NBME 15-1, And UWORLD mix Flashcards
External hemorrhoid
Looks like a brown poop ball on anus. Very painful. They tried to trick with HPV warts, anal fissure, and anal carcinoma.
Radiolabeled Iodide toxicity antidote
Potassium iodide
DM II neurological pain type
Burning. They tried to trick by saying he had decreased sensation to pinprick when DR poked him.
Non-symptomatic man - stressed - jaundice
Gilbert syndrome
Deoxygenated blood and its affinity for oxygen and carbon dioxide
Deoxyhemoglobin is a better buffer of hydrogen ions than oxyhemoglobin
Protease deficiency aka EMPHYSEMA (OBSTRUCTIVE LUNG DISEASES) Others: * chronic bronchitis - blue bloater * asthma * bronchiectasis
Progressive shortness of breath.
Trick: smoked marijuana 8 years when younger.
Diffuse wheezing
Mild hepatomegaly
CXR lung hyperinflation - air trapping (dec FEV1)
Decreased diffusing capacity
IFN-y deficiency AKA IL-12 receptor deficiency = decreased Th1 response. Autosomal Recessive.
Disseminated mycobacterium and fungal infections.
Child, Diarrhea - 2 weeks, lymphadenopathy
Lymph biopsy - histiocytes and numerous segmented neutrophils
No granulomas
Hx: numerous acid-fast bacilli - Mycobacterium Avium-intracellulare
Normal IgA, IgG, IgM, B and T lymphocytes, and normal CD4 and CD8 T lymphocytes.
Woman - frequent thirst and urination. 7 lb wt loss. Dehydration and tachypnea. Glucose - 330 mg/dL. 2+ ketones. 7.2 pH
Given fluids and insulin and she feels better.
What liver enzyme is increased after administration of insulin?
Glucokinase
What does glucokinase do?
Defects of cleft lip and palate, micrognathia, and glossoptosis are consistent with altered development of which pharyngeal arch?
First pharyngeal arch
HMG-CoA reductase - inhibits cholesterol synthesis by blocking HMG-CoA to Mevalonate [> Cholesterol].
It upregulates what protein/enzyme?
LDL receptor
Woman - 24 - acute pain, LLQ
CBC - leukocytosis /w increased HCG
Gross pathology shows photo of excised ovary and kidney bean inside.
Likely diagnosis?
Ectopic pregnancy
Diagnosis + Psychology -
Old man - abdominal pain, 20 lb wt loss. Jaundice. Dr. Tells old man he has a mass on head of his pancreas /w “EXTENSION” to stomach and biliary system. (Metastasis)
Pt is likely to develop what disorder?
Major Depressive Disorder. Pancreatic cancer has a very short life expectancy once diagnosed.
Man - 59 - 2 wk dyspnea,cough,fatigue. Lungs clear auscultation. 12 respiration’s/min
Hb - 11.8 HCT - 36% Leukocytes - 146,000 47% neutrophils Platelet count - 804,000
Appropriate treatment?
Imatinib
What does this pt have?
Mechanism of imatinib?
What are adverse effects of imatinib?
What else is imatinib used for?
Woman - 32 - 6 months increased urinary frequency and thirst.
History /w bipolar disorder tx with Lithium.
Serum sodium concentration 154
Urine osmolality - 180
Most likely has abnormal function of?
Proximal consulates tubule.
What is wrong with her?
Woman - 75 - temp 103, back pain for 1 day
111 bpm/tachy
32 respiration’s/min
115/79 BP
Left sided costovertebral angle tenderness
CBC - leukocytes @ 17,000 (9% bands) and pyuria
Urine cultures - E.Coli
Fever - IL-1 produced during immune response induced IL-6 high fever.
Describe role of IkB in nuclear-factor-kappa B (NF-kB) signal transduction pathway from IL-1 binding to IL-6 induction in the pt?
Release NF-kB after undergoing phosphorylation
What is this pathway?
Dr. Designing study to compare new behavioral program for ADHDi vs old/standard behavioral modification program for ADHD.
Boys and girls are randomized into the two treatment groups separately. What type of treatment allocation is being used in this study?
Stratification
What is stratification?
Pt. /w Calcium Stones Tx?
Ammonium-magnesium struvite stones tx?
Uric acid stones (rhomboid) tx?
Cystine (hexagonal)?
Thiazides, citrate, low sodium diet
Low sodium diet and thiazides
Underlying infection and removal of staghorn by surgery
Low sodium diet, alkalinization of urine, cheating agents if refractory
Diabetes HTN 1st line?
AT2 inhibitors or ACE inhibitors
AT2 I- sartans
ACE I - Prils
Increases potassium
Decreases GFR
Decreases BP
Teratogenic
Which diuretics behave antiproteinuric effects that are independent of their effects on systemic blood pressure?
ACE inhibitors and AT2 Recetpr blockers
Urinary acid excretion
NH4 and titratable H2PO4. Metabolic acidosis - urinary pH decreases due to increased excretion of H, NH4, and H2PO4. ALL BICARBONATE IS REABSORBED TO TRY TO RETURN BODY TO HEMOSTASIS
What two things does Aldosterone stimulate reabsorption of?
Primarily regulates serum osmolality; also responds to low blood volume states. Stimulates
reabsorption of water in collecting ducts. Also stimulates reabsorption of urea in collecting ducts to
maintain corticopapillary osmotic gradient.
What is a ADH (Vasopressin analog?)
Desmopressin
A patient with hypertension and hypokalemia that has
Increased renin
Increased aldosterone
Diagnosis?
Secondary hyperaldosteronism caused by:
- Renovascular hypertension
- Malignant hypertension
- Renin-secreting tumor
- Diuretic use
Hypertension /w hypokalemia causes /w…
Decreased renin
Increased aldosterone
Primary hyperaldosteronism
- Aldosterone producing tumor
- Bilateral adrenal hyperplasia
Causes of hypertension with hypokalemia when…
Decreased renin
Decreased aldosterone
Non-aldosterone causes:
- Congenital adrenal hyperplasia
- Deoxtcorticosterone-producing adrenal tumor
- Cushing syndrome
- Exogenous mineralocorticoids
Where is the majority of water reabsorbed in the kidney?
Proximal convulsed tubule - Descending limb.
LOOP OF HENLE IS WRONG ANSWER.
What affects the amount of water absorption in the late distal consulates tubule and COLLECTING DUCT?
Increased water reabsorption in presence of ADH
Decreased water reabsorption in absence of ADH
What segment of the collecting duct does ADH increase urea and water reabsorption?
Medullary distal collecting duct
Potassium reabsorption
100 - BC, 35% PCT, 10% DLOH, 110% CD
Most of K+ filtered by glomeruli is resorted in PCT and LOH.
The primary sites of regulation are the late distal and cortical collecting tubules.
K+ depletion stimulates alpha-intercalated cells to reabsorbed extra potassium; principle cells secrete K+ under conditions of normal or increased K_ load.
A patient with diabetic ketoacidosis has acidic pH and low serum bicarbonate. PaCO2 also decreases as a result of respiratory compensation for primary metabolic acidosis.
Sx:
1. Hyperosomolality (water loss)
2. Na+ loss with water, K+ also
3. Lipolysis > ketogenesis > metabolic acidosis > K+ shift out of cell > norms or hyperkalemia
1st line tx of choice?
Intravenous saline and insulin.
It increases serum bicarbonate and sodium and decreases serum glucose, osmolality, and potassium.
Differential diagnosis of metabolic alkalosis. What is the next best method in diagnosing?
Once met. Alk is determined next best test to run is urine chloride to rule out vomiting/aspiration/prior diuretic or current diuretic use which are both responsive to saline.
Hypervolumemia /w high urine chloride is caused by excess mineralocorticoids activity (cushings, ectopic ACTH, and primary hyperaldosteronism)
What type of hypersensitivity reaction is Post-Strep Glomerulnephritis?
What is the mechanism of damage?
Antigen-antibody immune complexes, activation of complement and cellular components are neutrophils.
Ex’s: serum sickness, SLE
Fever
Maculopapular rash
Acute renal failure 1-3
weeks post rx of a medication (ampicillin) in this case
(Antibiotics and proton pump inhibitors)
Peripheral eosinophilia Sterile pyuria Eosinophilia White blood cell casts (+/-) Histology: leukocyte infiltration and edema of renal interstitium.
DX?
Acute interstitial nephritis
Calcium oxolate crystals in a homeless man
Px: found unresponsive. Given IV fluids, condition improves and flank pain is noted. Renal biopsy showed ballooning and vacuolar degeneration of proximal renal tubules with multiple o slate crystals in tubular lumen.
Causes?
This patient (homeless) most likely drank some ethylene glycol (antifreeze)
Other causes include:
Vitamin C abuse, hypocitraturia, malabsorption (Crohn’s disease)
Tx: thiazides, citrate, low sodium diet.
Alpha-3-chain of type IV collagen antibodies are seen in what syndrome? (Hint: Also known as anti-GBM antibodies)
Goodpastures syndrome -
Rapidly progressive glomerulonephritis -
Presents similar to Wegners which fortunately is also RPGN
Mouth, lungs, kidneys!
3 week SOB, cough, hemoptysis /w upper respiratory tract infection
150/85 BP. No fever. HR normal.
Urine - proteinuria, hematuria /w dysmorphic RBCs (casts)
CXR - bilateral pulmonary infiltrates.
Increases carbon monoxide diffusing capacity (DLCO) on pulmonary functioning tests
CXR scan shows both kidneys. One shrunken. Pt male - 64 yo presents with HTN.
Answer choices are A-Z. Contrast in kidneys showing
Renal artery stenosis
Linear IgG and C3 deposits on immunoflourescence?
Goodpastures syndrome - RPGN
Discrete subepithelial humps on electron microscopy
Lumpy bumpy granular deposits on IGG and C3
Enlarged, hypercellular glomeruli open light microscopy
PSGN
Multiple myeloma PTH - inc or dec Urinary Ca+ - inc or dec 1,25-vit D - inc or dec PTH-related protein - inc or dec
Decrease
Increase
Decrease
Normal
If an organism is negative for nitrites
Gram positive
If an organism is gamma-hemolytic
It doesn’t do hemolysis and its either S. Bovis- sensitive to 6.5% NaCl
Or enterococcus species (fascism or faecalis) and can grow in 6.5% NaCl)
*pyrrolidonyl amylamidase positive
All grow in bile.
PSGN immunoflourescense. The green deposits that are immunoflourescent represent what most likely?
C3b deposits
The net secretion of substance A:
Insulin - 100
PAH - 500
Plasma concentration Substance A - 0.5
Tubular resorption of substance A - 25
100/0.5 - 25 = 25 mg/min
Net excretion of A = (inulin x plasma concentration of A) - tubular reabsorption of A
Potassium normal
Calcium low
What are serum levels and hormone levels of
Phosphate
Parathyroid hormone
Calcitriol
Increase
Increase
Decrease
Efferent constriction does what to GFR and FF?
Increase
Increase
What is posterior to the ureter?
What is anterior to the ureter?
Internal iliac artery
Uterine artery or Vas Deferens lie anterior.
Ureter being the WATER under the bridge.
Metanephros - derivatives form?
1) ureteric bud -
2) metanephric mesenchyme -
Metanephros - derivatives form?
1) ureteric bud - ureter, pelvises, calyces, collecting ducts
2) metanephric mesenchyme - glomerulus > DCT
Ureteropelvic junction - last to canalize and most common site of obstruction. Can lead to what detectable problem on prenatal ultrasound?
Hydronephrosis
Mesonephros derivatives?
Interim kidney during 1st trimester and most importantly the males genital system
Pronephros -
Week 4 > degenerates. Useless.
Acute transplant rejection of kidney
Increased serum creating
Lymphocytic infiltrate of vessels, tubules, and renal interstitium.
Hypertension
Reduced urine output - oliguria
Can be cell mediated or antibody mediated cell responses.
Acute immunosuppressants are tacrolimus and cyclosporine
Minimal change disease in a child - aka lipoid nephrosis -
Nephrotic syndrome: Massive proteinuria Hypoalbuminemia > edema Hyperlipidemia Frothy urine /w fatty casts
Due to damage to glomerular filtration charge barrier
primary = podocytes
Secondary = systemic damage to podocytes (diabetes)
Minimal change disease occurs post infection, immunization, or immune stimulus IE insect bite
Primase of DNA Replication cycle AKA RNA PRIMASE does what?
It lays down the RNA Dick in which DNA Polymerase III Pussy sits on to create RNA Babies
Renal osteodystrophy - complication the book mentions in good detail about chronic kidney disease. What is its mechanism?
CKD > dec. GFR > decreased vit D/dec Ca+ and dec phosphate filtration.
This increases PTH to get rid of phosphate < ostentatious fibrosis cystica
AKA secondary hyperparathyroidism
Potassium sparing diuretics aka aldosterone receptor antagonists do what
The inhibit the effects of aldosterone which is a component of the renin-angiotensin-aldosterone system that acts on the principal and intercalated cells of the renal collecting tubules causing resorption of water and sodium and loss of potassium and hydrogen ions.
Most cutanous lymph from the umbilicus down, including the external genitalia and anus (below dentate line) go to he superifcial inguinal nodes. This patient had a mass in his right groin. (They did not say it was cutaneous, that’s how they tricked me). Three weeks go by and a new mass comes in area of lymph nodes palpate at right inguinal area inferior to inguinal ligament. Where did the cancer originate?
Orifice of anal canal.
Exceptions are the glans penis and posterior calf which drain to the deep inguinal, nodes.
Myoglobin affinity for oxygen vs hemoglobin
Myoglobin has a much higher affinity for oxygen than does hemoglobin so that it may take oxygen from blood and take it to tissue it needs. Hemoglobin has a much higher affinity for CO2 than O2 (for gas exchange in lungs).
AML presentation and treatment:
Epistaxis and gum bleeding. Mucosal pallor. Colonial proliferation of white blood cells containing an abnormal protein. Proliferation was inhibited in an experiment using ATRA (retinol)
Dactylitis (painful swelling of hands and feet) is a sign of Sickle Cell anemia in young children. Suckling episodes result in hemolysis which leads to increased indirect bilirubin and lactate dehydrogenase and decreased levels of what?
Haptoglobin
Veganism, Crohn’s disease, gastrectomy, fish tapeworm, alcoholic
B12 deficiency - macrovalocytes /w +6 lobed neutrophils
Woman/teenager of childbearing age - MCC? Even if she is a vegan?
Iron deficiency secondary to menstrual blood loss.
Decreased ferritin
Increased transferrin
Microcytic hypochromic RBCs
Activation of a non-receptor tyrosine kinase protein in hematopoietic cells leading to persistent activation of signal transducers and activators of transcription (STAT) proteins.
This can be any of the myeloproliferative disorders:
- Polycythemia Vera - increased RBCs, itching, ERYTHROMELALGIA (burning) and clotting of fingers/extremities
- Essential thrombocythemia - increased # megakaryocytes, increased # platelets, bleeding and thrombosis. ERYTHROMELALGIA
- Myelofibrosis - Increased fibroblast activity - massive splenomegaly, bone marrow dry tap, teardrop RBCs
- CML - philidelphia chromosome - t(9:22) BCR-ABL fusion protein. Splenomegaly, leukocytosis with marked left shift (myelocytes, metamyelocytes, band forms)
Glioblastoma multiforme
40-70 YEARS OLD
Astrocyte cell origin
Frontal and temporal lobes, basal ganglia. Commonly crosses midline (butterfly distribution)
Central necrosis and vascular proliferation. (Remember to look for absence of nucleus). Small round cells, bizarre giant cells, large number of mitoses.
Headache, seizure, mental status change, focal neurological symptoms. Highly malignant. Duh.
24 yo F, heavy menstrual periods, frequent nosebleeds as a child, MCV 72, hemoglobin 9.2. Diagnosis?
She has vWF deficiency - lifelong history of mucosal bleeding, including gingival bleeding, epistaxis, and or menorrhagia. The patients have normal platelet levels but typically have prolonged bleeding time due to impaired platelet functioning. Can be treated with desmopressin.
What does vWF normally bind to?
Collagen (endothelial energy) beneath endothelium lies collagen normally. Think about how i saw the slides of sloughing off epithelium with a thin layer of collagen followed by another layer of epithelium beneath the collagen.
Prospective cohort study
Selecting a group of individuals (cohort) - eg; 400 women, smokers vs non smokers.
Determine their exposure status, and then following them over time for development of disease of interest.
Desmopressin therapeutic effect for stopping bleeding?
Releases circulating factor VIII and vWF from endothelial cells. It is treatment for mild hemophilia A and Von willibrand disease.
Also used in central diabetes insipidus and nocturnal eneuresis - binds to V2 receptors in renal tubular cells, leading to increased aquaporin channels, increased water reabsorption and decreased urine output.
Cure for folate - b9 deficiency?
Also how does it present?
Megaloblastic anemia. Cells commit apoptosis. Found to be increased in homocysteine and normal methylmalonic acid. Supplementation of thymidine dimine is curative.
Vitamin b12 is a necessary cofactors for methionine synthase, the enzyme that transfers a methyl group from 5-m-THF to homocysteine, forming methionine and regenerating THF. Cobalamin defiency can cause folate to become trapp[ed in 5-m-THF, resulting in secondary folate defiency. However b12 supplementation would not be significant benefit in this experiment as the primary folate deficiency prevents synthesis of THF in the first place.
Encapsulated bacteria? ~ threat to asplenic/HbS sickle cell patients?
Encapsulated (Please SHINE my SKiS): Pseudomonas aeruginosa, Streptococcus pneumoniae, Haemophilus Infuenzae type b, Neisseria meningitidis, Escherichia coli, Salmonella, Klebsiella pneumoniae (I) Group B Streptococcus
PPP consists of oxidative (irreversible) branch, and can function independently based on cellular requirements. Transketolase, an enzyme of the nonoxidative branch, is responsible in part for the inter conversion of r-5-p (nucleotide precursor) and f-6-p (glycolysis intermediate)
Transketolase is essential for conversion of f-6-p to r-5-p
Rasburicase - drug used for what?
Rasburicase
MECHANISM
Recombinant uricase that catalyzes metabolism of uric acid to allantoin.
CLINICAL USE
Prevention and treatment of tumor lysis syndrome.
Sickle cell anemia is a change of glutamic acid to valine. But what does that create clinical difficulty?
HbS allows hydrophobic interaction among hemoglobin molecules - and results in HbS polymerization and erythrocyte sickling. The hydrophobic pocket formation on the beta globulin surface allows for interaction with a complementary non polar residue on another hemoglobin molecule.
Heparin antidote?
Protamine
Blasts with auer rods in a 64 yo male?
AML
Hepcidin is an acute phase reactant synthesized by the liver that acts as the central regulator of iron homeostasis. It…?
Inhibits iron storage and transport in blood during infection and high iron levels. It promotes production of ferritin and transferrin in low iron conditions.
Ferritin is a transmembrane protein that transfers intracellular iron to the membrane for circulation to be picked up by transferrin.
Hemolytic anemia precipitated due to infection in a baby who has G6PD defiency. What energy transport mechanism is most likely compromised?
G6PD is the rate limiting enzyme of the PPP. G6PD is a common x-linked recessive disorder resulting in episodes of hemolytic anemia during times of increased oxidative stress (antimalarials, sulfonamide, infection). G6PD —> 6-phosphogluconate with enzyme that glucose-6-phosphate dehydrogenase
Most chemical carcinogens enter the body in an active state (pro-carcinogens). They are converted into active metabolites by cp-450 oxidase system. Eg. Someone with what enzyme would be more susceptible to developing benz(o)pyrene induced lung cancer. Which enzyme would that be?
Microsomaln monooxygenase. (Cytochrome P-450 monooxygenase) metabolizes steroids, alcohol, toxins, and other foreign substances by rendering them soluble and easier to excrete. This metabolic processing also converts pro-carcinogens into carcinogens capable of causing mutations in human DNA!
Lymph node follicles
B-cells
Lymph node paracortex?
T-cells
Medullary sinus of lymph node?
Reticular cells
Macrophages
Medullary cords of lymph node
Lymphocytes
Plasma B cells (mature B cells)
Healthy man with diabetes mellitus works out and runs every day and shows glucose levels of 150 resting. A1c 3.7 (very low). And Hemoglobin A2 levels 7.5 (normal 1.5-3.7) what is the reason or his hemoglobin A1c?
High Hemoglobin A2 levels are associated with B-thalassemia. Glaciated hemoglobin forms within circulating RBCs as hemoglobin A is exposed to glucose, and HbA1c levels are useful indicators of average glycemic control over the erythrocyte life-span. Hemolytic anemia on the other hand can cause falsely low HbA1c levels.
Absence of CD55 on surface of RBCs. Hb 8.9. Platelets 134,000, bilirubin - high. LDH - hi. Haptoglobin - low. Abdominal tenderness. Mesenteric vein thrombosis. What does he have? What is a likely pathological finding if he had a renal problem?
This man has paroxysmal nocturnal hemoglobinuria > complement mediated hemolysis. Triad: hemolytic anemia (hemoglobinuria), pancytopenia, and thrombosis of atypical sites. Chronic hemolysis > iron deposition in kidney (hemosiderosis)
Hypochromic, microcytic anemia - iron deficiency. Replacement therapy will increase hemoglobin levels approximately 2 g/dL per week for the first three weeks. What will you see?
This increases erythropoietin and accelerates release of both mature and immature blood cells (reticulocyte). Reticulocytes are slightly larger and bluer than mature RBC on wright-giemsa stain. This is due to ribosomal RNA in cytoplasm.
Basophillic stippling
Sideroblastic anemia - lead poisoning, myelodysplastic syndromes, thalassemias.
Peripheral smear.
Heinz bodies
G6PD deficiency
G6PD defiency due to subsequent oxidation of Hb-SH groups to S-S groups > Hb precipitation and presence of Heinz bodies.
Subsequent phagocytes damage to RBCs > Bite cells
Degmacytes - bite cells
G6PD defiency due to subsequent oxidation of Hb-SH groups to S-S groups > Hb precipitation and presence of Heinz bodies.
Subsequent phagocytes damage to RBCs > Bite cells
Howell-jolly bodies
Patients with asplenic ort hyposplenia - basophilic nuclear remnants found in RBCs. Normally removed by splenic macrophages.
Ringed sideroblasts on Prussian blue stain
Bone marrow - sideroblastic anemia, excess iron in mitochondria.
Bcl-2 gene prevents what?
Cell death cascade by allowing release of cytochrome c from mitochondria into the cytoplasm > apoptosis.
Follicular lymphoma tumor cells express pan B-cells antigens (CD19,CD20, and CD79a), CD21, and CD10. What is the characteristic cytogenetic abnormality?
Translocation of bcl-2 oncogene from chromosome 18 to the Ig heavy chain locus on chromosome 14 [t(14:18)]. This inhibits apoptosis by preventing release of cytochrome c from mitochondria.
Man with testicular cancer receives external beam radiotherapy. What is the likely effect of such therapy?
DNA damage through DNA double stranded fractures and formation of oxygen free radicals.
Man takes methotrexate daily instead of three times a week. Marked immunodeficiency. Low hemoglobin. Low platelets. Low leukocytes. Mouth ulcers, etc… full fledge methotrexate toxicity. What’s the next best step in management?
Give this man some god damn folinic acid aka leucovorin. It’s the same treatment for 5-FU as well.
T(8:14)
Burkittc (Burk-S) lymphoma (C-MCC)
T(9:22) (philidelphia chromosome)
CML (BCR-ABL hybrid), ALL (less common, poor prognostic factor)
T(11:14)
Mantle cell lymphoma (Cyclin D1 activation)
T(14:18)
Follicular cell lymphoma (BCL-2 activation)
T(15:17)
APL (M3 type of AML) tx with retinoids acid
Rituximab
Non Hodgkin lymphoma. Rituximab is a monoclonal antibody directed against B-cell CD20 antigen. It’s introduction has improved the prognosis of lymphomas.
Cytokeratin stain + for?
Epithelial cells
CD20 marks for?
CD 3 marks for?
CD20 - B lymphocytes
CD3 - T lymphocytes
Vimentin stain?
Mesenchymal tissue (intermediate filament) - can detect sarcomas
Myeloperoxidase stain?
Peroxidase enzyme present in myeloid cells such as those in AML
Chromogranin A and synaptophysin stains?
Markers for neuroendocrine tumors
Anaplastic tumors
Are nothing like the tissue of origin. They have lost their way. They are pleomorphic cells with large, hyperchromatic nuclei that grow in disorganized fashion. Anaplastic tumors may also contain numerous abnormal mitoses and giant cell tumors.
Dark gallstones with low cholesterol pigment likely due to:
Chronic hemolysis (sickle cell anemia, b-thalassemia, hereditary spherocytosis), etc… and increased enterohepatic cycling of bilirubin. Other causes could be parenteral nutrition, Crohn’s disease, alcoholic cirrhosis, advanced age, and biliary infections.
A colon adenocarcinoma is identified. Discussion on therapy treatment using monoclonal antibodies against Epidermal Growth Factor receptors is considered. A mutation in what would make that treatment ineffective?
KRAS protein is resistant to anti-EGFR therapy.
30 yo man /w HIV and history of IV drug abuse. Abdominal dissension, anorexia, ascites, and a large mass surrounding small intestine.
Bx: uniform, round medium sized tumor cells /w basophillic cytoplasm and proliferation fraction (Ki-67) > 99%. What’s associated with current condition?
Epstein Barr virus is prevalent in up to 50% of systemic B-cell lymphomas and almost all primary CNS lymphomas occurring /w HIV infection. A high mitotic index is typical for Burkett lymphoma. Translocation of t8:14 > over expression of c-MYC - transcription regulator of cell proliferation. This is the lymphoma with “starry sky” appearance. Due to presence of benign macrophages.
Integrin mutations would have poor adhesion to what components of the extracellular matrix?
membrane proteins that maintain integrity
of basolateral membrane by binding to collagen,
laminin, and fibronectin in basement membrane.
Central necrosis, precancerous lesion, confined to ducts and lobules - a type of noninvasive breast cancer
DCIS
Eczema toys nipple lesion, extension of DCIS into ducts - a type of noninvasive breast cancer -
Paget disease
Most common type, nests and cords of cells - a type of invasive breast cancer
Ductal carcinoma
Small cells in single file, mammary stroke invasion - a type of invasive breast cancer
Lobular carcinoma
Peau d’orange, dermal lymphatic invasion - a type of invasive breast cancer
Inflammatory breast cancer
Hypophosphorylated retinoblastoma protein (Rb) does what?
Prevents G1/S cell cycle transition
32 yo white Female - 3x episodes DVT /w history of PE. PTT normal. PTT unchanged /w addition of protein C. Cause of pt’s problem?
Inherited causes of hypercoaguability should be considered in pts under 50 yo who present with previous episodes of thrombosis and no obvious explanation for an acquired prothrombotic state. Factor 54 Leiden mutation, which causes factor 5a resistance to inactivation by activated protein C may account for approximately 20% of cases of atypical venous thrombosis.
What other disease has cells that resemble Ringed Sideroblasts?
Hint: it presents in young Jews. It’s autosomal recessive lysosomal disorder caused by B-glucocerebrosidase deficiency. It leads to accumulation of a glycolipid of leukocyte and erythrocyte membranes called Glucocerebroside. The lipid-laden macrophages or (gaucherie cells) are described as “wrinkled tissue paper”, “wrinkled silk” or “crumbled newspaper” in a bone marrow aspirate. They’re found throughout the body: liver bone, lymphatic tissue (spleen, lymph nodes, tonsils).
Gaucherie disease - onset childhood to early adulthood. Px: bone pain - bone marrow inflammation/invasion. Abdominal dissension - hepatosplenomegaly, easy bleeding, bruising, pallor, and fatigue due to pancytopenia.
Splenomegaly presents before hepatomegaly. Anemia, thrombocytopenia, and Leukopenia all can be present.
Aplastic anemia - bone marrow failure due to hematopoietic stem cell defiency (CD34+)
Causes?
Clinical and laboratory findings?
Causes: autoimmune, infections (parvovirus b19, EBV), drugs (carbamazepine, chloramphenicol, sulfonamides), exposure to radiation or toxins (benzene, solvents)
Findings: pancytopenia, anemia (fatigue, weakness, pallor), thrombocytopenia (mucosal bleeding, easy bruising, petechiae), leukopenia (recurrent infections).
Biopsy: hypocellualr bone marrow with fat and stromal cells
Phases of ARDS
Exudative - AI
Proliferation - CI - fibroblasts
Fibrotic - fibrosis - RBCs cannot pick up O2 through thick fibrotic wall.
30 wk old baby, mom poor diabetes and about to rupture membrane. What’s best thing to do for baby?
Give that bitch some steroids to help with its surfactant maturation. Duh!
Systemic sclerosis (Crest Syndrome) would be obstructive or restrictive? What would you see?
Obstructive: decreased FEV/FVC ratio, increased pulmonary HTN, for pulmonale [RHF], raynaud phenomnenon, accentuated 2nd heart sound.
Systemic sclerosis causes pulmonary hypertension due to damage of pulmonary arteriosus (sclerosis)
Shoulder pain? Nerve?
Phrenic, mediastinal/diaphragmatic pleura C3-5. Parietal pleura irritation worse on inspiration (lower lobe bacterial pneumonia)
Dyspnea, chest discomfort. 56 yo male. Radioactive material inserted for imagine while man breaths and larger area of lower right lung is not visualized in second scan as compared to control (without radioactive injection). What does this signify?
Unmatched perfusion defects. Patient had a DVT > pulmonary embolism
Type 1 hypersensitivity reaction?
B cells - antigens
Eosinophils
What mediates the EFFECTS of allergic reactions?
Basophils and mast cells
What mediates Type 4 delayed HS?
T Lymphocytes. No antibodies involved.
APC brings antigen to Th cell and it secretes inflammatory cytokines. Tc cell binds to antigens and kill them. Cytokines activate macrophages to go be the dumpster that they are.
Normal pulmonary pressure:
10-14 mmgH
Pulmonary hypertension pressure?
> 25 mmhg
Symptoms and findings in pulmonary htn?
Arteriosclerosis
Medial hypertrophy
Intimate fibrosis of pulmonary arteries
Plexiform lesions
Course: severe respiratory distress > cyanosis and RVH > death from decompensated for pulmonale.
Causes of pulmonary HTN
Young, female with inheritable BMPR2 gene mutation that normally inhibits vascular smooth muscle proliferation. Causes: increased vasoconstriction (endothelial) and decreased vasodilation (NO- and prostacyclins).
Other causes: amphetamines, cocaine, connective disuse disease, HIV infection, portal hypertension, congenital heart disease, schistosomiasis.
What stimulates neutrophil chemotaxis?
LTB4 secreted from arachadonic-prostaglandin H2 pathway. (Also platelet aggregation)
Also: prostacyclins - vasodilation and decreased platelet aggregation
Also: prostaglandins - vasodilation and increased vascular permeability
DVT > embolism in truck drivers lower right lung lobe. Why doesn’t he have lung tissue necrosis?
Dual innervation. The lungs are supplied by dual circulation from both the pulmonary and bronchial arteries. This collateral circulation can help protect against lung infarction due to pulmonary artery occlusion (embolism), as the bronchial circulation can continue to provide blood to the lung parenchyma.
Abcesses formation:
Largely driven by neutrophil recruitment and activation leading to the release of cytotoxic granules that kill bacteria but also cause liquefying necrosis of surrounding tissue.
Major basic protein
Predominant component of eosinophilic granules and plays a crucial role in the elimination of parasites. Lung abcess formation is primarily mediated by neutrophils, not eosinophils.
Sputum suggest role of which cytokine?
Young man - 24
Paroxysmal episodes breathlessness and wheezing.
Nothing associated with it.
Sputum microscopy shows granule-containing cells and crystalloid masses.
Young skipper has asthma. He’s got some Charcot-laymen crystals characterized by eosinophils.
Recruited by allergic activated Th2 cells. The cytokine issssssssss: IL-5.
Yellow granules. Filamentous gram positive branching bacteria with sulfur granules. They can be aspirated, but most commonly affect mouth area.
Actinomyces israelii
On LM it looks like purple blob. Cannot really see branching filaments. Looks like giant troll hair purple color. No nuclei visible.
Mucicarmine stain
Cryptococcus neoformans pneumoniae
India ink stain
Cryptococcus neoformans
Histoplasmosis capsulatum
Dimorphism fungi that exists in small, ovoid yeast at tissue temperatures. Replicates within macrophages. Spreads through lymphatic and reticuloendothelial system. Immunocompetenet patients usually have asymptomatic pulmonary infection, but immunocompromised can have disseminated disease of liver, spleen, and bone marrow. (AIDs)
Vagus nerve
Parasympathetic, ACh, nicotinic, Muscarinic
Ipratropium, tiotropium
Cystic fibrosis presentations:
Recurrent respiratory infections
Kartageners syndrome presentation
Dynein cilia dysfunction dyskinesia.
Chronic sinusitis, situs inversus, bronchiectasis, and infertility
Selective IgA deficiency
Recurrent sinopulmonary, gastrointestinal infections. Autoimmune disease, anaphylaxis during transfusions
Dx: low or absent serum IgA levels. Normal IgG and IgM levels.
X-linked agammaglobulinemia
Absence of B cells. Low or absent CD19, and 20 B cells and pan-hypogammaglobuplinemia. Increased susceptibility to pyogenic bacteria, giardia lamblia due to absence of opsonizing and neutralizing antibodies.
Seizure disorder
Cough producing thick yellowish sputum > 2 weeks. Night sweats, fatigue. 101F Temp. Crackles on lung auscultation. Nonspecific pulmonary lesion. TNA biopsy performed and shows:
Peptostreptococcus, fusobacterium, and other cultures.
Aspiration pneumonia, alcoholism, drug abuse, seizure disorders, and previous stroke/dementia.
Pulmonary infarct
IV drug user with tricuspid valve endocarditis. Causes multiple septic pulmonary infarcts due to embolization of tricuspid valve vegetation fragments.
PRIMARY TUBERCULOSIS INFECTION
1 OR MORE AREAS UPPER MOST COMMON BUT CAN ALSO BE LOWER. THIS GUY WAS IVDA /W HEP C.
SO HE HAD FIBROSIS (GHON COMPLEX) IN ONE AND CASEATION (CALCIFICATION) IN ANOTHER
Tuberculosis resolution -
Bacterial clearance and scar formation.
Tuberculosis latency
Dormant bacteria contained within walled off foci
Tuberculosis that progresses -
Failed immune response. Goes from primary tuberculosis to continued damage…. consolidation and necrosis.
Eventually to miliary tuberculosis which is flat out hematogenous dissemination to multiple organs. Looks ugly.
ST segment elevation and elevation in leads 1, and V3-V6 is strongly suggestive of anterolateral left ventricle infarction. Left ventricular failure, cardiogenic acute pulmonary edema, pulmonary venous hypertension (congestion), and transudate of plasma into the lung interstitium and alveoli.
ST segment elevation and elevation in leads 1, and V3-V6 is strongly suggestive of anterolateral left ventricle infarction. Left ventricular failure, cardiogenic acute pulmonary edema, pulmonary venous hypertension (congestion), and transudate of plasma into the lung interstitium and alveoli.
Hemosiderinuria containing macrophages in alveoli (heart failure cells/siderophages) are suggestive of prior episodes of pulmonary congestion and edema and those are due to CHF. Not infarct.
M. Pneumoniae has what as a cell membrane?
Cholesterol. One single cholesterol-rich phospholipid belayer.
It contains no peptidoglycan cell wall, cell envelope, or capsule.
Fungi also have sterols (ergosterol) for their cell membranes
Mesothelioma
Thoracocentesis - bloody fluid, pleural biopsy - proliferation of epithelioid-type cells that are joined by desmosomes, contain abundant tonofilaments, and are studded with very long mnicrovilli.
Right sided pleural effusion and diffuse nodular thickening
Primary risk factor is asbestos exposure
The most important factor in preventing influenza infection in subjects?
Antibodies against hemagglutinin
ALCOHOLICS ASPIRATIONS
S. Pneumoniae is still most common cause of pneumonia… even in alcoholics, but they are very likely to aspirate gram negatives also… so you have to hit the lung with something that covers both. This is generally CLEANDAMYCIN.
Anaerobics:
Bactericides, prevotella, fusoform bacterium, and peptostreptococcus
Anaerobic alternative coverage: metronidazole
