March 19 Flashcards
Fidaxomicin
Treatment for c. diff
macrocyclic antibiotic that inhibits the sigma subunit of RNA polymerase –> CIDAL
coverage more narrow than metro or vanc
First Dose Hypotension
ACE Inhibitors (-prils)
Significant hypotension due to loss of vasoconstricting effects of AngII
especially seen in volume depleted pts, like those taking diuretics
Tissue Hypoxia
increase in intracellular NADH causes decreased pyruvate dehydrogenase activity and shunting of the pathway towards Lactate production by LDH
Essential Fructosuria
aka Benign Furctosuria
Defect in Fructokinase causes consumed fructose to be peed out unchanged
Primary CNS Lymphoma
EBV
AIDS and Immunosuppressed
PE effects of ABG (arterial blood gas)
PE causes V/Q mismatch
hypoxemia –> increased respiratory drive –> hyperventilation (which doesn’t improve blood oxygenation)
blow off the CO2 without taking up enough O2
decreased PaCO2 and respiratory alkalosis
bicarb is unchanged acutely
Mitral Stenosis
Rheumatic Fever
low-pitched diastolic rumble at the apex
can cause hemoptysis due to occlusion at mitral valve and resultant high pulmonary pressure
Peutz-Jeghers Syndrome
Autosomal Dominant mutation in STK11 on Chr 19
pigmented mucocutaneous macules (freckles on the lips) and hamartomatous polyps in GI
symp: abd pain, GI bleeds, obstruction
Liposarcoma
Scalloping of the nuclear membrane
Pemphigus vulgaris
autoantibodies to desmogleins
flaccid bullae
+ Nikolsky
see Ig deposition between keratinocytes
intercellular IgG andC3 in ‘chicken wire’ pattern
Bullous pemphigoid
tense bullae with IgG deposition at Basement Membrane
- Nikolsky
like a bull frog
Pancoast Tumor
Apical bronchogenic carcinoma that invades brachial plexus –> clumsy limb
compresses cervical ganglion –> Horner syndrome (miosis, ptosis, anhidrosis)
anisocoria = unequal pupils, like in Horners Syndrome
ADR of Lithium
Nephrogenic DI
dysfunction of the collecting tubules - do not respond to ADH/ddAVP
Hypertrophic Cardiomyopathy
LV and septum hypertrophy
LW outlet obstruction
ischemia due to immense thickness of myocardium
coronary arteries normal
S2 Heart Sound
@ closure of Aortic (A2) and Pulmonic (P2) valves
inspiratory split due to delayed closure of pulmonic valve as blood moves ‘forward’
‘wide S2’ = splitting A2/P2 - seen with Right Bundle Branch Block and Pulmonary Stenosis - prolong RV ejection time
CD40 Ligand Deficiency
Hyper IgM syndrome
inability to class switch B-cells decreased IgE, IgA, IgG
HNPCC
Mismatch Repair Defect.
ADR Tacrolimus
Tacrolimus and Cyclosporine are Calcineurin inhibitors
NEPHROTOXIC
renal arteriolar vasoconstriction and obliterative vasculopathy, glomerular scarring
Cyclophosphamide
alkylating agent
tx: solid tumor, leukemia, lymphoma
ADR: myelosuppression
hemorrhagic cystitis - prevent with MESNA
N-acetylcysteine
liquifies mucus
tx: COPD and CF
also for acetaminophen OD (regenerates glutathione)
Cyclosporine
calcinuerin inhibitor - blocks IL-2/mTOR pathway by preventing IL-2 transcription
NEPHROTOXIC
tx: transplant and PAIR diseases
gingival hyperplasia
Metoclopramide
D2 antagonist
tx: gastroparesis and antiemetic
Contraindicated in Parkinsons
Alkaptonuria
Autosomal recessive defect in Homogentisic Acid Deoxygenase –> impaired tyrosine metabolism
urine turns black on standing
Osteoarthropathy!!
homogentisic acid accumulates in cartilage - ochronosis - gives blue/black pigment
Acute Ischemia
depletion of ATP –> dysfunction of Na/K ATPase –> increased K extracellular
Cytoplasmic accumulation of Ca++ is the hallmark of ischemic injury
Normal:
Na outside
K inside
Marfanoid Body Habitus
Marfans - normal intellect - upwards lense dislocation (looking up at Mars)
Homocysteinuria - Intellectual Disability + Thrombosis - downward lens dislocation defective CBS (cystathionine-beta-synthase)
MEN2B - medullary thyroid, pheo, mucosal neuroma
DNA Polymerase
Reads 3’-5’
Writes 5’-3’
need a primer at 3’ end to amplify
Peaked T waves
Hyperkalemia
Pineal gland tumor
upward gaze palsy
absent pupillary light reflex
impaired convergence
mass effect on dorsal midbrain @ superior colliculus
buy AT 30
CCEL at 50
Aminoglycosides and Tetracyclines - 30S
Chloramphenicol, Clindamycin, Erythromycin (Macrolides), Linezolid
Fluoroquinolones
inhibit DNA gyrase -floxacins
moxi/ciprofloxacin
tendon rupture
Lactase deficiency
expression of lactase genes declines with age
Kluver-Bucy Syndrome
Lesion of the amygdalae
loss of anger and fear
disinhibition –> inappropriate sexual activity, oral fixation, hyperphagia, placidity, amnesia
associated with HSV-1 encephalitis
Tardive Dyskinesia
longterm use of D2 blockers –> upregulation of DA receptors
rhythmic movements of face/lips/tongue + choreoathetoid movement of trunk and extremities
associated with 1st gen antipsychotics
switch tx to clozapine and quetiapine
Saddle embolus
decreased CO
increased SVR - systemic vascular resistance
increased Central Venous Pressure
Polio Vaccine
Live = Sabin = Oral
gives IgA and IgG immunity
can become virulent :(
Killed = Salk = IM
IgG only
cannot revert to virulence
Functions of Radial Nerve
extensor of elbow, wrist, and fingers
supination of forearm
abduction of thumb
sensory to posterior arm/forearm
radial revs the motorcycle
radial injury give wrist drop
Adenovirus
dsDNA virus, naked causes URIs
replicates via DNA-dependent DNA polymerase in the nucleus
pink eye, pneumonia, tonsilitis, URI, hemorrhagic cystitis
Rabies
Negri bodies - esosinophilic round cytoplasmic inclusions in the hippocampus
Renal Artery Stenosis
Afferent arteriole Dilation
Efferent arteriole constriction to maintain GFR
so RBF decreases MORE than GFR
FF = GFR/RBF, this gets bigger!
Synergy of Beta-Lactams and Aminoglycosides
Beta-lactams like penicillin disrupt the cell wall and allow aminoglycosides to get IN. and target 30S
Membranous Nephropathy
most common Nephrotic in Adults
LM w/ Jones methenamine silver stain –> thickened GBM
capillary loops are thickened and have ‘spike and dome’ due to subepithelial immune complex deposition
Metastasis of Colorectal Cancer
Distal rectum and anus drain to internal iliac veins –> caval system –> mets to LUNGs
above dentate line –> superior rectal vein –> portal system –> LIVER mets
Xerosis
winter itch - itchy rash dry cracked skin in old people during the winter - put on lotion
Insulin
increases Fructose-2,6-bisphosphate and activates PFK-1 –> glycolysis
Glucagon
decreases Fruc-2,6-bisphos –> gluconeogenesis
Basic Amino Acids
Histadine
Arginine
Lysine
“HAL is so basic”
Acidic Amino Acids
Aspartate and Glutamate
Nonpolar Amino Acid
Alanine Phenylalanine Valine Leucine Isoleucine Tryptophan Methionine Proline Glycine
Probenecid
inhibits renal tubular secretion of penicillin via blockade of the Organic Anion Transporter OAT
UV DNA damage
thymine dimers
repaired with Nucleotide Excision Repair
defective in: Xeroderma Pigmentosum
AR
huge risk for cutaneous malig
Follicular Lymphoma
t(14:18)
increased Bcl-2 –> increased inhibition of apoptosis
waxing/waning LAD
small lymphocytes with cleaved nuclei
What is in a Neurofibroma?
Schwann Cells and Fibroblasts
Complication of Endometriosis
Infertility due to scarring
Paclitaxel
Microtubule inhibitor blocks @ Mitosis M
same family as Vinblastine and Vincristine
used in stent platelet to inhibit cell division and prevent intimal hyperplasia –> stent restenosis
Increased Urinary Orotic Acid
Ornithine Transcarbamoylase Deficiency.
congenital hyperammonemia
Consequence of impaired hydroxylation of collagen
abnormal triple-helix formation
need to hydroxylate and glycosylate for triple helix
Transduction
bacterial host DNA mistakenly packaged into bacteriophage –> transmitted to another bacteria and integrated into host DNA
generally @ LYTIC infection (lysis of infected cell)
Uncal Hernitation
CN III lesion
fixed and dilated pupil on ipsilateral side
due to head trauma
temporal love under tentorium cerebelli
Somatic Symptom Disorder
Real symptom that causes disproportionate stress/disruption of daily life
OCD about 1 tiny problem - excessive persistent thoughts about symptom(s)
Korsakoff Syndrome
Memory impairment with CONFABULATION
confabulation = unintentional fabrication of memories (pt believe the lies are true)
thiamine deficiency in alcoholics
Mismatch Repair Defect
HNPCC
increased micro-satellite instability –> increased cancer incidence
Early signs of hypokalemia
fatigue
myalgia
muscle cramp
weakness
U waves at EKG
Acute Respiratory Distress Syndrome
diffuse damage to lung parenchyma causes air spaces to fill with fluids
increased dead space
right-to-left shunting
hypoxemia and hypercapnia
Site of Femoral Nerve Block Injection
Inguinal Crease
at lateral border of femoral artery
ACEi and Renal Perfusion
AngII - constricts efferent arteriole
(up at low blood volume, restores GFR)
ACEi reduce AngII - efferent arteriole DILATION
(reduces GFR)
Rhomboid-shaped crystals
calcium pyrophosphate crystals
but also
uric acid stones
Hexagonal stones
cystine stones (6stine, have 6 sides)
seen @ cystinuria
defect in PCT, cannot resorb
C - cystine
O - Ornithine
L - Lysine
A - Arginine
Coffin lid stones
Ammonium magnesium phosphate
caused by infection with urease +
Saph saprophyticus, Klebsiella, Proteus
precipitate at increased pH - alkaline urine
form staghorn calculi
Parotitis
Inflammation of the Parotid
generally caused by Staph aureus
symp: firm, erythematous pre/post auricular swelling
dx: elevated amylase without pancreatitis (normal lipase_
risk factors: dehydration, intubation, anticholingerics (decreased salivation), dental work
Buspirone
5-HT1a receptor agonist
Anxiolytic
tx: generalized anxiety disorder
does NOT interact with alcohol
SLOW onset of action takes 1-2 for effect
Von Hippel-Lindau Disease
mutation at VHL tumor suppresor gene on Chr 3
hemangioblastoma (@cerebellum and retina)
Renal Clear Cell Carcinoma
Pheochromocytoma
cysts in the kidneys and pancreas
Fetal Hemoglobin
Left shit in the oxygen dissociation curve
like decreased 2,3-BPG
made of 2alpha2gamma
Kayser-Fleischer rings
Wilson’s Dz
brownish gray-green rings of Cu deposition in the Cornea
Lisch Nodules
hamartomas in the iris
NF-1 on chr19
Fibroadenoma
estrogen-sensitive benign breast tumor in young women
solitary, nontender, firm, well-demarcated, spherical nodule
Melanoma
irregular nuclear contours, hyperchromasia, and round/spindle shape
commonly due to mutation of CDKN2A on Chr9p21 - dysregulation of the cell cycle
Basal Cell Carcinoma
islands of basaloid tumor cells budding from epidermis or within dermis + nuclear palisading
Telencephalon
Cerebral hemispheres and lateral ventricles
Diencephalon
thalamus and 3rd ventricle
Mesencephalon
Midbrain and aqueduct
Metencephalon
pons, cerebellum, upper 4th ventricle
Myelencephalon
Medulla and lower 4th ventricle
Rhombencephalon
Metencephalon + Myelencephalon
all of brainstem except midbrain
Prosencephalon
Telencephalon + Diencephalon
all of cerebral cortex
Leucine Zipper
transcription factor composed of 2 alpha helix that form a dimer
basic amino acids + Leucine every 7th
Hodgkin Lymphoma
Reed-Sternberg cells - ‘owls eyes’
large cell with abundant cytoplasm, bilobed nucleus, prominent eosinophilic nucleoli
painless LAD
B symptoms
Where are nucleotides synthesized?
the cytoplasm
p57 staining
indicates expression of maternal DNA
(paternal p57 is imprinted and silenced)
for differentiation of partial vs complete moles
complete is all paternal, no p57
Primary HyperPTH
most common = Parathyroid Adenoma
“painful bones, renal stones, psychiatric moans, abdominal groans”
hypercalcemia, depression, fatigue, cardiac valve calcifications
Esophageal hiatus
esophagus, anterior and posterior trunks of VAGUS
@T10
Aortic Hiatus
aorta, thoracic duct, and azygos vein
Amlodipine and Nifedipine
lower systemic blood pressure vasodilating at arterioles –> decreased afterload –> decreased stroke volume –> decreased blood pressure
Glucokinase
liver and pancreatic beta cells
good for post-prandial uptake of glucose
mutated in MODY
high Km and Vmax than Hexokinase
van Gierke Disease
Deficiency with Glucose-6-phosphatase
hepatomegaly
fasting hypoglycemia
lactic acidosis
hyperuricemia hyperlipidemia
cannot do gluconeogenesis
“fructose syrup results in lactic acidosis without increase in blood glucose)
McArdle Disease
Deficiency with glycogen phosphorylase
weakness and fatigue
no rise in blood lactate after exercise
myoglobinuria
Pontine hemorrhage
pinpoint pupils
loss of horizontal gaze
quadriparesis
decerebrate posturing = extended upper and lower limbs
–> coma –> death.
Reactive Arthritis
Can’t see = conjunctivitis
Can’t pee = urethritis
Can’t climb a tree = asymmetric oligoarthritis
Chlamydia trachomatis
or GI infection - salmonella, shigella, campy, yersinia
What makes bruises look green?
heme –> biliverdin via heme oxygenase
Blood flow to retina
internal carotid –> ophthalmic –> retinal Artery
statistic used to compare mean of 2 patient groups?
Two-sample t test
Thrombocytopenic thrombotic purpura - hemolytic uremic syndrome
TTP-HUS
pentad:
platelet activation in arterioles and capillaries
diffuse microvascular thrombosis (@ brain, kidneys, heart)
microangiopathic hemolytic anemia with schistocytes
thrombocytopenia
lethargy, renal failure, anemia, thrombocytopenia, @ GI illness
Small cell lung carcinoma
clusters/sheets of small ovoid cells with scant cytoplasm and high mitotic count
neuroendocrine tumor
+ chromogranin
+ synaptophysin
centrally located mass associated with smoking
increased ADH, ACTH
Giant cell Temporal Arteritis
granulomatous inflammation of the media
polymyalgia rheumatica - achy pain in shoulder and hip - seen in 50% of pts
Nitroprusside
balanced venous and arterial vasodilator
decreased LV preload and afterload
lowers LV end diastolic pressure (preload)
lowers mean systolic intraventricular pressure (afterload)
SV maintained
Tx for combined absence and tonic-clonic seizures
Valproate
measure LFTs - can cause fatal hepatotoxicity
also GI distress, NT defects, pancreatitis, wt gain
increases Na channel inactivation, increases GABA
soft crescendo-decrescendo systolic murmur at apex of left sternal border
LV outflow obstruction (due to HCM)
avoid: vasodilators [DHPR Ca channel blockers and nitro] (decreases afterload and causes lower LV volumes which makes obstruction worse)
diuretics - decrease LV venous filling = preload, makes it worse
Bartonella henselae
“cat-scratch disease’
vesicle –> erythematous papule –> LAD
esp axillary LAD
bacillary angiomatosis - benign capillary skin papule often mistaken for Kaposi but has neutrophils - in immunocompromised pts (CD<500)
Pneumococcal vaccines
Provide immunity to strep pneumo polysaccharide capsule
Polysaccharide Pneumovax - not strongly immunogenic in children, covers 23 strains, only last ~5years - no mucosal immunity
Conjugate Prevnar -conj to diphtheria protein more efficacious in children and elderly , better immunogenic memory (memory B-cells)
Acute Interstitial Nephritis
associated with fever, rash, hematuria, azotemia, and CVA tenderness
Hypersensitivity to Drugs that make you Pee (diuretics) Pain-free (NSAIDS) Penicillins and cephalosporins PPIs rifamPin
affects renal interstitium –> edema and WBC recruitment
Galactokinase Deficiency
less severe than galactose-1-posphate uridyl transferase (presents in neonate with vomiting, lethargy, failure to thrive)
cataracts and reducing substances in the urine
cataracts due to accumulation of galactitol in lens
CO Poisoning
increase in Carbodyhemoglobin
no change in methemoglobin
no change in PaO2
left shift in HgB O2 dissociation curve - poor tissue offloading
LTC4 LTD4 LTE4
involved in pathogenesis of Allergic Asthma
cause bronchial constriction, mucosal edema, mucus hypersecretion
synthesized by mast cells, eosinophils, and basophils
receptor antagonists: zafirlukast, montelukast
Methadone
mu-opiod receptor agonist with a LONG hlaf life
good for treatment of opiate addiction
Thiazide diuretics
Work at Distal Convoluted Tubule
block Na/Cl symporter
ADR: metabolic alkalosis, hypoK+
hyperglycemia
hyperuricemia
hyperlipidemia
hypercalcemia (with low PTH)
Holosytolic murmurs
Tricuspid Regurg - increased in intensity with inspiration @
Mitral Regurg - high pitched @ apex, best heard in left lateral decubitus
VSD - best heard at left sternal border @ 3/4 intercostal space
Right-sided colon cancers
Ascending colon cancers
bulky, increased bleeding –> iron deficiency anemia
Left-sided colon cancers
Descending colon
smaller, infiltrate colon wall, narrow lumen –> obstruction, distension, nausea, vomiting
Differential cyanosis and clubbing
Affects lower extremities > upper
without discrepancy of pulse pressures (no coarctation of aorta) = PDA
PDA! - Eisenmenger syndrome
Schizophreniform Disorder
symptoms of Schizoprenia for 1-6 months
delusions, hallucinations, disorganized speech/behavior, social withdrawal
Congenital Rubella
microcephaly
cataracts (white pupils)
deafness (sensory-neural)
PDA and pulmonic stenosis
preventable; all women of child bearing age should get the Live Attenuated Vaccine!
kids also get it at 12-15mo and 4-6 years
Rubella is a Togavirus, +ssRNA linear enveloped
Parvovirus B19
naked linear ssDNA virus
‘slapped cheek’ rash after prodrome of malaise, congestion, HA, fever
replicates in RBC precursors in the bone marrow
can cause aplastic crisis, esp in beta-thalssemia, Hereditary spherocytosis, and HbS
Zenker Diverticulum
due to cricopharyngeal motor dysfunction
oropharyngeal dysphagia w/ feeling of obstruction
food gets stuck in the pouch –> halitosis
flame-shaped hemorrhages
severe HTN
Enlarged coronary sinus
elevated Right Heart pressures secondary to Pulmonary Hypertension
Blocks peripheral conversion of T4 –> T3
Beta-blockers
PTU (propylthiouracil)
Ipodate (contrast agent)
Carcinoid Syndrome
neuroendocrine cell proliferation
increased 5-HT and 5-HIAA (5-hydroxyindoleacetic acid)
diarrhea, cutaneous flushing, asthmatic wheezing, tricuspid regurg/pulmonic stenosis, pellagra (niacin deficiency due to increased tryptophan –> 5-HT)
Octreotide to relieve symptoms before
ACEi contraindicated in?
Bilateral Renal Artery Stenosis
angII constricts efferent arteriole
decreased AngII –> dilated efferent arteriole –> decreased GFR :(
Effects of DA at various doses
Low: increased GFR, RBF, and Na excretion
Medium: beta1 activity –> increased contractility, pulse pressure, systolic BP
High: alpha1 activity –> increased afterload and decreased CO
Variant Angina
due to coronary vasospasm - transient seemingly unprovoked angina
provoked by: dihydroergotamine, cigarette smokes, cocaine, amphetamines, triptans,
Complications of Rheumatoid Arthritis
cervical spine joint destruction –> subluxation of cervical vertebrae (at endotracheal intubation)
Complication of Warfarin Therapy
Skin necrosis - esp in pts with Protein C and Protein S deficiency
protein C has a short half-life, leads to a transient hypercoag state in first few days of warfarin therapy
Cytokeratin
epithelial cell marker
Active SLE
consumption of complement and REDUCED serum complement
Segmented Viruses
orthomyxo, bunya, arena, rota, reo
capable of reassortment
Typical Cardiac Chamber pressures
RA: 2-10
RV: 2-25
Pulm Artery: 10-25
Wedge: ~10
