Q-bank Flashcards
What is an common GI complication of UC that should be diagnosed w/ plain film x-ray?
Toxic Megacolon
Presents w/ fever, diarrhea, signs of shock
Physcians are ethically and legally obligated to report impaired colleagues to _______
Physician HealthProgram
What can most minor consent to w/o parental consent or notification?
Prenatal care
STI tx
Contraception
Drug/Alcohol rehabilitation
Can most minors consent to abortion?
No. 2/3 of the states require parental consent for abortion
From what cells do Renal Cell Carcinomas originate?
Epithelial cells of the PCT
What is the most common type of kidney tumor?
Clear Cell Carcinoma
Which renal cells cancers often form Papillary Tumors?
Transitional Cell Carcinomas
What is the cause of calcifications causing Aortic Stenosis?
Dystrophic calcification on damaged/necrotic tissue in the setting of NORMAL Ca levels
Describe the normal change that occur due to agin of the heart
Decreased LV chamber apex-to-base dimension
Development of sigmoid-shaped ventricle septum
Myocardial atrophy
Increased Collagen deposition
Accumulation of cytoplasmic Lipofuscin pigment
Vegetations associated w/ bacterial endocarditis are made up of what?
Fibrin and platelet deposition
How do Support and Empathy differ?
Support: expressing concern independent of understanding
Empathy: Physician expressed understanding and vicarious experience
In Acute Hepatitis, what is seen on microscopy?
Ballooning degeneration
Mononucular cell infiltrate
Councilman bodies (eosinophilic Apoptotic hepatocytes)
Chronic NSAID-use can lead to what in the kidney?
Papillary Necrosis
Interstitial Necrosis
Describe the murmur of Aortic Stenosis
(Diamond-shaped) Crescendo-decrescendo systolic murmur
For Hypertrophic Cardiomyopathy, what types of maneuvers will increase the murmur?
Those that decrease preload or afterload (Increase outflow tract obstruction)
Which maneuvers decrease preload and afterload?
Sudden standing
Valsalva
Nitroglycerine
Which maneuvers increase preload and afterload?
Squatting
Hand Grip
Passive leg raise
List the early findings in Rheumatic Fever
Migratory arthritis
Pancarditis
Sydenham chorea
What do the Brachiocephalic Veins drain?
Ipsilateral Jugular and Subclavian veins
Which areas do the External Jugular veins drain?
Scalp and lateral face
How do Strawberry-type Capillary Hemangiomas progress?
Initially grow in proportion to growth of child, then usually regress completely by age 7.
Crohn’s Disease is assoc w/ what in the kidney? How?
Ca-oxalate kidney stones–> Impaired bile acid reabs–> more lipids in gut–> lipids bind to Ca–> Calcium cannot bind oxalate for excretion–> oxalate reabs. and forms renal stones
Why do myocardial cells swell in MI?
ATP deficiency–> Ion pump failure–> increased intracellular Na and Ca –> draws in free H2O–> cells swell
What 3 questions should you ask to screen for elder abuse?
- Do you feel safe at home?
- Who prepares your meals?
- Who handles your checkbook?
Compare the complications of an anterior and posterior duodenal ulcer
Anterior: Perforation
Posterior: Hemorrhage of Gastroduodenal Artery
Describe the course of the ureters as they come out of the kidney
Cross UNDER the gonadal vessels and Uterine vessels in females
Cross OVER the Common/External Iliac Arteries
Anteriolateral to internal iliac vessels
Medial to ovarian Vessels
What kind of acid-base disturbances or Salicylate Intoxication cause?
Acute Resp. Alk–> then Metabolic acidosis
If the PaCO2 level is the LESS than predicted by Winter’s Formula, what does that mean?
There is a concurrent Resp. Alkalosis.
Are physicians required to provide medical services that are against their beliefs?
No
Which form of IBD is more assoc w/ an increased risk of colorectal carcinoma?
UC
How does UC-assoc. Colorectal carcinoma compare to sporadic CRC?
UC-assoc. CRC:
- More likely to affect younger pts
- progress from flat to non-polypoid dysplasia
- histologically appear mucinous/signet ring
- Develop early p53, late APC (reverse of sporadic)
- Be multifocal in nature
- Be in Proximal colon (esp. w/ Crohn’s)
The left kidney lies immediately deep to the tip or which rib?
12th
How do you calculate the Net Excretion Rate of a substance?
(GFR x Plasma conc) - Tubular Reabsorption
What is the current treatment for Hep C?
Interferon-alpha and Ribavirin
What is Ribavirin used to treat?
Hep C and RSV
What are the mech of action for Ribavirin?
- Lethal hypermutation
- Inhibiting RNA Polymerase
- Inhibiting Inosine Monophosphate DHase (depletes GTP)
- Defective 5’-cap formation
- More effective immune response (enhances Th1 immunity and inhibits Th2 cytokine production)
How is PAH handled by the kidneys?
It is freely filtered, and actively secreted by the PCT (CARRIER-mediated—> can become saturated!!!)
NOT reabsorbed at all in the nephron.
What does CREST stand for?
C= Calcinosis R= Raynaud's E= Esophageal Dysmotility S= Sclerodactyly T= Telangiectasia
Which hormone has trophic effects on Parietal Cells?
Gastrin
What stimulates release of Secretin?
Increased duodenal H+ conc.
What does increased Secretin cause?
Pancreatic Bicarbonate secretion
How do pancreatic secretions compare to plasma in terms of tonicity?
Isotonic
Same conc. of Na and K
Increased HCO3-, decreased Cl-
Gallbladder hypomotility can cause ______
Biliary sludge and bile precipitation
What are some risk factors for gallbladder hypomotility?
Pregnancy
Rapid weight loss
High Spinal cord injuries
Prolonged parenteral nutrtion
What reduces the likelihood of gallstone formation?
Decreased cholesterol levels
Increased bile salts and Phosphatidylcholine levels
Why do Renal Cell Carcinoma cells appear clear?
They are filled w/ glycogen and lipids
How does Niancin (Vit. B/Nicotinic Acid) work in the tx of hyperlipidemia?
Inhibits VLDL production and increases HDL levels
How do Statins tx hyperlipidemia?
Inhibit cholesterol synthesis (HMG-CoA Reductase)–> up-regulate LDL-receptors in liver
What are common side effects of Niacin?
Flushing and Pruritis
What are side effects of Bile-binding resins?
Constipation, bloating, hypertriglyceridemia, cholesterol gallstones, vit. K malabsorption
What is Oseltamivir (Tamiflu)?
Neuaminidase Inhibitor
Slow viral penetration of mucous secretions and protect resp. epi.
Used to treat/prevent Influenza A and B
What is Calcineurin?
Activator of IL-2, which promotes growth and differentiation of T-cells
How does Calcineurin work?
Calcineurin–> NFAT–> IL-2–> growth and proliferation of T-cells
What measure would lead to decreased rates of Hepatocellular Carcinoma worldwide?
Vaccination of children against HBV
Which cells are primarily responsible for the uptake of Shigella?
M-cells on Peyer’s Patch
A positive “whiff” test (fishy odor) w/ addition of KOH on vaginal discharge is a sign of________
Bacterial vaginosis (most commonly caused by Gardnerella vaginalis)
What is the toxic component of LPS?
Lipid A
How do Bile acid-binding resins affect Triglyceride levels?
Increase triglyceride levels
How does Chronic Cholestasis from Biliary Obstruction lead to night blindness?
Decreased fat absorption–> decreased vit. A absorption
How does the Beta-adrenergic pathway affect the RAAS pathway?
B-adrenergic pathway–> stimulates RAAS through Beta-1 receptors on JG-cells
B-Blockers inhibit this–> decrease RAAS–> Decrease HTN
What do the Superficial Inguinal lymph nodes drain?
All skin from the umbilicus to the feet, including the anus up to Dentate line, including scrotum, but NOT including:
Posterior calf–> drains into the Popliteal lymph nodes–> Deep Inguinal
Glans penis –> Deep Inguinal
Testes –> Para-aortic
Fistulas are more commonly seen in Crohn’s Disease or UC?
Crohn’s Disease
List the indicators of Liver Function
Prothrombin time
Albumin levels
Bilirubin
List the indicators of hepatocellular injury
AST
ALT
List the indicators of Biliary injury
GGT
Alkaline Phosphatase
In the Crescent form of Rapidly Progressive Glomerulonephritis, what do the Crescents consist of?
Fibrin
Glomerular Parietal Cells
Monocytes/Macrophages
Which artery supplies blood proximal 1/3 of the ureter?
Renal Artery
For this reason, the donor’s proximal 1/3 ureter is preserved in renal transplant
In a Renal Transplant, which arteries/veins are anastomosed?
Donor’s Renal Artery/Vein to Recipient’s External Iliac Artery/Vein
What is the function of the Poly-A tail?
Protects mRNA from degradation w/in cytoplasm after exiting the nucleus
What is the 5’-Cap that is added to mRNA?
7-methyl-Guanosine
What is the Filtration Fraction?
FF= GFR/RPF
How does the Filtration Fraction change in hypovolemia?
It INCREASES I b/c FF=GFR/RPF and GFR decreases less that RPF b/c of compensatory RAAS that maintains GFR
What inputs go to the VPL of the thalamus?
Spinothalamic and Medial Lemniscus
What inputs go to the VPM of the thalamus?
Trigeminal and gustatory pathways
Failure of neural tube closure in week___ of fetal life leads to neural tube defects.
4th
What is a Persistent Vitelline Duct/Fistula?
Complete failure of vitelline duct to close–> small connection b/t intestine and outside of body
What is a Vitelline Sinus?
Partial closure of vitelline duct. Patent portion open at umbilicus.
What is a Vitelline Duct Cyst?
Peripheral portions of vitelline duct obliterate, but central part remains
What is the difference b/t enhancers/repressors and promoters?
Enhancer/repressors: can be located ANYWHERE
Promoters: Typically 25-70bp upstream
What composes the Lesser Omentum?
Hepatogastric ligament
Hepatoduodenal ligament
How do you calculate the total resistance for resistors that are in parallel?
1/Total= 1/R1 + 1/R2 + 1/R3….
What are the 1st and 2nd most common brain tumors in adults?
1st: Glioblastoma
2nd: Meningioma
What do meningiomas arise from?
Arachnoid villi
What is a characteristic feature of Mengiomas?
Psammoma bodies (concentric laminar calcifications)
How is DNA methylation carried out?
DNA Methyltransferase transfers methyl group from donors (like S-adenosyl-methionine) to cytosine
Describe the genetics of Classical Galactosemia
Autosomal recessive
What causes Classical Galactosemia?
Defective Galactose-1-P Uridyltransferase
CanNOT convert Galactose-1-P –> UDP-Galactose
Describe the genetics of Lesch-Nyhan syndrome.
X-linked recessive
Describe the genetics of Leber Hereditary Optic Neuropathy
MT inheritance
Describe the inheritance of Huntington’s Disease
Autosomal Dominant
When does implantation usually occur after fertilization?
6-7days
When is B-hCG usually detectable after ovulation if fertilization occurs?
8 days
Does ALS affect sensation?
NO!
What are the signs of Syringomyelia?
Upper Extremity: Loss of pain/temp sensation, LMN signs Lower Extremity (with expansion of syrinx): weakness and HYPERreflexia
Measures of what two markers allow for prenatal diagnosis of Neural Tube Defects? Which one can be detected in Maternal Serum?
Amniotic Fluid: a-FP and Acetylcholinesterase
Maternal serum: a-FP (can cross placenta)
What is the treatment of choice for Diabetic Ketoacidosis?
Insulin and IV hydration
What does Insulin do in the setting of DKA?
Decreases serum glucose, osmality, and K+
Increases serum HCO3-
Beta-endorphin is an endogenous opioid that is derived from what? What else is derived from this?
POMC
ACTH and MSH are also derived from this
What are Brunner’s Glands?
Compound tubular gland in duodenum
Submucosa layer
Secrete alkaline mucous
Mucous–> Submucosa–> crypts of Lieberkuhn–> duodenal lumen
What 3 mutations have been assoc w/ early-onset Alzheimer Disease/
Amyloid Precursor Protein (APP)- Chrom 21
Presenilin 1- Chrom 14
Presenilin 2- Chrom 1
All promote production of A Beta-amyloid
What mutation(s) are assoc w/ late-onset Alzheimer Disease?
E4 Apolipoprotein
Are jejunal, ileal, and colonic atresias (distal to duodenal) caused by abnormal fetal development?
No. They are caused by vascular accidents in utero.
What is the cause of intestinal atresias distal to the duodenum?
Vascular accidents in utero
What happens in Intestinal atresia distal to duodenum?
Blind-ending intestinal pouch w/ absence of long length of small bowel and dorsal mesentery
Distal portion assumes spiral configuration around ileocecal vessel
What kind of visual defect do macula lesions cause?
Central Scotomas
Dizygotic twins always have ___ amnions and ___ chorions.
2 amnions and 2 chorions
For monozygotic twins, separation at 0-4 days results in ____ chorions and ____ amnions.
2 chorions
2 amnions
For monozygotic twins, separation at 4-8 days results in ____ chorions and ____ amnions.
1 chorion
2 amnions
For monozygotic twins, separation at 8-12 days results in ____ chorions and ____ amnions.
1 chorion
1 amnion
For monozygotic twins, separation at >13days days results in ____ chorions and ____ amnions.
Conjoined twins
1 chorion
1 amnion
Vertigo is commonly due to dysfunction of the __________.
Vestibular system
In Fragile X, where are the trinucleotide repeats located?
Long arm of the X-chrom
Where does the name “Fragile X” come from?
In cytogenetic studies, the area of increased repeats does not stain–> appears broken–> “fragile X”
What is an example of Uniparental disomy?
Complete hydatidiform mole
What are the causes of Down Syndrome?
- Trisomy 21 (95%)
- Unbalanced Robertsonian translocation. Have 46 chrom, but an extra arm of chrom 21 is attached to another chrom.
- Mosaicism
Damage to the Frontal Eye fields causes the eyes to deviate to the ______________ side.
Ipsilateral
Frontal Eye fields control visual attention and eye movements of the ______________ side.
Contralateral
What is Superior Mesenteric Artery Syndrome?
Transverse portion of the duodenum is entrapped b/t the SMA and aorta.
What can cause Superior Mesenteric Syndrome?
Diminished mesenteric fat
Pronounced lordosis
Surgical correction of scoliosis
Tay-Sachs Disease is due to a deficiency in what?
Beta-hexosaminidase A
In Tay-Sachs disease you have accumulation of what?
GM2-ganglioside
What is the inheritance of Tay Sachs?
Autosomal recessive
What is Fabry Disease?
X-linked
Deficiency: a-galactosidase
Accumulated: Ceramide trihexoside
What is Gaucher Disease?
Autosomal recessive
Deficient: B-glucocerbrosidase
Accumulated: glucocerbroside
What is Hurler Syndrome?
Autosomal recessive
Deficient: a-L-iduronidase
Accumulated: Dermatan and Heparan sulfate
What is Hunter Syndrome?
X-linked
Deficient: iduronate sulfatase
Accumulated: Dermatan and heparan sulfate
What is Niemann-Pick Disease?
Autosomal recessive
Deficient: Sphingomyelinase
Accumulated: Sphingomyelin
What is Krabbe Disease?
Autosomal Disease
Deficient: Galacto-cerbrosidase
Accumulated: Galactosyl-sphingosine and galactocerbroside
What is Metachromatic Leukodystrophy?
Autosomal recessive
Deficiency: Arylsufatase A
Accumulated: Cerbroside sulfate
Symptoms: muscle wasting, dementia, ataxia
What are the symptoms of Tay Sachs?
Cherry-red spot in macula
Progressive neurodegeneration
NO hepatosplenomegaly
What is the typical Filtration Fraction for a healthy individual?
20%
How can RPF be calculated using PAH?
RPF= PAH clearance
How can you calculate urinary clearance?
Clearance= (Urine conc x Urine flow) / Plasma conc.
How do you calculate GFR from the Starling Equation?
GFR= Kf ((Pg - Pb)- (oncotic press in Glom - oncotic press in Bowman’s))
How are lipids handled by the GI system?
Digested in duodenum
Absorbed in the jejunum
How do Bile Acids affect lipid absorption?
Necessary for lipid absorption
How does cholecystectomy affect lipid digestion?
Little effect on digestion and absorption
Difficult to eat large meal
What kind of changes occur after cholecystectomy?
Increased rate of enterohepatic circulation
Constantly released into duodenum b/c no storage place
What are the 2 muscles of the middle ear?
Tensor tympani and Stapedius
What innervated the Stapedius muscle?
CN VII
What innervates the Tensor tympani?
CN V3
What is Hyperacusis?
Increased sensitivity to sound
What can cause hyperacusis?
Paralysis of the Stapedius muscle (CN VII, Bell’s Palsy, etc)
What delineates the anterior 2/3 and posterior 1/3 tongue?
Terminal sulcus/ Foramen cecum
Which nerve collects GUSTATORY inputs from anterior 2/3 of tongue?
Chorda tympani of VII
Which nerve collects GUSTATORY inputs from posteriod 1/3 of tongue?
CN IX
Which nerve collects GUSTATORY inputs from posterior area of tongue root and taste buds of larynx?
CN X
Which nerve collects SENSORY inputs from anterior 2/3 of tongue?
CN V3 (Mandibular branch)
Which nerve collects SENSORY inputs from posterior 1/3 of tongue?
CN IX
Which nerve collects SENSORY inputs from root of the tongue?
CN X
The 3rd cranial nerve courses through which two arteries?
Posterior Cerebral and Superior Cerebellar
What are the symptoms of 3rd Nerve Palsy?
Unilateral HA Eye pain Diplopia Dilated, nonreactive pupil Ptosis Ipsilateral eye down and out
Which 2 organs are protected from the general circulation?
Brain and Testes
What is the equation for Loading Dose?
Loading Dose= Cp x (Vd/F)
Cp= Target plasma conc. Vd= vol. of distribution F= Bioavailability
What is the equation for Maintenance Dose?
Maintenance Dose= Cp x (Cl/F)
Cp= Target plasma conc. Cl= Clearance F= bioavailability
What is the equation for Clearance of a Drug?
Clearance= Rate of drug elim/ Plasma drug conc.
How do maintenance and loading doses change if a patient has hepatic or renal insuff?
Same loading dose
Decreased maintenance dose
What is used to treat CO poisoning?
100% O2, Hyperbaric O2
What is used to treat Cyanide toxicity?
Amyl nitrite and Sodium Nitrite–> prevent and reverse binding of cyanide to cytochrome oxidase
Sodium thiosulfate–> accelerates detox of cyanide to thiocyanate
Hydroxocobalamin–> chelates cyanide, forming cyanocobalamin
What is used to treat Methanol poisoning?
Ethanol (competitive antagonist for Alcohol DHase)
Fomepizole (inhibits Alcohol DHase)
What is Strychnine?
Competitive anatagonist of Glycine in CNS
What is used to treat Strychnine toxicity?
Benzodiazepines and Neuromuscular block
What is the mechanism of Arsenic poisoning?
Interferes w/ Oxidative Phosphorylation
What are the symptoms of Arsenic poisoning?
Early: Garlic breath, bloody diarrhea
Late: Hair loss, neuropathy, hyperpigmentation, lung cancer
What is used to treat Arsenic poisoning?
Dimercaprol,
Dimercaptosuccinic acid
D-penicillamine
In terms of Calcium levels, when do Neuromuscular Hyperexcitability become apparent?
Calcium </= 7
What is the most common cause of hypocalcemia?
Primary Hypoparathyroidism
How is Cryotococcal meningitis stained?
India ink–> Negative stain technique due to thick capsule
In Cryptococcal infections, are CSF Leukocyte counts increased or decreased?
Decreased
Lymphocytes predominate
Esp. in HIV pts
How do you treat Cyptococcual meningitis?
Amp B and Flucytosine
Long-term: Fluconazole
Patients w/ both sporadic and hereditary (VHL-assoc) Renal Cell Carcinmoa are found to have deletions of the _______ gene on chrom_____.
VHL (tumor suppressor)
Chrom. 3p
Defects in VHL-gene are found in the majority of patients (40-50%) w/ ______________
Sporadic Renal Cell Carcinoma
What is the cause of Wilson’s Disease?
Mutation in ATP7B
Chrom. 13
Decreased Ceruloplasmin and Decreased secretion of Cu into biliary system–> Less Cu metabolism–> Cu causes oxidant damage to liver–> Cu leaks from injured hepatocytes into blood–> goes to various tissues (brain and eyes)
What are the symptoms of Wilson’s Disease?
Neurological: ataxia, slurred speech, personality change, rigidity/catatonia
Liver: cirrhosis, hepatitis, portal HTN, liver fcn abnormalities
What causes Annular Pancreas?
Abnormal migration of the ventral pancreatic duct
What can happen to the gallbladder in hospitalized patients?
Acute acalculous cholecystitis (Acute inflammation)
Which cytokines are thought to be anti-inflammatory?
TGF-beta
IL-10
Which cytokines are thought to be pro-inflammatory? Which of these acts systemically to promote acute phase repsonse?
IL-1 (acts systemically to promote fever, etc) IL-4 IL-5 IL-12 TGF-alpha
What produces TGF-alpha?
Pro-inflammatory cytokine produced by T-cells and Monocytes
Which organisms are known to infect w/ a very small inoculum?
Shigella (10) Campylobacter jejuni (500) Entamoeba histolytica (1) Giardia lamblia (1)
How can you calculate Renal Plasma Flow from Renal Blood Flow?
RPF= (1-Hct)(RBF)
What are the 3 areas that control bladder function?
- Sacral micturition center
- Pontine Reticular Micturition center
- Cerebral cortex
Which areas stimulate urination?
- Sacral micturition center–> Bladder contraction.
2. Pontine Reticular Formation–> coord. relaxation of External urethral sphincter.
Which inhibits urination?
Cerebral cortex—> inhibits sacral micturition center
What effects do Loop Diuretics have in the kidney?
Inhibit Na-K-Cl symporters
Stimulate PG release
What is Gallstone ileus?
Mechanical bowel obstruction caused when large gallstone erodes into intestinal lumen.
Air in the biliary tract (pneumobilia) is suggestive of this
What is Thalamic Syndrome?
Total sensory loss on contralateral side of body
Proprioception loss
No motor deficits
What vessel abnormalities cause lacunar infarcts?
Small vessel lipohyalinosis
Atherosclerosis
What is the inheritance of Neurofibromatosis Type 1?
Autosomal dominant
Defect in NF-1 gene on chrom. 17
Neurofibromas are tumors of ___________ cells.
Schwann cells
What is Sucrose?
Fructose + Glucose
What is Lactose?
Galactose + Glucose
What is Maltose?
Glucose + Glucose
Aldolase B Deficiency results in ________ intolerance. What should be excluded from their diet?
Fructose intolerance.
Fructose and sucrose should be eliminated from diet.
In cerebral necrosis, what forms glial scar along periphery of cystic space?
Astrocytes
3-5 days after ischemic injury to the brain, which cells will be hyper-dense on Lipid Staining?
Microglia
Phagocytose myelin, dead neurons
What helps to accelerate fetal lung maturity?
Both fetal and maternal Cortisol
Which hormones help accelerate fetal lung development?
Glucocorticoids (BIGGEST effect) PRL Insulin Estrogens Androgens Thyroid Hormones Catecholamines
How do Achalasia and Gastroesophageal Reflux compare in terms of resting pressure?
Achalasia: Increased resting pressure
GERD: Decreased resting pressure
What slows the progression of Hemochromatosis in women?
Menstruation
What is used to stain Iron?
Prussian Blue
Activation of which enzyme is the central event in Acute Necrotizing Pancreatitis?
Trypsinogen–> activates all of pancreatic enzymes
What converts Trypsinogen to Trypsin?
Enteropeptidase
What is Conn’s Syndrome?
Primary Hyperaldosteronism
What are the symptoms of Conn’s Syndrome?
Primary Hyperaldosteronism
Na+ retention–> HTN
K+ secretion–> Hypokalemia–> parasthesia, muscle weakness
What are the 3 most common causes of meningitis in infants (0-3mts)?
- Group B Strep
- E. coli
- Listeria
Which virulence factor allows E. Coli to cause meningitis in infants?
K1 Capsule antigen–> allows bacteria to survive in blood and go to CSF
What are the STOP codons?
UGA
UAG
UAA
What kinds of FA’s cannot be oxidized in the MT?
Very Long Chain Fatty Acids
FA’s w/ branch points at odd-numbered carbons (e.g. Phytanic acid)
What kinds of defects do Peroxisomal Diseases cause?
Neurological defects from improper CNS myelination
What is another name for Lactose?
Galactosyl-Beta-1,4-Glucose
What are the functions of Hypocretin 1/2 (Orexin-A/B)?
Promote wakefulness
Inhibit REN sleep-related phenomena
Where are Hypocretin 1/2 (Orexin-A/B) produced?
Lateral Hypothalamus
What can you measure to diagnose Narcolepsy?
Hypocretin 1/2 (Orexin-A/B) levels in CSF
Where does Hypocretin 1/2 (Orexin-A/B) circulate?
CSF
NOT in blood or peripheral tissues
How do Females and Males differ in their presentation of Non Salt-wasting 21-Hydroxylase Deficiency?
Males: 2-3yrs w/ early virilization, increased linear growth, elevated 17-hydroxyprogesterone and androgens
Females: Ambiguous genitalia at birth (w/ or w/o sal-wasting)
How do you treat Congenital Adrenal Hyperplasia?
Low doses of exogenous corticosteroids to suppress excessive ACTH and reduce stimulation of adrenal cortex.
The virilizing effects of Congential Adrenal Hyperplasia are due to what?
Excessive ADRENAL androgen production
Which artery serves the Internal Capsule?
Anterior Choroidal Artery
What is a Craniopharyngioma?
Tumor arising from Rathke’s Pouch
How is the Pituitary Gland formed?
Out-pouching of the pharyngeal roof (Rathke’s Pouch)
How is the Posterior Pituitary formed?
Extension of hypothalamic neurons
What are the 3 characteristics of Craniopharyngiomas?
Solid
Cystic
Calcified
How do Craniopharyngiomas usually present?
Childhood
Mass effect, visual deficits
What is the onset of Hyperacute transplant rejection?
Minutes to hours
What is the mechanism of Hyperacute Transplant Rejection?
Preformed Abs (usually anti-ABO or anti-HLA) Hypersensitivity Type II
The Phrenic nerve arises from which spinal cord segments?
C3-C5
Involvement/Irritation of the Phrenic Nerve can cause what?
Hiccups (ipsilateral diaphragm)
Dyspnea
Shoulder pain
The Brachial Plexus includes which nerve roots?
C8-T2
What are some neonatal complications of gestational diabetes?
Premature delivery Fetal Macrosomia Hypocalcemia Hypoglycemia Polycythemia Neural tube defects (including Caudal/Sacral Regression Syndrome) Resp. Distress Transient hypertrophic cardiomyopathy
What are the symptoms of Pompe’s Disease?
Acid-Maltase (alpha-glucosidase) deficiency Hepatomegaly Cardiomegaly Macroglossia Hypotonia Mental Retardation
What is the most common extracranial tumor in children?
Neuroblastoma
What do neuroblastomas develop from?
Adrenal Medulla
N-myc proliferation
Opsoclonus-myoclonus is a _______________ syndrome associated w/ _______________.
Paraneoplastic Syndrome
Neuroblastoma
What symptoms does Creutzfelt-Jakob cause?
Rapidly progressive dementia
Myoclonic jerks
What is the most common cause for elevated alpha-Fetoprotein?
Underestimation of gestational age
When should a Pregnancy Triple Test be performed?
16-18 weeks
What is included in a Triple Test during pregnancy?
alpha-FP
hCG
Estriol
What produces alpha-FP?
Early gestation: Fetal liver, GI tract, yolk sac
Maternal AFP increases w/ gestational age
What causes increases alpha-FP?
Neural tube defects
Anterior abdominal wall defects
Multiple gestation
What do Estriol levels reflect in pregnancy?
Placental and fetal function
What produces hCG?
Trophoblast
What are increased hCG levels assoc. with?
Multiple gestation
Hydatidiform mole
Choriocarcinoma
What is C-peptide formed from?
Proinsulin
When do patients w/ Aldolase B deficiency present?
When fructose-containing foods are introduced into the diet.
What are the symptoms of Fructose Intolerance (Aldolase B deficiency)?
Vomiting
Hypoglycemia
20-30min after fructose ingestion
Hepatomegaly
What does Aldolase B Deficiency cause?
Fructose Intolerance
How does Fructose Intolerance lead to hypoglycemia?
Intracellular accumulation of Fructose-1-P and depletion of inorganic phosphate–| glycogenlysis and gluconeogenesis
____% of all values are w/in 1 SD of the mean.
68%
____% of all values are w/in 3 SD’s of the mean.
99.7%
What is the definition of Negative Predictive Value?
Probability of being disease free if the test result is negative.
What affects Negative Predictive Value?
Pre-test Probability
Prevalence (b/c it is directly related to the pre-test probability)
How long to glycogen stores last when fasting?
12-18hrs
Once glycogen stores have been depleted, how does your body produce glucose?
Gluconeogenesis
What are the main steps in gluconeogenesis?
Pyruvate–> Oxaloacetate–> Malate–> (MT to cytosol)–> covert back to Oxaloacetate–> PEP–> Glucose
______________ proteins are involved in the posttranslational processing of oxytocin and vasopressin.
Neurphysins
Which nuclei of the hypothalamus produce ADH and Oxytocin?
ADH: Supraoptic nuclei
Oxytocin: Paraventricular nuclei
What cells give rise to Medullary Thyroid Cancer?
Parafollicular calcitonin-secreting C-cells
What are the characteristics of Medullary Thyroid Cancer microscopically?
Uniform polygonal or spindle-shaped cells
Extracellular Amyloid deposits
MEN 1 syndrome is characterized by tumor of what organs?
Pituitary
Parathyroid
Pancreas (usually Gastrin, sometimes VIP)
How do Gastrinomas present? What is a specific finding?
Upper GI ulcerations, abd pain and diarrhea
Jejunal ulcers are VERY specific
Gastrinomas can be assoc. w/ what syndrome?
MEN1
Should do work-up of: Calcium, Pituitary hormones, PTH hormones
Which medications are strongly assoc. w/ Body Fat Redistribution Syndrome?
HIV-1 Protease Inhibitors
Glucocorticoids
What is the most common cell type in the normal pituitary?
Somatotrophs (Somatostatin)
What are the characteristics of Thyroiditis?
Elevated ESR
Thyroid tenderness
Reduced Radioactive uptake
Mixed cellular infiltrate w/ occasional multinucleate giant cells
In Diabetic Ketoacidosis, what happens to body K+ stores?
Total body K+ DEFICIT
Normal to increased serum K+
Low intracellular levels
This happens b/c increased serum osm–> mov’t of H2O out of cells–> K+ follows so that intracellular levels remain the same
What does Permissive mean in terms of drug effects?
Allows a drug to act at its full potential
What is necessary for two compounds to be synergistic or additive?
Each must be able to elicit effect alone
What kind of bone changes do you see in Hyperparathyroidism?
Osteitis fibrosa cystica
Involves cortical (compact) bone
Subperiosteal thinning and cystic degeneration
What kind of bone changes do you see w/ Osteoporosis?
Trabecular thinning w/ fewer interconnections
What is the Sorbitol (Polyol pathway)?
Glucose—> (Aldolase)–> Sorbitol–> (Sorbitol DHase/Polyol DHase)–> Fructose
Where is the Polyol/Sorbitol pathway esp. active?
Seminal vesicles (sperm) Lens in eyes--> but can become overwhelmed--> cataracts in pts w/ Diabetes
What tissues contain low levels of Sorbitol DHase?
Retina
Renal Papilla
Schwann Cells
How are vit. D, Ca, Phos, and PTH levels affect in patients w/ Celiac Disease ?
Decreased Vitamin D absorption
Decreased Ca and Phos
Increased PTH
What should always be checked before/ monitored in patients taking Amiodarone?
Thyroid Function Tests
What side effects is Amiodarone assoc/ with?
Thyroid Dysfunction Corneal micro-deposits Blue-gray Skin discoloration Drug-related hepatitis Pulmonary Fibrosis
How can Amiodarone affect the thyroid?
Hypothyroidism in iodine-SUFFICIENT areas
Thyrotoxicosis (increased TH) in iodine-DEFICIENT areas
How do sex hormones affect growth?
Promote growth AND Epiphyseal closure
How does Precocious puberty affect growth?
Initial growth spurt–> then short stature b/c promotes epiphyseal plate closure
What histologic change is characteristic of Type II DM?
Pancreatic islet amyloid deposition
Islet amyloid polypeptide=Amylin
Which cells secrete Inhibin?
Sertoli cells
What are the functions of Sertoli cells?
Maintain spermatogenesis
Release Inhibin
Secrete MIF
What is the function of Aldosterone?
Increase Na+ reabs.
Increase K+ and H+ secretion
What is the Aldosterone escape?
High Aldo–> increase Na and H2O reabs–> increase RBF and GFR–> increase rate of Na excretion
What does the overproduction of Aldosterone cause?
- Na+ retention
- HTN
- Metabolic alkalosis
- Hypokalemia
What is the function of the HMP shunt?
Generate NADPH and pentose sugars
Which processes rely on NADPH?
Anabolic rxns that use NADPH as e- donor, such as:
Cholesterol synthesis
FA synthesis
Reduce Glutathione (oxidative damage in G6PD deficiency)
What is the mechanism of Thiazolidinediones?
Bind to Peroxisome Proliferator-Activated Receptor-gamma (PPAR-gamma)
Controls metabolism of Sugar and lipids
Part of steroid and thyroid superfamily nuclear receptors
What is the most important gene regulated by PPAR-gamma?
Adiponectin- a cytokine secreted by fat
Low levels in Diabetes–> increase w/ TZDs
How does Tamoxifen affect Bone, Breast, Endometrium, and Vasculature?
Bone: prevents osteoporosis (pro-estrogen)
Breast: Anti-estrogen
Endometrium: pro-estrogen–> may cause hyperplasia/cancer
Vascular: pro-thrombotic
What is a side effect of Risperidone?
Hyperprolactinemia–> amenorrhea and breast tenderness
What is the treatment of choice for Gestational Diabetes id diet/exercise change as not worked?
Insulin
What are Canagliflozin and Dapagliflozin?
SGLT-inhibitors
Oral anti-diabetic drugs
How do SLGT2 inhibitors work?
Decrease PCT reabsorption of glucose–> promote urinary loss
What must you monitor when patients are taking SGLT2 inhibitors?
Serum Cr and BUN
The mech of action of these drugs is in the kidney
Where does rT3 come from?
T4
How does Cortisol affect Insulin?
Can increase insulin resistance
How does DECREASED Aldosterone affect Na+, K+, HCO3-, Cl-, and H+ levels?
Decreased Na+ Increased K+ Increased H+ Decreased HCO3- Increased Cl-
How does Finasteride work?
5-alpha-reductase inhibitor
Suppressed PERIPHERAL conversion of Testosterone to DHT
What is MEN 2A?
Medullary carcinoma of Thyroid (Calcitonin)
Pheochromocytoma
Parathyroid tumor
What is MEN 2B?
Medullary Carcinoma of Thyroid (Calcitonin)
Pheochromocytoma
Marfanoid habitus/Mucosal neuromas
What drugs are used to treat Grave’s Disease ophthalmopathy?
High-dose gluccorticoids
Decrease inflammation due to lymphocyte infiltration and extraocular volume
What is Anastrozole?
Inhibitor of Aromatase
Used in treatment of metastatic breast cancer
What is Ketoconazole?
Anti-fungal
Decreases androgen synthesis
What is Trastuzumab?
Inhibitor of EGF and HER2/Neu pathways
Apoptosis of breast cancer cells
What is the difference between the causes of Transient and Permanent Central Diabetes Insipidus?
Transient: Posterior Pituitary
Permanent: Hypothalamus
Lipoic Acid is a co-factor for which MT enzymes?
- Pyruvate DHase–> deficiency causes lactic acidosis
- Alpha-Ketoglutarate DHase–> deficiency causes Maple Syrup Urine Disease
- Branched Chain Ketoacid DHase
Where are Thyroid Hormone Receptors located? How des this differ from other Steroid Hormones?
Thyroid Hormone Receptor–> located in nucleus
Other Steroid Receptors–> located in Cytoplasm and translocate to nucleus
What is the most common cause of Hypothyroidism?
Hoshimoto’s Thyroiditis
What is characteristic of Hoshimoto’s histologically?
Intense mononuclear infiltrate w/ Lymphocytes and Plasma cells (Mononuclear)
Well-developed Germinal Centers
What is Kallmann Syndrome?
Absence of GnRH secretory neurons in Hypothalamis
Defective migration of olfactory placode
Symptoms: Central hypogonadism, Anosmia, delayed puberty
How does Botulism toxin work?
Blocks release of ACh from nerve terminal at NMJ
Cerebellar hemangioblastoma is assoc w/ cysts of the kidneys, liver, and/or pancreasis highly suggestive of…..
von Hippel-Lindau Disease
Vin Recklinghausen’s Disease (NF-1)
Inherited PNS tumor syndrome
Presentation: Neurfibromas, optic nerve gliomas, Lindau nodules (pigmented nodules in iris), and cafe-au-lait spots, Pseudoarthrosis
NF-2
Autosomal dominant
Bilateral CN VIII schwannomas
Multiple meningiomas
Sturge-Weber syndrome
“Encephalotrigeminal angiomatosis”
Presentation: Cutaneous facial angiomas (typically CN V1 and V2), leptomeningeal angiomas, mental retardatiion, seizures, hemiplegia, skull radiopacities
Tuberous Sclerosis
Autosomal dominant
Presentation: Kidney, liver, pancreatic CYSTS, BILATERAL renal Angiomyolipomas, CORTICAL subependymal hamartomas, CUTANEOUS angiofibromas and Ash-leaf patches, visceral cysts, cardiac rhabdomyomas
Seizures (major complication)
Osler-Weber-Rendu Syndrome
Hereditary Hemorrhagic telangiectasia
Autosomal Dominant
Telangiectasia Ruptures can cause epistaxis, GI bleed, hematuria
NO cysts
Friedriech Ataxia
Autosomal recessive Cerebellar ataxia Loss of position/vibration sense Kyphoscoliosis Hypertrophoc cardiomyopathy Foot abnormalities DM
Which nerves control the Cremaster Reflex?
L1, L2
What connects the Lateral and Third Ventricle?
Foramen of Monro
What connects he Third and Fourth Ventricle?
Cerebral Aqueduct
What is the mechanism of Opiod Tolerance?
Possibly increased Phos pf Opiod Receptor–> increase AC–> increased NO levels
Activation of NMDA by Glutamate enhances morphine tolerance
What is Ketamine?
NMDA receptor blocker (block action of Glutamate)
Decrease morphine tolerance
Subacute Cerebellar Degeneration
Paraneoplastic Syndrome
Assoc. Small cell lung cancer, breast cancer, uterine cancer
Usually targets Purkinje Cells of cerebellum
Anti-Yo, Anti-P/Q, Anti-Hu Antibodies
What does the Meningitis vaccine contain?
N. meningitidis capsule polysaccharides from 4 diff. serotypes.
Conjugated to Diptheria Toxin
In AIDS pts, the radiographic finding of ring-enhancing lesions in both cerebral hemispheres is most often…….
Toxoplasmosis
What is the 1st line tx for Toxoplamsmosis?
Primethamine and Sulfadiazine
What is the difference b/t DNA polymerase I and III?
I: only one that has 5’–> 3’ exonuclease activity to remove RNA primer
III: 3’–>5’ exonuclease activity to remove mismatched bp
What is found on histology in Wenicke’s Encephalopathy?
Foci of hemorrhage and necrosis in mamillary bodies and periaqueductal gray matter
What is the main function of Thiamine (B1) ?
Glucose utilization
In Thiamine Deficiency you have decreased function which 3 enzymes
- Transketolase
- Pyruvate DHase
- alpha-ketoglutarate DHase
What enzyme can be measured to diagnose Thiamine Deficiency?
Erythrocyte transketolase activity
Which enzymes are inactivated by lead? (Lead poisoning)
Delta-Aminolevulinate DHase
Ferrochelatase
What accumulates in lead poisoning?
Delta-ALA
Protoporphyrin IX
What is the rate-limiting step enzyme in Heme Synthesis pathway?
Delta-Aminolevulinate SYNTHASE
What is Maple Syrup Disease?
Defect: Alpha-keto Acid DHase
Inability to degrade branched a.a. beyond alpha-keto acid state
Presents: Dystonia, poor feeding, maple-syrup urine
What are the symptoms of Vitamin A OVERDOSE?
Intracranial HTN
Skin changes
Hepatosplenomegaly
What are the symptoms of Naicin deficiency?
3 D’s
Dementia
Dermatitis
Diarrhea
What are the symptoms of Vitamin B2 (Riboflavin) deficiency?
Cheilosis Stomatitis Glossitis Dermatitis Corneal vascularizaion
The 1st Pharyngeal Arch is assoc. with the _____________ Nerve.
Trigeminal Nerve
The Neural Crest Cells of the 1st Pharyngeal Arch forms what?
Maxilla Zygoma Mandible Vomer Palatine Incus Malleus Mesodermal: mastication, ant. digastric, mylohyoid, tensor tympani, tensor veli palatini
What structures does the 2nd Pharyngeal Arch from?
Styloid process
Lesser horn of the Hyoid
Stapes
Muscles of fascial expression, stylohyoid, stapedius, posterior digastric
The 2nd Pharyngeal Arch is assoc. w/ the ___________ Nerve.
Facial (CN VII)
What do the 4th and 6th Pharyngeal Arches form?
Cartilaginous Structures of the larynx
What is the most common cause of sporadic encephalitis?
HSV-1 (predisposition of Temporal Lobe)
Edema, hemorrhagic necrosis
What are the anatomic landmarks for CN V?
Lateral aspect Middle Cerebral Peduncle
Which Hypothalamic Nuclei secrete ADH and Oxytocin?
Paraventricular and Supraoptic
What does the Arcuate nucleus of the Hypothalamus release?
DA
GHRH
GnRH
What does the Paraventricular nucleus of the Hypothalamus release?
ADH
Oxytocin
TRH
CRH
What are the most common causes of Aseptic (viral) Meningitis?
Enteroviruses (Coxsackievirus, Echovirus, Enterovirus, Poliovirus)
In Huntington’s Disease you have loss of ______-containing neurons in the________ due to __________ in Chrom ___.
GABA-containing neurons in the STRIATUM
Trinucleotide repeats of glutamate
HD gene in Chrom 4
Which 2 childhood brain neoplasms affect the cerebellum?
Pilocytic astrocytoma (1st most common brain neoplasm of childhood) Medulloblastoma (2nd most common brain neoplasm in children)
What is the difference between Medulloblastoma and Pilocytic Asytocytoma?
Medulloblastoma: often at the vermis. Sheets of small, blue cells. Poorly differentiated.
Pilocytic Astrocytoma: Rosenthal fibers. Low-grade, well-differentiated.
What embryologic tissue is Rathke’s pouch derived from?
Surface Ectoderm
What is derived from surface epithelium?
Rathke's Pouch (Ant. Pit.) Lens and Cornea Inner ear Sensory organs Olfactory epithelium Nasal/Oral epithelium Epidermis Salivary, sweat, mammary glands
What is derived from Neural Tube?
Brain and Spinal cord
Post. Pit.
Pineal Gland Retina
What are the skull bones derived from?
Neural crest
What kind of Immune Deficiency can lead to recurrent infections w/ Neisseria?
Complement factors that form MAC (C5b-C9)
“Clasp-knife” spasticity represents what kind of motor lesion?
Upper Motor Lesion
What is Incidence?
Number of new cases/ total pop. at risk
What Chrom is the Frataxin (Friedreich Ataxia) on?
Chrom. 9
Which areas of the brain are most susceptible to ischemia?
- Pyramidal cells of the Hippocampus and Neocortex
2. Purkinje cells of Cerebellum
What is the first area of the brain to be damaged during global ischemia?
Hippocampus
What kind of virus is JC virus? What is it assoc. w/?
DNA virus
Assoc. w/ Progressive Multifocal Leukoencephalopathy
Subacute Sclerosing Panencephalitis (SSPE)
Rare complication of Measles infection
Several yrs after infection–> accumulation of nucleocaspids
Oligoclonal bands of Measle virus (RNA virus) in CSF
Hemagglutinin and Matrix Protein
Presents: Dementia, various neurologic deficits, rapidly progressive, fatal
What kind of virus is the Measles virus?
RNA virus
What are complications of Measles?
- Primary measles pneumonia
- Secondary bacterial infection
- Neurologic: Encephalitis (days), Acute Disseminated Encephalomyelitis (weeks), SSPE (years)
Describe the Measles virus
Live attenuated
In brain ischemia, when do the first sign of macro and micro changes become visible? What is the first change you see?
12-48hrs
“Red Neurons” is the first change you see.
In brain ischemia what tissue changes happen?
12-48hrs: Red Neurons 24-72hrs: Necrosis and Neurtrophilic infiltration 3-5days: Macrophage infitration 1-2weeks: Reactive gliosis More than 2 weeks: scar
Ornithine Transcarbamoylase Deficiency
Most common disorder or Urea Cycle
High blood ammonia levels
Presents: Severe neurologic abnormalities
Increased Urine Orotic Acid excretion
What are the symptoms of Carpal Tunnel Syndrome?
BILATERAL
Median N. (Compression–> Nerve ISCHEMIA)
Sensory impairment, pain, parasthesias
Palmar surface of 1st 3 digits and half of 4th digit
Motor weakness during thumb abduction/opposition and thenar atrophy
(+) Tinel and Phalen signs
Which protein is involved with Prion Diseases?
PrP (Prion Protein)
Normally in a-helix form–> Beta-pleated sheaths–> resistant to proteases
What co-factor is used by the enzymes in this 2-step rnx? Phenylalanine–> Tyrosine–> DOPA
Tetrahydrobiopterin(B4)
Made by Dihydrobiopterin Reductase
Leber Hereditary Optic Neuropathy
MT Disease
Bilateral vision loss
Myoclonic Epilepsy With Ragged-Red Fibers
MT Disease
Myoclonic seizures and myopathy assoc. w/ excercise
Skeletal muscle has irregularly shaped muscle fibers (“Ragged Red Fibers”)
Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like Episodes (MELAS)
MT Disease
Stroke-like episodes w/ residual neurological deficit
Muscle weakness
Increase serum Lactate
What is the triad of Ataxia Telangiectsia? What is mutated in this disease?
IgA deficiency- Upper and Lower infections
Ataxia
Telangiectasia
Mutation: ATM (Ataxia Telangiectasia Mutated) gene–> DNA break repair
Delirium
Acute
Reversible
Acute-onset confusional state
Fluctuating consciousness
Deficits in attention, memory, executive function
Indicates underlying MEDICAL condition that must be addressed
What kinds of neonatal infections are acquired DURING delivery?
HSV Chlamydia Neisseria Viruses Group B Strep
How is Congenital Toxoplasmosis acquired?
ONLY If mother is infected during first 6mts of pregnancy
In-utero
What is the classic triad for Congenital Toxoplasmosis?
Intracranial calcifications
Chorioretinitis
Hydrocephalus
In tRNA- what are the functions of the 3’ and 5’ ends?
3’- Amino acid attachment
5’- Terminal Guanosine
What is the Cryptococcus found in nature?
Pigeon droppings and soil
What is the primary entry site for Cryptococcus?
Lungs
Even though it usually caused meningitis
What are the clinical manifestations of Rabies Encephalitis?
Restlessness
Agitation
Dysphagia
Progresses to coma 30-50days after exposure to bats
What kind of vaccine for Rabies?
Inactivated virus
Various strains of Rhabdovirus
What is the Length Constant (Space Constant)?
Measure of how far along an axon an electrical impulse can propagate
What neuronal property does Myelin affect?
Length Constant/Space Constant
Increases the distance an electrical impulse can propagate
What is Propionyl-CoA?
Derived from amino acids (Val, Ile, Met, Thr), odd-numbered FA, cholesterol side chains
Precursor for Methylmalomyl-CoA–> Succinyl-CoA–> TCA
Congenital Deficiency of Propionyl-CoA Carboxylase
Cannot convert Propionyl-CoA to Methylmalonyl-CoA
Propionic acidemia–> Poor-feeding, vomiting, hypotonia, lethargy, dehydration, Anion-Gap acidosis
Which CN control the salivary glands?
CN VII: Submandibular and Sublingual glands
CN IX: Parotid gland
What do Craniopharyngiomas arise from? What organ is derived from the same tissue
Rathke’s Pouch
Anterior Pituitary is also derived from Rathke’s Pouch
What is the cellular receptor for the Rabies virus?
NAch Receptors on peripheral nerves–> travels retrograde to CNS
What is Marcus Gunn pupil?
No consensual defect
What is the first step of the Urea Cycle? What activates this step?
CO2+NH3+ATP–> Carbomyl-phosphate
ACTIVATED by N-acetylglutamate (made by N-acetylglutamate synthase)
What is Synaptophysin?
Protein found in neurons, neuroendocrine, and neuroectodermal cells
(+) staining indicated Neuronal origin
Cauda Equina Syndrome
Low back pain Saddle anesthesia Loss of anocutaneous reflex Loss of ankle-jerk reflex Assoc. w/ damage to S2-S4
Cauda Medullaris Syndrome
Lesion at L2
Flaccid paralysis of bladder, rectum
Impotence
Saddle anesthesia
When is Vertical Diplopia most noticeable?
When affected eye looks toward the nose Reading newspaper, walking downstairs Trochlear Nerve (CN IV) palsy
What are the motions of the Superior Oblique and Inferior Oblique muscles?
Superior Oblique: Down and In
Inferior Oblique: Up and In
What is the significance of the Pterion?
Where frontal, parietal, temporal, and sphenoid bones come together
Where Middle Meningeal Artery is located
The Middle Meningeal Artery is a branch of which arteries?
Direct branch of the Maxillary Artery (branch of External Carotid Artery)
Where does the Middle Meningeal Artery enter the skull?
Foramen Spinosum
Where does Succinyl-CoA in the TCA come from?
Methylmalonic acid (Methylmalonyl CoA) ISOMERIZATION to form Succinyl-CoA
How does CN III Diabetic neuropathy/Nerve Ischemia present?
Acute onset diplopia
“Down and out” position (Somatic fibers located CENTRALLY)
Ptosis
NORMAL light and accommodation reflexes (Parasym fibers on PERIPHERY)
Describe the tomography of CN III in terms of somatic and parasympathetic innervation.
CENTRAL: Somatic. Ischemia–> Eye down and out, ptosis. Normal pupil size and light/accommodation reflexes.
PERIPHERAL: Parasympathetic. Compression–> Dilated pupil w/ Loss of accommodation.
Polymyalgia Rheumatica
Occurs in more than 50% pts w/ Temporal Arteritis
Neck, torso, shoulder, pelvic girdle pain
Morning stiffness
Fatigue, wt loss
What is the most feared complication of Temporal Arteritis?
Blindness
What are the 2 enzymes involved in Orotic Aciduria?
Orotate phosphoribosyl transferase
OMP Decarboxylase
Which step is inhibited in Orotic Aciduria?
Orotate–> UMP
How do you treat Orotic Aciduria?
Uridine Supplements–> converted to UMP–> Negative FB–> inhibits Carbomoyl-Phosphate Synthetase-II to attenuate orotic aciduria
Can subarachnoid hemorrhages present w/ nuchal rigidity?
Yes b/c blood in subarachnoid space–> meningeal irritant
What does Strep. pneumo look like on Gram Stain?
Gram +
Lancet-shaped cocci in pairs
What is Conversion Disorder?
Unconscious manifestation of neurologic symptoms when pathophysiological explanations cannot be found.
After significant life stress.
Which part of the spinal cord does B12 Deficiency affect?
Dorsal columns
Corticospinal tract
Symptoms: loss of position and vibration sensation, ataxia, spastic paresis
What is a severe complication of Subarachnoid Hemorrhage? How to prevent?
Vasospasm 4-12 days after
Prevention: Ca+ Channel Blocker
Lambert-Eaton is most commonly associated w/ what other illness?
Underlying malignancy, usually Small cell lung cancer
What is Myasthenia Gravis assoc. with?
Risk of Thymoma
Tetrodotoxin
Pufferfsh
Binds to Na+ channels–> INHIBIT Na+ influx–> prevent AP
Saxitoxin
Dinoflagellates in “Red Tide”
Binds to Na+ channels–> INHIBIT Na+ influx–> prevent AP
Ciguatoxin
Exotic fish, Moray eel
Binds to Na+ channel–> Keep OPEN–> persistent depolarization
Batrachotoxin
South America frogs
Binds to Na+ channel–> Keep OPEN–> persistent depolarization
What kind of teratogenic effects does Valproate cause?
Neural Tube defects
Inhibits absorption of Folic Acid
What is DRESS Syndrome?
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)
Occurs 2-8wks after exposure to drug
Drugs: Anticonvulsants (Phenytoin, Carbamazepine), Allopurinol, Sulfonamides (Sulfasalazine), Abx (Minocycline, Vancomycin)
Symptoms: Fever, generalized lymphadenopathy, facial edema, diffuse skin rash, Eosinophilia, organ dysfunction
In terms of congenital defects, what is “Malformation”?
Primary defect in the cells or tissues that form an organ. Intrinsic developmental abnormality
Ex) Holoprosencephaly, Congenital heart defects, anencephaly, polydacyly
In terms of congenital defects, what is “Deformation”?
Fetal structural anomalies that occur due to extrinsic mechanical forces
Ex) Congenital hip dislocation, Potter Syndrome, clubbed feet
In terms of congenital defects, what is “Disruption”?
Secondary breakdown of a previously normal tissue/structure
Ex) Amniotic band syndrome due to amnion rupture
In terms of congenital defects, what is “Sequence”?
A number of abnormalities result from a single primary defect
Ex) Potter Syndrome
In terms of congenital defects, what is “Agenesis”?
Complete absence of an organ
Ex) Renal agenesis
What kind of changes do you see in the brain with Compression Atrophy?
Decrease in number and size of neurons
What is Axonal Reaction?
Changes in the cell body of a neuron that has been severed
Enlarged, rounded cells w/ peripherally located nucleus and dispersed finely granular Nissl substance
Reflects increased protein synthesis for axonal repair
When do you see the biggest amount of change in the axons of severed neurons?
12days after injury
For amino acid reactions, what is vit. B6 (Pyridoxine) important for?
Transamination and Decarboxylation reactions
What is the most common location for Neonatal Intraventricular Hemorrhage?
Germinal Matrix (becomes less prominent 24-32 weeks) The risk of intraventricular hemorrhage increases w/ decreased weight and birth weight (PREMATURITY)
What are the symptoms of PKU?
Normal birth, presents at 6mts
Mental impairment, hyperactivity, seizures, decreased pigmentation of hair/skin, eczema, “Mousy” odor
Which amino acid is essential in pts w/ PKU?
Tyrosine
Which enzyme is most commonly deficient in PKU?
Phenylalanine Hydroxylase
What are the different functions of the Deep and Superficial branches f the Radial Nerve?
Deep branch: Arises near lateral epicondyle of humerus/top of radius. Purely MOTOR innervation of forearm extensor compartment muscles. NO sensory.
Superficial branch: Purely SENSORY to radial half of dorsal hand (EXCEPT distal 1st-3rd digits). NO motor!
In the Urea Cycle, where is the Nitrogen derived from?
NH3 and Aspartate
During an Action Potential, when is the membrane of a neuron most permeable to K+?
Repolarization period
What increases and decreases in Lesch-Nyhan Syndrome?
Decreases: HGPRT, purine salvage pathway
Increases: Degradation of Hypoxanthine and Guanine to uric acid, PPRP levels, and PRRP Amidotransferase activity
CN V3 exists through which foramen?
Forman Ovale
Pick Disease
Rare cause of dementia
Symptoms: social disinhibition, speech abnormalities, emotional flattening
Pronounced atrophy of frontal-temporal regions
What is commonly found in the brains of pts with Alzheimer’s Disease?
Amyloid
What is the most common cause of Intracranial Hemorrhage?
HTN through formation of Charcot-Bouchard psudoaneurysms in small arterioles in basal ganglia and thalami
What is the difference between rupture of Saccular Aneurysm and Charcot-Bouchard Pseudoaneurysm?
Saccular: Subarachnoid hemorrhage
Charcot-Bouchard: sudden onset of focal deficits (basal ganglia, internal capsule, thalamus, pons
What is the key difference between Physostigmine and Neostigmine/Edrophonium? How are they similar?
ALL: AChE inhibitors
Physostigmine: can reverse BOTH CNS and peripheral effect of severe Atropine toxicity
Neostigmine/Edrophonium: Have a quaternary ammonium stx that limits CNS penetration
What is the drug of choice for Trigeminal Neuraliga?
Carbemazepine
Carbemazepine
Mech: Inhibits high-freq firing by reducing ability of Na+channels to recover from inactivation
Uses: first-line treatment for Trigeminal Neuralgia, other uses also
Side Effects: Aplastic anemia, P450-inducer
What is the genetic mechanism of Fragile-X?
Increased number of CGG repeats lead to hypermethylation of Cytosine bases–> Gene inactivation
What side effects can Atropine (anti-cholinergics) have in the eye?
Mydriasis–> Close-angle glaucoma
Cylcoplegia (paralysis of accommodation)
What distinguishes Listeria from Corynebacterium?
Both are Gram + with V or L formations
BUT Listeria have tumbling motility!
Drug-Induced Parkinsonism
Caused by medications that block D2 receptors (more common w/ 1st generation anti-psychotics)
Management: Decreasing/stopping offending drug. Benztropine or Amantadine
Contraindicated: Do NOT give Levodopa or DA-agonists–> will precipitate psychosis
List the Dopamine Agonists
Stimulate DA-receptors
Ergot compounds: Bromocrptine and Pergolide
Nonergot Compounds: Pramipexole and Ropinirole
How do bacteria gain resistance to Cephalosporins?
Change in structure in Penicillin-Binding Proteins
What is the signaling pathway for the following receptors: a1, b2, b2, mAChR, NAChR
a1: IP3–> Ca+
b1: cAMP–> PKA
b2: cAMP–>PKA
mAChR-1/3: IP3–> PKC
mAChR-2: cAMP (decrease)
NAChR: Ion channel–> Na, Ca, K
What is a pathological finding in Creutzfeldt-Jacob Disease?
Large intracytoplasmic vacuoles
How are the side effects of Levodopa affected by adding Carbidopa?
Carbidopa can DECREASE most peripheral side effects of Levodopa
However, behavioral effects can INCREASE b/c more DA (agitation, anxiety, confusion, insomnia, delusion, hallucinations)
What are the symptoms of Vitamin E Deficiency?
Neuromuscular disease (skeletal myopathy, spinocerebellar ataxia, pigmented retinopathy)
Hemolytic anemia
In Wernicke-Korsakoff Syndrome, which symptoms are reversible?
Reversible (Wernicke-syndrome): oculomotor dysfunction, ataxia, confusion
Irreversible (Korsakoff-syndrome): Memory loss, confabulation
Describe HA’s of Brain Tumors
Involve entire head
Progress slowly over time
Lying down (recumbent) makes it worse
May be accompanied by papilledema, vomiting, cognitive decline
What are the 2 types of exacerbations that can occur when treating Myasthenia Gravis? How do you distinguish?
Myasthenic crisis: due to undertreatment
Cholinergic crisis: due to overtreatment
Distinguish: Edophorium will improve Myasthenic crisis, but NOT Cholinergic crisis
What is the most common cause of Communicating Hydrocephalus?
Dysfunction or obliteration of subarachnoid villi
Usually a sequelae of meningeal infection
CYP 450 Inducers
Carbamazepine Phenobarbital (and other Barbituates) Phenytoin Rifampin Griseofulvin
CYP 450 Inhibitors
Cimetidine Ciprofloxacin Erythromycin Azole Antifungals Grapefruit juice Isoniazid Ritonavir (Protease Inhibitors)
What is a common side effect of SSRI’s?
Sexual dysfunction
Selegiline
MAO, Type B
Can prevent MPTP-induced damage of DA-neurons
Used to clinically delay progression of Parkinson’s
Used in 1st line tx of Parkinson’s with Anti-Cholinergics and Amantadine
In opioid use, you NEVER develop tolerance to which side effects?
Constipation
Miosis
Penicillin and Cephalosporins IRREVERSIBLY bind to which proteins?
Penicillin-binding proteins, such as transpeptidases
How do Lipid Solubility and Blood Solubility affect general anesthetics?
DECREASE Blood Solubility: Rapid induction and recovery
INCREASE Lipid Solubility: IncreasePotency
Ataxia Telangiectasia
Autosomal recessive
Defect in DNA-repair genes
DNA is hypersensitive to radiation
Cerebellar ataxia, oculocutaneous telangiectasias, repeated sinopulmonary infections, increased incidence of malignancy
Pneumocystic pneumonia is practically diagnostic for……
HIV
What tests can you use to diagnose Cryptococcus neoformans?
India ink (round or oval budding yeast)
Latex agglutination–> polysaccharide capsule
Culture (Sabouraud’s agar)
Methenamine (GMS), mucicarmine stains of tissue
What is the Blood/Gas Partition coefficient?
Onset of action of a gas anesthetic depends on its solubility
HIGH Blood/Gas Partition Coefficients are MORE soluble in blood–> SLOWER equilibrium in the brain–> LONGER onset time
Transentorial Herniation
Uncal herniation
Medial temporal lobe (uncus) herniates through crus cerebri and tentorium
Compression of: CN III, Posterior Cerebral Artery, Brainstem hemorrhage (stretching Basilar Artery), Contralateral Cerebral Peduncle (ipsilateral hemiparesis)
Subfalcine Herniation
Cingulate gyrus herniates
Under Falx Cerebri
Compression of: Anterior Cerebral Artery
Tonsillar Herniation
Cerebellar tonsils
Through Foramen Magnum
Compression of: Medulla
Arginase Deficiency
Arginase converts Arginine to urea + ornithine
Increase Arginine levels
Symptoms: Spasticity, athetosis
Tx: Low protein, NO Arginine
What is Ornithine transport used for?
Urea Cycle
Transport Ornithine into MT to combine w/ Carbomyl Phosphate to form Citrulline
In Maple Syrup Urine Disease, what gives the urine the sweet smell?
Isoleucine metabolite
What cofactors are important for Branched-Chain alpha-ketoacid DHase, Pyruvate DHase, and alpha-ketoglutarate DHase?
Thiamine Lipoate Coenzyme A FAD NAD
What kinds of drugs can increase Lithium concentrations?
Drugs that increase PCT absorption of Na+
NSAIDs
Thiazide diuretics
ACE-Inhibitors
Common Peroneal Nerve
Most commonly injured leg nerve
Injury: Lateral aspect of leg, Fibular neck fractures, external pressure due to prolonged immobility
Presentation: “Foot Drop”, Plantarflexed and Inverted, Decreased sensation to anteriolateral leg and dorsum of foot
What causes the rapid plasma decay of Thiopental?
Redistribution of drug throughout the body, NOT metabolism!!!
What is the mechanism of Timolol and other Beta-Blockers in Glaucoma tx?
Decrease Aqueous humor production by Ciliary Epithelium
Where are Alpha-1 Receptors located?
Peripheral Vasculature (constriction)
Bladder
Eye (Myadriasis)
Where are Beta-1 Receptors located?
Heart
Where are Beta-2 Receptors located?
Peripheral vasculature (skeletal muscle-vasodilation)
Bronchi
Uterus (Relaxation)
What is the effect of Renal Agenesis on amniotic fluid levels?
Oligohydranminos (too little amniotic fluid)
Not able to produce urine
Waterhouse-Friderichsen Syndrome
Caused by meningococcal sepsis with N. meningitidis
Symptoms: Sepsis, hemorrhagic Adrenal gland destruction, DIC, shock
Does not necessarily cause meningitis
Which drugs are metabolized by CYP450?
Warfarin Phenytoin Propranolol Metoprolol Quinidine Theophylline
What is a side effect of Cimetidine?
Gynecomastia
Pentazocine
Opioid narcotic designed for analgesic effects, but NO Abuse Potential
Partial agonist and weak antagonist activity at Mu-Receptors
Can cause withdrawal symptoms in pts with tolerance or dependence on opioids
Primidine
Anti-convulsant AND 1st-line for Essential Tremor
Active metabolites: Phenobarbital and Phylethylmalonamide
SE: Sedation from phenobarbital
Germinomas
Most common location–> PINEAL gland region
Histologically, similar to testicular seminomas
Symptoms: Precocious puberty, Parinaud Syndrome, obstructive hydrocephalus
Parinaud Syndome
Paralysis of upward gaze and Convergence
Due to compression in tectal area of midbrain (dorsal)
Common of symptom of Pineal Tumors (Germinomas)
First Generation H1-Histamine Receptor antagonists
Diphenhydramine and Chlopheniramine
Can cause significant sedation, esp. when used with other CNS-depressors (Benzodiazepines, etc)
Severe Vitamin E deficiency can mimic…….
Friedriech Ataxia
Dorsal columns, peripheral nerves, and Spinocerebellar tracts
What are some long-term sequelae of Hydrocephalus?
Hypertonicity, Hyperreflexia, learning disabilities, visual disturbances
Damage to Periventricular pyramidal tracts
Myotonic Dystrophy
Autosomal Dominant
Trinucleotide repeat for Myotonia-Protein Kinase
2nd most common inherited muscle disease (after Muscular Dystrophy)
Muscle Atrophy, Type 1 Fibers affected (NO muscle necrosis/fatty replacement like myscular dystrophy
Presenting Symptoms: Can’t let of doorknob/hand during handshake, Cataracts, Frontal Balding
1st generation Antihistamines (Diphenhydramine, Chlorpheniramine) also have what kind of actions?
Antimuscarinic (dry mouth, pupil dilation, constipation, blurry vision), urinary retention)
Anti-Serotonergic
Anti-alpha adrenergic
What are the effects of Antimuscarinic effects?
Dry mouth Pupil dilation Constipation Blurry vision Urinary retention
What is the cause of decreased ACh release in Alzheimer’s?
Decreased activity of Choline Acetyltransferase
Meniere’s
Vertigo
Tinnitus
Sensorial hearing loss
Cause: Increase volume and pressure in endolymph in vestibular apparatus
How do you treat Hyperpyrexia (Temp >40C)?
1st: Cold blankets
2nd: Anti-pyretics (Aspirin, Acetaminophen)
What is the first-line treatment for Narcolepsy?
Frequent naps
Modafinil (Psychostimulants)
How/When does Neimann-Pick Disease present?
When: Infancy
Present: Cherry-red macular spot, hypotonia, loss of motor skills, hepatosplenomegaly
Foamy Histiocytes on microscopy
Death by Age 3
Neuroleptic Malignant Syndrome
Most commonly assoc. w/ Haloperidol Mech: Anti-DA effects Symptoms: Hyperthermia, generalized rigidity, autonomic instability, altered mental status Tx: Dantrolene, Bromocriptine NO way to prevent!
How long can it take to see the effects of Buspirone?
2-several weeks
How does Phenytoin cause Gingival Hyperplasia?
Causes increased expression of PDGF–> Gingival macrophages–> Stimulate proliferation of gingival cells an alveolar bone
What are the main side effects of Phenytoin?
Cerebellar and Vestibular
Nystagmus and Gait instability
What are the durations of the different Benzodiazpeines?
Triazolam: short Lorazepam: Intermediate Diazepam: Long Flurazepam: Long Chlordiazapoxide: Long
Organophosphates
Insecticides
AChE-Inhibitors
Symptoms: Excessive salivation, lacrimation, diaphoresis, urinary incontinence, diarrhea, emesis, miosis, bradychardia
What are the mechanisms of Diabetic Neuropathy?
- Microangiopathy- non-enz glycosylation–> hyalinization and narrowing–> nerve ischemia
- Intracellular hyperglycemia–> Aldolase Reductase–> Glucose converted to Sorbitol and Fructose–> Sorbitol increases osm–> water influx–> osm damage
Which Anticonvulsants can be used to treat Absence seizures?
Ethosuximide
Valproic acid
Lamotrigine
Essential Tremor
Autosomal Dominant
Slowly progressive symmetric postural or kinetic tremor
Tx: Propranolol (Beta-adrenergic antagonist)
What are the side effects of Buproprion?
Psychosis
Seizures (esp. w/ increase dose)
Dry mouth
Which drugs are known to cause seizures?
Buproprion (anti-depressant) Clozapine (antipsychoic at high doses) Isoniazid (Anti-TB, if given w/o Pyridoxine) Ciprofloxacin (Abx) Imipenem (Abx)
What are the symptoms of Atypical Depression?
Mood Reactivity
Criticism/Rejection sensitivity
Increased sleep
Increased appetite
What is used to treat Atypical Depression?
MAO-Inhibitors
What are some things that can worsen the symptoms of Multiple Sclerosis?
Hot showers
Strenuous exercise
Heat exposure
What chemical changes can occur in the brain due to long-term alcohol use?
Downregulation of GABA Rec
Upregulation NMDA Rec (EtOH usually inhibits NMDA)
Increase synthesis of excitatory mediators (NE, Serotonin, DA)
What is the timeline for EtOH withdrawal symptoms?
Within 5-10hrs
- Tremulousness
- GI distress, anxiety, autonomic disturbance
- Delirium Tremens 48-72hrs
How does Listeria stain on blood agar plate?
Narrow-zone of Beta-hemolysis
What kind of immune reaction does Listeria require to fully eradicate?
Cell-mediates
Listeria is a Facultative Intracellular
How does Listeria survive in Macrophages?
Listeriolysin-O
Pore-forming toxin that is activated in acidified phagosomes
What kind of cytokines does Listeria infection stimulate?
IFN-gamma
TNF-Beta
IL-2
How does temperature affect Listeria?
22C: Tumbling motility
4C: Can multiply
How can you prevent spreading N. meningiditis to close contacts?
Rifampin!!!!!
How do the Lateral and Ventromedial nuclei of the Hypothalamus affect food intake? How does Leptin affect them?
Lateral–> Hunger. Inhibited by Leptin.
Ventromedial–> Satiety. Activated by Leptin.
Cerebral Amyloid Angiopathy
Common cause of recurrent hemorrhage
Hemorrhages are smaller than those seen in those caused by HTN
Usually in cerebral hemispheres, not basal ganglia
In First generation Antipsychotics, what is the difference in side effects of the low- and high-potency drugs?
Low-Potency: “Make you feel low” Sedation, Anticholinergic, Orthostatic hypotension
High-Potency: Increase Extrapyramidal symptoms (dystonia, akinesia, tardive dyskinesia
How do Muscarinic-ACh receptors affect the endothelium?
mAChR of endothelial surface
Release Nitric Oxide (Endothelium-Derived Relaxation Factor)–> GC–> cGMP–> Ca+ Efflux–> Vascular Relaxation
What kind of diagnosis if Tetanus? Is there a serum toxin you can measure?
Clinical
There is NO serum toxin that you can meausure
Besides Antidepressants, what other kind of drugs can cause Serotonin Syndrome?
Tramadol (analgesic)
Ondansetron (antiemetic)
Linezolid (Abx)
How does N. meningitidis gain access to the meninges?
Pharynx–> blood–> choroid plexus–> meninges
“Red Ragged” Muscle fibers- what are they characteristic of?
Seen in MT diseases!!
MERRF (Myoclonic Epilepsy with Red Ragged Fibers)
MT Disease
What is the mechanism of Botulinum poisoning?
Blocks presynaptic exocytosis of ACh
BOTH NACh and mACh effects!
What are symptoms of Nicotinic ACh blockade?
Diplopia
Dysphagia
Describe the acute and prophylactic tx for migraines.
Acute: Triptans (Sumatriptan)
Prophylaxis: Beta-blocker, Antidepressants (Amitryptyline, Venlafaxine), Anticonvulsants (Valproate, Topiramate)
What are the similarities/differences between Entacapone and Tolcapone?
BOTH are COMT-Blockers
Entacapone: ONLY decreases peripheral degradation of L-Dopa
Tolcapone: ALSO decreases degradation of DA centrally
What kinds of Antidepressants should not be used in pts with BPH?
TCAs should not be used because have higher Anticholinergic effects–> urinary retention
What is the cause of Homocystinuria? What are the symptoms?
Cystathionine Synthetase Deficiency
Symptoms: Resemble Marfan Syndrome, ectopic lentis, developmental delay, increased risk for thromboembolus
About 50% of pts with Homocystinuria respond to tx with ___________.
Vitamin B6 (Pyridoxine)
Besides Lithium, which other Anti-convulsants can be used for Bipolar Disorder?
Valproate
Carbemazepine
Lamotrigine
What Chromosome is the NF-2 gene on?
Chromosome 22!
Cocaine Intoxication (Symptoms)
Agitation Tachycardia HTN Light-responsive mydriasis Myocardial Ischemia (possible) If used nasally, overtime can lead to nasal mucosa atrophy--> perforation
What is the mechanism of Cocaine?
Inhibits reuptake of NE, DA, and Serotonin
What kind of psychiatric problem can Anti-depressants cause?
Mania
Esp. in those susceptible for Bipolar Disorder
Which drugs are used to treat Alzheimer’s?
Memantine: NMDA-Antagonist
Donepezil, Galantamine, Rivastigmine: AChE-Inhibitors
Vitamin E: Antioxidant
What kinds of drugs should be avoided in pts with Alzheimer’s?
Drugs with depressive effects (Benzodiazepines, etc) UNLESS using to treat anxiety or insomnia
Akathisia
Extrapyramidal side effect of antipsychotic meds
Inner restlessness and inability to sit or stand in one position
***Often misdiagnosed!!! Can make worse if increase drug dose!
What is a rare, but very severe complication of Halothane exposure?
Massive Hepatic necrosis
What causes PKU?
Deficiency of Phenylalanine Hydroxylase OR Tetrahydrobiopterin/Dihydropteride Reductase
How does a Central Retinal Artery Occlusion present?
Acute, painless monocular vision loss
Cherry-red macula
Pale retina
Acute Neonatal Narcotic Withdrawal Syndrome
Pupillary dilation Rhinorrhea Sneezing Nasal stuffiness Diarrhea Nausea Vomiting Chills, tremors, jittery movements Tx: Opium solution (Diluted tincture)
Which virulence factor is responsible for toxic effects seen in meningitis and meningicoccemia?
Lipooligosaccharide (LOS)
What causes liquefactive necrosis in hypoxic brain tissue?
Release of lysosomal enzymes from ischemic neurons
In Organophosphate intoxication, Atropine will NOT reverse which effects?
Muscle paralysis (NAChR)
What is the mnemonic for the symptoms of Organophosphate intoxication?
D=diarrhea U=urination M=muscle paralysis B=bronchospasm E=emesis L=lacrimation S=salivation/ Sweating
What is good and bad about short-acting benzodiazepines?
Good: Less drowsiness
Bad: INCREASED risk for developing dependence
What is the most important virulence mechanism for Staphylococcus epidermidis?
Ability to form BIOLFILMS
If you are suspicious of Temporal Arteritis, what test should you order?
ESR (Erythrocyte Sedimentation Rate)
How can Pancoast Tumors present?
Can manifest as Horner’s Syndrome and/or ipsilateral compressive brachial plexopathy
What do Schwannomas look like histologically?
Biphasic pattern of high cellularity (Antoni A area) and myxoid region (Antoni B)
Elongated, spindle cells
+ S-100
List the 3 Dopaminergic Systems
Mesolimbic-Mesocortical–> Behavior–> Schizophrenia
Nigrostrtiatal–> Coord of voluntary mov’t–> Parkinson’s
Tuberoinfundibular–> Prolactin release–> Hyperprolactinemia
Thiopental (where does it go after going to the brain?)
Barbiturate
Used for SHORT-acting general anesthesia
After equilibrium w/ the brain–> fat and muscle–> quick recovery
What does the Arteriovenous Concentration Gradient tell you about a drug?
Reflects overall tissue solubility of anesthetic–> High tissue solubility–> High arteriovenous conc. gradient–> Slower onset of action
Clozapine (What is the MAJOR side effect you must monitor?)
Atypical Antipsychotic
Blocks D4 DA-receptors( NOT D2 like typical antipsychotics)
Less likely to cause DA-side effects (Pseudoparkinsonism, Tardive dyskinesia, hyperprolactinemia)
SIDE EFFECT: Agranulocytosis–> MUST check WBC
What are the 1st and 2nd generation Antihistamines?
1st: Chloropheniramine, Diphenhydramine, Promethazine
2nd: Fexofenadine
2nd, Do NOT cross BBB, non-sedating, NO antimuscarinic, antiserotoniergic, no anti-alpha adrenergic
SOB, wheezing, and prolonged expirations are indicative of………….
An asthma attack
Why do patients have to wait 2 weeks after discontinuing an MAO before initiating an SSRI?
Allow time for MAO to regenerate/ increase synthesis
To avoid Serotonin Syndrome
Treatment for Alcohol Withdrawal
Benzodiazepines
First-line: Long-acting Benzos (Chlorodiazepoxide, Diazepam)
Liver Dysfunction: Short-acting (Lorazepam, oxazepam)
What are the 3 big side effects of Lithium?
- Hypothyroidism
- Diabetes Insipidus (Nephrogenic)
- Tremors
What is the treatment for Motion Sickness?
Antimuscarinic
OR Antihistamines w/ Antimuscarinic effects (First generation)
How do you prevent cerebral vasospasm after Subarachnoid Hemorrhage?
Ca-Channel Blocker!
Nimodipine!
What is the most common cause of Aseptic Meningitis?
Enteroviruses (Poliovirus, Coxsackivirus Echovirus)
Where do Enteroviruses get their name from?
Fecal-oral transmission
They do NOT typically cause gastroenteritis
Which areas of the brain does Wilson’s Disease affect?
Basal ganglia
What is a common side effect of Trazadone that makes it bad for Adolescent boys?
Priapism
With Trendelenburg’s Sign, which nerve is injured? Which muscles affected?
Superior Gluteal
Gluteus medius, gluteus minimus, tensor fasciae latae
Treatment for TCA-assoc. Cardiac Abnormalities
Bicarbonate
for QRS prolongation, reverse hypotension, ventricular dysrhymias
“On-Off” Phenomenon in Parkinson’s patients with Levodopa
Long-term tx w/ Levodopa
Fluctuations in motor function
Consequence of Nigostrial Neurodegeneration–> decreased therapeutic window for Levodopa–> small changes in drug levels–> bradykinesia
UNPREDICTABLE!!!
Symptoms of Serotonin Syndrome
Confusion Agitation Tremor Tachycardia HTN Clonus Hyperreflexia Hyperthermia Diaphoresis
How doe you treat Serotonin Syndrome?
Cyproheptadine (Antihistamine w/ anti-serotonergic properties)
Serotonin receptor antagonist
What is Phenotypic mixing b/t viruses?
Co-infection of a host cell w/ two viral strains, resulting in progeny virion that contains nucleocapsid proteins from one strain and the genome of the other strain
What are the 3 most important side effects of ALL Protease Inhibitors?
- Hyperglycemia (Insulin resistance)
- Fat redistribution/ Lipodystrophy
- P-450 Inhibitor
How does an Abortive Viral Infection present?
Does NOT cause significant cytopathic effects
No change in host cell
How does a primary HSV-1 infection usually present?
Vesiculoulcerative lesions of oral mucsa
Gingivostomatitis
Cervical lymphadenopathy
Fever
What kind of cells do you see on microscopy with HSV and VZV?
Multinucleated giant cells with intranuclear inclusions
Which Blot Test should be used to assess gene expression?
Northern Blot
How does HBV aid in the infection with HDV?
HDAg must be coated with HBAg
What do the Homeobox genes code for? What is their purpose?
DNA-binding transcription factors
Role in morphogenesis
What is a rare, but serious adverse effect of ACE-Inhibitors?
What is the cause?
Angioedemia (facial, tongue, lips, eyelids swelling)
Sometimes laryngeal edema
Cause: Bradykinin accumulation
What type of antivirals are currently recommended for primary genital herpes?
Nucleoside analogs (e.g. Acyclovir)
What is the mechanism of Nucleoside analogs?
Incorporated in newly replicated DNA–> terminate viral DNA synthesis
Require activation by Viral Thymidine Kinase
What is Thayer-Martin medium? What does it contain?
Used to isolate Neisseria species
Chocolate agar with:
1. Vancomycin: inhibit Gram +
2. Colistin (Polymyxin): inhibit Gram - (E. coli)
3. Nystatin: inhibit Fungi
4. Trimethoprim: inhibit Gram - other than Neisseria (Proteus)
Enterobius vermicularis (Enterobiasis)
Occurs frequently in school-age children
Presentation: Perianal pruritis
Diagnosis: Scotch Tape Test
Tx: Albendazole (1st), Pyrantel Pamoate (Pregnant women)
In HBV, which marker indicates infectivity?
HBeAg
HBsAg- What does it indicate?
Detectable during ACUTE infection
Persistence >6mts–> CHRONIC
Anti-HBs- What does it indicate?
Appearance indicates resolution of acute infection
Confers long-term immunity
Present after vaccination
Anti-HBc IgM- What does it indicate?
Present during ACUTE infection and window phase when both HBsAg and Anti-HBs are absent
Anti-HBc IgG- What does it indicate?
Detectable w/ Anti-HBs and Anti-HBe after recovery from acute infection
Present w/o Anti-HBs in chronic infection
HBeAg- What does it indicate?
Appears after HBsAg during ACTUTE infection
Marker of viral replication activity
Detectable in chronic infection w/ high infectivity
Anti-HBe- What does it indicate?
Present after recovery from acute infection
HBeAg/Anti-Hbe–> transition of chronic infection from high to low viral replication and infectivity
What is the mechanism of Penicillins?
Inhibit Transpeptidase
Structural analogs of D-ala-D-ala
Failed synthesis of bacterial peptidoglycan cell wall
Reactive Arthritis
Triad: Non-Gonococcal urethritis, Conjunctivitis, Arthritis
HLA-B27
Seronegative Spondyloarthropathy (including Ankylosing Spondylitis)
Presentation: Occurs several weeks after genitourinary OR enteric infection
Complication: Sacroiliitis (20%)
What is the most common outcome of HBV infection in adults?
Acute hepatitis w/ mild or subclinical symptoms that completely resolve
>95%
What is the current treatment for sexually transmitted urethritis?
Cetriaxone (N. gonorrhea)
Doxycycline/Azithromycin (C. trachomatis)
Neonatal HBV
Transmission usually during fetal passage, but also transplacentally
High levels of HBV replication
MILDLY elevated liver enzymes
High risk of chronic infection (> 90% higher than adults and children)
What is the p24 protein in HIV?
Nucleocapsid protein
“gag” gene
What is N-myc?
Transcription Factor
What kind of proteins are c-Jun and c-Fos?
Nuclear transcription factors
Bind DNA via Leucine Zipper Motif
In viruses, what is the function of the Nucleocapsid?
Surround the viral genome
Changes in which proteins can change a virus’s host range?
Surface glycoprotein
Mediates attachment to target cell plasmalemma recetors
Which antibiotics are used for Anaerobic coverage?
Above the diaphragm: Clinamycin
Below the diaphragm: Metronidazole
What are Clavulanic acid, Sulbactam, and Tazobactam?
Beta-lactamase inhibitors
Extend the spectrum of Penicillin Abx (include Beta-lactamase producing org)
S.aureus, H.influenzae, Bacterioides, other Gram Neg bacteria
Which Antibodies are SPECIFIC for SLE? What % of pts have them?
anti-dsDNA (Only present in 60% cases–> cannot rule out)
anti-Smith
What kind of genome does HBV have?
ds-DNA
What is the replication sequence for HBV?
ds-DNA–> + RNA template –> progeny ds-DNA
What is Zidovudine (AZT)?
HIV tx (esp. Prophylaxis in Pregnant Women) Nucleoside Reverse Transcriptase Inhibitor Mech: Competitively binds to reverse transcriptase--> incorporated into viral genome and thymidine analog--| 3' -5' bond formation b/c does NOT have 3'-OH
Mucormycosis
Causes: Mucor, Rhizopus, Absidia
Symptoms: Facial Pain, HA, Black necrotic eschar in nasal mucosa, periorbital pain
Diabetic Ketoacidosis, Immunocompromised
Microscopy: Broad, nonseptate hyphae at 90 degree-angle branching
Diagnosis: affected tissue biopsy
Tx: Amp-B
Why is it so difficult to form lasting immunity to N. gonorrhea? What else can cause repeated N. gonorrhea infections?
Antigenic variation of Pili
Other reasons for repeated infections: Inability to form MAC (complement)
How does CMV present in Immunocompetent vs. Immunocompromised pts?
Immunocompetent: Subclinical OR Mononucleosis
Immunocompromised: Retinitis, Hepatitis, Colitis, Esophagitis, Pneumonia
Describe the characteristics of HBV.
Genome: partially circular dsDNA
Contains Reverse Transcriptase
Enveloped- obtained from ER
What is the difference between Efficacy and Potency of a drug?
Efficacy: Maximal achievable effect of drug
Potency: Drug dose needed for given effect
What are the different stages of Syphilis?
Primary: Chancre (painless)
Secondary: 5-10 weeks later. Bacteremic. Diffuse maculopapular rash on soles/palms. Condylomata lata (wart-like).
Latent: Asymptomatic.
Tertiary: Neurosyphilis, Cardiovascular involvement (aortic aneurysm, aortic valve insuff), Gummas (bones, skin, mucosa, subcutaneous, organs)
What makes C. trachomatis resistant to Penicillins and Cephalosporins?
No Peptidoglycan in cell wall
What is unique about Ureaplasma urealyticum?
NO cell wall
What is the treatment of C. diptheria? What is the most important in tx?
Diptheria Anti-toxin (passive immunity) MOST IMPORTANT!!! Penicillin or Erythromycin DPT vaccine (active immunity)
What is Ebstein anomaly?
Abnormality in the tricuspid valve
What phase are oocytes in right after ovulation?
Metaphase II
What are the 2 most common causes of Osteomyelitis in pts with Sickle Cell Disese?
Salmonella
Staph. aureus
What is the virulence factor of Salmonella?
Vi-antigen in Capsule–> prevents opsonization and phagocytosis
Actinomyces isrealii
Gram +
Causes cervicofacial actinomycosis following dental manipulation or oral trauma
Slow-growing and firm abscess in face or neck region
Tx: Long-term Penicillin and debridement
What is the Nucleosome composed of?
2 of each: H2a, H2b, H3, H4
H1 is BETWEEN/OUTSIDE of the nucleosome
How does HAV infection usually present in CHILDREN? Adults?
Subclinical, silent,”Anicteric”. Can also have acute-jaundice, malaise, nausea, vomiting, etc.
Clinical presentation is LESS common in adults, but more severe.
What is the difference between Wegner’s and Goodpasture’s?
Wegner’s: BOTH upper and lower respiratory involvement
Goodpastures: ONLY lower respiratory involvement
Wegner’s (Granulomatsis Polyangiitis)
- Necrotizing vasculitis of upper and lower respiratory tract
- Rapidly progressive glomerulonephritis
- Diagnosis: c-ANCA (target neutrophil Proteinase 3)
What binds at the TATA-Box?
RNA Polymerase
Catalase activity distinguishes what?
Staph vs. Strep
Novobiocin distinguishes what from what?
S. saprophyticus (+)
S. epidermidis (-)
Optochin distinguishes what from what?
S. pneumo (-) Strep viridans (+)
Bacitracin distinguishes what from what?
S. pyogenes (Group A) (-)
S. agalactiae (Group B) (+)
Bile w/ High Salt distinguishes what from what?
Enterococcus, E. faecium (+)
Strep. bovis (Group D) (-)
What is the function of 16s in Prokaryotic Ribosomes?
In 30s subunit
ONLY rRNA in 30s
Binds to Shine Dalgarno sequence on mRNA–> initiation
Why don’t IgG against HCV envelope confer life-long immunity?
Antigenic variation of envelope proteins
What is the difference between Post-Strep Glomerulonephritis and Rheumatic Fever?
Post-Strep Glom: Can follow EITHER pharyngitis OR skin infection
Rheumatic Fever: Can ONLY follow pharyngitis
Small vessel vasculitis with IgA and C3 deposits is typical of ___________________.
Henoch Schonlein Purpura
How does Henoch Schonlein Purpura present?
Palpable purpura rash (100%) Abdominal pain (85% Polyarthralgia (70%) Children: 3-11yrs Complication: Glomerulonephritits and ESRD
What is the most important virulence factor in Uropathogenic E. coli?
P Fimbriae
What kind of media can E. coli grow on?
Blood agar
MacConkey
Eosin Methylene Blue
Eosin Methylene Blue agar
Isolates enteric organisms
If ferment lactose–> bind green dye–> “Green metallic” appearance
Describe how Aspergillus looks on microscopy.
Thin
Septate hyphae
Acute angles (‘Y’)
How much V. cholera must a person ingest to become infected?
A lot
10^6-10^10
What kind of chemical environment does V. cholera like to grow in?
Very Alkaline
What are the 2 functions of Eosinophils?
- Type I hypersensitivity
2. Defense aga. Parasite infections
How do Eosinophils aid in eliminating parasite infections?
IgE binds parasites–> Eosinophils bind Fc of IgE–> Antibody-Dependent Cellular Cytotoxicity–> destroy w/ enzymes from cytoplasmic granules
Which cells rely on Antibody-Depended Cellular Cytotoxicity for killing?
Eosinophils
Macrophages
Natural Killer Cells
What are snRNPs?
Small nucleotide Ribonucleotide Proteins that bind to mRNA to help facilitate splicing
Which HIV structural proteins are glycosylated and cleaved?
Env protein (gp160) --> gp41 and gp120 Occurs in ER and Golgi
What is the major virulence factor for Strep. pyogenes (Group A)?
M-protein
Inhibits phagocytosis and complement activation
Mediates bacterial adherence
How is immunity to re-infection with Influenza A mediated? Which Antibodies?
Anti-Hemagglutinin IgG (circulation) and IgA (mucosal)
Scabies
Sarcoptes scabiei
Highly contagious
Presentation: Intensely pruritic (esp. at night), flexor surfaces of the wrist, lateral surfaces of the fingers. Excoriations with small, crusted, red papules
Diagnosis: Skin scrapings microscopy- mites, ova, feces
What are the transmission routes for the diff. Hepatitis viruses?
Hep A: fecal-oral
Hep B: blood, sex, breastmilk, tears, saliva, semen, etc.
Hep C: blood
Hep D: blood
What symptoms do TNF-alpha elicit?
Systemic inflammatory response (hypotension, tachycardia, tachypnea, change in body temp)
Septic shock, cachexia
Which cytokines cause the symptoms of the systemic inflammatory response?
TNF-alpha
IL-1
IL-6
What is the most important mediator of the septic shock response?
TNF-alpha
IL-3
Produced by T-cells
Stimulates the growth and differentiation of stem cells in bone marrow
IL-10
Anti-inflammatory
Limits production of pro-inflammatory cytokines
IL-4
Produced by Th2-helper cells
Stimulates B-cells and stimulated growth of Th2-cells
IFN-gamma
Produced by activated T-cells
Recruit leukocytes and activate phagocytosis
What key complications are associated with Measles, Mumps, and Kawasaki?
Kawasaki: Coronary artery aneurysm
Mumps: Orchitis
Measles: Neurological Encephalitis (Acute), Acute Disseminated Encephalomyelitis (recovery), Subacute Sclerosing Panencephalitis (years)
What are the 3 most common causes of Bacterial Otitis media, Sinusitis, and Conjunctivitis in childhood?
- Strep pneumo
- H. influenzae
- Moraxella
Which agar do you use to grow C. diphtheriae? What other features can you see?
Cysteine-tellurite agar
Black colonies
Bacterium produces intracellular polyphosphate granules- “Metachromatic granules”- Methylene blue staining
What kind of virus is HSV?
Enveloped
dsDNA
What is the FTA-ABS test for?
Syphilis
What is the pathogenesis behind Aortic Aneurysm in Syphilis?
Vasa vasorum endarteritis and obliteration–> inflammation, ischemia, weakening of aortic adventitia
Polyarteritis Nodosa. What illness is it assoc. with?
Transmural inflammation with fibrinoid necrosis. Usually segmental.
Symptoms: Malaise, wt loss, abdominal pain, melena. LUNG usually NOT involved.
Assoc. with Hep. B (30%)
What is the most common bacterial cause of septic arthritis in non-sexually active people and children?
S. aureus
For most cases of monosomy X (Turner’s, XO), what is the etiology? How does this compare to other aneuploidies?
Loss of parental X chromosome during MITOSIS, compared to other forms of aneuploidy- MEIOTIC nondisjunction.
What is the purpose of DNA Polymerase I?
5’–> 3’ Exonuclease activity
Excise RNA primers —> then replaces w/ DNA
How do most enveloped viruses obtain their envelope? What are the exceptions?
Most acquire from plasma membrane
EXCEPT Herpesviruses- acquire from nuclear membrane
What is the most likely outcome for HCV infection?
Stable chronic hepatitis w/ persistent elevated liver enzymes
May progress to cirrhosis
What is the mechanism of Superantigens?
Interact with MHC-II on APC’s and TCR’s on T-cells–> Nonspecific “widespread” activation T-cells–> IL-2 (T-cells) and IL-1& TNF (Macrophages)
Which immune cells are involved in the Superantigen response?
APC’s and T-cells
Bacterial Vacinosis
Grayish-white discharge Usually no evidence of inflammation (unlike Candida or Trichomoniasis) "Fishy" odor (esp. w/ KOH whiff test) Gardnerella vaginalis Clue cells on wet mount Tx: Metronidozole w/ topical agent
What is oral candidiasis associated with?
Dentures
Diabetes mellitus
Immunosuppression
What is HBsAg? What kind of structures does it form?
Component of the viral envelope
Noninfective glycoprotein
Forms spheres and tubules 22nm
Infected hepatocytes may secrete ENORMOUS quantities, often exceeding amount of HBcAg produced
Which amino acids are ONLY Ketogenic? What does this mean?
Lysine and Leucine
They can NOT increase the blood lactate levels
A germ-line mutation in which gene causes MEN2a and MEN2b? What embryonic cell line are these syndrome derived from?
RET proto-oncogene
Derived from Neural Crest Cells
What do Ecological studies analyze?
Populations, NOT individuals
CanNOT be used to make assumptions about individuals (Ecological Fallacy)
Achondroplasia (inheritance and mutation)
Autosomal Dominant
Mutation: GAIN-of-function in Fibroblast Growth Factor Receptor 3
How can you inactivate Hepatitis A Virus? (4)
- Chlorination
- Bleach (1:100)
- Formalin
- UV
- Boiling at 85C for 1min
What are the functions of the Smooth ER?
Lipid synthesis
Drug detoxification
Carbohydrate metabolism
Steroid synthesis
How does a Glucagonoma present?
Necrolytic Migratory Erythythema
Anemia
Hyperglycemia
Diagnosis: Elevated Glucagon
Necrolytic Migratory Erythema
Erythematous papules/plaques on perineum, face, extremities
Lesions enlarge and coalesce
Bronze colored, central indurated area w/ peripheral blistering and scaling
How does 21-Hydroxylase Deficiency present?
Salt-wasting (LOW Na+, HIGH K+) LOW: Aldosterone and Cortisol HIGH: Increased 17-Hydroxyprogesterone, Androgens, and ACTH Males: normal Females: virilization
What is the most common cause of Type 1 DM?
Autoimmune insulitis w/ progressive beta-cell loss
What is the underlying mechanism of Autoimmune Type 1 DM?
Cell-mediated destruction (Leukocytes)
Abs against islet antigens (ONLY permissive)
What do high glucose levels during pregnancy cause?
Beta-islet cell hyperplasia (Increased Insulin)
This causes macrosomia
When should a Dexamethosone Test be used?
Distinguishing between Ectopic ACTH or Pituitary Adenoma
Measurement of which body feature has good correlation with Insulin Resistance?
Waist-hip ratio
Compares visceral to subcutaneous fat
Increased visceral fat correlates w/ increased Insulin Resistance
What is the mechanism of Sulfonylureas?
Increased release of endogenous Insulin
How do VIP-omas present?
Watery diarrhea, hypokalemia, achlorhydria
Excess loss of K+, Na+, water in stool
Decreased gastric acid secretion
Tobacco smoking increases your risk of………
- Macrovascular disease (MI)
- Microvascular disase
- Diabetes Mellitus
- Diabetes Mellitus complications
How does Riboflavin deficiency present?
Angular stomatitis Cheilitis Glossitis Seborrheic dermatitis Eye changes Anemia
What is the function of Riboflavin (Vit. B2)?
Produces FMN and FAD
FMN and FAD–> Electron transport chain
FAD–> TCA (Succinate DHase)
Aromatase Deficiency
Autosomal Recessive
Accumulation of androgens during pregnancy
Maternal virilization (deepening of voice, etc)
Female infants–> Virilization and ambiguous genitalia
Male infants–> Normal
Histologically, how does A1AT appear in the liver?
Reddish-pink granules on PAS-stain
Unsecreted, polymerized A1AT in periportal hepatocytes
What is the function of A1AT? Where is it produced?
Reduces tissue damage from inflammation
Inhibits Neutrophil Elastase
It is produced in the liver
A1AT Deficiency (inheritance and prognosis)
Autosomal Co-dominant
Liver: Cirrhosis or Hepatocellular carcinoma
Lungs: Emphysema
What kind of neurological effects does Wilson’s Disease cause?
Cystic degeneration of the Putamen or other basal ganglia structures
What does a low-dose and high-dose Dexamethasone test tell you?
Normal individuals: Low-dose will suppress ACTH Cushing Disease (Ant. Pit adenoma): ONLY High-dose will suppress ACTH
After a Nuclear Accident, where Radioactive Iodine is released, how can you prevent Thyroid Carcinoma in those exposed? (FASTEST method)
Give Potassium Iodine to competitively inhibit uptake of radioactive Iodine
Propylthiouracil (P-TU)
Treats Hyperthyroidism
Inhibits Thyroid Peroxidase–> Inhibit Iodine Organification
What method of transport do most cells use to intake glucose?
Facilitated diffusion (Carries-mediated) (GLUT) Stereospecific for D-glucose
Where are IFN-alpha and IFN-beta secreted from?
Virally-infected Eukaryotic cells
What is the function of IFN-alpha and IFN-beta?
Signal to neighboring cells (Paracrine signaling)
Activates RNAase L–> degrade virus AND host mRNA
Activates Protein Kinase–> inhibit virus AND host protein synthesis
What are the functions of IFN-gamma?
Produced by NK and T-cells
- Th1 differentiation
- MHC-II expression
- Macrophage activation
What are the different mutations of the 3 different Thyroid cancers?
- Medullary: RET proto-oncogene
- Follicular Thyroid Cancer: RAS
- Anaplastic: p53
What is the main measure used in a Case-Control study?
Exposure Odds-Ratio
How does Galactokinase Deficiency present?
Benign cataracts
Otherwise, asymptomatic
Cause: Galactitol accumulation in lens. Formed by Aldolase Reductase due to from galactosemia.
What is the most common cause of HPA-axis depression?
Glucocorticoid therapy
HPV 16, 18, and 31 are strongly correlated with what?
Cervical squamous cell carcinoma
Anal squamous cell carcinoma
Where is rRNA synthesized?
Nucleolus
Which organisms are Catalase + ?
Psuedomonas Listeria Aspergillus Candida E. coli S. aureus Serratia
Alemtuzumab
anti-CD52
Uses: CLL
Bevacizumab
anti-VEGF
Uses: Colorectal cancer, Renal cell carcinoma
Cetuximab
anti-EGFR
Uses: Stage IV Colorectal cancer, Head and neck cancer
Rituximab
anti-CD20
Uses: B-cell non-Hodgkin Lymphoma lymphoma, Rheumatoid Arthritis (w/ MTX), ITP
Tratuzumab
anti-HER2/Neu
Uses: Breast cancer, gastric cancer
Infliximab, Adalimumab
anti-TNF-alpha
Uses: IBD, Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriasis
Natalizumab
anti-a4 Integrin (leukocyte adhesion)
Uses: Multiple Sclerosis, Crohn Disease
AVOID: in pts w/ JC virus (risk of PML)
Abciximab
anti-GLycoprotein IIb/IIIa
Uses: Prevent ischemic complications
Denosumab
anti-RANKL
Uses: Osteoporosis (inhibits osteoclast maturation)
Digoxin Immune Fab
anti-Digoxin
Uses: Digoxin toxicity
Omalizumab
anti-IgE (prevent from binding to FceRI)
Uses: Allergic Asthma
Palivizumab
anti-RSV F-protein
Uses: RSV prophylaxis (high-risk pts)
What is the first-line treatment for Myoclonic seizures?
Valproate acid
What are the first and second-line treatments for Absence seizures?
1st: Euthosuximide
2nd: Valproate
What is the first-line treatment for Simple Seizures?
Carbamazepine
What is the first-line treatment for Complex Seizures?
Carbemazepine
What is the first-line treatment for Tonic-Clinic Seizures?
1st: Phenytoin, Valproate, Carbamazepine
How does Adenovirus usually present?
Pharyngitis Conjunctivitis Fever Lymphadenopathy Affects people in close quarters
In Alzheimer’s Disease, where is atrophy most pronounced in the brain? Which appears first?
Hippocampus (appears early)
Cerebral cortex
List the Beta-Lactamase Inhibitors.
Cavulanic acid
Sulbactam
Tazobactam
Atropine vs. Organophosphate
Atropine–> ANTI-muscarinic
Organophosphate–> Muscarinic (AChE inhibitor)
What is the mnemonic for Anti-muscarinic effects?
Blind as a bat Mad as a hatter Red as a beet Dry as a bone Hot as a hare Bowel and bladder lose their tone Heart works alone
Hydatid cysts (Org, tx)
E. granulosus (monolocular lesions)
E. multilocularis (multiple lesions)
Tx: Surgery + Chemo (Mebendazole and Albendazole)
Do NOT aspirate b/c can cause ANAPHYLAXIS!
Why shouldn’t you aspirate a Hydatid Cyst?
Can cause Anaphylaxis!
What are Psammoma Bodies?
Dense areas of calcification surrounded by collagen-fiber bundles
What can cause bilateral wedge-shaped necrosis the brain?
Hypoxia-Ischemia due to low perfusion
For drugs that have are highly charged, highly protein-bound, or have a high molecular weight, what will their Volume of Distribution be?
3-5L
Describe the tonotopy of the cochlea.
High-freq: Cochlea base (Oval and round windows)
Low-freq: Cochlea apex (Helicotrema)
What is the most common cause of Heterophile Antibody NEGATIVE Mononucleosis? Others?
CMV
Others: HHV-6 and Toxoplasmosis
What does Heterophile-Antibody POSITIVE test suggest?
EBV
90% cases
Lamotrigine (Uses, Major complication)
Uses: Partial and Generalized seizures
Complication Steven-Johnson’s Syndrome, TEN
Which sinuses are most commonly affected in an Orbital Blowout Fracture?
Ethmoid sinus: Medial
Maxillary Sinus: Inferior
Thin walls
What are the effects of Mu-Opioid Receptors?
Respiratory and Cardia depression Physical dependence Euphoria Sedation Decreased GI motility
What are the effects of Kappa-Opioid Receptors?
Miosis
Dysphoria
Sedation
What are the effects of Delta-Opioid Receptors?
Anti-depressant
Which Hepatitis Viruses are NOT enveloped? Why not?
Hep A & E
Fecal-oral transmission
Non-envelope–> less susceptible to bile acids
What kind of genomes do the Hepatitis Viruses have?
Hep A: RNA, +, single-stranded Hep B: DNA, partially double stranded Hep C: RNA, +, single-stranded Hep D: RNA, -, single-stranded Hep E: RNA, +, single-stranded
Which nerve runs near the Inferior Thyroid Artery? What happens if this nerve is injured?
Recurrent Laryngeal Nerve
Anterior Neck
Symptoms: Dyspnea, hoarseness, and laryngeal muscle paralysis
–> Innervates ALL laryngeal muscles EXCEPT Crycothyrpoid (External branch of Superior Laryngeal Nerve) and Sensation BELOW vocal cords
The Superior and Inferior Thyroid Arteries are branches of which arteries?
Superior Thyroid: External Carotid
Inferior Thyroid: Thyrocervical trunk of Subclavian Artery
The Superior Thyroid Artery runs near which nerve? What happens if this nerve is injured?
Superior Laryngeal Nerve (External and Internal branches)
External Branch: ONLY innervates the Crycothyroid muscle
Internal Branch: Sensation ABOVE the vocal cords
Patients with Familial Retinoblastoma are at increased risk for what?
Osteosarcoma (and other tumors)
Metronidazole has side effects that make it act like which other drug?
Disulfram-like side effects
Do NOT take w/ EtOH
Foscarnet
Uses: HIV, Herpes (Acyclovir-resistant), and Gancyclovir Resistant-CMV
Mech: Directly Binds to DNA-Polymerase in Herpes Virus & Reverse Transcriptase in HIV. Pyrophosphate analog.
** Does NOT require intracellular activation***
Why are Chloroquine and Primaquine used together to treat Malaria?
Chloroquine: Used to eradicate uncomplicated Plasmodium from bloodstream. Has NO activity aga. latent infection in liver est. with P. vivax and P. ovale.
Primaquine: Used in P. ovale and P. vivax infections to eradicate intrahepatic stages.
How do you get Cleft Lip?
If the Maxillary Prominence fails to fuse with the Medial Nasal Prominences (Intermaxillary segment)
How do you get Cleft Palate?
Maxillary Prominences fail to fuse to each other
OR
Maxillary prominence fails to fuse with Medial Nasal Prominences (Intermaxillary Segment)
Zolpidem
Short-acting Hypnotic
Uses: Insomnia
Unrelated to Benzodiazepines, but SAME mechanism!
LESS potential for tolerance and dependence
NO Muscle-relaxant activity and NO anti-convulsant activity
Low serum levels of C1-Esterase Inhibitor is diagnositc of what?
Hereditary Angioedema
Also have Increased Bradykinin levels
ACE-Inhibitors should NOT be used in which patients?
Pts with Angioedema (LOW levels of C1 Esterase Inhibitor)
Which Antibiotic should always be used empirically in neonatal meningitis and immunocompromised adults to cover Listeria?
Ampicillin
NOT sensitive to Cephalosporins
What mechanism have Enterococci acquired to make them resistant to Aminoglycosides? How did they acquire this mechanism?
Aninoglycoside-modifying enzymes that transfer different chemical groups (acetyl, adenyl, phosphate)
Resistance acquired by plasmids or transposons.
Dantrolene (Uses, mech)
Uses: Malignant Hyperthermia after inhaled anesthesia administration or Succinylcholine
Mech: Prevents intracellular Ca2+ release from SER (Ryanodine Receptors) of muscle fibers
What are the most common causes of death in TCA overdoses? (Tx)
Refractory Hypotension
Cardiac Arrythmias (Inhibition of Na+ Channels is cardio myocytes) MAJOR factor
Tx: Fluid resuscitation w/ Normal saline and HYPERtonic Sodium Bicarbonate
What makes Methadone such a great drug from Heroin addiction? What are other characteristics?
**Long-acting
It is a FULL-agonist! Also potent with good bioavailability
In a Cricothyrotomy, what structures are cut through?
Superficial cervical fascia
Pretracheal fascia
Cricothyroid membrane
What are the common side effects of General Inhaled Anesthetics?
Increase in Cerebral Flow
Decrease in Renal Function
Cardiac and Respirator depression
Hypotension
What is the most common cause of Malignant Otitis Externa in Diabetic pts?
Pseudomonas
In terms of motility, describe Pseudomonas, Shigella, and Salmonella.
Pseudomonas: Motile
Shigella: NON-motile
Salmonella: Motile
Which drugs are known to have Antimuscarinic effects?
Anti-H1(Diphenhydramine) Atropine TCAs (Amitryptiline) Antipsychotics Anti-Parkinsons drugs
Isoniazid is directly toxic to which organ? What happens if continue to take INH?
Liver–> can cause acute hepatitis/ liver dysfunction
In most cases, liver function tests return to baseline w/ continued INH use.
Which proteins bind STOP codons?
Releasing Factors
How do you get Rebound Rhinorrhea?
Using an Alpha-Adrenergic Agonist Decongestant more than 3days –> Get negative feedback –> less NE release (Tachyphylaxis)
How does the HBV virus cause damage to hepatocytes?
Infected hepatocytes express viral proteins on MHC-I –> CD8-mediated cell death
What is a good drug alternative for pts taking SSRI’s who do not like the side effect of sexual dysfunction?
Buproprion
It only affects NE uptake, does not affect Serotonin, ACh, or Histamine.
What are the risk factors for Hepatocellular Carcinoma?
HBV BCV Aflatoxins Alcoholic cirrhosis Hemachromatosis
Which compensatory mechanisms exacerbate the symptoms of CHF?
- RAAS system
- Sympathetic NS
- -> Increase Afterload, excess fluid retention, deleterious cardiac remodeling
What is Brain Natriuretic Peptide?
Released by the ventricles in response to stretch
Causes vasodilation, diuresis/natriuresis, decrease in BP–> Alleviate symptoms of heart failure
Elevated in pts with Heart Failure (used to diagnose CHF exacerbation)
How is Nitric Oxide synthesized?
Synthesized from Arginine by Nitric Oxide Synthase
Arginine + O2 + NADPH–> NO
What is the mechanism of Nitric Oxide?
NO–> GC–> cGMP–> decrease in cytosolic Ca+–> relaxation of sm. muscle.
What do the Common Cardinal Veins of the embryo develop into?
Common cardinal veins–> Sinus Venosus–> SVC and other constituents of the venous sys.
What do the Ascending Aorta, Pulmonary Artery, and Descending Artery develop from? (Embryology)
Ascending Aorta: Truncus arteriosus
Pulmonary Artery: Truncus arteriosus
Descending Aorta: Embryonic Right and Left Dorsal Aortas
Which two LOCAL factors are the most important in influencing CORONARY blood flow?
Adenosine –> Small coronary arterioles
Nitric Oxide –> Dilation of large arteries and pre-arteriolar vessels
How do some neonates with Turner’s Syndrome present?
Lymphedema (swelling of hands and feet)
Cystic Hygroma on the neck (tumor)
In a Biventricular Pacemaker, where is the Left Ventricular lead placed (if used)?
Coronary sinus, which resides in the atrioventricular posterior aspect of the heart
Which nerves innervate the Carotid and Aortic Baroreceptors?
Carotid Sinus—> Glossopharyngeal Nerve (CN IX)
Aortic Arch–> Vagus Nerve (CN X)
Where the Carotid Sinus located?
It is a dilation of the Internal Carotid Artery
Lies at bifurcation of Carotid Artery
What kind of collagen is Granulation Tissue composed of? What is it replaced by?
Granulation Tissue if Type III collagen
Replaced by Type I after 7 days.
What is the primary collagen in MATURE scars?
Type I
What are the two sample z- and t-tests used for?
Compare 2 group means
What are common cardiovascular abnormalities associated with Turner’s Syndrome?
Aortic coarctation
Bicuspid Aortic Valve
How does Coarctation of the heart present in children/young adults?
Lower extremity claudication
Blood pressure discrepancy between upper and lower extremities
Delayed/Diminshed femoral pulses
What cardiac abnormality is assoc. w/ Friedreich Ataxia?
Hypertrophic cardiomyopathy
What cardiac abnormality is assoc. w/ Marfan Syndrome?
Cystic medial necrosis
Mitral valve prolapse
What cardiac abnormality is assoc. w/ Tuberous Sclerosis?
Valvular obstruction due to cardiac rhabdomyomas
What cardiac abnormality is assoc. w/ DiGeorge?
Tetralogy of Fallot
Interrupted Aortic Arch
What is the most common paroxysmal tachycardia?
Paroxysmal Supraventricular Tachycardia (re-entrant circuit in AV node)
What easy maneuvers can you do to treat Paroxysmal Supraventricular Tachycardia? Medications?
- Carotid massage
- Valsalva maneuver (transiently increases Aortic pressure)
In hospital–> Adenosine
What precautions should you take before inserting a Central Venous Catheter?
- Proper Handwashing
- Full barrier precautions
- Chlorhexidine for disinfection
- Avoidance of Femoral site
- Removal when no longer needed
Where is the IVC located in abdominal CT? What veins feed into it? Where?
Anterior to Right half of vertebral bodies
Renal Veins–> L1/L2
Common Iliac Veins–> L4
When do surgeons use Internal Mammary Artery vs. the Great Saphenous for coronary artery occlusion?
Internal Mamm. Artery–> LAD only
Great Saphenous Vein–> multiple grafts
Where do surgeons often access the Great Saphenous Vein for vessel bypass?
Medial leg or at its origin in upper thigh near femoral triangle.
What acid/base changes do you see in pts with Pulmonary Embolism? Why?
Respiratory ALKALOSIS Increased pH Reduced PaCO2 Low PaO2 Normal HCO3- Hypoxemic--> stim respiratory drive--> hyperventilation--> even though have less blood oxygenation, CO2 is MORE dependent on ventilation--> Increase O2 relative to CO2
Endocardial Cushion Defects result in what kind of defect? When do these pts present?
Atrioventricular septum defects
Do NOT present with cyanotic symptoms at birth
What do Tetralogy of Fallot, Transposition of the Great Vessels, and Truncus Arteriosus have in common?
Cyanotic Heart Diseases (Cyanotic at birth)
Caused by abnormal migration of the neural crest cells through Primitive Truncus Arteriosus and Bulbus Cordis
Which tissue extracts the highest % of O2 from blood?
Myocardium
Resting- 75-80%
Working- 80%
Which structure has the LOWEST O2 content?
Coronary Sinus
List the Cardiac stxs in order from fastst–> slowest conduction velocity
(FAST) Purkinje system–> Atrial Muscle–> Ventricular muscle–> AV node (SLOW)
“Water-hammer” pulses and “Head-bobbing” are characteristic findings of ______________.
Aortic Regurgitation
Why is skeletal muscle NOT affected by Verapamil?
Unlike cardiac and smooth muscle, skeletal muscle does NOT require an influx of extracellular Ca2+ (ONLY intracellular Ca2+ from SER)
What are the symptoms caused by Thiamine (B1) deficiency in adults?
Dry Beriberi: Symmetrical peripheral neuropathy w/ sensory and motor impairments, esp. in distal extremities
Wet Beriberi: Dry Beriberi + Cardiac involvement (Cardiomegaly, CHF, etc)
What is the most common cause of endocarditis in IV drug users? 2 most common cause?
1st: S. aureus
2nd: P. aeruginosa
Describe the C. diptheriae vaccine.
Diptheria toxoid against exotoxin B-subunit (A/B toxin)
What are the serious sequelae of Diptheriae?
Neurologic toxicity
Myocarditis/Heart failure
What are common triggers for Acute Heart Failure?
MI
Severe HTN
Arrhythmias (a-fib)
Drug Use (Cocaine)
DiGeorge Syndrome results from maldevelopment of what?
3rd and 4th pouches
Deletion on chrom. 22
What structure lies directly posterior the Esophagus?
Descending Aorta
What is the most common organism involved in Subacute Bacterial Endocarditis following dental work?
Strep. Viridans
Transposition of the Great Arteries
Aorta lies ANTERIOR to and to the RIGHT of the Pulmonary Artery
Cause: Failure of the fetal aorticopulmonary septum to spiral normally during septation of Truncus Arteriosus
Presents: Life-threatening Cyanosis at birth
Where does ANP act?
- Kidney–> dilates afferent arterioles–> diuresis
- Adrenal Gland–> restricts Aldosterone release
- Blood vessels–> vasodilation
Describe the “Streak ovaries” seen in Turner’s Syndrome.
Small and underdeveloped
Consist of connective tissue w/ no follices
What is Nitroprusside? How does it affect Afterload and Preload? Stroke volume?
Short-acting venous AND arterial vasodilator
Decreases BOTH preload and afterload
SV unchanged!
What is the definition of Absolute Risk Reduction?
Event rate in CONTROL group - Event rate in TREATMENT group
What is the “Median” value?
When you put the number is order—> number in the middle is the median
What Aortic Arch is the Ductus Arteriosus derived from?
Sixth Aortic Arch
Which arteries are derived from the 3rd Aortic Arch?
Common Carotid Artery
Proximal Internal Carotid Artery
Which Arteries are derived from the 4th Aortic Arch?
LEFT–> Aortic Arch
RIGHT–> Proximal Right Subclavian Artery
What arteries are derived from the 6th Aortic Arch?
Proximal Pulmonary Arteries
On LEFT–> Ductus Arteriosus
Which artery is derived from the 1st Aortic Arch?
Maxillary Artery
Which arteries are derived from 2nd Aortic Arch?
Hyoid Artery
Stapedial Artery
What mediates the decrease in intracellular Ca2+ in cardiac myocytes?
Ca2+-ATPase pump –> Ca2+ back into SER
Na+/Ca2+ Exchanger in sarcolemma
How are blood flow and resistance to blood flow related to the radius of a vessel?
Blood flow is DIRECTLY proportional to r^4 (Flow= r^4)
Resistance in INVERSELY proportional to r^4 (Resistance= 1/r^4)
How does a Chronic Arteriovenous Shunt affect the following: sympathetic stimulation to the heart, peripheral resistance, venous return, and mean systemic pressure?
Increases Sympathetic stimulation of heart
Decreases peripheral resistance
Increases venous return
Increases mean systemic presssure
Which maneuvers can increase as S3 heart sound?
Lying on left lateral decubitus position
Fully exhaling–> shrinks lungs–> brings heart closer to chest wall
What is needed for Strep Viridans to cause subacute endocarditis?
Require preexisting valvular damage (Fibrin-platelet aggregates)
How do Strep viridans adhere to Fibrin?
Produce extracellular DEXTRANS using Sucrose as a substrate
What is the difference between Odds Ratio and Relative Risk in terms of when they can be used?
BOTH are used in Case-control an Cohort studies
ONLY Odds Ratio can be used in Case-Control b/c these studies do not follow pts to calculate risk.
How do you calculate Odds Ratio? Relative Risk?
Odds Ratio: (a/b) / (c/d) = ad/bc
Relative Risk: [a/(a+b)] / [c/(c+d)]
How do you calculate the “Number Needed to Harm”?
NNH= 1/ Attributable Risk
AR=ADVERSE event rate in treatment - ADVERSE event rate in placebo
What does the Number of Needed to Harm tell you?
The number of people who must be treated before an adverse event occurs
What is the Standard Error? How is it calculated?
It is the range of values w/in which one cane be confident that the true mean falls
SE= Mean +/- (1.96 SD/sqroot n) for 95% Confidence interval
ST-elevations in leads V1-V4 on ECG are consistent with an occlusion in which artery?
LAD
ST-elevations in leads I, aVL, V5, V6 on ECG are consistent with an occlusion in which artery?
LCX
ST-elevations in Inferior leads on ECG are consistent with an occlusion in which artery?
RCA
Homocystinuria (what a.a. is essential?, symptoms)
Cysteine is essential
Cause: Cystathionine Synthetase
Symptoms: Hypercoagulability, premature athersclerosis
What is the cause of Lingual Thyroid? What can happen if surgeons remove too much?
Failure of migration
If remove too much–> Hypothyroid symptoms
What are symptoms of childhood hypothyroidism? When can this occur?
Can occur if remove too much thyroid after Lingual Thyroid removal Lethargy Feeding problems Constipation Macroglossia Umbilical hernia Large fontanels Dry skin Hypothermia Jaundice
During A-fib, what determines the Ventricular rate? What keeps ventricles from firing rapidly?
AV node
Refractory period that occurs after each time the AV-node is excited slows down ventricular rate
What is the weakest point in the male urethra? What does this mean in terms of injuries?
Membranous urethra
Pelvic fracture often injures the Posterior Urethra at Bulbomembranous junction, where sphincter it located
What kind of injuries are assoc. w/ anterior and posterior male urethral injuries?
Posterior injuries: Pelvic fractures (Membranous portion usually)
Anterior injuries: Straddle injuries
What procedure is contraindicated in Urethral injury?
Placement of Foley catheter
How many calories are obtained from protein and fat?
1g Protein= 4 cal
1g Fat= 9 cal
Describe the embryologic formation of the female reproductive tract?
Fusion of Paramesonephric ducts–> Uterine tubes, Uterus, Cervix, Superior 1/3 of vagina
What does Mesonephric Ducts for in females and males?
Females: “Gartner’s Ducts”. Normally DEGENERATES in Females.
Males: Epididymis, Ductus deferens, Seminal vesicles, Ejaculatory ducts
What is the effect of Progesterone on the endometrium?
Growth and differentiation into Decidual cells that can accommodate pregnancy
What happens to endometrial cells after withdrawal of Progesterone?
Apoptosis
What does a 99Tc-Pertechnetate scan detect? What is it used to diagnosed?
Presence of gastric mucosa
Accumulation of 99Tc-P in RLQ is diagnostic for Meckel Diverticulum
INITIAL tx of Coagulase-neg Staph infection should include what? Why?
Vancomycin
Most strains are Methicillin-resistant
What can cause Biotin deficiency?
Poor diet
Excessive raw egg white consumption (high levels of Biotin-binding avidin)
What is the function of Biotin?
CO2 carrier on Carboxylase enzymes
Lipid and Carb metabolism
In the Pancreatic Beta Cell, what is responsible for stimulating K+ channels to close (leading to depolarization)?
Increase ATP:ADP ratio –> closure of K+channels
What is the 3rd part of the duodenum assoc. with? What level of vertebrae?
Superior Mesenteric Artery
Unicate process of pancreas
L3 (2nd part of duodenum goes from L1-L3)
Which arteries are the 1st and 3rd parts of the duodenum assoc. with?
1st: Gastroduodenal
3rd: Sup. Mesenteric
Describe the process of Base Excision Repair.
- Gycosylation (remove defective base)
- Endonuclease
- Lyase (remove sugar phosphate)
- DNA Polymerase
- Ligase
Which enzyme is elevated/released in formation of Brown Pigment Stones? What does this lead to?
Brown Pigment Stones typically arise from infection to biliary tract–> release of Beta-Glucuronidase from injured hepatocytes and bacteria–> hydrolysis of Bilirubin Glucoronides–> Unconjugated bilirubin in bile
What are the functions of ApoA-I?
LCAT activation (cholesterol esterification)
What are the functions of ApoB-48?
Chylomicron assembly and secretion by intestine
What are the functions of ApoB-100?
LDL particle uptake up EXTRA-hepatic cells
What are the functions of ApoC-II?
Lipoprotein Lipase activation
What are the functions of ApoE-3 and E4?
VLDL and chylomicron remnant uptake by liver cells
Familial Dysbetalipoproteinemia
Which step(s) of mRNA processing occur in the cytoplasm?
Interaction with P-bodies
Important role in mRNA translation regulation and mRNA degradation
Which tissue(s) canNOT utilize ketones? Why?
- RBCs (b/c do not have MT)
2. Liver (b/c does not have Succinyl-CoA-Acetoacetate CoA Transferase)
Enterococcus is a component of the normal flora in what parts of the body?
Colonic
GU
What it Lead-Time Bias?
When a screening test diagnoses a disease earlier than normal and makes it look like survival is increasing.
What is Power (1-Beta) of a study? What is it typically set at?
Probability of rejecting the null when there truly is a difference.
Typically set ay 80%
What is a Type II error?
When researchers reject the null even though there is a true difference.
What is a Type I error?
When researchers reject the null hypothesis, even though there is no true difference.
What is alpha? (statistics)
Usually compared to the p-value
The probability of observing a difference even though the null hypothesis is true.
What are Clue Cells?
Seen in Pap Smears w/ bacterial vaginosis (Gardneralla vaginalis)
Squamous cells covered w/ bacilli
What are Koilyocytes?
Hallmark of HPV infection
Pyknotic or immature squamous cell with dense, irregular staining cytoplasm and perinuclear clearing
Chediak-Higashi Syndrome
Autosomal Recessive
Immunodeficiency (No Neutrophilic phagosome-lysosome fusion)
Neurologic (nystagmus, neuropathies)
Albinism
What are the 1st and 2nd most common causes of SCID?
1st- X-linked
2nd- Adenosine Deaminase Deficiency
Which surface of the heart forms the diaphragmatic surface? Which artery supplies this surface?
The inferior wall of the LV
This is supplies by the PDA in most people (85-90%)
What are Birbeck granules? What are indicative of?
They are intracellular granules (Racquet-shaped)
Found in Langerhans Cells
Which endogenous substances act on Phase 4 of the nodal potential to decrease HR? What mechanism?
Adenosine- activates K+ channels
ACh- blocks L-Type Ca2+channels
How can you reduce recurrence of genital Herpes infection?
DAILY treatment of oral Acyclovir, Valacyclovir, and Famcyclovir
In a Case-Control study- how are case and control groups chosen?
Cases: Have outcome of interest
Control: Do NOT have outcome of interest
Compare to look at different exposures
Which co-factor is necessary for the synthesis of Delta-Aminolevulinic Acid?
Pyridoxyl Phosphate
Can linkage disequilibrium occur when they are on different chromosomes?
YES!
Due to mutation, genetic drift, migration, selection pressure, non-random mating
What is Pantothenic Acid?
Coenzyme CoA
The Picornaviridae virus family includes which genera? Which is acid-stable?
Rhinovirus
Enterovirus- Acid-stable–> can pass through stomach and colonize GI
Which form of Leprosy is more severe? What determines the severity?
Lepromatous is more severe than Tuberculoid leprosy
Strength of cell-mediated immune response (Th1) determines severity
How do you test for Treponema pallidum? (Screening and Confirmatory)
Screening: RPR and VDLR
Confirmatory: FTA-ABS
What does the nonspecific treponemal Rapid Plasma Reagin (RPR)? Does it measure treponemal abs?
This is a NONtreponemal serologic test
Serum is mixed w/ Solution of Cardiolipin, Cholesterol, and Lecithin
Aggregation/ “Flocculation” –> presence of Abs.
This tests for Abs to human cellular lipids released into the bloodstream after cell destruction by T. pallidum
***Can also be positive in Yaws, Pinta, Beejal (T. pallidum subspecies)
Wide, fixed S2 is characteristic of what?
ASD
What can happen after prolonged ASD?
Muscular Pulm Arteries develop laminated medial hypertrophy–> Chronic Pulmonary HTN–> increase PVR>SVR–> Eisenmenger Syndrome
How do you calculate Number Needed to Treat?
1/ (Absolute Risk Reduction)
1/ (Control Rate- Treatment Rate)
What are the function of Sertoli cells in Male Embryonic development?
Sertolic Cells–> MOF–> Mullerian Duct Degeneration
What are the functions of Leydig cels in male embryologic development?
Leydig cells—> Testosterone –> Wolffian duct development–> Male Internal organs
Testosterone–> DHT–> Male external genetalia
What are features of Psychogenic Erectile Dysfunction?
Presence of spontaneous erections (in the morning)
Rapid onset
Which medications can cause impotence?
SSRI's Sympathetic blockers (Clonidine, Methyldopa, Beta-blockers)
How does Cardiac/Pericardial Tamponade present?
Hypotension Tachycardia Elevated Central Venous pressure w/ JVD Muffles heart sounds Pulsus Paradoxus (possibly)
Drugs that cause ____________ can cause Coronary Steal Phenomenon?
Selective Vasodilators of Coronary vessels
Ex) Dipyridamole and Adenosine
How do pts with von Willebrand Disease present?
Lifelong history of mucosal bleeding (epistaxis, gingival bleeding, menorrhagia)
Normal Platelet #
Increased Bleeding Time (abnormal platelet function)
The S3 heart sound can be associated with what?
CHF
Severe Mitral Regurgitation
NORMAL in children, pregnant women, atheletes
What audible changes can signal severe Mitral Regurgitation? How does orifice size affect murmur?
Presence of S3 heart sound (due to LV volume overload)
Increase orifice size actually DECREASED murmur
When does edema become clinically apparent?
ONLY when net plasma filtration has risen sufficiently to overwhelm resorptive capacity of tissue lymphatics
What compensatory mechanism can prevent edema in the setting of increased Central Venous Pressure?
Lymphatic Drainage
What can significantly exacerbate Aortic Stenosis?
Loss of atrial contraction–> decrease in LV filling–> decrease CO
Pts w/ AS rely on atrial contraction for LV filling
What is the timeline for Cardiomyocytes in terms of loss of contractility and when injury becomes irreversible?
Loss of contractility: w/in 1min
Ischemia 30min: irreversible
Describe the lymphatic drainage of the testes and scrotum
Testes: Para-aortic lymph nodes
Scrotum: Superficial Inguinal lymph nodes
Nonseminomatous germ cell tumors of the testicle can secrete high levels of what? This can lead to increased levels of what?
hCG
hCG and TSH are similar (alpha and beta subunits)–> can have paraneoplastic hyperthyroidism (increased T4 and T3)
The alpha subunits for which hormones are the same? Which hormones share the same Beta-subunits?
Alpha: hCG, TSH, LH, FSH
Beta: hCG and TSH
What is the difference between S3 and S4 in young people in terms of pathology?
S3: can be normal in young people
S4: Always pathologic in young people
Where does Trauma Aortic Rupture usually occur? When?
Aortic Isthmus
Rapid deceleration motor vehicle accident
In Mitral Stenosis, when does the opening snap occur?
Early Diastole
Right after the Mitral Valve opens
What is the best way to visualize T. pallidum?
Darkfield Microscopy
In terms of symptoms- what is the difference between Coagulopathies and Platelet defects?
Coagulopathies: Deep tissue bleeding (joints, muscles, subcutaneous tissue)
Platelet Defects: mucosal/ superficial bleeding (epistaxis and petechiae)
What does vWB bind in the setting of vascular injury?
Subendothelial Collagen and Platelet Glycoproteins
Prolonged exposure to loud noises damages what part of the inner ear?
Stereociliated hair cells of the Organ of Corti
How can amyloidosis affect the heart?
Can lead to Restrictive LV Diastolic Dysfunction
How do infectious myocarditis and cardiotoxic agents (alcohol, doxorubicin, etc) affect the heart?
Can lead to Dilated Cardiomyopathy
Ventricular hypertrophy and/or volume overload can lead to increased expression of which proteins?
BOTH ANP and BNP
In the pathogenesis of Atherosclerosis, what causes the increase in proliferative stimuli?
Release of PDGF from adhered platelets, Macrophages, and endothelial cells–> promotor migration AND proliferation of smooth muscle cells
Bilateral Renal Angiomyolipomas are associated with what?
Tuberous Sclerosis
What mechanism can molecules use to create Insulin Resistance? Which molecules use this mechanism?
Activate Serine Kinases–> Phosphorylation of IRS-1serine and threonine residues–| phos by Insulin Receptor
TNF-alpha, Catecholamines, Glucocorticoids, Glucagon
What is Menotropin (Human Menopausal Gonadotropin)? What is it used for?
Acts like FSH–> stimulates formation of dominant follicle?
Used to treat infertility, followed by hCG–> LH-surge–> ovulation
What can prevent the formation of ALL types of kidney stones?
Increased fluid intake
What is the most common obstructive lesion of the female genital tract?
Imperforate Hymen
How can Imperforate Hymen present?
At birth:Bulging introitus (Mucocolpos- accumulated vaginal secretions)
After Birth: Cyclical abdominal/pelvic pain, vaginal bulge suggestive of Hemacolpos–> back pain, difficulty urinating/defecating
Which bacteria produce IgA Protease?
N. gonorrhea
N. meningiditis
S. pneumoniae
H. influenzae
What does IgA Protease allow certain bacteria to do?
Facilitates bacterial adherence to mucosa
What is the mechanism of Acute Organ Rejection?
Host T-lymphocytes react against graft MHC molecules
How do you prevent Acute Organ Rejection and how do you treat it?
Prevent: Calcineurin-inhibitors
Tx: Systemic corticosteroids
What are laboratory findings in Poststreptococcal Glomerulonephritis?
Anti-Strep Abs (anti-Streptolysin O, anti-DNAase B, anti-Cationic Proteinase) LOW C3 LOW Total Complement NORMAL C4 Presence of Cryoglobulins
What is the function of Calcitonin?
Provide Negative FB for Ca2+ levels
Decrease bone resorption
In Poststreptococcal Glomerulonephritits, Immunofluoresence shows what?
Granular deposits of IgG, IgM, and C3 in Basement Mem and Mesangium.
“Starry Sky” appearance
How does Citrate prevent kidney stones?
Binds free Ca2+
What structures arise from the Ureteric Bud and Metanephric Mesoderm? (Blastema)
Ureteric Bud: Collecting sys- collecting tubules, collecting ducts, major and minor calyces, renal pelvis, ureters
Metanephric Mesoderm: Glomeruli, Proximal Tubule, Loop of Henle, DCT
What determines if a chemical reaction is spontaneous?
Gibbs Free Energy is negative
Transketolase is an enzyme of which pathway? Where does this pathway occur in the cell?
Pentose Phosphate Pathway
Occurs in the Cytoplasm
What is the most common known Viral cause of Acute Hemorrhagic Cystitis in children?
Adenovirus
How do GFR and Creatinine levels correlate?
When GFR is normal, large decrease in GFR results only in small increase in serum creatinine
When GFR is very low, small decreases in GFR lead to relatively large changes in Creatinine
In the PRESENCE of ADH, which parts of the Nephron has the most concentrated fluid?
Collecting Tubules
Also, Descending loop of Henle
In the ABSENCE of ADH, which part of the Nephron has the most concentrated urine?
Descending loop of Henle
What is Spironolactone?
Aldosterone Receptor Inhibitor
Which portion of the nephron is impermeable to H2O regardless of ADH?
Thick Ascending Limb
On microscopy, what will Chronic Transplant Rejection show?
Obliterative fibrous intimal thickening
Tubular atrophy
Interstitial fibrosis
In what forms do we secrete acid in urine? What about HCO3-?
NH4+
H+
H2PO4-
NOTE: HCO3- is completely reabsorbed!
Where is most filtered K+ reabsorbed?
PCT (~66%)
Thick Ascending Limb (~23-30%)
NOTE: These values are FIXED! Do NOT play a big role in regulation of K+
Which cells are primary regulators of K+ regulation?
Principal Cell
alpha-Intercalated Cell
How do alpha-Intercalated and Principal cells affect K+ levels?
HYPO-K+ : Alpha-Intercalated cells reabsorb K+ (H+/K+ ATPase)
HYPER or Normal K+: Principal cells secrete K+
What is Supine Hypotension Syndrome? When can it occur?
Lying in Supine position–> compression of IVC–> decreased preload
Can occur in Pregnancy >20weeks
The nerves and vessels supplying the Ovary are in which ligament?
Suspensory Ligament
NOTE: The Ovarian Ligament carries no named vessels. Connects ovary to uterus.
Which hormones use PKA as the primary mediator for intracellular effects?
TSH
Glucagon
PTH
B-adrenergic
What happens to Total SVR during exercise? How?
Decreases due to local vasodilation in exercising muscle
What is Pulsus Paradoxus? When does it occur?
A decrease in Systolic BP >10mmHg on Inspiration
Occurs w/ pericarditis, tamponade, restrictive cardiomyopathy, severe obstructive lung disease (asthma, etc)
What intracellular changes to B2-agonists cause?
Gs–> AC–> increase in cAMP
What is a rare, but serious potential side effect of Nitroprusside? What is the antidote?
Cyanide toxicity
Tx: Sodium Thiosulfate (Sulfur)
In Diastolic Heart Failure, what happens to LVEDP and LVEDV
LVEDP increases to try to maintain LVEDV
SV and LVEDV normal (until have decompensation)
How do HDL levels a cardiovascular risk relate? Tx to increase HDL?
Pts with high HDL are at lower risk to have cardio event, BUT tx to improve HDL does NOT lower risk of cardio event.
What is the difference between QRS and QT in terms of what they represent?
QRS: Depolarization of ventricles
QT: Mechanical contraction of ventricles
When is Aortic Regurgitation murmur heard?
Early Diastole (When pressure gradient b/t aorta and LV is at its max)
What do Temporal Arteritis and Takayasu Arteritis have in common?
Granulomatous inflammation of the media
For Nitrate drugs and NO, what is the downstream effect of increasing cGMP?
cMGP–> decrease Ca2+–> less activity of MLCK–> Myosin dephosphorylation
What labs can help you differentiate between Drug-Induced Lupus and SLE?
DIL: anti-ANA, but NO anti-dsDNA
SLE: BOTH!
Which drugs are known to cause Drug-Induced Lupus?
Procainamide
Hydralazine
Isoniazid
In the treatment of Angina Pectoris, what is the MAIN cause of symptoms relief?
Decrease preload–> decrease LV volume–> decrease O2 demand and cardiac work
What is a potential side effect of Daptomycin?
Increase in CPK
Myopathy
What is the main difference between Nitroglycerin and Isosorbide dinitrate?
Isosorbide dinitrate is 100% bioavailable when taken orally
What is the ONLY intravenous anti-HTN drug that can also improve renal perfusion?
Fenoldopam (Selective D1-Dopamine Agonist)
Coronary, Peripheral, RENAL, splanchnic vasodilation
What are the biggest side effects of HMG-CoA Reductase Inhibitors?
Hepatitis
Rhabdomyolysis–> can lead to Acute Renal Failure
Long-term increases in pulmonary venous pressure leads to decreases/increases in which molecules?
Decreased NO release
Increased Endothelin release
Vascular remodeling of pulm vasculature & smooth muscle proliferation
Sympathetic outflow to which 2 organs is unique?
Sweat Glands
Adrenal Gland
Use ACh outflow!
What is Lipofuscin?
Yellow-Brown granules
Product of free radial injury and Lipid Peroxidation
Migratory Thrombophlebitis should make you think of what?
Cancer!
Paraneoplastic syndrome (Trousseau sign)
Most common w/ adenocarcinomas (pancreas, colon, lung)
Which organ is the most likely to suffer from an embolism?
Kidney b/c it is perfused at rate 3-5x that of any other organ
What can reduce the stability of atherosclerotic plaques?
Inflammatory macrophages–> release Metalloproteinases–> degrade collagen
What are the side effects of Digoxin? What can predispose a patient to Digoxin toxicity?
Nausea, vomiting, diarrhea, blurry yellow vision, AV-Block, Ventricular tachycardia, Hyperkalemia, confusion, dizziness, HA, delirium
Hypokalemia can make WORSE and Renal failure
How do you treat Digoxin toxicity?
- Fix K+ slowly
- Anti-Digoxin Abs
- Oral-activated charcoal
- Mg+
- Cardiac pacer
What effects does Niacin have on vessels?
Vasodilatory
Persistene Lymphedema can predispose to what?
Lymphangiosarcoma
E.g. post-radical mastectomy
What can be protective aga. LV wall rupture after an MI?
LV Hypertrophy
Prior MI
What is the most common cause of in-hospital death post-MI?
Cardiogenic shock (LV failure)
What is a typical sign of irreversible cell damage?
MT vacuolization –> MT cannot generate ATP
What things can lead to Candida overgrowth?
Broad-spectrum Abx
SYSTEMIC corticosteroids
Diabetes Mellitus
Immunosuppression
What are Ephelides?
Freckles
In Tetralogy of Fallot, what is the major determinant of Right-to-Left shunting?
Degree of RV Obstruction (Pulmonic Valve Stenosis)
What is the most important risk factor for Aortic Dissection?
HTN
Leads to medial hypertrophy–> decreased blood flow to media–> degeneration and loss of sm. muscle
Cyanotic spells are associated with what?
Tetralogy of Fallot
What are the actions of EP?
HR: Increase (Beta-1)
Sys. Resistance: Increase (Alpha-1 and Beta-1)
Diastolic BP: Decreases at LOW dose (Beta-2 > Alpha-1), Increases at HIGH dose (Alpha-1> Beta-2)
What forms vWF?
Endothelial Cells
What are the 2 mechanisms of Digoxin?
- Block Na+/K+ ATPase pump
2. Increase Parasympathetic outflow (decrease AV node conduction)
What is the mechanism for Vancomycin resistance?
Substitution of D-alanine with D-lactate
High levels of what can cause Insulin Insensitivty?
Free fatty acids and Triglycerides
What process does Carnitine Deficiency impair?
Ketone Body production
How can you treat/prevent tissue necrosis caused by NE infusion?
Phentolamine (alpha-1 Blocker)
Which drug that causes QT Prolongation has very LOW risk of Torsades of Pointes andd other Proarrhythmias?
Amiodarone
What effect do Alpha-2 and Beta-2 Adrenergic Receptors have on Insulin Secretion?
Alpha-2: DECREASE Insulin secretion
Beta-2: INCREASE Insulin secretion
What are the symptoms of Rubella?
Low-grade fever
Maculopapular rash–> Progression from Head/Neck downward
*Posterior auricular and Suboccipital lymphadenopathy
Sequelae: Polyarthralgia
How does Congenital Rubella present?
Sensorineural deafness
Cataracts
Cardiac malformations (PDA)
McArdle’s Syndrome (Type 5 Glycogen Storage Disease)
Myophosphorylase Deficiency (Glycogen Phosphorylase)
Failure of Glycogenlysis (cannot Glycogen–> Glucose-1-P)
Presents: Decreased exercise tolerance, myoglobinuria, muscle pain w/ physical activty
What are common side effects of TZD’s?
Weight gain
Edema (can exacerbate CHF)
What are the side effects of Methimazole and PTU?
BOTH: Agranulocytosis
Methimazole: teratogen, cholestasis
PTU: hepatotoxicity, ANCA-vasculitis
What is Comedocarcinoma?
DCIS
Solid sheets of pleomorphic, high-grade cells
CENTRAL NECROSIS
How do cAMP levels affect vasodilation?
Increase cAMP–> Vasodilation!
Explains hypotensive side effects of Milrinone and Amrinone
What is the difference between Phenoxybenzamine and Pentolamine?
Phenoxybenzamine: IRREVERSIBLE, competitive inhibitor of Alpha-1 receptos
Phentolamine: REVERSIBLE, competitive inhibitor Alpha-Adrenergic receptors (Non-specific)
What is the difference between FA-oxidation and Glucose oxidation nd Glycolysis in terms of O2 requirements?
FA-oxidations requires more O2
Which patients should NOT be on ACE-inhibitors? Why?
Pts w/ Renal Artery Stenosis b/c they are dependent of ACE-mediated efferent arteriole constriction to maintain renal perfusion and GFR.
Can lead to Acute Renal Failure in these pts.
Which anti-arrhythmics can cause Prolonges QT?
Quinidine Procainamide Disopyramide Ibutilide Dofetilide Sotolol
Which drugs can cause QT Prolongation?
Antiarrythmics
Phenothiazines
TCAs
What is the most common cause of death in pts with DM?
Coronary Heart Disease
What are the 3 highest risk factors for Coronary Heart Disease?
Noncoronary Atherosclerotic disease
Diabetes Mellitus
Chronic Kidney Disease
***They are at the SAME risk as pts w/ known Coronary Heart Disease!!!
Hepatic Angiosarcoma (risk factors/exposure, cell markers)
Assoc w/ exposure to Arsenic, thorotrast, polyvinyl choride
Tumor cells express CD31 (endothelial cell marker)
How do you treat Anyphylactic shock?
Epinephrine
Which Signaling molecules use JAK/STAT pathway?
Colony-stimulating factors
Prolactin
Growth Hormone
Cytokines
What substance mediates the flushing side effect of Niacin?
PGs
How does Capsaicin reduce pain? (What substance?
Reduces Substance P levels in PNS
What kind of Beta-Blocker should be prescribed to a diabetic?
Selective Beta-1 b/c by blocking Beta-2 you don’t get hypoglycemic symptoms of responses (gluconeogenesis and glycogenolysis)
What are the side effects of Verapamil?
AV-block
Gingival Hyperplasia
Constipation
Patients taking Nitrates have to have a _________________ to avoid______________.
A NITRATE-FREE PERIOD daily to avoid TOLERANCE.
What are common side effects of Nitrates?
Hypotension
HA
Facial flushing
–> vasodilating effects on meninges and skin
What are the localized amyloidosis for each organ?
Heart: ANP Thyroid: Calcitonin Pancreatic: Amylin Brain: Beta-amyloid Pituitary: Prolactin
What effect do Beta-1-Blockers have on Renin?
Beta-1-Blockers DECREASE Renin release from JG-cells
What should you warn men about after having a vasectomy?
There will still be viable sperm in the ejaculate up to 3mts after ligation.
Jervell and Lange-Nielsen Syndrome
QT Prolongation (Torsades de Pointes) Neurosensorial deafness
What are different cyanotic symptoms of PDA, Coarctation, and ToF?
PDA: LOWER extremity cyanosis once shunt has reversed
Tetralogy of Fallot: whole body cyanosis
Coarctation: No cyanosis, ONLY discrepancy in BPs in upper vs. lower
ASD/VSDs: No cyanosis, unless get reversal of shunt, but would be whole-body
In Carcinoid Syndrome, what substances are inactivated in the lungs?
Serotonin
Bradykinin
What are the functions of Prostacyclin? What is it produced from? What does it oppose?
Produced by Prostacyclin Synthase by Prostaglandin H2 Inhibits platelet aggregation Vasodilates Increases vascular permeability OPPOSES function of Thromboxane-A2
What age-related problem can cause Isolated Systolic HTN?
Age-related Aortic Stiffening
In SIADH, describe the volume status.
Euvolemic!!!
B/c increased H2O reabs (transient)–> Decreased Aldosterone and Increased ANP–> Increased Na+ secretion–> Euvolemia
Romano-Ward Syndrome
Congenital QT Prolongation
What are the molecular mechanisms of Congenital QT Prolongation?
Mutations in K+ channels–> Delayed rectifier currents
What kind of epithelium does the Ovary have?
Simple Cuboidal
Where can Teratomas occur?
Ovary, NOT the uterus.
Choreocarcinoma
Derived from Trophoblast (Cytotrophoblasts/Syncytotrophoblasts)
Usually follow removed mole, abortion, pregnancy
Increased hCG
Abnormal vaginal bleeding, uterine enlargement
Histo: Bulky, yellow-white, necrosis, hemorrhage, NO vili
VERY responsive to chemotherapy
What signaling transduction path do alpha-1 receptors use?
PLC–> IP3–> DAG–> increased Ca2+
Which adrenergic receptors does NE act on?
BOTH alpha (1 and 2) ONLY Beta-1
What are Neurophysins?
Carrier proteins for ADH and Oxytocin
Mutations in Glucokinase can lead to what?
Gestational Diabetes
What is the difference between Glucokinase and Hexokinase?
Glucokinase has higher Km
Glucokinase serves as glucose sensor for Pancreas
What kind of changes do you in the uterus of a patient with Ectopic Pregnancy?
Same changes you would see in normal pregnancy (due to hormones)
“Deciduated” endometrium
BUT, NO chorionic villi
What are the effects of EP on Uterine contractions?
Affinity for B2 > A1
B2: Decrease uterine contractions
A1: Increase uterine contractions
BUT! If give with Beta-Blocker–> Robust uterine contractions
What are the effects of EP on Uterine contractions?
Affinity for B2 > A1
B2: Decrease uterine contractions
A1: Increase uterine contractions
BUT! If give with Beta-Blocker–> Robust uterine contractions
In an atherosclerotic plaque, which cells secrete mediators that promote sm. musc. migration into the intima?
Endothelial cells (PDGF) and recruited monocytes
How do Dobutamine and Nitroglycerine affect HR and myocardial O2-consumption?
BOTH increase HR (Nitroglycerine through Reflex Tachycardia)
Dobutamine INCREASES O2 consumptions
Nitroglycerine DECREASES O2 consumption
What is the most commonly deficient enzyme in the Beta-Oxidation pathway? Symptoms?
Acetyl-CoA DHase
Symptoms: Hypoglycemia after prolonged fasting (16-24hrs) AND LOW ketone bodies
Why are pregnant women and women taking OCP’s at increased risk for gallstones?
Estrogen: Increases cholesterol synthesis by upregulating HMG-CoA
Progesterone: Reduces bile acid secretion and slows gallbladder emptying
Which medications inhibit Dihydrofolate Reductase?
Trimethroprim
Methotrexate (Antimetabolite)
Pyrimethamine (anti-parasite)
High levels of 17-Hydroxyprogesterone is diagnostic for what?
21-Hydroxylase Deficiency (CAH)
Which Glucose Receptor is responsive to Insulin? Where is it expressed?
GLUT-4
Expressed in Muscle and Adipose
What molecule serves as an allosteric activator of Gluconeogenesis?
Acetyl-CoA–> activates Pyruvate Carboxylase
The combination of Statins + Fibrates increases your risk for__________.
Myopathy
The combination of Fibrates + Bile acid-binding resins increases your risk for _________.
Cholesterol gallstons
What are the side effects of Thiazide Diuretics?
DECREASE: K+, BP
INCREASE: Ca2+, Uric acid, Lipids, Glucose
Metabolic Alkalosis
What kind of health care decisions can incapacitated individuals make?
None!
This includes people who are drunk- must keep in hospital until they are sober.
When are anovulatory cycles common?
First several years after menarche and last few years before menopause.
What causes Buerger’s Vasculitis? Describe Histology also.
Endothelial cell toxicity from tobacco or Hypersensitivity to them
Segmental thrombosing acute AND chronic inflammation of arterial walls that extends into contiguous veins and nerves (rare).
What are the most common causes of Native Valve Bacterial Endocarditis?
- Mitral Valve Prolapse (esp. in the US)
2. Rheumatic Valvular Disease (less in the US)
In Hypertrophic Cardiomyopathy, what is mutated?
Cardiac Sarcomere proteins (usually Beta-Myosin Heavy Chain)
How many cases of Dilated Cardiomyopathy are genetic? What is mutated?
1/3 cases
Cardiac Muscle Cytoskeleton (dystrophin) OR MT enzymes
Which genetic diseases can predispose to Berry Aneurysm?
Type IV Ehlers-Danlos
NOT Marfans!!! No assoc. w/ Marfans’s (only aortic aneurysms)
In Atherosclerosis, which arteries are most heavily involved?
Abdominal Aorta–> Coronary Arteries–> Popliteal–> Internal Carotid–> circle of Willis
How do you treat Maternal Group B Strep?
INTRAPARTUM Penicillin OR Ampicillin
Describe the molecular mechanism of Topical Vitamin D drugs that are used to treat Psoriasis.
Bind to and ACTIVATE vit. D receptor –| keratinocyte proliferation and –> keratinocyte differentiation
What is Avoidant Personality Disorder?
Maladaptive pattern of behavior characterized by feelings of inadequacy, timidity, fear of rejection
Describe how Ventilation, Perfusion, and V/Q change in the lungs going from apex–> bases.
Ventilation increases (V)
Perfusion INCREASES A LOT (Q)
V/Q decreases
What is increased Bleeding Time caused by?
Quantitative or Qualitative platelet abnormalities
Hemophilia
X-linked
Isolated prolonged PTT
PT, TT, and Bleeding Time are NORMAL
Deep bleeding (hemarthrosis, intramuscular, prolonged bleeding from surgery)
Which artery primarily supplies blood to the Femoral head and neck?
Medial Circumflex Artery
What are 4 common physical findings a person who smoked marijuana will have?
Injected Conjuntiva
Tachycardia
Dry mouth
Increased appetite
What condition is frequently assoc. w/ vit. D deficiency?
Osteomalacia
Diffuse Esophageal Spasm (What is it? What can it resemble?)
Uncoordinated contractions of the esophagus
Sporadic, Intermittent
Dysphagia, Chest pain
Can MIMIC Unstable Angina
Which areas of the bowel are most susceptible to ischemia?
Splenic flexure (SMA and IMA) Distal Sigmoid Colon (IMA and Hypogastric Arteries)
What kind of bone changes do you see with Hyperparathyroidism?
Subperiosteal resorption and cystic formation
What is the regulator molecule of Iron? What synthesizes it?
Hepcidin
Secreted by the Liver
Increases secretion in HIGH Iron levels & Inflammatory–> decreases Fe absorption in gut by downregulating Ferroportin and release from Macrophages
Decreased secretion in Hypoxia and erythropoiesis
What is a Tzanck smear used to test?
HSV
VZV
What does “Pap” in pap smear stand for?
Papanicolaou
What is the most common mutation see in Melanoma?
BRAF (protein kinase)
V600E (valine replaced by glutamate)
40-60% of cases
What is the antidote for Acetominophen toxicity? How does it work?
N-Acetyl-Cysteine (NAC)
Provides sulfhydryl groups (toxicity due to saturation of sulfation and glucoronide conjugation)
Also acts as glutathione and binds to metabolites
Which gastric layers contain Parietal cells and Chief cells?
Parietal cells: Superficial GLANDULA layer (under Comlumnar epi)
Chief cells: Deep GLANDULAR layer
What conditions cause sickle RBC’s to sickle?
Hypoxia
High 2,3-DPG
Low pH
What is Schizophreniform disorder?
Same symptoms of schizophrenia, but shorter (more than 1mt, less than 6mt)
What do you need to qualify for schizoaffective disorder?
Have to meet criteria for major depressive or manic episode, with concurrent active symptoms of schizophrenia
What are the criteria for Schizophrenia?
At least 6mts 2 of the following 5: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Disorganized behavior 5. Negative symptoms 1 MUST include delusions, hallucinations, or disorganized speech.
What increases and decreased in Restrictive Lung Disease?
Increased: Expiratory flow rates, FEV1/FVC
Decreased: TLC, Forced Expiratory Volume, Radial traction on airway walls
Etanercept
TNF-alpha inhibitor
Fusion protein (TNF receptor to Fc-Ig)
Usually added to Methotrexate to treat RA
Mech: Acts as a decoy molecule
What do the following suffixes mean? (-mab, -cept, -nib)
- mab: Monoclonal Ab
- cept: Receptor molecule
- nib: Kinase Inhibitor
What is the mechanism of Rifampin?
Inhibits DNA-dependent-RNA Polymerase–> NO mRNA synthesis!!!
Is there an Amino-Acid proof-reading mechanism during protein synthesis?
NO!!! If the wrong a.a is attached the a tRNA, it WILL get incorporated!
What are Peptostreptococcus, Prevotella, Bacteroides, and Fusobacterium? Where are they normally found?
Anaerobic bacteria
Normally found in oral cavity
Common cause of lung abscess
Risk factors for lung abscess: Increase aspiration risk (Dysphagia, loss of consciousness, seizure disorder, etc)
What is seen on microscopy for Glioblastoma?
Areas of necrosis (palisading) and hemorrhage
Inherited defects involving IFN-gamma signaling results in what kind of infections?
Disseminated Mycobacterial infections in infancy or childhood
Require lifelong anti-mycobacterials
Lactic acidosis is caused by low activities of what?
Low activity of Pyruvate DHase
Increased activity of Lactate DHase
Pyruvate Carboxylase is involved in which metabolic process?
Gluconeogenesis
What labs do you see with Hereditary Spherocytosis?
Increased MCHC (Hb concentration, due to dehydration)
Increased LDH
Increased Reticulocytes
Decreased Haptoglobin
Immune deficiency with delayed umbilical separation and wound healing should make you think about what?
Leukocyte Adhesion Deficiency
Leukocyte Adhesion Deficiency
Autosomal Recessive CD18 Recurrent skin infections WITHOUT pus Delayed Umbilical detachment Poor wound healing
What causes an DECREASE in Haptoglobin levels?
Increased Hb levels–> Binds to Haptoglobin–> less free Haptoglobin
What is Demeclocycline?
ADH- antagonist
Used to tx SIADH
What is the difference between Osteitis Fibrosa Cystica and Renal Osteodystrophy?
OFC: Due to primary HyperPTH
RO: Due to secondary or tertiary HyperPTH (renal disease–> low vit. D)
The pathogenesis of Emphysema is mediated by what cells? What enzymes do they release?
Neutrophils and Alveolar Macrophages–> release Proteinases (Elastase)
Which nerve(s) go through the Obturator Foramen?
Obturator Nerve is the ONLY nerve that travels through that foramen.
Is it possible for women with Turner’s Syndrome to become pregnant? If so, how?
Yes!
By in vitro fertilization (donor oocytes) b/c pts w/ Turner’s have Ovarian Failure.
What is the difference between Unfractionated Heparin and Low-Molecular Wt Heparin?
BOTh can bind the Anti-Thrombin to increase its activity aga. Factor Xa
ONLY Unfractionated Heparin can bind to BOTH antirthrombin and thrombin to inactivate Thrombin.
What effect do Glucocorticoids have on the following tissues: Skin, Muscle, Bone, Lymphoid Tissue, Liver?
Skin: Inhibit fibroblast proliferation & collagen formation (skin thinning)
Muscle: Proteolytic–> proximal muscle weakness
Bone: Decrease bone mass. Inhibit osteoblastic activity
Lymphoid tissue: Decrease # of circulating T-cells (helper)
Liver: INCREASES gluconeogenesis and glycogenesis
What is used to treat Bleeding caused by Heparin Toxicity?
Protamine Sulfate
What is the mainstay tx for an Acute Manic episode?
Lithium, Valproate, or Carbemazepine
+
Atypical Anti-psychotic (Olanzepine)
Which Inhaled anesthetic is assoc. w/ Hepatotoxicity?
Halothane
What are the symptoms of hepatotoxicity from Inhaled Anesthetics?
Histo: Liver can atrophy, widespread centrilobular necrosis and inflamm. of portal tracts and parenchyma. Indistinguishable from viral hepatitis.
Labs: Elevated Aminotransferases, Prolonged PT, NORMAL Albumin
At FRC, what are the airway, alveolar, and intrapleural pressure?
Airway and Alveolar: 0
Intrapleural: Negative (-5 cm H20)
Which organism is responsible for “Hot Tub Folliculitis”
P. aeruginosa
In Giardia infections, what is the major player in the adaptive immune response?
***Secretory IgA
and T-helper CD4+
What is administered to prevent Maternal Rh alloimmunization?
Anti-Rh (D) IgG
At 28wks and Immediately Postpartum
How can you distinguish Endometriosis and Adenomyosis?
Adenonyosis: ENLARGED uterus
What are the symptoms of Endometriosis?
Dysmenorrhia
Dyspareunia (retroversion of the uterus and endometrial tissue in uterosacral ligaments)
Dyschezia (pelvic adhesions)
What is the antiseptic properties of Isopropyl alcohol?
Disruption of cell membranes
Denaturations of proteins
What is the antiseptic properties of Chlorhexidine?
Disruption of cell membranes
Coagulation of cytoplasm
What is the antiseptic properties of Iodine?
Halogenation of proteins and nucleic acids
Which pregnancy hormone(s) is responsible for increased Insulin Resistance?
hPL Placental growth hormone Estrogen Progesterone Glucocorticoids
What changes in Pregnancy is hPL responsible for?
Increased Insulin Resistance
STIMULATES Proteolysis and Lipolysis
INHIBITS gluconeogenesis
Which muscles does the Median Nerve run through?
B/t Humeral and Ulnar heads of Pronator Teres–>
B/t Flexor Digitorum superficialis and Flexor Digitorum profundus
What is the most abundant a.a. in Collagen?
Glycine
Where is Coccidioides immitis found?
Southwestern US
Where is Histoplasma endemic?
Central US (Mississippi and Ohio Rivers)
What is Allergic Bronchopulmonary Aspergilliosis (ABPA)?
Due to Aspergillus fumigatus
Asthmatic pts on steroids
Transient recurrent pulmonary infiltrates and eventual proximal bronchiectasis
High: Eosinophilia, IgE, IgG
What do you use to treat VIPomas?
Somatostatin (Octreotide)
What are the symptoms of a VIPoma?
Pancreatic Islet cell tumor
Watery diarrhea
Hypokalemia
Achlorhydria
What is Bethanecol?
M2 and M3 agonist–> Promotes urination
Used for postpartum/post-operative urinary retention
What is the usual cause of death in Potter Syndrome?
Lung Hypoplasia due to oligohydraminos
What kind of receptor is JAK2?
NON-Receptor Tyrosine Kinase
Assoc. w/ EPO-receptor
What is the initiating event for Appendicitis?
Obstruction of the lumen
What are severe adverse effects of Succinylcholine?
- Hyperkalemia (pts w/ burns, crush injury, myopathy, denervation)
- Arrythmia
- Bradycardia
- Malignant Hyperthermia
How do you treat Acute Intermittent Porphyria? What is the mechanism>
Heme & glucose–> Neg FB on ALA-Synthase
Why is the rectum always involved in Hirschsprung’s Disease?
Neural Crest cells travel caudally, along Vagus N. from 8th-12th week.
How can you distinguish between CML and Leukemoid Rxn?
BOTH cause increase in WBC count
ONLY Leukemoid Rxn has increase in Leukocyte Alkaline Phosphate (LAP)
CML: LOW LAP b/c leukocytes immature
What are the symptoms of Fibromyalgia?
Spot tenderness
Stiffness
Muscle pain (worse in the morning, exacerbated w/ exercise)
Fatigue, Poor sleep
Which muscles do you to sit up from the supine position?
Hip flexors (Iliacus, Psoas minor/major)
Rectus femoris
Abdominal oblique muscles
Tensor fascia lata
Where should thoracocentesis be performed? (Midclavicular, Midaxillary, Paravertebral)
Medclavicular: ABOVE 7TH
Midaxillary: ABOVE 9TH
Paravertebral: ABOVE 11th
In the Lac Operon, how do lactose and glucose affect transcription?
Lactose: Increase b/c binds to Repressor–> cannot bind to operon
Glucose: Decrease b/c leads to decreased cAMP levels–> Catabolite Activating Protein cannot bind to DNA
How does Sleep Apnea affect the systemic and pulmonary resistance?
Systemic and Pulmonary HTN
How can you gauge the severity of Mitral Stenosis?
A2- Opening Snap interval
SHORTER interval–> more SEVERE
What is the most common cause of kidney stones?
Idiopathic
Normal Ca2+ levels
Increased Ca2+ in urine
What is Rheumatoid Factor?
IgM: Anti-Fc portion of IgG
What are the symptoms/ cause of death in Fabry Disease?
Symptoms: Angiokeratomas, Peripheral neuropathy (“burning sensation”), Hypohidrosis (absent sweating), renal disease, cardiac disease
Death: Renal Isufficiency
What effects can Amp-B have on the kidneys?
Decreased GFR
Hypomagnesium
Hypokalemia
Toxic effects on Tubular epithelium
What is unique about EHEC, compared to most E. coli?
CanNOT ferment Sorbitol
CanNOT make glucuronidase
What are the Catalase (+) organism? Which disease causes people to be more susceptible to these?
*Aspergillus
*Serratia
*Burkholderia
*Norcadia
*S. aureus
Pseudomonas
Listeria
Candida
E. coli
Increased Susceptibility: Chronic Granulomatous Disease (defect in NADPH Oxidase)
What is the mechanism of Isoniazid?
Decreases synthesis of Mycolic acids
What is the mechanism of Rifampin/Rifabutin?
Inhibits DNA-dependent RNA-Polymerase
Rifampin: P-450 stimulation
Rifabutin: Does NOT stimulate P-450
In Elderly pts w/ chronic anemia w/ no other cause for anemia, what is the most likely deficiency? Why?
Vit. B12
Gastric atrophy w/ age–> decreased acid secretion
In “Foot Drop”, which never is damaged?
Common Peroneal
For particles in Resp. Tract, what determines how they are cleared?
Size:
>2.5um–> Muco-Ciliary transport
Macrophages
What is the most common cause of Meconium Ileus?
Cystic Fibrosis
What is Cheyne-Stokes respirations? When is it commonly seen?
Cyclic breathing of apnea, then gradually increasing, then gradually decreasing tidal volumes
Seen in advances CHF (bad prognostic sign)
During rest and exercise, what is same/different b/t pulmonary and systemic circulation?
Same: Rate of blood flow
Different (at ALL times): arterial resistance, O2 content
What effects can exogenous steroids cause?
Acne Voice deepening Decreased testicular size Increase Hct (Erythrocytosis) Increased liver size
Describe the structure of MHC-I and MCH-II.
MHC-I: Alpha and Beta polypeptide chains
MHC-II: Heavy Chain and B2-Microglobulin
If a patient has symptoms of Carcinoid Syndrome, what does that mean?
MALIGNANT tumor!!!! Has metastasized to the liver!!!
OR That the tumor is NOT in the intestines!
Which nerve controls the Cough Reflex?
Internal Laryngeal Nerve of the Vagus N.
Location: Piriform Recess
Mediates Afferent Limb above Vocal cords.
What is the Piriform Recess? Function?
During swallowing, food is diverted into the esophagus into the Piriform Recess by the epiglottis.
Location: Laryngeal Orifice
Which Abx work aga. P. aeruginosa?
Aminoglycoside+ Ciprofloxacin, Levofloxacin, Carbapenems, Piperacillin, Cefepime, Imipenem, Meropenem, Ticaracillin, Ceftazidime
What is the function of NF-kB?
Increase production of CYTOKINE genes
How do you diagnose vWB Disease?
Ristocetin cofactor assay–> Decreased Agglutination is diagnostic
What is the function of Vitamin K?
Gamma-Carboxylation of Glutamate
What an Nitrites cause?
Methemoglobin
Oxidizes Hb to Ferric form
How do you treat Cyanide Poisoning?
- Nitrites–> oxidize Hb to Meth-Hb–> binds Cyanide
2. Thiosulfate–> forms Thiocyanate–> Renally excreted
In collagen formation, what happens extracellularly?
- Proteolytic processing (cleavage)
2. Cross-linking
What is the cause of Zenker Diverticulum?
Disordered swallowing–> increased pressure in pharynx–> heria
Cricopharyngeal muscle dysfunction
Where is the prostate located in cross-section? Between which organs?
Between the rectum and bladder
What are the side effects of Niacin?
Red, flushed face (Improved by Aspirin)
Hyperglycemia (Acanthosis nigricans)
Hyperuricemia (exacerbated gout)
What are the 2 functions of ADH in the kidney?
- Increase H2O reabsorption in Cortical segment of Coll. Duct
- Increase Urea permeability in Medullary segment of Coll. Duct
What mediates Margination of Neutrophils?
Increased vascular leakage
What mediates Rolling of Neutrophils?
Lose binding
L-Selectin on Neutrophils
E/S-Selectins on Endothelial cells
What mediates Tight Adhesions and Crawling of Neutrophils?
CD18-Beta-2-Integrins (Mac-1 and LFA-1) (Neutrophils) to ICAM-1 on Endothelial cells
What mediates Transmigration of Neutrophils?
PECAM
How do Reticulocytes look different from normal RBC’s?
More blue in color Reticular precipitates (rRNA)
Where is Secretin released from?
Duodenum
What is the difference between and Ulcer and Erosion?
Erosion: Does NOT go through the Muscularis Mucosa.
Ulcer: Can go through the Muscularis mucosa.
What causes Duodenal ulcers in H. Pylori infections?
H. pylori leads to Gastric Antral Ulcers–> destruction of Somatostatin-producing cell–> uncontrolled acid leaking into duodenum–> ULCER
Duodenal ulcer NOT caused by H. pylori itself (H.pylori loves the stomach too much to leave)
How do you treat C. diff? First-line drugs?
First-line: Metronidazole, Vancomycin
Other: Fidaxomicin (RNA-Polymerase inhibitor) for RECURRENT C. difff
Where in the cell does the hydroxylation of Vit. C take place? What is a required cofactor in this process?
ER
Vit. C is required.
Which first-line TB drugs requires an acidic env?
Pyrazinamide
How do you treat “Increased Motility” and “Secretory” diarrhea?
Increased Motility: Meperidine, Diphenoxylate, Loperamide
Secretory: Octreotide
What is the most common cause of Fetal Hydronephrosis?
Inadequate recanalization of the Ureteropelvic Junction (b/t renal pelvis and ureter)
What are the symptoms of Systemic Mastocytosis?
Increased Histamine:
- Increased Gastric acid secretion
- Hypotension–> reflex tachycardia
- Pruritus
- Flushing
For which organism do you find “Spherules containing endospores” in the tissues?
Coccidioides immitis
What is the most common cause of inflammatory diarrhea that can be obtained from domestic animals or food?
Campylobacter jejuni
Animals: cattle, sheep, dogs, chicken.
Which pigment and enzyme is responsible for the green color seen in bruises?
Pigment: Biliverdin
Enzyme: Heme Oxygenase
Occurs in Reticuloendothelial system.
What color are Klebsiella and Pseudomonas colonies on MacConkey plates? Why?
Pseudomonas: White (non-lactose fermenting)
Klebsiella: Pink (lactose-fermenting
Where does Complement bind on IgG and IgM?
Hinge point
Varencycline
Partial NAch-agonist
Uses: Smoking cessation
Reduces withdrawal cravings and attenuates rewarding effects of nicotine.
When can you reverse Succinylcholine toxicity?
Phase I: NO antidote! Neostigmine (Anti-ACh-E- Neostigmine makes worse)
Phase II: Can use Neostigmine
Which Lipid-Lowering Agent is the most effective at lowering TG levels?
Fibrates
Which type of Renal Coliculi are Radioluscent?
Uric Acid stones are the ONLY Radiolucent stones on X-Ray. All other are radiopaque on X-ray.
What is the #1 risk factor for Squamous Cell Carcinoma of the Cervix?
Multiple sex partners!!! (even more than genetics)
Others: Smoking, early sexual intercourse (coitarche), HIV, lower socioeconomic status
What is the cause of Presbyopia?
Denaturation of the stx’l proteins in the lens–> loss of elasticity of the lens
How does Rb regulate the cell cycle?
Hypophosphorylated (Active)–| G1–> S
Phosphorylated (Inactive) –> G1–> S progression allowed.
What does Cryoprecipitate contain?
vWB
Factor VIII
Factor XIII
Fibrinogen
Most available Rodenticides contain what? How do you treat?
Brodifacoum
4-Hydroxycoumarin
Mech: Deplete all vit-K Coag. factors
Tx: Cryoprecipitate
What are the Prophylactic tx for Opportunistic AIDS infections?
P. jirovecii: TMX-SMX
Toxoplasma: TMX-SMX
Mycobacterium avium: Azithromycin
Histoplasma capsulatum: Itraconazole
What are the symptoms of Mycoacterium avium?
Symptoms: wt loss, diarrhea, hepatosplenomegaly, anemia, Increased LDH and Alk Phos (involves RES)
Grows at high temp (41C)
Tx: Resistant to many antimycobacterials. Azithromycin, Clarithromycin
What effect does Estrogen have on cholesterol synthesis?
Facilitates biosynthesis of cholesterol by increasing activity of HMG-CoA Reductase
How is a Hyperacute Transplant/Transfusion Reaction mediated?
Type II Hypersensitivity (usually IgM)
Activates Complement
Myasthenia Gravis is assoc. with abnormalities of which organ?
Thyroid
Which Pharyngeal Pouch is the Thyroid gland derived from? Which other glands are derived from this pouch?
3rd Pharyngeal Pouch
Inferior Parathyroid glands are also derived from 3rd Phayngeal Pouch
Why is pO2 in the left atrium lower than the pO2 in the pulmonary veins?
Deoxygenated blood from the Bronchial Veins
Where does more of the blood from the Bronchial Veins go?
Majority goes to LA
Rest goes to Azygos, Hemizygous, or Intercostal Vein
Blastomyces dermatidites
Immunocompetent: Pulmonary disease, even chronic.
Granulomatous nodules.
Immunocompromised: Systemic infection
Malassezia furfur
Causes degradation of lipids–> damages melanocytes–> Hypopigmented lesions
Hot humid weater
Tx: Topical Miconazole, Selenium sulfide
What mechanisms does our body use to defend aga. Candida?
Local (skin, mucosa): T-lymphocyte
Hematogenous/Systemic: NEUTROPHILS!!!
What is the most common side effect of Aspirin?
GI bleed
What are the side effects Foscarnet? What is it used for?
SE: Nephrotoxicity, Hypocalcemia, Hypomagnamesia
Use: 2nd-line tx for CMV
What is the histologic description of Rickets/Osteomalacia?
Increased unmineralized osteoid matrix and widened osteoid seams
Features: Bowed legs, rachitic rosary, Harrison’s sulci, craniotabes, growth retardation
What are the most common cancers in women in incidence and mortality?
Incidence: Breast, lung, colon
Mortality: lung, breast, colon
What causes the hypercalcemia seen in Sarcoidosis?
Increased formation of vit. D by activated macrophages in granulomas
Which drug commonly used to treat RA can cause interstitial pneumonitis and fibrosis?
Methotrexate
What is “Pica”?
The compulsive consumption of a nonfood and/or non-staple food
Common in PREGNANCY
“Ice” is the most common
Assoc. w/ Iron Deficiency
How does F-2,6-BisP regulate metabolism?
Activates Glycolysis
Inactivates Gluconeogenesis
What is the Germ Tube test?
Used to test C. albicans
Leave in serum at 37C for 3hrs
Hyphae are “germ tubes”
Oxacillin, Nafcillin, Methicillin are used for what kinds of infections?
Penicillinase-resistant Staph infections (S. aureus, S. epidermiditis)
How does HIV enter the T-cell?
gp120 binds CD4 and CCR5
What is Niacin important for? What is Niacin derived from?
Essential component of NAD and NADP
Derived from diet or Tryptophan
What is the virulence factor for H. influenzae?
Capsule (Type B) Polyribotol Phosphate
Non-encapsulated HiB–> part of normal flora–> can cause sinusitis, otitis, bronchitis, conjunctivitis
What are some risk factors for First-dose Hypotension in pts starting on ACE-Inhibitors?
Hypovolemia (Loop diuretics) Hyponatremia Low BP High renin/Aldosterone levels Renal Impariment Heart failure
What are fatty streaks? At what age do you start seeing them?
Intimal, lipid-filled foam cells
Derived from macrophages, smooth muscle cells that have engulfed lipoproteins
Which is better for pregnant women- Heparin or Warfarin?
Heparin!!!
Warfarin can cross the Placenta
What is the function of Lamellar Bodies in Type II Pneumocytes?
Produce and secrete surfactant
What is the most common initiating event for Acute Calculous Cholecystitis? What is usually the last step?
Obstruction
LAST step: Bacteria invade
How far up do the apices of the lungs extend?
ABOVE the clavicle and 1st rib
Which bone does the Carotid Body lie next to?
Carotid Body is at the bifurcation of the Common Carotid Artery
Lies next to the Hyoid Bone
What does the Tibial N. innervate? What area of sensation?
Flexors of the lower leg
Extrinsic digital flexors of the toes
Plantar surface of feet
Which cells do Natural Killer Cells target?
Cells w/ decreased MHC-I
Large lymphocytes
Use perforins and granzymes to kill cells
What electrolyte abnormalities occur in CF?
Decreased Cl- secretion
Increased Na+ and H2O absorption
Leads to dehydrated and thick mucus
What are the 3 most common bacteria responsible for Secondary Bacterial Pneumonia?
S. pneumonia
S. aureus
H. influenzae
What are the 3 functions of Thyroid Peroxidase?
- Organification
- Oxidation
- Coupling to produce T4 and T3
What is commonly used to treat the Side effects of Myasthenia Gravis?
Scopolamine (selective mAChR antagonist)
What are the major side effects of Theophylline?
Tachyarrhythmia
Seizures
What congenital defect can Lithium cause?
Ebstein’s anomoly
Which protein is responsible for the drug resistance to chemotherapy?
MDR1 P-glycoprotein
Transmem protein ATP-dependent
Can reduce influx or increase efflux
What is the difference between Suppression and Repression as coping mech?
Suppression: CONSCIOUS, mature
Repression: UNconscious, immature
What is Raltegrivir?
HIV Integrase Inhibitor–> prevents mRNA transcription
What is Cystinuria?
Defect in Transporter of Cystine, Ornithine, Arginine, Lysine.
Autosomal Recessive
Symptoms: Nephrolethiasis (20’s and 30’s) (ONLY symptom!!!)
What changes in pH, pCO2, and HCO3- do you see in DKA?
Low pH
Low Bicarb
Low pCO2 (compensatory resp. alkalosis)
What is Abetalipoproteinemia?
Autosomal Recessive
MTP gene
Cannot synthesize Apo B
Symptoms: Malabsorption in 1st yr of life. Low cholesterol, TG’s, chylomicrons, VLDL, Apo B
Women with PCOS are at increased risk for developing what?
DM2
Endometrial adenocarcinoma
Which cytokines recruit Neutrophils?
IL-8
Leukotriene B4
5-HETE
Complement 5a
Where is the most common place to have colonic adenocarcinoma?
Rectosigmoid colon
Which landmark can distinguish between an Indirect and Direct Inguinal Hernia?
Inferior Epigastric Vessels
Direct Hernias–> Medial to vessels
Indirect Hernias–> Lateral to vessels
Which lab tests should be done before starting someone on a Statin?
Liver Function Tests
Why do Estrogen levels increase in pts with Cirrhosis?
Decreased Estrogen catabolism
Increased Sex-Binding Protein Globulin
What is the Hawthorne Effect?
Observer Effect
Tendency of subjects to change their behavior when realize they are being studied
How do you diagnose Strongyloides? What do you see in the stool sample?
Rhabditiform (noninfectious) larvae in the stool
What is the difference in immune response to the oral and intramuscular Polio vaccines?
Oral –> Increased levels of MUCOSAL IgA
Serum IgA will be the same in both vaccines
What is the difference between H2S production in Shigella and Salmonella?
Shigella–> canNOT produce H2S
Salmonella –> can produce H2S
Which sugar is metabolized the fastest in the liver? Why?
Fructose
It bypasses PFK-1 (rate-limiting enz of glycolysis)
How many half-lives does it take to clear 75% of a drug?
2 half-lives
How do you treat Arsenic poisoning?
Dimercaprol
Displaces Arsenic from sulfhydryl groups
What causes a Direct Hernia?
Breakdown of Transversalis fascia
What runs through the Hepatoduodenal Ligament?
Portal triad
What are the different forms of IgA?
Serum: monomeric
Saliva, tears, Colostrom, mucus: Dimeric
In intestinal Malrotation, what will be found on dissection?
Cecum in RUQ
Duodenojejunal junction remains to right of midline
What is alpha-Amanitin? And where is it found?
It is in Amanita phalloides (mushroom)
Inhibits RNA Polymerase II (mRNA)
Who should Informed Consent be obtained by?
The person who will be performing the procedure
What changes do you see in hepatocytes in a person being treated with a Statin?
Increased density of LDL Receptors
What is the mechanism of Flutamide?
Androgen Receptor antagonist
What is Traction in terms of a causal agent for diverticula?
Due to scarring from inflammation
True diverticulum b/c also includes muscular layer
How can Granulosa Cell Tumor present? What else can it be assoc. with?
Abnormal uterine bleeding
Increased ESTROGEN–> endometrial hyperplasia–> uterine bleeding
How does Estrogen Thyroid protein levels?
Estrogen–> decreased catabolism of TBG–> increased TBG–> increased total T4/T3, NO change in free T4/T3
Describe the Lung Cancer incidence and mortality in women.
Increased over the last 40yrs
What are the functions of the HMP pathway?
- NADPH (reducing agent) (Oxidative reaction)
- Ribose-5-P–> Nucleotides (Non-oxidative reaction)
- Fructose-6-P–> Glycolysis (Non-oxidative reaction)
What does the Candida Skin Test gauge?
Type IV Hypersensitivity (Cell-Mediated Immune Response)
Which cells are involved in the Type IV Hypersensitivity?
Macrophages
CD4+
CD8+
NK cells
Which infections is Rifampin use for prophylaxis?
H. influenzae
N. meningitidis
In a skeletal muscle contraction, what does Ca2+ bind to?
Troponin C
Which cells have high activity of Telomerase?
Stem cells
Cancer cells
What are Enoxaparin and Dalteparin?
Low-Molecular Weight Heparin
What is Protein A (S. aureus)?
Found in peptidoglycan cell wall
Binds to Fc portion of IgG–> impaired complement activation, opsonization, and phagocytosis
What is the virulence factor used by N. gonorrheae and S. pneumoniae?
IgA protease
What is alkaptonuria?
Deficiency in Homogentisate Osidase–> canNOT degrade byproduct of Tyrosine (Alkapton= Homogentisic acid)–> Fumarate–> TCA
Symptoms: Does NOT present until adulthood. Debilitating ARTHRITIS, dark connective tissue, Brown pigment in sclera, urine turns black if left out.
What can decrease the risk of Ovarian and Endometrial cancer?
OCP’s
Multiparity
Breast-feeding
What can cause O2 diffusion limitation?
Emphysema
Pulmonary fibrosis
Physiologically in states of very high pulmonary blood flow (exercise)
What will the hemodynamic profile show for Aortic Stenosis?
Pressure gradient between LV and Aorta during systole.
Magnitude of murmur is proportional to gradient (loudest when pressure difference is greatest)
What gross histologic changes in the spleen do you see in a Sickle Cell pt?
Fibrosis, brownish discoloration, and eventual autosplenectomy.
What is the most common pediatric malignancy?
ALL
What are the different prevalences of B-cell and T-cell ALL?
B-cell 70-80%
T-cell 15-17%
What are the different manifestations of B-cell and T-cell ALL?
B-cell: fever, malaise, bleeding, bone pain, hepatosplenomegaly
T-cell: Anterior mediastinal mass–> compress great vessels, dysphagia
What is the main difference between Dysplasia and Carcinoma?
Reversibility!
What cells are Small Cell Carcinomas derived from? What can you use to stain?
Neuroendocrine cells
Staining: Neurofilaments, Chromogranin, Synaptophysin, Neuron-specific Enolase
What is the major difference in appearance between Achondroplasia and IGF-1 deficiency?
Achondroplasia- Normal axial length, short limbs. Fibroblast Growth Factor 2 Activating mutation.
IGF-1 deficiency- Proportional
What is a rare, but major side effect of Ticlopidine? What is it’s mech of action?
Neutropenia
Mech: irreversibly binds ADP receptor
What are the symptoms of Anterior Shoulder Disolocation?
Flattening of Deltoid
Axillary Nerve injury
Deltoid paralysis
Loss of sensation over lateral arm
Histologically, what distinguishes bronchi from bronchioles and terminal bronchioles?
Bronchi: pseudostratified columnar ciliated epi, goblet cells, submucosal mucoserous glands, cartilage.
Bronchioles/Terminal bronchioles/Resp. bronchioles: Pseudostratified ciliated columnar. NO goblet cells, glands, or cartilage
Terminal bronchioles: Ciliated simple cuboidal. Smooth muscle.
What is the inheritance of Androgenic Alopecia?
Polygenic inheritance with variable penetrance
What tests can you use for Chronic Granulomatous Disease?
Nitroblue Tetrazolium (blue) Dihydrorhodamine flow cytometry (fluorescent green). Assesses production of superoxide radicals--> convert DHR to rhodamine.
How does the kidney handle glucose, Na, PAH, and Inulin?
Glucose: increasing fractional excretion at higher plasma levels
Na: fractional excretion normally <1%
Inulin: Neither reabsorbed or secreted. Completely excreted.
PAH: completely secreted.
How do organisms become resistant to Aminoglycosides?
Inactivate 30S ribosomal unit
How do organisms become resistant to Isoniazid?
Decreased activity of bacterial Catalase-Peroxidase
How do organisms become resistant to Rifampin?
Stx’l alteration of enzymes involved in RNA synthesis
What molecules do Integrins bind to?
Fibronectin
Collagen
Laminin
What is the function of Heparan Sulfate?
Proteoglycan component of ECM
Vascular endothelial cell attachment to BM
What is the function of Keratan sulfate?
Maintaining Type I Collagen fibril org. in cornea
List the NNRTI’s.
Nevirapine
Efavirenz
Delavirdine
How do you distinguish between Schizophrenia and Major Depressive/Bipolar Disorders?
Schizophrenia: psychosis MUST occur in absence of major mood disturbances
MDD/BD: Psychosis occurs EXCLUSIVELY during mood episodes
What is the tetrad of symptoms seen in Measles (Rubeola)?
Cough
Coryzea
Conjunctivitis
Koplik Spots
What is the equation for Maintenance dose?
MD= desired conc x (Clearance/ Bioavailability)
Which Antifungals interact with Ergosterol?
Polyene antifungals (Amp B and Nystatin)
What is the ONLY clinically significant virus that is non-enveloped and contains ss-DNA?
Parvovirus B19
Which anti-arrhythmics are used for ischemia-induced arrhythmias?
Class 1B
In terms of binding strength to Na-channels, rate the Class 1 Anti-arrythmics.
1C> 1A> 1B
Which Hep virus integrates into the human genome?
Hep B!!!
How does sweat loss differ between Cystic Fibrosis pts and Normal pts?
Cystic Fibrosis: sweat contains high conc. of Na+ and Cl-
Normal: Free H2O (hypotonic)
What are the major stimuli of Peripheral and Central Chemoreceptors?
Central: CO2 (and H+ in CSF)
Peripheral: pO2 (hypoxemia) mostly
Is clubbing of the nails assoc. w/ Bronchial Asthma?
NO!
What causes Acute Tubular Necrosis? What is seen on urinalysis?
Renal ischemia–> Hypoxemia–> Tubules very sensitive (esp. PCT and Thick Ascending Limb)
Muddy Brown Casts
What causes Papillary Necrosis?
Diabetes
Analgesic nephropathy
Sickle Cell Disease
Can S. pneumo cause disease without its capsule?
No!!!
Capsule prevents phagocytosis
How do you calculate PAO2?
PAO2= 150- (PaCO2/0.8)
What can cause Pulsus Paradoxus?
Cardiac tamponade Pericarditis Sleep apnea Asthma COPD
Which epithelium in the resp. tract is covered w/ Stratified Squamous Epi?
Oropharynx TRUE vocal cords (Vocal folds) Laryngopharynx Epiglottis (Everything else covered w/ Psedostrat. Columnar epi)
What do 95% and 99% confidence intervals correspond to?
95%: p<0.01
What is the most important prognostic factor in Post-infectious Glomerulonephritis?
Age!
95% children recover
60% adults
What happens to blood O2, CO2, pH, HCO3- levels at high altitude?
Decreased PaO2 (b/c decreased O2 sat of inspired air)
Hyperventilation–> Higher pH and Decreased PaCO2
Decreased HCO3- (b/c increased HCO3- renal excretion to compensate for resp. alkalosis)
Significant Renal Artery Stenosis can cause hypertrophy of what?
Juxtaglomerular cells (sm. musc) of the Afferent Arterioles JGA increases Renin synthesis
What is the MOST common mutation resulting in Cystic Fibrosis?
3-bp Deletion (Delta 508)
Misfolding–> Impairment of Post-translational processing of CFTR–> proteasome–> complete absence
What is the main toxin produced by C. perfringens?
Lechithinase (Alpha toxin)
Degrades lecithin, which is a component of cellular phospholipids–> mem. destruction, cell death, widespread necrosis and hemolysis
What is the difference between Projection and Transference?
Transference: unconscious shifting of emotions with one person to another person
Projection: misattributing one’s own unacceptable thoughts to another person.
How can blood transfusions lead to Hypocalcemia?
Packs RBCs contain citrate–> chelates Ca2+ AND Mg2+
How does Glucose get into and out of the PCT?
Freely filtered INTO PCT, needs Na+/Glucose Co-transporter to be reabsorbed (can be saturated or inhibited)
Describe the resistance pattern in the respiratory system (Trachea–> Terminal bronchioles).
Trachea: High resistance
Medium-sized bronchi: HIGHEST resistance
Terminal Bronchioles: LOWEST resistance
What can result from Ethylene Glycol ingestion?
Acute Renal Failure
Precipitation of Calcium Oxalate crystals in renal tubules
Anion Gap Metabolic Acidosis
What is the primary site for Complement production?
Liver!!!
What do C3 and C5-C9 deficiencies result in?
C3: Encapsulated bacterial infections and increased sensitivity to Type III Hypersensitivity
C5-C9: N. meningiditis and N. gonorrhea
What kind of damage do X-rays and UV light cause?
UV: ds breaks
X-rays: Thymine-dimers–> causes nick in DNA due to DNA repair enzymes
Azothiaprine and 6-MP are activated and inactivated by what?
Activated by HGPRT
Inactivated by Xanthine Oxidase
How does Ipratropium help treat COPD?
ONLY reverses Vagally-mediated bronchoconstriction
In the rare cases of lethal Acute Rheumatic Fever, what is the cause of death?
Severe myocarditis
How do Left-sided and Right-sided Colon Adenocarcinoma present?
Left-sided: Partial obstruction. Encircle lumen. Change in stool caliber, constipation, cramping, abd distention, vomiting, nausea.
Right-sided: Iron-deficiency anemia and systemic symptoms. Blood loss. Constitutional systems.
What are the different electrolyte problems of Thiazides?
Hyponatremia
Hypercalcemia
Hypokalemia
What are the different electrolyte problems of Loop Diuretics?
Hypocalcemia
Hypokalemia
What does MUDPILES stand for?
M= methanol U= uremia D= Diabetic ketoacidosis P=Propylene glycol I=Iron tables, INH L= lactic acidosis E= Ethylene glycol S= Salicylates
What does HARD-ASS stand for? (Normal Anion Gap)
H=Hyperalimentation A= Addison's R= Renal Tubular Acidosis D= Diarrhea A= Acetozolamide S= Spironolactone S= Saline infusion
Which drugs are known to cause Acute Interstitial Nephritis?
NSAISs PPI's Allopurinol Diuretics Rifampin Sulfonamides Penicillin
Which part of the nephron are most susceptible to Ischemic and Nephrotoxic ATN?
Ischemic: PCT and Thick Ascending Limb
Nephrotoxic: PCT
What can cause Nephrotoxic ATN?
Aminoglycosides, Lead, Cisplatin
Radiocontrast
Crush injury
Myoglobinurua, Hemoglobinuria
How/when do you treat Age-Related Macular Degeneration?
“Dry”- Non-exudative: Multivitamin and antioxidants
“Wet”- Exudative: anti-VEGF or laser
Describe the different types of Macular Degeneration.
“Dry/ Non-exudative”: Deposition of yellowish extracellular material in and beneath Bruch mem and retinal pigment epithelium. Tx= mulitvit and antixidants
“Wet/Exudative”: Due to bleeding secondary to neovascularization. Tx= anti-VEGF
Where do Myosin and Actin filaments attach to structural proteins?
Myosin- M-line
Actin- Z-line
Why do maturing RBC’s lose their ability to produce heme?
They lose their MT
Which receptor interactions are required for B-cell isotype switching?
CD40 and CD40Ligand (activated T-cells)
What activities occur in the follicles?
B-cell proliferation and Isotype-switching
Stridor, and a brassy, barking cough w/ history of URI is suggestive of what? What is the most common cause?
Croup Parainfluenza virus (Paramyxovirus)
How can you differentiate between a Metabolic and Respiratory Alkalosis?
pCO2
Respiratory: Low
Metabolic: High
When a person has a Metabolic Alkalosis, what are the first 2 things you want to assess?
- Urinary Cl-
2. Volume status
How does Cl- affect HCO3- levels?
Low Cl- in blood inhibits HCO3- excretion
What is the most important prognostic factor for Bladder Cancer?
Tumor penetration
What is the function of T-tubules?
Invaginations of the sarcolemma–> extend into each muscle fiber–> trigger Ca2+ release from SR
Uniform distribution–> ensures coordinated contraction of myoibrils
What are the most common organisms to cause Osteomyelitis in children?
S. aureus
S. pyogenes
Which factors stimulate Angiogenesis?
FGF-2
VEGF
Which cytokines can help stimulate angiogenesis?
IL-1
IFN-gamma
But, NOT directly like VEGF and FGF
After a severe MI, when do myocardial changes first become apparent?
4hrs!!! Myocardium will appear normal anytime before this!
What is the Virulence Factor of Mycobacterium tuberculosis?
Cord Factor
Allows them to have linear growth–> “serpentine cords”
Neutrophil inhibition, Macrophage destruction, induce release of TNF
What contributes to Elastin’s ability to recoil?
Lysine crosslinking (formed extracellularly by Lysyl Hydroxylase)
Which growth factors does H. influenza need?
Hematin
NAD+
What is the major side effect of Ethambutol?
Optic neuropathy
Which kidney stones are Thiazides and Acetazolamide used to treat?
Thiazides: Ca+ renal stones (prevents Ca2+ excretion)
Acetazolamide: Uremic stones (alkalinizes urine)
What is Familial Chylomicrinemia?
Lipoprotein Lipase deficiency
Symptoms: pancreatitis, hepatosplenomegaly, Eruptive/pruritic xanthomas
NO risk for Atherosclerosis!!!
If a child is born with Bicuspid Aortic Valve, when are they likely to see symptoms?
60yrs old- Aortic Stenosis (compared to 80/90yrs old)
Which Pneumoconioses is assoc. with Eggshell Calcifications?
Silicosis
Which Hypersensitivity Pneumonitis is assoc. w/ Non-caseating granulomas?
Berryliosis
What is “Erb Palsy”?
Injury: Upper trunk, C5-C6
Muscles: Deltoid, Supraspinatus, Infraspinatus, Biceps brachii
CanNOT: Abduct, flex, laterally rotate, supinate arm
What is “Klumpke” Palsy?
Injury: Lower trunk, C8-T1
Muscles: Intrinsic hand muscles
Defect: “TOTAL Claw hand”
Thoracic Outlet Syndrome
Injury: Lower Trunk AND Subclavian vessels
Muscles: Intrinsic hand muscles
Defect: TOTAL claw hand with ischemia, pain, edema (due to vascular compression)
Winged Scapula
Injury: Long Thoracic N.
Muscle: Serratus Anterior
Defect: Elevated scapula, cannot abduct arm above horizontal
How do you treat Fibromyalgia?
Anti-depressants (TCA, SNRI’s)
Regular exercise (NOT strenuous, because will make worse)
Anti-Convulsants
What histological changes do you see with Psoriasis?
Increased Stratum Spinosum
Decreased Stratum Granulosum
Hyperkeratosis
Parakeratosis
Which infection is Erythema Multiforme most commonly assoc. with?
HSV
Also Mycoplasma pneumoniae
What kind of UV light does PABA absorb?
UVB
What is the mechanism of action of Probenecid (Gout tx)?
Inhibits reabsorption of Uric Acid in PCT
What is seen on histology of a liver biopsy of Reye Syndrome?
Microvesicular steatosis w/ larger, pleomorphic MT
If a patient cannot abduct their arm past the horizontal, what is injured? (Nerve and Muscle)
Nerve: Long Thoracic
Muscle: Serratus anterior
What causes abscess formation?
Lysosomal enzyme release from Neutrophils and Macrophages
What is the ONLY Beta-Lactam drug that can be used against MRSA?
Ceftaroline (5th generation Cephalosporin)
What are the effects of PCP?
Antagonizes NMDA- Receptor Hallucinogen Dissociative symptoms NYSTAGMUS Ataxia
What is the function of IL-12?
Induces differentiation of T-cells into Th1-cells–> produce IFN-gamma
Activates NK cells
A deficiency in IL-12 would lead to what?
Decrease Th1 cell population
Decreased IFN-gamma
Less NK cell activation
In terms of resistance, how do you choose treatment for Malaria?
Chloroquine: first-line. (Caribbean and Latin America)
Chloroquine resistant: Mefloquine
P. vivax and P. ovale: ADD Primaquine to prevent relapse and kill one in liver
P.falacifarum: Atovaquone/Proguanil or Artemether/Artesunate
How do you test for Cystinuria?
Sodium-Cyanide-Nitroprusside test–> PURPLE Color
Hexagonal Cysteine crystals
What are the stages of Paget Disease?
- Osteoclastic
- Both
- Osteoblastic
4 Quiescent
What is the problem in Osteopetrosis? Tx?
Defective Osteoclastic activity
Tx: Bone marrow transplant
Which factors stimulate Osteoclast differentiation?
RANK-L
M-CSF
BOTH produced by osteoblasts
What are the side effects of Loop Diuretics?
O= Ototoxicity H= Hypokalemia D= Dehydration A= Allergy (Sulfa) N= Nephritis (Interstitial) G= Gout (Hyperuricemia, secondary to Na+ reabs)
Vitamin A can be used to treat what?
Measles AML (subtype M3)
How do you calculate the PAO2?
(150- PaCO2)/ 0.8
People with Silicosis are more susceptible to what?
TB
Also, increased risk for Bronchogenic carcinoma
What are the different histological changes you will see with Malignant HTN, Essential HTN, and Diabetes?
Essential HTN/Diabetes: Hyaline ateriosclerosis
Malignant HTN: Onion-skinning of arterioles
How does the genomic mutation rate affect HIV replication?
Positively correlates
More mutations–> assoc. w/ higher replication
Why are CF patients infertile?
Bilateral absence of Vas Deferens (Azospermia)
How do you treat Primary Pulmonary HTN?
Bosentan (Endothelin Receptor antagonist)
What is the difference between Strawberry and Cherry Hemangiomas?
Strawberry: Kids. Increase and then regress in size. Capillary.
Cherry: Adults (elderly). Do NOT regress.
How do you differentiate between Orotic Aciduria and Ornithine Transcarbamylase Deficiency?
Orotic Aciduria: UMP Synthase defect. Megaloblastic anemia, Orotic aciduria. Tx= Uridine Monophosphate to bypass enz.
OTD: Increase Orotic acid AND Hyperammonemia
What (3) effects can DA have on the Cardio system based on dose?
Low dose: Renal and Mesenteric vasculature vasodilation
Medium Dose: Increase Cardiac contractility (Beta-1)
High Dose: Generalized vasoconstriction (Alpha-1)
The Lower Trunk of the Brachial Plexus carries which nerves? Injury results in what?
C8-T1–> Median and Ulnar N. (Intrinsic muscles of the hand)
Grabbing onto a tree branch when falling–> injury
Total Claw Hand
List Organ susceptibility to infarctions from most to least.
CNS Heart Kidney Spleen Liver
Which labs are abnormal/normal in Gilbert’s?
Abnormal: Elevated Unconjugated Bilirubin
Normal: LFTs, CBC, Blood smear, reticulocyte count
Which Hepatitis can present with a “Serum Sickness-like” syndrome?
Hep B
Fever, malaise, skin rash, pruritus, lymphadenopathy, joint pain
In order to increase the Creatinine level by 2-fold, what must happen to the glomeruli?
50% reduction in GFR–> 75% of all Glomeruli affected (A LOT!!!)
In Polymyositis, there is increased expression of what on muscle cells?
MHC-I –> recognized by CD8+ cells
What are the different chelators used for treating Lead, Fe, and Cu overload?
Lead: Dimercaprol, EDTA, Succimer
Fe: Deferocamine
Cu: Penicillamine, Trientine
What are the different causes of Hepatic Abscess formation?
Hematogenous: S. aureus
Ascending Cholangitis/ Portal Vein/ Direct invasion: Enteric bacteria (E. coli, Klebsiella, Enerococci)
Foodborne: Entamoeba histolytica
What causes keloid formation?
Excessive collagen formation
How does a foreign body or ongoing bacterial infection affect wound healing?
Delays it
What are the effects of Isoproterenol?
Increases cardiac contractility
Decreases vascular resistance
Which diseases affect Globin and Heme?
Globin- Thalassemias
Heme- Prophyrias
What did the RALES trial show?
Adding low dose Spironolactone to standard therapy can reduce morbidity and mortality in class III and IV Heart Failure pts. Due to inhibition of Aldosterone's effects on Ventricular remodeling.
Besides glucose levels, what can affect HbA1c?
Alteration in RBC survival
Increased turnover can increase HBA1c (anemia, chronic kidney disease, thalassemia, etc)
In Osteogenesis Imperfecta, what process is defective?
Bone matrix formation
Cannot form Type I collagen (Triple Helix Formation)
What are the different phases of Acute Tubular Necrosis?
- Inciting event
- Maintenance- Oliguria, risk of hyperkalemia, low GFR
- Recover- Re-epithelization of tubules. Polyuria, decreasing BUN & Cr
What can increase the risk of Neonatal Resp. Distress Syndrome?
Prematurity
Maternal Diabetes
C-section (decreased release of fetal glucocorticoids)
What is the main complication of Concentrated O2 therapy for Neonatal Resp. Distress Syndrome?
Retinopathy of prematurity & Bronchopulmonary dysplasia
What are the 1st, 2nd, and 3rd-line drugs for Gout?
1st- NSAIDs
2nd- Colchicine
3rd- Glucocorticoids (if contraindications for NSAIDs or Colchicine- renal failure, ulcers)
What is the cause of Sterile vegetations on cardiac valves and Trousseau syndrome (migratory thrombophlebitis)?
Hypercoagulable state
What is the first step in M. tuberculosis infection?
Intracellular bacterial proliferation in Alveolar Macrophages
In the Rotator Cuff muscles, which tendon is most commonly injured?
Supraspinatus tendon b/c sits right under the acromion
What are the different ways pts w/ Fibrosis and COPD/Asthma decrease their work of breathing?
Fibrosis: High RR, low TLC
COPD/Asthma: Low RR, High TLC
Which cells use the enzyme Bisphosphoglycerate Mutase?
RBC’s!!!
To make 2,3-BPG from 1,3-BPG
This reaction consumes the energy that would have been used to produce energy in the form of ATP
In Ehlers-Danlos, which processes are dysfunctional?
Collagen cross-linking
Peptide cleavage of Disulfide bonds
What is a common side effect of direct arteriolar vasodilators?
Sympathetic activation (tachycardia, increased contractility, and Na/H2O retention-edema)
How do you treat a Beta-Blocker overdose?
Glucagon!!!
Can increase HR and contractility independent of Adrenergic receptors
Activates AC–> increase cAMP
What is the most common cause of pneumothorax?
Rupture of apical subpleural blebs
What is the difference between Apocrine and Eccrine/Merocrine glands?
Apocrine: Sweat glands. Initially odorous, but can become malodorous secondary to bacterial decomposition in skin surface. Only in certain areas- active after puberty.
Eccrine/Merocrine: Present in all skin. Watery fluid (Na+ and Cl).
Which cofactors are needed to make Methionine and Cysteine?
Methionine: Homocysteine Methyltransferase requires B12
Cysteine: Cystathionine Synthase requires B6
What stimulates IgE and IGA synthesis?
Th2 cells produce:
IL-4 and IL-13–> IgE
IL-5–> IgA and Eosinophils
What are the effects of IL-2?
Released by T-helper cells.
Stimulates CD4, CD8, and B-cells.
What increases expression of MHC-I and MHC-II mlcs?
IFN-gamma
What is normal/ abnormal in Sickle Cell Trait pts?
Asymptomatic. Relative protection from malaria (P. falciparum)
Normal: MCHC, peripheral smears, reticulocyte count, RBC indices, NO sickling.
ONLY Abnormal: Sickle w/ Na Metabisulfite. (+ Sickling test)
What does the Musculocutanous N. innervate?
Motor: Flexor muscles of the Upper arm
Sensory: Lateral forearm
Injury: Upper trunk of brachial plexus. Forceful injuries that separate neck form shoulder.
What is the inheritance of PKU?
Autosomal Recessive
What is the cause of wrinkles?
Decreased synthesis and net loss of dermal Collagen & Elastin.
What is the mechanism of action of Ethambutol?
Inhibits carbohydrate polymerization
Inhibits Arabinosyl Transferase
How do Androgens lead to acne?
Stimulate follicular Epidermal Hyper-proliferation & Excessive Sebum production
What should be avoided in pts that get Heparin-Induced Thrombocytopenia?
Heparin
LMWH (Low-molecular wt)
Warfarin
Tx: Direct Thrombin Inhibitors (Argatroban, Bivalirudin, Dabigatran)
What are the side effects of Methotrexate?
Myelosuppression (tx w/ Leucovorin)
Liver fatty change
Mucositis/ Stomatitis
Pulmonary Fibrosis
What is a serious side effect of Cyclophosphamide/Isofamide? How can you prevent it?
Hemorrhagic Cystitis (due to toxic metabolite, Acrolein) Prevent: MESNA and hydration
What causes retraction of the overlying skin in Invasive Breast Cancer?
Cooper’s (Suspensory) Ligament infiltration
What is Avascular Necrosis commonly assoc with?
Sickle Cell Disease
SLE
Steroid Therapy
What is the inheritance of Muscular Dystrophy?
X-linked!!!
How does Renal Cell Carcinoma affect RBC’s?
POLYcythemia (overproduction of EPO)
Pure RBC Aplasia is assoc. w/ what?
Thymoma
Parvovirus B19
Lymphocytic leukemias
In ARDS, what is normal?
PCWP b/c NOT cardiogenic cause of pulm. edema
Which viruses produce a Polyprotein product?
Single-stranded (+), Linear, Non-segmented RNA
Ex) Echovirus (Picornaviridae family)
What is the difference in immunity conferred from Inactivated vs. Live attenuated viral vaccines?
Inactivated: Humoral response (neutralizing Abs–> PREVENT ENTRY!!)
Live attenuated: Humoral response + Strong Cell-mediated response
Which receptor does Gastrin bind to?
CCK2
Describe the differences between Zone I and Zone III of the Hepatocyte.
Zone I: Portal triad. Viral Hepatitis. Ingested toxins. Bile stasis.
Zone III: Central vein. Alcoholic Hepatitis. Metabolic toxins. P-450. Ischemia.
What kind of virus is Parvovirus B19?
Non-enveloped
ss-DNA
What kind of virus is CMV?
Enveloped
ds-DNA
Herpesviridae family
How does decreasing False Negatives and Positives affect the Sensitivity and Specificity?
Increases BOTH!!!
What kind of injuries affect the Deep Brachial Artery and Brachial Artery?
Deep Brachial Artery and Radial Nerve: Post. Humerus. Midshaft injuries.
Brachial Artery: Supracondylar fractures.
What kind of molecule are Mycolic Acids?
Long, Branched-chain Fatty Acids
What is the mutation in Factor V Leiden?
Resistant to degradation by Protein C
When a pt has a Megaloblastic Anemia that canNOT be cured by B12 or Folate, what should you think of? What other symptoms might they have?
Orotic Aciduria UMP Synthase defect NO Hyperammonemia (compared to Ornithine Transcarboxylase def) Tx: Uridine Monophosphate (to bypass mutated enz)
Which lung cancer is usually positive for Neuroendocrine markers?
Small Cell Carcinoma
In Tumor Lysis Syndrome, where in the nephron are the Uric Acid crystals found? Why?
Distal tubules & Collecting Ducts
These are the most acidic env (uric acid insoluble)
What is the difference between Superficial and Cherry hemangiomas?
Cherry–> 30s, 40s. Always superficial. ADULTS.
Superficial–> Infantile, Capillary, or Starwberry.
What are the most common organisms that cause Intraabdominal infections?
E. coli
Bacteriodes fragilis
What is the spectrum of Pipercillin? What must it be used with?
Gram +, Gram -, Anaerobic bacteria
What kind of bacteria grow in areas of low blood supply (necrosis, ulcers)?
Anaerobes!
What happens in the Heart, Lungs, Liver, and Kidney as a result of Chronic Transplant Rejection?
Heart: Atherosclerosis
Lungs: Bronchiolitis obliterans
Liver: Vanishing bile ducts
Kidney: Vascular fibrosis, Glomerulopathy
What does Pyelonephritis look like on Microscopy? Compared w/ Post-Strep Glomer?
Massive interstitial infiltration w/ PMN’s
PMN’s in Tubular Lumen
Post-Strep Glom: NO tubular infiltration, just enlarged, hypercellular glomeruli w/ infiltrating leukocytes
What phases are the ova in when a girl is born and right after ovulation?
Born with Primary Oocytes, stuck in Prophase I
Ovulate Secondary Oocytes, stuck in Metaphase II
What heart problem can Hypomagnesium and Hypokalemia cause?
Torsades de pointes
Which organ has the largest Arteriovenous O2 Difference? What does this mean?
Heart–> 80% O2 extraction
This means that an increase in O2 demand can ONLY be met by increase in coronary Blood flow
Homocysteine is converted to ______________, using vit. B12 and Folate?
Methionine
What is the clinical triad for Cardiac Tamponade?
- Distended JVP
- Hypotension
- Muffled heart sounds
When treating a Non-Coagulase Staph infection (esp. nosocomial) what Abx should you ALWAYS start with? What may you be able to switch to later down the line?
ALWAYS start w/ Vancomycin
If later, find out that it is penicillin-sensitive–> switch to Nafcillin or Oxacillin
What do the Right Common Cardinal Vein and Right Anterior Cardinal Vein give rise to?
SVC
What do the Bulbous Cordis give rise to?
Smooth parts of the VENTRICLES
What do the Primitive Atria/Ventricles give rise to?
Trabeculated parts of the atria and ventricles
What does the Left Horn of Sinus Venous give rise to?
Coronary Sinus
What do the Primitive Pulmonary Vein and Right horn of SV give rise to?
Primitive Pulmonary Vein- Smooth part of the LEFT atrium
Right Horn of SV- Smooth part of RIGHT atrium
Where does the Great Saphenous Vein begin?
Begins on MEDIAL aspect of foot–> Medial Malleolus–> Medial surface of leg–> joins Femoral Vein at Femoral Triangle
What can you administer to help you diagnose Prinzmetal’s Angina?
Ergonovine (Ergot Alkaloid)
Alpha-adrenergic agonist and Serotonerigc agonist
What is the most common cause of Abdominal Aortic Aneurysm? What happens first?
Atherosclerosis!!!!
Begins w/ Intimal streak!!!
Where can the different collagens be found?
Type I: bone, tendons, ligaments, scar tissue (mature)
Type II: Cartilage, Vitreous humor, nucleus Pulposus
Type III: Granulations tissue, lung, blood vessels, skin, bone marrow, lymphatics
Type IV: Basement Mem
Norepinephrine primarily has effects on which receptors?
Alpha-1 and Beta-1
What is Chylomicronemia?
LPL deficiency
Elevated TG’s
Symptoms: Recurrent pancreatitis, Lipema retinalis, Eruptive Xanthomas (erythematous background)
What kind of maneuvers can increase the murmur of Ventricular Hypertrophy?
Maneuvers that DECREASE Pre-load or Afterload
What is the most common cause of Atrial Spetal Defect? Down Syndrome?
Ostium Secundum
Down Syndrome: Ostium Primum
What congenital infection can cause PDA?
Rubella
What maneuvers can increase/decrease Mitral Valve Prolapse?
Increase: Decrease venous return (earlier)
Decrease: squatting (later, softer)
In a stab wound in the left sternal border in the 4th intercostal space, which structure is most likely to be penetrated?
Right Ventricle
No lung penetration b/c no left middle lobe
How do you image a stroke?
MRI: 3-30min. BRIGHT.
CT (NON-Contrast): 12-24 hr. DARK. Highly specific to exclude hemorrhage.
What are the Anterior and Posterior Pituitary derived from?
Anterior: Surface Ectoderm
Posterior: Neuroectoderm
What are common signs of Sarcoidosis?
Erythema nodosum Arthralgias Hilar lymphadenopathy Elevated ACE Noncaseating Granulomas in Liver
In Supine pts, where are they most likely to aspirate?
Posterior segments of Upper Lobes
Superior segments of Lower Lobes
In Acute Intermittent Porphyria, which enzyme is deficient? What accumulates?
Enzyme:Porphobilinogen Deaminase
Accumulates: Porphobilinogen, Delta-ALA.
How can Tumor Lysis Syndrome be prevented?
- Hydration
2. Allopurinol or Rasburicase
What histologic features are seen in Celiac Disease?
- Blunt vili
- Crypt Hyperplasia
- Increased intraepithelial lymphocytes
What reaction does Alpha-Ketoglutarate DH’ase catalyze?
alpah-ketoglutarate dh’ase—> Succinyl-CoA
What is the difference between Pilocystic Astrocytoma and Medulloblastoma in terms of gross imaging?
Pilocystic Astrocytoma: Cystic + Solid
Medulloblastoma: ONLY Solid
How do you treat Lyme Disease?
Doxycycline or Penicillin-type Abx
How can Mycoplasma infection affect RBC level?
Anemia
IgM Cold Agglutinins
How do you do an Acid-Fast stain?
- Aniline Dye (Carbofuscin)
2. Acid + Ethanol (De-colorize)
Which Beta-Blockers are non-selective and selective?
Non-Selective: Propranolol, Timolol, Nadalol
Selective: Metoprolol, Atenolol, Acebutolol, Esmolol
How can you distinguish between Multiple Myeloma and CLL?
CLL: LOW Immunoglobulin
Multiple Myeloma: Increased
What is the difference between mechanism the liver uses to take up Unconj. Bilirubin and excrete Conjug. Bilirubin?
Uptake: Passive. OATP
Excretion: Active (ATP) MRP2 transport
What are the common causes of Elevated CK Myopathy?
Hypothyroid Myopathy Autoimmune Muscular Dystrophy Drug-induced (Statins, Glucocorticoids) PMR
What can cause idopathic Membranous Nephropathy?
IgG Anti-PLA2 Receptor (Phospholipase A2 Receptor)
Compare the Hb movement on Gel Electrophoresis for HbA, HbS, and HbC.
HbA > HbS > HbC
How can you prevent the toxicities of Cisplastin?
Toxicity: Nephrotoxicity and Acoustic Nerve Damage
Prevent: AMIFOSTINE
Why might someone still not absorb B12 even after giving IF?
Absorption problem:
Pancreatic Insufficiency
Ileal Disease
Intestinal Overgrowth
What can prolonged consumption of Appetite Suppressants cause?
Ex) Fenfluramine, Phentermine
Pulmonary HTN!!! May lead to RV Hypertrophy down the line
Which enzyme Conjugates Bilirubin?
Glucuronyl Transferase
Most pro-Carcinogens are converted to Carcinogens by what enzyme?
P-450 (Microsomal Monooxygenase)
How can you tell if a patient has a True Polycythemia?
Look at RBC mass!!!!
If normal –> Dehydration, Excessive diuresis
If high–> Polycythemia Vera, Erythrocytosis secondary to hypoxia
What is the drug of choice for treating lung abscesses? Why?
Clindamycin
B/c covers anaerobic mouth flora AND Aerobic bacteria (S. pneumo)
What do you use to stain C. neoformans?
Methenamine silver (GMS) Mucicarmine (stains RED)
How do you treat Legionella?
Flouroquinolone (Levofloxacin) or Macrolide (Azithromycin)
What molecules do the following viruses bind to for cellular entry? HIV, EBV, CMV, B19, Herpes viruses?
HIV: gp120 binds to CD4
EBV: gp350 binds to CD21
B19: binds to Erythrocyte P antigen
Herpes Viruses (including CMV): Glycosaminoglycans
What is the difference between the enzymes mutated in Xeroderma Pigmentosum and HNPCC?
XP: ENDOnucease to remove Thymine Dimers
HNPCC: EXOnuclease to look for mismatch bps
What is the best way to manage Somatic Symptom Disorder?
- Regularly scheduled visits
2. ONLY once physician-patient relationship is well est.–> Mental Heath Referral
How early can you start to see symptoms of Asthma?
About 1yr (5-8mts) When smooth muscle of bronchioles form
What are Cromolyn/Nedocromil?
Mast Cell Stabilizing agents–> inhibit mast cell degranulation INDEPENDENT of stimuli
