Deck 1 Flashcards
Do a card for AD and AR diseases etc
Absolute contraindications for OCPs
- Hx of thromboembolic event or stroke
- Hx of E2 dependent tumor
- women over age 35 who SMOKE
- High Triglycerides
- Active or decompensated liver dz
- Pregnancy
Effect modification?
When the effect of the main exposure is modified by the presence of another variable
- NOT a bias
- how is it different than confounding?
reaction formation vs altruism vs sublimation
RF - excessive, opposite reaction from feelings
Altruism - helping others to alleviate guilt and low self esteem
Sublimation - channeling unacceptable impulses into productive activity
Blood gas at high altitudes?
- PaO2 decreases to 60 or less
* stimulates carotid and aortic chemoreceptors—> incr ventilation - leads to hyperventilation and RESP ALKALOSIS (low PaCO2)
- incr blood pH
- Low Bicarb as renal compensation
Femoral hernia anatomy
- below inguinal ligament
- thru femoral ring
- lateral to pubic tubercle
- medial to femoral artery and vein
*present with pelvic pain, thigh mass. if incarceration: N/V abd pain, etc
Clue cell vs Koilocyte
- Clue: BV, squamous cell covered with bacilli
- Koilocyte: HPV infection, immature squamous cell with dense, staining cytoplasm and peri-nuclear clearing. looks like HALO
What enzyme is INCREASED in Lesch-Nyann?
- PRPP
- to compensate by increasing de novo purine synthesis
histoplasma infxn: sx and cell appearance
- in immunocompromised: HSM, ulcerated tongue lesions, pulm infiltrates causing SOB, hilar adenopathy, cavitary upper lobe lesions, fever, wt loss etc
- Cell: small ovoid bodies within macrophage
Underlying pathophys in Beta-thalassemia? Smear?
- Defective transcription, processing, and translation of beta-globin mRNA
- microcytic anemia, target cells, incr Hgb F and A2
drugs causing myopathy:
- Statins
- fibrates
- niacin
- hydroxychloroquine
- glucocorticoids
- colchicine
- IFN-alpha
- Penicillamine
Vincristine side effect and mechanism?
- Mech: microtubule inhibition, M-phase specific agent
- Neurotoxicity
Bone findings in primary hyperparathyroidism?
- Subperiosteal thinning
- cystic degeneration
kid with grey pharyngeal exudates, unvaccinated? What agar does it grow in?
- C. Diptheriae
- Tellurite agar….can also be detected on microscopy after methylene blue staining
Non-bacterial thrombotic endocarditis (NBTE)
hypercoagulable state
- cardiac valve vegetations
- similar to trousseau’s syndrome (migratory thrombophlebitis)
Prinzmetal’s angina
- episodic, transient anginal CP
- occurs at night and at rest
- temporary ST-segment elevations
- vasospasm
-Test: ergonovine…diagnostic:
constricts vascular SM via alpha stim and serotonergics as well. causes CP and ST segment elevation
Tx: CCBs
What are charcot-bouchard psudoaneurysms?
- Aneurysms caused by hypertension in the brain
- usually in small arterioles that penetrate the basal ganglia
- cause intracerebral hemorrhage, vs SAH in saccular aneurysms
Drug of choice for GDM?
-Insulin
avoid oral hypoglycemics bc they can cross placenta and cause hypoglycemia, hyperinsulinemia
What tx for severe allergic asthma has been shown to decr exacerbation recurrence? Mechanism?
- Omalizumab
- anti-IgE antibody subQ injection
- for use in pts with severe asthma, on oral steroids
How to workup metabolic alkalosis:
- Volume status
- Urine Cl
- Vomiting and diuretics = saline and Cl responsive
- Mineralocoticoid excess = saline and Cl UNresponsive
In hemophilia, addition of ______to blood will lead to clotting: why?
- Thrombin
- No 8 or 9 = no 10a
- No 10a = no conversion of prothrombin to thrombin —> decr thrombin
What is intrapleural pressure at FRC?
negative 5 mmHg
Pathophys in HbS disease?
- Valine in place of glutamate in 6th AA position of Beta subunit
- promotes hydrophobic interaction between Hgb molecules
- polymerization of Hgb —> RBC distortion (sickling)
What happens to volume-pressure curve in AV shunts?
- Vol incr due to incr preload
- Pressure decreases due to decr afterload
defective enzyme in galactosemia?
- Galactose-1-phosphate uridyl transferase
- cant go from G-1-P to UDP-galactose
What is the tx for Bblocker overdose? Mechanism?
- Glucagon
- incr cAMP in cardiac myocytes –> incr Ca –> incr contractility and HR
Blood levels of ______ correlate with morbid/mortality of neisseria meningitidis infxn?
LOS
-Lipooligosaccharide on the outer membrane (endotoxin)
What nerve levels make sciatic nerve? Which level for ankle-jerk reflex?
- L4-S3
- S1 (purely posterior thigh and leg pain, plabtar flexion weakness, loss of ankle jerk)
- L5 = post and lateral thigh and leg pain, shooting to inner foot
How is isoniazid, dapsone, hydralazine, procainamide metabolized?
- Acetylation via N-acetyl transferase (NAC)
- Bimodal (some fast metabolizers, some slow)
What muscles allow you to sit up without hands?
- External obliques
- rectus abdominus
- hip flexors: iliopsoas (psoas maj and min, iliacus)
- rectus femoris, sartorius, IT band also help
What is thiopental used for and how does it work?
- induction of anesthesia
- rapid acting barbituate…accumulates in the brain within 1 minute —> LOC
- subsequently is rapidly redistributed to muscle and adipose tissue –> declining plasma levels —> regain conciousness
Manifestations of friedrich’s ataxia
- cerebellar ataxia
- loss of position and vibration
- Kyphoscoliosis
- Hypertrophic cardiomyopathy
- high plantar arch
Levels of Androgen, LH, FSH in PCOS?
- high
- high
- normal
*incr LH/FSH ratio > 3
What type of collagen is found in scarring of myocardium?
Type 1: bone, skin, tendon
Inheritance of androgenic alopecia (male pattern baldness)?
- polygenic inheritance
- variable penetrance
Middle meningial artery is a branch off of the _______
Maxillary
Which enzymes are deficient in narcolepsy?
- hypocretin 1 and 2 (Orexin A and B)
* Measure in the CSF….undetectable levels
What chromosome is affected in hemochromatosis? inheritance? effect?
- chromosome 6
- ?
- increased iron absorption in gut
immunofluorescence = linear deposits in GBM LM = crescents
- anti-GBM dz, aka GOODPASTURES
- igG and C3 deposits vs alphaa 3 chain of type 4 collagen
- nephritic syndrome + hemoptysis
- middle aged?
What markers are clue for NTD?
- AFP (elev in amniotic and mom’s serum as well)
- Acetylcholinesterase
Describe the PI3K/Akt/mTOR pathway…
Growth factor pathway:
- GF binds to its rec-tyrosine kinase
- autophosphorylation
- These activate PI3K
- PI3K P-lates PIP2 –> PIP3 (plasma membrane)
- Activation of Akt, or protein kinase B (serine/threonine kinase)
- Akt activates mTOR –> translocation to nucleus
- Induces genes involved in cell survival, anti-apoptosis, angiogenesis
- mTOR inhibited by PTEN (removes P from PIP3)
- many cancers have overactivation of this system or inactivation of PTEN
Little girl with ambiguous genitalia (clitoral enlargement, labial fusion), high BP, Hypokalemia?
11-Beta-hydroxylase deficiency
- 2nd most common form of congenital adrenal hypoplasia
- 21-hydroxylase presents with HoTN and hyperkalemia
What value depicts the potency of an inhaled anesthetic?
MAC
- minimal alveolar concentration
- conc of anesthetic in the alveoli that renders 50% of pts unresponsive to painful stimuli
- Potency is inversely proportional to MAC (lower MAC = higher potency)
Concentration of what substances increase as fluid runs along renal tubules?
- PAH
- Creatinine
- Inulin
- Urea
*bicarb, glucose, and AAs decrease (bc they get reabsorbed)
Serotonergic neurons are only found in the _______ nuclei, and project all over the CNS
Raphe
What is the main site of digestion of lipids? Main site of absorption?
- Digestion = duodenum
- absorption = Jejunem
How does diphtheria immunization work?
Induces production of IgG vs exotoxin B circulating protein
-exotoxin B binds and allows exotoxin A to enter cells and inhibit ribosome function
*clinical sequelae: oropharynx (grey) –> cardiotox and neurotox
Alkaptonuria
-Black urine
-black pigment in ears, nose, cheeks
Mech:
-Deficiency of homogentisic oxidase –> incr homogentisate –> has black pigment in urine etc
Chi square test
used to test association between 2 categorical variables
- ex: # of patients with ____ in group A vs group B
- for actual values/means…use t or Z test
Psuedomonas is a __________ fermenter , oxidase _______, motile/non-motile?, Gram_____ rod
- Non-lactose fermenter
- oxidase positive
- motile
- Gram negative rod
Pantothenic acide, or vit B5 is biologically active as ______. An example of its use is _____
- Coenzyme A
- Binds with Oxaloacetate to form citrate in first step of TCA cycle!
What is use for succinylcholine and how does it make a train of four response curve look?
-Depolarizing NMJ blocker
-used for rapid sequence induction and intubation
-train of 4 is used to assess degree of muscle relaxation
phase 1: shows sustained and equal reduction in all 4 phases
phase 2: fading pattern, reduction in each subsequent phase (down-step) In phase 2, cholinesterase inhibitors can rapidly reverse NMJ blockade (neostigmine)
How do fatty acid oxidation inhibitors work? and what are they used for?
- inhibit oxidation and shift energy production to glucose oxidation, thus promoting oxygen efficiency (less O2 use per one ATP synthesized)
- decreases amount of O2 required for cardiac myocytes
- decreases toxic FA metabolites
Describe the Ras-MAP kinase pathway
- GF binding –> autophosphorylation
- Ras activation by P-lation of GDP to GTP attached to Ras
- Ras activates Raf kinase
- Activation of MAP kinase
- MAP kinase enters nucleus to influence transcription
What type of virus is CMV? What do infected cells look like on histo?
- Enveloped, ds DNA
- Enlarged, centrally located epithelial cells with intranuclear and cytoplasmic inclusions
Ether and other organic solvents can impair infectivity of what type of viruses?
Enveloped
-Dissolves lipid bilayer that makes up envelope
Occlusion of the Anterior cerebral artery causes ______
LE weakness, sensory loss, etc
-Bc it supplies medial aspect of cortex, near midline. Like a mohawk
What drug do you use for HTN in a patient with bradycardia and prolonged PR interval?
- Nifedipine
- Selective peripheral action –> periph vasodilation –> reflex tachy….so good for bradycardia
- Wont affect AV node unlike verapamil, diltiazem, and metoprolol
What structures arise from the Müllerian ducts? Features of mullerian agenesis?
- tubes, uterus, cervix, upper vagina
- Amenorrhea, normal secondary sex char., weird vagina and/or uterus
About 2/3 of filtered K+ is reabsorbed in the _______. An additional 24-30% is reabsorbed in the ________
- proximal tubule
- Thick ascending limb of loop of henle
**EVEN IN HYPERKALEMIC STATES. The change in hyperK occurs distally, at the principal and alpha-intercaleted cells of the distal tubules and collecting ducts. They can secrete/reabsorb accordingly
What 2 enzymes are required for gluconeogenesis? and what is the reaction?
- Pyruvate carboxylase
- PEPCK
reaction: Pyruvate –> PEP (phosphoenoylpyruvate)
* requires GTP
What is the relationship between blood flow and vessel radius?
Flow is directly proportional to vessel radius^4th power
-Ex: radius decrease by 1/2 = decr flow by 16x
Mech of hartnup disease? result? clinical feature? Lab findings?treatment?
- Defective intestinal and renal absorption of tryptophan
- Niacin deficiency (tryptophan is precursor for niacin)
- Usually Asx, but can have pellagra-like presentation along with neuro stuff like ataxia
- Aminoaciduria (except for proline, hydroxyproline, and arginine**….unlike fanconi)
- Tx = Nicotinic acid or nicotinamide and high protein diet
What makes snRNPs? and where?
- RNA polymerase II
- nucleus
In CAH, most common enzyme deficiency is ________. This creates incr levels of _______, due to inability to convert _______.
- 21-Hydroxylase
- 17-hydroxyprogesterone
- Prgesterone –> 11-deoxycorticosterone
Damage to the neck of the fibula can damage the ______ nerve, leading to problems with _______
- Common peroneal nerve
- weakness of dorsiflexion
- weakness of eversion
- loss of sensation over dorsum of the foot
*inversion and plantar flexion intact bc tibial nerve is intact
What anti-epileptic causes generalized lymphadenopathy? Mechanism? Uses?
- Phenytoin
- reduces Na+ channels’ ability to recover from inactivation –> incr refractory period
- seizure ppx following trauma or before neurosurgery
*limited use bc of: hirsutism, acne, skin rash, gingival hypertrophy)
What drug acts as a partial agonist/weak antagonist of mu opioid receptors?
- Pentazocine
- Little abuse potential, but bc of this can precipitate withdrawal in pts with existing opiate dependence etc
What anxiolytic has reduced abuse potential, minimal hypotonia, minimal sedation, and minimal euphoric effects?
- Buspirone
- Non-sedating, serotonin agonist. Good for ppl with hx of abuse
What conditions cause polyhydramnios?
- Decr fetal swallowing: GI obstruction, Anencephaly
- Incr urine production: High CO from anemia,twin-twin transfusion syndrome
How do you calculate odds ratio (OR)?
construct 4x4 table
-OR = AD/CB
What is drug of choice for Paroxysmal SVT? Side fx? Other use?
- Adenosine
- flushing, chest burning, HoTN, high grade AV block
- Chemical stress test!
Which AAs have 3 titratable H+’s
- Histidine, arginine, Lysine (HAL)
- Also aspartic acid, glutamic acid, cysteine, tyrosine
What antiviral can cause bone marrow suppression? What about an HIV drug?
- Gancyclovir
- Zidovudine
What are clinical and lab abnormalities in patient with primary hyperaldosteronemia?
- HTN
- Low K+
- metabolic alkalosis
- low renin
- normal sodium (aldosterone e
What type of vaccine promotes prolonged synthesis of mucosal IgA?
-Live attenuated
what are 3 ways in which Down syndrome can occur?
- meiotic non-disjunction
- robertsonian translocation
- mosaicism
Name 2 drugs that can cause drug-induced luppus or exacerbate lupus? How are they metabolized?
- Hydralazine and procainamine
- Acetylation in the liver
*create histone antibodies
Which drugs affect PT? PTT? Both?
- extrinsic
- intrinsic
- Direct 10a inhibitors (apixaban, rivaroxaban) (does not affect Thrombin time)
What protein from bacteria facilitates mucosal penetration? Which prevents complement-mediated cell lysis?
- IgA protease (Neisseria men and gon)
- Staph protein A (binds to Fc region of IgG
What is responsible for Ca efflux from cardiac myocytes just before relaxation? what about initiation of contraction cycle?
- Ca/Na exchanger
- Voltage-dependent Ca channels (ryanodine receptors amplify via SR)
What is genome recombination?
- Between 2 defective viruses co-infecting same host
- gene exchange that occurs through crossing over of 2 ds DNA molecules
Chronic granulomatous disease pathophys and features:
- Genetic defect in NADPH oxidase (impaired intracellular killing)
- recurrent bacterial and fungal infections
- Diffuse granuloma/abcess formation
- Catalase + bugs responsible: Staph A, Burkholderia, serratia, Nocardia, Aspergillus
Which bacteria produces Alpha toxin? how does it work?
- C. perferingens
- toxin aka Lecithinase
- It decrades lecithin, destroying cell membranes (necrosis, hemolysis)
What is drug of choice for tx of drug-induced parkinsonism?
- Benztropine or amantadine
- Dont use Levodopa or carbidopa bc they can precipitate psychosis
What is the cell type lining bronchi epithelium?
- pseudostratified columnar, ciliated
- Eventually changes to simple cuboidal ciliated distally
What receptors are found on pancreatic Beta cells, and what are results of stimulation?
- Alpha 2 : inhibits insulin secretion
- Beta 2: stimulates insulin secretion
*Epinephrine works on both, but alpha effect predominates
Which family of enveloped viruses obtain their envelope by budding through the host’s NUCLEAR membrane, rather than plasma membrane?
-Herpes viruses (including CMV)
What is a normal A-a gradient?
10-15
-Alveolar - arterial O2
- hypoxemia with normal A-a gradient = hypoventilation or inspiration of low PO2 (altitude)
- hypoxemia with incr gradient = diffusion impairment or V/G mismatch
What is the net production of the HMP shunt? (from 1 glucose)
- 5 carbon sugar (ribose-5-P)
- 2 molecules of NADPH
- CO2
Patient with bleeding has prolonged BT, prolobged PTT, NORMAL platelet aggregation in response to ADP, and DECR platelet aggregaton in response to RISTOCETIN. DIagnosis?
Von-willebrands
-Hereditary GP 2b/3a has opposite effects (normal Ristocetin, impaired ADP)
Diagnosis in a patient with PKU who has decr dopamine levels (Incr prolactin) with possible neuro Sx, despite adequate dietary changes and normal phenylalanine level?
Dihydrobiopterin deficiency
- enzyme for Tyrosine –> DOPA —–> (eventually dopamine, NE, Epi)
*AKA atypical PKU
What is Isoniazid’s mechanism of action? How does TB develop resistance to it?
- Inhibition of mycolic acid synthesis by TB
- Since Isoniazid must be processed by mycobacterial catalase-peroxidase, resistance is accomplished by non-expression of the catalase-peroxidase enzyme
How does blood arrive to the fetal circulation?
- Through the umbilical vein –> Ductus venosus
- *remnants: ligamentum teres –> ligamentum venosum
What is the most notable side effect of ethambutol?
-Optic neuritis: color blindness, scotoma, decr visual acuity
other TB drugs (RIP) all affect Hepatic function potentially
What glands secrete sweat into hair follicles in the areola, axilla, and genital regions….and can cause odor 2/2 bacterial breakdown?
-Apocrine
What cell type moves to areas of brain infarct at 3-5 days, and contain high amounts of lipids from phagocytosis of myelin, etc?
- Microglia
* Expect to see this at about a week after infarct on microscopy
Difference in skin test between Tuberculous and lepromatous leprosy?
- tuberculoid: TH1 response –> IL-2, IFN-g, IL-12 in tissues —> limits disease
- Lepromatous: Acid fast bacilli within macrophages in tissues, TH2 cytokine profile: IL-4, IL-5, IL-10, more widespread throughout the body…..SKIN TEST IS USUALLY NON-REACTIVE
DiGeorge results from maldevelopment of what embryonic structures?
-The 3rd and 4th pharyngeal (branchial) POUCH
What are some features of Anaplastic cells?
- poorly differentiated –> very different from original tissue
- high grade
- disruption of tissue architecture, disorganized, infiltrative
- Variation in size and shape
- Large nuclei, deep staining
- Mitotic figures abundant
- Giant, multinucleated cells
What statistical test is used to compare the means of more than 2 groups?
-Analysis of variance (ANOVA)
What agent causing gastroenteritis is very sensitive to acid, and therefore is much more infectious with decreased stomach acid?
-Vibrio cholera
What organism affects immunocompromised individuals, most commonly causing meningitis, but potentially also pulm infxn……detected in lungs by mucicarmine staining…..shows budding yeast with thick capsules?
-Cryptococcus neoformans
What is Calcipotriene used to treat? And by what mechanism?
- Psoriasis (topical)
- Vitamin D analog, bind to Vit D receptor, activating nuclear transcription factors which inhibit keratinocyte proliferation and stimulate their differentiation
What DNA enzyme has 5’ to 3’ exonuclease activity? What does this function accomplish?
- DNA polymerase I
- Removal of RNA primer ….also repairs damaged DNA
Describe what happens when blood flow is chronically decreased to a kidney:
- Macula densa senses Decr GFR
- Signals to nearby JG cells (modified smooth muscle cells)
- JG cells secrete more renin
- JG cells hypertrophy and hyperplasia if long term decr perfusion
What cytogenetic abnormality is associated with AML? CML?
- AML: t(15;17)
- CML: t(9;22) (bcr-abl…philadelphia)
How does Heparin work?
-Indirect thrombin inhibitor…..increases effect of anti-thrombin-III when bound to it
What is the most bio-available oral Nitrate?
- Isosorbide mononitrate
* nitorglycerin too if given sub-lingually….no orally (swallowed)
Where is tetrodotoxin found, and how does it work?
- Puffer fish
- Binds to voltage-gated sodium channels, preventing influx and depolarization
What 2 things can reverse warfarin effects? which acts rapidly vs slowly?
- FFP and vit K
- FFP fast….vit K slow
WHat makes HCV genetically unstable?
-It lacks 3’ –> 5’ exonuclease activity in its RNA polymerase. makes it prone to frequent mutation
What structures drain into the superficial inguinal nodes?
-all CUTANEOUS lymph from the umbilicus to the feet, including external genitalia and anus
How can you differentiate between pancytopenia caused by aplastic anemia vs myeloproliferative stuff like leukemia?
-Aplastic anemia = no hepatosplenomegaly
How does atrial myxoma present? what does it look lke on histo?
- constitutional sx, mid-diastolic rumble, positional CV sx, embolic sx
- Scattered cells within a mucopolysaccharide stroma, abnormal blood vessels, hemorrhaging
What is Lipofuscin?
product of lipid oxidation, accumulates in aging cells (especially in malnourished or cachectic patients)
Most common defect associated with imperforate anus?
-Genitourinary tract malformations
WHat vitamin is required to form Aspartate from Oxaloacetate + glutamate?
-B6 (transamination!)
What defect is seen in pts with familial dysbetalipoproteinemia?
- They lack ApoE3 and ApoE4
- Their Liver cant remove chylomicrons or VLDL remnants from circulation
- Result = xanthomas and premature coronary and periph vascular disease
What antibiotic can induce serotonin syndrome? what is that antibiotic normally used for?
- Linezolid (it is a weak MAO inhibitor)
- serious gram+ infxns, particulary VRE and MRSA
*other drugs that can do the same: tramadol, odansetron
How does Vibrio cholerae cause diarrhea and what is seen on stool microscopy?
- Cholera toxin (similar to heat labile toxin of ETC)
- increases levels of cAMP in mucosal cells –> efflux of Cl and Na –> watery diarrhea
*DOES NOT penetrate cells –> no leukocytes or erythrocytes on microscopy, only mucous and epithelial cells
What substances increase gastric acid production? which of these also induces parietal cell proliferation?
*In what disease is incr acid secretion AND incr parietal cell proliferation seen?
- Gastrin, Histamine, Acetylcholine
- Gastrin
*Zollinger-Ellison syndrome
Direct inguinal hernias commonly occur in older men. They appear _____ the inguinal ligament, ________ to the inferior epigastric vessels, portrude through the _________, and are covered by _________.
They are caused by ________
- Superior to inguinal ligament
- Medial to inferior epigastrics
- Portrude through only the external inguinal ring
- Covered by external spermatic fascia
- Weakness of the transversalis fascia
Describe effects of dopamine at different doses on vasculature:
- Low dose: stimulates D1 receptors in renal vessels –> incr GFR + rbf
- Higher doses: stimulates Beta-1 –> incr cardiac contractility
- Higher still: stimulates alpha-1 is systemic vasc –> incr SVR –> incr afterload —> decr CO
What structures enter the orbit via the superior orbital fissure?
- CN3
- V1 (ophthalmic nerve….does afferent corneal reflex)
- CN4
- CN6
- ophthalmic vein
In IP3 second messenger system….________ activates IP3 and DAG, then DAG activates ________ and IP3 causes _______
- Phospholipase C activates IP3 and DAG
- DAG activates Protein kinase C
- IP3 releases Calcium from sarcoplasmic reticulum
H. Influenzae needs _____ and ______ to grow on agar? What other organism provides one of these things?
- X factor (exogenous hematin)
- V factor (NAD+)
- Staph aureus provides NAD+, which it produces
- in a culture medium w blood and staph….H influenza gets X factor from lysed RBCs, and V factor from staph A
What is the clinical presentation of an adrenal crisis?
- No steroids
- HoTN, tachycardia, hypoglycemia, vomiting, abd pain, wt loss, hyperpigmentation
WHat are calcium, phosphorus, and PTH serum levels like in primary osteoporosis?
All NORMAL!!
WHat is the mechanism of action for anastrazole?
- Aromatase inhibitor
- decreased androgen aromatization to estrogen –> postmenopausal E2 levels
- as good or better than tamoxifen
During continuous infusion of a drug metabolized by 1ST ORDER KINETICS, how many half-lives does it take to reach steady state?
- 4 to 5
In statistics, what is power?
1-Beta
-probability of rejecting the null hypothesis when it is truly false
What adrenergic receptors are located on the Uterus? which ones in pupillary cilliary muscles?
*What drugs are used for tocolysis
- Beta 2 in uterus: stimulation –> tocolysis (inhibits contractions)
- Alpha 1 in eyes: contraction –> mydriasis
*Tocolytics: terbutaline and ritodrine (Beta 2 agonists)
in respiratory pathway….what is the cell type from nose –>sinuses–>nasopharynx–>most of larynx–>tracheobronchial tree?
-Pseudostratified, columnar, mucus-secreting epithelium
What are ways to screen vs diagnose syphllis?
- Screening = non-treponemal tests (VDRL, RPR)
- Diagnosis: Treponemal tests (FTA-Abs, MHA-TP) OR Visualiation of spirochetes under darkfield microscopy
What structures in the neck derive from the 3rd pharyngeal pouch?
- Thymus
- inferior parathyroid glands
Where do repressor proteins bind to lac gene?
Operator locus
What are the lab features of CML?
- WBC > 50K
- few blasts <10%
- Neutrophil Alk Phos = Low
- All types of granulocytic cells seen (myelocytes + neutrophils predom)
- Bcr-abl t(9;22) Philly
What is the difference between a complete and a partial molar pregnancy?
Complete:
- Sperm fertilizes empty egg, then duplicates –> 46XX
- More severe sx, VERY HIGH Beta HCG
- High malignancy risk
Partial:
- more than one sperm fertilize one egg
- 69 XXX or 69XXY
- Some fetal parts
- Lower malignancy risk
Murmur that increases with inspiration = ________
R-sided!
-tricuspid regurg
At low doses, aspirin inhibits ________, at higher doses, it inhibits ______
- COX1 alone
- COX1 and COX2
COX1=platelets, etc
COX2=inflammation
Is rabies virus live or killed?
Killed
Describe Arginase deficiency
- Problem wth urea cycle
- Cant turn arginine into Ornithine and urea
- Get high arginine levels, spastic paresis, choreoathetoid movements
WHat is the best way to prevent neonatal tetanus infection? (other than obvious sterile procedures)
- Vaccinate mom!
- Allows transfer of IgG’s across placenta to the fetus
What are some side effects caused by thiazide diuretics?
HYPERs:
- Hyperuricemia
- Hypercalcemia
- Hyperglycemia
- Hyperlipidemia
HYPOs:
- Hypokalemia
- HoTN
What is the workup for Cushing’s syndrome?
- Measure ACTH
-Measure cortisol
-Dexamethason suppression test
suppression test:
-suppressed = Pituitary (cushings disease)
-Not suppressed = exogenous source (small-cell carcinoma)
What does fibroadenoma look like histologically?
- cellular, often myxoid stroma encircling and sometimes compressing epithelium-lined glandular and cystic spaces
- Q 1109
What might low AFP be? Low estriol?
- Downs
- placental insufficiency
Disease associated with acidemia and increased propionic acid? pathophys?
- Propionyl coA carboxylase deficiency
- Propionyl coA made from AAs Valine, threonine, methionine, cholesterol, and odd chain FAs
- this enzyme converts propionyl coA to methylmalonyls coA….which then can convery to succinyl coA for TCA cycle
-clinical: poor feeding, vomiting, hypotonia, lethargy, AG acidosis, dehydration
Patient with joint stiffness, dark pigment in sclera and helix of ears…..enzyme deficiency?
- Alkoptonuria
- Homogentisic acid oxidase
- Cant break down homogentisic acid–> accum –> pigment, dark urine, arthralgias from deposits etc
What is the TATA box?
- A promotor region on eukaryotic DNA
- binds TFs to facilitate transcription and binding of RNA polymerase II
- 25 base pairs upstream from initiation site
What class of drug is acarbose? how does it work?
- Alpha-glucosidase inhibitor (another is miglitol)
- Decreases activity of disaccharidases at the brush border –> delays/impairs monosaccharide absorption
*Side fx: bloating, flatulence, abd pain, rash…dont use with malab, IBD, etc
What is the cause of focal neuro deficits in a pt who had a SAH 4-12 days ago? What drug prevents this from occuring?
- Vasospasm
- Nimodipine
What AA is an immediate source of nitrogen for urea production in the urea cycle?
Aspartate
How can you differentiate between diffusion limited vs perfusion limited exchange in the alveoli?
-Diffusion limited = O2 will always be more affected
What type of drug is Leuprolide? what is it used for?
- GnRH analog (long-acting)
- Causes brief intial increase in LH and FSH –> incr testosterone……but ultimately causes suppression of axis and low testosterone
- Used to treat androgen-dependent cancers
*DHT is made from testosterone in tissues by 5-alpha-reductase
Excellent DNA replication summary on question 1471!
Baby with vom, lethargy, hypertonicity/rigidity, and sweet smelling urine has __________ deficiency causing what disease?
What is the pathophys?
- Branched-chain alpha-keto-acid dehydrogenase deficiency
- causes maple syrup urine disease
- cant break down BCAA…..Leucine, Isoleucine, Valine —> buildup = neurotoxicity and urine smells sweet
What is Laplace’s law regarding spheres? model for alveoli….
P = 2T/r
- Pressure required to keep a sphere open (P) is directly proportional to surface tension (T) and inversely proportional to radius (r)
- surfactant counteracts collapse by decreasing surface tension!
What do enterotoxin A and cytotoxin B of C. diff do?
- Enterotoxin A = causes watery diarrhea
- Cytotoxin B = colonic epithelial cell necrosis and fibrin deposition (psudomembranous colitis)
*Dx c.diff with stool toxin gene PCR
Neonates with positive HBV have _____ levels of HBV replication, have _____ levels of transaminases, and are at _______ risk for chronic infection
- High levels of replication
- Mildly elevated transaminases (immature immune response)
- High risk for chronic disease
How do you calculate risk?
Number of ppl with disease / number of people at risk
How do cromolyn and nedocromyl work? what are they used to treat?
- Mast cell stabilizers –> prevent degranulation
- Treat bronchial asthma and allergic rhinitis
*not as effective as ICS
Where is panacinar emphysema usually localized? What about centriacinar?
Panacinar = lower lobes…a-1-at deficiency
centriacinar = upper lobes ….chronic smoking
What drug is used to treat male pattern baldness?
5-alpha-reductase inhibitors such as Finasteride
-decreases DHT
What are the characteristics of schwannomas on histology?
- biphasic pattern of cellularity
- S-100 positive (neural crest origin)
- Elongated cells with regular, oval nuclei
What is the underlying mechanism of amenorrhea in annorexia nervosa?
- loss of pulsatile secretion of GnRH from hypothalamus
- leads to low E2
What causes the genetic form of dilated cardiomyopathy? what about HOCM?
- Mutations affecting cytoskeletal proteins or enzymes of oxidative phosphorylation
- Mutations affecting cardiac sarcomere proteins, usually Beta-myosin heavy chain
What products play important role in alzhemier’s and accumulate in neurons?
-Neurofibrillary tangles and A-B-amyloid plaques
In the ovaries, where are androgens and progesterone synthesized and what influences this process?
What about conversion to estradiol?
- androgens and progesterone are synthesized in the Theca interna cells, under the influence of LH
- Aromatase converts androgens to estradiol in the Granulosa cells, stimulated by FSH
After X-linked SCID, what is the next most common cause?
- Adenosine deaminase deficiency
- Normally deaminates adenosine and inosine –> no function = adenosine accumulation –> toxic to lymphocytes –> destruction of both B and T cells
What bacteria causing bloody diarrhea is a non-motile, non-lactose fermenting, who’s effects are mostly caused by mucosal invasion?
- Shigella
* does not produce H2S!
What is the Fas receptor and Ligand and their function?
- They act to initiate the extrinsic pathway of apoptosis.
- Mutation in Fas receptor or ligand can prevent apoptosis in auto-reactive lymphocytes –> incr risk of autoimmune diseases
What type of drug is raloxifene?
- SERM
- in breast….antagonist (prevents breast cancer)
- Bone…..agonist (protects bone)
What is NF-kB, and in what disease is it mutated?
- TF responsible for cytokine production
- Crohn’s disease
What is telomerase? WHat exactly does it do? what cells can you find it in?
- Reverse transcriptase enzyme
- Adds TTAGGG repeats to the 3’ end of chromosomes. this protects DNA and allows for continued replication
- FOund in stem cells and cancer cells
What proliferative disorders tend to have a mutation in the cytoplasmic tyrosine kinase, JAK2…leading to constitutively active STAT transcription factors?
Myeloproliferative disorders
- polycythemia vera
- essential thrombocytosis
- primary myelofibrosis
Whats the difference between cortisol vs. glucagon and catecholamine activation of gluconeogenesis?
- Cortisol –> receptor in the cytosol…translocates to nucleus
- Glucagon and catecholamines –> receptors on cell surface…G-prot
How do you acutely tx diphtheria?
- Diphtheria antitoxin
- inactivates circulating toxin, but not toxin already in cardiac or neural cells. administer ASAP
- Known as “passive immunization” bc transfer of pre-existing, neutralizing antibodies - Penicillin or erythromycin
- kills bacterua–> stops release of toxin, prevents transmission - DPT vaccine
- lasting immunity vs future infection
What is the clinical picture and histologic appearance of granulomatous thyroiditis?
Clinical
- recent infection
- features of thyrotoxicosis
- tenderness over thyroid gland
- incr ESR
- Markedly reduced Iodine uptake**
Histology:
- Mixed, cellular infiltration
- occasional multi-nucleated giant cells
What might you prescribe a patient with initial incr anxiety and insomnia following start of SSRI therapy?
Short acting benzo before bed:
- Alprazolam
- Triazolam
*since short acting, reduces certain side effects like daytime sleepiness or impaired judgement
What structures arise from fusion of the paramesonephric ducts in females?
- uterine tubes
- uterus
- cervix
- superior 1/3 of vagina
*failure to fuse = bicorneate uterus or uterus didelphys
what is PrP, how can a change in this cause disease? and what disease?
- Prion protein
- If it alpha-helix normal structure converts to Beta-pleated sheets….it becomes resistant to proteases
- leads to accumulation, causing deposition in gray matter –> spongiform transformation
Phenytoin toxicity and side fx
- Gingival hyperplasia
- coarse facial features
- hirsutism
- megaloblastic anemia
- decreases blood level of many drugs (P450)
- pregnancy –> fetal hydantoin syndrome
Tox:
- ataxia
- nystagmus
What compound is an activator of pyruvate carboxylase and thus gluconeogenesis?
-Acetyl CoA
Glomerular immunofuoresence showing granular deposits of IgG, IgM, and C3….in the mesangium and BM = _____?
-Post-strep GN
What is phenotypic mixing?
- 2 viruses co-infect a host cell
- progeny have nucleocapsid proteins from one virus and genome from other virus
- since genome is still the same though…..next generation has original characteristics from grandma/grandpa
What amino acids are typically found within the transmembrane domains of transmembrane proteins?
Hydrophobic AA’s
- Valine
- Alanine
- Isoleucine
- methionine
- Phenylalanine
*VAL and AL were scared of water……so they Used ICE to make crystal METH out of FENNEL
In what 2 locations can the ulnar nerve typically be injured?
- Medial epicondyle of the humerus
- Guyon’s canal near the hook of the Hamate and pisiform bone in the wrist
What are neurophysins?
- carrier prroteins for oxytocin and vasopressin
- carry from site of synthesis to posterior pituitary
- Mutation in neurophysins = Diabetes insipidus (vasopressin defic.)
Why might someone with Parkinson’s disease want to avoid certain supplements?
- Vit B6 increases peripheral metabolism of Levodopa–> decr effectiveness
- if theyre taking levoddopa of course…
What are some side effects of Cimetidine?
Cimetidine - H2 receptor antagonist for peptic ulcer disease:
- Gynecomastia*
- P450 system inhibition: incr levels of warfarin, phenytoin, propranolol, metoprolol, quinidine, theophylline
What are some hormone receptors that use the G-protein/adenylate cyclase 2nd messenger system?
- TSH
- Glucagon
- PTH
- Beta-adrenergic receptors
*Reminder:
Adenylate cyclase activated –> cAMP –> PKA activation –> P-lation of serine/threonine residues on downstream products –> transcription
What is the Kozak sequence? and what type of mutation can lead to disease? WHich disease?
- sequence that helps initiate translation (mRNA binding to AUG start codon)
- When Guanine is replaced by cytosine in this sequence….3 bases upstream, the result = THALASSEMIA INTERMEDIA
What fungal infection shows spherules filled with lots of endospores on histo?
-Coccidioides
Which bacteria’s toxin compromises cytoskeletal integrity of intestinal mucosal cells?
-C. diff
AB toxin:
- A = watery diarrhea
- B = epithelial cell necrosis and fibrin depositin –> cytoskeletal integrity damaged
What is coronary steal and what drugs can cause it?
- phenomenon in which dilation of coronary arteries increases BF to normal areas, decreasing or “stealing” BF from ischemic areas
- Drugs: Adenosine, Dipyridamole
For what patients is Isoniazid MONOTHERAPY acceptable?
-Pts with positive PPD and negative CXR (no clinical evidence of dz)
In gigantism in kids….excess GH increases ______ secretion from the _______
- IGF-1
- Liver
Which HIV gene allows for resistance to Reverse transcriptase inhibitors?
Which gene allows for escape from host neutralizing antibodies?
- Pol gene
- Env gene
- HIV cant RESIST dancing on that POLe
- HIV in ENVious of other bugs that escaped the immune system
What is Flutamide and what is it used for?
- non-steroid anti-androgen
- competes with testosterone and DHT for testosterone receptors
-Used in Tx of prostate cancer in combination with GnRH agonists
Describe tuning fork finding in conductive vs sensorineural hearing loss:
Conductive:
- Rinne test = Abnormal in affected ear (decr sound when put outside ear)
- Weber = Localizes (louder) to affected ear
Sensorineural:
- Rinne = Normal in both ears
- Weber = Localizes (louder) to unaffected ear
In pemphigus vulgaris, Antibodies to ______ create flaccid bullae…usually ruptured
- Desmosomal proteins 3 and 1
* in other disease, bullous pemphigoid, bullae are more tense, and Antibodies are vs hemidesmosomes on BM
What will you find in patients with primary TB exposure?
Ghon complex:
- lower lobe lung lesion
- ipsilateral hilar adenopathy (with calcification)
Describe a case control study:
- select patients with disease and without disease
- Determine exposure differences
Myelination increases the _______ constant of an axon, and decreases the ________ constant.
- Increases the length constant…..allows signal to travel further
- Decreases the time constant….amount of time it takes for a signal to be transduced?
What is seen in renal arterioles of patients with diabetes long term?
- deposition of eosinophilic hyaline material (stains pink homogenously)
- same occurs with chronic HTN
What drug, used to treat acute angle closure glaucoma, affects the kidneys as well? What part of the kidney does it affect and how?
- Acetazolamide: carbonic anhydrase inhibitor
- works in the proximal tubule….inhibits CA, decreasing HCO3 reabsorption in proximal tubules
- incr HCO3 and water excretion –> incr urine pH
- Eyes also produce HCO3……so they are the target for glaucoma
*side fx: incr urine pH, somnolence, dehydration, paresthesias, metabolic acidosis (rarely), hypokalemia, hyponatremia
Incomplete obliteration of the __________ in males causes either Hydrocele or indirect inguinal hernia
- Processus vaginalis
- normally, it descends with testes from peritoneum, and remnants become tunica vaginalis. If incompletely obliterated and only fluid gets through (the inguinal canal) —> hydrocele….if abd contents get throu –> indirect hernia
How does nitrite affect O2 delivery?
- Changes Iron in Hgb from ferrous Fe2 to ferric Fe3 –> cant bind oxygen well
- Leftward shift of dissociation curve
- PO2 stays NORMAL bc that is measure of O2 dissolved in plasma
What is a side effect of high dose loop diuretics (furosemide, torsemide, bumetanide, ethacrynic acid)?
Ototoxicity
*more common sid efx: hypoK, hypoMag, hypoCalcemia
What organism most commonly causes traveler’s diarrhea, and how does it do this?
-ETEC
2 toxins:
Heat labile:
-very similar to cholera toxin
-increases intracellular adenylate cyclase activation and cAMP
-Incr fluid and e-lytes secretion –> watery diarrhea
Heat Stable toxin:
- icr cyclic GMP…guanylate cyclase
- Same end result
Describe the 3 types of lung transplant rejection: Hyperacute, Acute, chronic
Hyperacute:
- within minutes
- preformed antibodies against ABO or HLA
- GRAFT BLOOD VESSEL SPASM —> Ischemia
- often irreversible
Acute:
- 1-2 weeks later
- reaction to HLA on the graft
- Cell-mediated, predom CD8+
- Vascular damage
- dyspnea, dry cough, low-grade fever
chronic:
- months - years
- inflammation of small bronchioles, fibrosis
- dyspnea, non-productive cough, wheezing
Where are VLCFA’s metabolized?
- Peroxisomes
- absent or non-functional peroxisomes –> disease, CNS defects from improper myelination
What does the posterior cerebral artery supply? Where does it branch off from?
- Branches off from Basilar artery
- Occipital lobe, CN 3 and 4, midbrain stuff, thalamus, medial temporal lobe, splenium of corpus collosum, fusiform gyrus
*Q: 2127
Describe the nephron’s actions on para-aminohippuric acid:
- freely filtered by glom. into bowman’s space
- BUT….majority is SECRETED in PCT by carrier-mediated active transport
- NOT REABSORBED in any portion
- highest conc is therefore in Bowman’s space
What are some clinical and pathologic features of Paget’s disease of the bone?
Clinical:
- bone pain
- bone mass (tender)
- hearing loss** (involves the skull as well)
Path:
- Excessive osteoclastic bone resorption
- childhood infxn of osteoclasts by paramyxovirus maybe
- Huge osteoclasts seen with sometimes 100+ nuclei
- incr bone turnover –> chaotic bone formation
- Stimulation for M-CSF and RANK-L
What are the 3 layers of the adrenal glands and what do they each produce?
GFR - glomerulosa, fasciculata, reticularis (outter –> inner)
G - mineralocorticoids (aldosterone)
F - cortisol
R - Androgens
what are the 5 steps (in order) of neutrophil migration to injury site?
- Margination - incr vascular leakage
- Rolling - loose binding and un-binding via selectins
- Activation - sampling of chemokines from inflammed tissue –> integrin activation
- Tight adhesion and crawling - Tight binding to integrins and ICAM-1
- Transmigration - PECAM-1 –> squeeze btwn endoth cells
Gogli-tendon organs are innervated by ________ fibers, and are exquisitely sensitive to muscle _________. They monitor this and contact inhibitory neurons in the spinal cord, causing activation of ______ neurons in the same muscle –> muscle relaxation
- group 1b sensory fibers
- MUSCLE TENSION, not length
- alpha motor neurons
*protect MSK system from damage
What 3 conditions are caused by Bartonella henselae?
- Cat-scratch dz
- Bacillary angiomatosis (immunocompromised)
- Culture-negative endocarditis
How does B12 deficiency cause methionine deficiency?
- need B12 for N-5-THF to donate its methyl and convert homocysteine to methionine
- this also impairs formation of THF from N-5-THF –> “Folate trap”
Staph. _______ causes UTI in young, sexually active women. it is Catalase _______, coagulase ________, and Novobiocin _______.
- Saprophyticus
- catalase positive
- coagulase negative
- Novobiocin resistant*
Why does infection with Neisseria gonorrhea not result in lasting immunity?
-Bc they modify their outer membrane proteins by antigenic variation
In what disease can you see bilateral renal angio-myo-lipomas? What about bilateral RCC?
- Tuberous sclerosis
- Von-hippel-Lindau (eyes, liver, cerebellum, kidneys)
What dz is associated with mutation in FMR-1 gene on the long arm of chromosome X?
- Fragile X
- CGG repeats –> dont stain….chromosome appears broken
- X-linked
What BP drugs can decr GFR and cause hyperkalemia?
ACE-i’s
What are the 2 functions of type 2 pneumocytes?
- Regeneration of alveolar lining following injury
- Surfactant production
*they are also progenitor cells for type 1 pneumocytes
What organism shows budding yeast on sputum culture and forms true hyphae aka “germ tubes” at 37 degrees C?
Candida
-common contaminant of sputum cultures, from oral cavity
What are risk factors for cervical cancer? What about endometrial?
Cervical:
- multiple sex partners
- smoking
- lower SE status
- early coitarche
Endometrial:
- nulliparity
- obesity
- early menarche
What bug causes pneumonia with GI Sx and high fever and some neuro Sx? What scenario do ppl normally get it in? Most common lab abnormality?
- Legionella
- Contaminated water (hotels, cruise ships, etc)
- Hyponatremia
How do you calculate the number needed to harm?
NNH = 1 / attributable risk
attributable risk:
- calculate the adverse event rate in the Tx and placebo groups
- subtract: Tx group risk - placebo risk = attributable risk
What enzyme deficiency causes hyperaldosteronism, and impairs synthesis of both cortisol and androgens?
-17-alpha hydroxylase
- Males are phenotypically female
- females have normal genitalia
What is a potential Tx for hypertensive HF? how does it work?
- Nitroprusside
- short acting balanced venous and arterial vasodilator
- Decreases both preload and afterload….balanced though…so C.O maintained at lower LVEDPs
What 2 tests can check for chronic granulomatous dz? What is the inheritance?
- Nitro-BLUE tatrazolium
- Dihydrorhodamine flow cytomety (fluorescent green = normal)
What is the lymph drainage for the scrotum vs testes?
- Scrotum = superficial inguinal nodes
- testes = Para-aortic nodes
Where is Hepcidin released from? What are its effects? What increases/decreases its release?
- Released from Hepatocytes
- Hepcidin interacts with Ferroportin. Ferroportin releases Iron to blood stream from macrophages and enterocytes. Hepcidin binds it and it gets internalized + destroyed —> decr iron release into blood
- High iron levels, inflammation INCREASE HEPCIDIN
- Hypoxia and erythropoesis LOWER HEPCIDIN
Why do NSAIDS decrease diuretic response to pts taking diuretics?
- THey inhibit prostaglandins
* diuretics normally incr prostaglandin release –> incr renal BF and incr GFR –> enhancing diuretic effect
What inflammatory enzyme is absent from most tissue, but induced upon inflammation?
-COX-2
Name some K+ sparing diuretics
- Amiloride
- triamterene
- Spironolactone
*Hyperkalemia, especially when used with ACEi’s
Why do uric acid stones form in tumor lysis syndrome? WHERE do they form and why?
- Incr cell lysis –> incr uric acid release
- DISTAL TUBULES AND COLLECTING DUCTS
- Uric acid is normally soluble at physiologic pH, but precipitates in ACIDIC pH of distal tubules and collecting ducts
How does Entacapone and tolcapone work?
- They are COMT blockers
- they increase Levodopa availability in the brain
*Levodopa is immediate precursor of dopamine, can cross BBB unlike dopamine. CARBIDOPA works similarly to Entacapone, but instead blocks DOPA DECARBOXYLASE
Name some viruses with a segmented genome:
-WHat makes them capable of dangerous rapid changes?
- Orthomyxoviruses and Rotaviruses
- Capable of genetic shifts through REASSORTMENT, in which entire segments of their genome are interchanged with an animal strain. This is bc of their SEGMENTED GENOME
Which bugs do not gram stain well?
“These Rascals May Microscopically Lack Color”
- Treponema
- Ricketsia
- Mycoplasma
- Mycobacteria
- Legionella
- Chlamydia
Which bugs are Obligate Aerobes?
“Nagging pests must breathe”
- Nocardia
- Pseudomonas
- Mycobacterium TB
- Bacillus
Which bugs are obligate Anaerobes?
“Can’t breathe Air”
- Clostridium
- Bacterioides
- Actinomyces
Which bugs are intracellular?
- Rickettsia and Chlamydia = OBLIGATE
“Some Nasty Bugs May Live F-acultative-LY”
- Salmonella
- Neisseria
- Brucella
- Mycobacterium
- Listeria
- Francicella
- Legionella
- Yersenia pestis
Which bugs are encapsulated?
“SHiN E SKiS”
- Strep pneumo
- H. Influenzae
- Neisseria Meningitides
- E. Coli
- Salmonella
- Klebsiella
- Strep (GBS)
Which bugs are Catalase-positive?
cats need “PLACESS” to live
- Pseudomonas
- Listeria
- Aspergillus
- Candida
- E. Coli
- Staph A.
- Serratia
Which organisms produce IgA protease
“SHiN”
- Strep pneumo
- H influenzae
- Neisseria
Helps colonize resp. mucosa
WHich organisms express Protein A? M protein?
-Staph Aureus
binds to Fc region of Ig, prevents opsonizaton and phagocytosis
-Group A Strep
prevents phagocytosis
Which 2 bugs’ toxins inhibit EF-2, halting protein synthesis?
- Diphtheria toxin
- Exotoxin A of Pseudomonas
Which 2 bug toxins inhibit prot synth by inactivating 60 S ribosome subunit?
- Shiga toxin (shigella)
- Shiga-like toxin (EHEC)
*both bugs can cause HUS
4 exotoxins increase fluid secretion…..which do so by incr intracellular cAMP? which 1 does cGMP?
cAMP:
- Cholera toxin
- Heat Labile toxin (ETEC)
- Edema factor (Bacillus anthracis)
cGMP:
-Heat Stable toxin (ETEC)
Which 2 toxins inhibit NT release by cleaving SNARE protein?
- Tetanospasmin (Clostridium tetani)
- Cotulinum toxin (clostridium botulinum
WHich 2 toxins Lyse cell membranes?
- Alpha toxin (clostridium perfringens)
- Streptolysin O (Strep Pyogenes…lyses RBCs)
Which 2 exotoxins cause shock?
- TSST (staph A)
- Exotoxin A (Strep pyogenes)
in strenuously exercising muscle cells undergoing anaerobic glycolysis, inhibition of Lactate dehydrogenase to slow lactate production causes a depletion of _________, which inhibits glycolysis?
NAD+
*NADH is used to make lactate…..which regenerates NAD+ needed to go from 1,3-BPG —> Pyruvate
What nerve provides sensation for the plantar surface of the foot?
Tibial nerve
What are 3 ways of differentiating between IgA nephropathy and post-infectious GN?
- Timing:
- IgA happens days after infection
- PSGN happens weeks later - Complement:
- Normal in IgA
- Low C3 is post-strep - Mesangial deposits
- Post-strep does not have mesangial IgA deposits
What enzyme is deficient is Niemann0Pick disease?
Sphingomyelinase
-Accum of sphingomyelin –> neuro deterioration
- Period of normal development then –> deteri., MR, HSM, hypotonia
- Foamy histiocytes
- cherry red macula
The ductus arteriosus is derrived from what embryological structure?
The 6th aortic arch
Patient with mono-like Sx, who’s blood fails to agglutinate sheep erythrocytes?
-CMV
Most common heterophile-Ab negative mononucleosis
Why do pts with sarcoid get hypercalcemia?
- Extra-renal formation of calcitriol by activated macrophages
- this occurs along with SUPPRESSION of PTH
How is imprinting accomplished?
-Methylation of DNA’s cytosine residues
What is an example of a methylxanthine drug? how does it work?
- Theophylline, aminophylline
- decr PDE –> incr cAMP –> bronchiodilation
What drug used to tx severe RA can cause stomatitis and liver function abnormalities?
-Methotrexate
What is an indirect method of measuring visceral fat content?
Waist to hip ration
*High ratio assoc. with insulin resistance, metabolic syndrome, and type 2 DM
Alcohols disrupt cell membranes and kill bacteria, mycobacteria, fungi, and viruses, they do not, however, kill __________
Bacterial spores
How does glucose influence the Lac-operon gene?
-Down-regulates adenylate cyclase –> low cAMP –> poor binding of CAP to its binding domain –> decr expression of lac genes
What are features of digitalis toxicity?
- fatigue
- BLURRY VISION
- CHANGES IN COLOR PERCEPTION
- N/V/D , abd pain
- headache
- dizziness
- confusion
- HYPERKALEMIA
- **BRADYCARDIA from AV nodal block –> eventually escape rythms and V-tach or V-fib
On an Abdominal CT slice, the portal vein is seen _______ to the IVC
Anterior
What is the tx for cryptococcal meningitis?
- Amphotericin B immediately
- Flucytosine
- follow with long-term Fluconazole (maintenance)
*CSF findings can have low glucose (like SBP)….but lymphocytes predominate
What PROTEINS can be identified with a DNA-PROBE?
only ones which can bind to DNA, such as: -transcription factors -steroids -Thyroid proteins -vit D receptors -retinoic acid receptors -DNA transcription and replication proteins etc
_____ is a drug that increases fetal hemoglobin. It is reserved for patients with sickle cell who have __________
- Hydroxyurea
- Frequent pain crises
How do gardos channel blockers work in sickle cell tx?
- hinder the efflux of K+ and water from the cell
- Prevents dehydration of RBCs and reduces polymerization of Hb S
In what condition do you see delayed relaxation of DTRs and dry, coarse, thick skin?
*What lab is notable?
- Primary Hypothyroidism
* Will not show low TSH in primary hypothyroid bc primary = TSH deficiency by definition!!!
How is the liver able to use Glycerol for TG synthesis, gluconeogenesis , and glycolysis??
*No other tissue can!
- It has Glycerol Kinase
* Glycerol —> G-3-P —->glycolysis or gluconeogenesis
Naked viruses containing _______ stranded, ________ -sense RNA can be infectious.
- Single-stranded
- Positive sense
*example = rhinovirus
When does amniotic fluid levels of Lecithin (phosphatidylcholine) sharply increase? What about phosphatidyl glycerol?
- 30 weeks
- 36 weeks
What happens histologically 5-10 days after MI in affected myocardium?
- WHat about 10-14 days after?
- 2 weeks to 2 months?
5-10 days:
-macrophage phagocytosis of dead cells
10-14 days:
- Granulation tissue…grows into and replaces dead myocardium
- Neovascularization
2 weeks - 2 months:
-Collagen deposition/scar formation
What are the most common organisms causing intra-abdominal infections?
- Bacterioides fragilis (unique surface polysaccharides –> abcess form)
- E. COli
- enterococci
- streptococci
MCD nephrotic syndrome is known as a _______ proteinuria
- Selective
- only allows passage of low mol. weight proteins like Albumin and transferrin
How do triptans work?
What drugs are usually used as migraine PPX?
-Serotonin agonists
Triptans inhibit the release of vasoactive peptides, promoting vasoconstriction and blocking pain pathways
-Beta-blockers, antidepressants, anticonvulsants
What drug used to treat heart failure can cause endocrine effects such as: gynecomastia, decreased Libido, and impotence?
Spirinolactone
- Because it is structurally similar to steroid
- Eplerenone is newer and may have less of these effects
What is the AA precursor for Serotonin?
Tryptophan
Sickle cell patient has very high MCV (114) and retics are 5…..why is the MCV likely high?
- Folate deficiency from incr erythrocytosis
- 5% retics not enough to incr MCV by that much
A kid who had delayed detachment of the umbilical cord, recurrent skin infections WITHOUT PUS, poor wound healing, has what disease?
*what is the pathophys?
- Leukocyte adhesion deficiency
- AR genetic absence of CD18 —> inability to synthesize integrins
Why can folate supplementation alone for a pt with B12 deficiency lead to worsening demyelination and thus worse neuro Sx?
-Bc it depletes Un-methylated B12 available for Methylmalonyl-CoA processing
The deep branch of the median nerve allows for what movements? Where is it most commonly injured?
- Weakness of forearm and hand extensors
- “Wrist drop”
-Injured near radial head, medical epicondyle of humerus, common is radial head sublaxation in kids
What is the best test to determine whether a gene is being transcribed?
-Northern blot –> to check for mRNA
In addition to sinopulmonary and GI infection, patients with selective IgA deficiency can have fatal consequences following _________.
- blood transfusions
- Anaphylactic response due to immune response against transfused IgA…..their bodies recognize it as foreign
ACL vs PCL superior attachments
- ACL more lateral
- PCL more medial
WHat type of transporter is the CFTR protein?
-ATP-gated
Patients with a much less severe form of galactosemia, causing only cataracts, have a deficiency of _________.
THis leads to increased production of ________, catalyzed by _______.
- Galactokinase deficiency
- Increased Galactitol
- Catalyzed by Aldose Reductase
In HIV patients, which organism causing esophagitis causes hyperemia and linear ulceration?
-CMV
What is Varenicline used for? how does it work?
- Smoking cessation
- Partial agonist of nicotinic AcH receptors –> decreases cravings and decreases pleasurable effects of cigarettes
Why does mycoplasma cause anemia? What mediates this?
- Shares antigens with RBC’s
- Body mounts response to these RBCs –> Lysis
- Antibodies are responsible (cold agglutinins…IgM)
Cortisol increases transcription of this enzyme, leading to increased synthesis of Epinephrine?
-Phenylethanolamine-N-Methyltransferase
NE –> Epinephrine
What e-Lyte abnormalities are present with amphotericin B treatment?
- Hypokalemia
- Hypomagnesemia
*from affects of kidney –> can lead to EKG changes (frequent premature beats)
What type of damage is caused in the kidneys by sickle cell dz or trait?
- papillary necrosis
- same for DM, analgesic nephropathy, or severe obstructive pyelo
-gross hematuria, colicky flank pain,tissue fragments in urine
What type of insulin is used acutely to Tx DKA?
- Regular insulin IV
- begins to lower glucose and ketones within minutes
*Sub-Q administration (not preferred) –> active within about 30 minutes. Volume depleted though –> erratic subQ absorption
WHat types of drugs are used to prevent motion sickness? examples?
- 1st generation anti-histamines, since they also have anti-muscarinic effects
- Meclizine, Dimenhydrinate, scopolamine
- Main side fx = Dry mouth
How does Niacin influence the effects of anti-HTN and Diabetes meds?
- Can potentiate anti-HTN effects by increasing vasodilation
- May need to decr HTN meds befoee starting Niacin
- Can increase insulin resistance
- May need to Incr Diabetes meds
**Can also increase serum uric acid
What does a blood gas look like in someone with a PE?
- Respiratory Alkalosis and hypoxemia
- Hypoxemia causes compensatory hyperventilation
pH = incr PaO2 = low PsCO2 = low HCO3 = normal, or low if renal comp has occured
What is the difference between Zero order and first order kinetics?
Zero order
-constant AMOUNT of drug is metab per unit time, independent of concentration
First order
-constant FRACTION of drug is metabolized per unit time, based on serum concentration
Treatment of Hydatid cyst from echinococcus? Why no drainage?
- Mebendazole or Albendazole
- Cyst contents in abdomen if released can cause anaphylactic shock
What is the major cause of AAA? What happens pathologically first?
- Atherosclerosis
- Intimal (fatty) streaks
- eventually these streaks can weaken the underlying media of the aortic wall
What causes the hypoglycemia of an infant of diabetic mom?
-hyperglycemia –> pancreatic islet cell hyperplasia –> hyperinsulinemia
How do nitrates work for CP?
- Venodilators
- decr in cardiac work by decreasing LV filling volume (preload)
WHere is damage done in ppl who get hearing impairment from chronic exposure to loud noises?
- Organ of Corti
- damage of stereociliated hair cells
Patient with flank pain radiating to the groin after having pelvic surgery?
-Hydronephrosis from ligation of the ureter
What should stop you from using ACE inhibitors in people with atherosclerotic disease?
- Development of ARF
- Bilateral renal artery stenosis
The enzymes _________ and __________ are inactivated by lead. This leads to impaired heme synthesis, and accumulation of _________ and ________
- Alpha-Aminolevulinate dehydratase
- Ferrocheletase
- Alpha-ALA (aminolevulinic acid)
- Protoporphyrin 9
What are the findings seen in caudal regression syndrome? What is thought to be a factor causing it?
- baby with flaccid paralysis,
- absent DTA,
- agenesis of the sacrum and/or lumbar spine,
- dorsiflexed contractures of of the feet,
- urinary incontinence
*Uncontrolled diabetes
What drug is used for reversal of heparin?
- Protamine sulfate
* Not great for LMW heparin
Parasitic infection causing renal stuff, liver and spleen granulomas, sometimes intestinal stuff?
- Schistosoma
- Snails
- can also cause SCC of bladder (S. haematobium)
Where is the saphenous vein harvested from for CABG? Where does it normally drain into?
- Just inferolateral to the pubic tubercle
- Drains into femoral vein
which pituitary hormone is constitutively controlled/inhibited by the hypothalamus? By what chemical?
- Prolactin
- Dopamine
*Hypothalamic lesion –> decr inhibition of prolactin due to decr dopamine –> increased prolactin
What sign can be seen on a cellular level that indicates irreversible cellular damage?
What about reversible signs?
- Mitochondrial vacuolization
- Myofibril relaxation, disaggregation of polysomes, disaggregation of nuclear granules, glycogen loss, TGA droplet accumulation
What 3 variables affect total oxygen content of blood?
*What condition shows normal PaO2, normal SaO2, and low oxygen content?
- Hgb concentration
- O2 saturation of Hgb (SaO2)
- Partial pressure of O2 dissolved in blood (PaO2)
*Anemia, which decreased Hgb concentration
_________ is an essential activator of CPS-1 in the urea cycle, and is formed by the enzyme ___________, from Acetyl CoA and glutamate
- N-Acetylglutamate
- N-Acetylglutamate synthetase
WHat 3 chemicals stimulate acid secretion in the stomach?
- AcH
- Histamine
- Gastrin
Erythrocytes use the enzyme ___________ to produce 2,3-BPG, which increases O2 delivery to tissues.
- Bisphosphoglycerate Mutase
* from 1,3-Bisphosphoglycerate –> leaves glycolysis and uses energy
What bacteria is PYR positive and causes tissue necrosis?
-Group A strep
Obstruction of the ______ causes dilated lateral and 3rd ventricles, with normal-sized 4th ventricle
-Cerebral aqueduct (of sylvius)
Describe the path of CSF flow:
- formed by choroid plexus
- Lateral ventricles to 3rd ventricle via foramen of monro (interventricular foramen)
- 3rd ventricle to 4th ventricle via cerebral aqueduct
- exits 4th ventricle into Subarachnoid space via foramen of Luschka (2) or the foramen of Magendie
How do TNF-alpha, catecholamines, glucocorticoids, and glucagon increase insulin resistance?
- through activation of Serine/Threonine kinases
- results in phosphorylation of IRS-1, interfering with it’s interaction with the insulin receptor
What drug is used for gram-positive bacteremia, including MRSA, and can cause incr CPK and myopathy?
How does it work?
- Daptomycin
- It is a Lipopeptide….it disrupts the bacterial membrane through creation of transmembrane channels –> leakage of ions –> depolarization of membrane –> inhibition of DNA, RNA, protein synthesis –> death
What gene is mutated in AML type 3 (acute promyelocytic leukemia) and what does that gene code for?
- translocation (15;17)
- gene for retinoic acid receptor alpha
*fusion gene PML/RAR-alpha results –> inhibits myelocyte differentiation –> promyelocytic leukemia
What drug specifically inhibits Mycolic acid, thereby making mycobacteria lose their acid-fastness, and preventing synthesis of new cell walls (stop proliferation)?
-Isoniazid
What is the clinical presentation of, and pathophys underlying Lambert-eaton syndrome?
- Proximal muscle weakness associated with malignancy (especially lung)
- improves throughout the day
- improves with exercise
- **No improvement with Tensilon test
- Nerve stim. study shows incremental response!
Pathophys:
-Antibodies vs. pre-synaptic calcium channels
Describe the filtration of PAH
- freely filtered in the glom.
- also secreted in PCT by carrier-mediated process
- Carriers can become saturated at high blood concentrations
How is acute organ TPX rejection treated?
-Calcineurin inhibitors and systemic steroids
CNS tumors of Neuronal origin stain positively for ________, whereas neoplasms of glial origin (astrocytomas, ependymomas, oligodendrogliomas) stain for __________.
- Synaptophysin (protein found in presynaptic vesicles of neurons)
- GFAP
WHat drugs reduce Grave’s ophthalmopathy?
- High dose steroids
* Conventional anti-thyroid meds dont help the eye symptoms
WHat is the Tx for orotic aciduria and how does it work?
- Uridine supplementation
- Inhibits CPS-2 –> decr orotic acid
What parameter influences Positive and negative predictive values?
-diseaase prevalence
What are some risk factors for formation of biliary sludge?
- Pregnancy
- TPN
- Rapid weight loss
- Prolonged use of octreotide
- High spinal cord injuries
WHat are some long term consequences of using topical steroids?
- Dermal atrophy with loss of dermal collagen (synthesis decr by roids)
- drying
- cracking
- tightening
- telangiectasias
- Striae
Where is factor 8 synthesized? Stored?
WHat drug releases vWF and factor 8?
-Liver , endothelial cells
-Desmopressin
Synthetic vasopressin analog that releases vWF and factor 8 from endothelial cells
Other than allopurinol, what other drug can be used to decr uric acid levels in tumor lysis syndrome?
- Rasburicase
* catalyzes conversion of uric acid to allantoin (more soluble)
________ is an extended spectrum PCN + BetaLactamase inhibitor that covers most Gram negative enteric bacilli, including pseudomonas and bacterioides
-Piperacillin-Tazobactam
In addition to having beneficial sympathetic down-regulation, Beta-blockers are also helpful for thyrotoxicosis bc they also ________
Decrease peripheral conversion of T4 to T3 (more active)
Riboflavin is necessary for which enzyme of the TCA cycle?
- Succinate dehydrogenase
* converts succinate to fumarate
What is the only bacteria that requires cholesterol for growth on culture?
Mycoplasma
What disease come from poor intestinal absorption and renal re-absorption of Lysine, Arginine, Ornithine, and cysteine?
What results clinically?
- Cystinuria
- normally absorbed in the jejunem, re-ab in the PCT
- Kidney stones! (Hexagonal cysteine crystals)
- Cysteine stones bc cysteine is not soluble at physiologic urine pH
Antibodies vs _______ have a high SPECIFICITY for RA
-Citrullinated peptides (CCP)
WHat nerve provides somatic sensation (temperature, etc) to the anterior 2/3 of the tongue ?
-Trigeminal nerve
V3, branch from the mandibular division called the lingual nerve
What drugs inhibit topoisomerases? What is the result?
- Etoposide and podophyllin……chemo drugs
- inhibit sealing activity of topoisomerase 2 –> chromosomal breaks acumulate –> cell death
Topoisomerase 1 makes single-stranded nicks. 2 induces transient breaks in dsDNA and seals them
What is the most common cause of fetal hydronephrosis?
- Obstruction at the ureto-pelvic junction
- From inadequate recanalization of ureters at this location
- 2nd most coomon is VUR
WHat is the characteristic histological finding in Hashimoto’s thyroiditis? (2)
- Mononuclear parenchymal infiltration
- Well developed germinal centers
*Q: 769
What cells are seen “hugging other cells” in peripheral smear of patient with EBV mono?
- CD8+ T cells
* They are activated in response to virally-infected B-cells to try to kill them
What should you suspect in a patient with EPISODIC tachycardia, HTN, diaphoresis….that resolve without intervention?
- Possible pheochromocytoma
* Also possible is autonomic dysfunction, cocaine abuse, Panic attacks
What does papillary cancer look like on histology?
- Large cells with nuclei containing FINELY DISPERSED CHROMATIN with GROUND GLASS APPEARANCE (orphan annie’s eye)
- Psammoma bodies (laminated calcium deposits
- Intranuclear inclusions
What enzyme defect is responsible for classic homocystinuria?
-Cystathionine-beta synthase
WHat NT/receptor is responsible for Opiate tolerance?
- Glutamate/NMDA
* Ketamine, an NMDA antagonist, may decrease morphine tolerance
Loop diuretics are more likely to _______ calcium, and thiazide diuretics ________ calcium
- Loop = Decrease
- Thiazides = increase
What the clinical findings associated with Churg-strauss disease?
- Adult onset asthma
- Eosinophilia
- Hx of allergy
- Mono or poly neuropathy***
- Pulm infiltrates
- Paranasal sinus abnormalities
Labs: p-ANCA …..aka antibodies vs Neutrophil Myeloperoxidase
What are 2 congenital syndromes associated with prolonged QT intervals?
- Lange-Nielsen syndrome
- AR
- Neurosensory deafness
- Romano-Ward syndrome
- AD
- No deafness
BOTH CAUSE MUTATIONS IN K+ CHANNELS
Name 4 organisms that require only a VERY small amount of organisms in order to cause gastroenteritis:
- Shigella (10)
- Campylobacter jejuni (500)
- Entamoeba histolytica (1)
- Giardia Lamblia (1)
What hypothalamic nucleus is responsible for satiety signals? What happens if it is damages?
- Ventromedial nucleus
- Bilateral lesions –> hyperphagia and obesity, sometimes also rage and aggressive behavior
*most common cause is tumor invasion….ex = craniopharyngioma
What do the lateral, suprachiasmatic, supraoptic, and anterior hypothalamic nuclei do?
- Lateral = signals hunger…..damage –> annorexa, starvation
- Suprachiasmatic = circadian (directly above optic chiasm
- Supraoptic = producce ADH and Oxytocin
- Anterior = Temperature control….initiates body cooling. damage = hyperthermia
What enzyme causes fructose intolerance? What are Sx and Tx?
- Aldolase B
- Sx = hypoglycemia following fructose ingestion , vomiting, cirrhosis, jaundice
- Tx = limit fructose in diet, including sucrose
What is Class 1B anti-arrhythmics’ dissociation speed compared to 1A and 1C? What is it useful for?
- Fastest dissociation —> least amount of use dependence
- Useful for treating ischemia-induced ventricular arrhythmias.
- *Exmples: Lidocaine, Tocainide, Mexilitene
- “One can C…the Canes usually and up in Mexico”
WHat enzyme allows individuals with fructosuria to metabolize fructose / use it for glycogen storage?
-Hexokinase
What forms the MAC complex? And pts with inability to form the MAC complex are especially succeptible to which bug?
- C5b and C9 complement factors
- Deficiency = Neisseria Mening. infections
What is cheyne-stokes breathing and who is it normally seen in?
- Apnea —> Gradually incr TV->gradually decreasing TV —> Apnea
- This CYCLE (pattern) is seen in pts with adv. CHF, or CNS disease
What drugs, when used along with statins, increase the risk of myopathy?
-Fibrates (gemfibrozil, fenofibrate)
In what organelle does heme synthesis occur?
-Mitochondria
How do you stop PSVT?
- Vagal maneuvers
2. IV Adenosine if maneuvers fail
What drugs can facilitate lithium toxicity?
- Thiazide diuretics
- ACEi’s
- NSAIDS
What releases IL-2 and what does IL-2 do?
- produced by helper T cells
- stim. growth, differentiation, and survival of:
- Antigen specific CD4+ T cells
- CD8+ T cells
- B cells
- Activates NK cells and monocytes
In Gibbs free energy, if delta G is negative, Keq will be _________ 1, and the concentration of products at equilibrium will exceed substrates.
If delta G is positive, Keq will be _______ 1, and formation of substrates will be favored
- Greater than 1
- Less than 1
What are the levels (Incr vs Decr) of CRH, ACTH, and Cortisol, in a patient on chronic steroids, during an adrenal crisis?
- Decr
- Decr
- Decr
Sertoli cells secrete _______, which prevents development of female internal genitalia.
Leydig cells secrete Testosterone, which leads to _________
- MIF
- development of male internal genitalia
- DHT converted peripherally from Testosterone, develops EXTERNAL male characteristics
What is the clinical presentation of Cori disease?
What is the pathophysiology?
What is seen on histology of Liver?
- Hypoglycemia, FTT, HyperTriglyceridemia, Ketoacidosis, Hepatomegaly
- De-branching enzyme deficiency –> Cant break glycogen down past limit dextrins –> accumulation and insufficient mobilization of glucose
- Hepatic fibrosis, WITHOUT FAT accumulation, accumulation of small chain Dextrin-like material within cytosol of hepatocytes
Which CCB is the MOST cardioeffective of the CCBs?
What are it’s side effects? (4)
- Verapamil
- Constipation, gingival hyperplasia, bradycardia, heart block (all degrees)
WHich anti-inflammatory drugs do not affect platelets? Whats an example of one?
- Selective COX-2 inhibitors
- Celecoxib
What is the first histologic sign seen in the brain following ischemic damage and when can it be seen?
- Red neurons (eosinophilic cytoplasm) , loss of Nissl substance, pyknotic nuclei
- 12-48 hours
WHat is the mechanism (intracellularly) of Nitrates for vasodilation?
- Transformed to NO at vascular SM membrane –> increased cGMP
- —> decr intracellular calcium —> myosin dephosphorylation –> SM relaxation and resultant vasodilation
What is the Amphoterin B most notorious for as far as side effects?
- Renal toxicity
* Monitor K+ and Mag!!
What molecule/substance prevents formation of Calcium-Oxalate stones in urine?
- Citrate!
* K+Citrate is often prescribed for recurrent calcium stones when dietary changes are unsuccessful
What pathology is seen in the blood vessels of someone with malignant hypertension?
- Hyperplastic arteriosclerosis
- Onion-like concentric thickening of arteriolar walls, especially in the renal vasculature
- *Decreases GFR –> incr renin –> further incr BP –> Viscious cycle!!
_____ cell lung carcinomas commonly secrete ACTH and/or Vasopressin, whereas ________ cell lung carcinomas secrete PTHrP
- Small cell = ACTH —> Hypercortisolism
- Squamous cell = PTHrP —> hypercalcemia
How does Carcinoid syndrome affect the heart?
What is seen on pathology?
What lab value is diagnostic?
- R-sided problems: Endocardial fibrosis, pulmonic stenosis, possible restrictive cardiomyopathy
- Dense fibrous deposits
- Incr serum SEROTONIN and URINE 5-HYDROXYINDOLEACETIC ACID
What causes retraction of overlying skin in breast cancer?
-Invasion of the suspensory (cooper’s) ligament
