FA, Rx, UW Flashcards
Chromosome 3
VHL, Renal Cell Carcinoma
Chromosome 4
ADPKD (PDK2), achondroplasia, Huntignton
Chromosome 5
Cri-du-chat syndrome, FAP
Chromosome 6
Hemochromatosis (HFE)
Chromosome 7
Williams syndrome, CF
Chromosome 9
Friedreich ataxia
Chromosome 11
Wilms tumor, Beta-globin gene defects (e.g. Sickle cell)
Chromosome 13
Patau syndrome, Wilson disease, RB, BRCA2
Chromosome 15
Prader-Willi, Angelman, Marfan
Chromosome 16
ADPKD (1), alpha-globin defects
Chromosome 17
NF Type 1, BRCA1, p53
Chromosome 18
Edwards Syndrome
Chromosome 21
Down syndrome
Chromosome 22
NF Type 2, DiGeorge Syndrome (22q11)
What is Hartnup disease?
An autosomal recessive deficiency of Tryptophan; results in pellagra-like symptoms.
Nondisjunction that produces trisomies occurs specifically at which stage of Meiosis 1/2?
Anaphase
Which cancer is associated with t(8;14)?
Burkitt lymphoma (c-myc activation)
Which cancer is associated with t(9;22)?
CML(BCR-ABL hybrid), ALL (less common, poor prognostic factor)
Which cancer is associated with t(11;14)?
Mantle cell lymphoma (cyclin D1 activation)
Which cancer is associated with t(14;18)?
Follicular lymphoma (BCL-2 activation)
Which cancer is associated with t(15;17)?
APL (M3 type of AML)
Which type of DNA repair mechanism is impaired in xeroderma pigmentosum?
Nucleotide excision repair
Goodpasture’s Syndrome has autoantibodies against what?
Anti-glomerular basement membrane (Type IV collagen)
What type of DNA repair mechanism is defective in Lynch Syndrome (HNPCC)
Mismatch repair
Fragile X syndrome is which tirnucleotide repeat, and is characterized by what phenomenon?
CGG repeat; hypermethylation of the FMR1 gene resulting in decreased expression
Which conditions result in a microcytic anemia?
Microcytic = MCV < 80fL
- SALTI
- Sideroblastic
- Anemia of chronic disease
- Lead poisoning
- Thalassemias
- Iron deficiency (late)
Where does collagen synthesis, hydroxylation, and glycosylation take place?
In the Rough ER
Where does collagen triple helix formation take place?
In the rough ER (hydrogen and disulfide bonds)
Where does cleavage of the C- and N- terminals of collagen take place?
In the extracellular space –> forms tropocollagen
A patient with increased lactic acid levels in the setting of acute mesenteric ischemia, most likely has decreased activity in which enzyme?
Pyruvate dehydrogenase
- Someone with mesenteric ischemia has inadequate O2 delivery to the intestinal tissues, which means that the accumulation of NADH under hypoxic conditions inhibits pyruvate dehydrogenase.
Which enzymes in glycolysis and the TCA produce NADH from NAD?
The dehydrogenases:
- Pyruvate dehydrogenase
- Isocitrate dehydrogenase
- Alpha ketoglutarate dehydrognase
Which cofactor is needed for transamination and decarboxylation reactions?
B6 (pyridoxine)
An inability to transport ornithine into the mitochondria indicates what disorder?
Ornithine translocase deficiency, which precipitates a defect in the hepatic urea cycle. Tx: protein restriction
Biotin is a cofactor for which enzymes?
The carboxylases:
- Pyruvate carboxylase (Pyr–>OAA)
- Acetyl-CoA Carboxylase (Acetyl-CoA–> Malonyl CoA)
- Propionyl-CoA carboxylase (Propionyl-CoA–>Methylmalonyl-CoA)
Of the non-glucose monosaccharides (mannose, fructose, galactose), which one bypasses phosphofructokinase?
Fructose
What are homeobox genes?
Homeobox (Hox) genes encode DNA-binding transcription factors. Mutations in Hox genes cause the genes for different appendages to be transcribed in the wrong places (because the Hox genes are expressed at the wrong time/place).
How does carbon monoxide (CO) impact hemoglobin?
CO competitively binds iron present in heme proteins. It has no impact on the partial pressure of O2.
Which type of factor has Zinc-finger domains?
Intracellular receptors (e.g. steroids, thyroid hormone, fat-soluble vitamin receptors)
Infusion of hemin (heme) for treatment of AIP, causes downregulation of what enzyme?
ALAS (aminolevulinate synthase) - the rate-limiting enzyme in the heme synthesis pathway
True or False? Patients with aldolase B deficiency can tolerate sucrose?
False. Sucrose is composed of glucose and fructose (which can’t be broken down in patients with aldolase B deficiency).
How can fibrates cause cholecystitis?
Fibrates inhibit cholesterol 7alpha-hydroxylase which is the rate-limiting enzyme in the synthesis of bile acids. Without bile acids, decreased cholesterol solubility in bile favors cholesterol stone formation.
How do the shapes of the hemoglobin and myoglobin dissociation curves differ?
The Hg curve is sigmoid in shape (due to positive cooperativity with O2 binding); the myoglobin oxygen dissociation curve is hyperbolic, because it only has a single heme group, and doesn’t have heme-heme interactions/facilitation.
Which findings are seen in Fabry disease?
X-linked Recessive
Early: 1. Hypohidrosis, Angiokeratomas, Peripheral neuropathy
Late: Renal Failure, LVH
FABRY ACC
- Febrile episodes (hypohidrosis)
- Angiokeratomas
- Burning pain (peripheral neuropathy)
- Renal failure
- Young death
- Alpha-galactosidase A (deficient enzyme)
- Cardiovascular disease
- Ceramide trihexosidase (buildup product)
Which findings are seen in Tay-Sachs disease?
“Tay’s not heppy about developing a crush on his OG eX Amanda”
- Not Heppy = NO hepatosplenomegaly
- Developmental delay
- CRush = Cherry Red spot
- O = onion skinned lysosomes
- G = GM2 ganglioside
- X Amanda - HeXosaminidase A
Which findings are seen in Krabbe disease?
“GOD, you’re so Kabbe”
- G = galactocerebrosidase/globoid cells
- O = Optic atrophy
- D = developmental delay
Which findings are seen in Niemann-Pick disease?
“Niemann-picked up his heppy, neurotic father from central spot station”
- Hepatosplenomegaly
- Foam cells
- Neurodegeneration
- Cherry-red spot
- Sphingomyelin/ase
Which findings are seen in Hurler syndrome?
- Corneal cLouding (HurLer)
- GargoLylism
- HSM
- alpha-L-iduonidase deficiency
Which findings are seen in Hunter syndrome?
- NO corneal clouding (there is no “L” in “Hunter”)
- Aggressive behavior (Hunters are aggressive)
- Iduronate sulfatase deficiency
Which congenital disorder of predisposes patients to E. coli sepsis?
Classic galactosemia (deficiency in galactose-1-phophate uridyltransferase). Presents with failure to thrive(soon after the onset of infant feeding, within days), jaundice, Hepatomegaly, infantile cataracts.
What is cretinism and what are its clinical features?
Cretinism = congential hypothyroidism
- 6 P’s:
- Pot-bellied
- Pale
- Puffy-faced
- Protruding umbilicus
- Protuberant tongue
- Poor brain development
Which hormones are coupled to cAMP?
FLAT ChAMP
- FSH
- LH
- ACTH
- TSH
- CRH
- hCG
- ADH
- MSH
- PTH
Which hormones are coupled to cGMP?
BAD GraMPa (vasodilators)
- BNP
- ANP
- EDRF (NO)
Which hormones are coupled to IP3?
GOAT HAG
- GnRH
- Oxytocin
- ADH (V1)
- TRH
- Histamine
- ATII
- Gastrin
Which hormones are intracellular receptors?
(Steroid hormones): PET CAT on TV
- Progesteron
- Estrogen
- Testosterone
- Cortisol
- Aldosterone
- T3/T4
- Vitamin D
Which hormones are coupled to a receptor tyrosine kinase?
Growth Factors
- Insulin
- IGF-1
- FGF
- PDGF
- EGF
Which hormones are coupled to a nonreceptor tyrosine kinase?
PIGGLET - uses JAK/TAT pathway
- Prolactin
- Immunomodulators (e.g. IL-2, IL-6)
- GH
- G-CSF
- Erythropoietin
- Thrombopoietin
Which cell-surface marker is associated with plasma cells?
CD27
Which cell-surface marker is associated with B cells?
CD19, 20, 21, 40
Which cell-surface markers are associated with NK cells?
CD56, CD16
What is the CD4 cell surface marker associated with?
Regulatory and Helper T cells
Which cell-surface markers are associated with regulatory T cells?
CD3, CD4, CD25 and FOXP3 (transcription factor)
Ebstein Barr virus affects which cells?
Infects B cells (but peripheral smear features reactive/atypical cytotoxic T cells)
Recipient’s cytotoxic T-lymphocytes destroy the graft within weeks to months of the transplant:
Acute graft rejection
Vessel occlusion, ischemia, or fibrinoid necrosis, occurring within minutes to hours after a transplant:
Hyperacute graft rejection
Donor peptides being displayed by recipient antigen-presenting cells, resulting in interstitial fibrosis, atherosclerosis, and vanishing bile duct syndrome:
Chronic organ rejection
Which cell type is associated with CD34?
Pluripotent stem cell (Stimulated by G-CSF) –> G-CSF is often given to patients who have experienced myelosuppression as a result of chemotherapy.
Which vasculitis is associated with asthma, sinusitis, skin nodules or purpura, peripheral neuropathy (eg, wrist/foot drop)?
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) - pANCA/MPO
What is the classic pentad of thrombotic thrombocytopenic purpura (TTP) and what is it caused by?
TTP is a platelet disorder that is due to inhibition or deficiency of ADAMTS 13 (vWF metalloprotease) –> reduced degradation of vWF multimers (therefore more clotting)
- Microangiopathic hemolytic anemia (MAHA)
- Thrombocytopenia (because platelets are being used up to form the clot)
- Neurologic abnormalities
- Renal abnormalities
- Fever
What is the drug of choice for diagnosing myasthenia gravis?
Edrophonium (irreversible acetylcholinesterase inhibitor with a short duration of ~10-20 minutes)
What is the classic triad of acute graft-versus-host disease (GVHD)?
Dermatitis, hepatitis (elevation in liver enzymes), and gastroenteritis
Antimicrosomal autoantibodies
Hashimoto’s Thyroiditis
What is the triad (quad) of Plummer Vinson syndrome?
(IDEA)
- Iron-deficiency anemia
- Dysphagia
- Esophageal webs
- Atrophic glossitis
What is the most common cause of death in infants born with congenital diaphragmatic hernia?
Pulmonary hypoplasia
What treatment should be immediately initiated for heparin-induced thrombocytopenia (HIT)?
A direct thrombin inhibitor such as argatroban
What is the mechanism of superantigens causing shock? (e.g. Staph aureus -TSST1 and Strep pyogenes-Exotoxin A)
Both involve binding to MHC II (remember exotoxins) and TCR outside of the antigen binding site, and cause an overwhelming release of IL-1, IL-2, IFN-gamma and TNF-alpha.
Acute hemolytic transfusion reaction (anti-ABO antibodies) is what type of hypersensitivity reaction?
Type II
Which cell types are involved in delayed-type hypersensitivity reactions?
CD4+ T lymphocytes and macrophages
What is the mechanism by which eosinophils are involved in host defense during parasitic infection?
Antibody-dependent cell-mediated cytotoxicity, in which they recognize antibodies bound to the parasitic organism and release enzymes from their cytoplasmic granules.
ALK mutation
Oncogene:
Receptor tyrosine kinase –> lung adenocarcinoma
BCR-ABL mutation
Oncogene:
Tyrosine kinase –> CML, ALL
BCL-2 mutation
Oncogene:
Anti-apoptotic molecule –> follicular and diffuse large B cell lymphoma
APC
Tumor suppressor gene:
Negative regulator of Beta-catenin/WNT pathway –> Colorectal cancer (assoc. w/ FAP)
BRCA1/BRCA2
Tumor suppressor:
DNA repair protein –> breast, ovarian and pancreatic cancer
BRAF
oncogene; serine/threonine kinase; involved in melanoma and non-Hodgkin lymphoma
c-kit
oncogene; cytokine receptor; involved in gastrointestinal stromal tumors (GIST); mutation indicates good candidacy for imatinib tx
c-myc
oncogene; ch. 8; transcription factor; involved in Burkitt lymphoma [t(8;14)]
HER2/neu
oncogene; tyrosine kinase; involved in breast, ovarian, and gastric carcinomas; mutation indicates good candidacy for trastuzumab
L-myc
oncogene; transcription factor; involved in lung tumors (small cell)
N-myc
oncogene; transcription factor; involved in neuroblastoma
KRAS
oncogene; GTPase; colon, lung, and pancreatic cancer
RET
oncogene; receptor tyrosine kinase; involved in MEN 2A (medullary thyroid cancer, pheochromocytoma, parathyroid hyperplasia) and 2B (medullary thyroid cancer, pheochromocytoma, mucosal neuromas), medullary thyroid cancer
DCC
tumor suppressor gene; “deleted in colon cancer”
DPC4/SMAD4
tumor suppressor gene; “deleted in pancreatic cancer”
MEN1
tumor suppressor gene; ch. 11; menin; involved in MEN1 (parathyroid adenoma, pituitary adenoma, enteropancreatic tumors)
NF1
ch. 17; tumor suppressor gene; neurofibronin, Ras GTPase activating protein; involved in neurofibromatosis type 1
NF2
ch. 22; tummor suppressor gene: Merlin (schwannomin) protein; involved in neurofibromatosis type 2
PTEN
tumor suppressor gene; Tyrosine phophatase of PIP3 (e.g. protein kinase B [AKT] activation); involved in breast cancer, prostate cancer, endometrial cancer
Rb
tumor suppressor gene; inhibits E2F blocking G1–>S phase; involved retinoblastoma and osteosarcoma
TP53
tumor suppressor gene; p53, activates p21, blocks G1–>S phase; involved in most human cancers, Li-Fraumeni Syndrome (a.k.a. SBLA cancer syndrome: sarcoma, breast, leukemia, adrenal gland)
TSC1
tumor suppressor gene; hamartin protein; involved in tuberous sclerosis
TSC2
tumor suppressor gene; tuberin(2berin) protein; involved in tuberous sclerosis
VHL
tumor suppressor gene; inhibits hypoxia inducible factor 1a; involved in von Hippel-Lindau disease (chr. 3)
WT1
tumor suppressor gene; transcription factor that regulates urogenital development (Wilms tumor - nephroblastoma)
What are psammoma bodies and which neoplasms are associated with them?
Psammoma bodies are laminated, concentric spherules with dystrophic calcifications. The cancers in which they are seen can be remembered by the mnemonic “PSaMMoma”:
- Papillary carcinoma of the thyroid
- Serous papillary cystadenocarcinoma of the ovary
- Meningioma
- Mesothelioma
alkaline phosphatase
- metastases to bone or liver, Paget disease of bone, seminoma (placental ALP)
- must exclude hepatic origin by checking LFTs and GGT levels
CA-125
ovarian cancer
CA 19-9
pancreatic adenocarcinoma
CA 15-3/CA 27-29
breast cancer
alpha-fetoprotein
- hepatocellular carcinoma
- hepatoblastoma
- yolk sac (endodermal sinus) tumor
- mixed germ cell tumor
- normally made by fetus, transiently elevated in pregnancy
- high levels associated = neural tube and abdominal wall defects
- low levels = down syndrome
beta-hCG
- hydatidiform moles
- choriocarcinomas (gestational trophoblastic disease)
- testicular cancer
- mixed germ cell tumor
- produced by syncytiotrophoblasts of the placenta
calcitonin
medullary thyroid carcinoma
CEA
major: colorectal and pancreatic cancers
minor: gastric, breast and medullary thyroid carcinomas
chromogranin
neuroendocrine tumors
PSA
prostate cancer
S-100
melanoma (and other neural crest tumors including schwannomas)
What is P-glycoprotein?
A transmembrane ATP-dependent efflux pump that is also known as multidrug resistance protein 1 (MDR1). Classically seen in adrenocortical carcinoma but can also be expressed by other cancer cells.
What are common metastases to the brain?
Lung > Breast > Melanoma, Colon, Kidney
What are common metastases to the liver?
Colon»_space; Stomach > Pancreas
What are common metastases to bone?
Prostate, breast > Lung, Thyroid, Kidney
Which cardiac anomaly results in a loud S1, a wide, fixed split S2?
Atrial septal defect (ASD)
Which neoplasm commonly presents with DIC?
AML (especially M3 subtype)
Spindle-shaped smooth muscle cells is most associated with which neoplasm?
Leiomyosarcoma
Which neoplasm is characterized on histology as having large, halo-like cells, and what is there an increased risk for?
Paget disease of the nipple presents with characteristic large, halo-like cells on histologic exam, and carries a high risk of underlying in situ or invasive ductal carcinoma.
What is TRAP and what is it associated with?
TRAP = tartrate-resistant acid phosphatase and is associated with Hairy Cell Leukemia
What is the mode of inheritance of glucose-6-phosphate dehydrogenase deficiency?
X-linked recessive
What causes a porcelain gallbladder, and what does this manifestation have an increased risk for?
Chronic cholecystitis; increased risk for gallbladder adenocarcinoma
What is the equation for the half-life of a drug eliminated via first-order pharmacokinetics?
t1/2 = (0.693 x Vd)/CL
What is the equation used to calculated oral bioavailability?
F = AUC (oral) / AUC (IV)
What is the equation for loading dose?
Loading dose = (Cp x Vd) / F
- Cp = target plasma concentration
- Vd = volume of distribution
- F = oral bioavailability
What is the equation for maintainence dose?
Maintenance dose = (Cp x CL X τ) / F
- Cp = target plasma concentration
- CL = clearance
- τ = dosage interval (time between doses)
- F = oral bioavailability
Which anti-arrhythmics can lead to torsades de pointes?
“Type 1A and III prolong QT”
- e.g. Type IA Quinidine, Procainamide, Disopyramide
- e.g. Type III Ibutilide
What is bethanechol and what is it commonly used for?
Bethanechol is a cholinomimetic that stimulates muscarinic receptors, but has no effect on nicotinic receptors. It is commonly used for postoperative ileus and neurogenic bladder.
What are all the clinical uses of somatostatin (octreotide)?
Acromegaly, carcinoid syndrome, gastrinoma, glucagonoma, esophageal varices.
What is the MOA of fibrates (e.g. gemfibrozil)?
Gemfibrozil is a fibrate that stimulates synthesis of lipoprotein lipase by activation of the PPAR-a protein. In turn, lipoprotein lipase increases hydrolysis of triglycerides and VLDL, which ultimately results in decreased triglyceride and LDL levels
What is the MOA of nitroglycerin?
Vasodilate by NO in vascular smooth muscle in cGMP and smooth muscle relaxation. Dilate veins»_space; arteries –> decrease preload (and therefore decrease myocardial oxygen demand).
What is the mechanism of toxicity of acetaminophen overdose?
Acetaminophen metabolite (NAPQI) depletes glutathione and forms toxic tissue byproducts in liver. N-acetylcysteine is antidote—regenerates glutathione.
What is the MOR of aminoglycosides?
The mechanism for aminoglycoside resistance is covalent modification via acetylation, adenylation, or phosphorylation.
What are the most common chelators used for lead poisoning?
Dimercaprol, EDTA, or succimer
Which chelator is commonly used for copper toxicity?
Penicillamine (can also be used for lead poisoning)
Which SERM carries an increased risk of endometrial cancer, and which one does not?
Tamoxifen increases risk of endometrial cancer.
Raloxifene does not, so you can “relax”
What are the mechanisms of action of tiotropium and ipratropium bromide?
They are M3 muscarinic antagonists.
Which HIV drugs can cause gastrointestinal intolerance and lipodystrophy?
Protease inhibitors (e.g. lopinavir-ritonavir, amprenavir, nelfinavir, indinavir, and saquinavir).
Which drugs increase the risk of digoxin toxicity?
Drugs that displace digoxin from tissue-binding sites, and clearance (eg, verapamil, amiodarone, quinidine)
What are signs of a salicylate overdose?
Salicylate (aspirin) overdose causes tinnitus; a combined metabolic acidosis (late) and respiratory alkalosis (early) will also develop.
What is the most common manifestation of amiodarone toxicity?
Hypothyroidism
(Pulmonary fibrosis, hepatotoxicity, and bluish skin discoloration are other less common, classic manifestations of amiodarone toxicity)
What is the mechanism of action of entacapone?
Entacapone is a COMT inhibitor that increases the bioavailability of levodopa by inhibiting its peripheral methylation.
Adding allopurinol to the treatment regimen of someone being treated with antimetabolites, will do what to the concentration of which metabolites?
Adding allopurinol to the regimen of a patient being treated with azathioprine and 6-mercaptopurine, will cause an increase in their concentration (because allopurinol inhibits xanthine oxidase, which prevents their metabolism).
What is the antidote for serotonin syndrome?
Cyproheptadine
Which antihypertensive agent(s) can most successfully prevent progression to diabetic nephropathy?
ACE inhibitors and ARBs
What is the MOA of digoxin in initiating ventricular rate control?
Digoxin is used for ventricular rate control in atrial fibrillation as it decreases atrioventricular nodal conduction by increasing parasympathetic vagal tone.
What is the most common adverse side effect of thrombolytic use (e.g. alteplase)
Hemorrhage
What is the most serious complication/ADR of metformin use?
Lactic acidosis (therefore contraindicated in patients with renal insufficiency)
What is the most common cause of bloody nipple discharge and how is it described histologically?
Intraductal papilloma is the most common cause of bloody nipple discharge; it is often described as a proliferation of papillary cells in a cystic wall or duct, that may contain focal atypia.
What is the initial drug of choice for status epilepticus?
Benzodiazepines (e.g. lorazepam)
What is the preferred treatment for restless leg syndrome?
Dopamine agonists (e.g. ropinirole, pramipexole)
What are symptoms of digoxin toxicity?
Most common: life-threatening arrhythmia
GI: anorexia, nausea and vomiting, abdominal pain
Neurologic: fatigue, confusion, weakness, color vision alterations
What is the mechanism by which niacin causes cutaneous flushing? What can b given to patients to reduce this SE?
- Niacin increases prostaglandin release
- Give NSAIDs
Which class of lipid-lowering agents causes an increase in TG synthesis?
Bile acid resins (e.g. chlestyramine, colestipol, colesevelam)
Long term survival in patients following heart failure due to left ventricular dysfunction, is most improved with use of:
beta blockers
What effect do corticosteroids have on neutrophils, eosinophils and lymphocytes?
Corticosteroids cause neutrophilia, eosinopenia and lymphopenia. Corticosteroids cause neutrophilia by decreasing the activation of neutrophil adhesion molecules, therefore impairing migration out of the vasculature into sits of inflammation. The eosinopenia and lymphopenia are caused by sequestration in lymph noeds and apoptosis, respectively.
What are some of the applications and ADRs of clonidine?
Clonidine is an alpha-2 agonist that decreases sympathetic outflow from the central nervous system.
Uses: hypertensive urgency (when refractory to other agents)
ADRs: CNS depression, bradycardia, hypotension, respiratory depression, miosis, rebound hypertension (with abrupt cessation)
What are some of the applications and ADRs of alpha-methyldopa?
The only actual implication for alpha-methyldopa is for hypertension in pregnancy.
ADRs: Direct Coombs (+) hemolysis - autoimmune hemolytic anemia; SLE-like syndrome (drug-induced lupus confirmed with positive anti-histone).
Which drugs are inducers of CYP450?
CHRONIC ALCOHOLics STeal PHEN-PHEN and NEver Refuse GReasy CARBS:
- Chronic alcohol use
- St. John’s wort
- Phenytoin
- Phenobarbital
- Nevirapine
- Rifampin
- Griseofulvin
- Carbamazepine
Which drugs are inhibitors of CYP450?
SICKFACES.COM
- Sodium valproate
- INH
- Cimetidine
- Ketoconazole
- Fluconazole
- Acute alcohol abuse
- Chloramphenicol
- Erythromycin (macrolides)
- Sulfonamides
- Ciprofloxacin
- Omeprazole
- Metronidazole
Pt with depression takes an SSRI. What is the typical suffix for this class of drug?
-etine (eg, fluoxetine)
A man with hyperlipidemia takes an HMG-CoA reductase inhibitor. What is the typical suffix for this class of drug?
-statin (eg, atorvastatin)
A pt takes an antibiotic that functions as a transpeptidase inhibitor. What is the typical suffix for this class of drug?
-cillin (eg, ampicillin); binds penicillin-binding protein
A pt takes a drug for erectile dysfunction that inhibits PDE-5. What is the typical suffix for this class of drug?
-afil (eg, sildenafil)
A pt receives an inhaled general anesthetic. What is the typical suffix for this class of drug?
-ane (eg, halothane)
A pt takes a benzodiazepine. What are the 2 typical suffixes for this class of drug?
-azepam (eg, diazepam) or -zolam (eg, alprazolam)
A pt takes a drug for a fungal infection that inhibits ergosterol synthesis. What is the typical suffix for this class of drug?
-azole (eg, ketoconazole)
A pt takes an antibiotic that inhibits protein synthesis and discolors teeth. What is the typical suffix for this class of drug?
-cycline (eg, tetracycline)
A pt receives a local anesthetic. What is the typical suffix for this class of drug?
-caine (eg, lidocaine)
A pt w/HIV takes a protease inhibitor. What is the typical suffix for this class of drug?
-navir (eg, ritonavir)
A pt w/CHF takes a β-blocker. What is the typical suffix for this class of drug?
-olol (eg, propranolol)
A pt w/schizophrenia takes a typical antipsychotic. What is the typical suffix for this class of drug?
-azine (eg, thioridazine)
A pt receives a barbiturate for sedation during a procedure. What is the typical suffix for this class of drug?
-barbital (eg, phenobarbital)
A pt w/Tx-resistant depression takes tricyclic antidepressants. What is the typical suffix for this class of drug?
-triptyline (eg, amitriptyline) or -ipramine (eg, imipramine)
A pt w/DM takes an angiotensin-converting enzyme (ACE) inhibitor. What is the typical suffix for this class of drug?
-pril (eg, captopril)
A pt w/asthma takes a β2-agonist. What is the typical suffix for this class of drug?
-terol (eg, albuterol)
A pt w/GERD takes an H2-antagonist. What is the typical suffix for this class of drug?
-tidine (eg, cimetidine)
A pt w/growth hormone deficiency takes a pituitary hormone as therapy. What is the typical suffix for pituitary hormones?
-tropin, (eg, somatotropin)
A pt w/prostatic hyperplasia takes an α1-antagonist. What is the typical suffix for this class of drug?
-zosin (eg, prazosin)
A pt w/DM takes a PPAR-γ activator. What is the typical suffix for this class of drug?
-glitazone (eg, rosiglitazone)
A pt w/osteoporosis is prescribed a bisphosphonate. What is the typical suffix for this class of drug?
-dronate (eg, alendronate)
A pt w/GERD takes a proton pump inhibitor. What is the typical suffix for this class of drug?
-prazole (eg, omeprazole)
A pt w/glaucoma takes a prostaglandin analog. What is the typical suffix for this class of drug?
-prost (eg, latanoprost)
A pt w/HTN takes an angiotensin-II receptor blocker. What is the typical suffix for this class of drug?
-sartan (eg, losartan)
A pt w/urinary retention after surgery takes a cholinergic agonist. What is the typical suffix for this class of drug?
-chol (eg, bethanechol, carbachol)
A pt undergoing surgery receives a nondepolarizing paralytic. What are 2 typical suffixes for this class of drug?
-curium (eg, atracurium) or -curonium (eg, vecuronium)
A pt w/myasthenia gravis takes an AChE inhibitor. What is the typical suffix for this class of drug?
-stigmine (eg, neostigmine)
A pt w/migraines takes a 5-HT1B/1D agonist. What is the typical suffix for this class of drug?
-triptan (eg, sumatriptan)
A pt w/a herpes infection takes an antiviral DNA polymerase inhibitor. What is the typical suffix for this class of drug?
-ovir (eg, acyclovir)
A pt w/HTN starts taking a dihydropyridine Ca2+ channel blocker. What is the typical suffix for this class of drug?
-dipine (eg, amlodipine)
A pt w/atypical pneumonia takes a macrolide antibiotic. What is the typical suffix for this class of drug?
-thromycin (eg, azithromycin)
A pt w/the flu receives a neuraminidase inhibitor. What is the typical suffix for this class of drug?
-ivir (eg, oseltamivir)
A pt w/pinworms receives an antiparasitic/antihelminthic agent. What is the typical suffix for this class of drug?
-bendazole (eg, mebendazole)
A pt w/atrial fibrillation starts taking a direct factor Xa inhibitor. What is the typical suffix for this class of drug?
-xaban (eg, apixaban, edoxaban, rivaroxaban)
A pt w/a recent kidney transplant takes a chimeric (human-mouse) monoclonal Ab. What is the typical suffix for this class of drug?
-ximab (eg, rituximab); suffix for chimeric human-mouse monoclonal Ab
A pt w/a recent kidney transplant takes a humanized mouse monoclonal Ab. What is the typical suffix for this class of drug?
-zumab (eg, bevacizumab); suffix for humanized mouse monoclonal Ab
A pt w/chronic myelogenous leukemia starts taking a tyrosine kinase inhibitor. What is the typical suffix for this class of drug?
-tinib (eg, imatinib)
How do the alkylating agents cyclophosphamide and ifosfamide cause hemorrhagic cystitis? What is it treated with and what is the MOA of that drug?
The condition is a result of the renal excretion of acrolein, a hepatic metabolite of these drugs.
Treat with mesna - a sulfhydryl compound that is oxidized to an inactive form but is reactivated in the kidney. Once in the urine, it binds to acrolein to form an inert compound that is excreted, preventing toxic exposure to the bladder epithelium.
At what point after ischemia to the myocardial tissue does myocyte injury become irreversible?
Myocyte injury becomes irreversible after about 20 minutes of oxygen starvation.
What is the MOA of cromolyn?
“Lynn’s Bee Control”
- Prevents mast cell degranulation, inhibiting the release of histamine.
What is the MOA of macrolides?
Macrolides act on the bacterial 50s ribosomal subunit and block translocation (specifically by binding to the 23S rRNA)
Which lab and exam findings might suggest multiple myeloma?
CRAB
- HyerCalemia
- Renal involvement
- Anemia
- Bone lytic lesions/back pain
What is MGUS?
Monoclonal Gammopathy of Undetermined Significance:
- An idiopathic, monoclonal expansion of plasma cells (M spike); asymptomatic but can lead to multiple myeloma in 1-2% of patients each year
- No CRAB findings
What is the first-line treatment for antipsychotic-induced acute dystonia and for most other EPSs associated with antipsychotic medications?
Anticholinergic agents, such as benztropines, are the first-line treatment. Anticholinergics are often given prophylactically with the initial administration of antipsychotics to prevent the onset of acute dystonia.
What are some signs and symptoms of hypoglycemia?
- Neurogenic Symptoms:
- Adrenergic (catechol mediated): tremor, palpitations, anxiety
- Cholinergic (ACh-mediated): cold sweats, hunger, paresthesias
- Neuroglycopenic Symptoms (due to low glucose in the brain):
- General weakness, confusion, drowsiness, syncope, difficulty speaking, blurry vision
What is Liddle Syndrome?
Liddle syndrome is a genetic condition characterized by a GOF mutation in the epithelial ENaC on the collecting tubule, leading to early hypertension characterized by low levels of renin and angiotensin due to negative feedback. Reabsorption of sodium without an accompanying anion creates a negative electrical gradient across the luminal membrane, causing increased secretion of potassium and hydrogen ions; this results in hypokalemia and metabolic alkalosis (note the patient’s elevated pH and bicarbonate levels). Liddle syndrome is commonly treated with a diuretic that inhibits ENaC, such as triamterene or amiloride.
Which major complication can arise from use of oral or IV corticosteroids, such as methylprednisolone, a common treatment for ulcerative colitis flares?
Avascular necrosis (esp. of femoral head).
Other complications include:
abdominal striae and increased girth, suppression of the hypothalamic-pituitary-adrenal axis, hyperglycemia, osteoporosis, moon facies, buffalo hump, immunosuppression, and impaired wound healing
What is the gold standard chemotherapy regimen for treating Hodgkin lymphoma?
The AVBD protocol:
- Adriamycin (doxorubicin)
- Bleomycin
- Vinblastine
- Dacarbazine
In which form of IBD are non-caseating granulomas seen?
Chron Disease
Graves’ disease is an example of which type of hypersensitivity?
Type II
Goodpasture Syndrome is an example of which type of hypersensitivity?
Type II:
anti-glomerular basement membrane antibodies (anti-GBM Ab), are autoantibodies against the alpha 3 chain of type IV collagen found in the glomerular basement membrane and pulmonary capillary membrane.
Which portal ↔ systemic shunt is responsible for esophageal varices?
Left gastric ↔ azygos vein
Which portal ↔ systemic shunt is responsible for caput medusae varices?
Paraumbilical ↔ small epigastric veins of the anterior abdominal wall
Which portal ↔ systemic shunt is responsible for anorectal varices?
Superior rectal ↔ middle and inferior rectal
A Pancoast Tumor can cause what spinal cord lesion, and consequently which syndrome?
Pancoast tumor can impinge on the stellate ganglion causing Horner Syndrome (ptosis, miosis, anhidrosis).
What is the pathophysiology of proteinuria seen in minimal change disease?
Disruption of the filtration barrier which is composed of heparan sulfate (negatively charged molecule which repels other (-) charges [e.g. albumin]).
What happens to TBG (thyroid-binding globulin) in states of high estrogen (e.g. pregnancy, OCP use)?
TBG increases, which causes total T4 to increase.
FREE T4 remains unchanged (due to normal negative feedback).
What is the difference between Langerhans cells and Langhans “giant” cells?
Langhans giant cells are found in granulomatous lung disease, whereas Langerhans cells are found specifically in pulmonary Langerhans cell histiocytosis.
How does succinylcholine differ from pancuronium, tubocurarine, and vecuronium?
Succinylcholine is a depolarizing NMJ blocker; therefore with the TOF test (train-of-four) it first exhibits an equal (lower across the board) attenuation of the motor endplate’s response to stimulation, followed by a faded phase II response.
Pancuronium, tubocurarine and vecuronium are all non-depolarizing, which means that they block pre-synaptic ACh release, thus resulting in an immediate faded TOF response.
What is the first-line treatment for an acute attack of gouty arthritis?
NSAIDs
Which of the lipid-lowering agents can precipitate gouty arthritis?
Niacin - via increased renal excretion of uric acid
What is octreotide and what is it used for?
Octreotide is a somatostatin analog, and is often used to treat the symptoms of carcinoid syndrome (e.g. secretory diarrhea).
What are symptoms of alcohol withdrawal and how is it treated?
Alcohol withdrawal symptoms:
- 3–36 hours: minor symptoms similar to other depressants: anxiety, tremor “the shakes”, sweating
- 6–48 hours: withdrawal seizures
- 12–48 hours: alcoholic hallucinosis
- 48–96 hours: delirium trmns
Treatment: benzodiazepines! (esp. long-acting due to self-tapered withdrawal effect: chlordiazepoxide, lorazepam, diazepam)
What is the mechanism by which nitrates causes vasodilation?
Nitrates (e.g. nitroglycerin, isosorbide dinitrate, isosorbide mononitrate) activate guanylyl cyclase which subsequently increases cGMP and causes dephosphorylation of myosin light-chain kinase (causes smooth muscle relaxation).
Which of the antibiotics has weak MAO inhibitor activity? What is a potential ADR.
Linezolid
Can cause serotonin syndrome.
What are the 4 “P’s” that can be used to treat thyroid storm?
- Propranolol (for adrenergic effects and prevents peripheral conversion of T4 to T3)
- Propylthiouracil (also blocks T4 to T3)
- Prednisolone
- Potassium iodide
What is the MOA of oseltamivir?
Oseltamivir (Tamiflu) is a neuraminidase inhibitor. It can be used to treat or prevent the flu by inhibiting the release of newly formed virions.
Why are tricyclic anti-depressants contraindicated in the elderly?
TCADs have strong anticholinergic effects (e.g. confusion, urinary retention, constipation), which can exacerbate those caused by comorbid conditions (e.g. BPH, dementia).
Which anesthetics exhibit hepatotoxicity?
Halogenated inhaled anesthetics (e.g. halothane, enflurane).
Which infection are HIV (and immunocompromised) patients at increased risk for if their CD4+ count is < 50? What is the best prophylactic treatment?
Mycobacterium avium complex.
Prophylaxis: macrolide (e.g. azithromycin)
Which lipid-lowering agent class is the most protective of cardiovascular events?
Statins (HMG-CoA reductase inhibitors)at is
What is the best measure/estimator of GFR?
Inulin clearance. Inulin is only filtered at the glomerulus, it is neither secreted nor reabsorbed.
Creatinine is often used clinically because it is easier to measure; however, it slightly overestimates GFR because it is also secreted. (CREatinine is seCREted).
What is the equation for RBF?
RBF = renal blood flow –> it is the amount of blood (i.e. RBCs only) that is flowing through the kidney. If we know renal plasma flow (includes RBCs and ECF plasma) we can calculate RBF. RBCs = Hct, therefore plasma = 1-Hct.
RBF = RPF/(1-Hct)
What is filtration fraction and what is a normal value?
FF = GFR/RPF
Normal: 20%
At what plasma concentration of glucose can one begin to observe glucosuria in an adult?
200 mg/dL
The PCT of the nephron exhibits nearly 100% reabsorption of which two substances?
Glucose and Amino Acids
Where and how does PTH affect solute reabsorption on the nephron?
- PO4^3-: PTH inhibits Na+/PO4^3- cotransport in the PCT
- Ca2+: PTH increases Ca2+/Na+ exchanger activity on the basolateral side of the DCT
What do RBC casts indicate?
Glomerulonephritis, malignant HTN
What do WBC casts indicate?
Tubulointerstitial inflammation, acute pyelonephritis, transplant rejection.
What do fatty casts indicate?
Nephrotic syndrom
What do granular (“muddy brown”) casts indicate?
Acute tubular necrosis
What do waxy casts indicate?
End-stage renal disease/Chronic renal failure
What do hyaline casts indicate?
Nonspecific; can be a normal finding and is often seen in concentrated urine samples
What is the most common cause of primary nephrotic syndrome in Caucasian adults?
Membranous nephrophathy
What do Kimmelstiel-Wilson bodies classically indicate?
Diabetic glomerulonephropathy
What is the WAGR complex?
Related to Wilms tumor/chr 11:
- Wilms tumor
- Aniridia (absence of iris)
- Genitourinary malformations
- Retardation/intellectual disability
What may painless hematuria indicate?
Transitional cell carcinoma (bladder cancer)
- There are no casts because the cancer occurs after the kidneys
- Associated with Pee SAC:
- Phenacetin
- Smoking
- Aniline dyes
- Cyclophosphamide (hemorrhagic cystitis)
What does an increased BUN/Cr ratio indicate?
Pre-renal azotemia
- Hypotension/dehydration lowers the RBF, which lowers GFR. In an attempt to conserve water, H2O reabsorption (and subsequently BUN) is increased. (Also results in an decreased FENa since the kidney reabsorbs more Na along with water and other solutes)
What does a decreased BUN/Cr ratio indicate?
Intrinsic renal failure
- An intrinsic issue with the kidney (e.g. tubular necrosis, ischemia/toxins) impairs the kidneys ability to reabsorb BUN. (Also results in an increased FENa since the kidney is unable to reabsorb Na)
What is acute interstitial nephritis (tubulointerstitial nephritis)?
A drug induced nephritis characterized by interstitial renal inflammation. Pyuria is seen with eosinophils, due to the fact of this being a Type I hypersensitivity reaction. Common culprits include: NSAIDs, diuretics, penicillins, PPIs, rifampin.
How does ADPKD lead to berry aneurysms?
ADPKD is characterized by polycystic kidneys which secrete excess renin and subsequently cause hypertension. This HTN can increase development/risk of aneurysms. Most causes of death from ADPKD are related to HTN.
Which vitamin can cause pseudotumor cerebri?
Vitamin A
Vitamin A is a precursor to CSF production. Therefore, in excess, it can produces pseudotumor cerebri.
Which class of diuretics is sulfa based? Which is the exception that can be used in patients with a sulfa allergy?
Loop diuretics e.g. furosemide, bumetanide, and torsemid are all sulfa basd.
Ethacrynic acid, is a nonsulfonamide inhibitor.
Goodpasture Syndrome is an example of which type of nephritic syndrome?
Rapidly progressive (crescentic) glomerulonephritis.
What drug should be given with chemotherapy to prevent tumor lysis syndrome?
Allopurinol - it prevents the conversion of purines to uric acid.
What is first-line treatment for an uncomplicated UTI in a patient with a sulfa allergy?
Nitrofurantoin (If not allergy, use TMP-SMX)
Episodic gross hematuria that is concurrent with a respiratory or GI infection is likely indicative of?
IgA nephropathy (Berger disease) - the most common cause of nephropathy worldwide
What is Conn syndrome and what is the best treatment?
Conn Syndrome is primary hyperaldosteronism. Treated with an aldosterone antagonist (e.g. spironolactone).
Where in/from the kidney is renin secreted?
Juxtaglomerular cells in the tunica media of the afferent arteriole.
Which immunosuppressant is classically nephrotoxic?
Cyclosporin - MOA: inhibits calcineurin by binding/enhancing cyclophilin. By preventing IL-2 transcription, T-cell activation is effectively blocked.
Nephotoxicity likely occurs due to impairment of endothelial cell function, leading to reduced production of vasodilators (prostaglandins and nitric oxide) and enhanced release of vasoconstrictors (endothelin and thromboxane) –> reduces RBF.
What happens to the afferent and the efferent arterioles in states of severe volume depletion?
Both the afferent and efferent arterioles constrict –> sympathetic response to preserve blood pressure.
What are the “4” symptoms of hypercalcemia?
“Stones, bones, groans and psychiatric overtones”
- Stones = kidney stones
- Bones = bone pain due to increased turnover
- Groans = abdominal pain
- Psychiatric overtones = anxiety, altered mental status
What are the equations for CO (cardiac output)?
CO = SV x HR
CO = (rate of oxygen consumption) / (arterial oxygen - venous oxygen)
What is the equation for stroke volume?
SV = EDV - ESV
SV = CO/HR
(HR can be estimated by the RR ratio, which is 60/RR in sec/beat)
How does Cushing disease differ from Cushing syndrome?
Cushing disease refers specifically to a ACTH-secreting pituitary adenoma.
Cushing syndrome refers to the general symptoms of cortisol excess (HTN, weight gain, moon facies, abdominal striae, truncal obesity, buffalo hump, etc.)
How can you distinguish Wilms tumor from a Neuroblastoma on palpation?
WilmS tumor is Smooth and unilateral
NeuroBlastoma is Bumpy/irregular and can cross the midline
What happens if you removal the adrenal glands of a patient who has a ACTH-secreting pituitary adenoma?
This is the pathophysiology of Nelson Syndrome
Removal of the adrenal glands in someone who has Cushing’s Disease, removes the negative feedback on the pituitary, causing pituitary hypertrophy and increased mass effect (headache, hyperpigmentation, bitemporal hemianopia).
Patient is presenting with euvolemic hyponatremia. What is the the most likely diagnosis and what is the pathophysiology of this condition?
SIADH (Syndrome of inappropriate antidiuretic hormone secretion)
- Excessive free water retention, with continued Na+ excretion
- The body responds to water retention with a decrease in aldosterone and increase in ANP and BNP –> kidneys will secrete Na+ since water will follow, which corrects the volume status; however, this doesn’t correct Na+ lvels
- Hyponatremia must be corrected slowly to prevent osmotic demyelination syndrome
- Treatmnt: fluid restriction, salt tablets, conivaptan (VAsoPression ANtangonists)
What are the 4 ways to diagnose diabetes mellitus?
- Hemoblogin A1C ≥ 6.5%
- Fasting glucose (8-hour) ≥ 126 mg/dL
- 2-hour Oral Glucose Tolerance Test (OGTT) ≥ 200 mg/dL
- Random glucose ≥ 200mg/dL with symptoms
Describe the type and presentation of the neuroendocrine tumor associated with pancreatic alpha cells?
Glucagonoma
Presents like diabetes. 4 D’s:
- Diabetes (hyperglycemia due to excess glucagon)
- Dermatitis (necrolytic migratory erythema)
- Declining weight
- DVT
Describe the type and presentation of the neuroendocrine tumor associated with pancreatic beta cells?
Insulinoma
Presents with hypoglycemia. Symptomatic patients will have low blood glucose and increased C-peptide (vs. exogenous insulin). 10% associated with MEN1.
Describe the type and presentation of the neuroendocrine tumor associated with pancreatic delta cells?
Somatostatinoma
Presents with an overproduction of somatostatin which basically halts the entire digestive system (i.e. prevents/downregulates secretion of secretin, insulin, glucagon, CCK, gastrin and GIP). This can lead to steatorrhea and gallstones (from decreased CCK), and achlorhydria (low H+ production from decreased secretin).
Which Vitamin deficiency may be present with Carcinoid syndrome?
Vitamin B3 - can cause pellagra
Remember, carcinoid syndrome results in excess 5-HT production. Since Tryptophan is a precursor to both serotonin and niacin, carcinoid syndrome shunts all of the Tryptophan into making serotonin, causing a relative deficiency of B3.
Which tumors are associated with MEN1?
MEN1 = menin gene (Chr 11 tumor suppressor)
3 P’s:
- Pituitary adenoma
- Pancreatic endocrine tumors (e.g. ZE, insulinomas, VIPomas)
- Parathyroid adenomas
Which tumors are associated with MEN2A?
RET mutation - receptor tyrosine kinase: 2 P's: - Pheochromocytoma - Pituitary adenoma - Medullary thyroid carcinoma
Which tumors are associated with MEN2B
RT mutation; associated with Marfinoid habitus 1 P: - Pheochromocytoma - Medullary thyroid carcinoma - Mucosal neuromas
Which diabetes drug produces modest weight loss and is often considered the safest? What is the MOA of this drug?
Insulin
MOA: prevents gluconeogenesis, increases glycolysis and increases insulin sensitivity via peripheral glucose uptake.
ADR: can cause GI and lactic acidosis (due to decreased conversion of lactate to glucose in the liver via the cori cycle, which leads to a build up of lactate in muscle).
Which drug class does the drug tolbutamide belong to and what is this class’ MOA?
Tobutamide and other “ides” = sulfonylurea
MOA: increase endogenous insulin release by close the K+ channel in the beta cell membrane (depolarization leads to increase insulin release via Ca2+ influx)
What drug class does pioglitazone belong to and what is it’s MOA?
“Glitazones” aka thiazolidinediones
MOA: increase insulin sensitivity in peripheral tissue via upregulation of PPAR-γ (perioxisome proliferated-activated R gamma)
ADR: weight gain (via decreased leptin), edema, HF
How do the sulfonylureas and the meglitinides differ?
They have the same MOA (bind and inhibit the K+ channel) but bind at different sites.
What drug class does exenatide belong to and what is it’s MOA?
GLP-1 analog
MOA: increase glucose-dependent insulin release
What drug class does saxagliptin belong to and what is it’s MOA?
Saxagliptin = Onglyza a DPP-4 inhibitor
MOA: DPP-4 is an enzyme that normally deactivates GLP-1; therefore by inhibiting DPP-4, these drugs increase glucose-dependent insulin release. They are weight neutral!
What drug class does pramlintide belong to and what is it’s MOA?
PrAMLINtide is an AMYLIN analog.
MOA: Decrease gastric empyting and glucacong release
What drug class does canagliflozin belong to and what is it’s MOA?
Sodium-glucose co-transporter 2 (SGLT2) inhibitor
MOA: block reabsorption of glucose in PCT (“lozin” glucose in the urine –> can cause UTI/yeast infections)
What drug class does acarbose belong to and what is it’s MOA?
α-glucosidase inhibitor
MOA: inhibit intestinal brush-border α-glucosidase leading to decreased intestinal absorption (decrease post-prandial hypoglycemia)
What are the two most commonly thioamides are how do they work? How do they differ?
PTU (propylthiouracil) and methimazole are both used to treat hyperparathyroidism by blocking thyroid peroxidase. They work by inhibiting the oxidation of iodide and organification/coupling of iodine.
PTU also blocks 5’-deiodinase and is safe to use in Pregnancy.
Methimazole is teratogenic.
ADRs: agranulocytosis, aplastic anemia, hepatotoxicity
What are the most common manifestations of prolactinoma or hyperprolactinemia in female vs. male patients?
Males: present with diminished libido
Females: present with amenorrhea
Hypercalcemia is a known paraneoplastic syndrome, most commonly associated with which cancer?
Squamous cell carcinoma of the lung
Which cartilage, muscles and nerves does the 1st pharyngeal arch give rise to?
All of the “M’s”
Cartilage:
- Maxillary process → Maxilla, zygoMatic bone
- Mandibular process → Meckel cartilage → Mandible, Malleus and incus, sphenoMandibular ligament
Muscles:
- Muscles of Mastication (temporalis, Masseter, lateral and Medial pterygoids), Mylohyoid, anterior belly of digastric, tensor tyMpani, anterior 2/3 of tongu
Nerves:
- CN V2 (Maxillary branch) and V3 (Mandibular) (“chew”)
Which cartilage, muscles and nerves does the 2nd pharyngeal arch give rise to?
All of the “S’s”
Cartilage:
- Reichert cartilage: Stapes, Styloid process, lesser horn of hyoid, Stylohyoid ligament
Muscles:
- Muscles of facial expreSSion, Stapedius, Stylohyoid, platySma, posterior belly of digastric
Nerves:
- CN VII (S = seven) (facial expreSSion) Smile
Which cartilage, muscles and nerves does the 3rd pharyngeal arch give rise to?
Cartilage:
- Greater horn of hyoid
Muscles:
- Stylopharyngeus (think of styloPHARYNGEus innervated by glossoPHARYNGEalnerve)
Nerve:
- CN IX (STYLo-pharyngeus)swallow STYLishly
Which cartilage, muscles and nerves do the 4th and 6th pharyngeal arches give rise to?
Cartilage:
- Arytenoids, Cricoid, Corniculate, Cuneiform, Thyroid (used to sing and ACCCT)
Muscles:
- 4th arch: most pharyngeal constrictors; cricothyroid, levator veli palatini
- 6th arch: all intrinsic muscles of larynx except cricothyroid
Nerves:
- 4th arch: CN X (superior laryngeal branch) simply swallow
- 6th arch: CN X (recurrent laryngeal branch) speak
What is necrolytic migratory erythema, and which neuroendocrine tumor is it classically seen in?
Necrolytic migratory erythema is a characteristic skin finding, identified by the pruritic and painful, small erythematous plaques typically affecting the face, perineum, and extremities, in patients with a glucagonoma.
Which acid suppressing agent used to treat GERD, has unfortunate anti-androgenic side effects? Which drug, with the same MOA can ben given instead?
Cimetidine (an H2 blocker) can cause decreased libido, gynecomastia, and impotence.
Ranitidine, is also an H2 blocker but doesn’t have antiandrogenic side effects.
What is the mechanism of contraction bands seen on histology following an acute MI?
Contraction bands can be seen within the first 24 hours of an MI, in the setting of reperfusion injury which generates free radicals and causes hypercontraction of myofibrils through increased free calcium reflux.
Which mnemonic describes the presentation of von Hippel-Lindau disease?
HARP:
- Hemangioblastomas (often described as highly vascular with hyperchromatic nuclei)
- Angiomatosis
- Renal cell carcinomas (bilateral)
- Pheochromocytomas
How can sarcodosis leader to hypervitaminosis D and hypercalcemia?
The macrophages responsible for the non-caseating granulomas contain 1α-hydroxylase activity, which converts Vitamin D to the active form and subsequently causes calcium reabsorption.
Medullary thyroid cancer is a malignancy of which cells? What are these cells derived from?
Medullary thyroid cancer = malignancy of the parafollicular C cells
These cells are derived from neural crest cells
What is the name of the gene regulated by PPAR-γ that is responsible for increasing insulin sensitivity when treated by a glitazone drug?
Adiponectin
Which lipid-lowering class is the most effective at treating hypertriglyceridemia? What is the MOA?
The fibrates
Fibrates upregular PPAR-alpha and increase the transcription of lipoprotein lipase, which increases the degradation of TGs circulating in chylomicrons and VLDL
What is the single-most preventable cause of death in the United States?
Smoking/tobacco cessation
Patient presenting with hypogonadism, anosmia and delayed puberty most likely has what?
Kallmann syndrome - an absence of GnRH secretory neurons in the hypothalamus due to defective migration from the olfactory placode.
What is the MOA of ezetimibe?
Ezetimibe prevents cholesterol absorption at small intestine brush border.
Describe the mechanism of pretibial myxedema in Graves disease:
Antibodies against the thyrotropin receptor causes an accumulation of glycosaminoglycans and adipogenesis.
Which ribs overlie the spleen?
The 9th, 10th, and 11th left ribs.
Congenital diaphragmatic hernia often leads to death due to:
Pulmonary hypoplasia (caused by compression of the developing lung buds).
What is the most important lecithin that composes pulmonary surfactant?
Dipalmitoylphosphatidylcholin (DPPC).
What mnemonic can be used to remember thoracic level at which the IVC, esophagus, and aorta penetrate the diaphragm?
“I (8), 10 Eggs At 12”
- IVC –>T8
- Esophagus –> T10
- Aorta –> T12
What is the equation for determining physiologic dead space
Vd = Tv x (PaCO2 - PeCO2)/PaCO2
- Vd = physiologic dead space (in mL)
- Tv = tidal volume (in mL)
- PaCO2 = arterial PCO2 - i.e. how much CO2 is going into the lungs
- PeCO2 = expired PCO2 - i.e. how much CO2 is exiting out of the lungs after gas exchange
Therefore, the closer the PeCO2 is to the PaCO2, the more efficient the gas exchange was.
How can you distinguish methemoblobinemia from carboxyhemoglobin?
Methemoglobinemia: cyanosis and chocolate-brown blood; due to oxidized form of Hb (Fe2+ to Fe3+; caused by nitrites, dapsone, etc.) which does not bind O2 as readily, but has increased affinity for cyanide.
Carboxyhemoblobinemia: bright read blood, headaches, cherry-red lips (cherry red is dead); CO binds competitively to Hb and with 200x greater affinity than O2.
What is the effect of CO on the Hb-dissociation curve?
Causes a left shift and reduces O2 binding capacity
Aspiration of a large foreign body is more likely to occur where?
Right mainstem bronchus
Epistaxis originating in which part of the nose and via which artery can cause a life-threatening hemorrhage?
A posterior segment bleed, due to a bleed in the sphenopalatine artery.
What is the most common cause of pulmonary embolism?
DVT
What is Virchow’s triad of DVT?
SHE:
- Stasis (e.g. car ride, flight)
- Hypercoagulability (e.g. high-estrogen states, defect in coagulation cascade proteins)
- Endothelial damage
Describe the time-course for a diagnosis of chronic bronchitis?
Must have a productive cough for > 3months in a year for > 2 consecutive years
What is the Reid index?
The Reid index is a measure of mucosal thickness to the thickness of the wall between the bronchial eipthelium and cartilage.
Someone with chronic bronchitis (i.e. hypertrophy and hyperplasia of mucus-secreting glands) will have a Reid index >50%
Which two lung diseases is silicosis associated with?
Bronchogenic carcinoma and TB
What is Pickwickian Syndrome?
A synonym for obesity hypoventilation syndrome.
What is the natural progression of lobar pneumonia?
CRGR:
- Congestion (Day 1-2): Red-purple with mostly bacteria
- Red hepatization (Day 3-4): Red-brown, with fibirn, bacteria, WBCs and RBCs
- Gray hepatization (Day 5-7): uniformly gray, mostly full of WBCs and fibrin
- Resolution (Day 8+): enzymes digest components of exudate
What are the 5 major complications of lung cancer (SPHERE)?
SPHERE:
- SVC syndrome
- Pancoast tumor
- Horner syndrome
- Endocrine (paraneoplastic)
- Recurrent laryngeal nerve compression (hoarsness)
- Effusions (pleural or pericardial)
Which lung cancer is considered a neoplasm of Kulchitsky cells and stains for Chromogranin A?
Small cell carcinoma
- Kulchitsky cells = small dark blue cells
Which lung cancer will stain positive for mucin?
Adenocarcinoma (remember “adeno” = mucus glands)
Which lung cancer produces PTHrP; how will it present?
Squamous cell
- PTHrP production leads to hypercalcemia
Which lung cancer has an excellent prognosis, and what are its findings?
Bronchial carcinoid tumor has an excellent prognosis, and rare metastases.
- Can present with carcinoid syndrome (flushing, diarrhea, wheezing)
- Nest (or rosettes) of neuroendocrine cells can be seen on histology
Why are 2nd generation antihistamines less sedating than 1st generation?
2nd generation has less CNS entry/penetration
What is the mechanism of action of N-acetylcysteine as a mucolytic?
N-acetylCYSTEINE disrupts disulfide bonds (made of 2 CYSTEINE residues)
What is the use and MOA of bosentan?
BosENtan is a competitively antagonist of the ENdothelin-1 receptor, it is used to treat pulmonary hypertension.
ADR: hepatotoxic
Why do patient’s with emphysema exhibit pursed-lip breathing?
Exhaling through pursed lips increases the pressure in the alveoli and prevents them from collapsing.
What is the histopathologic description of granulomas found in TB?
TB granulomas are composed of epithelioid cells (macrophages with abundant pink cytoplasm) with surrounding multinucleated giant cells and lymphocytes
Which lung pathology has a honeycombing appearance on CXR and often presents with clubbing of the nails?
Idiopathic pulmonary fibrosis (restrictive lung disease)
How does a positive skew differ from a negative skew?
The direction of the “skew” is determined by the outliers of the set.
Positive skew: high outliers cause the mean to be greater than the median (tail is to the right)
Negative skew: low outliers cause the mean to be less than the median (tail is to the left).
What is the most commonly recommended treatment for TB prophylaxis and LTBI monotheraphy?
INH + pyridoxine (B6) X 6months
A child with recurrent infections is presenting with absent heart sounds in the mitral, tricuspid and pulmonary position, but a normal sound in the aortic position. Which lung pathology is this patient at increased risk for?
This child has Kartagener’s (indicated by the recurrent infections and suggestion of situs inversus) and is at increased risk for bronchiectasis.
Which two enzymes are produced by the macrophages in sarcoidosis, and can therefore be used as markers?
1alpha-hydroxylase and ACE
How can osteogenesis imperfecta be distinguished from child abuse?
OI will generally involve a history of fractures from benign incidents (i.e. standing height)
Abuse will involved fractures (eg, ribs, long bone spiral, multiple in different stages of healing), bruises (eg, trunk, ear, neck; in pattern of implement), burns (eg, cigarette, buttocks/thighs), subdural hematomas, retinal hemorrhages. During exam, children often avoid eye contact.
What gives elastin its elastic properties?
Cross-linking that takes place between lysine residues.
Which interleukin is chemotactic for eosinophils?
IL-5
What is most recommended therapy for thromboembolic therapy in pregnant women?
Low molecular-weight heparins (e.g. enoxaparin) are recommended because they don’t cross the placenta and therefore don’t carry a high risk of bleeding.
What does the truncus arteriosus give rise to?
Ascending aorta and pulmonary trunk
What does the bulbus cordis give rise to?
Smooth outflow tracts of the left and right ventricles
What does the endocardial cushion give rise to?
Atrial septum and membranous interventricular septum
What does the primitive pulmonary vein give rise to?
Smooth part of left atrium
What does the left horn of the sinus venosus give rise to?
Coronary sinus
What does the right horn of the sinus venosus give rise to?
Smooth part of right atrium
What do the right common cardinal vein and right anterior cardinal veins give rise to?
The SVC
Kartagener’s syndrome causes situs inversus due to defects in which protein?
Left-to-right dynein
What is the first functional organ in vertebrate organisms and when does it begin?
The heart
- week 4 of development
Describe the process of atrial septation:
- Septum primium begins superiorly, makes its way down toward the endocardial cushion and then pauses to form foramen primium. As the septum primium continues down, it closes the foramen primium and forms the foramen secundum
- The septum secundum then develops to the right (patient’s right) of the septum prim and begins to expand down to cover most, if not all of the first septum to form the foramen secundum and allow the R –> L
What are the three important fetal cardiac shunts and what are their functions?
- Ductus venosus - 2/3 of the oxygenated blood coming in from the umbilical vein the bypasses the fetal liver and goes straight to the RA via the IVC where in can be directed straight to systemic circulation via the FO:
- Foramen ovale - a R–>L shunt in which oxygenated blood in the RA goes straight to the LA where it can then be pumped by the LV into systemic circulation (esp. to the head).
- Ductus arteriosus - deoxygenated blood that came in via the SVC goes through the LV and enters the pulmonary trunk, but instead of going to the lung, it is shunted to the aorta (after the main stems) where it descends down the thoracic/abdominal aorta before returning to the umbilical arteries where it is returned to mom.
What does the allantois become?
MediaN umbilical ligament
Foramen ovale becomes –>
Fossa ovalis
Notochord becomes –>
Nucleus pulposus (spinal cord discs –> can impinge and cause nerve damage)
UmbiLical arterials become –>
MediaL umbilical ligaments
Which part of the heart has dual blood supply from two major coronary arteries?
The anterolateral papillary muscle (receives blood from the LCX and LAD)
Explain the physiology behind a wide split:
Wide splitting occurs when there is any cadiac etiology that delays the emptying of the RV (therefore delaying closure of the pulmonic valve):
- pulmonic stenosis
- RBB - the LV contracts before the RV
What causes a fixed split?
Fixed splitting is when the second heart sound is split (i.e. A2 and P2)the same distance on both inspiration and expiration (because RV is increased throughout both systole and diastole) –> most commonly due to ASD.
What a mid-systolic click most diagnostic for?
Mitral valve prolapse
- Mid-systolic click followed by a crescendo systolic murmur
- Often occurs due to myxomatous degeneration
How can you distinguish between a holosystolic murmur caused by tricuspid regurgitation vs. VSD?
The tricuspid regurgitation murmur will radiate to the axilla.
Blowing murmur during early diastole?
Aortic regurgitation
Which murmur occurs continuously (i.e. over both systole and diastole)?
PDA (because blood will always be flowing through the PDA no matter what phase you’re in)
Where is the SA node located?
SA node is located near the SVC
Where is the AV node located?
AV node is located in the posteroinferior part of the interatrial septum (near tricuspid orifice)
What are the conduction speeds of the heart?
- AV: 0.05 m/sec
- Ventricle: 0.3 m/sec
- Atria: 1.1 m/sec
- Purkinje: 2.2 m/sec
What is the treatment for Torsades de pointes?
Magnesium sulfate
What is the difference between Romano-Ward syndrome and Jervell-Lange-Nielsen syndrome?
- Romano-WarD is autosomal Dominant, and purely cardiac (pure heart like the ROMAN Catholics)
- Jervell and Lange-Nielsen syndrome - autosomal recessive and is accompanied by sensorineural deafness (longer name, harder to hear)
What is Brugada syndrome?
Brugada syndrome is an autosomal dominant disorder (mostly in Asain males - Brugada is a Japanese surname). Has an ECG pattern of pseudo-RBBB due to a defect in the sodium channel that prevents both ventricles from depolarizing simultaneously.
Delta waves and a widened QRS likely indicate:
Wolff-Parkinson-White syndrome
Absent P waves with irregularly irregular spacing of QRS complexes?
Atrial fibrillation
4:1 sawtooth pattern with regular spacing and discernible P waves
Atrial flutter
No discernible rhythm at all (no P wave, no PR interval, no QRS)
Ventricular fibrillation! EMERGENCY - not compatible with life without immediate CPR and defibrillation
Which AV block is characterized by a prolonged PR interval?
First degree
“If the R is far from P then you have a 1st degree”
Which AV block is characterized by increasingly prolonged PR intervals with a sudden absence of QRS interval?
Second degree - Mobitz Type 1: Wenckebach
“Longer, longer, longer drop then you have a Wenckebach”
Which AV block is characterized by dropped beats that are not preceded by change in the length of the PR interval?
Second degree - Mobitz Type 2
“If only some P’s don’t get through, then you have Mobitz Type 2”
Which AV block is characterized by a complete lack of coordination between atrial and ventricular contraction?
Third Degree (Complete) "It P's and Q's don't agree, then you have a 3rd degree"
Which disease is associated with a 3rd degree AV block?
Lyme disease
True or false, central chemoreceptors can respond to pO2?
False! O2 can’t cross the BBB
What are the normal cardiac pressures?
RA: 5 mmHg RV: 25/5 mmHg Pulmonary artery: 25/10 mmHg PCWP: 4-12 mmHg LA: <12 mmHg LV: 130/10 mmHg Aorta: 130/90
What are the T’s associated with early cyanosis?
- Truncus arteriosus (1 vessel)
- Transposition of great vessels (2 vessels switch)
- Tricuspid atresia (3 = tri)
- Tetralogy of Fallot (4 = tetra)
- TAPVR (5 letters in name) - total anomalous pulmonary venous return
What causes rib notching which occurs with coarctation of the aorta is caused by?
By blocking the normal flow out of the aorta, collaterals are accessed via the intercostal arteries. The intercostals are locating on the underside of the ribs, which results in a “notched” appearnace on Xray due to the dilation of these arteries producing an indentation.
What is the pathophysiology of heart defects seen in congenital rubella?
Viral proliferation effects the normal fusion/activity of the cardiac myocytes, smooth muscle and endothelium. This results in a failure of closure of various tissues.
- PDA, PA stenosis, septal defects
What is the pathophysiology of heart defects seen in Down Syndrome?
Down Syndrome results in endocardial cushion defects:
- AV septal defect, VSD, ASD
An which two pathologies are associated with maternal diabetes?
- Transposition of great vessels
- Caudal regression syndrome
Williams syndrome features what cardiac anomaly?
Remember, WilliAmS syndrome features AS (aortic stenosis) due to elastic defect resulting in a stenotic/stiff aortic valve.
What is fibromuscular dysplasia?
A strange occurence of high-blood pressure (usu. in a healthy, YA woman) –> due to genetic defect that causes the tunica media to develop invaginations narrowing the lumen
- beads on a string
Pipe stem arteries on xray indicate what pathology?
Mönckeberg sclerosis (medial calcific sclerosis) - doesn’t obstruct blood flow because the intima are not involved
Sudden, tearing chest pain that radiates to the back is most likely?
Aortic dissection
Which aortic dissection, Type A or Type B has a greater risk of cardiac tamponade, and why?
Type A - because it is ABOVE the ligamentum arteriosum and can therefore leak into the pericardial space
What type of cardiomyopathy is associated with Friedreich Ataxia?
HCOM
Are most cardiac tumors primary or secondary (due to metastases)? What are the most common causes, regardless?
Most cardiac tumors are due to metastases (melanoma = #1)
The most common primary cardiac tumor in adults is a myxoma.
The most common primary cardiac tumor in children is a rhabdomyoma.
What is the diagnosis?
- Elderly patient with a temporal artery headache, and flu-like symptoms with widespread joint and muscle pain?
Giant cell (temporal) arteritis, characterized by focal granulomatous inflammation (resulting in “giant cell”).
Which two anti-arrhythmic drugs can cause a lupus-like syndrome?
Procainamide and hydralazine
anti-histone Abs
Which structures are derived from the 1st aortic arch?
Maxillary artery (1st arch is MAXimal)
Which structures are derived from the 2nd aortic arch?
Stapedial artery and hyoid artery (Second = Stapedial)
Which structures are derived from the 3rd aortic arch?
Common Carotid artery and proximal internal Carotid (C = 3rd letter of alphabet)
Which structures are derived from the 4th aortic arch?
LARS:
- Left –> aortic arch
- Right –> subclavian artery
Which structures are derived from the 6th aortic arch?
Proximal part of pulmonary arteries and ductus arteriosus
Which arteritis is associated with and increased ESR, granulomatous thickening and narrowing of aortic arch and proximal great vessels?
Takayasu Arteritis (“pulseless disease”)
What are the findings in Kawasaki’s disease?
Usually affects Asian children <4yo. The symptoms can be remembered by “CRASH and BURN”
Asian children < 4 years old.
- Conjunctival injection,
- Rash (polymorphous desquamating)
- Adenopathy (cervical)
- Strawberry tongue (oral mucositis)
- Hand-foot changes (edema, erythema)
- Fever (Burn)
These patients are also at an increased risk for coronoary artery aneurysms which can thrombose and rupture.
- Therefore they are the only pediatric patients in which taking aspirin with a fever is not contraindicated (not a risk for Reye’s syndrome)
Following an acute MI, when do Troponin I levels become elevated and how long do they remain elevated?
Troponin I levels first become elevated 4 hours after an MI, and remain elevated for 7-10 days.
Following an acute MI, when do CK-MB levels become elevated and how long do they remain elevated?
The CK-MB fraction level increases 6–12 hours after an MI and peaks within the first 24 hours. It is used to detect a subsequent MI, or reinfarction, but is not used to diagnose an initial MI.
Which vasculitis is features transmural inflammation of the arterial wall with fibrinoid necrosis, and may involve different stages of inflammation coexisting in different vessels?
Polyarteritis nodosa
- Hepatitis B seropositivity is found in 30% of patients
Which neurocutaneous syndrome is associated with childhood cardiac rhabdomyomas?
Tuberous sclerosis (HAMARTOMAS) Hamartomas in CNS and skin Angiofibromas Mitral regurgitation Ash-leaf spots Rhabdomyoma (Tuberous sclerosis) autosomal dOminant; Mental retardation (intellectual disability); Angiomyolipoma (renal) Seizures, Shagreen patches.
What is the minimum cutoff value for stable angina?
> 70% occlusion
What is an Aschoff body?
An Aschoff body is a granuloma with giant cells, that are seen in acute bacterial rheumatic fever. They may often contain Anitschkow cells (enlarged macrophages with ovoid, wavy rod-like nucleus).
What is the best indicator for the severity of mitral stenosis?
The length of time between S2 and the opening snap. (Shorter S2-OS interval = worse)
What type of collagen composes the scar tissue that is observed weeks to months following an MI?
Type 1 collagen (MI = M1)
What is the intrapleural pressure at FRC?
-5 cm H2O
What is the most common CF mutation?
The ∆F508 is the most common cystic fibrosis mutation, a 3-base pair mutation in the CFTR gene in which there is a deletion in Phe, causing impaired post-translational processing (improper folding). This abnormal protein is detected by the ER and sent to the proteasome for degradation, so it never reaches the cell surface.
Which genus of bacteria lack a cell wall?
Mycoplasma
Which personality disorder often features the immature defense mechanism of splitting?
Borderline personality disorder
At what time/duration of depriving infants of affection, does irreversible damage result?
Deprivation for > 6months
What is the most common form of child maltreatment?
Child neglect
What is the order that a patient experiencing delerium loses orientation?
(First) time > place > person (last)
What is Korsakoff syndrome and what are its features?
Korsakoff syndrome occurs in the setting of severe B1 deficiency (part of Wernicke’s), due to destruction of the mammillary bodies. Features:
- anterograde amnesia
- confabulations (“konfabulations”)
What are some reversible causes of dementia?
- Depression (pseudodementia)
- Hypothyroidism
- Vitamin deficiency (esp. B1, B3, B12)
- Normal pressure hydrocephalus
How is schizoaffective disorder differentiated from a major mood disorder with psychotic features?
Schizoaffective disorder = criteria met for both schizophrenia and a major mood disorder (e.g. the patient can have both schizophrenia and have bipolar disorder); however, the main difference is that schizoaffective disorder must have a period >2weeks of hallucinations or delusions on their own, without a major mood episode
What criteria can be used to diagnose a manic episode?
DIGFAST: 3 or more of the following present for at last 1 week:
- Distractibility
- Irresponsibility—seeks pleasure without regard to consequences (hedonistic)
- Grandiosity—inflated self-esteem
- Flight of ideas—racing thoughts
- Increase in goal-directed Activity/psychomotor Agitation
- need for Sleep decreases
- Talkativeness or pressured speech
Which personality disorder can be treated/managed with dialectical behavior therapy?
Borderline
How does a sleep terror differ from a nightmare?
Sleep terrors involve sudden screaming in the middle of the night and occur during Slow-wave sleep and there is generally no memory of the arousal episode upon waking.
NightMares occur during REM sleep, and are remembered upon waking.
What neurotransmitter abnormality leads to narcolepsy/cataplexy?
Narcolepsy is caused by decreased production of hypocretin(orexin) in the lateral hypothalamus (normally responsible for preventing early entry into REM sleep)
What are the general signs of depressant intoxication and withdrawal:
Intoxication: mood elevation, decreased anxiety, sedation, respiratory depression
Nonspecific (think about it…you’re taking away GABA/inhibition): anxiety, tremor, seizures, insomnia
What are the specific signs and symptoms of alcohol intoxication and withdrawal?
Intoxication:
Emotional lability, slurred speech, ataxia, coma, blackouts. Serum γ-glutamyltransferase (GGT)—sensitive indicator of alcohol use. AST = 2x ALT value
Withdrawal:
Time from last drink:
3–36 hr: minor symptoms similar to other depressants
6–48 hr: withdrawal seizures
12–48 hr: alcoholic hallucinosis (usually visual)
48–96 hr: delirium tremens (DTs) in 5% of cases
Treatment: benzodiazepines.
What are the specific signs and symptoms of opiate intoxication and withdrawal?
Intoxication:
Euphoria, respiratory and CNS depression, gag reflex, pupillary constriction (pinpoint pupils), seizures (overdose). Most common cause of drug overdose death.
Treatment: naloxone
Withdrawal:
Sweating, dilated pupils, piloerection (“cold turkey”), fever, rhinorrhea, yawning, nausea, stomach cramps, diarrhea (“flu-like” symptoms).
Treatment: long-term support, methadone, buprenorphine
What are the specific signs and symptoms of barbiturate intoxication and withdrawal?
Intoxication:
Low safety margin, marked respiratory depression
Withdrawal:
Delirium, life-threatening cardiovascular collapse
What are the specific signs and symptoms of benzodiazepine intoxication and withdrawal?
Intoxication:
Greater safety margin. Ataxia, minor respiratory depression. Treatment: flumazenil
Withdrawal:
Sleep disturbance, depression, rebound anxiety, seizure.
What are the general signs of stimulant intoxication and withdrawal?
Intoxication:
mood elevation, psychomotor agitation, insomnia, cardiac arrhythmias, tachycardia, anxiety
Withdrawal:
post-use “crash,” including depression, lethargy, appetite, sleep disturbance, vivid nightmares
What are the specific signs and symptoms of amphetamine intoxication and withdrawal?
Effects of intoxication last for hours:
Euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention, hypertension, tachycardia, anorexia, paranoia, fever. Severe: cardiac arrest, seizures. Treatment: benzodiazepines for agitation and seizures
What are the specific signs and symptoms of cocaine intoxication and withdrawal?
Effects don’t last as long as amphetamines:
Impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid ideations, angina, sudden cardiac death. Treatment: α-blockers, benzodiazepines. ß-blockers not recommended
What are the specific signs and symptoms of caffeine intoxication and withdrawal?
Intoxication:
Restlessness, diuresis, muscle twitching.
Withdrawal:
Headache, difficulty concentrating, flu-like symptoms
What are the specific signs and symptoms of nicotine intoxication and withdrawal?
Intoxication:
Restlessness
Withdrawal:
Irritability, anxiety, restlessness, difficulty concentrating. Treatment: nicotine patch, gum, or lozenges; bupropion/varenicline
What are the specific signs and symptoms of LSD intoxication and withdrawal?
Perceptual distortion (visual, auditory), depersonalization, anxiety, paranoia, psychosis, possible flashbacks]- NOT habit forming
What are the specific signs and symptoms of marijuana intoxication and withdrawal?
Intoxication:
Euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal, increased appetite, dry mouth, conjunctival injection, hallucinations. Pharmaceutical form is dronabinol: used as antiemetic (chemotherapy) and appetite stimulant (in AIDS)
Withdrawal:
Irritability, anxiety, depression, insomnia, restlessness, decreased appetite
What are the specific signs and symptoms of MDMA (ecstasy) intoxication and withdrawal?
Intoxication:
euphoria, disinhibition, hyperactivity, distorted sensory and time perception, teeth clenching. Life-threatening effects include hypertension, tachycardia, hyperthermia, hyponatremia (via diaphoresis, SIADH and water intoxication from users replacing fluid due to dehydration from sweating).
Withdrawal:
Depression, fatigue, change in appetite, difficulty concentrating, anxiety.
What are the specific signs and symptoms of phencyclidine (PCP) intoxication and withdrawal?
Intoxication:
Violence (super strong and can’t feel pain), impulsivity, psychomotor agitation, nystagmus (BUZZWORD), tachycardia, hypsertension, analgesia, psychosis, delirium, seizures. Trauma is most common complication. Treatment: benzodiazepines, rapid-acting antipsychotic
Which drug should be given to a patient experiencing acute alcohol withdrawal?
Benzodiazepines (specifically oxazepam, lorazepm or temazepam because these drugs undergo Phase II metabolism and are therefore not contraindicated in someone with liver disease)
What embryologic structure is the neural tube derived from?
The Neural plate/folds
What does the notochord give rise to?
The Nucleus pulposus of intervertebral discs
Which primary vesicle is the telencephalon derived from, and what are the adult wall/cavitary derivatives that it gives rise to?
Forebrain –> Telencephalon –> Walls: cerebral hemispheres and cavities: lateral ventricles
Which primary vesicle is the diencephalon derived from, and what are the adult wall/cavitary derivatives that it gives rise to?
Forebrain –> Diencephalon –> Walls: thalamus, hypothalamus and cavities: third ventricle
Which primary vesicle is the mesencephalon derived from, and what are the adult wall/cavitary derivatives that it gives rise to?
Midbrain –> Mesencephalon –> Walls: midbrain and cavities: aqueduct
Which primary vesicle is the metencephalon derived from, and what are the adult wall/cavitary derivatives that it gives rise to?
Hindbrain –> Metencephalon –> Walls: pons, cerebellum and cavities: upper part of fourth ventricle
Which primary vesicle is the myelencephalon derived from, and what are the adult wall/cavitary derivatives that it gives rise to?
Hindbrain –> Myelencephalon –> Walls: medulla, and cavities: lower part of fourth ventricle
Which two serum markers can be used to diagnose NTDs?
ACHE and AFP
What is the diagnosis?
This patient is presenting with loss of pain and temperature sensation in a cape-like distribution, with preserved position and vibration sense. MRI also reveals a cystic cavity within the central canal of the spinal cord.
Syringomyelia
What are some of the functions and features of astrocytes?
- Provide physical and repair support to neurons
- Remove excess neurotransmitter
- Component of the BBB
- Contributes to reactive gliosis in response to neural injury
- Marker: GFAP
- Derived from neuroectoderm
What are the function of microglia? How are microglia unique compared to the rest of the CNS?
Phagocyte scavenger cells. They are derived from mesoderm.
Which kinetic constant does myelin increase to increase the conduction velocity of an axon?
The space constant (aka. the length constant - the distance that a graded electric potential will travel along a nemuron via passive electrical conduction before requiring a second depolarization)
What are the difference between the C fibers and the Aδ fibers in free nerve endings?
C = slow, unmyelinated –> cold/hot
Aδ = fast, myelinated –> pAin
What is the function of Meissner corpuscles?
Found on hairleSS skin; soft “s’s” = soft/light touch
What is the function of Pacinian corpuscles?
Pressure –> felt in deep skin/ligaments/joints
What is the function of Merkel discs?
hard “k” is SHARP like shapes/edges
What is the function of Ruffini corpuscles?
Can feel objects with a ruff(rough) surface won’t slip from the skin
Where is acetylcholine synthesized?
Basal nucleus of Meynert
Where is dopamine synthesized?
Ventral tegmentum, SNc (think PD)
Where is GABA synthesized?
Nucleus accumbens
Where is NE synthesized?
Locus cerulus
Where is 5-HT synghtesized?
Raphe nucleus
Which part of the brain lacks a BBB?
Area postrema the “vomiting center” - this is why chemo drugs cause vomiting
What are the stages of sleep and which wave forms are seen in each?
At night “BATS Drink Blood”
- Awake (eyes open) = Beta waves - highest freq, lowest amplitude
- Awake (eyes closed) = Alpha waves
- Stage N1 = Theta waves (5%) - light sleep
- Stag N2 = Sleep spindles/K complexes (45%) - deep sleep where bruxism (pronounce bruKxism) occurs
- Stage N3 = Delta (25%) - deepest non-REM, when sleepwalking, night terrors and bedwetting occur
REM
- REM sleep = Beta (25%) - loss of motor ton, variable pulse and blood pressure driven by ACh
What is the equation for the cerebral perfusion pressure?
CPP = MAP - ICP
Which structures pass through the cribriform plate?
CN1 (duh…olfactory nerve!)
Which structures pass through the optic canal?
CNII and ophthalmic artery (makes sense—optic canal leads to the eye)
Which structures pass through the Superior orbital fissure?
CNIII, CNIV, CN VI (i.e. all of the extraocular muscle nerves
and CN V1 - the ophthalmic branch of trigeminal
Which structures pass through the foramen rotundum?
CN V2 - the maxillary branch of trigeminal
Which structures pass through the the foramen ovale?
CN V3 - the mandibular branch of trigeminal
Which structures pass through the foramen spinosum?
Middle meningeal artery
Which structures pass through the internal auditory meatus?
CNVII and CN VIII
Which structures pass through the jugular forament?
CN IX, X, XI and the jugular vein
Which structures pass through the hypoglassal canal
the HYPOGLOSSAL nerve (CNXII)
Which structures pass through the foramen magnum?
Brainstem, spinal root of CNXI, vertebral arteries.
Where is the needle most safely placed for lumbar puncture?
Between L3 and L4 or L4 and L5
“L3 and L5 to keep the cord alive!”
What is the time course for the various changes in ischemic brain disease?
12-24 hours - red neurons (eosinophilic cytoplasm with pyknotic nuclei and loss of Nissl substance)
24-72 hours - necrosis and neutrophils
3-5 days - Macrophages (microglia)
1-2 weeks - Reactive gliosis + vascular proliferation
> 2 weeks - glial scar (around cystic space)
Rupture of which blood vessels results in a subdural hematoma?
Bridging veins
What should a subarachnoid hemorrhage be treated with?
CCB to prevent vasospasm
What is a Charcot-Bouchard aneurysm?
A type of intraparenchymal hemorrhage that occurs in the basal ganglia or internal capsule, usually due to a microaneurysm of lenticulostriate vessels.
What are the clinical manifestations of medial medullary syndrome and which artery is affected?
Anterior spinal artery - duh…the ASA lies along the medulla
- contralateral paralysis (motor tract decussates here)
- contralateral proprioception decrease (DCML decussats here)
- ipsilateral hypoglossal dysfunction (CN12 is located right there!)
What are the clinical manifestations of lateral medullary (Wallenberg) syndrome and which artery is affected?
Posterior inferior cerebellar artery - duh..the PICA is located off to the lateral medulla, which would affect the nerves of the nucleus ambiguus (IX, X, XI)
“Don’t PICA horse (hoarseness) that can’t eat (dysphagia)
- decreased pain and temp sensation from contralateral body/ipsilateral face
What are the clinical manifestations of lateral pontine syndrome and which artery is affected?
Anterior inferior cerebellar artery - duh…the AICA sits on the lateral pons
“Facial droop means AICA’s pooped”
- paralysis of face (decreased lacrimation, salivation, and decreased tates from anterior 2/3 of tongue)
- ipsilateral Horner syndrome
What are the clinical manifestations of “Locked-in” syndrome and which artery is affected?
Basilar artery (runs right up the center of the pons)
- reticular activating system (RAS) is spared therefore consciousness is preserved
- quadriplegia
- loss of horizontal, but not vertical eye movments
How dos the neurodegeneration in vascular dementia differ from that in AD?
Vascular dementia involves a step-wise decline in cognitive ability, with lat-onset memory impairment whereas AD has early recent/short-term memory loss.
Which neurodegenerative disease features increased 14-3-3 protein in the CSF?
Creutfeldt-Jakob disease
What causes communicating hydrocephalus?
Decreased CSF absorption by arachnoid granulations
What causes normal pressure hydrocephalus?
Idiopathic dilation of the ventricles that distorts the corona radiata –> wet (urinary incontinence), wacky (cognitive dysfunction) and wobbly (ataxia)
What is a noncommunicating hydrocephalus?
One that’s due to blocakge/obstruction
What is Lhermitte’s phenomenon?
Flexion of the neck in a patient with MS causes them to feel an electric-shock sensation down their spine
Increased myelin basic protein in the CSF can be indicative of?
MS
What are some of the main features of GBM?
Glioblastoma multiforme (Grade IV astrocytoma)
- Most common primary adult tumor
- Can cross midline (butterfly glioma)
- Has the worse prognosis
- GFAP + (makes sense because they are derived from astrocytes)
- Can involve both necrosis and hemorrhage
- “Pseudopalisading” on histology
What are some of the main features of meningioma?
- Often appear in the falx, or parasagital regions
- Can fature dural tail
- PSaMMoma bodies on histology
What are some of the main features of hemangioblastomas?
- HEMANGIO=blood –> can produce EPO and causes 2º polycythmia
- Arise from blood vessel (hemangio)
- Often occur in the cerebellum
- Associated with von Hippel-Lindau syndrome
What are some of the main features of schwannomas?
- classically occur at the cerebellopontine angle
- often localized to CN VIII
- S-100 (+) - “S” for schwannoma
What are some of the main features of oligodendrogliomas?
- Rare; slow growing tumors
- “Fried egg” “O’s” on histology
What is the most common benign childhood brain tumor?
Pilocytic astrocytoma
What is the most common malignant childhood brain tumor?
Medulloblastoma
What are some of the main features of pilocytic astrocytoma?
- Most common benign childhood brain tumor
- Most often found in posterior fossa (e.g. cerebellum)
- Glial cell origin
- GFAP (+)
- May feature Rosenthal fibers and hair like (pilocytic) projections
What are some of the main features of medulloblastomas?
- Most common malignant childhood brain tumor
- Can compress the 4th ventricle and cause non-communicating hydrocephalus
- Features Homer-Wright rosettes = small blue cells surrounding a central area of eosinophilia
What are some of the main features of ependymoma?
- Poor prognosis because they can obstruct the 4th ventricle and cause hydrocephalus
- features perivascular rosettes (e.g. looks like Homer-Wright rosettes, but instead surrounding a blood vessel)
How do craniopharyngiomas differ from pituitary adenomas?
Both lie in the sella turcica, however craniopharyngiomas generally involved HYPOsecretion.
What are some of the findings of an uncal herniation?
An uncal herniation occurs when part of the medial temporal lobe slides out and under the tentorium cerebelli causing:
- ipsilateral CN III damage
- ipsilateral PCA damage (contraltral homonymous hemaniopia with macular sparing)
- ipsilateral pareesis
Which MN lesion presents with clasp-knife spasticity?
UMN
Which MN lesion presents with weakness?
Both UMN and LMN
What are the findings/lesions seen in poliomyelitis and Werdnig-Hoffmann disease?
- Both involve the anterior horns of the spinal cord –> cause LMN signs
- Werdnig-Hoffmann disease is an autosomal recessive inherited degeneration of anterior horn –> threfore symmetric
What are the findings/lesions in amyotrophic lateral sclerosis?
- Combined UMN and LMN deficits with no sensory/bowel/bladder deficits
- Can be caused by a defect in superoxide dismutase –> increased free radical damage
Treatment: Riluzole (Ri”Lou”zole)
What are the findings/lesions in tabes dorsalis?
- Caused by 3º syphilis
- Results from degeneration of dorsal columns and roots lading to sensory ataxia
- Present with Romberg sign
- Treatment: penicillin G
What are the findings/lesions in syrngomyelia?
- Syrinx expands and damages the anterior white commissure of the spinothalamic tract –> bilateral loss of P/T sensation
- Associated with Chiari I malformation
What are the findings of Brown-Séquard syndrome?
Brown-Séquard is a hemisection of the spinal cord that results in:
- Ipsilateral LMN signs at the level of the lesion
- Ipsilateral UMN signs below the level of the lesion
- Ipsilateral loss of all sensation at the level of the lesion
- Ipsilateral loss of fine touch/proprioception/vibration below level of lesion
- Contralateral loss of pain/temperature below level of lesion
Damage in what nerve causes an afferent pupillary defect?
Optic nerve of the affected eye –> light shown in the affected eye produces a decrease (or dilation) in the pupillary reflex compared to the unaffected eye
What type of nephritic syndrome is Goodpasture syndrome?
Rapidly progressive (crescentic) glomerulonephritis
What is the difference between basophilic stippling and ring sideroblasts?
Both can be indicative of iron excess or lead poisoning, but stiPPling is seen on PeriPheral smear, while sideroBlasts are seen in Bone marrow.
Give an example of HMG-CoA reductase inhibitors. What are their MOA, ADRs and effect on LDL, HDL, and TG.
“statins”
- MOA: inhibit conversion of HMG-CoA to mevalonate (cholesterol precursor)
- ADRs: hpatotoxic, myopathy (sp. with fibrates or niacin)
- LDL: ↓↓↓
- HDL: ↑
- TGs: ↓
Give an example of bile acid resins. What are their MOA, ADRs and effect on LDL, HDL, and TG.
“chol” drugs: cholestyramine, colestipol, colesevelam
- MOA prevent intestinal reabsorption of bile acids; liver must use cholesterol to make more
- ADRs: GI upset
- LDL: ↓↓
- HDL: slightly ↑
- TGs: slightly ↑ (think…because they cause increased cholesterol synthesis)
Describe ezetimibe’s MOA, ADRs and effect on LDL, HDL, and TG.
- MOA: provent cholesterol absorption at small intestine brush border
- ADRs: rare increase in LFTs, diarrhea
- LDL: ↓↓
- HDL: ↑/—
- TGs: ↓/—
Give an example of fibrates. What are their MOA, ADRs and effect on LDL, HDL, and TG.
gemfibrozil, bezafibrate, fenofibrate
- MOA: upregulate LPL increasing TG clearance (fiBRates BReak up TG)
- ADRs: myopathy, cholesterol gallstones
- LDL: ↓
- HDL: ↑
- TGs: ↓↓↓
Describe niacin’s MOA, ADRs and effect on LDL, HDL, and TG.
- MOA: inhibits lipolysis in adipose tissue; reduces hepatic VLDL synthesis
- ADRs: red, flushed face, hyperglycemia, hyperuricemia
- LDL: ↓↓
- HDL: ↑↑
- TGs: ↓
Give an example of PCSK9 inhibitors. What are their MOA, ADRs and effect on LDL, HDL, and TG.
“-cumabs” - alirocumb, evolocumab
- MOA: prevent of LDL-receptor degradation –> increase amount of LDL removed from the bloodstream
- ADRs: myalgias, delirium/demntia
- LDL: ↓↓↓
- HDL: ↑
- TGs: ↓
Why should you not administer epinephrine to a patient with acute closed-angle glaucoma?
Epinephrine will cause mydriasis, which will significantly worsen the angle! Do NOT give epinephrine!!
Black bone spicule-shaped deposits on the macula and painless progressive vision loss beginning with night blindness should clue you in to which ophthamalogic condition?
Retinitis pigmentosa - an inherited retinal degeneration
How does the presentation and cause of CNIII differ for the motor arm vs. parasympathetic arm?
Motor: will present with a down/out gaze - causes are usually related to ischemia and lack of nutrients, since the O2 has to diffuse across the muscle fibers, and can be compromised in cases of vascular disease (e.g. DM)
Parasympathetic: will present with a blown pupil and often down/out gaze - usually caused by compression (e.g. increasd IOP, PCom aneurysm, uncal herniation)
What drug is used to treat narcolepsy and//or cataplexy?
Modafinil, an atypical dopamine reuptake blocker, is used to treat narcolepsy, although its exact mechanism of action is unknown. Patients suffering from cataplexy may also be treated with sodium oxybate.
What is the treatment for serotonin syndrome?
cyproheptadine (5-HT2receptor antagonist
In HSV1, which motor protein is responsible for anterograde transport in which is responsible for retrograde transport?
DRAKe:
- Dynein = retrograde = latency
- Kynesin = anterograde = reinfection
How does demyelination affect the time constant and the space constant?
- Demyelination increases the time constant (i.e. causes a decrease in velocity) and decreases the length/space constant (i.e. it decreases the length the electrical impulse can propagate without requiring active regeneration by ion channels)
Describe the microscopic changes that occur over time following in ischemic stroke:
- 12–24 hours: read neurons (eosinophilic cytoplasm with pyknotic nuclei)
- 24–72 hours: necrosis and neutrophils
- 3–5 days: macrophages
- 1-2 weeks: reactive gliosis and vascular proliferation
What is the most common cause of spontaneous lobar hemorrhage?
Cerebral amyloid angiopathy (particularly in the elderly)
What accounts for the rapid onset and relatively short duration of propofol and other highly lipophilic drugs?
The quick onset and fast offset is due to the fact that highly lipophilic drugs first accumulate quickly into the brain, heart and other organs with high blood flow, before being re-distributed (e.g. within 15 minutes) to other tissues such as the skeletal muscle and eventually bone and adipose tissue.
What are the most common causes of meningitis in newborns (0 to 6 months)?
- GBS
- E. coli
- Listeria
What are the most common causes of meningitis in patients over 60yo?
- S pneumoniae
- Gram (-) rods
- Listeria
The patient presents with contralateral paralysis in sensory loss, without any cortical signs (e.g. neglect, a facia, visual field loss). What is the artery, brain area most likely affected and what is this usually secondary to?
This is most likely a stroke in the lenticular-striate artery causing a loss of function in the striatum and internal capsule. This is a common location of lacunar infarcts, due to hyaline arteriosclerosis secondary to unmanaged hypertension
How do PPV and NPV vary with changes in disease prevalence?
PPV varies directly with pretest probability (i.e. prevalence), while NPV varies inversely with prevalence.
Therefore, for a disease with a high prevalence, the test will have a high PPV and a low NPV (therefore, if there are more people with the disease in the population, it is more likely that a positive test result is truly positive, and less likely that a negative test result is truly negative)
What are the most common causes of meningitis in children and adults (up to 60yo)?
- S pneumoniae
- N meningitidis (#1 in teens)
- Enteroviruses
- HSV
How do PPV and NPV vary with changes in disease prevalence?
PPV varies directly with pretest probability (i.e. prevalence), while NPV varies inversely with prevalence.
Therefore, for a disease with a high prevalence, the test will have a high PPV and a low NPV (therefore, if there are more people with the disease in the population, it is more likely that a positive test result is truly positive, and less likely that a negative test result is truly negative)
What is the equation for NNH
NNH = 1 / AR
Where AR = attributable risk
What is the equation for NNT?
NNT = 1 / ARR
Where ARR = absolute risk reduction
What is the equation for NNH
NNH = 1 / AR
Where AR = attributable risk
Which embryologic tissues are dervied from surface ectoderm?
- Tissues that are somehow connected to the external environment: MO’S APPLE
- Mammary glands
- Olfactory epithelium
- Adenohypohphysis
- Parotid gland
- Pectinate line (anal canal below)
- Lens of eye
- Epidermis
Which embryologic tissues are derived from the neural tube?
the Brain and spinal cord (CNS) make up the neural tube - Brain, spinal cord and retina:
- Brain (neurohypophysis, CNS neurons, oligodendrocytes, astrocytes, ependymal cells, pineal gland), retina, spinal cord
Which embryologic tissues are derived from the neural crest cells?
PNS and non-neural structures nearby: MOTEL BED PASS
- Melanocytes
- Odontoblasts (teeth)
- Tracheal cartilage
- Enterochromaffin cells
- Laryngeal cartilage
- Bones of the skull
- Endocardial cushions
- Dorsal root ganglia
- Parafollicular cells
- Adrenal medulla
- Schwann cells
- Spiral membrane
Which embryologic tissues are derived from mesoderm?
Middle = “meat” layer:
- Muscle, bone, connective tissue, serous linings of body cavities, spleen, CV structures, lymphatics, blood, wall of gut tube, upper vagina, kidneys, adrenal cortex, dermis, testes, ovaries
Which embryologic tissues are derived from endoderm?
“Enternal” layer:
- Gut tube epithelium, including anal canal above pectinate line, most of urethra and lower vagina, lungs, liver, gallbladder, pancreas, eustachian tube, thymus, parathyroid, thyroid follicular cells
What is the #1 cause of intellectual disability and congenital defects in the US?
Ftal alcohol syndrome
How does alcohol use during pregnancy lead to FAS?
Alcohol prevents neural crest cells from migrating
What is the most common type of monozygotic twin pregnancy?
Monochorionic, diamniotic (75% of monozygotic twins)
Which structures are derived from the 1st-4th branchial pouch?
Ears, tonsils, bottom to top
- 1st pouch = ears: middle ear, eustachian tube, mastoid air cells
- 2nd pouch = palatine tonsils
- 3rd pouch= inferior parathyroids, thymus
- 4th pouch - 4th pouch structures migrate above 3rd pouch: superior parathyroids
How does a bicornuate uterus differ from uterus didelphys?
Bicornuate uterus is due to a incomplete fusion of Müllerian ducts, results in two uteri with a single cervix.
Uterus didelphys is the result of a complete failure of fusion, resulting in a double uterus, cervix and vagina. pregnancy is still possible
How do the embryologic causes of hypospadias and epispadias differ?
Hypospadias = abnormal opening of penile urethra on ventral (underside) of penis due to failure of urethral folds to fuse
Epispadias = abnormal opening of penile urethra on the dorsal (topside) of penis due to faulty positioning of genital tubercle
Which lymph nodes do the head and neck drain into?
Cervical
Which lymph nodes do the lungs drains into?
Hilar
The mediastinal lymph nodes drain what oragns?
Trachea and esophagus
The axillary lymph nodes drain what part of the body?
Upper limb, breast, skin above umbilicus
Which structures are drained by the celiac lymph node cluster?
Liver, stomach, spleen, pancreas, upper duodenum (i.e. structures that receive blood supply from the celiac a.)
Which structures are drained by the superior mesenteric lymph node cluster?
Lower duodenum, jejunum, ileum, colon to splenic flexure
Which structures are drained by the inferior mesenteric lymph node cluster?
Colon from splenic flexure to upper rectum
Which lymph node cluster drains the body of the uterus, cervix and superior bladder?
External iliac nodes
Which lymph node cluster drains the prostate, cervix, corpus cavernosum, proximal vagina, and lower rectum above the pectinate line?
Internal iliac nodes
Which lymph node cluster drains the distal vagina, vulva, scrotum and distal anus?
Superficial inguinal nodes
Which lymph node cluster drains the glans penis?
DEEP inguinal nodes
Which structures lie within the infundibulopelvic ligament and must therefore be ligated prior to oophorectomy?
Infundibulopelvic ligament = the suspensory ligament of the ovary; contains the ovarian vessels
Which structures lie within the cardinal ligament and what other structure is at risk of being cut during hystrectomy?
The uterine vessels lie within the cardinal ligament. The ureter is at risk of injury during ligation.
What is the pathway of sperm during ejaculation?
SEVEN UP:
- Seminiferous tubules
- Epididymis
- Vas deferens
- Ejaculatory ducts
- (Nothing)
- Urethra
- Penis
When can beta-hCG be detected in the blood and in the urine?
Blood: 7 days after fertilization
Urine: 14 days after fertilization (i.e. think of a woman doing a pregnancy test after she misses her period - which would have occurs 14 days after ovulation/fertilization)
What are the components of the APGAR score?
APGAR:
- Appearance: Pink-2pts, Extremities blue-1pts, Everything blue - 0pts
- Pulse: > 100bp-2pts, <100bpm-1pt, No pulse-0pts
- Grimace: Cries/pulls away-2pts, Grimaces/weak cry-1pt, No response to stimulation-0pts
- Activity: Active movement-2pts, Arms and legs flexed-1pt, No movement-0pts
- Respiration: Strong cry-2pts, Slow/irregular-1pt, No breathing-0pts
What causes Kallmann syndrome?
Failure of migration of GnRH-releasing neurons and subsequent failure of GnRH-releasing olfactory bulbs to develop (results in anosmia)
What height should the uterus be at 12 weeks gestation and 20 weeks gestation?
12 weeks: pubic symphisis
20 weeks: umbilicus
Which malignancy of trophoblastic tissue is associated with elevated beta-hCG and cannonball metastases to the lungs?
Choriocarcinoma - suspect in a woman with a history of molar pregnancy and histology shows absence of chorionic villi
Exposure to DES in utero causes what vaginal tumor?
Clear cell adenocarcinoma
What is sarcoma botryoides?
An embryonal rhabdomyosarcoma variant that affects girls <4yo
“botryoides = bunch of grapes”
Which proteins do HPV 16 and 18 produce and what do they inhibit?
Produce E6 which inhibits p53 and E7 which inhibits RB
Which histologic finding is pathognomonic of HPV infection?
Koilocytes - dense, irregular cytoplasm and perinuclear halo
What is the primary insult that leads to PCOS?
Hyperinsulinemia/insulin resistance leads to disregulation of the HPG axis by causing an increase in pulsatile GnRH secretion which increase LH and FSH secretion in a 3:1 ratio
Benign ovarian neoplasm with fallopian tube-lik pithlium?
Serous cystadenoma
Mucus-secreting lined ovarian neoplam?
Mucinous adenoma
Chocolate cyst
Endometrioma - presents with pelvic pain, dysmenorrhea, and dyspareunia.
Pale yellow-tan tumor that looks like the bladder?
Brenner tumor (B = bladder)
Ovarian tumor that causes a “pulling” sensation in the groin?
Fibroma
Germ cell tumor that often present with hyperthyroidism and is the most common ovarian tumor in females 10-30 years old
Mature cystic teratoma (aka dermoid cyst)
Which malignant ovarian neoplasm has the pathognomonic finding of “Call-Exner Bodies” and what are they?
Call-Exner Bodies = Granulosa cell tumor; “don’t forget to CALL your GRANny”
Most common malignant ovarian neoplasm that presents with PSaMMoma bodies?
Serous cystadenocarcinoma
Aggressive malignant ovarian neoplasm usually diagnosed before the age 20?
Immature teratoma
Common ovarian tumor in adolescents described as having a “fried egg” appearance on histology.
Dysgerminoma
Aggressive tumor that is most common in male infants and features “Schiller-Duval bodies” which appear like glomeruli?
Yolk sac tumor
GI malignant that metastasizes to ovaries and features “signet cells”
Krukenberg tumor
Dilitation and curettage is often associated with which endometrial condition?
Asherman syndrome –> adhesions/fibrosis of the endometrium
Which endometrial condition is the most common tumor in females, with a peak in those aged 20-40? This tumor increases in size with pregnancy, decreases with menopause, and is often classified on histology as having a “whorled pattern of smooth muscle”
Leiomyoma
A woman in her 50s/60s with vaginal bleeding, should have what DDx considered?
Endometrial carcinoma
A collection of serous fluid between the parietal and visceral layers of the tunica vaginalis is known as a:
Hydrocele
What is the most common testicular germ cell tumor, and which serum marker is diagnostic?
Seminioma; ALP
Prostatic adenocarcinoma is most common in:
Posterior lobe (Peripheral zone)
What are the rotator cuff muscles?
SItS
- Supraspinatus (abducts arm until deltoid takes over)
- Infraspinatus (laterally rotates arm)
- teres minor
- Subscapularis
What are the wrist bones?
From radial to ulnar: “So Long To Pinky, Here Comes The Thumb”
- Scaphoid
- Lunate
- Triquetrum
- Pisiform
- Hamate
- Capitate
- Trapezoid
- Trapezium
Which nerve is commonly injury due to an anterior dislocation of the humerus or fractured cervical neck, and how does this injury present?
- Axillary nerve
- Presents with a flatten deltoid muscle and loss of abduction greater than 15°
Which nerve is commonly injury due to compression of the upper trunk, and how does this injury present?
- Musculocutaneous nerve (C5-C7)
- presents with loss of forearm flexion and supination
Which nerve is commonly injury due to midshaft fracture of the humerus or compression of the axilla, and how does this injury present?
Radial (C5-T1)
- presents with a wrist drop
Traction or tear of the upper trunk (C5-C6) leads to which palsy?
Erb’s Palsy involves the ERBer trunk
Traction or tear of the upper trunk (C8-.T1) leads to which palsy?
Total claw hand with loss of fine finger movements
An injury to which nerve and subsequently which muscle results in a “winged scapula”?
Long thoracic nerve and serratus anterior muscle
A trendelenburg sign/gait is due to a lesion in which nerve/muscles? How can you tell which side is affected?
- Due to an injury of the superior gluteal nerve (L4-S1) which causes weakness in the gluteus medius and gluteus minimus muscles. This injury can occur when there is an intramuscular injection to the upper-medial gluteal region
- The lesion is contralateral to the side of the hip that drops (i.e. ipsilateral to the extremity on which the patient stands)
Which muscles and which nerve is responsible for hip adduction?
Muscles: adductor Magnus, adductor longus, adductor brevis
Nerve: obturator
Which muscles and nerves are responsible for hip extension?
- gluteus Maximus (Inferior gluteal nerve)
- Semitendinosus
- Semimembranousus
Which muscles and nerves are responsible for hip flexion?
- Iliopsoas
- Rectus femoris
- Tensor fascia lata
- Pectineus
Which group of muscles in which nerve is responsible for internal rotation of the hip?
- nerve: superior gluteal nerve
- muscles: gluteus medius, gluteus minimums, tensor fascia lata
Which group of muscles is responsible for external rotation of the hip?
- iliopsoas, gluteus Maximus, piriformis, obturator
How does osteoporosis differ from osteopenia?
Osteoporosis: T-score ≤ -2.5
Osteopenia: T-score between -2.5 and -1
What would the Ca2+, PO4^3-, ALP, and PTH levels be in a patient with osteoporosis?
All normal - osteoporosis is caused by a loss of mass in trabecular and cortical bone; bone mineralization is still normal and lab values are normal
- diagnosis is based on DEXA scan/T-score
What would the Ca2+, PO4^3-, ALP, and PTH levels be in a patient with osteopetrosis?
All normal - although sometimes calcium may be low due to decreased osteoclast activity and hence decreased bone resorption
What would the Ca2+, PO4^3-, ALP, and PTH levels be in a patient with Paget disease of bone?
Only increased ALP since Paget’s is primarily due to a balanced increase in both osteoclastic and osteoblastic activity. Presents with a mosaic pattern of woven and lamellar bone. Hx: increasing hat size with hearing loss (due to narrowing of auditory foramen)
What would the Ca2+, PO4^3-, ALP, and PTH levels be in a patient with osteomalacia/rickets?
Calcium: decreased, phosphate: decreased, ALP: increased, PTH: increased.
The primary insult here is a deficiency in vitamin D resulting in a defective mineralization of osteoid in osteomalacia and defective cartilaginous growth plates in rickets.
Which part of the bone and which age group is generally affected by giant cell bone tumors?
- 20-40 years old
- Epiphysis of long bones
Which part of the bone and which demographic is most commonly affected by osteochondroma?
- Metaphysis of bones
- Males < 25yo
Which tumor is commonly described as having a sunburst appearance on X-ray? Which part of the bone is affected, what are risk factors, and what is the most common demographic?
Osteosarcoma:
- Bimodal: 10-20yo, and >65yo
- Most commonly affects the metaphysis
Risk factors: Paget disease, familial RB, Li-Fraumeni syndrome
Which aggressive bone tumor is described as “small blue cell” with and “onion skin” periosteal reaction in bone? Which part of the bone, which demographic is affected and what is the translocated associated with this tumor?
Ewing Sarcoma
- Affects boys < 15yo
- Occurs in diaphysis of long bones
- t(11;22) translocation
What drugs can be used to treat gout acutly?
Focus on pain relief: NSAIDS, glucocorticoids, colchicine
What drugs can be used for the chornic treatment of gout?
Preventative: allopurinol (xanthine oxidase inhibitor)
Which type/shape of crystals are seen in “pseudogout” and what conditions are commonly associated?
Pseudogout = calcium pyrophosphate deposition disease
- Features rhomboid-shaped positively birefringent crystals
- Associated with: hemochromatosis, hyperparathyroidism
Which MHC molecule is associated with the seronegative spondyloarthropathies, and what are the names of those arthropathies?
HLA-B27: PAIR
- Psoriatic arthritis
- Ankylosing spondylitis
- Inflammatory bowel disease
- Reactive arthritis
Uvitis and aortic regurgitation is commonly associated with which seronegative spondyloarthropathy?
Ankylosing spondylitis
Which antibodies are associated with SLE and what are their respective sensitivities/specificities?
- Antinuclear antibodies (ANA) - sensitive, not specfic
- Anti-dsDNA - specific (poor prognosis)
- Anti-Smith - specific, but not prognostic
- Anti-histone - sensitive for drug-induced lupus (e.g. INH, procainamide)
Which antibody is specific and pathognomonic for mixed connective tissue disease?
anti-U1 RNP antibodies
A woman > 50yo presenting with pain and stiffness in her shoulders and hips without weakness, most likely has what condition? What other disease is her condition associated with?
She likely has polymyalgia rheumatica, which is often associated with giant cell (temporal) arteritis.
How do the antibodies seen in diffuse scleroderma and CREST syndrome (limited) differ?
- Scleroderma: anti-Scl70 (an anti-topoisomerase I Ab)
- CREST syndrome: anti-centromere Ab.
Which virus causes molluscum contagiosum?
Poxvirus
What is the most common skin cancer?
Basal cell carcinoma
Which skin cancer is associated with actinic keratoses and exposure to sunlight?
Squamous cell carcinoma
Which skin cancer is associated with rolled/heaped up borders and has palisading nuclei on histology?
Basal cell carcinoma
Which skin cancer has the greatest risk for metastasis?
Melanoma
Which COX-2 inhibitor is contraindicated in patients with sulfa allergy?
Celecoxib
Pencil-in-cup deformity is most commonly seen in what condition?
Psoriatic arthritis
What is the most specific antibody for RA?
Anti-citrullinated protein (anti-CCP)
What are the lab values for the first-trimester and second-trimester screens for Trisomy 21?
1st trimester: ↓PAPP-A, ↑hCG
2nd trimester: ↓AFP, ↓estriol, ↑hCG, ↑ inhibin A
What are the lab values for the first-trimester and second-trimester screens for Edwards syndrome (trisomy 18)?
1st: ↓PAPP-A and hCG
2nd: ↓AFP, hCG, estriol and inhibin A
What are the lab values for the first-trimester screen for Patau syndrome (trisomy 13)?
↓AFP, hCG
What is Meigs syndrome?
Triad of: ovarian fibroma, ascites, hydrothorax. “Pulling” sensation in groin.
What does the bluish color of the Wright-Giemsa stain of reticulocytes indicate?
Residual rRNA
Where does fetal erythropoiesis occur at various stages of development?
“Young Liver Synthesizes Blood”
- Yolk sac (3-8 weeks)
- Liver (6 weeks-birth)
- Spleen (10-28 weeks)
- Bone marrow (18 weeks-adulthood)
A deficiency in GpIb results in what bleeding disorder?
Bernard-Soulier syndrome
A deficiency in GpIIb/IIIa results in what bleeding disorder?
Glanzmann thrombasthenia
What pathology is associated with acanthocytes?
Liver disease, abetalipoproteinemia
What pathology is associated with basophilic stippling?
Lead poisoning
What pathology is associated with dacrocytes?
Bone marrow infiltration (e.g. myelofibrosis)
What pathology is associated with degmacytes?
Degmacyte = bite cell
G6PD deficiency
What pathology is associated with echinocytes?
Echinocyte = burr cell
End-stage renal disease, liver disease, pyruvate kinase deficiency
What pathology is associated with elliptocytes?
Hereditary elliptocytosis, usually asymptomatic; caused by mutation in genes encoding RBC membrane proteins (eg, spectrin)
What pathology is associated with macro-ovalocytes?
Megaloblastic anemia
What pathology is associated with ringed sideroblasts?
Sideroblastic anemia
What pathologies are associated with schistocytes?
- Microangiopathic hemolytic anemias (e.g. DIC, TTP/HUS, HELLP syndrome, mechanical hemolysis)
What pathologies are associated with target cells?
HALT:
- HbC disease
- Asplenia
- Liver disease
- Thalassemia
Which two enzymes in heme synthesis are impaired in lead poisoning?
- Ferrochelatase
- ALA dehydratase
Which CD markers are present in Hodgkin Lymphoma?
CD15 and CD30
Which non-Hodgkin lymphoma is associated with “waxing and waning” lymphadenopathy?
Follicular lymphoma
How do multiple myeloma, Waldenström macroglobulinemia and monoclonal gammopathy of undetermined significance (MGUS) all differ from one another?
- Multiple myeloma: M spike composed mostly of IgG along with symptoms of cancer (CRAB - hyperCalcemia, Renal involvement, Anemia, Bone/back pain)
- Waldenström macroglobulinemia - M spike composed mostly of IgM, no CRAB symptoms
- MGUS: monoclonal expansion of plasma cells < 10% and no CRAB findings
Which leukemia has the histologic finding of “smudge cells”?
Chronic lymphocytic leukemia - “crushed little lymphocytes”
This leukemia has a dry tap on bone marrow aspiration, and stains for what protein?
Harry cell leukemia - TRAP
What is LAP and what is it a measure of?
LAP = leukocyte alkaline phosphatase and it is a measure of the body actively fighting off infection
- LAP is low in CML and high in leukemoid reaction
A child presents with lytic bone lesions, a skin rash and recurrent URIs, what is the most likely diagnosis and what markers do these cells express?
Langerhans cell histiocytosis: a group of proliferative disorders of dendritic cells
- express: S-100 and CD1a
- “Berbeck granules” are characteristic
Which drug class is given for acute coronary syndrome (STEMI, NSTEMI, unstable angina)?
ADP receptor inhibitors
Hydroxyurea is often given to sickle cell patients. What is the effect/MOA?
Hydroxyurea increases HbF
What is the most common type of tracheoesophageal anomalhepay?
Esophageal atresia with distal tracheoesophageal fistula (EA with distal TEF)
Which GI organ, supplied by the celiac trunk is derived from mesoderm?
The spleen
Which three structures are contained in the hepatoduodenal ligament?
Portal triad: proper hepatic artery, portal vein, common bile duct
Which structures distinguish the main three sections of the small intestine?
- Duodenum: Brunner’s Glands
- Jejunum: Plicae circulares
- Ileum: Peyer’s Patches
How do Zones 1, 2 and 3 of the liver differ based on what substances/toxins/organisms they are susceptible to?
Zone 1: closest to the hepatic triad is most susceptible to ingested toxins and viral hepatitis (1st to contact these things)
Zone 2: II = yellow fever
Zone 3: closest to the central vein and therefore the least deoxygenated blood, making this zone most susceptible to ischemia, and metabolic toxins (i.e. substances that become toxic after being activated by the liver: alcohol, acetaminophen)
This salivary gland tumor is the most common type and features both chondromyxoid stroma and epithelium:
Pleomorphic adenoma
This salivary gland tumor is associated with smoking and has a papillary cystic composition with germinal centers:
Warthin tumor (papillary cystadenoma lymphomatosum)
This salivary gland tumor is the most common malignant type, and consists of mucinous and squamous components:
Mucoepidermoid carcinoma
Barrett esophagus is associated with an increased risk for which type of cancer?
Esophageal adenocarcinoma
What are a Virchow node, Krukenberg tumor, and Sister Mary Joseph Nodule?
All represent GI cancer metastases:
- Virchow node: left supraclavicular node
- Krukenberg: bilateral mets to the ovaries
- Sister Mary Joseph nodule: periumbilical met
H. pylori is more likely to be associated with which type of peptic ulcer?
Duodenal
Which type of peptic ulcer is more likely to be malignant?
Gastric
Is a Zenker diverticulum a true or false diverticulum? Which structures are involved?
A false diverticulum "Elder MIKE has bad breath" - Elderly - Males - Inferior pharyngeal constrictor - Killian triangel (what the outpouch goes through) - Esophageal dysmotility - Halitosis
What is the purpose of the pertechnetate (99-Tc) study for Meckel diverticulum?
The pertechnetate study is used to identify ectopic gastric mucosa, as in Meckel’s diverticulum,; this is important to distinguish it from acute appendicitis, which can present similarly to this condition.
A child who fails to pass meconium within 48 hours of birth, should be worked up for what condition?
Hirschsprung disease
What is the most common cause of small bowel obstruction in adults?
Adhesions
Which two colonic polyps have malignant potential?
- Adenomatous polyps (associated with AAPC and KRAS mutations; villous > tubular because villous = VILLainOUS)
- Serrated polyps (BRAF mutations and CpG hypermethylation results in microsatellite instability)
Which polyposis syndrome features supernumary teeth?
Gardner syndrome
Which polyposis syndrome features both colonic involvement and CNS tumors?
Turcot syndrome (“TURcot = TURban”)
Peutz-Jeghers syndrome and Juvenile Polyposis syndrome are characterized by which type of polyps?
Hamartomatous polyps
Lynch Syndrome classically involves what section of the colon?
Ascending/proximal colon
How do right-sided colon cancer and left-sided colon cancer differ?
Right: more likely to bleed and cause iron deficiency anemia
Left: more likely to obstruct the entire lesion and cause an “apple core” lesion ; presents with hematochezia
What type of mutation is responsible for Lynch Syndrome?
Microsatellite instability
What absolute neutrophil count is needed to diagnose spontaneous bactrial peritonitis?
ANC > 250 cells/mm^3
What are an elevated AST and ALT indicative of?
Hepatocyte death/necrosis
What are an elevated ALP and GGT indicative of?
Biliary obstruction - note: GGT is specific to biliary disease, and therefore will b normal in bone disease where ALP is elevated
Which markers indicate liver function?
- Bilirubin ↑
- Albumin (↑ in advanced liver disease)
- Prothrombin time (↑ in advanced liver disease)
- Platelets (↓ in advanced liver disease/portal HTN)
What is the most common cause of hepatocellular carcinoma in the absence of cirrhosis?
Hepatitis B
Which liver cancer is associated with exposure to arsenic and vinyl chloride?
Angiosarcoma
What is the primary cause of Budd-Chiari syndrome?
Hypercoagulable states: e.g. polycythemia vera, postpartum state, anti-phospholipid syndrome –> causes nutmeg liver
What is the “true” pathophysiology of alpha1-antitrypsin “deficiency”?
The name is a bit of a misnomer, as there is not a true deficiency of this protein that inhibits elastic tissue breakdown, but instead a mutation that causes the protein to be misfolded, and hence non-functional. These aggregates can be visualized with a PAS stain
Which hereditary hyperbilirubinemia is associated with stress/fasting? What is the pathophysiology of this disease?
Gilbert syndrome = decreased UDP-glucuronosyltransferase conjugation AND impaired bilirubin uptake
What is the difference between Type I and Type II Crigler-Najjar syndrome?
Both have to do with UDP-glucuronosyltransferase
- Type I = no activity at all; fatal without liver transplant
- Type II = some activity; tx with phototherapy
What is the difference between Dubin-Johnson syndrome and Rotor syndrome?
Both cause conjugated hyperbilirubinemia due to defective liver excretion
- Dubin-Johnson = black liver
- Rotor = no black liver
What is the Courvoisier sign and what is it most commonly indicative of?
Painless jaundice = pancreatic cancer
What is a common cause of osteomyelitis in patients with sickle cell disease?
Salmonella
What is the CD55/59 marker indicative of and what disease are these markers absent in?
CD 55 = decay accelerating factor (DAF) - normally protects RBC membrane from complement
CD59 = MAC inhibitory protein
These two markers are absent in paroxysmal nocturnal hemobloginuria
What are the 11 symptomatic fatures of SLE?
RASH OR PAIN
- Rash (malar or discoid)
- Arthritis (nonerosive)
- Serositis
- Hematologic disorders (eg, cytopenias)
- Oral/nasopharyngeal ulcers
- Renal disease
- Photosensitivity
- Antinuclear antibodies
- Immunologic disorder (anti-dsDNA, anti-Sm, antiphospholipid)
- Neurologic disorders (eg, seizures, psychosis)
Which fetal component of the placenta synthesizes and secretes hCG?
the SYNcytiotrophoblast SYNthesizes hormones and hCG
The 1st branchial cleft develops into what ftal structure?
External auditory meatus
The 2nd through 4th branchial clefts develop into what fetal structure?
Temporary cervical sinus which are obliterated by proliferation of 2nd arch mesenchyme.
What happens if the cervical sinuses persist?
Branchial clef cyst within the lateral neck (anterior to the sternocleidomastoid)
Which factor is the primary determinant of whether testes or ovaries will develop from the undifferentiated gonads?
Testes = presence of SRY Ovaries = absence of SRY
What factor inhibits development of the internal female genitalia and which factor promotes development of male internal genitalia?
The development of female internal genitalia is inhibited by MIH secreted by the sertoli cells.
The development of male internal genitalia is promoted by the presence of the mesonephric duct and stimulation by testosterone.
Describe the peaks of FSH, LH, Estrogen, and progesterone during the various phases of the menstrual cycle
- FSH and LH are low throughout the entirety of the follicular phase and luteal phase, but peak right at ovulation.
- Estrogen: there is a small blip during menses as the follicle develops, a large peak at ovulation since E2 is needed to stimulate the proliferation of the endometrium to prepare for the follicle, and then another peak midway through the secretory face (Luteal) during which the corpus luteum produces both estrogen and progesterone.
- Progesterone: peaks during the luteal phase
Which cell types have GLUT4 transporters?
Insulin-dependent glucose transporter:
Fat, striated muscle
Which cell types have GLUT1 transporters?
RBCs, brain, cornea, placenta
Which cell types have GLUT2 transporters?
GLUT2 transporters are bidirectional and are found in the liver, kiney, small intestine and beta islet cells
Which cell types have GLUT3 transporters?
brain, placenta
Which cell types have GLUT5 transporters?
GLUT5 transporters are fructose transporters and are found in spermatocytes and GI tract (think…they require a lot of fructose to function)
Which male and female structures are derived from the genital tubercle?
GeT PC: Penis and clitoris
GeT CV: Corpus cavernosum and Vestibular bulbs
Which male and female structures are derived from the urogenital sinus?
US BB: Bulbourethral glands, Bartholin Gland
PUSS: Prostate, Skenes gland
Which male and female structures are derived from the urogenital folds?
SUFL: Shaft (ventral), labia minora
Which male and female structures are derived from the labioscrotal swelling?
Labia majora and scrotum
What does the Paramesonephric (Müllerian) duct develop into and what is the male remnant?
Develops into female internal structures—fallopian tubes, uterus, upper portion of vagina (lower portion from urogenital sinus).
Male remnant is appendix testis.
What does the Mesonephric (Wolffian) duct develop into and what is the female remnant?
Develops into male internal structures (except prostate)—Seminal vesicles, Epididymis, Ejaculatory duct, Ductus deferens (SEED).
In females, remnant of mesonephric duct = Gartner duct
Which cells in the CNS are responsible for maintaining the extracellular K+ buffer?
Astrocytes
How does the microglia of HIV-infected indivduals appear in the CNS?
They fuse to form multinucleated giant cells
Which layer of the peripheral nerve is responsible for the blood-nerve Permeability?
the Perineurium (starts with P)
What is the nuclear equivalent of Wallerian degeneration of the axon?
Chromatolysis - the reaction of the neuronal cell body to axonal injury characterized by cellular swelling, displacement of the nucleus to the periphery and loss of Nissl substance
Which part of the hypothalamus is responsible for cooling and which is reponsible for heating?
Anterior hypothalamus = A/C (cooling - parasympathetic)
Posterior hypothalamus = heating (sympathetic)
What is thge role of the limbic system and which structures are involved?
The 5 F’s: feeding, fleeing, fighting feeling, sex
Papez circuit includes: hippocampus, mammillary bodies, anterior thalamic nuclei, cingulate gyrus
How does a transient ischemic attack differ from an ischemic stroke?
A TIA is a brief, reversible episode of focal neurologic dysfunction, and is not a true infarction, therefore it will have a normal MRI. It is usually just due to a brief period of ischemia. It should be managed with low-dose aspirin.
Rupture of which blood vessels results in an epidural hematoma?
Rupture of the middle meningeal artery (branch of maxillary) esp. 2º to skull fracture involving the pterion
Where do saccular aneurysms tend to ccur? What is the most common site?
Tend to occur at bifurcations in the circle of Willis (weak areas)
- Most common site is the junction of the ACom artery and ACA
Which protein in Alzheimer disease, ApoE2 or ApoE4 is associated with an increased risk of the sporadic form of AD?
ApoE4
How does Lewy body dementia differ from Parkinson disease?
Lew body dementia presents with parkinsonian features, as well as dementia and visual haLEWYcinations
What is another name for Sturge-Weber syndrome, that can be used to help remember its presentation. What are some of the hallmarks of SWS?cherr
Struge-Weber syndrome = encephalotrigeminal angiomatosis (i.e. brain findings and vascular findings in a trigeminal distribution)
- Sporadic/Stain(por-wine)
- Tram track calcifications (on gyri of brain)
- Unilateral
- Retardation (due to abnormal neural development caused by GNAQ mutations)
- Glaucoma (due to increased IOP)/ GNAQ
- Epilepsy (mass effect)
How does transference differ from countertransference?
Transference = (paTienT to doctor) CountertransferenCe = (doCtor to patient)
How does depersonalization/derealization disorder differ from conversion (functional neurologic symptom) disorder?
Depersonalization/derealization is characterized by THOUGHTS/FEELINGS of estrangement from one’s own self, whereas conversion disorder features SYMPTOMS (e.g. sensory or motor such as blindness, paralysis, etc.) that were triggered by some stressful event.
How does the time course and features of schizophrenia, brief psychotic disorder, schizophreniform disorder and schizoaffective disorder differ from one another?
- Schizophrenia: > 6months (diagnosis requires at least 1 positive symptom (delusions, hallucinations, disorganized speech, disorganized speech or catatonic behavior) and negative symptoms
- Schizophreniform disorder: lasting 1-6months
- Brief psychotic disorder: lasting <1 month
- Schizoaffective disorder: meets criteria for schizophrenia in addition to major mood disorder; hallucinations/delusions must be present on their own for > 2weeks
What is the #1 risk factor for suicide completion?
Previous attempt (increases risk by 5-6x)
How dos schizoid personality disorder differ from avoidant personality disorder?
- Schizoid = Cluster A (“weird”) - they voluntary withdraw from society and are content with this isolation
- Avoidant = Cluster C (“worried”) - they are hypersensitive to rejection, and want to have relationships with others but are too cowardly
How does somatic symptom disorder differ from illness anxiety disorder?
Somatic symptom disorder = patient has real bodily complaints/symptoms, and worries about them excessively
Illness anxiety disorder = hypochondriasis; patient doesn’t actually have any symptoms but is worried about acquiring a serious illness/disease
Which cytokines induce differentiation of Th1 cells, what is the function of Th1 cells and which cytokines are they inhibited by?
- Induced by: IL-12, IFN-gamma
- Inhibited by IL-4 and IL-10 (secreted by Th2 cells)
- Function: activate macrophages, cytotoxic T cells, and induce class switching
Which cytokines induce differentiation of Th2 cells, what is the function of Th2 cells and which cytokines are they inhibited by?
- Induced by: IL-2, IL-4
- Inhibited by: IFN-gamma (secreted by Th1 cells)
- Function: Th2 achoo! –> induce IgE
Which cytokines induce differentiation of Treg cells, what is the function of Treg cells?
- Induced by: TGF-beta (also secrete IL-10, TGF-beta)
- Function: help maintain immune tolerance by suppressing CD4 and CD8 T-cell effector functions
How does Alzheimer disease differ from vascular dementia?
- Alzheimer disease is the second most common cause of dementia in the elderly. It usually presents with a slow-onset of memory loss (short term goes first) as well as decreased ability to perform activities of daily living (e..g. driving, groceries)
- Vascular dementia is the 2nd most common cause of dementia in the elderly. It presents with a step-wise decline in cognitive ability with late-onset memory impairment.
Describe which branches of the nervous system are responsible for the three phases of the male sexual response: erection, emission and ejaculation
“Point, Squeeze, and Shoot”
- Erection (Point - Parasympathetic via pelvic nerve)
- Emission (Squeeze - Sympathetic peristalsis of the semen via hypogastric nerve)
- Ejaculation (Shoot - Somatic via pudendal nerve)
What is CD55?
CD55 = Decay-accelerating factor - an inhibitor of complement
- Deficiencies in DAF/CD55 cause complement-mediated lysis of RBCs and paroxysmal nocturnal hemoglobinuria (DAF normally prevents activation of complement against “self” cells)
Which cytokines are secreted by macrophages and what are their functions?
“1 Macrophage 8((ate) 6 Tumors (TNF-alpha)”
- IL-1 –> fever
- IL-8 –> chemotactic for neutrophils “Clean up on IL-8”
- IL-6 –> causes fever and stimulates acute phase proteins
- IL-12 –> (macros) induces differentiation of T cells into Th1 cells
- TNF-alpha –> activates endothelium, causes WBC recruitment and vascular leak; causes cachexia, IMPORTANT: maintains granulomas in TB
Which cytokines are secreted by all T cells and what are their functions?
Hint: Michael Jordan = #2-3 the GOAT- greatest of ALL T-cells
- IL-2 –> stimulates growth of helper, cytoxic and regulatory T cells the “T” in HOT T-B stEAK
- IL-3 –> supports growth and differentiation of bone marrow stem cells. The “B” in HOT T-B stEAK
Which cytokine is secreted by Th1 cells and what is its function?
IFN-gamma –> secreted by NK cells and T cells in response to antigen; stimulates macrophage and inhibits Th2
Which cytokines are secreted by Th1 cells and what are their functions?
- IL-4 –> induces differentiation of T cells into Th2 cells; enhances class switching to IgE and IgG “E” in HOT T-B stEAK
- IL-5 –> stimulates eosinophils, and enhances class switching to IgA “A” in HOT T-B stEAK
- IL-10 –> atTENuates inflammatory response (along with TGF-beta)
Which blue-green hme-containing pigmenet gives sputum its color?
Myeloperoxidase
How do aplastic anemia, Diamond-Blackfan anemia, and Franconia anemia all differ from one another?
- Diamond-Blackman anemia = a rapid onset anemia caused by an intrinsic defect in erythroid precursor cells, that also presents with craniofacial abnormalities and triphalangeal thumbs
- Aplastic anemia = an acquired pancytopenia caused by failure or destruction of myeloid stem cells (e.g. radiation, viruses, idiopathic)
- Fanconi anemia = a genetic DNA repair defect that causes bone marrow failure leading to pancytopenia, but also accompanied by short stature, thumb/radial defects, cafe-au-lait spots and increased risk for cancer.
What is the relationship of the pulmonary artery to the bronchus at each lung hilum?
RALS:
- Right pulmonary artery is Anterior to the hilum
- Left pulmonary artery is Superior to the hilum
Which kidney structures are derived from the metanephric mesenchyme?
- all tubing from the glomerulus to the DCT (i.e all the stuff in the middle)
Which arteries supply the upper, middle and lower 1/3 of the ureter?
R.CG.I
- upper = renal artery
- middle = common gonadal
- lower = internal iliac
What are the percentages for the body fluid compartments?
60% of a person’s body mass is made up of water (the other 40% is non-water substance)
- composing that total body water 40% of the TBM is ICF (i.e. RBCs) and 20% is ECF (plasma and interstitial fluid)
- Plasma makes up 25% of the ECF and interstitial fluid makes up 75%
What is the quation for Henderson-Hasselbalch?
pH = 6.1 + log (HCO3/0.03PCO2)
What is the Winters formula, what is it used for, and how are the values interpreted?
The Winters formula is used to predict the appropriat/expected respiratory compensation for a simple metabolic acidosis.
PCO2 = 1.5[HCO3-] + 8 ± 2
- If measured PCO2 > Predicted = concomitant respiratory acidosis
- If measured PCO2 < Predicted = concomitant respiratory alkalosis
How does the presentation of acute posstreptococcal glomerulonephritis (PSGN) differ from IgA nephropathy (Berger disease)?
In PSGN, the renal symptoms occur ~2-4 weeks following a Group A strep infection of the pharynx or skin.
IgA nephropathy features episodic gross hematuria that occurs concurrently with the respiratory or GI infection.
What is the relationship of the pulmonary artery to the bronchus at each lung hilum?
RALS:
- Right pulmonary artery is Anterior to the hilum
- Left pulmonary artery is Superior to the hilum
What is the equation for the “alvolar gas equation”
PAO2 = PIO2 - PaCO2/0.8
- PAO2 = alveolar PO2
- PIO2 = PO2 of inspired air (usu. 150mmHg at sea level)
- PaCO2 = arterial PCO2
Describe the relationship between P(A), P(a), and P(v) in zones 1, 2 and 3 of the lungs:
Note: in all cases P(a) > P(v) –> the only thing that changes in P(A) from Zone 1 to Zone 3
- Zone 1 (apex/top of lungs –> air rises): P(A) > P(a) > P(v)
- Zone 2 (middle of lungs): P(a) > P(A) > P(v)
- Zone 3 (bottom/base of lungs –> blood sinks): P(a) > P(v) > P(A)f
In performing the McMurray maneuver for a meniscal tear, how do you know if the tear is medial or lateral?
LIME:
- Pain on Internal rotation = Lateral meniscus
- Pain on External rotation = Medial meniscus
Which three ligaments are injured in the “unhappy triad”?
An unhappy triad is a common injury in contact sports in which a lateral force applied to a planted leg damages the:
- MCL
- ACL
- MM
Where is specifically in the cell dies steroid synthesis take place?
In the smooth endoplasmic reticulum
Which enzyme and which cofactor are implicated in maple syrup urine disease?
- Enzyme: branched-chain alpha-ketoacid dehydrogenase
- Cofactor: thiamine (Vit. B1)
What are the findings in homocystinuria?
HOMOCYstinuria:
- Increased Homocysteine in urine
- Osteoporosis
- Marfanoid habitus
- Ocular chantes (downward lens subluxation)
- Cardiovascular effects
- kYphosis
Which enzyme is deficient in Von Gierke disease?
- Glucose-6-phosphatase –> unable to breakdown glycogen in liver, resulting in severe fasting hypoglycemia
Which enzyme is deficient in Pompe disease?
- lysosomal acid alpha-1,4/1,6-glucosidase (acid maltase)
Which enzyme is deficient in Cori disease?
- debranching enzyme (alpha-1,6-glucosidase) - limit dextrin accumulates
Which enzyme is deficient in McArdle disease?
- myophosphorylase
While most drugs exhibit first-order metabolism, which drugs show zero-order metabolism?
PEA:
- Phenytoin
- Ethanol (at certain concentrations)
- Aspirin
What are the percentages for ±1, 2, and 3standard deviations from the mean?
±1 = 68%
±2 = 95%
± 3 = 98.5%
Which neoplasm presents with cutaneous lesions, hypercalcemia and is common to Japan and Caribbean, ? Which virus causes this neoplasm?
- Adult T-cell lymphoma –> causd by HTLV
What is the mechanism of Type 1 RTA?
- Defect in H+ excretion in the DCT leads to impaired reabsorption of K+
- Urine pH > 5.5 (basic because no acid) and Hypocalcemia (because no K+ reabsorption)
- Causes: amphotericin B
What is the mechanism of Type 2 RTA?
- Impaired total reabsorption in the PCT results in low HCO3, low K+, and low phosphate (can result in hypophosphatemic rickets)
- Causes: Fanconi syndrome
What is the mechanism of Type 4 RTA?
- Hypoaldosteronism impairs the ability to reabsorb H+ leading to acidic urine (urine pH < 5.5) and hyperkalemia
What is the presentation of serotonin syndrome?
The three “A’s”
- hyperActivity (clonus, hyperreflexia, hypertonic, seizures)
- Autonomic stimulation (hyperthermia, diaphoresis, diarrhea)
- Agitation
