismatch repair
What cells release CCK?
I cells of the duodenum and jejunum
What is the stimulus for CCK release?
Fat and amino acids
What can CCK release contribute to?
Biliary colic
What happens to alcoholic steatosis if you stop drinking alcohol?
Complete regression
What do chief cells in the stomach secrete? What does this do?
Pepsin which aids with protein digestion.
What do D pancreatic islet cells secrete? What does this do?
Somatostatin, inhibits enzymatic secretions/hormonal secretion and gallbladder contractin
What does CCK do?
Stimulates pancreatic enzyme secretion and gallbladder contraction
What does gastrin do?
Stimulates secretion of gastric acid, pepsinogen and stimulates gastric motility
Where and what do G cells secrete?
Located in the stomach and duodenum, secrete gastrin
What do S cells secrete? What does this hormone do?
Secretin, which inhibits gastric acid secretion and stimulates pancreatic bicarb secretions to neutralize gastric acid
Where are S cells located?
In the duodenum
What is one function of migrating motility complexes?
Maintaining low bacterial counts in the upper intestine.
What is duodenal atresia?
Failure of recanalization of the duodenum’s lumen (the lumen is blocked).
How does duodenal atresia present?
Early bilious vomiting (usually with first feeding) and a double bubble picture in X-rays
What is duodenal atresia associated with?
Down syndrome
What presents similar to duodenal atresia?
Annular pancreas
What is procholrperazine? What is it used for? Where anatomically does it work?
Anti-emetic agent that blocks dopamine receptors in the chemoreceptor trigger zone of the 4th ventricle?
What does acute salicylate poisoning cause? (i.e. aspirin)
Respiratory alkalosis
How does acetaminophen hurt the liver?
Makes hepatotoxic metabolites
What is alkaline phosphatase a marker for?
Biliary tree pathology (gallstones)
What is pentagastrin?
A synthetic gastrin
Would there be a greater or smaller increase in gastric secretion if pentagastrin was administered in the context of chronic gastritis?
Smaller
What does somatostatin do to pancreatic bicarb secretion?
Decreases
What 2 factors potentiate pancreatic bicarb response induced by secretin?
Acetylcholine and CCK
What is the purpose of adding glucose to oral rehydration salts?
Primer the glucose sodium co-transporter.
What is a cancer that can present with painless jaundice?
Pancreatic cancer
What pro-kinetic/anti-emetic agent can result in pseudoparkinsoism?
Metoclopramide.
Review the anatomy of the ligaments in the abodmen
x
What ligament covers the pancreas anteriorly and superiorly?
The hepatogastric ligament
What structures are contained within the hepatoduodenal ligament? (3)
Common bile duct Proper hepatic artery Hepatic portal vein
What is a complication of cirrhosis involving ones anus?
Hemorrhoids
What is one way that hemorrhoids present?
Bright red blood in the stool.
What is the relationship of Ach, histamine and gastrin to acid secretion?
Synergistic
How does primary biliary cirrhosis typically present? (Plasma findings)
Elevated alk phos and conjugated hyperbilirubinemia
What is seen microscopically in primary biliary cirrhosis?
Chronic granulomatous inflammation around medium-sized intahepatic bile ducts
What is associated with primary biliary cirrhosis?
Anti-mitochondrial antibodies
With what GI procedure can vitamin D deficiency be seen?
Ileal resection. Vit D deficiency is secondary to fat malabsorption.
What electrolyte changes are seen in vitamin D deficiency?
Low calcium and phosphate.
What is Reye syndorme?
Encephalopathy and hepatic failure that presents in children younger than 15 years of age.
What disease is primary sclerosing cholangitis associated with?
Ulcerative colitis.
What structures does primary sclerosing cholangitis involve?
Intra-hepatic and sometimes extra-hepatic bile ducts
What would be the secretin levels in the context of a gastrinoma? Why?
High in an effort to decrease gastric acid secretion.
What do high levels of secretin result in?
Secretory diarrhea through increased levels of bicarb in the lumen.
What hormone is responsible for stress ulcers?
Pepsin
What is the gene mutated in familal adenomatous polyposis? What is the chromosomal location?
APC, 5q21
What shaped lesion does colon cancer produce radiographically?
Circumferential lesion.
What part of the small bowel to celiac disease affect?
The proximal small bowel.
What white oral plaque can be cancerous?
Leukoplakia.
What is gastroschisis?
Herniation of abdominal viscera near the midline
Elevation of what marker is seen with gastroschisis prenatally?
alpha-fetoprotein
What does the free edge of the lesser omentum contain?
The proper hepatic artery, the portal vein and the bile duct.
How do esophageal varices present?
Life threatening bleeding often.
What is pernicious anemia a risk factor for?
Gastric carcinoma
What are the signs and symptoms of hypertrophic pyloric stenosis?
Projectile, non-bilious vomiting after feeding Olive like, mobile epigastric mass that is palpable after the baby has vomited.
What is the opiod of choice for analgesia in acute cholecystitis? Why?
Meperidine because it is least likely to cause spasm of the sphincter of Oddi due to its anti-muscarinic properties
What is Meckel’s diverticulum? What causes it?
Congenital outpouching of the distal ileum. Failure of the vitelline duct to atrophy completely
What structure contains the splenic vessels?
The splenorenal ligament
What is achalsia? What is the etiology?
Loss of enteric inhibitory neurons resulting in increased tone of the lower esophageal sphincter.
What 2 cancers of the GI tract have a very poor prognosis?
Pancreatic adenocarcinoma and adenocarcinoma of the esophagus
What are 2 common causes of infective esophagitis in immunocompromised patients?
HSV, CMV
What does HSV esophagitis look like histologically?
Intranuclear eosinophilic inclusions
What two arteries does the splenic artery give rise to?
The short gastric artery and left gastroepiploic artery.
What gives rise to the cystic artery? What structure does the original artery exist within?
The hepatic artery which lies in the hepatoduodenal ligament.
What would obstructive jaundice result in urine wise? Why?
Tea colored urine due to increased urinary secretion of conjugated bilirubin
What is docusate?
A stool softener
What ethnicity is predisposed to get mixed and cholesterol gallstones?
Native american
What lab findings are elevated in patients with primary biliary cirrhosis? (4)
Alk phos AST/ALT Bilirubin Cholesterol
What is one deadly sequelae of diverticulitis?
Septic shock due to fecal peritonitis that leads to septicemia.
What is the level of the celiac artery leaving the aorta with respect to vertebrae?
T12
What organ near the foregut is not derived from endoderm?
The spleen, derived from mesenchyme
What does AST/ALT >1.5 suggest?
Alcoholic hepatitis
What is the only gastric hormone whose release is stimulated by fats, proteins and carbohydrates?
GIP
What is the most frequent site of a large bowel volvulus?
The sigmoid colon
What is intussusception?
When one segment of bowel telescopes into another segment, causing GI acute obstruction.
What is the peak age of presentation of intussusception?
5 to 10 months
What is the lymphatic drainage of the descending colon?
The inferior mesenteric lymph nodes, around the IMA
What are the 4 features of Von Hippel-lindau disease?
Autosomal dominant Retinal angiomas Hemangioblastomas of CNS (esp. cerebellum) Bilateral renal cell carcinomas/other tumors
Which MEN is associated with a marfanoid stature?
MEN2B
What are the findings associated with MEN2B? (4)
Medullary carcinoma of the thyroid Pheochromocytoma Neuromas of mucosal surfaces Marfanoid habitus
What is a useful test for diganosis medullary carcinoma of the thyroid?
Penta-gastrin stumulated calcitonin studies.
Where do AVM’s usually hemorrhage?
In the cerebral hemispheres.
What can hyperkalemia lead to EKG wise?
Tall, tented T waves
Does direct bilirubin mean conjugated or unconjugated?
Bilirubin conjugated.
What is a pharmacologic treatment for esophageal varices? How does it work?
Octreotide, by decreasing portal blood flow
What is the sequence of events leading to an MI from an atherosclerotic plaque?
Fatty streak leading to SMC proliferation with foam cells. Fibrous covering dislodges and becomes thrombogenic leading to occlusion of a coronary artery.
How does proylthiouracil work?
Inhibits thyroid peroxidase, interfering with the oxidation of iodide to iodine
Where should an intercostal nerve block be performed?
Just below the rib and lateral to the angle of the rib to be anesthetized
What does the lateral pterygoid muscle do?
Opens the jaw
What does the masseter muscle do?
Closes the jaw
What does the medial pterygoid muscle do?
Closes the jaw
What does the temporalis muscle do?
Closes the jaw
What is in the axillary sheath? (3)
Axillary artery, vein and brachial plexus
What is paget disease?
A chronic disorder characterized by increased bone density, cortical thickening and overgrowth. Skull enlargement can be seen
What are the lab findings in paget disease?
Normal alk phos, calcium and phosphate
Injury to what nerve would result in weakened wrist flexion? Why?
Ulnar-due to innervation of the flexor carpi ulnaris.
Injury to what nerve would cause loss of abduction and adduction of the digits?
Ulnar
What nerve innervates the hypothenar muscles?
Ulnar
What nerve is responsible for flexion of the 4th and 5th interphalangeal digits?
Ulnar
What nerve is responsible for sensation to digit 5 and half of 4?
Ulnar
What and who does Ewing sarcome affect?
The long bones of young patients
What does Ewing sarcoma look like histologically?
Small blue cells
What is a heritable disorder of collagen synthesis that may result in pathologic fractures in kids?
Osteogenesis imperfecta.
What is seen in terms of imaging in Osteogenesis imperfecta?
Multiple fractures in the absence of soft tissue damage
What can sometimes be indicative of osteogenesis imperfecta?
Blue sclera
What non-GI findings can be indicative of celiac disease?
Dermatitis herpetiformis, an itchy, papulovesicular skin lesion
How does thoracic outlet syndrome present?
Parasthesia on the medial aspect of one hand and forearm and a diminshed radial pulse on the affected side.
Review pg. 617 in clinical anatomy
x
What is being compressed in scalene triangel syndrome?
THe lower trunk of the brachial plexus and the subclavian artery between the anterior and middle scalene muscles.
What nerve is in the scalene triangle?
Phrenic nerve
What muscles does the median nerve innervate? (4)
Opponens pollicis, flexor pollicis brevis, abductor pollicis brevis, 1st and 2nd lumbricals
What muscles does the ulnar nerve innervate?
Adductor pollicis, all interosseus muscles, all digiti minimi muscles
What muscles does the radial nerve innervate?
Abductor pollicis longus, extensor indicis, extensor pollicis longus
What would one see histologically with rheumatoid arthritis?
A proliferative synovitis with lymphocytes, macrophages and plasma cells
What is McArdle’s disease? What is the underlying cause?
Glycogen storage disease that is restricted to skeletal muscle and is due to a myophosphorylase deficiency
What are the symptoms of mcardle’s disease?
Cramping and weakness during activity. Rhabdomyolysis sometime, leading to red urine
What is the source of bone-forming cells following a fracture?
Periosteum
What symptoms can myasthenia gravis present with that don’t involve the muscle?
Double vision/ptosis
Review pages 434 to 437 in clinical anatomy, esp brachial plexus
x
How is gout treated?
With allopurinol
What is gout due to?
An abnormality in the purine salvage pathway
How do gout crystals look? What are they composed of?
Negatively birefringent and needle shaped. Made of sodium urate crystals
What pattern of bone growth is seen in paget’s disease?
Mosaic pattern of newly formed woven bone
How does injury to the lower trunk of the brachial plexus present (C8-T1)?
Loss of motor function of the intrinsic hand muscles and numbness along the inner aspect of the hand.
What is the inheritance pattern of Duchenne’s?
X-linked recessive
Where does muscle weakness begin in duchenne’s?
Proximally in the lower extremities
How do kids with Duchenne’s get up from the ground?
With their arms
What is rhabdomyosarcoma a neoplasm of?
Striated muscle
Rhabdomyosarcoma: kids or adults?
Kids
Where does rhabdomyosarcome usually appear?
Head and neck
What is a marker for rhabdomyosarcoma histologically?
Desmin
What is the signaling mechanism of Beta-1 adrenergic receptors?
cAMP
What is usually associated with HepA infection?
Contaminated raw seafood
What pharyngeal arch gives rise to the trigeminal nerve and part of the maxillary artery?
1
What pharyngeal arch gives rise to the facial nerve?
2
What pharyngeal arch gives rise to the glossopharyngeal nerve, common carotid and internal carotid arteries?
3
What pharyngeal arch gives rise to the superior laryngeal bracnh of the vagus, the aortic arch and subclavian arteries?
4
What pharyngeal arch gives rise to the recurrent laryngeal branch of the vagus, the pulmonary arteries and ductus arteriosus?
6
What are the HYPER problems of thiazide diuretics? (4)
Hyperuricemia hypercalcemia hyperglycemia Hyperlipidemia (cholesterol and LDL)
What are the HYPO problems of thiazide diuretics? (2)
Hypokalemia Hypotension
What is the power of a study?
The probability of seeing a difference when one truly exists
What is type II error and how is it related to power?
Type II error: Stating there is no difference between groups when one exists = X Power = 1-X
What is Wilson’s disease?
Disease of copper due to ATP7B mutation on chromosome 13 which decreases the secretion and formation of ceruloplasmin, which carries copper into the biliary try.
How does Wilsons disease present?
Hepatic disease (wide range) neurologic (pariknosian like) symptoms Kayser-Fleischer rings
How does one identify Kayser-Fleischer rings?
With a slit lamp examination.
What are the toxins of ETEC? Which one is simular to cholera toxin? How does that toxin make watery diarrhea?
ST and LT. LT is similar to cholera toxin and activates cAMP leading to NaCL secretion and watery diarrhea. ST increases cGMP and also contributes to waterry diarrhea.
Where else are beta-1 receptors aside from the heart? What do they do there?
Juxtaglomerular cells of the kidney where they are used to release renin.
What do beta blockers due to renin production?
Decrease renin release
When is S4 heard?
Presystolic (right beforeS1)
What does and S4 represent?
Atrial contraction into a ventricle with reduced compliance.
What are the 2 types of insulin that diabetics usually have?
A basal long acting insulin and a postprandial short acting insulin
What are the basal long acting insulins?
Glargine and detemir insulin
What insulin is good for 18 hours/twice a day?
NPH
What are the short acting insulins that have a rapid onset time?
Lispro, aspart, glulisine
When would one use the normal insulin? (2)
For IV use/DKA
Name 1 possible presentation of pyruvate dehydrogenase deficiency? What is the pathogenesis?
Lactic acidosis. Pyruvate dehydrogenase normally converts pyruvate into acetyl-CoA, without oxygen (or pyruvate dehydrogenase) pyruvate is instead converted into lactic acid.
What are the amino acids that are exclusively ketogenic?
Lysine and leucine
What does the smooth ER contain?
Enzymes for steroid and phospholipid biosynthesis
What are the organs that have abundant SER?
Adrenals, gonads and liver
What is the collagen that dominates in scar tissue?
Type I
What contains type I collagen? (8)
Dermis Bone Tendon Ligaments Dentin Cornea Blood vessels Scar tissue
What is a disease of type I collagen?
Osteogenesis imperfecta
What contains type II collagen? (3)
Cartilage Vitreous humor Nucleus pulposus
What contains type III collagen? (7)
Skin Lungs Intestines Blood vessels Bone Marrow Lymphatics Granulation tissue
In what disease is collage type III messed up?
Ehlers Danlos syndrome
What contains collagen type IV?
Basement membranes
In what disease is collagen type IV messed up?
Alport syndrome
What is found in acute rheumatic carditis (bacterial infection)?
Aschoff bodies interstitial myocardial granulomas (plump macrophages with abundant cytoplasm)
How does Giardia lambia look on imaging?
A pear shaped, bilaterally symmetric organism, with 4 flagella and 2 nuclei
How does Giardia cause disease?
Adheres to duodenum and jejunum and causes inflammation.
What is the major immune defense molecule for Giardia?
IgA
What are the clinical features of Klinefelter syndrome? (XXY)
Hypogonadism Long slender habitus Small firm testes XXY
What would one expect for LH and FSH levels to be in a Klinefelter’s patient?
High because there are low levels of testosterone and inhibin due to a lack of testicular development
What injury typically injures the axillary nerve?
Anterior dislocation of the humerus
What are the potential side effects of glucocorticoid use?
Hypocalcemia Hypokalemia Hyperglycemia Hypernatremia Fluid retenion Think of it as acting like aldosterone when given at high levels
What amino acids are in type I collagen?
Glycine/proline
What would a knife wound to the left 4th intercostal space result in?
Injury to the right ventricle, the most anterior part of the heart.
What does osteoarthritis look like radiographically? (4)
Narrowing of the joint space osteophytes dense sclerotic bone subchondral pseudocysts
What does the flexor digitorum longus do?
Flexes the digits (plantar flexion)
Where does the flexor digitorum longus arise from?
The posterior surface of the middle tibia
Review the foot and leg anatomy
x
What is a potential complication of DMD that doesn’t involve walking?
Cardiomyopathy
How does compression of vertebral arteries present?
Carnial nerve/cerebellar abnormalities
How does spinal nerve compression at the cervical level present?
Pain, burning sensation and weakness
What disease produces fine, radiographically dense crystals that are composed of calcium pyrophosphate dihydrate?
Pseudogout
What are the motor targets of the median nerve?
Thenar muscles, 1st and 2nd lumbricals
What is a Baker’s cyst? Where does it appear?
Inflammation of the bursa-appears on the posterior of the knee.
What ions are released during prolonged muscle stimulation?
Potassium
What drug class is succinylcholine? How does it work?
Depolarizing muscle relaxant. Works by maintaining nicotinic receptors in an open state.
What muscle relaxant can cause hyperkalemia in burn patients?
Succinylcholine
What muscle protrudes the tongue?
Genioglossus
What muscle retracts the tongue?
Hyoglossus, plataoglossus
What cords is the muscluocutaneous nerve derived from? What roots does this represent?
The lateral (C5, C6)
What cords is the median nerve derived from? What roots does this represent?
Medial and lateral cords (C5-T1)
What cords is the ulnar nerve derived from? What roots does this represent?
The medial (C8-T1)
What does paralysis of the buccinator muscle result in?
Food and saliva accumulating in the mouth during chewing
What nerve supplies the buccinator?
Facial
What does the masseter muscle do?
Elevates the mandible
What nerve supplies the masseter muscle?
The mandibular division of the trigeminal nerve
What do the palatoglossus and palatopharyngeus muscles do?
Assist with swallowing
What nerve innervates the palatoglossus and palatopharyngeus?
Vagus
What is the I band composed of?
Actin
What is the A band composed of?
Myosin
Which band gets smaller during muscular contraction?
I band
Study the Brachial Plexus
What is cyclobenzaprine?
A centrally acting muscle relaxant with anti-cholinergic properties
How do corticosteroids promote osteoporosis?
Increased osteoclast activity and decreased osteoblastic activity
What may be fractured when someone falls on the ground with an outstreched hand or hits the ground hard with a stick? What are the clinical findings?
Hook of hamate, results in ulnar nerve damage.
What controls the velocity of muscle contraction?
Myosin ATPase activity
What function does the subclavius muscle serve?
To protect structures underneath the clavice: the brachial plexus and associated vessels
What non-GI diseases are associated with Celiac’s disease?
Osteoporosis
What do metastatic lesions to bone look like?
Sclerotic
What does scaphoid fracture result in?
Pain over the anatomic snuffbox
What is alkaptonuria?
Deficiency of homogentistic oxidase
What are the symptoms of alkaptonuria (2)?
Black urine and joint damage
How does DMD arise spontaneously?
Frameshift mutations that oocur during meiosis I
What conditions are associated with HLA B27? (5)
Reiter syndrome (Can’t see, can’t pee, can’t climb a tree)
Acute anterior uveitis
Postgonococcal arthritis
Ankylosing Spondylitis
Psoriatic arthritis
What is the nerve that runs in the carpal tunnel?
Median
What are Heberden nodes?
Distal interphalangeal joint bony swelling
What are Bouchard nodes?
Bony swelling of proximal interphalangeal joint
What is the etiology of osteoarthritis?
Repetitive joint trauma
What bounds the carpal tunnel anteriorly?
Flexor retinaculum
What bounds the carpal tunnel posteriorly?
Carpal bones.
What artery is the main artery of the anterior arm?
What artery courses in the anatomic snuffbox?
What muscles does the axillary nerve innervate?
The teres minor and the deltoid muscle.
What is a Trendelenburg sign?
When a patient stands on one leg and the hip on the lifted leg side drops.
What does a positive Trendelenburg sign represent?
Paralysis of the muscles that abduct the hip: the gluteus medius and minimus.
What are the bones that form from intramembranous ossification?
Skull, facial bones, clavicals (basically above the neck)
What is cleidocranial dysotosis?
Absence of the clavicles with a broad skull, facial and dental anomalies.
What does calcitonin do?
Opposes increases in blood calcium levels
What is delusional disorder characterized by? What is it NOT characterized by?
The presence of non-bizarre delusions for at least one month.
Non bizarre: situations that are unlikely but possible.
These patients do not have “general life” impairment like schizophrenics.
What can C02 be viewed as equivalent too?
Acid
What will happen to PaC02 in the context of metabolic acidosis?
Should decrease since the patient will dry to decrease acid by ‘blowing off’ CO2.
What is metabolic acidosis characterized by in terms of pC02 and bicarb?
Decreased serum bicarb (primary problem) and decreased PaC02 as a response.
What non-cancerous cell types have relatively high levels of Alk phos?
Bone and liver/heptobiliary
What should an elevated alk phos of unclear etiology be followed up with?
gamma-glutamyl transpeptidase-more specific for hepatic injury
What do ANP and BNP do?
Faciliate natriuresis and diuresis
How does polymyositis present?
Symmetric proximal muscle weakness
What is the etiology of polymyositis?
Overexpression of MHC class I leading to CD8 lymphocyte infiltration and myocyte damage.
What are the lab findings for polymyositis? (2)
Increased creatine kinase
anti-Jo-1 antibodies
What is thalamic syndrome?
Vascular lesion of the thalamus which causes complete contralateral sensory loss
What is lipohyalinosis?
Vessel lesion that are composed of mural foam cells, fibrinoid vessel wall necorsis and appear as cavities filled with clear fluid.
What are lacunar infacrctions?
Small, 5 mm cavities located in deep brain structures (basal ganglia etc.)
What causes lacunar infarctions?
Lipohyalinosis and atherosclerosis
What are risk factors for lipohyalinosis and lacunar infarctions?
Uncontrolled HTN, DM
Is JAK2 a receptor tyrosine kinase?
NO!
What is the cell type that is responsible for PVera?
Clonal proliferation of HSCs
How do inhaled anesthetics affect cerebral blood flow?
Increase
How do inhaled anesthetics affect the respiratory system?
Respiratory depression
How do inhaled anesthetics affect CV system?
Myocardial depression: decreased CO, increased atrial and ventricular pressures.
Decreased CO leads to hypotension
How do inhaled anesthetics affect the kidneys?
Decreased GFR and RPF
How do fluorinated anesthetics affect the liver?
Decrease hepatic blood flow
What types of interferons are produced by non-immune cells in response to viral infection?
Infererons alpha and beta
What doe interferons alpha and beta do?
They act as cytokines on neighboring cells, stimulating them to synthesize anti-viral proteins that impair viral protein synthesis.
Draw out the galactose metabolism pathway. Which enzyme is usually deficient in galactosemia?
Galactose 1 phosphate uridyl transferase
How does galactosemia usually present?
Vomiting, lethargy, failure to thrive soon after breastfeeding has begun.
What is the mnemonic for atropine (anti-muscarinic) poisoning?
Blind as a bat, mad as a hatter, hot as a hare, dry as a bone, the bowel and bladder lose their tone and the heart runs alone.
What does the enzyme PRPP synthetase do? What would over activity of this enzyme potentially lead to?
Produces purines
Could produce gout
What cells are responsible for the inflammation observed with gout?
Neutrophils
What does Colchicine do? What disease is it used to treat?
Prevents microtubule formation
Used to treat gout by inhibiting neutrophil chemotaxis
What tumor cells express CD31?
Hepatic angiosarcoma
What chemical exposures are associated with hepatic angiosarcoma?
Arsenic, thorotrast, polyvinyl chloride
Name 5 drugs that would accelerate warfarin metabolism by inducing the cytochrome p450 system?
Rifampin
Griseofulvin
Barbituates
Carbamazepine
Phenytoin
Name 4 drugs that would decrease warfarin metabolism by inhibitng the p450 system
Trimethoprim
Isonaizid
Fluconazole
Cimetidine
Where does iron absorption occur?
The duodenum and proximal jejunum
What is diagnositc of echocardiogram for TGA?
Aorta lying anterior to and to the right of the pulmonary artery
What 2 drugs are well know for causing drug-induced lupus erythematosus (DILE)?
Procainamide, hydralazine
What 2 antibodies may be present in DILE? What antibody would probably not be seen?
Present in DILE: ANA and anti-histone
Not present in DILE: Anti-dsDNA
How does glycogen get degraded during weight lifting? (4 step process)
1) Calcium is released by muscle contraction
2) Increased calcium astoerically activates phosphorylase kinase
3) Phosphorylase kinase phosphorylates and activates muscle phosphorylase
4) Phosphorylated Muscle phosphorylase breaks down glycogen in the muscle.
What is the portal and systemic circulation for esophageal varices?
Portal: left gastric vein
Systemic: esophageal vein
What is the portal and systemic circulation for hemorrhoids?
Portal: superior rectal vein
Systemic: Middle and inferior rectal veins
What are the portal and systemic circulation for caput medusae?
Portal: paraumbilical veins
Systemic: superior and inferior epigastric veins
What is one possible etiology of Paget’s disease?
Paramyxovirus infection of osteoclasts.
What would injury to the lower trunk of the brachial plexus look like?
Loss of abduction and adduction of the digits.
Loss of opponens ability of the thumb
Where does the long saphenous vein run and drain?
What lymph nodes does it drain into?
The medial side of the leg
Inguinal lymph nodes
Where does the short saphenous vein drain and run?
What lymph nodes does it drain into?
Drains the lateral side of dorsum of the foot and runs on the posterior aspect of the leg
Drains into lymph nodes in the popliteal fossa
What color are the crystals in gout if viewed parallel? Perpendicular
Parallel: yellow
Perpendicular: blue
What drug used to treat chronic arthritis has a sulfa component?
Celecoxib
What nerve wraps around the head of the fibula?
The common fibular nerve
What does the fibular nerve do motor-wise?
Innervates muscles that dorsiflex the foot.
Review the sensory innervation of the foot/leg
What is the only muscle that can elevate the eye from the abducted position?
Superior rectus
What should one use to treat an acute attack of gout?
Colchicine and NSAIDs like indomethacin
What is Legg-Calve-Perthes disease? What artery is affected? What is it a branch of?
Avascular necrosis of the femoral head.
Medial femoral circumflex artery-a branch of the femoral
How does Legg-Calve-Perthes disease present?
Limp with referrered pain to the anterior thigh.
What is a plasmacytoma? What are the lab findings?
Localized soft-tissue myeloma with an M-spike on SPEP.
What nerve extends the thumb?
Radial
What are 4 disease that may cause clubbing?
Lung cancer
Lung disease
Congenital cyanotic heart disease
Liver disease
What happens when you lift heavier weights (2 things)
Increased number of motor units are recruited
Increased frequency of motor nerve action potentials
What would you see on histology of subcutaneous nodules in rheumatoid arthritis?
Fibrinoid necrosis with palisalting epetheliod cells
What muscles elevate the tongue? (2)
Styoglossus (CN XII)
Palatoglossus
What is the formula for the confidence interval?
Mean +/- zscore *SD/sqrt n
SD/sqrtn = SEM
What is the diagnosis when a patient has schizophrenic like symptoms but for less than 6 months?
Schizophreniform disorder
What is the maximal amount of time symptoms can last for someone to be diagnosed with a brief psychotic disorder?
One month
What structures are specfic to the duodenum?
What do they secrete?
Tubular Brunner’s glands
Secrete alkaline fluid
What structure is unique to the ileum?
Peyer’s patches
What can failure of migration of the thyroid result in?
Lingual thyroid
What are the clinical features of hypothyroidism in children/
Dry skin, lethargy, feeding problems, prolonged jaundice
What change in hepatocytes is seen with statin treatment? Why?
Upregulation of the LDL receptor
Occurs since there is less circulating LDL
What is altruism medically?
Alleviation of guilty feelings through selfelss service or giving
What would CCBs due to pacemaker cells? Why?
Slow the gradual diastolic depolarization
The gradual diastolic depolarization is due to sodium and, towards the end, calcium influx
What causes paroxsymal supraventricular tachycardia?
Re-entrant cirucit in the AV node.
How does carotid massage affect the AV node?
Prolongs the AV node refractory period
What drug is used to treat insomnia and depression-associated insomnia?
Trazodone
What is a potential side effect of trazodone use?
Priapism
What is prevalence?
The total number of cases at a particular point in time
What is incidence?
The number of new cases diagnosed in a given period of time
What is the relationship between incidence and prevalence?
Prevalence = incidence x time
What is lymphangiosarcoma?
A neoplasm of the endothelial lining of lymphatic channels
What predisposes to the development of lymphangiosarcoma?
Persistent lymphedema-chronic dilatation of lymphatic channels
What molecules induce chemotaxis in neutrophils? (5)
IL-8
C5a
Leukotriene B4
5-HETE (leukotriene precursuror)
N-formylated peptides
What is the molecular mechanism of insulin resistance?
Serine and threonine residue phosphorylation by serine kinase.
What promotes the activity of serine kinase? (4)
TNF-alpha
Catecholamines
Glucocorticoids
Glucagon
What is the path of the median nerve through the arm? (2 parts)
1) courses through the humeral and ulnar heads of the pronator teres
2) courses between flexor digitorum superficialis and flexor digitorum profundus
What is ganciclovir?
A guanine nucleoside analogue
What is ganciclovir used to treat?
CMV retinitis
What is acyclovir used to treat?
HSV infections
What is interferon-alpha given to treat?
Hep B and C infection
What type of overload is seen in aortic regurgitation? What would this result in with respect to ventricular remodeling?
Volume, not pressure overload
Results in eccentric hypertrophy with chamber dilatation.
What are Thiazolidinediones (pigolitazone, troglitazone etc) used for? How do they work?
DM treatment
Decreases insulin resistance
What are the major side effects od thiazolidinediones?
Hepatotoxicity
Increased fluid retention (don’t use for CHF)
What does niacin do pharamcologically?
Prevents the conversion of cholesterol to VLDL
How is NAD+ regenerated during anaerobic glycolysis?
NADH transfers electrons to pyruvate to form lactate and regenerate NAD.
What step is NAD required for in glycolysis?
Conversion of glyceraldehyde-3-phosphate to 1-3-bisphosphoglycerate.
What are is long standing IBD associated with an increased risk of?
Colorectal cancer
What do colitis associated carcinomas arise from?
Non-polyploid dysplastic lesions
Colitis associated carcinoma: mutlifocal or one focus?
Multifocal
Colitis associated carcinoma: p53 early or late? APC early or late?
p53 early
APC late.
Colitis associated carcinoma: high or low grade typically?
High grade
When does Klumpke paralysis occur?
During a breech delivery with the arms in an extended position after the head.
What is the pathogenesis of Klumpke paralysis? Which part of the brachial plexus is affected?
Stretching of the lower part of the brachial plexus (C8-T1) resulting in:
Weakness of the intrinsic hand muslces
Numbness along the inner aspect of the hand
What is 1 very superifical structure in the politeal fossa?
Common fibular nerve
What muscle does a spinal infection commonly spread to?
The psoas major
What does the psoas major muscle do?
Flexes the hip
What does a psoas abscess look like?
Bulge on one flank with a similar buldge in the groin on the same side.
What muscles does the superficial fibular nerve innervate?
The muscles of the lateral compartment of the leg
What muscles does the deep fibular/peroneal nerve innervate?
Dorsiflexors of the foot and the extensor digitorum longus.
What muscles does the superficial peroneal nerve innervate?
Lateral muscles of the foot (involved in foot eversion.
What would compression of the superficial peroneal look like sensory wise?
Loss of sensation over the dorsum of the foot.
A fracture of what part of the humerus would result in loss of abduction of the arm and loss of sensation over the lateral upper arm? What nerve is injured?
Surgical neck
Axially nerve
Where would the humerus have to be fractured to injure the radial nerve? (2)
Lateral epicondyle
Mid shaft
Where would the humerus have to be fractured to cause injury to the ulnar nerve?
Medial epicondyle
What is the calcium binding protein in skeletal and cardiac muscles?
Troponin
What is the calcium binding protein in smooth muscle?
Calmodulin
What happens in injury to the upper trunk of the brachial plexus?
The arm is medially rotated and adducted.
What is seen histomogically with rickets?
Widened osteoid seams
What protein in the SR is responsible for lowering calcium stores post muscle contraction?
Calsequestrin
What nerve innervates the opponens pollicis?
The median nerve
Before the median nerve enters the carpal tunnel what two tendons does it run between?
The palmaris longus tendon and the flexor carpi radialis tendon.
What would you expect alk phos, calcium and PTH to be in a Paget’s disease?
Alk phos elevated
PTH normal
Calcium normal
Nerve root mediates elbow flexion?
C5
What nerve roots are responsible for finger extension?
C7, C8
What nerver roots are responsible for extension of the shoulder?
C7, C8
What nerve roots mediate flexion of the wrist?
C6, C7
What nerve roots mediate pronation of the elbow?
C7 and C8
What disease that may be caused by a virus can increase bone density?
Ostetitis deformans AKA Paget’s disease
What is the basis of McArdle disease?
Muscle phosphorylase deficiency
What does muscle phosphorylase do?
Liberates glucose one phosphate from glycogen
How does McArdle’s disease present clinically?
Painful cramps and myoglobinuria during strenuous exercise
No increase in lactic acid in the blood during exercise (as would normally be seen)
What artery supplies the lower third of the forearm?
The anterior interosseus artery.
What does it mean chemically to have 3 titratable protons?
3 different PKas
Which amino acids have 3 titratable protons?
Histidine
Arginine
Lysine
Aspartic acid
Glutamic acid
Cysteine
Tyrosine
What are the 2 most common cause of death in patients with TCA overdose?
Refractory hypotension and cardiac arrythmias
What causes cardiac arrythmias in TCA overdose?
Inhibition of fast sodium channels in cardiac myocytes.
What is ataxia telangiectasia?
Inheritance pattern?
Gene class?
Clinical manifestations (2)
AR
DNA repair gene
Cerebellar ataxia, repeated sinopulmonary symptoms
What biochemical proccesses occur in the mitochondria? (5)
Beta oxidation of fatty acids
Ketogenesis
TCA
Urea cycle (caramoyl phosphate synthetase 1, ornithine transcarbamoylase)
Pyruvate carboxylation
What biochemical process occurs in the cytoplasm? Name one enzyme of this pathway?
Pentose phosphate pathway
Transketolase
Draw out this pathway 3x
What nuclei releases serotonin in the brain?
Raphe nuclei
What e coli virulence factor is implicated in neonatal menigitis?
K1 capsular polyssacharide
What molecule promotes the migration of SMC from the media into the intima and allows for their proliferation?
What cell types secrete this molecule?
PDGF
Adherent platelets, Endothelial cells, Macrophages
What does the zona glomerulosa secrete?
What does the fasiculata secrete?
What does the reticulata secrete?
Glomerulosa: aldosterone
Fasiculata: cortisol
Reticularis: small amounts of androgens
What is passive aggresive behavior for the USMLE?
Expression of hostile feelings in a non-confrontational manner.
What is buspirone used to treat?
What is its target? Agonist/antagonist?
Generalized anxiety disorder
5HT1A receptor agonist
What are 2 advantages of buspirone over benzos?
Less chance for abuse
No hypnotic effects
What type of cancer is HPV associated with in men?
What serotypes?
Anal carcinoma
16, 18, 31
What would be seen on stool microscopy with vibrio or ETEC diarrhea?
Mucus and epithelial cells
What would be seen on stool microscopy with Salmonella enteridis?
Leukocytes with predominant neutrophils
What would be seen on stool microscopy for diarrhea due to EIEC or Shigella?
Erythrocytes and some leukocytes.
What would be seen on stool microscopy for EHEC diarrhea?
Erythrocytes without leuckocytes (kills epithelial cells but doesn’t invade)
What class of drugs causes methemoglobinemia?
Nitrites
What are the 3 classic features of Turners?
Primary amenorrhea
High arched palate
Widely spaced nipples
What happens to the ovaries in turners?
Ovarian dysgenesis
How do non-K+ sparing diuretics result in hypokalemia?
A decrease in intravascular volume leads to increased aldosterone secretion resulting in hypokalemia
How does hypokalemia manifest?
Muscle cramping and weakness
What is a common cause for elevated alpha-fetoprotein?
Underestimation of gestational age
What do high levels of afalotoxin exposure increase the frequency of?
What cancer does this predispose to?
G to T mutation in codon 249 of the p53 gene.
Greatly increases the risk of HCC
What drug class can cause angioedema?
How does angioedema present?
What is the etiology?
ACE inhibitors
Diffuculty breathing, swelling usually involving part of the face
Increased bradykinin levels increase vascular permeability
What is a side effect of colchine use?
Why?
Nausea, vomiting and diarrhea
The tomach needs microtubules for motility
How does Mifepristone work?
What is it used for?
What agent is it commonly used with to increase its effectiveness?
Anti-progestin agent
Used for abortions-progesterone is necessary for implantation and maintanence of pregnancy
Misoprotol, a prostaglandin analog is used with it
In whom does meningococcal septicemia often happen?
Young children
What is the combination of lab findings usually seen in adrenal hemorrhage? (3)
Hyponatremia
Hyperkalemia
Hypoglycemia
What would be the skin findings of meningococcal septicemia?
Petechial rash over the trunk, lower extremities
What is a common complication of meningococcal septicemia?
Adrenal hemorrhage (Waterhouse Friderichsen syndrome)
What lavers do you pass through for a cricothyrotomy?
Superficial cervical fascia
Pretracheal fascia
Cricothyroid membrane
When is a cricothyrotomy indicated?
When an emergency airway is required and orotracheal or nasotracheal intubation is not a good option.
What is the mechanism of phosphate reabsorption? (2)
Where does this occur?
Active transport and Na+ coupled transport
Proximal tubule
What causes cytinuria?
What do the stones look like?
What are the clinical manifestations?
Genetic defects in renal reabsorption of cysteine
Radiopaque stones
Colicky pain
What is responsible for renal glucose reabsorption?
At what serum glucose level does glucose appear in the urine?
Sodium glucose co-transporter
Above 200 mg/dL
What is the usual clinical presentation of Berger disease? What does it follow?
Hematuria following a recent viral infection
What is the pathogenesis of Berger disease?
IgA deposition in the glomerular mesangium
What structure gives rise to the definitive kidney?
The ureteric bud
What induces the development of the metanephros?
The ureteric bud
What class of diuretics should be used to treat edema in patients with low creatinine clearance?
Loop diuretics
What is prerenal failure defined as?
Renal failure due to decreased renal blood flow
What would the fractional sodium excretion be in prerenal failure?
Why?
Less than 1%
Since their is low renal plasma flow the patient is try to increase blood volume
What would the fractional sodium excretion be in a patient with ATN?
Greater than 2%
What type of diuresis does acetazolamide cause?
Osmotic diuresis
What does the osmotic diuresis of acetazolamide result in at the macula densa?
Increased delivery of sodium to the macula densa
What does increased Na at the macula densa result in?
Constriction in the afferent arteriole
What is a side effect of cyclosporine use?
Nephrotoxicity
Ureteropelvic junction obstruction:
Common or uncommon?
Males or females?
Common
Males
What is the formula for clearance of a substance?
Clearance = urinary excretion/plasma concentration
What does inulin represent? Why?
GFR since it is neither secreted nor reabsorbed
What is a renal failure diet?
Why?
Low protein
High carbs
Moderate fat
To prevent gluconeogenesis (and its associated nitrogenous products)
What agent should not be co-administered with fluoroquinolones?
Why?
Antacids
Decreased bioavailability
Where would tubular osmolatrity be lowest with high ADH levels?
In the early parts of the DCT
Where does PTH act in the kidney? What does it do there
In the DCT to increase calcium reabsorption
What is urinary incotinence?
What causes it?
Uncontrolled loss of urine preceded by a strong, unexpected urge to void
Detrusor hyperreflexia or sphincter dysfunction
What are oxybutynin and tolterodine used for?
Urge incontinence
How do oxybutynin and tolterodine work?
Block muscarinic receptors and cause detrusor muscle relaxation
What part of the tubule is impermeable to water?
What goes on in these segments?
What does that mean for tonicity?
The cortical thick ascending limb and early distal tubule.
Solutes actively reabsorbed
Means that tonicity is very low in those regions
What are the features of nephrotic syndrome?
Proteinuria
Hypoalbuminemia
Edema
Hyperlipidemia
What is seen microscopically in minimal change disease?
Effacement of foot processes
What type of kidney disease happens in minimal change disease?
Nephrotic syndrome
What organ systems does Goodpasture syndrome target?
What is the molecular pathogenesis of Goodpasture?
The kidney and the lungs
IgG directed against the basement membrane of glomeruli and alveoli
What is one side effects of amiodarone therapy?
Why?
Hypothyroidism
It is 40% iodine by weight
What substance is responsible for regression of the paramesonephric (mullerian) ducts?
MIF
How does toxin B of C diff work?
Destabilizes the cellular cytoskeleton
What is linkage disequilibrium?
If 2 or more alleles are inherited more or less frequently together than would be expected by random chance
Can happen even if the alleles are on different chromosomes
What are the 3 stop codons (write them down)?
UAA
UAG
UGA
What does DiGeorge syndorme have immunologically?
Thymic aplasia
Smaller paracortex regions
Name 2 oncogenes that act as transcription factors
c-fos, c-jun
What goes through the SOF?
CN III, IV, V1, VI and superior opthalmic vein
What is the reflex arc for the corneal reflex?
CN V1 (afferent) via SOF to CN VII (efferent)
What does N-acetylglutamate do? What does this contribute to?
Activates carbamoyl phosphate synthase I
Part of the urea cycle
Draw out the urea cycle
x
What is the IVC formed from?
The union of the common iliac arteries
Review CT sections of the abdomen
What are koliocytes?
What disease are they associated with?
Squamous epithelial cells with a peri-nuclear clearing
HPV
What injury is falling on an outstreched hand associated with?
Scaphoid fracture
What is a complication of scaphoid fracture?
Avascular necrosis of the scaphoid
How does scaphoid fracture present?
Pain in the anatomic snuffbox
What is a potential complication of infliximab treatment?
Reactivation of latent tuberculosis.
How can the fick equation be used to calculate CO?
O2 consumption/AV O2 difference
How do colipdogrel and ticlopidine work?
What class of drugs are they?
What is one side effect of ticlopidine?
Block ADP preventing platelet aggregation
Anti-platelet
Neutropenia
How can ACE inhibitors cause acute renal failure?
Prevents efferent arteriole vasoconstriction which reduces renal filtration.
How does the heart respond to nitrate use?
How can you blunt this?
Nitrates induce a relative hypotension that the body responds to with catecholamine release
Can blunt this with beta blockers
What is the mecahnism of stress ulcers in response to head trauma?
Increased parasympathetic outflow, leading to high gastric acid secretion
Parasympathetic outflow attempts to decrease CPP
What would you expect the following characteristics to be for an inhaled anesthetic with high blood/gas partition coefficient:
Amount needed to saturate blood?
Rise in partial pressure in blood?
Equilibriation with the brain?
Onset of action?
Total amount that has dissolved in blood at max saturation relative to low blood/gas partition?
Amount needed to saturate: large
Rise in partial pressure: Slow
Equilibriation with the brain: Slow
Onset of action: Slow
Total amount dissolved relative to low blood/gas at max saturation: Higher
What would you expect for an inhaled anesthetic with a low blood gas partition coefficient?
Amount needed to saturate blood
Rise in partial pressure in the blood
Equilibriation with the brain
Onset of action
Amount needed to saturate blood: Small
Rise in partial pressue: Rapid
Equilibriation with the brain: Rapid
Onset of action: Rapid
What is LEMS? What other disease is it associated with?
Neuromusclar disorder presenting with:
Proximal muscle weakness
Cranial nerve involvement
Autonomic symptoms
Associated with malignancy (usually lung cancer)
What is CEA a useful marker for with respect to colon cancer?
Detecting disease recurrence
What does the ureteric bud give rise to? (4)
Ureters
Renal pelvis
Calyces
Collecting tubules
What do the paramesonephric ducts give rise to? (3)
The uterine tubes
Uterus
Upper third of the vagina
What does the urogenital sinus give rise to? (3)
Urinary bladder
Urethra
Sexual glands
What does the urorectal septum separate? (2)
The urogenital sinus and rectum
What causes renal papillary necrosis?
DM
Analgesic abuse
Sickle cell disease
Aside from low oxygen, what other condition can cause sickling of RBCs?
Where does this occur in the kidney?
What does this lead to?
High osmolarity
Occurs in the vasa recta of the renal medulla
Leads to papillary necrosis
What places in the kidney are responsible for ADH-independent water reabsorption? (2)
PCT and loop of henle
What part of the kidney is responsible for most water reabsorption?
PCT (65%)
What is the pathophysiology (involving the kidney) behind essential hypertension in some patients?
Increased sympathetic activation of renin release
What would a carbonic anhydrase do to NH4+ excretion?
Why?
Decrease
Think of it as less intracellular H+ ions
What would thrombosis of the renal vessels look like histologically?
Diffuse cortical necrosis.
What type of GU disease are casts in the urine indicative of?
Kidney disease/involvement
What is damage to the renal arteries often a sign of?
Hypertension
What is a clinical complication of kidney/urinary stones?
Pyelonephritis
What does the obliterated urachus form?
What does that structure do?
What does failure of the urachus to be obliterated cause?
The median umbilical ligament, which connects the upper end of the bladder to the umbilicus
Drainage of the urine through the umbilicus
Wilms tumor:
What is its origin?
Where does it present?
What does it appear like histologically?
Embryonic renal blastema
Unilateral abdominal mass
Forms primitive renal structures
What controls sodium reabsorption in the distal tubule?
Aldosterone
What substance is freely filtered and secreted in the proximal tubule?
Creatinine
How do osteocytes communicate with each other?
Via gap junctions
What are abnormalities of the omphalomesenteric (vitelline) duct responsible for?
Meckels diverticula (rules of 2)
Enterocysts.
What is responsible for the different severity of mitochondrial diseases?
Heteroplasmy: Mitochondria are randomly distributed between daughter cells during mitosis
If cells have less of the bad mitochondrial DNA then smaller phenotype
What pattern of inheritance do mitochondrial disorders display?
Exclusively maternal
What is Leber hereditary optic neuropathy?
What is its inheritance pattern? Why?
Bilateral vision loss
Maternal/mitochondrial
What is myoclonic epolepsy with ragged red fibers?
What is seen histologically?
What is the pattern of inheritance? Why?
Myoclonic seizures and myopathy associated with exercise
Ragged red fibers seen histologically
Maternal/mitochondrial
What is mitochondrial encephalomypathy with lactic acidosis and stroke-like episodes (MELAS)?
What is the pattern of inhertiance? Why?
Seizures/strokes, muscle weakness, increased serum lactate levels
Maternal/mitochondrial
What is the drug of choice for treating heroin addiction? Why?
Methadone
Long half life
What is obstructive sleep apnea caused by?
Poor oropharyngeal tone during sleeping, resulting in airway obstruction during sleeping
What are the clinical symptoms of obstructive sleep apnea? (3)
Daytime sleepiness
Morning headaches
Depression
What are the levels of total T4/T3 with estrogen treatment?
What are the levels of free T4/T3 with estrogen treatment?
Total increased
Free normal
What would a water deprivation test show in a patient with primary polydipsia?
Significant increase in urine osmolality
What would the serum sodium look like in a patient with primary polydipsia?
Low
What is the treatment for primary polydipsia?
Water restriction
What is the characteristic finding of common peroneal nerve damage?
Foot slap.
What other disease can clostridium perfrigens cause aside from gas gangrene?
Late-onset food poisoning resulting in a transient, watery diarrhea
What sinuses are frequently filled with fluid during orbital blowout fractures?
The ethmoid and maxillary sinuses
Review pg 529 and 589 in clinical anatmy
x
What is the most important treatment for a child actively suffering from diptheria exotoxin?
Why?
Anti-toxin/passive immunization
Inactivates circulating toxin, which antibiotics/active immunization will not do
What is high QRS in the precordial leads inidcative of?
Ventricular hypertrophy
What is the range at which glucosuria occurs?
180-200 mg/dL
What does the blood pressure of patients with adult polycystic kidney disease look like?
Very high
What is a side effect of ACE inhibitors renally?
Why does this make sense?
Acute renal failure
Blocking the formation of angiotensin II should decrease the GFR
What is nephrotic syndrome? (3)
Protein loss due to ‘leaky’ capillaries
Hyperlipidemia
Edema
What is nephritic syndrome? (4)
Hematuria
Azotemia
Oliguria
Sometimes hypertension
Not as much proteinuria as nephrotic
What percentage of salt intake do the kidneys excrete?
95%
What should you treat probable E coli UTIs with?
IV amp and gentamicin
What is the chemical composition of stones caused by urease + bacteria (like Proteus)?
Magnesium ammonium phosphate
What do prostaglandins do in the kidney?
What would a decrease result in, in a patient with a stressed kidney?
Vasodilate the afferent arteriole
Lower prostaglandin levels would result in potentially acute renal failure
What is type of epithelium covers the nose?
Pseudostratified columnar
What type of epithelium covers the nasopharynx?
Pseudostratified, columnar
What type of epithelia lines the larynx?
Stratified squamous epithelium
What type of epithelium covers the tracheobroncheal tree?
Pseudostratified columnar
What type of epithelium covers the oropharynx, anterior epiglotits, upper half of the posterior epiglottis and vocal folds (true vocal cords)?
Stratified squamous epithelium
What condition are ARBs (losartan) good for besides hypertension?
Diabetic nephropathy
What class of drugs does clozapine belong to?
What is its molecular target?
What are its potential side effects? (2)
Anti-psychotics
D4
Agranulocytosis, seizures
What are the 2 cytokines that down-regulate the immune response?
TGF-beta
IL-10
How does trigeminal neuralgia present?
What is the drug of choice for trigeminal neuralgia?
Stabbing pains on the face
Carbamazepine
Where does uric acid usually precipitate in the kidneys?
Why?
In the distal tubules and collecting ducts
Most acidic environment in the kidney
Where does the musculocurtaneous nerve provide sensory information to?
To the lateral forearm
What is the side effect of phenytoin that affects the gums?
What is the mechanism?
Gingival hyperplasia
Due to increased PDGF which stimulates proliferation of gingival cells
What is a side effect of phenytoin (not gum related)?
Ataxia, nystagmus
What is the inheritance pattern of hemophilia B?
X-linked recessive
What is the inheritance pattern of HD?
AD
What is the inheritance patern of Lesch Nyhan syndrome?
X-linked recessive
What is the inheritance pattern of leber hereditary optic neuropathy?
Mitochondrial
What is the inheritance pattern of galactosemia?
AR
What is high output congestive heart failure and neurologial symptoms suggestive of?
Thiamine deficiency
Wet beriberi
What is the cofactor needed for the synthesis of delta-aminolevulinic acid?
When is delta-aminolevulinic acid elevated?
Pyridoxal phosphate
Elevated in cases of lead poisoning
What is different about procollagen compared to collagen moleculary?
What syndrome is this seen in?
Procollagen has disfulide rich termini (that peptidases normally cleave off)
Ehlers Danlos Syndrome
What contributes to the increased risk of cholelithiasis in women who are pregnant or are on OCT? (2)
Estrogen induced cholesterol hypersecretion
Progesterone induce gallbladder hypomotility
What does loss of infectivity of a viral particle after exposure to ether tell you?
Its enveloped
What causes hypo/hyperpigmented skin patches that are more visible after tanning?
Malassezia furfur
What lymph nodes drain the glans penis and superficial nodes?
The deep inguinal nodes
What lymph nodes drain the testes?
Para-aortic nodes
What lymph nodes drain the scrotum?
The superficial inguinal nodes
What does valporate use by a mother increase the risk of in fetuses?
Increases the risk of neural tube defects
What is a side effect of loop diuretics (furosemide)?
Ototoxiticty
What are the changes seen in the kidneys of diabetics on histology?
Nodular PAS+ deposits (hyaline) of mesangial matrix
Thickened basement membranes
Nephrotic syndrome
What would renal histology show for post-streptococcal glomerulonephritis?
Subepithelial humps
What diuretics may increase calcium levels?
Thiazide
How does one calculate plasma osmolarity?
Plasma osmolarity = (total body osmoles - urine osmoles) / (total body water - urine volume)
How do you caclulate total body water?
body weight * 0.6
What part of the kidney has epithelial brush border cells?
PCT tubular epithelium
Where are the 2 places type IV collagen are found?
Lens of the eye
Basement membrane
What is used to decrease bladder hyperactivity in people with spinal cord injuries?
What class of drugs is this?
Tolterodine, an anti-muscarinic.
What part of the kidney is damaged by DIC?
The cortex
What are antibodies directed against in Wegner’s granulomatosis?
Serine proteinase 3
What do the sertoli cells secrete?
Where are they located?
What is their purpose?
Inhibin, androgen binding protein, MIF
Line the seminiferous tubules
Supports sperm synthesis
What does inhibin do?
Inhibits FSH
What does androben-binding protein do?
Maintains high local levels of testosterone
What do spermatogonia do?
Produce primary spermatocytes
What do leydig cells do?
Where are they located?
Secrete testosterone
Located in the interstitium
What is the tumor that is filled with clear fluid, lined by epithelkial cells and forms papillary fronds?
What is a marker for this tumor?
Serous cystadenocarcinoma
CA-125
When do graafian follicles begin to express LH receptors?
During the transition to a functional corpus luteum
How does syphillis orchitis look micorscopically?
Obliterative endarteritis
Prominent lymphocytes and plasma cells
What is preeclampsia?
What is thought to be the pathogenesis?
Susained elevation of BP > 140/90 after 20 weeks of pregnancy
Proteinuria
Due to placental ischemia
What is the processus vaginalis composed of?
Where does it travel through?
What happens if it doesn’t fuse?
Made of pareital periotneum that descends through the inguinal canal
If it doesn’t fuse is makes a cystic structure called a hydrocele
What does a bifid/bicornuate uterus cause?
Habitual abortions
What adrenergic receptors are expressed on uterine smooth muscle cells?
What does each type do?
Alpha 1: increases SMC contraction
Beta 2: Reduces SMC contraction
What is a marker for testicular-germ cell tumors?
Alpha-fetoprotein
What is the triad observed in Meigs syndrome?
Ovarian mass (usually a benign fibroma)
Hydrothorax
Ascites
What does PCOS look like clinically? (3)
Hirsutism
Amenorrhea
Obesity
What would one see in terms of lab findings with PCOS? (4)
Increased LH
Decreased FSH
Increased testosterone
Cystic follicles in the ovaries
What is responsible for the increased circulating estradiol levles during the follicular phase of menstruation?
Granulosa cell proliferation
What is adenomyosis?
What are the clinical/lab findings (2)?
Endometrial glands in the myometrium of the uterus
Severe perimenstrual pain, non-focal thickening of the myometrium
What are the gonadal manifestations of turner’s syndrome?
Streak ovaries
Amenorrhea
What are the vascular problems in turner’s syndrome?
Coarctation of the aorta
Injury to which nerve/muscles causes a positive trendelenburg sign?
Superior gluteal nerve/gluteus medius and minimus
What are the normal signs of aging in the heart?
Decreased LV chamber size
Sigmoid shaped ventricular septum
Interstitial fibrosis
Accumulation of cytoplasmic brownish pigments (lipofuscin)
What do patients with femoral neuropathy often complain of?
Knee buckling
Through what muscle does the femoral nerve run in the hip?
Psoas major
Where would femoral neuropathy cause a loss of sensation?
Over the anterior aspect of the thigh and medial aspect of the leg
Where would obturator neuropathy cause a sensory deficiet?
On the medial aspect of the thigh
What is the first place damaged during global cerebral ischemia?
THe hippocampus
What types of carbohydrates can be absorbed by the intestinal brush border cells?
Monosaccharides like D-xylose
What lipid lowering drug increases blood TG levels?
How does this work?
Bile acid-binding resins
Prevents recirculation of bile acids, making the liver use LDL and cholesterol to make new bile acids, causes TGs to go up
What does facial pain, headache and black, necrotic eschar in the nasal cavity of a patient in DKA suggest?
Mucormycosis
What type of histology does mucor rhizopus have?
90 angles
What is potter syndrome?
What are the clinical features (3)?
Bilateral renal aplasia
Oligohydramnios (decreased amniotic fluid)
Facies
Pulmonary hypoplasia
What is a common cause of death in Potter syndrome?
Why?
Respiratory failure
Due to olgiohydramnios, since kidneys are needed to keep amniotic fluid in the fetus
Amniotic fluid supports pulmonary development
What diuretic is useful for treating nephrolithiasis?
Why?
Thiazide diuretics
Promote calcium reabsorption from the tubule
What is the Ras substrate that determines its activity?
What pathway is Ras a part of?
GTP (active), GDP (inactive)
MAP kinase pathway
What provides somatic sensation to the anterior 2/3 of the tongue?
V3 (mandibular)
What provides somatic and gusttory sensation to the tongue root?
Vagus
What is appropriate DVT prophylaxis for pregnant women?
What about for non-pregnant people?
Pregnant: Heparin
Non-pregnant: warfarin
Does a positive delta G (and thus a negative Keq) favor the formation of substrates or products?
Formation of substrates is favored
How does StAR deficiency present?
Pseudohermaphrotism for males
Enlarged adrenals
Low levels of all adrenal hormones
What does a complete mole result from?
What is a potential complication of this?
What is the rate of this complcation
Sperm fertilization of an empty ovum
Cholangiocarcinoma (2%)
What would you expect for a healthy woman who keeps on having spontaneous, 1st trimester abortions?
A robertsonian translocation
What is an anovulatory cycle?
What does this lead to?
Would you see typia or atypia histologically?
Unopposed estrogenic stimulation of the endometrium
Leads to excessive bleeding at irregular intervals
Typia
What is one of the TORCHES that can cause pneumonia in offspring?
When and how is it transmitted to the neonate?
Chlamydia tachomatis
Transmited via mother’s vaginal secretions
What substance is required for proper differentiation of the male internal genital tract?
Testosterone
What substance is required for proper differentiation of the male external gentiala?
What enzyme mediates this?
What would deficiency of this enzyme present like clinically?
dihydrotestosterone
5-alpha reductase
Genotypic male with feminized external genitalia and normal male internal reproductive tract
What is the histology of uterine leiyomas?
Whorls of spindle-shaped smooth muscle cells
What drugs should be given for PID where the etiologic agent is not known?
Erythromycin and ceftriaxone
Name 3 anti-histamines with few anti-cholinergic side effects
(write it down)
Fexofenadine
Loratadine
Cetirizine
What do Th1 cells do?
What pathogens does this defend against?
Activate cell mediated immunity (including cytotoxic T cells)
Intracellular pathogens
What do Th2 cells do?
Help B cells to class switch
How do granulosa cell tumors present?
Why?
Post menopausal bleeding
Produce estrogens that lead to the post menopausal bleeding
What is a histological sign that is associated with an increased risk of developing invasive carcinoma?
Sclerosing adenosis with epithelial changes
What prostaglandin analog is used to induce delivery?
What is a specific analog for?
Dinoprostone
PGE2
What enzymatic deficiency leads to the accumulation of small chain detxtrin like material?
Debranching enzyme (Cori disease)
What does deficiency of lysosomal alpha glucosidase present like clinically? (2)
Severe cardiomegaly
Glycogen accumulation in lysosomes
What embryonic strudcture forms the kidneys?
The metanephros (ureteric bud + mesoderm)
What embryonic structure gives rise to the male GU components?
The mesonephros
What is the most cause of fetal hydropephrosis?
Inadequate recanalization of the ureteropelvic junction
What would pyruvate dehydrogenase deficiency result in?
What is a cofactor for this enzyme
Lactic acidosis
Lipoic acid
What would a deficiency in alpha-ketoglutarate dehydrgenase and branched chain ketoacid dehydrogenase result in?
What is a cofactor for these enzymes?
Maple syrup urine disease
Lipoic acid
How do you treat toxoplasmosis?
Primethamine, sulfadiazine
In whom does primary CNS lymphomas occur?
What are these lymphomas composed of?
Immunocompromised individuals
Composed of B cells
What can type of treatment can precipitate a mania in bipolar patients?
Anti-depressants when used without an anti-psychotic or mood stabilizer
What is an HIV integrase inhibitor?
Raltegavir
What is an HIV fusion inhibitor?
Enfuvirtide
What are the HIV RT inhibitors?
Efavirenz, tenofovir, lamivudine
(LET)
What are the HIV protease inhibitors?
Saquinavir, ritonavir
What is the HIV CCR5 receptor inhibitor?
Maraviroc
How do you caculate the filtration fraction?
GFR/[(1-Hct)(RBF)]
Also known as GFR/RPF
Deficiency of what vitamins can cause night blindness?
How might this happen?
Fat soluble vitamins (namely vitamin A)
Biliary obstruction
What is flutamide?
What is it used to treat?
Competitive androgen receptor
Prostate cancer
What is the histology of primary oocytes?
One or more layers of cuboidal-like granulosa cells
What is the histology of secondary follicles? (2)
Several layers of follicular cells
Small antrum
What is the marker for a seminoma?
What are the 2 cell types seen with semimomas?
PLAP +
Neoplastic cells, lymphoctyes
What would a constitutively active LH receptor look like:
Clinically (1)
Lab wise (3)
Clinically: incomplete precocious puberty
Lab: elevated testosterone, decreased gonadotropin levels, Leydig cell hyperplasia
What would one see histologically in kleinfelters? (4)
Completely hylanized seminiferous tubules
No germ cells
Rare sertoli cells
Leydig cells in large clumps
What are the key features of leydig cell tumors that differentiate them from other testicular cancers?
What is one way it might present?
Golden brown color
Produces androgens/estrogens
May present with gynecomastia
What is exemestane?
What is it used to treat?
A steroidal aromatase inhibitor
Used to treat estrogen dependent breast cancer
What is the genetic basis of MEN2B?
What type of a gene/protein is this?
What are the 3 cancers associated with this?
RET, an RTK
Pheos, medullary carcinoma, mucosal neuromas
What does hypertension before 20 weeks of age suggest?
A hyatidform mole
What is the protein that is responsible for cardiac amyloidosis in the absence of amyloid deposition elsewhere?
Transthyretin
What is testosterone bound to peripherally?
Sex-steroid-binding globulin
What does inhibin inhibit the secretion of?
FSH
What is paget’s disease of the breast?
Ulcerating lesion of or near the nipple
Malignant glandular cells in the epidermis
What is acute mastitis?
Nipple trauma leading to acute inflammation and necrosis
What is intraductal papilloma?
Subareolar tumor in ducts
Bloody or serous nipple discharge
What is invasive lobular carcinoma?
Poorly circumscribed, rubbery breast mass
What would the fractional excretion of sodium be in a patient with ATN?
Greater than 2%
What is the fractional excretion of sodium in a patient with pre-renal disease?
Less than 1%
What would the BUN/plasma Creatinine ration be in a patient with post-renal obstruction?
Greater than 20
What would the BUN/plasma creatinine ratio be in a patient with pre-renal disease?
Greater than 20
What would be the BUN/Cre ratio in a patient with acute tubular necrosis?
Less than 20 to 1
Where does a direct inguinal hernia herniate through with respect to the epigastric vessels?
Which ring?
Medial to inferior epigastric vessels
Through superficial inguinal ring
Is a direct inguinal hernia covred by all 3 layers of fascia?
No
Where does an indirect inguinal hernia herniate through with respect to the epigastric vessels?
Which ring?
Lateral
Deep inguinal ring
Is an indirect inguinal hernia covered by all 3 layers of spermatic fascia?
Yes
What is Bowen disease?
What does it look like on examination?
Penile squamous cell carcinoma in situ
Solitary whitish plaque
What is bowenoid papulosis?
What does it look like on exam?
Reddish bown papules
Penile squamous cell carcinoma in situ
What is erythroplasia of Queyrat?
What does it look like clinically?
Penile squamous cell carcinoma in situ
Shiny red plaques
How does congenital syphillis present in a child? (3)
Saddle nose
Deformed teeth
Saber shins
What is the 1st line treatment for syphillis?
2nd line?
1st: Penicillin
2nd: Doxycycline/tetracycline
What vessel do the gonadal vessels come from?
The aorta
What does the 3rd pharyngeal pouch give rise to?
The thymus and inferior parathyroid glands
What does VIP do? (2)
What does a VIPoma result in?
Stops gastric acid secretion
Increases secretion of pancreatic bicarb
Secretory diarrhea
What is BNP released from?
What does it do?
Released from stretched ventricles
Dilates arteries, veins, promotes diuresis
What is anemia associated with neurologic abnromalities specific for?
Vitamin B12 deficiency
What serum marker would be elevated in vitamin B12 deficiency?
Methylmalonic acid
What is triglyceride broken into by hormone sensitive lipase?
Glycerol and fatty acids
What is the only tissue that can break down triglycerides for use in gluconeogenesis?
What enzyme is responsible for this?
Liver
Glycerol kinase
What organelle is necessary for heme synthesis?
Mitochondria
What is the genetic defect in phenylketonuria?
What does this mean?
How does it present?
Phenylalanine hydroxylase
Means that phenylalanine can’t be converted into tyrosine
Presents with mental retardation
