RANDOM BOARD REVIEW Flashcards
CD55, CD59 should make you think of this particular blood d/o. What are the triad that this d/o commonly presents with?
Paroxysmal Nocturnal hemoglobinuria (PNH)
ø CD55/CD59 prevents complement from inactivating -> complement stays activated -> hemolysis
hemolytic anemia
hypercoagulable state (thrombosis on imaging)
decreased blood counts (leukopenia + thrombocytopenia)
location of carnitine acyltransferase II
inner-mitochondrial matrix
patient w/ thyroid w/ mixed, cellular infiltration w/ multi-nucleated giant cells
sub-acute thyroiditis “de Quervain’s thyroiditis” aka granulomatous thyroiditis - usually due to viral infection of the thyroid; starts off w/ brief thyrotoxic phase followed by transient hypothyroidism.
Painful, tender thyroid
cola-colored urine following a URI + renal biopsy of the mesangium showing darkened areas of deposits
cola-colored urine following a skin infection + renal biopsy that shows granular deposits in the mesangium + BM
IgA nephropathy “Berger’s disease” (deposits = IgA)
Post-strep glomerulonephritis (deposits = IgG, IgM, C3)
bug that can cause achalasia, megacolon, and megaureter, and enlarged cardiac apex
chaaaaaaagas disease (american trypanosomiasis)
endemic in rural areas of centra/south america
how do you think these variables will change in a patient with lactase deficiency:
stool osmotic gap
stool pH
breath H content
- **stool osmotic gap - increase **due to presence of poorly absorbable contents in the colon
- pH - decrease because more lactose is delievered to the colon where it is fermented by bacteria to produce SCFA + excess H+
- breath H content - increase
3yo M presents with arm held close to the body w/ elbow extended and forearm pronated; is in minimal distress until attempts are made to move the elbow. No other problems are noted
What happened to get the child in this?
how to reduce this?
radial head subluxation “nursemaid’s elbow”
occurs when there is a sharp pull on the hand while the forearm is pronated and the elbow extended, which causes the annular ligament to slip over the head of the radius and slide into the radiohumeral joint, where it becomes trapped
reduce: fully supinating the arm, followed by full flexion of the elbow
how do these factors change with Glanzmann thrombasthenia
Platelet Count
Bleeding time
PT
PTT
ristocetin response
Platelet Count = NC
Bleeding time = increase
PT = NC
PTT = NC
ristocetin = normal
common sx of TTP/HUS in adults vs kids
trmt?
pentad: neurologic ∆’s, renal failure, fever, thrombocytopenia, and microantiopathic hemolytic anemia
adults: mostly neurological ∆s
kids: mostly renal ∆s
trmt: plasmapheresis
Patient comes in complaining of a sensory deficit (green). What is the nerve injury and accompanying motor deficits? What is usually the cause of injury?
Femoral n. (L2-L4)
∆ thigh flexion, leg extension (ie difficulty w/ stairs, frequent falling due to knees buckeling, diminished patellar reflex)
usually due to mass (hematoma) involving iliopsoas or iliacus muscles, since the femoral n. travels through the psoas major m. and emerges laterally btwn the psoas and iliacus m. and runs down the inguinal ligament into the thigh
patient comes in with this has what d/o? how do yout ell?
inheritance pattern of this d/o?
NF-1
- cutaneous neurofibromas - fleshy, dome-shaped, pedunculated
- cafe-au lait spots (hyperpigmention)
AD
Medial malleolus
what runs anterior to it? posterior to it?
anterior: saphenous n. + great saphenous v
posterior: posterior tibial a., tibial n., flexor digitorum longus, flexor hallucis longus, tibialis posterior
buzzword: polymyalgia rheumatica
Temporal arteritis (increased ESR)
∆ btwn sampling and selection bias?
- sampling bias = type of selection bias that occurs due to non-random sampling of a target population
- selection bias (attrition bias) = loss to follow-up; usually a problem in prospective studies because
absence seizure
description (post-ictal state)?
first line treatment?
brief episodes of staring, ø post-ictal confusion
ethosuximide
valproate
diagnosis?
Malassezia furfur - spaghetti and meatballs appearance on LM
tetralogy of fallot
caused by abnormal development of?
what determines the severity of symptoms?
how do these patients usually present?
neural crest cell migration through the primitive truncus arteriosus and bulbus cordis
degree of RV outflow tract obstruction (pulmonic stenosis) - the more severe it is, the more blood will flow from RV -> LV across the VSD and cause cyanosis
infants: cyanosis that worsens w/ feeding, crying, or exercis
older children: squatting to improve pulmonary blood flow
how do these factors change with TTP-HUS d/o?
Platelet Count
Bleeding time
PT
PTT
plasma fibrinogen levels
smear
Platelet Count = decrease
Bleeding time = increase
PT = NC
PTT = NC
plasma fibrinogen levels = normal
smear = RBC fragmentation
unilocular cystic mass w/ clear fluid in ovaries; cyst wall covered w/ papillary outgrowths
dx?
serous cystadenocarcinoma - thin-walled, lined with fallopian-like epithelium
what is the lecithin-sphingomyelin ratio indicative of?
when and why does this ratio increase?
fetal lung maturity
note that lecithin is also known as phosphatidylcholine
>1.9 = indicative of mature fetal lungs, usually at ~32-32wks gestation; Lecithin increases sharply while sphingomyelin is unchanged; increases are due to cortisol
<em>(due to ACTH/CRH from fetal pituitary and placenta; CRH secretion from the placenta is also upregulated by cortisol)</em>
ectopic pregnancies are generally treated with…
MTX - folate antagonist that ultimately inhibits trophoblast division
muscle rigidity is observed in experimental animal with chemically destroyed dopaminergic neruons of the substantia nigra, but the rigidity fails to improve w/ continuous dopamine infusion. Why?
BBB (tight junctions = zonula occludens), duh
“ballooning degeneration” is indicative of
acute viral hepatitis
reducing substance in urine that is not glucose
fructose - fructokinase deficiency (AR, benign, asymptomatic condition)
HTN Rx to avoid if you’re also hypoparathyroid
loop diuretics bc they decrease blood Ca levels.
what exits the formaen ovale
v3 - provides sensory + motor innervation to muscles of mastication and the muscles that open the jaw
what is a compression lesion that can result in 3rd nerve palsy?
what is an ischemic process that can also result in 3rd nerve palsy?
compression: aneurysm of R posterior cerebral artery (remember that it courses between this and the superior cerebellar arteries as it leaves the midbrain)
ischemic: diabetes
afftects ipsilateral eye
HBV antigen that correlates w/ viral replication
HBcAg, HBeAg
of these, which one is resistant to outliers?
mean
mode
standard deviation
variance
range
mode
how do you calculate GFR?
calculated using creatinine or inulin clearance, or the Starling equation
Clearance = (Urine Conc * Urine Flow Rate ) / plasma conc.
patient suspected of malaria has enlarged erythrocytes containing punctate granulations + oval bodies. Which malaria subtype?
plasmodium vivax or ovale
newborn with scrotal sac w/o palpable testes, enlarged phallus w/o the normal appearance of a penis. Urogenital sinus is present. CT shows 2 normal sized ovaries. Karytotype is 46 + barr body
21 - hydroxylase deficiency -> ø cortisol, ø aldosterone, but increased androgen production (which control the external genital differentiation) -> F fetus will be masculinized (ie labial fusion, phallic enlargement, urogenital sinus)
karyotype = genetically F (barr body = inactivated X chromosome, which only happens in females)
ø SRY = Mullerian develops into uterus, fallopian tubes, ovaries
pathogenicity of H influenza
anti-phagocytic capsule
Type B is most invasive - made w/ polyribitol phosphate
Which one does this graph represent? (choose one)
Aortic insufficiency
Aortic Stenosis
Mitral Stenosis
Mitral regurgitation
mitral regurgitation
Eaton Lambert Syndrome is a paraneoplastic syndrome of….
small cell carcinoma of the lung
forms autoantibodies that react w/ PRE-synaptic Ca channels and hamper the release of ACh
nerve that passes the lateral epicondyle of the humerus? medial epicondyle?
lateral: radial
medial: ulnar
baby w/ subdural hematoma + bilateral retinal hemorrahages
shaken baby syndrome - results in tearing of bridging veins -> subdural hematoma
if angle btwn SMA and aorta is decreased, what structures are going to be obstructed by the artery?
transverse portion of duodenum -> partial intestinal obstruction
oxaloacete reacts with glutamate to form aspartatey. What cofactor is required?
B6 - pyridoxine - cofactor for transamination + decarboxylation of a.a., gluconeogenesis
transamination rxns occur btwn amino acid and a-ketoacid: the amino group is transferred from the a.a to the a-ketoacid, which becomes an a.a.
key to this question is to know that oxaloacetate (a-ketoacid) reacts w/ glutamate (a.a.) –> aspartate (resulting a.a.) + a-ketoglutarate (resulting a-ketoacid)
dx + complication?
bicornuate uterus
- congenital malformation taht results in an abnormal Y shaped uterine cavity
- complication: recurrent spontaneous abortions, esp. in the 2nd trimester, because it results in defective placental implantation
patients with allergic bronchopulmonary aspergillosis (ABPA) have very high serum levels of what?
serum IgE
eosinophilia
IgE + IgG antibodies against aspergillus
causes intense airway inflammations + mucus pluggings w/ remission + exacerbations; repeated exacerbations -> transient pulmonary infiltrates + proximal bronchiectasis
34M, tall/slender w/ disproportionately long arms and legs has flesh colored nodules on lips and tongue. underwent tyroidectomy a few years ago.
dx?
MEN2B - marfanoid habitus + mucosal neuromas + thyroidectomy (suggests hx of MTC)
17yo girl is troubled by her sexual dreams and tells her friends that she is going to become a nun.
Reaction formation - unconscious adoption of behavior opposite to that which owuld reflect true feelings and intentions
How does the etiology of hepatic absesses differ between developed countries vs developing countries?
developed countries - 2˚ to bacterial infection (S. aureus)
developing countries - 2˚ to parasitic infection (amebic or echinococcal)
demeclocycline
ADH antagonist
to make the diagnosis of hirschsprung’s disease, where should you sample?
mucosa or submucosa or muscular layer
dilated or narrow part
submucosa of the narrow part - the disease is due to failure of the neural crest cells to migrate into the bowel and develop into the ganglion cells of the submucosal (meissner) and** myenteric (auerbach)** plexus of the bowel wall
patient w/ thyroid that extends into the surrounding structures; hard and fixed
reidel’s thyroiditis w/ (+) anti-thyroid peroxidase antibody titers; hard and fixed gland can simulate a malignancy
infant w/ persistant jaundice, muscle rigidity, lethargy and seizures and kernicterus
dx?
trmt?
Crigler-Najjar
∆UGT = no bilirubin conjugation = elevated unconjugated hyperbilirubinemia
patients have kernicterus (bilirubin deposition in brain)
trmt: phototherapy + plasmapheresis
why would you treat Crigler-Najjar - type II patients with phenobarbital?
phenobarbital increases hepatic enzyme synthesis, and may increase UDP-GT in patients with Crigler-Najjar
patient w/ enlarged ventricles only has a problem w/ what type of cells?
arachnoid granulations (resorbs CSF into the venous sinuses)
when is pulmonary vascular resistance the LOWEST?
at FRC, which occurs at the end of an expiration during normal tidal volume change
incr. lung volume -> incr PVR due to longitudinal stretching of alveolar capillaries
decr. lung volume -> incr PVR due to decreased radial traction from adjacent tissues onto the large extra-alveolar vessels
patients w/ non-coronary atherosclerotic disease are most likely to die from what disease?
how about diabetes?
how about chronic kidney disease
cardiovascular mortality, stroke, MI
How do you determine RBF? RPF?
RPF = PAH clearance = (urine PAH * urine flow rate) / plasma PAH
RBF = PAH clearance / (1-Hct)
how does N. Meningitidis infection occur
pharyngeal colonization - adheres + penetrates mucosal epithelium into the blood
fibrous intimal thickening w/ endocardial plaques limited to the R heart
what correlates with disease severity?
carcinoid heart dz associated with carcinoid syndrome
degree of endocardial fibrosis is correlated w/
- plasma levels of serotonin + urinary 5-OH-indoleacetic acid (serotonin metabolite)
defective ossicles causes what type of hearing loss
condutive
cell involved in clearing the infection in a patient with PID
Th1 cells - if it’s not mentioned, assume gonococci or chlamydia.
In the US - chlamydia is the most common bacterial STD; intracellular pathogens -> elicit Th1 lymphocyte response
how does small cell carcinoma compare to squamous cell carcinoma of the lung compare in terms of the paraneoplastic symptoms?
small cell - ACTH + vasopressin + Lambert Eaton Syndrome
squamous cell - PTHrP
CMV treatment?
CMV treatment in HIV patients?
gangciclovir - guanine nucleoside analog
foscarnet - may cause nephrotoxicity, electrolyte ∆s (hypo-Mg, Ca, K)
status epilepticus
treatment to stop the seizures?
Rx to prevent recurrence of seizures?
if patient continues to seize?
- 1st line treatment: Benzodiazepines (lorazepam) - binds GABAA channels and increases Cl conductance, thereby stabilizing the membrane from further depolarization
- Prevention: Phenytoin - reduces ability of Na channels to recover from inactivation
- continues to seize: phenobarbital - same MoA as benzo
immunocompetent hosts infected w/ coccidiodes immitis can present with?
what about immunocompromised hosts?
immunocompetent: acute pneumonia + erythema nodosum
immunocompromised: chronic progressive pneumonia, pulmonary nodules, meningitis, erythema nodosum
patient w/ small bowel bx w/ nests of mast cells within mucosa, pruritus, rash, flushing, and abd cramps most likely also has …
gastric hypersecretion
why? mast cells release histamine -> parietal cell production of HCl
this person has systemic mastocytosis - where mast cell proliferation occurs in the bone marow and other organs
MoA for Rx used to treat acute asthma excerbations
ß2 (Gs) agonist - results in increased cAMP in smooth mucle cells -> bronchial smooth muscle relaxation
IL4 function
stimulates growth of B cells and increases # of Th2 cells to site of inflammation (produced by Th2 cells)
F w/ small mobile mass taht changes in size with her menstrual cycle should make you think of this breast tumor
Fibroadenoma
- Small, mobile firm mass, usually in stroma
- ∆s with menstrual cycle, pregnancy (due to ∆’s in estrogen)
- not a precursor to breast Ca
MEN 1
gene mutation?
what does it affect?
MEN1 gene mutation
pituitary gland, parathyroid gland, pancreas (the 3 “P”s)
(presents w/ kidney stones + stomach ulcers)
sleeping agent that has less potential for tolerance and addiction compared to other medications
Zolpidem - binds to GABAA receptor and enhances the inhibitory action of GABA in the CNS
less risk of potential compared to other sleeping agents (ie Benzodiazepines such as Temazepam and estazolam) since it has a shorter half-life than these.
eye field looks like this:
where is the lesion?
R optic tract or optic radiation
E
Enteracept MoA
“decoy receptor” - TNFa-receptor molecule linked to the Fc component of IgG1, thereby sequestering TNFa w/ subsequent removal
note: get PPD before initiating therapy to determine if there is latent TB
what is the Hawthorne effect?
tendency of study population to affect an outcome (ie change their behavior) due to the knowledge of being studied
think of hawthorne as a “hawk” that is watching their prey (study population); obviously if the prey knows thier being watched by their predator, they will modify their behavior to avoid getting caught
26yoM w/ single genital ulcer that is indurated and painless. What should you treat him with? What is the MoA of this Rx?
Patient likely has syphillis (Treponema pallidum); treat w/ Penicillin G
MoA: structural analog of D-Ala-D-Ala, thereby inhibiting transpeptidase, which normally cross-links peptidoglycan cell wall formation. Weakened cell wall integrity = osmotic lysis of bacterium
pupillary light reflex involves which 2 nerves?
afferent: CN 2
efferent CN 3
S. bovis endocarditis is associated with?
GI lesions (Colon cancer)
increase HR and CO w/ a normal PaO2 + PaCO2
exercising
not to confuse w/ panic attacks, which usually has increase RR –> respiratory alkalosis
why is making an anti-gonococcal vaccine using the pilus component likely to fail?
b/c the pilus is known to undergo antigenic variation at high frequency
what’s going on here?
blood transfusion
increased MSFP and decreased resistance to VR (extra blood distends the BV)
pt w. signs of CHF on aspirin and hctz should also add what to his regimen
hx is signficant for HTN and MI 2 years ago
- ß blockres, esp. carvedilol - slows ventricular rate and decreases PVR (afterload) by antagonizing ß1, ß2, and alpha1 receptors
- ACEi/ARB - prevents chronic AII-mediated L ventricular hypertrophy and remodeling that occurs in association w/ myocardial failure
1yo M w/ severe hypotonia, hepatomeagly, cardiomeagly
deficient enzyme?
Pompe disease - alpha-1,4-glucosidase
evidence of acute graft rejection in a cardiac transplant?
usually occurs within 1-4 weeks following transplant
dense infiltrate of T cells (rejection is mediated by host T cells sensitization** **against graft MHC)
sx: systolic dysfunction (dyspnea on exertion or paroxysmal nocturnal dyspnea)
A patient presents to your office after lunch at one of the better restaurants in town. She is complaining of dizziness, flushing, diarrhea, tachycardia, and a severe headache. This started about 30 minutes after she had a grilled tuna fish steak for lunch. A number of other patrons had the fish as well but did not develop symptoms.
The fish tasted fine although a bit peppery for her liking. She has never had an allergic reaction to seafood before.
The most likely diagnosis is:
A) Staphylococcus food poisoning.
B) Bacillus cereus food poisoning.
C) Ciguatera poisoning.
D) Scombroid poisoning.
E) Seafood allergy.
C) Ciguatera poisoning
Scombroid poisoning occurs when bacteria in a dark-meat fish produce histidine which is broken down into histamine (ie tuna, mackerel, bluefish, mahimahi, etc.) and the food is improperly handled. Fish may have a metallic or peppery taste. When eaten, patient develops a symptom complex suggestive of histamine effects including: flushing, diarrhea, dizziness, wheezing, tachycardia, and severe HA. An occasional patient will become hypotensive. The symptoms occur 20-30 minutes after ingestion. Self-limited, generally lasting less than 6 hours, but patient respond well to antihistamines such as diphenhydramine.
Patients with ciguatera poisoning present with GI symptoms such as cramping, vomiting, and diarrhea followed by nondermatomal neurologic symptoms such as perioral numbness, burning foot pain, ataxia, weakness, and vertigo. The neurologic symptoms can last for up to 1 year. An almost pathognomonic finding for ciguatera poisoning is hot-cold sensory reversal on the face.
complication of subarachnoid hemorrhage
what can the patient be treated with to prevent this?
arterial vasospasms (occur due to impaired brain autoregulation)
trmt: Nimodipine - selective Ca channel blocker
11yoM w/ difficulties with balancing and night vision. Mother complains of foul smelling stools and failure to thrive as an infant.
PE: poor muscle coordination, ataxia, decreased proprioception, and vibratory sense. Labs: decreased cholesterol and vitamin E.
Dx?
∆ MTP (microsomal transfer protein) - transfers TG onto apolipoprotien B as part of VLDL synthesis and affects abosrption of dietary fats, cholesterol, and fat-soluble vitamins
- inability to generate chyloµ -> fat accumulation in enterocytes -> foamy enterocytes
- decreased VLDL secretion into blood stream
findings: failure to thrive, steatorrhea, acanthocytosis, ataxia, night blindness, clear foamy macrophages
bcr-abl
CML t9;22
contraindication for thiazolidinediones (TZD) such as rosiglitazone
CHF patients
main pancreatic duct is derived from what structure?
ventral pancreatic primordium
superior vs inferior parathyroid glands originates from:
shares embryological origins with
superior: 4th pouch
inferior: **3rd pouch; **shares embryological origins thymus
patient w/ vitamin C deficiency has gingival bleeding, petechiae, ecchymoses and poor wound healing. Why?
impaired collagen hydroxylation of proline + lysine residues, which happens in the RER
this process helps collagen attain its maximum tensile strength
discrete subepithelial humps on EM is seen in which renal disease?
post-strep glomerulonephritis (PIGN) - usually occur a few weeks following a skin or pharyngeal infection
down syndrome is associated with
two leukemias
two GI abnormalities
cardiac defects
ALL, AML
duodenal atresia, Hirschsprung
ASD, VSD (endocardial cushion defects)
interpret this
HBsAg negative
anti-HBc positive
anti-HBs positive
Immune due to natural infection
c-myc
burkitt’s lymphoma t8;14
hamartoma definition
growth of a tissue type native to the organ of involvement
genes involved adenoma to carcinoma sequence (what structures are typically seen w/ each mutation?
AK53 (with intervening mutations)
- APC - hyperproliferative epithelium -> small (if you can see the entire polyp on the slide) adenomatous polyp w/ a fibrovascular stalk w/ tubular glands + villous components
- **COX2 **
- <em>patients taking aspirin have been shown to have a lower incidence of adenomas compared to the general population</em>** **
- Kras -> unregulated cell proliferation -> large adenomatous polyp
- DCC
- P53 -> disordered/carcinoma
Pathophysiology of Zenker’s diverticulum
type of diverticula?
cricopharyngeal muscle dysfunction
FALSE diverticulum = contains only mucosa + submucosa layers
how do you tell whether a transplant patient is undergoing rejection (acute/chronic) or GVHD?
-
rejection (acute/chronic) - host CTLs activated aganist donor MHC -> rejection of graft
- findings: acute rejection = vasculitis of graft vessels; chronic rejection = fibrosis of graft stroma + BV
-
GVHD - **graft T cells **activated aganist against host MHC -> rejection of host
- findings: any host organ may be a target of GVHD, but the skin, liver, and GI tract are most severely affected -> desquamating skin rash, bloody diarrhea
What does this represent? (choose one)
Increase preload
Increase afterload
Systolic dysfunction
Increased ejection Fraction
Normal Saline Infusion
Increased afterload
Serotonin syndrome (mental status ∆, neuromuscular dysfunction, autonomic instability - rapid/large ∆BP, ∆HR) is treated with….
Cyproheptadine - antihistamine w/ anti-serotonergic properties
pt w/ a-fib and hx of pulmonary disease. Of these Rx, what would you give to the patient?
amiodarone
diltiazem
esmolol
lidocaine
procainamide
diltiazem - Ca blocker that inhibits Ca influx into the VSM and myocardium; also has AV nodal blocking effects and is used to control rapid a-fib and a-flutter
- amiodarone - cases ARDs/pulmonary fibrosis
- esmolol - selctive ß1 blocker - generally not use in patients w/ poorly controlled pulmonary disease
- lidocaine - used in MI
- procainamide - class IA - often used for ventricular arrhythmias
maculopapular rash that starts on head and progresses downwards to the extremities
cough, coryza, conjunctivitis, and koplik spots
measles (rubeola)
Rust colored urine + facial swelling should make you think of…
what determines prognosis?
PIGN
prognosis determined by** AGE!! **
young children = good; most recover completely w/ conservative Tx
adults = not so good; only 50% will resolve completely; rest will develop chronic GN or RPGN
what is tertbutaline and what is it used for?
ADR?
ß mimetic tocolytic drug used to delay labor + delivery by suppressing uterine contractions
ADR: increased risk of neonatal intraventricular hemorrhage, hypoglycemia, hypocalcemia, ileus
During excitation-contraction coupling, Ca released from the sarcoplasmic reticulum binds to ___________ and causes ___________
troponin C (bound to tropomyosin)
causes the tropomyosin to shift, thereby exposing the actin binding sites for myosin and allowing contraction to occur
“bilateral wedge-shaped bands of necrosis seen over the cerebral convexity that follow the interhemispheric fissure - just a few cm lateral to it”
hx report described in a patient who suffered a massive MI/cardiogenic shock
watershed infarction - necrosis that occurs btwn the zones of perfusion of the MCA, ACA, and PCA
why is it that a heavy smoker w/ chronic cough + lower extremity edema + cyanosis + expiratory wheezes faint with supplemental O2?
prolonged hypercapnia = CO2 doesn’t stimulate the respiratory drive in central chemoreceptors (medulla) as it normally does
therefore hypoxia is the only stimulator of respiratory drive; rapid increase in O2 –> respiratory stimulus disappears –> decr. respiration -> confusion + fainting
bipolar patient recently started a HTN Rx and develops involuntary movements, ataxia, and tremor. What HTN Rx was she given?
basically anything that increases PCT reabsorption of Na/H2O
Thiazide
ACEi
NSAIDS
(not loop diuretics)
in menstruation:
proliferative phase begins with_________ and ends with _________
secretory phase begins with_________ and ends with _________
proliferative phase begins with** menstruation_ and ends with _ovulation**
secretory phase begins with **ovulation **and ends with onset of menses
46xx with BP 150/95, serum K 3.2, elevated plasma androgens, and 17OH progesterone, and decreased aldosterone has a mutation in what enzyme
11ß hydroxylase - note the high P and low K - indicates that some Aldo-like factor is being made (ie DOC)
hypophysectomy (removal of pituitary gland) induces a decrease in epinephrine secretion by the adrenal glands. What enzyme is responsible for the observed effect?
in the adrenal medulla, the synthesis of catecholamines begins with conversion of tyrosine -> DOPA via tyrosine hydroxylase
conversion of NE -> Epi occurs via phenylethanolamine-N-methyltransferase (PNMT), which is under the control of cortisol (increases the synthesis of PNMT).
Therefore, ø ACTH = ø Epi
46 XX neonate w/ male external genitalia should make you think of…
androgen excess during gestation; usually due to CAH (21 hydroxylase or 11 hydroxylase deficiency)
why are there 2 peaks in isoniazid metabolism?
what other Rx have similar patterns of metabolism?
2 peaks = 2 distinct groups in the population that suggest a polymorphism in drug metabolizing capacity
isoniazid is metabolized via acetylation, therefore there are
fast acetylators (normals)
slow acetylators (leads ot accumulation of Rx in plasma)
other Rx that show this pattern: dapsone, hydralazine, procainamide
note: slow acetylators have a higher risk of developing drug-induced lupus!!
what 2 disorders specificially cause degeneration of spinocerebellar tracts, dorsal column of the spinal cord, and peripheral nerves
Vitamin E
Friedreich ataxia
both result in ataxia, dysarthria, and loss of position/vibration sensation
how is MCHC affected in patients with hereditary spherocytosis?
elevated MCHC - indicates membrane loss and red cell dehydration (think of these cells going through the spleen and the macrophages taking a bite of the cytoplasm every time, therefore the Hgb concentration increases with every bite removed).
dx best confirmed with the osmotic fragility test
45yo F w/ long history of pruritis and fatigue who developed pale stool and xanthelasma
**primary biliary cirrhosis - **pruritis is often the first symptoms and may be very severe, esp at night.
- hx: destruction of intralobular bile ducts by granulomatous inflammation and infiltrate of macrophages, lymphocytes, plasma cells, eosinophils
blastomycosis dermatitidis
where is this endemic to?
dimorphic fungus - cause pulmonary symptoms (cough, sputum production, hemoptysis, dyspnea, and pleuritic chest pain) in immunoCOMPETENT hosts; usually w/ travel Great Lakes, Mississippi, Ohio River basins
forms GRANULOMATOUS inflammation
in immunocompromised hosts, it may lead to disseminated mycosis (fever, lung + skin + bone involvement)
trmt: itraconazole
describe all of the MEN and associated organs
1,2,3 — 3,2,1
Type I has 3 Ps: Parathyroid, Pancreas, and Pituitary
Type II has 2 Ps: Parathyroid, and Pheochromocytoma
Type III has 1 P: Pheochromocytoma.
difference between hypnagogic vs hypnopompic hallucinations?
hypnagogic = occur when patient is falling asleep
hypnopompic = occur when a person is just awakening from sleep; usually with sleep paralysis, cataplexy, and sleep attacks (narcolepsy)
metabolic enzyme that is most upregulated when cells switch to anaerobic metabolism
PFK-1 (first committed step of glycolysis)
why? glycolysis becomes the sole source of ATP via substrate level phosphorylation + phosphoglycerate kinase + pyruvate kinase
anti-arrhythmia agent that causes agranulocytosis, bbone marrow suppression, neutropenia, hypoplastic anemia
procainamide, class IA
short stature, hypotonia, obesity, mental retardation
Pradar Willi Syndrome - microdeletion on chr. 15 that is inherited from the father
adherent membrane, gram + rod
diphtheria - produces toxins that inactivates eukaryotic elongation factor 2
what is metyrapone?
- agent used to test whether there is an interruption in the HPA feedback loop
-
inhibits 11ß-hydroxylase, which is responsible for the conversion of 11ß-deoxycortisol -> cortisol (resulting in increased pituitary secretion of ACTH, which causes the adrenal glands to produce even more 11ß-deoxycortisol - measurable in the urine as 17-OH-corticosteroids)
- normal HPA = metyrapone will cause significant increase in 11-deoxycortisol and 17-OH-corticosteroids in urine
Patients w/ alcoholic-induced cirrhosis have gynecomastia, palmar erythema, spider angiomata, asterixis, ascites, pedal edema, testicular atrophy, hepatic encephalopathy, and splenomeagly.
What causes the signs in bold?
Hyperestrinism “hyper-estrogenism” is due to:
1) liver cannot metabolize circulating androstenedione (which results in increased estradiol levels)
2) SHBG rises, which results in a higher binding of testosterone, thus decreasing the ratio of free T to E (ie more estrogen)
64yo M w/ persistent back pain, constipation, easy fatigability, low hemoglobin, and eelvated serum creatinine should make you think of….?
What would a biopsy of the affected organ show?
Multiple myeloma
easy fatigability - due to anemia
constipation - due to hypercalcemia
bone pain - osteoclast activation by myeloma cells
renal failure (zaotemia)
Bx: large eosinophilic casts (bence-jones proteins)
ulnar nerve (C8-T1) is commonly injured at which location?
passes in “Guyon’s Canal” (btwn hook of hamate and pisiform bone)
medial epicondyle of humerous “funny bone”
pt with recurrent URI (susceptible to strep. pneumonia and H. influenzae) has a mutation in..
bruton agammaglobulinemia (x-linked recessive)
derivative of the common cardinal veins
SVC
drug that reduces post-prandial hyperglycemia in diabetics
acarbose - inhibits alpha-glucosidase on intestinal brush border to delay glucose absorption)
(car going through the intestines)
Aspart, Lispro, Gluisine - activates insulin receptors in fat, muscles, and liver
spherules should make you think of…
coccidiodes immitis
thick-walled spherules filled w/ endospores
common in southwestern states (desert area, mold form is present in soil
pulmonary form: flu-like illness, cough, erythema nodosum
disseminated form can affect skin, bone, and lungs
name this please
cryptococcus
only partially dsDNA circular virus
HepB
where embryonic hemoglobin synthesis occurs during 1-7 month
liver
(before that will be in the yolk sac)
(after that will be in the bone marrow)
What do you want to treat AML patients with? What is absolutely contraindicated and why?
AML - acute myelogenous leukemia M3 form - treat with ATRA (all trans-retinoic acid) since it stimulates the differentiation of myeloblasts into mature granulocytes and induces remission
DO NOT TREAT WITH CHEMORX - it can induce release of Auer rods and cause DIC
how to differentiate between CML + leukemoid reaction
leukocyte alkaline phosphatase
CML = LOW (granulocytes are dysfunctional)
**leukemoid = HIGH **(granulocytes are functional)
bromocriptine
dopamine agonist that inhibits prolactin secretion; trmt for prolactinoma
macrocondida
histoplasma capsulatum
cause of unilateral SVC syndrome (R face + arm swelling and engorgement of subcutaneous veins on the R side of the neck)
obstructed R brachiocephalic vein (drains R internal jugular + R subclavian v. (which drains the R external jugular), usually due to an apical lung tumor, thrombotic occlusion, or prolonged central cathther placement
alkaline phosphatase is a marker of?
osteoBlasts
staining with this enzyme can help identify bone tumors
Urinary deoxypyridinoline reflects activity of which cell type?
osteoClasts
note that these cells use carbonic anhydrase to produce H+, which are then pumped from the cytoplasm -> resorptive pit to create the acidic milieu required for bone demineralization
common cause of pyelonephritis?
can occur via hematogenous or **ascending **(more common)
in ascending pyelo - there is vesicoureteral reflux, which brings pathogens present in the bladder up to the ureter. this is common in patients w/ frequent bladder infections, which may **weaken the vesicoureteral junction **and facilitate reflux
gastric ulcer on the lesser curvature can penetrate into which arteries?
L/R gastric (both form gastro, depending on its location
decreased exercise tolerance, muscle pain and cramping during exercise + myoglobinuria
blood lactate is very low post exercise
muscle bx: excess glycogen
McArdle - ∆ glycogen phosphorylase
what two statistical measures depend on disease prevalence in the population?
NPV and PPV
NPV = inversely related (lower prevalence = higher NPV)
PPV = directly related (higher PPV = lower NPV)
(sensitivity and specificity of a test do not depend on the prevalence of the disease in the population)
how would SV or compliance change in order to increase PP?
increase in SV
decrease in compliance
42yo alcoholic has a smear that shows hypersegmented neutrophils. What is he deficient in?
folic acid deficiency
(note that B12 deficiency also shows hypersegmented neutrophils, but folic acid deficiency is common in alcoholics)
normal function of progesterone?
what happens if you withdraw progesterone?
function: differentiation of endometrial stromal cells into decidual cells that can accomodate pregnancy
withdrawal: endometrial cells undego apoptosis -> bleeding
where is the sphenoid sinus located?
anterior to the optic chiasm
cause of megaloblastic anemia (low Hg and elevated MCV) in an alcoholic
folic acid deficiency -> defect in DNA synthesis (due to ø purine/pyrimidine production) -> megaloblastic RBCs
a drug is virtually eliminated after how many half-life intervals?
5
What should you monitor continuously in cirrhotic patients who are at risk of developing HCC?
AFP
normal atrial/ventricular pressures on the R vs L side of the heart
max/ min
- R atria = 10, 0
- R ventricle = 25, 4
- Pulmonary artery = 25, 9
- L atria = 12, 2
- LV = 130, 9
- Aorta = 130, 70
virulence factor of bacillus anthracis?
what are diagnostic clinical features of this bug?
what do you treat bacillus anthracis with?
D-glutamate capsule - antiphagocytic
mediastinal widening + black eschar + serpentine/medusa head on microscopy
ciprofloxacin
clavulanic acid, sulbactam, and tazobactam can “extend the spectrum” of penicillin-family antibiotics. What does this mean?
allows the the penicillin family of antibiotics to be effective aganist organisms that produce ß-lactamases (ie S. aureus, H. influenza, Bacteriodes, and other GN bacteria)
internuclear ophthalmoplegia
cause
common manifestation in what d/o?
demyelination of MLF -> impaired adduction of corresponding eye during lateral gaze (note that bilateral adduction during ocular convergence is spared)
(MLF connects ipsilateral abducens w/ contralateral medial rectus to allow horizontal conjugate gaze movements)
MULTIPLE SCLEROSIS (or MLF stroke)
hammerhead ribozymes
degradation of mutant SOD1 mRNA
Werdnig-Hoffman Syndrome
what is another d/o that can present the same way?
aka spinal muscular atrophy
congenital degeneration of anterior horn cells -> LMN lesion
floppy baby w/ marked hypotonia, tongue fasciculations, areflexia, muscle atrophy
other d/o: poliomyelitis
korotkoff sounds
first become audible during expiration and subsequently becomes audible during all phases of respiration ∆ greater than 10mmHg = think pulsus paradoxicus (acute cardiac tamponade, constrictive pericarditis, severe obstructive lung dz, restrictive cardiomypathy
greatest concentration of H. pylori is found where?
pre-pyloric areas of the gastric antrum
rhomboid crystals w/ weak positive birefringence under polarized light
calcium pyrophosphate
(black arrow indicates the direction of the compensator)
Crystals parallel to the compensator = blue
Crystals perpendicular to the compensator = yellow
(compare to monosodium urate crystals, which are yellow when parallel to the light)
hamartomatous polyps
Peutz-Jegher’s syndrome
non-malignant hamartomas in the GI
hyperpigmented mouth, lips, hands, and genitalia
brain imaging shows a 9mm cavitary lesion in the brain. what type of infarct is this? what is it usually caused by?
lacunar infarcts (
often due to hypertensive arteriosclerosis of small, penetrating arteries.
what accounts for the sx (acute abd. pain + neurological sx) observed in acute intermittent porphyria (AIP)?
treatment for these sx?
d-aminolevulinic acid + porphobilinogen
hepatic heme production is used for CYP450; AIP can precipitated by anything that alter levels of CYP450 (ie phenobarbital, griseofulvin, phenytoin, OH, low calorie diet), which result in low heme []’s
As a result ALAS is upregulated and there is increased formation of the two substrates above.
AIP patients have ∆porphobilinogen deaminase, which results in an accumulation of these substrates -> acute abd. pain, port-wine colored urine, neurologic symptoms (anxiety, muscle weakness)
trmt: heme (inhibits ALAS, thereby decreasing production of these substrates)
identification
modeling of one’s behavior after someone who is perceived to be more powerful (ie parent who was abused as a child becomes an abusive parent)
buboes vs chancroid vs chancre
bugs that cause them?
what do they look/feel like?
buboes = chlamydia trachomatis (swollen, painful inguinal nodes that coalesce, ulcerate, and rupture)
chancroid = haemophilus ducreyi (tender red papules)
chancre = treponema pallidum (painless lesion)
Meningioma
Location
Appearance
Prognosis, presentation
Brain surface (extraaxial attached to dura)
Spindle cells in whorled pattern w/ psammoma bodies, well circumscribed
Adults, Benign; seizures or focal deficits
What does this represent? (choose one)
Increase preload
Increase afterload
Systolic dysfunction
Increased ejection Fraction
Normal Saline Infusion
Systolic Dysfunction
Pregnancy and the usage of OCs predispose to gallstone formation. How?
- Estrogen - increases cholesterol synthesis by upregulating HMG-CoA activity, which causes bile to become supersaturated with cholesterol
- Progesterone - reduces bile acid secretion and slowing gall bladder emptying (hypomotile)
phenytoin
MoA
ADR
MoA: inhibits electrical activity in the brain by blocking VG Na channels in neurons, thus increasing the refractory period
ADR:
- gingival hyperplasia (via increasing PDGF)
- megaloblastic anemia (interferes w/ folic acid metabolism)
- ataxia and nystagmus (affects cerebellum+vestibular system)
- induces CYP450 cytochrome oxidase
- fetal hydantoin syndrome
- pseudolymphoma (generalized lymphadenopathy)
what is the common ground between sildenafil and ANP?
sildenafil - inhibits cGMP phosphodiesterase -> increase cGMP
ANP - increases **cGMP **via a second messenger system
(NO also has the same MoA as ANP)
ADR of TMP-SMX
TMP = Treats Marrow Poorly
Megaloblastic anemia (folate antagonist), leukopenia, granulocytopenia
Steven-Johnson Syndrome, Toxic Epidermal Necrolysis
causes of 1˚ hemolytic anemia
defect in glycolysis or hexose monophosphate shunt (PPP) - pyruvate kinase (due to G6PD)
urine measurement of this would allow diabetic nephropathy to be detected at its earliest stage.
albumin - screen for microalbuminuria
(30-300mg/day in a 24h collection or 30-300protein/mg of creatinine in a spot collection)
MoA of CRH in the H-P axis
stimulate release of ACTH, MSH, ß endorphin
diuretics that cause ototoxicity
furosemide
L homonymous hemianopia w/ macular sparing
R primary visual cortex - occipital lobe - usually due to occlusion of posterior cerebral artery. macula spared due to collateral flow from MCA
fructose intolerance
∆ aldolase –> hypoglycemia
patient on NTG cannot be on these Rx and why?
sildenafil - both cause incr. cGMP –> extreme vasodilation
fever and ulcers on the tongue and oral mucosa + maculopapular and/or vesicular rash on the palms and soles
HFMD - coxsackie type A
sandpaper-like erythematous rash (blanches w/ pressure) that begins on the neck, armpits, and groin, and then generalizes
fever + sore throat (gray-white tonsillar exudates) + bright red tongue
s. pyogenes (scarlet fever)
may result in rheumatic fever + glomerulonephritis later on
immediate treatment for patients in adrenal crisis (hypotensive, tachycardia, hypoglycemic, vomiting, abd pain, weight loss, hyperpigmentation)
steroids
adrenal glands normally respond to stress by secreting large quantities of glucocorticoids to that is essential to cardivascular and metabolic adaptations during stress
gp120 and gp41
function?
what can you use to block their functions with?
env proteins of HIV - viral envelope
gp120 = mediates attachment via CD5 + CCR5 (or CXCR4); block w/ **maraviroc **
gp41 = mediates fusion; block w/ **enfuvirtide **“FOURSION; enFOURvirtide”
6mo F w/ crying, sweating, shaking chills 1 hr after eating apple-sauce and pureed pears
Deficient enzyme?
Fructose intolerance - ∆ frustose-1-phosphate aldolase
how does TLC, RV, FRC, elastic recoil, FEV1/FVC ratio affected in COPD
increased TLC, RV, FRC
decreased elastic recoil, FEV1/FVC
external stimulus applied to cells increases the activity of several enzymes, including DHFR and DNA polymerase. What immediately precedes the observed effect?
Rb protein phosphorylation by cyclin kinases (CDK 4, 6) = thereby inactivating it and allowing G1->S transition to occur.
42 F complains about episodic spinning sensation associated w/ nausea, ringing on L ear, and always having to use R ear when talking on the phone.
Meniere’s disease - increased endolymph (due to defective resorption) causes damage to vestibular + chochlear components of inner ear
-> triad of tinniitus, vertigo, and sensorineural hearing loss
patient w/ sx of dysphagia and chest pain
what would you do if a patient came in complaining of these sx?
diffuse esophogeal spasms = intermittent dysphagia and occasional chest pain - may mimic angina pectoris and thereoore it is important to get a cardiac workup to r/o a cardiac cause of chest pai
6yo living in old house is irritable, constipated, and has anemia. He has high blood levels of delta-aminolevulinic acid, which is maintained secondary to the presence of which cofactor?
b6 - pyridoxal phosphate
splinter hemorrhages on subungual areas
janeway lesions - small, nontender, lesions that can appear on the soles of the feet, palms of hthe hands - sign of microembolism
likely due to bacterial endocarditis, where vegetations on the cardiac valves are the source of microemboli
when is Ig therapy useful for herpes infections?
immunocompromised hosts, neonates whose mother developed a perinatal varicella infection, or prophylaxis in pregnant females exposed to varicella
diagnose this patient:
recurrent epistaxis, ecchymoses
marked thrombocytopenia
normal Hgb, leukocyte count, and differential
normal fibrinogen levels and PT/INR
no hepatosplenomeagly
immune thrombocytopenic purpura - acquired d/o where there is immune destruction of platelets via anti-platelet antibodies.
major stimulator of RR in normal folks
PaCO2 is the major stimulator of respiration (input from central + peripheral chemoreceptors + airway mechanoreceptors)
Which one corresponds to this graph?
Acute GI bleed
Pyschogenic polydipsia
Diabetes insipidus
Hypertonic saline infusion
Hypertonic saline infusion - leads to hypertonic volume expansion (both volume + osmolarity of ECF are increased); high osmolarity of ECF causes water to shift from ICF into ECF, further increasing extracellular volume
net: decreased ICF, increased ECV
virluence factor of e. coli that causes UTIs
p. fimbrae - allows adhesion of e. coli to the uroepithelium
patient w/ DIC
if you could only order 3, which labs should you order
Platelet count
fibrinogen levels
FDP
ultrastructural change that would most likely indicate irreversible myocardial cell injury?
appearance of vacuolization or amorphous densities in the mitochondria = implies permanent inability to generate ATP via oxidative-phosphorylation
(note: mitochondrial swelling may be associated with reversible cellular injury)
diagnose
CMV - owl eye inclusions
what is calcitriol?
1,25-dihydroxycholecalciferol (ie active form of vitamin D)
how will a dose-response curve change if you add a competitive vs non-competitive antagonist to the solution?
competitive = R shift
non-competitive - shift down
palatine tonsils
originates from…
originates from **2nd **pharyngeal pouch
mild fever + maculopapular rash that spreads from the head inferiorly to the trunk and extremities; resolves in 3-5 d
PE: occiptal and posterior cervical lymphadenopathy
rubella
high fever for 3-5d with rash appearing once fever subsides
macules + papules that begin on trunk and spreads to extremities
roseola infantum (HHV6)
riboflavin - used to make what? what reactions is it involved in?
FAD, FMN
serve as coenzymes that participate in the TCA cycle as a coenzyme of
- succinate dehydrogenase (converts succinate into fumarate)
- Complex I (FMN) /Complex II (FAD) of the ETC
diagnose w/ RBC glutathione reductase assay or measuring urinary riboflavin excretion
why is it that excess alcohol can inhibit gluconeogenesis?
ethanol is metabolized to acetaldehyde by alcohol DH and then to acetate via aldehyde dehydrogenase, and in the process, converting NAD+ to NADH
high NADH favors conversion of
- pyruvate -> lactate
- conversion of oxaloacetate -> malate
thereby inhibiting gluconeogenesis
tumor cells can become resistant after exposure to various anti-cancer agents. Why?
due to expression of MDR1 (multi-drug-resistance) gene, which codes for P-glycoprotein a transmembrane protein that functions as an ATP-dependent efflux pump
gene for both breast cancer + ovarian cancer is on this chromsome
17q (17 is when girl’s prime age for developing everything!)
male physician spends extra tiem with an attractive F patient but insists that it is because her case is more complicated than the others
rationalization - offering of a false but acceptable explanation for behavior
equation for TPR
TPR = (MAP - RAP) / CO
since RAP = 0
TPR = MAP/CO
remember this to help you remember TPR: P = QR
brocas and wernicke’s area are both supplied by this artery
MCA
patient with sx of night blindness, dry skin, and generalized pruritis has which of the following
- decreased sunlight exposure
- stright vegetarian diet
- chronic renal failure
- prolonged biliary obstruction
- chronic hemolytic anemia
- RA
prolonged biliary obstruction - her sx are consistent with vitamin A deficiency. Biliary obstruction -> cholestasis -> fat soluble vitamin malabsorption
how do these factors change with ITP d/o?
Platelet Count
Bleeding time
PT
PTT
plasma fibrinogen levels
smear
Platelet Count = decrease
Bleeding time = increase (less platelets)
PT = NC
PTT = NC
plasma fibrinogen levels = normal
smear = isolated thrombocytopenia
usually occurs in females of childbearing age
digoxin - MoA 2
OD can result what side effects? 3
what can you treat it with? 2
what worsens digoxin toxicity? 2
BOTTOM LINE - DIGOXIN IS A COMPLICATED DRUG
1) inhibits Na/K ATPase -> decreased Na efflux -> decreased Na/Ca exchanger (pumps Na in, Ca out) -> increased Ca intracellular -> increased contractility
2) increase parasympathetic tone -> increased parasympathetic tone
OD: Hyperkalemia (weakness), blurry yellow vision, life-threatening arrhythmias
trmt: anti-digoxin Fab fragments + Mg
Worse OD w/:
- age-related decreases in renal function (digoxin is renally cleared; renal fxn declines w/ age and is often not associated w/ a concomitant rise in creatinine since muscle mass also declines w/ age)
- **hypokalemic **- K and digoxin competes for the same binding site on Na/K ATPase, there is less K to compete w/ digoxin!
(compare to hyperkalemia, which reduces digoxin efffect!)
Oligodendroglioma
Location
Appearance
Prognosis, presentation
WM of frontal lobe
Chicken-wire capillary pattern w/ fried egg cells (round nuclei w/ clear cytoplasm); often calcified
Adults, Slow growing
glyburide, repaglinide, metaglinide
MoA
Sulfonylureas - ATP-like molecule that **binds to KATP channels **on pancreatic ß cells, causing them to close -> depolarization -> VG Ca channels open -> Ca influx -> insulin release via exocytosis
radiographic findings of mesotheliomas
diffuse nodular or smooth thickening of the pleura
may present w/ hemorrhagic pleural effusions
Female
LH / FSH stimulates which cells? stimulates production of what?
LH = theca (interna) cells; stimulates conversion of cholesterol -> T
FSH = granuolosa cells ; stimulates conversion of T -> estrogen (estradiol)
prazosin
major ADR w/ this?
selective alpha -1 blocker that is used in HTN and BPH - peripherally acting vasodilator
first dose-effect - tendency to cause hypOtension when the first dose is started; prevent by starting off w/ a very small first dose
amyl nitrate
use for cyanide poisoning
induces **formation of methemoglobin (Fe3+) **which cannot carry oxygen, but has a high affinity for cyanide, thereby sequestering cyanide in the blood and keeping it away from mitochondrial enzymes.
29yoM w/ scrotal mass (malignant neoplasm) complains of sweating, palpitations, and recent weight loss. Labs show increased T3 and T4.
What should this make you think of?
What serum markers would be elevated?
testicular malignancy + hyperthyroidism should make you think of a hCG-secreting teratoma (non-seminomatous germ cell tumor ofen found in testes and ovaries) or seminoma
hCG is similar to TSH, LH, and FSH, therefore it can bind to TSH receptor on thyroid gland -> hyperthyroidism
patient on anti-pyschotics develops corneal deposits.
Rx?
chlorpromazine
anterior dislocation can result in injury to which nerve?
outcome?
axillary n.
deltoid paralysis, loss of sensation over lateral arm
Aspirin should be avoided in all children, with this one exception
Kawasaki’s disease
What is Reyes Syndrome and what is caused by??
histological findings?
how does this happen?
hepatic failure/dsyfunction + acute encephalopathy (due to hepatic dysfunction)
when a parent treats a viral infection (VZV, influenza B) with **ASPIRIN **
histological findings: microvesicular steatosis (ø necrosis or inflammation)
MoA: aspirin metabolism causes decreased ß oxidation of fatty acids
organophosphate poisoning reversed with atropine still puts the patient at risk of this
what’s a better option?
muscle paralysis
organophosphate stimulates both N + M cholinergic receptors
atropine reverses M cholinergic receptors only, but does not prevent the development of N effects (ie paralysis)
better option: Pralidoxime - reverses N + M cholinergic receptors by restoring cholinesterases
TdT (+), CD19, CD10
ALL - precursor B cell leukemia
how does coronary steal work?
in coronary artery disease, coronary vessel occlusion can be bypassed by the presence / recruitment of collateral vessels that allow blood flow to myocardium distal to an occluded vessel.
Drugs such as adenosine + dipyridamole are selective vasodilators of coronary arterioles. Use of these agents in patients w/ MI can cause vasodilation of these vessels, thus resulting in decreased perfusion within the collateral microvessels that were supplying the ischemic myocardium (ie diverts blood from ischemic areas to non-ischemic areas), leading to hypoperfusion/worsening of existing ischemia
15 M w/ periodic sudden onset of arrhythmic jerking movements, usually happen in the AM and are aggravated by stress or sleep deprivation; denies losing consciousness, but he has fallen during these episodes
dx? trmt?
myoclonic seizures - generalized seizures
trmt: valproate acid
what nerve passes from the obturator foramen?
what happens there is compression of this nerve?
**obturator n. **- splits into anterior + posterior divisions after exiting the foramen to supply the medial (adductor) compartment of the thigh
therefore, nerve impingement or injury can result in impaired adduction of the thigh
in systemic mastocytosis, where the small bowel contains nests of mast cells within the mucosa, what is a common occurence?
gastric acid hypersecretion by parietal cells (due to histamine stimulation)
STEMI in I, aVL leads
lateral wall - LCX
infant w/ white pupils, hearing loss, and continuous machinery mumur over L infraclavicular area. What could’ve prevented this?
live-attenuated rubella vaccine
patient has congenital rubella syndrome
classic clinical triad: white pupils (cataracts), deafness, and PDA (heart problems).
type of hernia that passes through through superficial inguinal ring, but not through the deep inguinal ring
direct inguinal hernia - passes through the inguinal triangle and medial to the inferior epigastric arteries
what decreases risk of non-hereditary ovarian + endometrial cancers?
increases risk?
decreases: OC, multi-parity, breast feeding
increases: infertility, nulliparity, miscarriages, use of clomiphene citrate (induce ovulation)
entacapone
MoA?
COMT inhibitors - prevents levodopa degradation -> more dopamine enters the brain
tolcapone - same thing
56yoM has a 20yr hx of alcoholism has increasing confusion + abdominal distension. Massive dilation of what essels will put him at risk of
azygous vein - major accessory pathway for VR in patients with cirrhosis and major outlet for the esophageal venous plexus
In cirrhosis, it can become engorged, making esophageal varices more prone to rupture
Based on the RFLP, at which stage did the non-disjunction occur?
Maternal meiosis I
Maternal meiosis II
Paternal meiosis I
Paternal meiosis II
Paternal meisois II
upper band = mother
lower band = father, but is thicker/darker, which signifies the inheritance of both sister chromatids
Type of collagen found when
- macrophages are present
- scar formation is complete
- macrophages: granulation tissue (type III collagen)
- scar formation: type I collagen
APC chromosome
5q (5 follows the outline of the GI)
Based on the RFLP, at which stage did the non-disjunction occur?
Maternal meiosis I
Maternal meiosis II
Paternal meiosis I
Paternal meiosis II
Maternal Meiosis II
lower band = father
upper band = thick, indicating that both sister chromatids were inherited<em> (producing an equal sized restriction fragment, but twice the normal amount)</em>
linear IgG and C3 deposits are characteristic of which renal disease?
Goodpasture - anti-GBM; often accompanied by pulmonary sx (hemoptysis), as well as GBM disruptions + fibrin deposition on EM later on in the disease
when lung injury occurs, local neutrophils and macrophages release what cytokines? what do they do?
TNFa, IL1, Il6 - mediate systemic inflammatory response (ie stimulate hepatic production of acute phase reactants, which can increase ESR)
26yoF w/ tremors, weight loss, and discomfort on warm days has a palpable unilateral abdominal mass. No ophthalmopathy, no neck masses. Lab shows Low TSH levels. US shows unilateral ovarian cystic mass. DX?
Monodermal Teratoma - Struma ovarii
what cells provide major proliferative stimuli for the cellular components of atherosclerotic plaques?
platelets - release
- PDGF - promote smooth muscle migration from the media -> intima
- TGF-ß - chemotactic for SMC and induces interstitial collagen production
4 things that can affect DCML
B12 deficency
Folate deficiency
Vitamin E deficiency
syphillis
virluence factor of e. coli that causes bacteremia leading to septic shock
LPS - toxin A - causes macrophage activation and widespread release of IL1, IL6, and TNFa
Avitaminosis A in CF patients can contribute to?
squamous metaplasia of epithelial lining of pancreatic exocrine ducts (which are already injured and predisposed to squamous metaplasia by inspissated mucus
why? bc Vit A is impt to maintain orderly differentiation of specalized epithelia
sodium (cyanide) nitroprusside test is used in this particular d/o
presence of** cystine** in the urine since the cyanide added to the urine converts cystIne -> cystEine, then nitroprusside binds the cysteine, resulting in a purple color
Cystinuria - defect in the PCT that causes decreased reabsorption of cystine, ornithine, lysine, and arginine - COLA; cysteine is the only one that will precipitate into hexagonal stones
do not confuse w/ nitroprusside - anti-HTN Rx
boundaries of inguinal triangle
bound
- laterally by inferior epigastric a/v
- medially by the lateral border of the rectus abdominis
- inferiorly by the inguinal ligament
Rx to treat post-op urinary retention
**Bethanechol **- muscarinic agonist that causes contraction of the detrusor muscle
(or an a1 blocking drug)
which organ is supplied by a foregut artery but is NOT a foregut derivative?
what other structures does the foregut a. supply?
spleen - derived from mesodermal mesentery - supplied by splenic artery (branch of celiac trunk - foregut)
also supplies:
pharynx -> proximal duodenum
liver
pancreas
22yoM w/ skin lesions on abdomen has fibroblasts that can’t metabolize ceramide trihexose. He is at greatest risk of…
cardiovascular + renal failure
dz: Fabry - ∆ alpha-galactosidase A - peripheral neuropathy of hands/feet, angiokeratoma, cardiovascular + renal failure problems
what kind of withdrawal: confusion, sweating, shakiness, tremulous
alcohol
endocarditis due to s. viridans
tooth extraction
hemisphere dominant for speech and verbal material in the majority of individuals?
L hemisphere
coronary sinus dilation
anything that causes R atrium dilation (ie pulmonary HTN)
why can corticosteroids cause reactivation of TB and candidiasis?
blocked IL2 production
patient with really high ferritin levels and a (+) family hx should make you think of…
What other presenting sx do you expect?
how do you treat this?
Hereditary Hemochromatosis - mutation in HFE gene (affect intestinal absorption of Fe that results in iron deposition in the body)
presenting sx: cirrhosis, DM, skin pigmentation, CHF, testicular atrophy
regular phlebotomy, diferasirox, deferoxamine
Low MCV
high serum Fe
**normal-to-decreased TIBC **
should make you think of…
sideroblastic anemia - abundant iron is available to developing RBCs but it is not used effectievly. Abundant Fe leads to decreased total Fe-binding capacity as the body compensates by downregulating fe-binding capacity
23yo w/ confusion has a blood glucose level of 38mg/mL; liver cells have high NADH. Why?
he likely has been consuming large volumes of alcohol lately - the high NADH in the setting of hypoglycemia indicates that a fuel other than glucose is being metabolized (ie ethanol)
ethanol is metabolized to acetaldehyde by alcohol DH and then to acetate via aldehyde dehydrogenase, and in the process, converting NAD+ to NADH
high NADH favors conversion of
- pyruvate -> lactate
- conversion of oxaloacetate -> malate
thereby inhibiting gluconeogenesis
27yoM w/ dyspnea, chest pain, and severe episodes of post-exertional syncope.
ECHO: anterior motion of hte mitral valve during systole, asymmetric LVH, early closing followed by reopening of the aortic valve
dx and treatment?
patient has hypertrophic cardiomyopathy
Best Rx: **ß blockers - **slows HR to improve diastolic filling
How are intracellular and extracellular K levels different in a patient with DKA ?
intracellular = decreased
extracellular = normal or increased
thus DKA patients have a normal-increased serum K levels despite a total K because of:
- increased plasma osmolality leads loss of intracellular free water loss, results in extracellular movement of K secondary -> increasing intracellular K concentration
- lack of insulin also causes extracellular shifting of K as insulin normally promotes cellular uptake of K
vaginal bx
dx and treatment?
HSV - ground glass nuclei + intra-nuclear inclusiosn (Cowdry type A), formation of multinucleated giant cells
trmt: acyclovir
12yoM w/ turbid plasma that forms creamy-appearning supernatant on standing
likely due to lipoprotein lipase deficiency ->
- increased conc. of serum chyloµ (hyperlipidemia)
- pancreatitis (abd. pain)
- lipemia retinalis
- eruptive skin xanthomas (mainly on extensor surfaces)
- hepatosplenomeagly
T4 can cannot be converted to T4 and rT3
T3 cannot be converted to T4 and rT3
which statement is true? which one is false?
- T4 can cannot be converted to T4 and rT3 = FALSE. T4 can be converted to both
- T3 cannot be converted to T4 and rT3 = TRUE
Based on the RFLP, at which stage did the non-disjunction occur?
Maternal meiosis I
Maternal meiosis II
Paternal meiosis I
Paternal meiosis II
Maternal Meiosis I
lower band = father
upper + middle bands = mother; ie both homologous chromosomes were inherited, therefore problem occured during meiosis I
perifollicular hemorrhages hair fragmentation purpura + ecchymoses all over splinter hemorrhages gum changes
Vitamin C deficiency - (vitamin C is impt for collagen formation) - leads to weak blood vessels aka Scurvy
drug that can be used to treat bipolar AND seizures?
valproic acid - augments inhibitory actions of GABA in CNS
what are howell-jolly bodies?
nuclear remnants within RBCs that are normally removed by the spleen; indicates splenetomy or spleen malfunctioning
cells that mediate wound contracture
myofibroblasts
hyponotic agent that has anxiolytic, muscle relaxant, and anti-convusalnt actions
benzodiazepines - bind gaba-a receptor and increase frequency of Cl channel opening
XY male born w/ feminized external genitalia, but male reproductive tracts and testes in the abdominal cavity.
Dx?
Potential cause?
**5a-reducase deficiency - **patients remain genotypically F until puberty, when increased T results in virilization (penis at 12 syndrome)
potential cause - Mother was using or handling Finasteride (blocks 5a-R enzyme) during her pregnancy
<em>do not confuse with testicular feminization (androgen insentivity), in which an XY male has neither male nor female reproductive parts (has MIF -> mullerian degeneration, but cells are unable to respond T, therefore Wolffian degenerates), but external genitalia defaults to female phenotype (since the cells can’t respond to T)</em>
ß endorphin is an endogenous opioid peptide that is derived from?
POMC
undergoes enzymatic cleavage to produce
ßendorphins, ACTH, and MSH
F w/ thin, gray malodorous discharge. Culprit?
Gardnerella vaginalis
Fondaparinux MoA
Synthetic pentasaccharide (“extremely LMWH”) that inhibits Factor Xa directly
virluence factor of e. coli that causes watery gastroenteritis
heat-stable/heat-labile enterotoxins - promote fluid and electrolyte secretion from intestinal epithelium
negative nitroblue tetrazolium test indication of?
measures reactive oxygen intermediates produced by NADPH
if negative -> chronic granulomatous disease (defect in NADPH oxidase); recurrent infections by catalase producing organisms inability to kill bacteria and fungi that are catalase (+)
first peak in the jugular venous pressure tracing is due to:
atrial contraction
pioglitazone
MoA
What should you check periodically if you prescribe this Rx?
ADR?
contraindications?
Thiazolidinediones (TZD) - binds and activates PPAR-gamma (an intracellular nuclear receptor ) -> increases production of adiponectin (cytokine secreted by fat tissue), thereby reducing insulin resistance (increases sensitivity of target tissues to insulin)
Get LFTS due to risk of severe hepatotoxicity
ADR: hepatotoxicity**, weight gain, edema**
Contraindications: patients with CHF
features of atypical depression?
how to differentiate from major depression?
**mood reactivity** (improvement in mood in response to something positive) = distinguishing feature from major depression
leaden fatigue (arms/legs feel really heavy)
rejection sensitivity (overly sensitive to criticism)
increased sleep and appetitie
how does a winged scapula occur?
what are other presenting sx?
damage to long-thoracic n. -> serratus anterior is unable to :
- hold the medial border and inferior angle of the scapula against the posterior chest wall
- unable to abduct the arm above the horizontal position, since it is required to rotate the glenoid cavity superiorly
breast lump bx shows focal calcifications + multi-nucleated giant cells.
Diagnosis?
Fat necrosis of the breast (likely due to trauma to the breast) -> release lipids that induce chronic inflammatory response -> multi-nucleated giant cells (key to dx)
common causes of decreased Mg
diarrhea aminoglycosides diuretics alcohol “DADA”
STEMI in V1-V4 leads
anterior wall (LAD)
what can reverse vagally-mediated bronchoconstriction?
anti-muscarinics (ipratropium), thereby blocking ACh-induced bronchoconstriction and enhancing bronchodilatory effects of ß-2 adrenergic agents
how do you calculate clearance?
clearance = (urine concentration * urine flow rate) / plasma concentration
peripheral blood smear looks like this. Dx?
CLL
What is the pygmalion effect?
researcher’s belief in the efficacy of treatment that can potentially affect the outcome
budding yeast should make you think of…
cryptococcus neoformans - round/encapsulated cells w/ naorrw based buds (NOT “spherules” which is more indicative of coccidiodes)
part of the aorta that is most susceptible to impact injury
aorta isthms, where the connection btwn the ascending + descending aorta occurs (distal to where the L subclavian a. branches off)
primary pulmonary artery hypertension is most likely caused by what
AD mutation in BMP-R2 -> vascular smooth muscle proliferation in the pulmonary vasculature and elevated pulmonary pressures
nname this please
aspergillus
recurrent lobar hemorrhages in elderly patient most likely results from…
cerebral amyloid angiopathy - occurs when ß amyloid is deposited into the arterial wall –> weakens it and predisposes it to rupture
NOT related to systemic amyloidsois
small, sterile, fibrinous vegetations along the edges of the mitral valve leaflets; no inflammation
nonbacterial thrombotic endocarditis (NBTE)
<strong>aka MARANTIC endocarditis</strong>
usually due to
- hypercoagulable state (cancer ie adenocarcinoma of the pancreas or lung)
- similar to Trousseau syndrome, where tumors release procoagulants that are responsible for migratory thrombophlebitis
- endothelial injury
see small, sterile, fibrinous vegetations along the lines of closure of cardiac valve cusps; no inflammation
uterine smooth muscle contains what kind of receptors?
which set of these drugs will produce these patterns?
alpha 1 and b2 adrenergic receptors
epinephrine (X) + propranolol (antagonist)
24yo AA mother has a child w/ sickle cell anemia decides to remarry. What is the initial best test to offer the family to determine the chances that their next child will be affected.
PATERNAL hemoglobin electrophoresis - why?
woman already has one child w/ sickle cell anemia, indicating that she is obviously a carrier of the trait, so you want to test the father to see if he’s a carrier.
breathing difficulty due to pain w/ inspiration AND sharp pain in neck in shoulder due to which nerves
phrenic nerve C3-4-5
invasive malignancy in the 3rd part of the duodenum can affect what structures?
ureter
SMA
portal vein
CBD
gastroduodenal artery
SMA
associations
1st part - nothing - its the bulb
2nd part - head of pancreas, ampulla of vater
3rd part - uncinate process of pancreas, SMA
how does verapamil, a Ca blocker, accelerate the progression/exacerbation of heart failure in certain patients?
strong negative ionotropic effects
(can exacerbate an already present heart failure (ie post-MI))
constipation
**gingival hyperplasia **
definition of reassortment
change in genetic composition when host cells are co-infected with two segmented viruses that exchange whole-genome segments; results in sudden alterations of the surface antngens of the viral progeny that is transmitted to the next generation
how does blood flow change w/ dynamic (running) vs static (weight lifting) exercises?
dynamic (running) = metabolic vasodilation of arterioles due to local vasodilator substances
static (weight lifting) = muscle contraction compresses blood vessels, which raises vascular resistance and decreases blood flow during the exercise. reactive hyperemia occurs during the recovery period
pathophysiology of alcohol-induced hepatic steatosis
alcohol DH + aldehyde DH -> excess NADH production -> decreased FFA oxidation -> TG accumulation in hepatocytes
amt of REM sleep in a patient with major depressive d/o
increase
odansetron
MoA (2)
- 5HT3 receptor antagonist - blocks vagus-mediated nausea and vomiting (which normally sends info back to the vomit center in medulla)
- blocks serotonin in the chemoreceptor trigger zone
immune response in a patient w/ PID
chlamydia trachomatis - obligate intracellular pathogen, therefore cell-mediated cytotoxicity, a Th1-dominant response) is the primary defense aganist the infection
fructosuria
∆ fructokinase –> asymptomatic
patient w/ renal cell carcinoma - lesion most likely originated from what part of the nephron/kidney?
histological features?
gross features?
epithelium of **PCT **
hx: clear cell carcinoma (most common type; due to high lipid content)
gross features: golden yellow mass
urge incontinence
what is it and what is caused by?
treatment?
caused by uninhibited bladder contractions (detrusor instability) that result in sudden sensations of urgency, with involuntary leakage of urine often before reaching the toilet
trmt: **M3 (Gq) antagonists (ie oxybutynin) **
- > decreased production of IP3/Ca
- > smooth muscle relaxation
- > decreased involuntary detrusor contractions
- > increased bladder capacity + decreased sense of urgency
ADR: anticholinergic effects: dry mouth, blurred vision, tachycardia, drowsiness, constipation
sensory innervation above the vocal cords and below the vocal cords are different.
above: superior laryngeal, internal br.
below: recurrent laryngeal
hapatients who undergo general anesthesia are at great risk of these 2 ADRs
halogenated anesthetics (HALOTHANE, enflurane, isoflurane, and sevoflurane) can cause massive CENTRILOBULAR HEPATIC NECROSIS, as evidenced by increased AST, ALT, and bilirubin levels
*usually presents 2d-4wks after exposure *
malignant hyperthermia - when anesthetic is given w/ succinylcholine -> induce fever+severe muscle contractions
trmt: dantrolene (muscle relaxant)
amyloid deposit only in heart
transthyretin (cardiac amyloidosis)
R nasal hemianopia has damage to
R perichiasmal lesion - ie calcification of ICA impinging on uncrossed, lateral retinal fibers
definition of phenotypic mixing
co-infection of a host cell by two viral strains, resulting in progeny virions w/ nucleocapsid proteins from one strain and the genome of the other strain; since there is no ∆ in the underlying viral genomes, the next generation of virions revert to their original, unmixed phenotypes
What should you consider in a patient with stable, compensated cirrhosis who suddenly decompensates without apparent reason?
Hepatocellular carcinoma, esp if serum AFP is elevated
atrial myxomas
common sx?
what does it like to produce?
scattered cells with mucopolysaccharide stroma, abnormal blood vessels, and hemorrhage - results in a pedunculated and gelatinous structure that can lead to valve obstruction
tend to occur in the LA; causes mid-diastolic rumbling best heard at apex; positional dyspnea
produces
- IL-6 –> constitutional sx (weight loss, fever)
- VEGF –> angiogenesis
MoA of somatostatin in the H-P axis
inhibits GH, TSH
a 36yo woman with 5 miscarriages, all which occured in her first trimester.
cause of her infertility?
suspect a robertsonian translocation in an apparently healthy woman who has many first-trimester spontaneous abortions
patient on anti-pyschotics develops agranulocytosis and seizures.
Rx?
clozapine
galactose ∆
blood, urine, cataracts (osmotic damage)
prevent herpes reactivation with…
daily valacyclovir after the first episode
a short course of acyclovir during the primary herpetic episode just reduces the duration of viral shedding, time for lesional healing, constitutional sx and pain
virulence factor of ALL bugs that cause increased cAMP
- b. anthracis - edema factor acts as an adenylate cyclase -> increased cAMP -> edema + phagocyte dysfunction
- bordetella pertussis - pertussis toxin disables Gi -> disinhibits adenyl cylase -> increased cAMP levels -> edema + phagocyte dysfunction
- ETEC: Heat-labile toxin activates adenylate cyclase -> increase cAMP -> increase Cl/H2O efflux
- Vibrio cholera - cholera toxin activates Gs -> increase cAMP -> increase Cl/H2O efflux
PETA-Vibes likes to cAMP
honey
spores from c. botulinum
inflammatory exudate causes rapid neutrophil chemotaxis. What signaling molecule the most responsible? Others that may play a role?
LT-**B3 **
others: 5-HETE (LT precursor), C5a
Note: LT-C4, D4, and E4 are impt for vasoconstriction, bronchospasm, and increased vascular permeability = role in pathogenesis of bronchial asthma because they cause bronchospasm and increased bronchial mucus scretion
what should you treat patients with age-related macular degeneration (AMD) with?
anti-VEGF if it’s “wet” AMD - meaning that it is due to abnormal blood vessels w/ subretinal fluid/hemorrhage, gray subretinal membrane, or neovascularization
antiarrhythmic drug that causes QT prolongation and also have ß-adrenergic blocking abilities (bradycardia)
Sotalol (other class 3 = amidarone, ibutilide, and dofetilide but these do not have ß adrenergic blocking abilities
Stretpomycin MoA
how does resistance to streptomycin develop?
aminoglycoside that binds to 30S ribosome and distorts the structure (thereby preventing bacterial protein synthesis)
resistance acquired via **ribosomal gene mutations **
acute myelogenous leukemia translocation
AML t15;17
∆ = 2 = hAMLet = 2 syllables
What about brown fat causes them to produce heat?
it contains more mitochondria and multiple intracytoplasmic fat vacuoles (compared to white fat, which only has one).
These mitochondria have electron transport and phosphorylation that is uncoupled (ie - the protons pumped out by ETC is returned to the matrix via thermogenin (uncoupling protein) and the energy released by e-transport is dissipated as heat; ø ATP is produced
bilateral lens subluxation + stroke should make you think of..
what could’ve prevented this?
homocystinuria
treatment w/ pyridoxine (B6)
drug-induced lupus is usually caused by which Rx?
Who is more likely to develop this?
**HIPP = Hydralazine, Isoniazid (INH), procainamide, phenytoin **
these are metabolized via** **hepatic **N-acetylation, **therefore slow acetylators are more likely to develop this (indicating that parent Rx are more likely culprits)
what is a glomangioma?
how does it present?
tumor of the modified smooth muscle cells of a glomus body
(glomus body = small encapsulated neurovascular organ found in the dermis of the nail bed, pads of fingers/toes/ears that is connected to a blood supply; functions to shunt bloood away from the skin surface in cold temperatures in order to prevent heat loss and to redirect blood flow to the skin surface in hot environments to facilitate the heat dissipation; ie THERMOREGULATION)
Presentation: small bluish lesion under the nail of the finger that is extremely tender to touch.
non-bacterial thrombotic endocarditis associated with disseminated cancer is termed …
marantic endocarditis
patient w/ R sided white pupillary reflex is at risk of developing what two neoplasms
Retinoblastoma
sarcomas (esp. osteosarcoma)
autism chromosome associations
15 and 11
csf culture from neonate w/ fever + poor feeding reveals GNR that forms pink colonies on macconkey agar
e. coli - contains K-1 capsular antigen
one of the main causes of meningitis in babies (*BEL*)
raltegravir
integrase inhibitor that disrupts the ability of HIV to integrate its genome into the host cell, thus preventing the host cellular machinery from being used to synthesize HIV mRNA
integrase rategravir
What are the functions of these molecules?
ICAM-1
VCAM-1
CD11/18 integrin
LFA-1
VLA-4
Intracellular adhesion molecules (ICAM) = involved in tight binding
Endothelial cells = ICAM-1, VCAM-1
leukocytes: CD11/18 integrin, LFA-1, VLA-4
leukocytes = L’A; blood vessels = CAM
what opposes insulin action?
glucagon
long-acting insulins
Glargine - 1x/day “Glarrrrrrrrrrr” = long
Detemir - 1x/day
NPH - 2x/day
common cause of Trisomy 21
non-disjunction at **maternal meiosis I **
chemoRx associated w/ leg swelling + orthopnea
doxorubicin
prevent w/ Dexrazoxane
definition of transformation
uptake of naked DNA from the environment or incorporation of viral DNA into a host cell chromosome; alters genetic composition of the host cell but typically does not cause genomic change in progeny virions
patient w/ acute intermittent prorphyria is deficient in what enzyme and has increased serum levels of..
enz: porphobilinogen deaminase
increased: ALAD and porphobilinogen
3 major causes of valvular aortic stenosis
valve w/ calcifications (ie bicuspid valve) calcified normal valve rheumatic heart disease
ELISA/WB tests in a recently acquired HIV
falsely (-)
Ependymoma
Location
Appearance
Prognosis, presentation
Ventricles, 4th -> hydrocephalus w/ drop metz to the spinal cord to form spinal ependymomas
hx: **ependymal pseudorosettes w/ GFAP processes tapering toward blood vessels **
kids dz
area implicated in hemiballism
subthalamic nucleus
(involuntary flinging movements is contralateral to the lesion)
patient with Myasthenia gravis is started on treatments and complains of abdominal cramping, nausea, sweating, and diarrhea. What can be used to control her new sx?
patient was probably given a cholinesterase inhibitor (AChEi), such as pyridostigmine and is now experiencing ADRs of excessive cholinergic stimulation.
Trmt: Scopolamine - muscarinic cholinergic receptor antagonist will reduce effects of the cholinesterase inhibitor in sites where ACh action is mediated by a muscarinic receptor (ie gut) w/o affecting the action of the cholinesterase inhibitor on skeletal muscles, which use nicotinic cholinergic receptors.
viral infections that usually show atypical (reactive) lymphocytes
atypical lymphocytes are non-specific (as are fever + joint pain), but EBV and CMV usually have the highest counts
14yoF w/ development of painful cramps in her legs during exercise. labs show no increase in serum lactate
dx and enzyme?
McArdle disease - lack of myophosphorylase (muscle glycogen phosphorylase) leads to abnormal glycogen accumulation in muscles -> painful cramps + myoglobinuria during strenuous exercise w/o an increase in lactic acid
In syringomyelia, where are the affected dermatomes relative to the actual lesion?
1-2 levels below the lesion, since first-order axons ascend slightly in the zone of Lissauer before synapsing)
in a woman who is able to conceieve but not maintain a pregnancy probably has a lab serum finding of..?
low progesterone levels - causes endometrium to atrophy and pregnancy to terminate
patient on anti-pyschotics develops weight gain.
Rx?
olanzapine
sickle cell anemia mutation
glutamic acid -> valine
vincristine affects this part of the cell cycle
common ADR of this drug?
how does vinblastine ADR’s differ (even though they have the same MoA)
M phase - prevents microtubule formation by binding to ß tubulin (therefore ø mitotic spindle) and therefore failure of division occurs
ADR: peripheral neuropathy
ADR of vinblastine: bone marrow suppression
STEMI in II, III aVF leads
inferior wall (RCA)
may cause sinus node dysfunction
loss of knee jerk is usually due to damage to which nerve?
femoral n. (L2-L4)
unlar nerve courses btwn these two structures.
injury to this nerve results in:
olecranon + medial epicondyle of humerus
injury - motor + sensory innervation to the last 1.5 fingers of the hand
what are pappenheimer bodies?
Fe containing, dark blue granules in wright stain RBC in patients with sideroblastic anemia
T/F tetanus can be confirmed by performing a serum toxin assay
FALSE!! There is no serum (or antibody) toxin assay available for tetanospasmin
Diagnosing tetanus = history & physical
defect in NADPH oxidase sequelae
chronic granulomatous disease
incr. susceptibility to catalase + organisms
how does epinephrine increase glucose?
- increased glycogenolysis and gluconeogenesis
- decrease glucose uptake from skeletal muscles
- increase alanine release from skeletal m. (subtrate for gluconeogenesis in the liver)
- increase breakdown of Tg in the adipose (FFA + glycerol substrate for gluconeogenesis in the liver)
type of diuretic that is implicated for treating HTN or CHF in a woman who is also at risk for osteoporosis
HCTZ - increases absorption of Ca in the DCT
beading along posterior aspect of the chest + lateral bowing of the legs in a 2yo boy
rickets - vitamin D deficiency - rosary chest + genu varus
histologically - there is an increase in unmineralized osteoid matrix + widening between osteoid seams
what factors reduce likelihood of gallstone formation? increase?
- reduce: low cholesterol, high level of bile salts + phosphatidylcholine
- increase: opposite of ^
brain histology - what does this person have?
Alzheimers
pol gene
HIV
contains 3 enzymes - reverse transcrpitase, integrase, and protease
when is phenylzine and tranylcypromine usually prescribed for?
MAOi - atypical depression or treatment-resistant depression
IFNg function
recruits leukocytes + activates phagocytosis
produced by activated T cells and NK cells; function to promote Th1 differentiation, induce MHCII, and activate macrophages
What is the MoA of ANP + BNP?
What factor(s) do ANP + BNP counteract?
activates guanylate cyclase, which increases cGMP; subsequently leads to vasodilation, diuresis/naturesis, and decrease in BP
endothelin, sympathetic effects, and AII
generalized edema, proteinuria, hypoalbuminemia, hyperlipidemia, lipiduria
nephrotic syndrome
prolonged exposure to loud noises can cause hearing loss due to damage of this
shearing-forces cause damage (distortion/fracture) to teh sterociliated hair cells of the organ of corti
What is a common OTC drug that patients with hyperthyroidism MUST avoid?
aspirin and ibuprofen because they displace TH from binding proteins –> worsens thyrotoxic state (acetaminophen is a-OK)
6mo F w/ seizures, diminished responsiveness + progressive blindness. PE shows no abnormalities, but fundoscopic exam shows retinal pallor except in the macular area.
D/O & Deficent enzyme?
Tay Sachs - Hexosaminidase A
TSH
in what diseases would you see an elevated AFP?
HCC
non-seminomatous testicular germ cell tumor (ie yolk sac tumor)
in what patients would you expect to see idiopathic hypertrophic subaortic stenosis?
typical sx + PE findings?
young adults - thickening of the interventricular septum at the level of the mitral valve
episodes of syncope, dyspnea, angina, dizziness, or CHF
PE: systolic ejection murmur + thrill, increased ejection fraction, impaired diastolic function
patients are often asymptomatic util they undergo sudden death, usually during strenuous exercise b/c the aortic outlet becomes completely occluded as a result of muscle contraction
excess ACh can cause
DUMBBELSS
Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Excitation of skeletal muscle and CNS, Lacrimation, Sweating, and Salivation.
phenylephrine
paradoxical effects of this?
a1 agonist - vasoconstrictor used in cases of shock or severe hypotension
can cause reflex bradycardia
F w/ bloody nipple discharge should make you think of this particular breast cancer
Intraductal papilloma - Small, usually in lactiferous ducts
what is the minimal alveolar concentration?
what is this a measure of?
concentration required to prevent movement in 50% of patients when exposed to noxious stimuli
meausre of potency: potent anesthetics have low MAC
this a.a. is a precursor for serotonin
tryptophan
prolonged bleeding time + thrombocytopenia + giant platelets
Bernard-Souiler Syndrome
Patient w/ Hodgkin lymphoma. What is the expected:
MCV
Serum Iron
TIBC
Ferritin
Anemia of chronic disease; common in patients with hodgkin’s lymphoma (or chronic infection, inflammation, cancer)
MCV = low
Serum iron = low
TIBC = low
Ferritin = normal/high
patient on anti-pyschotics develops retinitis pigmentosa
Rx?
thioridazine
patient on anti-pyschotics develops corneal deposits
Rx?
chlorpromazine
patient on anti-pyschotics develops extrapyramidal symptoms
Rx?
haloperidol
patient on anti-pyschotics develops prolonged QT
Rx?
ziprasidone
patient on anti-pyschotics gains weight
Rx?
olanzapine
patient on anti-pyschotics develops agranulocytosis + seizures
Rx?
clozapine
epinephrine binds these receptors
a1, b1, b2
patient on anti-pyschotics develops retinitis pigmentosa
Rx?
thioridazine
glutamate activates what type of receptors? be very specific
NMDA receptor - ligand gated and voltage gated channel
Composition of
hemoglobin F
hemoglobin A
F = a2g2 (Fag)
A = a2b2
what is retinopathy of prematurity?
neonatal RDS-induced retinal neovascularization (due to temporary hyperoxia as a result of oxygen therapy for RDS), followed by possible retinal detachment and blindness
what is the pathophysiology behind a bicornuate uterus? uterus didelphys?
How do these patients usually present?
bicornuate uterus = partial failure of paramesonephric duct fusion; patients have a partially septate uterus attached to a single cervix and vagina
uterus didelphys = complete “” - patients have 2 separate vaginas, cervies, and uterine horns
neurons that display cell body rounding, peripheral displacement of the nuclei and dispersion of Nissl substance to the periphery is indicative of:
- **Wallerian degeneration - **severed axon degenerates distally and axonal retraction proximally to the site of injury
- axonal reaction - cell increases proteins in an attempt to repair the axon; cell body shows signs of cellular edema (described above); usually occurs 12-48hrs post injury
congenital QT interval prolongation is generally associated with?
K channel abnormalities
neurosensory deafness (because endolymph is normally composed of high K concentrations and defects in these channels will result in abnormal endolymph production)
uniform, diffuse thickening of glomerular capillary walls on LM is seen in which renal disease?
membranous glomerulopathy - most common cause of nephrotic syndrome
flutamide
MoA
clinical use
non-steroid anti-androgen that impairs androgen-receptor interaction
prostate cancer
Physical differences btwn short stature and achondroplasia?
Short stature (∆ IGF1) - axial and appendicular skeleton are proportionately small
Achondroplasia (∆FGF-R3 at the epiphyseal plate) - appendicular skeleton is a lot smaller than the axial skeleton
FRC
what is it?
calculation?
where is this on the spirometry graph?
what is the intrapleural pressure at FRC?
point where the PVR is the lowest
tendencies of the chest wall to expand and the lung to collapse oppose one another equally
FRC = RV + ERV
Spirometry graph - at the bottom of the VT trough
intrapleural pressure at this point = -5 cm H2O
22 yo presents to the ED complaining of severe HA and vomiting; slips into coma and dies. Autopsy shows atraumatic head w/ ruptured cerebral aneurysm w/ extensive intracranial hemorrhage.
Dx?
spontaneous intracranial hemorrhage (SICH) - usually due to AVM, ruptured cerebral aneurysm, or cocaine use.
berry aneurysms are prone to rupture when there is an associated coarctation bc of HTN in the branches of the aortic arch proximal to the coarctation
Pathophysiology of Hemochromatosis
typical labs (Fe,
why do women present later?
trmt?
Hemochromatosis
AR, ø HFE (normally regulates transferrin/Fe uptake)
Labs: elevated Fe, elevated ferritin, >50% TIBC (transferrin sat.)
Classical Triad: skin pigmentation, DM (2˚ to pancreatic islet destruction), Cirrhosis
Complications: CHF, testicular atrophy, HCC
Trmt: phlebotomy, deferasirox, deferoxamine
Women tend to present later due to blood loss during menstruation + pregnancy
rapid treatment of hypoglycemia -induced loss of consciousness in a non-medical setting
IM glucagon - corrects hypoglycemia by increasing hepatic glycogenolysis and gluconeogenesis
IM injection of hypertonic glucose solutions can damage local tissues and is unpredicatable in systemic absorption
toxin responsible for producing bright red tonsils, enlarged anterior cervical LN and skin rash
SCARLET FEVER - complication of strep pyogenes - pyrogenic exotoxin
ß glucuronidase
enzyme that deconjugates bilirubin
released by damaged hepatocytes and bacteria
Violent stretch btwn the head and shoulder can result in this particular injury
ERb-Duchenne palsy
damage to musculocutaneous n. + suprascapular n. -> waiter’s tip posturing of arm (shoulder adducted, arm pronated, elbow extended)
CT findings of constrictve pericarditis
thickening and calcifications of pericardium (bright white outline surrounding heart) sx: slowly
sporangium should make you think of…
mold fungi
Diagnosis
Tzanck smear
multi-nucleated giant cells - HSV
patient w/ pulmonary mass complains of dyspnea and hiccups. Why?
pulmonary mass likely impinges upon the phrenic n. C3,4,5 resulting in hiccups + diaphragmatic paralysis w/ dyspnea
benzos that have a short half-life.
why is this impt?
Triazolam
Alprazolam
Oxazepam
“TAO”
impt for reducing daytime drowsiness/”hangover” effect that can impair judgement and concentration, and cause ataxia (increased risk of falls)
on the flip side, this can cause a makes it so that it has a higher addictive potential
What are Clara Cells and what is their role in the body?
non-ciliated, secretory cells present in the terminal respiratory epithelium; secrete stuff that inhibit neutrophil recruitment and activation
MoA of mifepristone
vs
MoA of misoprostol
**mifepristone (RU486) = progesterone receptor antagonist - results in decidual necrosis + expulsion of products of conception; **used as an abortifacient (up to 49d post-conception) since progesterone is necessary for implantation and maintenance of pregnancy
misoprostol = prostaglandin analog - causes uterine contractions + cervical dilation; also used to prevent NSAID-induced ulcer dz
don’t confuse them!!!
patient with increased susceptibility to encapsulated, pyogenic bacteria (strep. pneumo, h. influenza, pseudomonas)
Bruton X-linked agammaglobulinemia (absence of C19+)
virluence factor of e. coli that causes bloody gastroenteritis
verotoxin (shiga-like toxin) - inactivates 60S component, halting ribosomal protein synthesis and causing cell death
5yo w/ fever, abd pain, diarhea mixed w/ small amounts of blood who develops marked pallor and oliguria should make you think of…
what test is going to be abnormal?
HUS - EHEC 0157-H7
bleeding time will be abnormal since widespread capillary thrombi consume platelets (also cause schistocyte formation) -> pallor, weakness, and tachycarida (compensatory response)
thrombocytopenia -> petechiae + purpura
labs: decr. hemoglobin, hct, RBC count
labs: increased LDH and reticulocytes, bleeding time (due to reduced platelets)
labs: normal coagulation studies because there are no clotting factor deficiencies or DIC associated with HUS
chromogranin A is a marker of…
neuroendocrine cells
amlodipine
MoA
clinical use
ADR
Ca channel blocker - selective for arteriolar smooth muscle
(decrease SVR and thereby decrease afterload + cardiac work)
HTN
flushing, peripheral edema (bilateral ankle swelling)
damage to tibial n. results in..
weak plantarflexion (ie foot is held in unopposed dorsiflexion) and weak inversion of ankle (ie food is held in eversion), inability to curl toes
loss of sensation over sole of foot
damage to common peroneal n. results in..
weak dorsiflexion (ie foot drop) and weak eversion of ankle (ie food is held in inversion)
loss of sensation over dorsum of foot
primary virulence factor of s. pneumoniae?
polysaccharide capsule
IgA protease
Segmented viruses
- Bunyavirus (california encephalitis, sandfly/Rift valley fever, crimean-Congo hemorrhagic fever, Hantavirus
- Orthomyxovirus (influenza)
- Arenavirus (LCMV, Lassa fever encephalitis)
- Reovirus (rotavirus)
capable of genetic shifts through reassortment
cohort study
compares a group with a given exposure or risk factor to a group without. LOOKS TO SEE IF EXPOSURE INCREASES LIKELIHOOD OF DISEASE
why would someone with acute pancreatitis (AST156, ALT 44) have a mean corpuscular volume of 108fL?
dude likely has OH abuse (his AST/ALT ratio is >2, which is indicative of alcoholic hepatitis)
chronic alcholism -> vitamin associated deficiencies (B12/Folate) -> macrocytosis
T/F aspirin is an effective anticoagulant for DVTs
T/F aspirin is an effective anticoagulant for MIs/ischemic stroke
F
T - aspirin is commonly used in patients who have had a TIA to prevent 1˚ or 2˚ coronary artery events and ischemic strokes
MoA of TRH in the H-P axis
stimulates TSH + prolactin release
23yoF with chronic viral hepB on liver bx.
presence of which serological marker is most likely to increase risk of vertical transmission of the virus?
what should you do?
HBeAg = marker of viral replication and increased infectivity
newborns: passive immunization with HepB Ig, followed with active immunization with recombinant HBV vaccine
in SLE, how does thrombosis occur? Libman-Sack’s endocarditis?
hypercoagulable anti-phospholipid antibody syndrome
IC deposition on the cardiac valves -> fibrosis
patient started on an anti-coagulant comes in 2 weeks later complaining of this. What was this patient given and what is his problem?
warfarin
he’s probably protein C deficient - which lead him to a relatively hypercoagulable state with thrombotic occlusion of the microvasculature and skin necrosis
source of blood in lateral ventricles of a preemie
germinal matrix- highly cellular + vascularized layer of the SVZ
BV are thin and lack the glial fibers that normally support the blood vessels, thereby increasing its risk of hemorrhage
occurs only in preemies because the germinal matrix becomes less prominent and its cellularity and vascularity decrease, thereby reducing the risk of intraventricular hemorrhage
drug for patient with both absence and tonic clonic seizures
valpric acid
(ethosuximide does not effective against tonic clonic seizures)
nifedipine
moA
peripherally acting Ca channel blocker -> reflex tachycardia
histology of type I dm? type II dm?
type I - leukocytic infiltrate of the islet
type II - islet amyloid deposition (IAPP)
PKU inheritance
AR
greast risk of long-term exposure to asbestos
**bronchogenic carcinoma **- 1st leading cause of death in this population
mesothelioma - 2nd leading of death
combination of
low MCV
normal serum Fe
normal TIBC
should make you think of..
thalassemia minor or lead poisoning
N-myc is a marker of…
neuroblastoma and small carcinoma of the lung
patients on clozapine should be monitored for…
seizures
CBC - can cause agranulocytosis
(MoA: acts on D4 receptors)
but note that it is an atypical antipsychotic that is less likely to cause EPS
cytokine that inhibits Th1 cells
IL-10 (produced by TH2 cells
which organ has an O2 extraction that exceeds that of any other tissue or organ in the body?
heart - resting myocardium extracts ~75% of the O2 present in the blood, while the myocardium at work extracts up to ~90% of the O2 in the blood
prolonged bleeding after tooth extraction and surgeries can be of two things. What can distinguish between them?
can be hemophilia A or vWF d/o
Hemophilia A = spontaneous hemoarthroses, prolonged PTT
vWF = prolonged PTT and prolonged bleeding time
Prolactin in the H-P axis
what factors can stimulate its release? inhibit it?
**inhibits GnRH -> ** decreased LH/FSH/sex hormones, thereby causing impotence in M and amenorrhea in women of reproductive age; aka “hypogonadotropic amenorrhea”
it is inhibited by Dopamine, and stimulated by TRH (in cases of severe hypothyroidism)
dopmaine antagonists (bromocriptine) are used to treat prolactinomas
anti-psychotics (dopamine antagonists) - galactorrhea
Which parts of the inner ear is best suited to detect high frequency sounds? low frequency sounds?
high frequency: base of the cochlea, near the oval/round windows
low frequency: apex of of the cochlea, near the helicotrema
“It’s low-ny at the top (apex)”
(can think of the base as having a wider area = big; high,
whereas the apex has a smaller area = small; low)
Patients w/ Trisomy 21 are at increased of 3 diseases
childhood: AML-M7, ALL
adulthood: Alzheimers
how does carotid sinus massage affect PaO2 and PaCO2?
causes reflex vagal discharge to the SA node, atrial myocytes, and AV node -> HR + CO is also decreased but carotid sinus massage would not signfiicantly affect the PaO2 or PaCO2
in what ways can you think of someone with ß thalassemia major experiencing heart failure?
these patients require a lot of transfusions, resulting in an Fe overload that results in hemosiderosis that can contribute to cardiac failure
The heart is damaged by the chronic high CO state needed to compensate for the anemia.
paraneoplastic syndromes of renal cell carcinoma (2)
EPO -> polycythemia
PTHrP -> hypercalcemia
what is the scala media composed of? What does it house?
endolymph; houses the tectorial membrane + organ of corti
surgeon w/ shaky hand was trying to ligate the inferior thyroid a. and accidently severed this nerve and its innervation to these structures
recurrent laryngeal n.
innervations: all laryngeal m. (except cricothyroid) and sensory innervation below the vocal cords
endocarditis with vegetations + negative blood cultures
HACEK organisms (haemophilus, actinobacillus, cardiobacterium, eikenella, kingella)
diffuse large b-cell lymphoma translocation
follicular t14;18; 4 = “four”llicular
OR
diffuse large b-cell lymphoma t14;18 = 4 words
L atrium enlargement can result in:
L recurrent laryngeal impingement difficulty swallowing
mother dx w/ GBS - what should you do?
give INTRApartum penicillin or ampicillin
common cause of oxalate stones in an alcoholic homeless with vomiting and prolonged oliguria.
ethylene glycol
increased osmolar gap with AG acidosis
Pilocytic astrocytoma
Location
Appearance
Prognosis, presentation
Cerebellum
Cystic tumor w/ nodule on the wall; pilocytic astrocytes (GFAP +), eosinophilic rosenthal fibers
Kids
Low-grade tumor
gluteus maximus functions in
hip extension
acute intermittent porphyria can be preciptiated by which epilepsy Rx?
phenobarbital (increases GABAA action)
other ADR: sedation, cardiovascular + respiratory depression
cause of pharyngitis and myocarditis
corynebacterium diphtheriae
Name these strctures
A = globus pallidus
B = putamen
C = internal capsule
D = caudate nucleus
E = amygdala
leading cause of chronic bronchitis
smoking
kappa and delta opioid receptors
excessive stimulation results in
mioiss
dysphoria
sedation
antidepressant effects
Rx that activates PPAR-gamma is used for…?
activation of this receptor does what?
Thiazolidinediones (TZDs) - exert their glucose lowering effect by binding to PPAR-gamma receptor, thereby activating genes (ie adiponectin) involved in glucose + lipid metaolism
net: decreased insulin resistance
what dopaminergic pathway connects hypothalamus and pituitary gland? such that it allows DA to inhibit PRL secretion?
tuberoinfundibular dopaminergic pathway
G6PD inheritance
X-Linked Recessive
schoolboy acts cruelly to a girl that he actually likes
reaction formation - adoption of a behavior that is opposite to that of one’s true feelings
name this please
mucormycosis
branches at 90˚
CA-19-9
pancreas adenocarcinoma - marker for tracking tumor recurrence, but not screening
what factors act through GPCRs?
peptide hormones (glucagon, PTH, ACTH, gonadotropins)
corneal reflex involves which 2 cranial n.?
afferent: CN V1
efferent: CN VII (enters the orbit via superoir orbital fissure)
mastectomy can injure what nerve? effects of this?
long thoracic - winged scapula + inability to abduct arm above the horizontal plane
viruses with segmented genome
ROBA
rotavirus (reovirus)
influenza (orthomyxovirus)
lymphocytic choriomeningitis california encephalitis (bunyaviridae)
virus (arenavirus)
how do these viruses enter the cells?
CMV
EBV
HIV
Rabies
Rhinovirus
CMV: cellular integrins
EBV: CR2/CD21
HIV: CD4, CXCR4, CCR5
Rabies: Nicotinic ACh receptor
Rhinovirus: ICAM
treatment for OCD
TCAs (clomipramine) or SSRIs
where are there high expiratory flow rates in restrictive lung diseases?
1) low lung volumes due to increased elastic recoil pressure
2) increased radial traction on the conducting airways by the fibrotic pulmonary interstitium
location of the great saphenous vein relative to the small saphenous vein?
great = medial aspect of the leg, courses upwards medially and drains into the common femoral vein just inferolateral to the pubic tubercle
small = lateral aspect of the leg; courses posteriorly to drain into the popliteal vein
initial cellular event triggered by Digoxin
decreased Na efflux (via inhibition of Na/K/ATPase) ultimately results in AV nodal blockage
how does damage to the inferior parietal lobe of the dominant hemisphere differ than that of the non-dominant hemisphere?
- dominant = Gerstmann syndrome - R/L confusion, dysgraphia, dyscalculia, and finger agnosia
- non-dominant = apraxia (inability to execute learned purposeful movements despite having the desire and physical capacity to perform the movements), contralateral hemi-neglect
45yo w/ pelvic pain that is worse before and during menstrual period. US shows non-focal thickening of the myometrium w/ normal ovaries. Pap + bimanual exam is normal. Dx?
Adenomyosis - presence of endometrial glands in the myometrium of the uterus in addition to their normal location in the endometrium. They undergo cyclic changes w/ menstrual cycle in response to the same stimuli as the normal endometrial glands.
brain tumors that are prevalent in the adults
Schwannoma
acoustic neuroma
Glioblastoma multiforme
meningioma
Oligodendrioma
ADULTS SAG MO’
long crystals that are negatively birefringent under polarized light are of what composition?
**monosodium urate (uric acid salt) **- is what accumulates in the synovial fluid and forms crystals that deposit in the synovium and cartilage
F w/ breast pathology that looks like this. What is her diagnosis?
what other findings should you expect?
paget’s - should see eczematous patches on nipple.
cells seen are paget’s cells = large cells w/ clear halo confined to the epidermis
What is Von Recklinghausen’s disease?
NF-1 - inherited peripheral nervous system tumor
2 symptoms of CN 3 palsy
somatic:
- down and out gaze (∆ innervation to inferior, superior, medial rectus, inferior oblique)
- ptosis (∆ innervation to levator palpebrae)
parasympathetic
- fixed, dilated pupil, loss of accomodation (∆ iris sphincter, ciliary muscle)
mercaptopurine affects this part of the cell cycle
common ADR of this drug?
how is it mostly cleared?
S. phase - purine analog that inhibit de novo purine synthesis after being converted to active metabolites by HGPRT
ADR: cholestasis, hepatitis (ie abd. pain, jaundice)
mostly cleared by xanthine oxidase (since they are purine analogs) in the liver
how do central chemoreceptors differ than peripheral chemoreceptors in terms of location + what they detect?
what happens in COPD patients?
Central: medulla, detect ∆H (CO2; main stimulator of respiratory drive)
- note that chronically elevated CO2 levels result in desensitization (ie CO2 ceases to stimulate the respiratory drive) and O2 is the only stimulator of respiratory drive. Therefore giving supplemental O2 to COPD patients decrease respiratory drive, since the body thinks that there’s enough O2!!)
Peripheral = carotid/aortic bodies; detect ∆O2
HIV patient who is non-adherent with his meds have a:
- colonoscopy = reddish violet flat maculopapular lesions or hemorrhoragic nodules
- hx = spindle shaped tumor cells with small vessel
kaposi sarcoma (HHV8)
2 causes and effect of congenital torticollis
birth trauma (breech delivery)
malposition of the head in utero (fetal macrosomia or oligohydramnios)
effect: SCM injury + fibrosis; head tilts towards affected site w/ the chin pointed away from the contracture
how to destroy hepA infection?
treat w/ acid
heat to 60˚C for 1 hr
boiling for 1 minute
treat w/ diethyl ether
drying
F/O transmission = inactivated w/ water chlorination, bleach, formalin, UVR, boiling for 1 min
methods that do not work:
- drying = stable
- ø lipid soluble envelop = resitant aganist diethyl ether, chloroform
- acid = HepA can withstand the acidic gastric environment (F/O, remember?)
- Heating to 60˚C will not inactivate it
What is the Berkson’s bias?
selection bias created by selecting hospitalized patients as the control group.
how do these factors change with Bernard Soulier d/o?
Platelet Count
Bleeding time
PT
PTT
ristocetin response
Platelet Count = NC to decreased
Bleeding time = increased
PT = NC
PTT = NC
ristocetin: abnormal
34yoM asthmatic develops wrist drop. CBC shows elevated eosinophils. Dx?
Churg-strauss syndrome - p-ANCA (myeloperoxidase)
- Wrist drop - develops secondary to a radial n. mononeuropathy, polyneuropathy
- adult-onset asthma
- eosinophilia
- hx of allergy
- migratory/transient pulmonary infiltrates
- paranasal sinus abnormalities
44yo w/ nuchal rigidity. gram stain would most likely show…
lancet shaped, GP cocci in pairs = STREP pneumo
most common cause of bacterial meningitis in adults
consider N. meningitidis only in outbreaks where individuals live in close quarters (ie dorms)
cardiac findings in digeorge syndrome
tetralogy of fallot, aortic root anomalies
warfarin - what factor is most implicated in skin/subcu fat necrosis?
inhibition of protein C activity can predispose patients to warfarin-induced skin necrosis. often seen in patients with protein C deficiency
reliability vs accuracy in terms of a particular lab test
- reliability = reliable test is a reproducible test in that it gives similar results on repeated measurements
- accuracy (validity) = test ability to measure what it is supposed to measure; must be compared to the gold standard
Female that has not yet begun menstruating has a shallow vagina, no palpable uterus, palpable masses in the labia majora. What does she have?
androgen insensitivity (testicular feminization)
phenotypically female but genetically XY
(SRY -> MIF -> regression of mullerian ducts, but cells can’t respond to T which results in external female development)
what drug is used to control severe Grave’s ophthalmopathy? (edema and infiltration of lymphocytes into the extraocular muscles and CT)
glucocorticoids
definition of recombination
exchange of genes between two chromosomes by crossing over within homologous regions; genetic changes will be passed down to subsequent generations
“jaundice and exertional dyspnea” should make you think of…
A1AT deficiency
eye field looks like this:
where is the lesion?
R parietal lobe (dorsal optic radiation)
G
genetic defect that leads to diminished proliferation of chondrocytes in the growth plate of long bones
achondroplasia - constitutive activation of fibroblast growth receptor inhibits chondrocyte proliferation (∆cell signaling)–> dwarfism
indicator of severity of a mitral reguritation
presence of audible S3 - reflects an increased rate of LV filling due to a large volume of regurgitant flow re-entering the ventricle during mid-diastole
liver bx: extensive lymphocytic infiltration + granulomatous destruction of interlobular bile ducts
**primary biliary cirrhosis **
(increase serum-mitochondrial antibodies)
pruritis is often the first symptoms and may be very severe, esp at night.
hx: destruction of intralobular bile ducts by granulomatous inflammation and infiltrate of macrophages, lymphocytes, plasma cells, eosinophils
how is a non-capsule forming strain of s. pneumo able to acquire genes that encode for the capsule and gain virulence?
transformation - acquisition of genetic material following the death/llysis of neighboring bacterial cells
other bacterias have the same ability to do so:
H. influenza
Neisseria gonorrhea and meningitidis
vimentin is a marker of…
mesenchymal cells
penicillamine is used to treat what d/o?
Wilson’s disease - AR d/o characterized by toxic accumulation of Cu within organ tissues (esp of the liver, brain, and eye)
Penicillamine is basically a chelator that removes excess copper in tissues
first EKG signs of acute transmural MI
peaked T waves (localized hyperkalemia)
followed by STEMI
followed by Q waves
Weightlifter lifts a very heavy bar over his head for a few seconds and suddenly drops it to the ground. What is the physiology behind this?
Golgi-tendon organs (GTO) - receptors at the junction of muscle + tendon; innervated by sensory axons (Grp Ib)
GTOs are activated when a muscle actively contracts against resistance, results in stimulation of inhibitory interneurons in the spinal cord, which inhibit contraction of the muscle. -> results in sudden muscle relaxation (prevents damage to musculoskeletal system, esp when a muscle exerts too much force)
Piriform recess in the pharynx contains
where food is directed as the epiglottis folds down on the laryngeal opening
contains the internal laryngeal n. (br. of superior laryngeal n. of CN-X) that mediates afferent limb of the cough reflex - damage to this may result in ø cough reflex
how does an indirect/direct inguinal hernia differ in terms of the layers that encase it?
what is it caused by?
how do they each present?
indirect = Li
- covered by all 3 spermatic layers
- failure of the processus vaginalis to obliterate
- hydrocele
direct = Md
- covered only by the external spermatic fascia
- weakness of the abdominal wall/transversalis fascia (@ hesselbach’s triangle)
- buldge on the groin that increases w/ during straining
last feature to disappear along the bronchial tree
serous glands
clilia
goblet cells
mucous glands
cartilage
cilia - prevents bronchiolar mucus accumulation and airflow obstruction; persist up to the end of the respiratory bronchioles
mucus + serous glands travel within the cartilaginous plates and end at hte smallest bronchi (bronchioles lack these features)
why would someone w/ severe aortic stenosis suddenly have heart failure?
a-fib
severe AS may already have reduced CO and this may be exacerbated by the sudden loss of normal atrial contraction that contributes significantly to ventricular filling
these patients depend on atrial contraction and w/o it, LV preload can decrease to the point of producing severe hypotension.
17yo man w/ fever, sore throat, and cervical + axiallary lymphadenopathy. Dx?
infectious MONO; picture: Downey cells
note - there are multiple causes of pharyngitis, but generalized lymphadenopathy is common w/ infectious mono!!
(do not confused with smudge cells (pictured below)
pyrophosphate analog that is used to treat osteoporosis
bisphophonates - alendronate, risedronate, ibandronate
makes hydroxyapatite more insoluble; decrease bone resorption by interfering w/ osteoclasts function
*patients must stay upright for at least 30 minutes to prevent reflux because these agents can cause stomach/esophageal inflammation + erosions*
fatty streaks begin as flat yellow spots on the inner surface of the aorta. When do these normally start appearing?
in children as young as 1 years old and are present in the aortas of all children over 10
how does an AVM affect cardiac circulation?
AVM shunts blood directly from Arterioles -> Venous system (bypassing arterioles)
–> increase preload by increasing the rate and vol. of blood flow back to the heart
–> decrease afterload/**TPR **since blood is allowed to bypass the arterioles (long-term response: sympathetic activation + kidneys -> increase MSFP)
definition of uniparental disomy
when do you normally see this?
when a fetus inherits 2 copies of homologous chromosomes from ONE parent and NO copy from the other parent
ex: hydatidiform mole
c. perfringenstoxins
alpha toxin - lecithinase
causes clostridial myonecrosis (gas gangrene) - a rapidly progressive form of fasciitis that is associated with penetrating injury by soil contaminated objects
c. diff toxins
toxin A - neutrophil chemotrractant -> inflammation -> mucosal death
toxin B -> actin depolymerization -> ∆ cellular integrity, death, and mucosal necrosis
both **inactivate Rho - **involved in signal transduction and actin cytoskeletal structure maintenance -> disrupts tight junctions, leading to increased paracellular intestinal fluid secretions as well as cell rounding/retractions
which two cell types in the body can’t use ketone bodies for energy and why?
RBC - lack mitochondria
hepatocytes - lack thiophorase (succinyl-CoA-acetoacetate CoA transferase). note: ketones are produced in the liver even though they can’t use it!!
what 2 factors cause insulin resistance in overweight individuals??
FFA and serum Tg
what is the specific site in the inner ear where sound is transduced into the nervous system?
organ of corti
Role of muscle spindles?
aka intrafusal muscle fibers (connected in parallel with extrafusal fibers, innervated by grp IA and grp II sensory axons)
mediate stretch reflex (myotactic reflex) which is commonly tested via deep tendon reflexes
when a muscle is stretched, reflex activation of the a-motor neuron causes contraction to resist the stretch
Which one corresponds to this graph?
Acute GI bleed
Pyschogenic polydipsia
Diabetes insipidus
Hypertonic saline infusion
Acute GI bleed - isotonic loss of ECF volume (ø osmolarity change, therefore normal ICF and decreased ECV); aka iso-osmotic volume contraction
diarrhea would result in a similar looking graph
72 M develops hypotension during surgical repair of abdominal aortic aneurysm. What part of the large bowel is most likely to be affected?
Splenic flexture + distal sigmoid colon = both are watershed area that are most susceptible to ischemic damage during hypotension/low perfusion states
opsonic antibody
IgG - binds to Fc receptors to enhance speed of phagocytosis
saccular aneurysms
where do they occur?
why do they occur?
rupturing of these can result in?
“Berry aneurysms”
typically within the circle of willis
occur due to hereditary weakness of blood vessels (ADPKD, Marfans, Ehlers-Danlos”
subarachnoid hemorrhage (WHOML)
nitroprusside moa
venous + arterial vasodilator that decreases BOTH preload and afterload; resulting in maintained SV
ddx of mitral valve thickening w/ vegetations
infectious endocarditis
rheumatic disease
Libman sacks- endocarditis associated wtih SLE
non-bacterial endocarditis
what does this patient suffer from?
lead poisoning - basophilic stippling on a background of hypochromic microcytic anemia.
stippling = abnormal aggregation of ribosomes
hypochromic microcytic anemia = ALAD inhibition -> reduced Fe incorporation into heme -> decreased Hb synthesis
pt. w/ grayish pharyngeal exudate + enlarged cervical nodes and partial soft palate paralysis bacteria produces exotoxin - what is the MoA of this toxin?
ribosylates and inactivates elongation factor 2 (EF2)
hormone profile of PCOS in terms of
GnRH
LH
FSH
estrogen
androgens
GnRH = elevated
LH = increased
FSH = low (not enough to recruit dominant follicle)
estrogen - may be low (due to low follicular maturation) or elevated
increased androgen production
21yo M patient w/ progressive impaired balance, difficult speaking; has elevated AST/ALT. Hx is otherwise unremarkable.
Diagnosis? Labs?
Wilson’s disease
low ceruloplasmin (
increased Cu excretion
Kayser-Fleischer rings (Slit lamp examination)
18yo M suddenly collapses and dies. Autospy likely shows…
hypertrophic cardiomyopathy (esp of the interventricular septum)
(don’t confuse w/ “endocardial thickening and non-compliant ventricular walls”, which is indicative of restrictive cardiomyopathy; often leads to CHF)
agent that blocks inositol triphosphate interaction w/ its intracellular receptor would most likely decrease the activity of..?
protein kinase C
remember: PLC -> IP3 + DAG
IP3 -> Ca release from SR
DAG + Ca -> PKC activation
Describe process of B12 absorption (from the mouth -> terminal ileum)
- salivary glands secrete R protein (haptocorrin), which binds B12 (protects it from denaturation by gastric acid)
- complex reaches the duodenum, where pancreatic proteases cleave the R protein to release B12, which then binds to IF (prevents digestion in the small intestines and also facilitates its absorption in the distal ileum)
resected testes show non-encapsulated, yellow, mucinous mass w/ endodermal sinuses. Tumor marker?
AFP - this is a yolk sac tumor. the endodermal sinuses are actually schiller duval bodies
what factors signal through nuclear receptors?
thyroid hormone
retinoids
peroxisomal proliferating activated receptors
fatty acids
virluence factor of e. coli that causes neonatal meningitis
K1 capsular polysaccharide - prevents phagocytosis and complement mediated lysis
at low doses, dopamine stimulates which receptors?
high doses?
even higher doses?
- low doses: D1 receptors in renal vasculature -> increase GFR, RBF, Na excretion
- high doses: ß1 receptors in the heart -> increase contractility, PP, systolic BP
- even higher doses: a1 receptors in systemic vasculature -> vasoconstriction (-> decreased CO due to increased afterload)
doped but amped
drug that is causes disturbed color perception + its ADR (2) treatment?
digoxin ventricular tachycarrhythmias hyperkalemia trmt: anti-digoxin antibody fragments
80yo man w/
creatinine: 2.0 mg/dL
BUN: 65 mg/dL
FeNa is 4%
Diagnosis?
BPH
note that his BUN/creatinine ratio is 62/2 = ~32, which is greater than the normal 12-20 for individuals on a normal diet.
High ratios w/ elevated creatinine levels are due to POST-RENAL OBSTRUCTION, ie BPH or POST-RENAL AZOTEMIA
baby boy at 37wks gestation shows a unilateral testicular mass.
Gross Hx shows homogenous, yellow-white in color
Hx shows epithelial lined spaces w/ flattened to cuboidal epithelial cells w/ vacuolated cytoplasm containing eosinophilic, hyaline-like globules. Scattered primitive glomeruli is observed.
eosinophilic hyaline-like globules will stain for what?
**AFP + **A1AT
(indicates yolk cell differentiation)
treatment of extra-pyramidal sx (cogwheel rigidity, resting tremor, masked facies, bradykinesia) caused by first-generation anti-psychotics
anti-muscarinic Rx (trihexyphenidyl, benztropine)
DO NOT USE LEVODOPA, or BROMOCRIPTINE because it can preciptate or exacerbate psychosis, respectively
mother taking her anger out on her son, who in turns, yells at his little sister
displacement
why is it that thyrotoxicosis (thyroid storm) results in hyper-adrenergic manifestations (ie racing heart, insomnia, SOB)
TH upregulates ß adrenergic receptor expression (also reason why ß blockers are used to treat thyroid storm!!!)
tachyphylaxis - what is it?
rapidly declining effect of drugs (such as phenylephrine or NTG) after a few days of use - occurs bc of a decreased production of endogenous NE or NO from the nerve terminals due to (-) feedback mxn, resulting in relative vasodilation and subsequent edema + congestion)
patients tend to see rebound rhinorrhea, edema, congestion w/ this
stop Rx to allow restoration of normal NE/NO feedback pathways
what stain is this? what is it used for?
prussian blue stain - stains iron; used to diagnose hemochromatosis
what should one do after D&C of hydatidiform mole??
serial measurements of ßhCG levels; if elevated or rising, it may signify the development of an invasive mole or choriocarcinoma
patient with CREST is at risk for developing what?
accentuated 2nd heart sound
pitting edema
hepatomeagly
ALL BECAUSE of intimal thickening of pulmonary arterioles (due to increased collagen deposition) –> leads to narrowed lumens and increased pressure in the pulmonary circuit –> Pulm HTN –> R sided CHF
chronic myelogenous leukemia
CML t9;22
∆ = 13 = rotate the 13 90˚ = CaMeL has 2 humps on its back
Glioblastoma multiforme
Location
Appearance
Prognosis, presentation
Hemispheres (frontal, temporal, or near basal ganglia); can cross midline “butterfly glioma”
Pseudopalisading pattern = central areas of necrosis and hemorrhage (ring enhancing lesion); GFAP (+)
Adults, Poor prognosis (1 yr survival)
ascending muscle weakness after GI or respiratory infection
name of dz and common culprit
Guillain-Barre Syndrome
Campylobacter jejuni
most important hormones to replace in hypopituitarism
corticosteroids and thyroxine
MoA of hydroxyurea
increase Hg F synthesis such that it confers protection against the polymerization of sickle cells
what molecules signal through TK associated receptors?
cytokines (ie IL-2)
GH
prolactin
all act via JAK/STAT pathway
Bony metz = if osteoblastic + osteolytic, you should think of…
breast cancer
what does it mean when the arteriovenous concentration gradient of a gas anesthetic is LOW in terms of
tissue solubility
time to reach blood saturation
brain saturation
- low tissue solubility (ie a small amt of anesthetic is taken up from arterial blood, which results in high venous concentration)
- time to reach blood saturation = faster
- brain saturation = faster because of the factors above
How is copper absorbed from the body? Removed?
Ingested Cu is absorbed in the stomach + duodenum and transported to the liver, where it is conjugated w/ a2-globulin to form ceruloplasmin, which is then resecreted into plasma
Ceruloplasmin + unabsorbed Cu is secreted into bile and excreted into stool, which is the 1˚ route for Cu elimination
what should you check in a patient w/ bitemporal visual field deficits w/ a history of hypercalcemia?
pancreas tumor (MEN1) - pituitary, parathyroid, and pancreas
How do you differentiate between alkaline phosphatase that originates from the bone vs those that originate from other sources (ie placenta, liver, intestines)
heat denaturation: bone-specific AlkPhos is easily denatured by heat (bone=boil)
patient w/ thyroid that has branching papillary structures w/ concentric calcifications (psammoma bodies) w/ ground glass nuclei
papillary thyroid cancer
cleft lip and palate, polydactyly, omphalocele
Patau - trisomay 13
initial reaction to form heme involves which two substrates
glycine + succinyl CoA
catalyzed by ALAS to form d-ALA
virus that can replicate in the cytoplasm of an enucleated cell
RNA virus (poliovirus, picoRNAviridae)
bone changes consistent w/ hyperparathyroidism?
subperiosteal **thinning **w/ cystic degeneration of cortical, aka compact, bone (due to PTH-mediated osteoclast activation and resorption
amastigote
Leishmania
how does TB develop resistance to isoniazid?
- decr. expression of catalase-peroxidase enz (required for isoniazid activation)
- modification of the protein target binding site
mother also likely experienced increased facial hair growth and some voice deepening during pregnancy should make you think of…
-
aromatase deficiency - inability to convert androgens to estrogens in the gonads and peripheral tissues; infants should:
- have high levels of T/androstenedione, since they’re not converted to estradiol or estrone, respectively
- F:
ambigious or male-type genitaliaa, 1˚ amenorrhea + tall stature (E is impt for epiphyseal closure) - M: tall stature + osteoporosis
- This hormonal imbalance can cause virilization in the mothers due to transfer of the excess androgens into the maternal circulation
why is HPV 16/18 oncogenic?
produce E6/E7
E6 = binds p53
E7 - binds Rb
bilirubin can be conjugated or unconjugated.
what happens if there are excessive amounts of these?
Bonus: what D/O are these present in?
conjugated = water soluble, loosely bound to albumin and excreted in urine when present in excess
- problems w/ hepatocellular excretion of bilirubin glucuronides into bile canaliculi: Dubin-Johnson (ø), Rotor (low)
unconjugated = water insoluble; tightly bound to albumin and therefore cannot be filtered by the glomerulus and therefore slowly deposits into various tissues, including the brain (-> seizures, neurologic impairment)
- problems with conjugation of bilirubin glucuronidation: Crigler-Najjar (ø), Gilbert (low)
HLA-B27 (+) patient w/ sx suggesting ankylosing spondylitis should be continuously monitored for…
- enthesitis (inflammation at the insertion sites of tendons into bone)
- pulmonary/chest expansion - since involvement of the costovertebral + costosternal junctions may cause limited chest movements and resulting hypoventilation
- ascending aortitis - dilation of aortic ring + aortic regurgitation
NT impt for induction of REM sleep
ACh
RNA dependent DNA polymerase
what is a form that is present in humans?
aka Reverse Transcriptase
in humans: Telomerase
hypophosphorylated Rb protein does what
prevents G1 -> S transition
allows damaged cells time to repair stuff
damage to inferior gluteal n. (L5-S2) can result in what motor deficit?
impaired thigh extension
this nerve exits the pelvis through the greater sciatic foramen (below the piriformis m.)
what should you think of when a MI occurs in the setting of normal coronary arteries?
coronary arteritis
hypercoabulability w/ acute thrombosis
coronary vasospasm
thoracentesis is usually performed between which ribs
5th and 7th ribs along midclavicular line
7th and 9th ribs on the midaxillary line
9th and 11th ribs along the paravertebral line
any higher or lower, there is a risk of injurying the lung or the liver
ab with valence of 4
IgA
man loses consciousness while buttoning a tight shirt collar. what nerve is stimulated?
CN 9 - buttoning a tight shirt places external pressure on the carotid sinuses, causing the baroreceptors to react as if there is an incrase in systemic BP
Afferent fibers from carotid sinus stretch receptors (Hering’s nerv, branch of CN9) sends signals to the NST of the medulla.
type of hernia that is covered by all 3 layers of spermatic fascia
indirect inguinal hernia; passes laterally to the inferior epigastric a/v
what do you expect the testicles of someone with Klinefelter to look like?
hyalinization + fibrosis of the seminiferous tubules + subsequent lack of testosterone synthesis (ie testes are small + firm)
ø T = eunuchoid body habitus (tall, gynecomastia, ø facial/body hair, low muscle mass)
how does a femoral hernia occur?
protrudes through the femoral ring, medial to the femoral vessels (NAV-L) and inferior to the inguinal ligament. Patients see a “tender buldge below the inguinal ligament, and just lateral to the pubic tubercle)
common in women
because the femoral canal is small, femoral hernias are prone to incarceration (can’t be reduced and cause N/V, abd pain, distension) and/or strangulation (leading to ischemia and necrosis)
nitrates have a paradoxical effect - what is it?
what drugs are effective in preventing this?
nitrates cause arteriolar + venous vasodilation -> decreased BP -> the body senses this and produces a reflex tachycardia via catecholamines, thus increasing mVO2.
prevent by giving ß blockers to slow conduction through AV node and cardiac conduction system by preventing catecholamines from stimulating ß1 receptors
can also use diltiazem or verapamil since they can also slow AV nodal conduction
depolarizing neuromuscular junction blockers?
non-depolarizing neuromuscular junction blockers?
what does this all mean?
both can be reversed by:
depolarizing
- succinylcholine - strong ACh receptor agonist
- produces sustained depolarization; prevents muscle contraction
- antidote
- phase I - none
- phase II - AChEi
- ADR: malignant hyperthermia, hyperCa, K
non-depolarizing
- pancuronium and tubocuarinine -
- competitive ACh-R antagonist*
- antidote: Neostigmine (AChEi), edrophonium, AChEi
Pneumocystis infx + chronic mucocutaneous candidiasis indicates this
underlying T cell deficiency (ie SCID)
newborn born at 37wks has puple splotches on the skin, hepatosplenomeagly, and jaundice. CT shows periventricular calcifications. Diagnostic test?
CMV
note that retinal inflammation, sensorineural deafness, and microcephaly are common manifestations
can cause mono-like sx, but the heterophile test is negative (unlike that of EBV)
white cottage cheese-like discharge. Culprit?
candida albicans
drugs that can cause nephrogenic DI
lithium
demeclocycline (ADH antagonist)
how does KI administration prevent thyroid absorption of radioactive iodine isotopes?
competitive inhibition, resulting in less radioactive material entering the thyroid, there therefore reduce the amount of tissue damage
kneeling all day is expected to result in…
pre-patellar bursitis “housemaid’s knee”
common in roofers, plumbers, and carpet layers
prophylaxis for meningococcal meningitis in patients who have come in close contact with a patient with active disease
**Rifampin **
(NOT vaccination)
ribavirin
MoA
clinical use?
what is it normally used in conjunction with?
nucleoside analog that inhibits synthesis of guanine nucleotides, thereby intefering w/ the duplication of viral genetic material via several mechanisms
used in chronic HepC (adults) and RSV (viral bronchiolitis in
HepC used in conjunction with IFNa
release of thyroid hormone is regulated through (-) feedback inhibition by….
T3 on hypothalamic TRH-secreting neurons and thyrotroph cells of the anterior pituitary
why is only physostigmine used to reverse atropine OD while neostigmine and edrophonium, both with the same MoA, are not?
physostigmine is the only one that can cross the BBB to alleviate teh CNS sx (psychosis, delirium)
Which pathogens produce factors that inactivate 60S ribosome by removing adenine from the tRNA, thereby preventing binding of tRNA?
Shigella and EHEC 0157:H7
You’re performing an eye exam on a patient and notice this. What d/o does this patient have?
NF-1 (von Recklinghausen disease)
these are lisch nodules (iris hamartomas - asymptomatic)
manifests w/ skin nodules (neurofibromas that contain schwann cell proliferations), cafe-au-lait macules, axially freckling
AD - 100% penetrance, variable expression
what is PEG used for?
osmotic laxative
others: MgOH, Mg Citrate
patient receiving broad-spectrum for extended periods of time are at risk of what and why?
blood in stool because vitamin K is made by bacteria in the gut
c. diff
adjustable gastric band (around cardiac part of stomach) must pass through which of the following ligaments?
what is contained within this particular ligament?
lesser omentum - dbl layer of peritoneum that extends from the liver to the lesser curvature of the stomach (divided into hepatogastric + hepatoduodenal ligament)
contains portal triad
pathogenesis of ascites in patients with cirrhosis (2)
- mechanical compromise of portal vein flow by fibrotic tissue -> increased hydrostatic pressure
- decreased systemic perfusion pressure -> RAAS activation -> avid Na/H2O retention
therefore the treatment for ascites secondary to cirrhosis is actually furosemide + spironolactone
What is the metabolic profile of patients with osteoporosis like for
Ca
PTH
Phosphorus
all normal b/c osteoporosis is generally due to micro-architectural deteriorartion of bone tissue, resulting in decreased bone strength
F w/ gray discharge
think bacterial vaginosis due to gardnerella vaginalis, usually has fishy odor + Clue cells (epithelial cells covered w/ garnerella bacteria)
what does a persistence of HBsAg and HBeAg over a long window period indicate with low to moderate levels of anti-HBcAg IgG + no detectable anti-HBsAg indicate?
acute hepB that progressed to chronic hepatitis with HIGH infectivity
crytococcus primary site of entry
lungs
23yoF w/ who developed irregular menses after having normal menses, negative pregnancy test, normal pelvic exam.
What does she have and what test will confirm diagnosis?
anovulation - likely cause of dysfunctional uterine bleeding (due to an interruption of the normal sequence of the follicular and luteal phases of the menstrual cycle)
preogestin challenge - causes breakthrough bleeding and can be used to confirm anovulation
isolated epithelial cells in crypts with fragmented, hyperchromatic nuclei and small discrete blebs containing both cytoplasm + nuclear fragments
apoptosis
GVHD
menstruation
embryogenesis
several episodes of migratory thrombophlebitis involving various sites in both arms + legs should make you think of….
Trousseau sign
(lung adenocarcinoma or pancreatic carcinoma)
adenocarcinomas produce thromboplastin-like substance that is capable of causing chronic intravascular coagulations that are both disseminated + tend to “migrate” -> produces redness + tenderness on palpation of extremities
could also be small vessel hypersensitivity type of vasculitis
palpitations that start/stop abruptly
suspicions: abnormal conduction pathway in the patient that bypasses the AV node
affects which part of the EKG?
Wolf-Parkinson-White
accessory pathway: Bundle of kent - allows recurrent temporary tachyarrhythmias by “pre-exicting” the ventricles ahead of the normal conduction pathway and results in:
- shortened PR interval
- delta wave (early upslope of each QRS complex)
- widened QRS complex - which conversts to a narrow QRS during tachyarrhythmias bc the accessory pathway no longer pre-excites the ventricles, but instead forms a re-entrant circuit back to the atria
Which one does this graph represent? (choose one)
Aortic insufficiency
Aortic Stenosis
Mitral Stenosis
Mitral regurgitation
Mitral Stenosis
what should patients be tested for prior to starting methotrexate or leflunomide?
baseline LFTs since hepatoxocity is a major ADR of these agents
Interpret this:
HBsAg negative
anti-HBc negative
anti-HBs negative
Susceptible
musculocutaneous nerve courses directly between these two muscles
injury to this will result in:
biceps brachii and coracobrachialis
injury: paralysis of biceps + brachialis = inability to flex arm
agratroban MoA and use
other Rx in the same class?
inds to thrombin active site directly and inhibits its function
use in treatment of HIT or patients w/ established HIT
other Rx in the same class: hirudin, lepirudin, and agratroban
NF-kB stimulates what?
cytokine production in immune response against infectious pathogens
where are ethmoid air cells located?
medial to the orbit
Omalizumab
MoA and use
mAb that prevents IgE binding to mast cells
use: allergen-induced bronchial constriction; uncontrolled severe allergic asthma
interpret this
HBsAg positive
anti-HBc positive
IgM anti-HBc positive
anti-HBs negative
Acutely infected
∆ btwn Mallory bodies and Councilman bodies?
what do they lookl ike on histology?
Mallory - intracytoplasmic; damaged cytokeratin filaments
Councilman - extracellular; apoptosed (shrunken) hepatocytes
BOTH eosinophilic
62F w/ cough, dyspnea + CXR w/ pulmonary infiltrate
Hx shows columnar mucin secreting cells that fill alveolar spaces w/o invasion of stroma or vessels
Bronchioalveolar carcinoma - subtype of lung adenocarcinoma.
arises in the periphery; multifocal
what should you suspect if the pH of 7.xx is less than PCO2=xx?
that there is a respiratory failure (or lack of respiratory compensation to some metabolic disease); normally the last two letters should be relatively the same
tat and rev genes
genes required for HIV replication
tenderness in anatomic snuff box - why does this usually occur and what should you worry about
cause: falling on an outstretched hand -> fracture of scaphoid bone
concern: avascular necrosis of the scaphoid bone (due to how the blood supply is oriented
median nerve courses between these two muscles in the forearm and in between these two muscles in the arm
denervation results in…
forearm: biceps brachii and brachialis
arm: flexor digitorum superficialis and flexor digitorum profundus
denervation = ape hand deformity” + loss of sensation on the palmar surface of the first 3 1/2 fingers
which two drugs has the highest risk of causing drug-induced lupus?
How do you tell that apart from actual SLE?
Procainamide, hydralazine
DIL + SLE both have (+) ANA and (+) anti-histone antibodies
but unlike SLE, anti-dsDNA are not seen in DIL
sharp mid-chest pain that increases w/ deep inspirations and decreases when sitting up
what physical findings are associated with this?
acute pericarditis - presence of friction rub
manuevers decrease the pressure on the parietal pericardium
eye field looks like this:
where is the lesion?
partial lesion in the retina, optic disk, optic nerve
A
trigger words: painless homogenous testicular enlargement
seminoma - placental ALP
patients w/ cirrhosis - what are 3 indicators of poor prognosis?
basically things that measure the liver’s functional reserve:
albumin levels
Prothrombin time (PT)
bilirubin levels
when ATP attaches to the sarcomere, _________
if ATP is not available, _____________
when ATP attaches to the sarcomere, myosin head deatches from the actin filament and then it energies a conformational change in that resets the myosin head to “contract’ again the next time it binds to actin
if ATP is not available, the actin/myosin cross-bridge will persist, resulting in rigor mortis
muromonab MoA + clinical uses
anti-CD3 mAb that inhibits T cells
treatment of acute rejection in patients w/ kidney, heart, and liver transplant
IgG4 antibodies to phospholipase A2
membranous nephropathy
T/F cardiac myocytes can divide in response to increased mechanical loads
F - cardiac myocytes are terminally differentiated cells and can no longer divide. They respond to increased mechanical loads by undergoing hypertrophy (increase sarcomere content and volume of individual ventricuar myocyte)
eye field looks like this:
where is the lesion?
R primary visual cortex (occipital lobe); usually due to posterior cerebral artery occlusion; macula spared due to collateral blood flow from the choroid arteries (middle cerebral arteries)
H
S-100
marker for melanoma, neural-derived tumors, and astrocytomas
drug used to lower intraocular pressure in glaucoma
carbachol
pilocarpine
leucovorin - when is it used?
prevent ADR of MTX
prednisone causes an increase in protein synthesis where? why?
LIVER - stimulate gluconeogenesis + glycogenesis (increase reserves in times of stress)
(note that it antagonizes action of insulin in muscle and adipose, thus favoring catabolism in these tissues, which provides substrates for the anabolic reactions in the liver. Results in
- skin thinning
- muscle weakness
- impaired wound healing
- osteoporosis
- immunosuppression
how does celiacs lead to rickets or osteomalacia?
How does it affect serum Ca, serum PO4, serum PTH?
atrophic intestinal mucosa -> malabsorption of vitamin D, Ca, PO4
low vitamin D -> impaired Ca/PO4 absorption from GI, impaired Ca absorption from kidneys, impaired excretion of PO4
low Ca -> increased PTH
- net:
- serum Ca = decreased
- serum PO4 = decreased
- serum PTH = increased
2 diseases that we’ve learned of that have strawberry tongues
scarlet fever (pyogenes)
kawasaki disease
also Toxic shock syndrome
most likely outcome for HepB infection? HepC?
- HepB: acute hepatitis w/ complete resolution (>95% of cases)
- HepC: acute hepatitis that develops into stable chronic hepatitis (55-85% of patients)
sabouraud’s agar is used for..
culturing coccidioides immitis
triad of - non-gonococcal urethritis - conjunctivitis - arthritis
reactive arthritis
potency of inhaled anesthetic is determined by?
minimum alveolar concentration
potency = 1/mac
the lower the MAC, the more potent the anesthetic
common side effect of HIV protease inhibitors
- lipodystrophy - fat redistribution from extremities to the trunk
- hyperglycemia, hyperlipidemia, and hyperinsulinemia (likely due to impair hepatic chyloµ uptake and Tg clearance)
- nephropathy
- hematuria (indinavir)
best treatment for
- vascular diseases (coronary, peripheral, and cerebrovascular disease)
- percutaneous coronary intervention (PCI)
- treatment of unstable angina and non-Q wave MI
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clopidogrel - inhibits ADP mediated platelet aggregation
cryptorchidism - how does it affect
sperm count
FSH
LH
inhibin
Testosterone
cryptorchidism (undescended testes) - if not surgically moved to the scrotal sac, the seminiferous tubules can become atrophic/hyalinized over time, resulting in:
sperm count - decrease
FSH - increase (loss of neg. inhibition by inhibin)
LH - normal
inhibin - decrease (due to eventual loss Sertoli cells)
Testosterone - normal
pheochromocytoma treatment
alpha blocker (phenoxybenzamine) BEFORE ß blocker to avoid HTN crisis
on a cellular level, how does hepB virus cause hepatitis?
presence of viral HBsAg and HBcAg on the cell surface stimulates the host cytotoxic CD8+ T cells to destroy infected hepatocytes
Based on the RFLP, at which stage did the non-disjunction occur?
Maternal meiosis I
Maternal meiosis II
Paternal meiosis I
Paternal meiosis II
Paternal Meiosis I
upper band = mother
middle + lower bands = father
treatment for nephrogenic DI
HCTZ
indomethacin
amiloride
hydration duh…
PKU - what a..a becomes essential?
tyrosine (since it can no longer be synthesized from phenyalanine)
IL-10 function
anti-inflammatory function by limiting the production of pro-inflammatory cytokines (ie IFNg, IL2, IL3, TNFa)
produced by macrophages and Th2 cells
what exits the jugular foramen?
IX, X, XI, jugular v.
dead pt w/ alveolar cells containing golden cytoplasmic granules that turn dark with Prussian blue staining
granules can be lipofuscin or hemosiderin, but prussian blue stain indicates that it is Fe - hemosiderin.
its presence in lung parenchyma indicates increased intravascular pressure that caused RBC to leak from congested capillaries, phagocytosed by alveolar macrophages and converted into hemosiderin “heart failure cells” - associated w/ chronic L heart failure
renal: effect of cholera in the small intestines
massive loss of ISOtonic fluid from the GI - decr. in EC volume without significant effect on the IC volume
fracture at the junction of frontal, parietal, temporal, and sphenoid will sever this artery
middle meningeal a. (br of maxillary a.) - can cause an epidural hematoma
site: pterion
low-pitched holosystolic murmur best heard at the L sternal border w/ accentuation during the hand-grip exercise
VSD accentuated because it increases afterload, which results in an increased movement of blood from the LV to RV (across the VSD)
patient w/ lung transplant complains of fatigue and exertional dyspnea. lung bx shows fibrotic obstruction of terminal bronchioles. Why?
chronic rejection - affects the small bronchioli producing the obstructive lung disease “bronchiolitis obliterans” - lymphocytic inflammation of the bronchiolar walls leads to the development of granulation tissue that is later replaced by connective tissue
F w/ purulent discharge
(has been described as white, or yellow-green on Uworld)
N. gonorrhoeae or C. trachomatis
usually accompanied w/ cervicitis, can progress to PID
conversion disorder
how does it differ from somatization disorder?
voluntary motor or sensory functions that are unexplained by any medical condition; often precipitated by psychological stressors
somatization = multiple physical complaints before 30yo, including 4 pain sx, 2 GI sx, 1 sexual sx, and 1 pseudoneurological sx
pathogenesis + biochemical abnormality in Alzheimers
conversion of ß-amyloid from an a-helical configuration -> ß-sheets, which are less soluble and more prone to aggregating and subsequent formation of extracellular senile plaques
decr. ACh in the hippocampus (impt for new memories) + nucleus basalis (impt for memory + cognition)** **due to deficiency of choline acetyltransferase
metformin
MoA
clinical use?
contraindications?
what should patients on metformin be monitored for every year?
clinical use: Type II DM
MoA - increase sensitivity of target tissues to insulin
ADR: GI upset + **lactic acidosis **
CI: **renal failure **or any situtation that my preciptate lactic acidosis:
- liver dysfunction
- CHF
- OHlism
- sepsis
therefore all patients on metformin are monitored yearly for creatinine
what enzyme is responsible for allowing patients with ∆fructokinase to be able to allow dietary fructose to enter the glycolytic pathways?
Hexokinase
6 day old infant with (+)HBsAg + HBeAg.
risk of chronic infection?
viral replication rate?
histologic findings of live injury?
how did this happen?
high, high, mild
vertical transmission occurs via passage of fetus through birth canal or transplacental
mild because the HBV is not inherently cytotoxic and the neonates immune system is still immature. But since they’re at risk of chronic dz, they can progress to cirrhosis and/or HCC
Which part of the nephron does renal cell carcinoma arise from?
Most common metz site of renal cell carcinoma?
Origin: renal tubular cells
Metz: lungs
LH, FSH, estradiol, and estrone in anorexic women?
ALL LOW
Why?
% body fat decreases –> estrogen low –> cyclic LH surge does not occur –> hypogonadoic amenorrhea
patient with recurrent episodes of SOB + wheezing has a CBC that shows eosinophilia. Best Rx?
atopic (extrinsic allergic asthma) - mediated by LTs and ACh
treat w/ zafirlukast + montekast to reduce LT synthesis by mast cells, eosinophils, and basophils, etc that infiltrate the bronchial mucosa in asthmatics
long term OH uses causes what in the CNS
treatment?
downregulaton of GABA receptors
inhibits NMDA receptors, leading to upregulation of these recepotors
increase NE, 5HT, and DA
all lead to tolerance - which cause withdrawal sx “Delirium tremens” =“shakes”/tremors, autonomic dysfunction, anxiety, agitation
trmt: benzos
5yo w/ acute colicky abd. pain + loose stools has ∆ mental status, urinated once in the past 10 hrs and urine was red in color; conjunctival pallor. Dx?
HUS
triad of anemia, thrombocytopenia, acute renal failure
T/F - ejection fraction is preserved in diastolic dysfunction.
TRUE because diastolic function is a matter of decreased ventricular compliance rather than impaired myocardial contractility. Therefore EF and LV-EDV is normal but LV-EDP is increased
what is CEA level used for?
sensitive indicator of CRC recurrence - measure preop and at regular intervals post-op
CANNOT BE USED TO DIAGNOSE CRC…
duh
artificial active immunity vs artificial passive immunity
artificial active - stimulus (vaccination with an antigen) was medically applied
artificial passive - stimulus (vaccination with an antibody) was medically applied
oocyte surrounded by several layers of follicular cells with a small antrum
secondary follcile
F w/ yellow-green foamy, foul smelling discharge
trichomonas - flagellated protozoan
gangciclovir
clinical use
ADR
CMV-induced retinitis
severe neutropenia
ADPKD pt w/ blood in subarachnoid space complains of weakness in in his R arm and leg 5 days after the incident. What would’ve prevented this?
Ca channel blockers,esp Nimodipine can prevent cerebral vascular spasms following SAH.
(cerebral vascular spasms occur due to degradation products of blood clots)
what causes hypoglycemia in both a diabetic and non-diabetic
exercise
anaphylaxis to a particular drug - what is most likely to be elevated in the serum
tryptase - released by mast cell degranulation
woman with nipple inflammation, pigmentation and eczematoid changes are at risk of..?
paget disease - presence of individual adenocarcinoma cells within the squamous epithelium of the skin near the nipple.
respiratory symptoms in an HIV patient
pneumocystis jirovecii (CD4
Aa-gradient calculation
Aa = PAO2-PaO2
PAO2 = 150 - (PaCO2/0.8) = (FiO2 * (PB-PH2O)) - PaCO2/R)
PaO2 = usually given
what should you suspect in a smoker w/ chronic bronchitis with recent onset of confusion, high fever, water diarrhea, and a mildly productive cough. Sputum gram stain shows numerous neutrophils but ø bacteria. What test should you perform?
Legionella - GN and facultative intracellular
perform urine antigen test
areas of the kidney that is most susceptible to injury in ATN
PCT and LOH
(NOT renal papillae - necrosis in this area is usually associated with DM, analgesic nephropathy, sickle cell disease)
pulsus alternans
LV dysfunction - beat to beat variation in the magnitude of pulse pressure in the presence of a regular cardiac rhythm
which two drugs are strongly associated with fat-redistribution from the extremities and gluteal region to the abdominal viscera (trunk) and neck (buffalo hump)
glucocorticoids
HIV - protease inhibitors (-navirs)
aortic valve calcifications can be associated with what heart sounds?
mid-systolic click followed by creschendo/decreschendo mumur
S4 - due to chronically elevated LV pressures +/- systemic HTN
how does taking NTG help with angina?
ADR?
it acts primarily as a _veNo_dilator (ie decrease in LV volume), causing a decrease in cardiac work and decreasing their symptoms
ADR: throbbin HA + cutaneous flushing (due to vasodilatory properties)
mid-humerus fracture can injure which nerve?
radial n. damage - can result in wrist drop (inability to extend the hand)
nevirapine, efavirenz, delaviridine
NNRTI - non-nucleoside RT inhibitors that do not require activation via intracellular phosphorylation
ADR: abrupt flu-like sx, abd pain, jaundice, fever (life-threatening hepatic failure w/ encephalopathy), SJS
What is acute calculous cholecystitis?
how does this happen?
how is the diagnosis made?
acute inflammation of the gallbladder
initiated by the obstruction of the gall bladder neck or cystic duct; stones disrupt the protective mucus layer, leaving the epithelium exposed to the detergent action of the bile salts. Prostaglandins released in the GB wall further incite inflammation of the mucosa and deeper tissues, and GB hypomotility ensues
increasing distension + internal pressure within the GB eventually results in ischemia. Bacteria then invades the injured and necrotic tissue, causing an infection
What is acute acalculous cholecystitis?
how does this happen?
how is the diagnosis made?
acute inflammation of the gallbladder in the absence of gallstones; common in the hospitalized and severely ill
thought to arise secondary to GB stasis and ischemia, which causes inflammation of and injury to the gallbladder wall
US: signs of acute cholecystitis (edematous and enlarged GB) and no gallstones
cause of tenosynovitis and pharyngitis
neisseria gonorrhoeae
tongue innervation
sensory
motor
taste
somatic sensations (pain, touch, temperature, pressure)
- anterior 2/3: CN V<strong>3</strong>(lingual branch) 5=S
- posterior 1/3: CN 9
- posterior area of the tongue root: CN 10
taste
- anterior 2/3: **CN 7 **(chorda tympani) 7=T
- posterior 1/3: CN 9
- posterior area of the tongue root: CN 10
motor
- CN 12 (except palatoglossus m., which is innervated by CN 10)
ANP’s actions
peripheral vasodilation increased urinary excretion of Na/H2O
how does e. coli transfer plasmids from one bacteria to anotehr?
conjugation
occurs via pili (often transfers genes for antibiotic resistance)
woman w/ ketosis, hypoglycemia, and increased serum levels of propionic acid. what enzyme is inhibited and what a.a. contributes to this patient’s condition?
∆ propionyl CoA carboxylase - converts propionyl CoA -> methylmalonyl CoA
catabolism of isoleucine, leucine valine, threonine, and **methionine **contributes to this problem
“I Love Vermot Maple Trees”
(underline - branch chain a.a. involved in maple syrup urine disease)
endocarditis after prosthetic valve placement
s. epidermidis
carbon tetrachloride - what does it do?
toxic substance that causes free radical damage. How?
it gets metabolized by P450 in the liver, resulting in the formation of a free-radical CCL3 which reacts w/ structural lipids of cell membranes (**lipid peroxidation) –> fatty change and hepatocyte necrosis **
Epileptic patient w/ bipolar d/o complains of a “lump” on her neck; admits to feeling “hot” from time to time.
PE shows generalized lymphadenopathy.
Rx responsible for this and its MoA, ADR
phenytoin - reduces ability of Na channels to recover from inactivation -> increases refractory period, thereby inhibiting neuronal high-frequency firing
ADR: hirsutism, coarsening of facial features, acneiform skin rash, gingival hypertrophy, generalized lymphadenopathy
macroorchidism
fragile X
affected individuals also have tall stature, large ears, long face, and mental retardation
carcinoid syndrome
labs?
typical presentation?
excess production of 5-hydroxytryptamine
facial flushing, bronchospasm, diarrhea
somatostatin analog (octreotide) or resection
bone changes consistent w/ osteoporosis
trabecular thinning w/ fewer interconnections; total bone mass is decreased, normal bone architecture is disrputed
box-car shaped bacterium
anthrax
tensor veli palitini and stylopharyngeus is derived from
4th pharyngeal arch
fragile x syndrome genetic finding
trinucleotide repeats
cauda equina syndrome (saddle anesthesia + loss of anal wink) affects which nerve roots
S3, S4 (winks galore)
aspirin alternative
clopidogrel - blocks ADP receptors on platelets and is just as efficacious as aspirin in preventing thromboembolic disease
T/F PPV and NPV are not influenced by disease prevalence
False. PPV and NPV are influenced by disease prevalence but specificity and sensitivity are not.
32yo F w/ hx of osteocarcoma presents w/ malignant breast mass. Family hx is (+) for brain tumors, rhabdomyosarcomas.
This story should make you think of…
Li-Fraumeni syndrome
- mutation of P53, which makes one genetically predisposed to early development of cancers
- family hx is usually positive for multiple cancers
- autosomal dominant inheritance.
acute lymphoblastic leukemia translocation
ALL t12;21
∆ = 9 = bALLerina has 9 letters; kids do ballet = kids dz.
corynebacterium diphtheriae virulence factor has the same mechanism as..di
c. diphtheriae - diphtheria toxin
pseudomonas aeruginosa - exotoxin A
both inactivate EF-2 via ribosylation
this particular vitamin has been shown the inhibit mycolic acid synthesis in mycobacterial cells
Vitamin B6 - remember that it is chemically related to isoniazid, which functions to inhibit mycolic acid in mycobacterial cells
4 tumors associated w/ AFP
HCC
yolk sac tumors
Teratoma
Embryonal carcinoma
30yoM w/ exertional calf pain + painful foot ulcers demonstrates hypersensitivity to intradermally injected tobacco extract.
Dx?
hx?
sx?
Buerger’s dz
hypersensitivity to a component of tobacco smoke
hx: segmental vasculitis extending into contiguous veins and nerves
sx: intermittent claudication + Raynaud’s, later: ulceration/gangrene toes, feet, fingers
MoA for diazoxide
blocks closure of K channels on pancreatic ß cells –> hyperglycemia (due to ø insulin release)
desmopressin
ADH analog - desmopressin treatment for central DI
Purpose of liver sulfate conjugation (Phase II)?
metabolic pathway that transforms drugs into more polar drugs that can be excreted (ie phenol + chloramphenicol)
difference between theca interna vs theca externa?
interna = cells that convert cholesterol -> T under the influence of LH
externa = connective tissue capsule
two studies - one with a p value of 0.03 and a second study with a p value of 0.07 - what should you conclude about the second p value if no other information is given? bastards….
problem with sample size - if the sample study of the second study is small, then it is underpowered to detect a difference in outcome between HRT treated and untreated patients.
patient w/ hypochromic megaloblastic anemia + very high urine orotic acid secretion
diagnosis?
treatment?
orotic aciduria - ∆ in UMPS (orotidine phosphoribosyl transferase and orotidine-5-phosphate decarboxylase)
trmt: **uridine **(inhibits CPS II)
F w/ frothy yellow-green malodorous discharge with reddening of the cervix mucosa. Culprit?
Trichomonas vaginalis - flagellated protozoa w/ corkscrew motility
T/F Black females have lower bone densities than caucasian females.
FALSE.
Blacks actually have higher bone densities than caucasian females.
Why do we care? dunnoooo
prophylaxis in a pregnant woman patient with HIV
ADR?
nucleoside analog zidovudine (ZDV, AZT) - inhibits reverse transcriptase (NRTI); lacks 3’OH group, thereby preventing transcription once its incorporated into the chain
ADR: bone marrow toxicity->anemia
how do L sided colon cancers present? R sided colon cancers?
- L side:
- tend to infiltrate the intestinal wall + encircle the lumen.
- sx of partial intestinal obstruction. change in stool caliber, constipation, cramping abd. pain, abd distension, nausea, vomiting
- R side:
- tend to grow as exphytic masses; don’t tend to develop intestinal obstruction because the lumen is larger on the R than it is on the L.
- sx of IDA due to ongoing blood loss (anorexia, malaise, weight loss)
which of these drugs would account for these changes?
isoproterenol
atropine
phentolamine
propranolol
atropine
NE
agonist = NE = raises BP via vasoconstriction. Decreased HR is a compensatory response via baroreceptor reflex.
antagonist = atropine = blocks muscarinic receptors; will HR via M2 receptors in SA node (due to removal of parasympathetic tone) has no effect on BP
administring NE after atropine will still lead to a1-vasoconstriction (incr. BP), but atropine is still blocking the muscarinic receptors in the SA node when NE is administered, therefore NE actions on ß1 receptors on the SA node act to increase HR.
isoproterenol = ß agonist - would decrease in BP via vasodilation
phentolamine = a-antagonist - decreases BP by blocking sympathetic tone to arterioles.
Propranolol = ß antagonist - small decrease in BP and decrease in HR
FYI - when looking at drug traces, always look at BP first, then HR second since BP will be due to a direct effect on blood vessels and and changes in HR may be due to either a baroreceptor effect or direct effect on the heart.
3 ß blockers w/ intrinsic sympathomimetic activity
in what patient population are they contraindicated in?
acebutolol
penbutalol
pindolol
that are not recommended for patients w/ angina
3 common causes of acute pancreatitis?
labs?
complications?
common causes: gallstone + ethanol + HyperTg
labs: increase amylase, lipase, diffuse fat necrosis + **calcium deposits **(-> hypocalcemia), fat malabsorption
complications: pancreatic pseudocyst - proteolytic enzymes may disrupt the walls of the pancreatic ducts and cause leakage of the pancreatic secretions into the peripancreatic space –> results in collection of fluid rich in enzymes and inflammatory debris. Walls consist of **granulation tissue and fibrosis **(not epithelium)
common causes of chronic pancreatitis?
labs/findings?
complications?
common causes:** ethanol abuse**
labs: amylase and lipase may or may not be elevated
findings: atrophied/calcified pancreas
complications: pancreatic insufficiency - steatorrhea, deceased DEAK, DM, pancreatic aenocarcinoma
thiamine particpiates in these 4 reactions
transketolase (PPP)
pyruvate DH
a-KG DH (TCA)
a-ketoacid DH (branched chain)
faintly erythematous macules on the abdomen, fever, abdominal pain, diarrhea
Tyhoid fever (Salmonella typhi)
macules are actually called “rose spots”
glucocorticoid administration will increase
- which cells in a blood cell count?
- protein synthesis in which organ?
- neutrophils - glucocorticoid administration results in demargination of leukocytes previously attached to vessel wall
- liver - esp enzymes involved in gluconeogenesis + glycogenesis (contributes to the development of hyperglycemia
mAb that blocks CD21 on B cells can prevent infection by which virus?
EBV - its glycoprotein binds to the cellular receptor for the C3d complement component (CR2 or CD21). CD21 is present on the surface of B cells AND nasopharyngeal epithelial cells
how do these factors change with Hemophiliac A d/o?
Platelet Count
Bleeding time
PT
PTT
clotting factor
Platelet Count = NC
Bleeding time = NORMAL (differentiates it from vWF, which is increased!!)
PT = NC
PTT = increase
Factor 8
*also presents w/ hemoarthroses*
osmotic fragility test is used for..?
hereditary spherocytosis
oocytes in ovaries are in which phase of meiosis?
oocytes after ovulation?
oocytes in ovaries = 1˚ oocyte = prophase of meiosis I
FSH stimulation during ovarian cycle causes some oocytes in the ovaries to complete meiosis I, forming secondary oocytes (+ polar bodies), which begin meiosis II but halts in metaphase.
oocytes after ovulation = 2˚ oocyte = metaphase of meiosis II
remains in this phase until fertilization occurs, at which point it divides into a mature oocyte (+2nd polar body)
resting membrane potential is determined by
permeabiilty to K+ via leak channels
what do eosinophils produce to help defend against worms?
limit reactions following mast cell degranulation?
worms defense: major basic protein
limit mast cell degranulation: histaminase and arylsulfatase
muscles used when sitting up from supine position sans hands
external abd. obliques
rectus abdominis
hip flexors (iliopsoas)
isoniazid
MoA
how does resistance to this drug occur?
clinical use?
- MoA: pro-drug; requires activation by the mycobacterial catalase-peroxidase before it can inhibit MYCOLIC ACID synthesis
- Resistance: decreasing the activity of catalase-peroxidase
- clinical use: TB
2 symptoms that are specific for Graves disease (hyperthyroidism)
infiltrative dermopathy (pretibial myxedema/ nonpitting edema)
**ophthalmopathy (proptosis, exophthalmos) **- due to lymphocytic infiltrates that that secrete cytokines to stimulate fibroblasts to secrete glycosaminoglycan ground substance (ie hyaluronic acid), which draws water into the orbit resulting in extraocular muscle edema; sensations of grittiness + excess tearing occurs because the lids do not completely cover the prototic globe; can be controlled by high-dose glucocorticoids
both due to autoimmune response directed against thyrotropin receptor that results in accumulation of glycosaminoglycans within the affected tissues
MoA of misoprostol
Prostaglandin E1 analog -> uterine contractions + cervical dilation
used as an abortifactant
germ tubes should make you think of…
candida albicans
32yoF w/ abnormal uterine bleeding + endometrial hyperplasia + R-adnexal mass. Pregnancy test is negative.
Dx?
Granulosa cell tumor - estrogen-secreting tumor -> endometrial hyperplasia, which can progress to endometrial carcinoma.
(can also cause precocious puberty)
Should see Call-Exener bodies (small follicle-like structures filled w/ eosinophilic secretions)
3 Stones that are radiolucent (what does this even mean?!)
how else can they be visualized?
URIC acid (kidney) stones
Brown Pigment Stones (GB stones due to Clonorchis Sinesis)
**Cholesterol (Gall bladder) Stones **
cannot be visualized via Xray “radiolucent”
U R Invisible…Be Cool
visualize via abdominal US or CT
Niacin
MoA
clinical use
ADRs
decrease hepatic VLDL and LDL production and raise HDL.
clinical use: lower TGs to avoid risk of pancreatitis
ADR: flushing (prevent w/ aspirin, since the flushing reaction is partially mediated through prostaglandin synthesis), chemical hepatitis
best treatment family members or close contacts of persons w/ meningococcal disease:
vaccine or antibiotics?
prophylaxtic antibiotics - esp. rifampin for Neisseria meningitidis
post-exposure prophylaxis with vaccine is not recommended bc there is no effective vaccine aganist GBS and children
You’re performing an eye exam on your patient and you notice this.
What d/o does he have?
What is it caused by?
typical findings?
trmt?
Wilson’s disease
∆ATP7B = ø Cu excretion into bile (for elimination) = Cu accumulation
Kayser-Fleischer rings (corneal Cu deposits), low ceruloplasmin, Cirrhosis/HCC
basal-ganglia atrophy (parkinsonian-like tremor, asterixis, dyskinesia)
Dementia, Dysarthria
trmt: penicillamine or trientine
cardiomeagly + severe generalized hypotonia
hx: abnormal glycogen accumulation in lysosomes
dx?
Pompe disease - ∆ acid maltase (alpha1,4 and alpha1,6 glucosidase activity)
What is Osler-Weber-Rendu Syndrome?
typical presentation?
hereditary hemorrhagic telangiectasi - AD inheritance - congenital telangiectasis of skin + mucous membranes
recurrent epistaxis or GI bleeding (melena)
MAO-Type B inhibitor
Selegiline
MAO-type B preferentially metabolizes dopamine over NE and 5-HT; inhibition of this results in increased dopamine availability to the brain
ADR: may enhance effects of L-dopa - arrhythmias, dyskinesia/akinesia
Rx to prevent perioperative venous thrombosis?
unfractionated heparin or LMWH - increases effect of endogenous anti-thrombin III
what exits the formaen rotundum
v2
PECAM1 (CD31)
transmigration into area of injury (“PlEAse-COME” IN)
present on both endothelial cells and leukocytes
cause of acute orchitis in young adults/adolescents? elderly?
young: C. trachomatis, N. gonorrhoeae
elderly: E. coli
when necrotic changes are first noticeable in ischemic MI
4-12 hrs
what factors act through steroid hormone receptors (cytoplasmic receptors)?
glucocorticoids
mineralocorticoids
androgens
estrogens
a high transepithelial potential difference is usually measured in what d/o? What causes this elevation?
Cystic fibrosis
high transepithelial potential difference (measured in nasal mucosa) is high due to increased Na absorption due to lack of inhibitory effect from the mutated CFTR protein.
first symptoms of normal pressure hydrocephalus?
urinary incontinence
ataxic gait
dementia
“wack, wobbly, and wet”
**Cholestyramine, Colestipol, **Colesevelam
Clinical Use
MoA
ADR
What increases ADR?
- Clinical Use: Elevated cholesterol
- MoA: bile acid resins that reduce reabsorption of bile acids in the intestines (interferes w/ enterohepatic circulation) -> hepatic cholesterol is used to resynthesize bile acids -> increases LDL uptake from circulation to do this -> decreases LDL
- ADR
-
HyperTg
- contraindicated in patients with hyper-Tg
- _Cholesterol Gall-stones (_esp. when used with gemfibrozil)
- decrease nutrients/drugs absorption
- statins must be taken at least 4 hours apart since the bile acid binding resin can impair its absorption
-
Constipation, bloating
- CI in patients w/ diverticulosis (constipation worsens the underlying diverticulosis)
-
HyperTg
hematogenous osteomyelitis usually occurs where?
metaphysis of long bones - contains slow-flowing sinusoidal vasculature that is conducive to microbial passage
among women, name the highest to lowest for:
greatest incidence of cancers
greatest deaths from cancer
greatest incidence of cancers: breast, lung, colon
greatest deaths from cancer: lung, breast, colon
endometrial bx w/ wavy glands w/ subnuclear vacuolization of epithelial cells and stroma that show prominent edema w/ widely separated stromal cells. dx?
asynchronous secretory endometrium - form of dysfunctional ovulatory bleeding that can cause infertility, where the secretory endometrium w/ a mismatch of 2 or more days between glands and stroma
- wavy glands w/ subnuclear vacuolization of epithelial cells = usually ocur around d17
- stroma that show prominent edema w/ widely separated stromal cell = usually occur on d22
impaired tetrahydrobiopterin synthesis affects which neurotransmitters?
NO, Serotonin, Tyrosine, Dopa
“say NO to STDs w/ THB”
how does high altitude affect PaO2 and PaCO2?
PaO2 and PaCO2 = both lower than normal due to hypoxemia and resulting hyperventilation and respiratory alkalosis
effect of muscarinic agonists on blood vessels
stimulate release of EDRF - endothelium derived relaxation factor
endothelium has receptors for muscarinic receptors –> causes release of NO (aka EDRF) –> increases cGMP –> activates Ca pump to cause Ca efflux –> decrease intracellular conc. –> VSM relaxation
newborn w/ hyperphenylalanemia receives tyrosine supplementation and is on a phenylalanine-restricted diet.
Several months later, his serum phenylalanine is normal, but his prolactin levels are elevated.
What is deficient?
dihydrobiopterin reductase - involved in the conversion of
- phenylalanine -> tyrosine (via phenylalanine hydroxylase)
- tyrosine -> DOPA (via tyrosine hydroxylase)
∆ dihydrobiopterin reductase -> both rxns are compromised, but since the patient is given tyrosine, only tyrosine -> DOPA is compromised
ø DOPA = ø Dopamine = increased prolactin
dIgital clubbing is usually associated with these d/o’s
any chronic d/o that causes hypoxia
large cell lung cancer, TB, CF, suppurative lung disease (empyema, bronchiectasis, chronic lung abcesss)
diagnose
koilocytes - HPV
Which one does this graph represent? (choose one)
Aortic insufficiency
Aortic Stenosis
Mitral Stenosis
Mitral regurgitation
Aortic Stenosis
when is isoniazid monotherapy recommended?
multi-agent therapy?
monotherapy: pts w/ PPD(+) and negative CXR / no evidence of clinical disease
multi-agent therapy: active TB
calculation for maintenance dose?
( ( Cp * CL ) / bioavailability fraction ) * # minutes
Cp = steady state plasma conc. CL = clearance
net units: mg
for IV Rx, bioavailability fraction = 1
HIV ELISA/WB tests in infants
falsely (+) in babies born to HIV+ mothers (anti-gp120 crosses placenta)
7yo w/ acute renal failure + bloody diarrhea. Smear shows schistocytes. What is the cause of his anemia?
HUS - likely due to EHEC shiga-like toxin and damaged endothelial cells, which activates platelets and microthrombic formation –> schistocytes.
BUT coagulation cascade is not activated and therefore PT/PTT is normal in HUS
superior laryngeal has an external br. and an internal br. - what do they each innervate?
external br: cricothyroid m.
internal br: sensory innervation above vocal cords
treatment for central DI
intranasal DDVAP
hydration duh…
16yo boy w/ painless, firm mobile mass beneath the nipple in his L breast. Dx?
gynecomastia
benign proliferation of ductal and stromal elements of the breast; idiopathic condition related to pubertal hormonal changes.
what kind of withdrawal: lack of concentration, HA
caffeine
2 anti-hypertensive that causes dyslipidemia
metroprolol
thiazides
inulin purposes
marker of extracellular volume (EC = IS + PV) measure of GFR bc it is freely filtered and not reabsorbed or not secreted
treatment of choice for anaphylaxis?
epinephrine - because it can stimulate
- a1 receptors - counteract the vasodilation of cutaneous + visceral vasculature -> increase BP
- ß1 receptors - increase cardiac contractility/CO
- ß2 receptors - bronchodilation (reverse the dyspnea caused by increase in smooth muscle tone in the bronchial wall)
do not use NE - because it has mostly a1 effects and can cause intense vasoconstriction, which may limit CO (since it doesn’t really have a big effect on ß1 receptors) and it does not reverse the increased bronchial wall tone)
angiogenesis is driven by two factors
VEGF and FGF
FGF = ** fluids grow first**
How does systolic and diastolic heart differ in terms of ventricular contractile performance?
In each scenario, what must the heart do in order to achieve a near normal stroke volume?
-
Systolic HF (impaired myocardial contractility) - decrease in ventricular contractile performance (decreased EF)
- requires increased LV-EDP and LV-EDV to improve stroke performance
-
Diastolic HF (decreased ventricular compliance) - decrease in ventricular diastolic compliance but normal ventricular contractile performance
- LV-EDP must be increased (a->b) in order to achieve a normal LV-EDV and keep CO at baseline
what part of the cell cycle does griseofulvin affect? what is this drug usually indicated for?
cell mitosis at metaphase
indicated for dermatophytoses
eye field looks like this:
where is the lesion?
R temporal lobe (Meyers loop)
F
stones that form under increased pH
stones that form under decreased pHs
increased pH (basic = phosphate)
- calcium phosphate
- ammonium magnesium **phosphate **
decreased pH (acidic = OUCH - the H indicates H+!!!)
- calcium oxalate
- uric acid
- cystine
heart findings in XO patients
coarctation of aorta
bicuspid aortic valve
T cell associated with Crohns? UC?
Crohns = Th1
Ulcerative Colitis = Th2 (2 words)
lamivudine
MoA
ADR
cytosine (nucleoside) analog RT inhibitor (NTRI) - inhibits HIV RT via chain termination
must be phosphorylated to its active form
ADR: Lactic acidosis + peripheral neuropathy
∆ btwn type I and type II muscle fibers?
**Type I = slow twitch **
- performs actions that require low-level sustained force (ie postural maintenance)
- paraspinal m.
- aerobic metabolism (high myoglobin + mitochondrial concentrations)
Type II = fast twitch (two-fast)
- generating rapid forceful pulses of movement
- latissimus dorsi, pec major, biceps, deltoid
- anerobic metabolism
role of eosinophils in host defense during parasitic infections?
ADCC (when stimulated by IgE bound to a parasitic cell) via major basic protein
Type I HSR
genetic abnormality of patient with macular pallor with cherry red dot, no hepatomeagly
Tay sach’s - frameshift
typical labs in a patient with sickle cell:
haptoglobin
LDH
bilirubin
abnormally low due to sickling + destruction of RBC results in decreased haptoglobin
increased LDH
increased indirect bilirubin
Quellung reaction is used to identify what
S. pneumo - capsule swells when specific anti-capsular antibodies are added
antibiotic that causes thrombocytopenia, optic neuritis and has a high risk of serotonin syndrome
linezolid - inhibits bacterial protein synthesis by binding to a 50s subunit
IL3 function
growth/differentiation of stem cells in bone marrow
thickened whitish plaque w/ slightly ulcerated crusted surface
vs
multiple reddish-brown papular lesions on penis
vs
single or multiple red-shiny plaques
Bowen disease - thickened whitish plaque w/ slightly ulcerated crusted surface
Bowenoid papulosis - multiple reddish-brown papular lesions on penis
Erythroplasia of Queyrat - single or multiple red-shiny plaques
A. Bowen B, Erythroplasia of Queyrat. C, Bowenoid papulosis.
cause of pharyngitis and glomerulonephritis
streptococcus
what will decrease the effects of Iodide that is used to treat hyperthyroisim?
perchlorate and pertechnetate - both are taken up by the thyroid via same mechanism that is used to transport iodide “competitive inhibition”
chemoRx associated w/ dry cough and exertional dyspnea
Bleomycin
Holiday heart syndrome
binge OH consumption that results in a-fib - irregularly irregular series of QRS complexes and absent P waves
What is this and what is it caused by?
aspiration of this puts the patient at risk of?
What do surgeons do to prevent this? 2
liver hydatid cyst; commonly caused by ingestion of Echinococcus granulosus eggs from dog feces…
can cause anaphylaxis if antigens are released
prevent by pre-injecting ethanol to kill cysts and treating with albendazole
thyroidectomy can injure these particular nerve branches w/ respect to specific arteries
recurrent laryngeal n. = inferior thyroid a.
external br. of superior laryngeal n. = superior thyroid a.
70M elevated Alk Phos + haphazardly-oriented cement lines that create a pattern of lamellar bone
cell type involved in the initial lesion?
Paget’s disease
osteoClasts
how does a defect in sertoli cells affect LH and testosterone?
defect in leydeg cells?
defect in sertoli cells -> decreased inhibin + spermatogenesis -> increased FSH but normal LH/Testosterone (since inhibin only feedsback to FSH)
defect in leydig cells -> increased GnRH (since there’s no negative feedback) -> increased LH, FSH, but decreased testosterone (since there’s no leydig conversion of cholesterol -> testosterone)
hepatic adenomas are usually caused by?
how do you treat them?
typically found in patients w/ a long hx of OC or anabolic steroid use
trmt: stop OC…duh
drug that prolong QT but does not predispose to torsades
amiodarone - via K-mediated repolarization on myocardial cells
losartan does what to
- arterial pressure
- TPR
- Na excretion
- Aldosterone levels
arterial pressure - decr
TPR - decr
Na excretion - incr
Aldosterone levels - decr
a positive Rinne test is considered..
NORMAL - if the sound is best heard at the EAM (compared to the mastoid; ie air counducted sound is normally louder and heard longer than bone-conducted sound)
(a negative Rinne test is abnormal if the patient hears the vibration better at the mastoid)
verapamil should not be prescribed to patients with…
heart failure because the (-) ionotropic effects- causes AV nodal block - of the Rx leads to a decrease in teh force/velocity of myocardial contraction, thereby exacerbating the patient’s heart failure
also causes constipation and gingival hyperplasia
typical anti-psychotic side effects
EPS
- akathisia - subjective restlessness, inability to sit still; may pace frequently or demonstrate other restless behaviors
- acute dystonia - sudden onset, sustained muscle contractions
- drug-induced parkinsonism - tremor, rigidity, bradykinesia
Tardive dyskinesia
NMS
bone changes consistent w/ Paget’s disease of the bone
mosaic pattern of lamellar bone w/ irregular sections of lamellar bone; linked by cement lines (represent previous areas of bone resorption)
Indinavir
Clinical Use
ADR
Protease inhibitor (enz. requierd for the final step of HIV replication)
- general ADR
- Lipodystrophy - increased fat deposition on the back and abdomen “buffalo humb” with decreased adipose adipose tissue on the extremities “peripheral wasting”
- **Hyperglycemia **- due to increased insulin resistance
- nephrolithiasis + hematuria** - unique to indinavir**
NAVIR Put SUGAR into LIPs - too much can cause kidney failure
General ADR of ‘navirs
Clinical Use
ADR
Protease inhibitor (enz. requierd for the final step of HIV replication)
- Lipodystrophy - increased fat deposition on the back and abdomen “buffalo humb” with decreased adipose adipose tissue on the extremities “peripheral wasting”
- **Hyperglycemia **- due to increased insulin resistance
NAVIR Put SUGAR into LIPs - too much can cause kidney failure
during the inflammatory response, a particular enyme is upregulated (that is normally undetectable in most normal tissues). What Rx would bind to this enzyme?
COX2 - inducible enzyme that is normally undetectable in most tissues except in cases of inflammation
bound to it by aspirin
16S rRNA - function?
rRNA in the prokaryotic 30S ribosome, contains a sequence that binds the Shine-dalgarno sequence on mRNA, which is impt for initiation of protein translation
Interpret this
HBsAg negative
anti-HBc negative
anti-HBs positive
Immune due to hepatitis B vaccination
location of fatty acyl coa synthetase
outer-mitochondrial matrix
patient w/ acute onset of hip/groin pain that is exacerbated by weight bearing; no swelling, erythema, or temperature change to the affected area.
dx?
how to diagnose?
avascular necrosis of the femoral head
use MRI
why is it that someone with prolactinoma can develop low bone density?
bc high levels of prolactin suppress GnRH, leading to hypogonadism, anovulation, and amenorrhea
prolonged hypogonadism can cause accelerated bone loss and increase risk of fractures
type II non-cytotoxic hypersensitivity
autoantibodies without complement or neutrophil-mediated destruction of the affected tissues (ie Graves, Myasthenia Gravis)
how does acute intravascular hemolysis affect these labs:
haptoglobin
total bilirubin
direct bilirubin
haptoglobin = decreased
total bilirubin = high
direct bilirubin = low
What does this represent? (choose one)
Increase preload
Increase afterload
Systolic dysfunction
Increased ejection Fraction
Normal Saline Infusion
Normal Saline Infusion
rupture of tympanic membrane causes what type of hearing loss
condutive
picorna virus that is acid labile
rhinovirus
(compare to rhinovirus that is acid-stable and can pass through the stomach to colonize the GI tract)
how does exercise affect PaO2 and PaCO2?
normal PaO2 and PaCO2 since there is increased HR, CO, and RR in to balance the increased total O2 consumption and CO2 production
lesions of macula are called
scotomas
polyvinyl chloride or arsenic exposure causes this tumor to form of CD31 positivity
**liver angiosarcoma **
CD31 is an endothelial cell marker
F w/ serosanguinous or watery discharge
atrophic vaginitis (post-menopause)
Smoking has a lower incidence of fibrocystic breast disease and uterine cancer. Why is that?
smoking has anti-estrogenic effects
Ezetimibe
Clinical Use
MoA
ADR
What increases its effects?
- clinical use: Hyper-LDL – 2nd line
- MoA: Decrease intestinal absorption of dietary cholesterol + bile acids -> decrease serum LDL (cholesterol)
- Additive effects of reducing LDL when used in combination w/ statins
recurrent laryngeal nerve of the vague innervates all laryngeal muscles EXCEPT
cricothryoid (innervated by EXTERNAL br. of superior laryngeal n.)
patient w/ coronary stent is placed on aspirn + other Rx. What is the risk of this other drug MoA and what are the associated risks?
ticlopidine - blocks ADP receptors
ADR: neutropenia
62yo immigrant from Asia has acute cholecystitis w. numerous dark stones in the gall bladder. Cause?
infection w/ E. coli, Ascaris lumbricoides, or** Opisthorchis sinensis**
Brown pigment stones usually arise secondary to infection of the biliary tract, which results in ß-glucuronidase release from injured hepatocytes, which hydrolyzes bilirubin glucuronides -> unconjugated bilirubin in bile
typical presentation of glucoagonoma
DM
anemia
necrolytic erythema
glucagonomas are rare pancreatic tumors
two factors that stimulate the development of osteoclastic precursors into mature, multinucleated osteoclasts. What is the stimulator of both of these signals?
RANKL and Monocyte-CSF
which viruses buds through and acquires the lipid bilayer envelope from the host** cell** membrane?
most enveloped nucleocapsid viruses
(except the herpesviruses, which bud through and acquire their envelope from the host cell nuclear membrane)
patient w/ fever, back pain or flank pain, inguinal mass, and difficulty walking. Currently lying supine with knee bent and resists extension of the leg and thigh, particularly at the hip.
Psoas abscess
- likely due to hematogenous or lymphatic seeding or spread from an adjacent site.
- pain exacerbated by movements that cause the psoas to be stretched or extended (ie hip extension)
- arises from T12-L5 and inserts on the lesser trochanter of the femur via tendon shared with the iliacus muscle; major flexor of the hip.
resected liver mass with this pattern is diagnostic of what d/o?
cavernous hemangioma
congenital malformations that enlarge via ectasia (dilation or distension of a tubular structure), resulting in cavernous, blood-filled vascular spaces lined by a single epithelial layer. benign; 30-50yo.
biopsy is contraindicated due to risk of hemorrhage
cisplatin
MoA
ADR - how to prevent?
- platinium containing compound that exerts its chemotherapeutic effect by forming ROS that can crosslink DNA
- ADR: nephrotoxicity - acute tubular injury
- prevent w/ **amifostine **- free radical scavenging agent that prevents radicals from
lymphadenopathy can represent inflammatory changes within the LN (reactive hyperplasia) or malignant transformation. How do you tell which is which?
reactive - benign, reversible enlargement of lymphoid tissue secondary to antigenic stimulus; polyclonal proliferation (many different cell types) within the LN
malignant - proliferation of malignant lymphocytes; evidence of monoclonality
GN spiral shaped bacteria associated with a decreased number of somatostatin producing antral cells. leads to what?
duodenal ulceration
loss of these somatostatin producing antral cells -> high gastrin levels -> increase histamine production -> increase gastric parietal cells to secrete acid
when this very low pH gastric fluid enters the duodenum, it is not adequately neutralized by local bicarb production, which causes duodenal ulceration
LT-B4 function
neutrophil chemotaxis to the site of inflammation
tiotropium, ipratropium MoA
muscarinic ACh antagonists - causes bronchodilation
useful for COPD, asthma
patient w/ thyroid that shows mononuclear parenchymal infiltration w/ well-developed germinal centers. Dx?
sx?
Hashimotos thyroidtis -> hypothyroidism due to presence of anti-thyroid peroxidase antibody
(also note, Hurtle cells are also present)
sx: fatigability, weight gain, constipation, cold intolerance
denosumab
mAb that prevents osteoclast activation by binding to RANKL and preventing its interaction with RANK
auditory tube
originates from…
shares its embryologic origin with..
originates from 1st pharyngeal pouch
shares its origin with middle ear epithelium
what is asterixis and what patients would you find them in?
flapping tremor of the hand when the wrist is extended - caused by abnormal function of the diencephalic motor centers in the brain as a result of ammonia accumulation in the body (since less is detoxified to urea)
common in patients w/ cirrhosis
where are most dietary lipids digested? absorbed?
Digested: duodenum
Absorbed: Jejunum (includes ADEK)
match enzymes w/ numbers
carnitine acyltransferase II
Fatty acyl-CoA synthetase
G6P DH
hexokinase
Pyruvate Kinase
Smooth ER
Citric Acid cycle
1 = carnitine acyltransferase II
2 = Fatty acyl-CoA synthetase
3 = G6P DH, hexokinase, Pyruvate Kinase
4 = Smooth ER
5 = Citric acid cycle
patient w/ L sided heart failure develops significant pulmonary arterial HTN. How does this develop?
L side heart failure -> LA pressure rises -> hydrostatic pressures in pulmonary circuit rise -> capillary leak -> pulmonary edema
edema causes collapse + results in decreased ventilation, which in turn, causes hypoxemia. Reactive vasoconstriction occurs to shunt blood toward areas where ventilation is less compromised -> pulmonary arterial HTN
first-line therapy for acute gouty arthritis
high dose NSAIDs
varicose veins pathophysiology
incompetent valves
most common hepatic lesion?
what does this look like on a CT scan?
metz from a primary tumor (breast, lung, colon) - usually shows multiple hypodense masses in the liver
how do these affect DNA?
irradiation
alkylating agents
UV radation
irradiation: double-strand breaks and ROS formation
alkylating agents: cross-linking
UV radation: thymine dimers
dx of patient with
weakness, gait disturbance, diffiulty releasing doorknob/handshake
cataracts, frontal balding, gonadal dystrophy
myotonic dystrophy - AD w/ anticipation; due to unstable trinucleotide repeats (CTG) that affects muscle maturation
hx: atrophy of muscle fibers, esp. type I
(compare to duchenne’s - necrosis + fibrofatty replacement of muscle fibers)
pain purely in the posterior thigh and leg as well as decr. ankle jerk reflex should make you think of..
sciatica - compression of S1 nerve root
NE binds these receptors
a1, a2, b1
plasma lipoprotein lipase activity after heparin injection is substantially lower than normal.
what is the heparin challenge?
what does the tests mean?
heparin causes release of endothelium bound lipases, encouraging the clearance of Tgs from circulation
lower-than-normal activity levels of lipoprotein lipase = deficiency = increased serum chyloµ (dietary lipids)
How does heroin affect pupil size + RR?
Miosis (smaller)
Respiratory depression
bcl-2
follicular lymphoma t14;18
what are these cells?
sertoli cells
- form tight junction (line = blood testes barrier)
- below the line = cells start meiosis I
- above the line (toward lumen) - cells are in prophase of meiosis I
- have prominent nucleoli
ectopia lentis
buzzword for..
homocystinuria - defect in cystathionine ß synthase deficiency; characterized by ectopia lentis, mental retardation, marfanoid habitus, and osteoporosis
diagnose
CMV - owl eye inclusions
cytokine produced from tumor that causes cachexia
TNFa (aka cachectin) - main mediator of paraneoplastic cachexia by suppressing appetite in the hypothalamus
rapid correction of hyponatremia results in?
rapid correction of hypernatremia results in?
HypO = central pOntine demyelination
HypER = cERebral edema
differential cyanosis (cyanosis of lower extremities, but not of upper body) in a kid should make you think of….
differential cyanosis is the result of reduced arterial saturation in the distal aorta compared to the proximal aorta
most likely cause: PDA (initial L-> R shunting, but over time the resultant pulmonary HTN can cause pulmonary vascular sclerosis, increase PVR, and reversal of shunt flow across the ductus)
what drains into the inferior mesenteric nodes?
anything supplied by the inferior mesenteric a.: L colon, sigmoid colon, upper part of rectum)
oseltamivir
MoA
neuraminidase inhibitor - prevents release of newly formed influenza A/B virions
virilization of genetically female infants w/ normal BP should make you think of…
aromatase deficiency - inability to convert androgens to estrogens in the gonads and peripheral tissues. Infant should have high levels of T/androstenedione.
(mother also likely experienced increased facial hair growth and some voice deepening during pregnancy)
cinacalcet
used to treat 2˚ hyperparathyroidism - increases sensitivity of CaSr to Ca
Filgrastim - when is it used?
G-CSF - used to stimulate proliferation/differentiation of granulocytes; used to minimize granulocytopenia after myelosuppressive chemoRx
which viruses buds through and acquires the lipid bilayer envelope from the host cell **nuclear **membrane?
all herpes viruses (1-8)
how does lactulose work?
acidifies colonic contents, which converts absorbable ammonia into non-absorbable ammonium ion (ammonia trap)
unfractionated heparin MoA
binds to thrombin + anti-thrombin to accelerate inactvation of factor Xa
how does amitriptyline cause death?
CARDIC death is most common
TCA inhibits fast Na channel conduction in cardiac myocytes and His Purkinje system –> arrhythmias + refractory hypotension
trmt: NaHCO3
why is skeletal muscle resistant to the effects of Ca channel blockers (ie verapamil)
bc skeletal muscle does NOT require an influx of extracellular Ca for excitation-contraction coupling whereas cardiac and smooth muscle cells depend on the extracellular Ca entering the cell via VG L-type Ca channels for excitation-contraction coupling.
39F w/ palpable nodularity in the R breast. Hx shows ducts distended by pleomorphic cells w/ prominent central necrosis; lesion does not extend beyond the ductal BM
comedocarcinoma (subtype of DCIS)
recent organ transplant recipient develops F, HA, V; lumbar puncture shows CSF pleocytosis and normal CSF glucose concentration. CSF microscopy shows GPR with tumbling motility.
Dx? How was it acquired?
Listeriosis
cause: listeria monocytogenes - facultative intraccellular parasite that grows within macrophages in immunocompromised hosts; able to multiply at 4˚ = acquired by eating contaminated foods (unpasteurized milk/milk products, undercooked meats, unwashed raw veggies)
part of the placenta that is derived from maternal origin
decidua basalis
follicle that extends through the entire cortex and bulges out at the ovarian surface
Graafian follicle
blood vessels most impt for minimizing the decrease in MSFP caused by blood loss?
venules + veins = impt blood reservoir for circulation during blood loss. Sympathetic activation of these vessels cause them to constrict in order to restore blood volume.
99mmTc pertechnetate is used to detect what?
presence of gastric mucosa (ie Meckel’s diverticulum)
primary amenorrhea in a patient w/ fully developed secondary sexual characteristics can be due to
anatomic defect in the genital tract:
imperforate hymen
Mullerian duct abnormalities
tumor cell that can appear in different locations (breast, stomach, ovary, colorectal areas, etc) and contains abundant mucin
signet ring cell carcinoma - do not form glands but contains abundant mucin that pushes nuclei to one side
S100 immunoreactivity
schwannomas
melanomas
(both neural crest cell origin)
gluteus medius + minimus functions in
hip ABduction
test to perform to confirm dx of acromeagly or gigantism
increase IGF1 failure to suppress GH following oral glucose test
when is ßhCG levels detectable after fertilization?
8 days post-ovulation (after the blastocyst implants)
what is the acoustic reflex?
dampens the effects of loud noise by causing contraction of the stapedius + tensor tympani m., thereby lessening the responsiveness of the ossicles to sound
8yo w/ a hx of fever, abd pain, and diarrhea; hx shows that the patient’s puppy also had diarrhea 1 week ago. which one is the most likely culprit?
s. aureus
shigella
bacillus cereus
vibrio parahemolyticus
giardia lamblia
campylobacter
campylobacter - only one in the list that can be transitted from domestic animals to humans; occurs via F/O
simple partial seizure
description (consciousness, postictal state)?
first line treatment?
one body part is involved, consciousness is intact, ø post-ictal confusion
carbamazepine
maculopapular rash on head that progresses down only on the trunk
occipital + post-auricular lymphadenopathy
german measles (rubella)
Tetanospasmin MoA
neurotoxin released by c. tetani - causes inhibition of inhibitory interneurons (which use glycine and GABA) in the spinal cord that regulate the firing of primary motoer neurons –> net increased activation of nerves innervating muscles (spasms, spastic paralysis, hyperreflexia)
what happens to screening test values when prevalence declines?
sens + specific = unchanged
increase NPV = NPV / (TN+FN)
decrease PPV
35yo w/ sickle cell anemia. What pathogens is he most suscetible to? What should he do to prevent his demise?
likely is asplenic - therefore he is at risk of encapsulated organisms (Ie S. pneumo, H. influenza, N. meningitidis) Salmonella is common in osteomyelitis
therefore patients should get penicillin prophylaxis + pneumococcal
what mediates adhesion of cells to the BM and ECM?
binding of **integrins **to fibronectin, collagen, and laminin
Craniopharyngioma
Location
Appearance
Prognosis, presentation
Pituitary (Rathke’s pouch)
Thick brownish fluid that is rich in cholesterol crystals; may have calcifications
Kids, Bitemporal hemianopia
how does PE affect PaO2 and PaCO2?
low PaO2 - due to V/Q imbalances (hypoxemia and stimulation of lung vagal irritant receptors causes hyperventilation, resulting in **low PaCO2 **
STEMI in V1, V2 leads
anteroseptal (LAD)
infranodal Mobitz type II second deg or third deg block would be possible
what molecules signal through TK receptors
Insulin
Growth factors (EGF, TGFß, PDGF, FGF etc)
all act via MAPK, Ras
why is the pO2 in the L atrium lower than that in the pulmonary veins?
admixture of deO2 bronchial blood (from the bronchial v.) that mixes with the oxygenated blood in the pulmonary veins
actin/myosin is to __________ as calmodulin and myosin light chain kinase are to _________
actin/myosin is to skeletal muscles as calmodulin and myosin light chain kinase are to smooth muscles
both are contractile elements
this is a liver bx. What is the diagnosis and what causes this appearance??
Hep B infection
notice the eosinophilic ground glass appearance, which is due to HBsAg filling the cytoplasm
calculations for
half-life
maintenance dose
loading dose
half-life (hrs) = Vd * 0.7 / CL
<em>a drug is virtually eliminated after 5 half-life intervals; 75% removal = 2 half-life intervals</em>
Maintenance dose: CPss * CL / bioavailability fraction
loading dose = CPss *Vd / bioavailability fraction
VD = volume of distribution
CL = clearance
CPss = steady state plasma conc.
Bioavailability fraction = 1 if given IV
ergonovine test
ergot alkaloid that constricts vascular smooth muscle by stimulating both a-adrenergic and serotonergic receptors in patients with angina, low doses of ergonovine can induce coronary spasms, chest pain, and STElevation
why does squatting help in tetralogy of fallot?
increase in systemic vascular pressure (SVP) reduces the amount of R->L shunting through the VSD, thereby increasing pulmonary flow
cox enzyme responsible for GI ulcers + bleeding
solution?
COX1 inhibition causes GI ulcers + bleeding
solution - use a COX2 inhibitor
Patients receiving kidney transplant usually receives cyclosporine + tacrolimus.
Why? What do these Rx inhibit?
both inhibit calcineurin activation, which is essential to the activation of IL2 (promotes growth and differentiation of T cells)
necrotic cell histology
nuclei are washed out, pyknotic (very compact) or fragmented (karyorrhexis) Necrotic = Nucleus
target of:
- enoxaparin
- unfractionated heparin
- fondaparinux
- rivaroxaban
- apixaban
- agratroban
- bivalruin
- dabigatran
target of:
-
enoxaparin (LMWH) = AT only
- enoxaparin is an ATypical anticoagulant - it is NOX your typical anticoagulant!!
- unfractionated heparin = AT + thrombin (factor 2)
- fondaparinux = factor x
- rivaroxaban = factor x
- apixaban = factor x
rule of thumb - X = factor 10 is involved (except enoxaparin)
- a
gratroban = thrombin - bivalruin = thrombin
- dabigatran = thrombin
25yoF w/ erythematous, painful, ulcerated lesions on labia and perineum.
Rx? MoA?
Acyclovir - inhibits viral DNA polymerase; must e activated by viral TK
damage to tibial n. will result in
weakness of inversion and plantarflexion of foot
cause of this graph?
chronic AVM.
evidence:
- increased CO
- decreased TPR (increased slope of both cardiac function curve + venous return curve)
- increased MSFP
(acutely, an AV fistula causes decreased TPR, which results in increased CO and increased VR, but the VR curve does not immediately shift along the x axis - see graph below. Compensatory responses from the sympathetic nervous system and kidneys results in the effects listed above)
small cavities in the deep structures of the brain (basal ganglia, posterior limb of internal capsule, pons, and cerebellum) filled with clear fluid are also known as…
what are they usually caused by?
lacunar infarcts
due to occlusion of small penetrating arteries that supply these structures; common chronic uncontrolled HTN or DM
vessels have **lipohyalinosis **and microatheromas
pathogenesis of CF
∆508 that cause abnormal protein folding and failure of glycosylation -> CFTR is degraded before it reaches the cell surface
definitive sign of heart failure and what can be done to accentuate this?
S3 - accentuated by having the patient lie in the L lateral decubitus position and fully exhale
patients with DM - type I is more prone to developing what
other autoimmune d/o (ie autoimmune adrenalitis)
how does simvastatin and cholestyramine affect hepatic cholesterol synthesis? what if they’re used together?
decrease, increase
if used together, then it will result in a net decrease in cholesterol synthesis and plasma LDL (since LDL will be used to resynthesize bile acids)
patient who experienced sudden onset of focal numbness + tingling that fully resolved with a non-remarkable medical history other than hypercholesteremia
what Rx to give her?
MoA / ADR?
She had TIA - give low dose aspirin to prevent 1˚ or 2˚ coronary artery events and ischemic strokes
MoA = irreversibly acetylating and inhibiting COX enzymes. at low dose it predominantely affects COX1, whereas at high doses, it inhibits COX1/2.
ADR: GI ulcers
hormones produced by pheochromocytoma are derived from which a.a.?
tyrosine!
increased appetite, hypersomnia, intense psychomotor retardation, severe depression
patient is undergoing withdrawal of…?
PE findings?
stimulants (cocaine, amphetamines)
PE: none
viral Rx that inhibits DNA polymerase AND reverse transcriptase, but does NOT require intracellular activation
Foscarnet - pyrophosphate analog
used to treat
- acyclovir-resistant herpesvirus
- ganciclovir-resistant CMV virus
- advanced AIDS patients
ovary eggs are arrested in what phase of the cell cycle?
DIPLOTENE stage of PROPHASE I stage of the FIRST MEIOTIC division
remains at this stage from before birth until ovulation; 2nd meiotic stage is completed at fertilization
what receptor type is the antagonist directed against
M2 cholinergic receptors - present on SA node, which acts to decrease HR
Blocking the M2 receptors on the SA node removes the parasympathetic tone –> increase HR
(<em>note that during the carotid occlusion, there is less stretch of the carotid baroreceptors and less afferent nerve activity is sent to the medulla by CN9; ie carotid occlusion tricks the body into thinking that it has a lower BP than ita ctually has</em>)
folic acid is impt in in generating which two factors?
deficiency can result in?
thymidine (dTMP) synthesis (via thymidylate synthetase)
conversion Homocysteine -> methionine
∆ = megaloblastic anemia + hypersegmented PMNs
cross-sectional study
data from a group of ppl to ASSESS FREQUENCY
what innervates the submandibular and sublingual gland?
CN 7
thymus
originates from…
shares its embryologic origin with..
originates from 3rd pharyngeal pouch
shares its origin with the inferior parathyroid glands
atrial septal defects are common in..
down syndrome patients
(these patients also have VSD)
tumors in the lung apices are also known as
what can they cause?
pancoast tumors - often form in the **superior sulcus (groove of subclavian vessels) **can cause
- ipsilateral horner syndrome (ispi ptosis, miosis, anhydrosis)
- edema of upper extremity (compression of subclavian vessels)
- rib destruction
- atrophy of hands muscles
- pain in the distribution of C8, T1, and T2 nerve roots (pain in shoulder that radiates towards axialla and scapula)
hydralazine
MoA
ADR?
selective arteriolar vasodilation
reduces MAP -> causes** reflex sympathetic activation**, leading to:
1) increased HR, contractility
2) increased renin activity -> Na/H2O retention
bony changes consistent w/ osteopetrosis
marble bone disease (decreased osteoClastic resorption)
persistence of primary, unmineralized spongiosa in medullary canals (in normal individual, bone marrow replaces the primary spongiosa)
ETEC - mechanism of disease
Heat-labile (LT) and heat-stable (ST) enterotoxins
LT is very similiar to cholera toxin in that it **increases intracellular cAMP **in gut mucosal cells by activating the Gs membrane, thus activating adenylate cyclase
ST - increass cGMP
both result in fluid/electrolyte loss /watery diarrhea
NOT due to endotoxin release, which is LPS. REMEMBER THIS!!!
24yo patient w/ ulcerated, painful lesion on precpuce and unilateral inguinal adenopathy
Culprit?
Haemophilus ducreyi - pleomorphic GNR that displays a characteristic “school of fish” pattern on gram stains (parallel short chains)
same growth conditions as H. influenza
amassed actin-containing fibroblasts and increased MMP activity after a skin laceration indicates…
actin containing fibroblasts = MYOfibroblasts
fxn: wound contraction
MMPs is not only involved in scar tissue remodeling, but also encourages myofibroblast accumulation at the wound edges, which would initiate wound contraction during healing by second intention
patients on diazepam should avoid what drugs?
drugs that cause sedation:
1st gen anti-histamines: **chlorpheniramine, diphenhydramine, promethazine, hydroxyzine **
what are choledochal cysts ?
congenital dilation of the common bile duct
mediastinal widening on CXR
anthrax; max spore production occurs during stationary phase
GABA is derived from which a.a.?
glutamate
MoA + 2 major ADR of valproic acid
suppresses abnormal electrical activity in the cortex by affecting GABA and NMDA receptors, as well as Na/K channels
severe hepatotoxicity (measure LFTs)
neural tube defects (spina bifida)
enzyme affected by citrate
PFK-1
citrate is produced by citrate synthase from acetyl coA and oxaloacetate, when the CAC slows down, citrate accumulates and acts as a negative allosteric regulator of PFK1 (catalyzes committed step of glycolysis)
Enoxaparin MoA
LMWH that binds to anti-thrombin only to accelerate inactivation of factor Xa
kuassmaul sign
paradoxical rise in JVP with inspiration - occurs because the volume restricted RV is unable to accomodate the inspiratory increase in VR
occurs in patients w/ constrictive pericarditis (thick fibrous tissue in the pericardial space that restricts venticular filling - increases JVP, low CO, and RHF that is resistant to medications)
where is folate absorbed
jejunum
(even though it’s not really a fat-soluble vitamin….)
cryptorchidism
undescended testes
general effects of ß1 blockers
act on ß1 receptors to:
decrease HR
decrease renin release from JG cells
treatment of atropine OD
physostigmine - AChE inhibitor - increases ACh availability to counteract atropine’s blockade of muscarinic cholinergic receptors
MTX is specific for which part of the cell cycle?
S phase because it prevents the synthesis of purine and thymidylic acid
48F received opioid analgesics suddenly feels severe abdominal pain. Why?
it causes contraction of the smooth muscles of the sphincter of oddi, leading to constriction and spasm, which increases pressure in the common bile duct, which increases biliary colic.
suspect this if ventricular myocytes express mRNA for ANP
ventricular hypertrophy (results in both MORPHOLOGIC + GENE changes)
non-bacterial thrombotic endocarditis (NBTE) causes
vegetations of bland thrombus w/o accompanying inflammation or valvular damage
causes:
- hypercoagulable states (dissemminated cancer “marantic” endocarditis)
- endothelial injury
histological finding in patients w/ temporal arteritis
focal granulomatous inflammation, esp. of the cranial arteries
Right anopia has damage to
R optic nerve - retinal artery/central retinal vein occlusion
squamous cell carcinoma lung histology shows
keratin pearls + intracellular bridges
surgeon w/ shaky hand was trying to ligate the superior thyroid a. and accidently severed this nerve and its innervation to this muscle
external branch of superior laryngeal nerve
innervation: cricothyroid m.
treatment of CAH?
low does exogenous corticosteroids to suppress excessive ACTH secretion and reduce stimulation of the adrenal cortex
F w/ white curd-like discharge
candida albicans - yeast forms w/ pseudohyphae
Follicular cell lymphoma translocation
follicular t14;18; 4 = “four”llicular
OR
diffuse large b-cell lymphoma t14;18 = 4 words
glucagon
MoA
give a scenario in which you would administer this?
- increases** hepatic glycogenolysis** AND **gluconeogenesis **to restore glucose levels, usually within 10-15min of administration
- stimulates insulin secretion from pancreas
administer to a little old lady who loses consciousness in a supermarket with a blood glucose of 34mg/mL (in a hospital, you’d just give IV glucose)
polycythemia can be subdivided into absolute vs relative. What does this mean?
absolute - true increase in RBC mass (likely due to polycythemia (1˚) or hypoxia/EPO tumors (2˚)
relative - normal RBC mass; likely due to excess diuresis or dehydration
how is REM affected in persons with major depressive d/o?
increased REM sleep (even though they complain of insomnia)
decreased REm latency
decreased N3 (deep) sleep
pathophysiology of hemochromatosis
complications of this d/o?
why do women tend to present signicantlly later?
AR d/o where HFE protein is NOT expressed on the basolateral surface of intestinal cells (where it normally binds to transferrin receptor and regulates traCopyright (c) USMLEWorld, LLC., Please do not save, print, cut, copy or paste anything while a test is active.nsferrin/Fe complex endocytosis into cells)
øHFE = unregulated uptake of dietary Fe = abnormally high levels of intestinal absorption = mildly elevated LFTs, elevated plasma Fe w. >50% TIBC, elevated serum ferritin
Complications: cirrhosis, HCC
Women tend to present later due to blood loss during menstruation + pregnancy
wide fixed splitting of S2 long-term sequelae if not treated?
ASD - creates a L->R shunt due to high pressures in the LA, resulting in increased blood flow through the pulmonary artery long-term: hypertrophy of the muscular pulmonary arteries to accommodate the extra flow (increased pulmonary vascular resistance, pulm HTN) results in a switch to R->L shunt “Eisenmenger’s syndrome”
Bombesin
marker for neuroblastoma, small cell carcinoma, gastric carcinoma
endocarditis due to s. bovis
colon cancer
case fatality rate is calculated as
of fatal cases / total # of people with the disease
difference between omphalocele and gastroschisis
- omphalocele - protrusion of abdominal contents that is covered by peritoneum
- gastroschisis - protrusion of abdominal contents that is NOT covered by peritoneum
A 30-year-old woman is brought into the emergency room. The patient had been dining in a local restaurant, and while eating dessert she noted the following symptoms. Initially there was a tingling sensation that affected the mouth and lips, but then it spread to the face and neck. Then the tingling spread down the arms and legs to the fingers and toes.
Cause?
The rapid onset (~30min) of symptoms, as well as the patient’s neurologic deficits, are most consistent paralytic shellfish poisoning. Saxitoxin, with actions similar to those of tetrodotoxin (puffer fish), blocks the opening of VG Na+ channels. Recovery is slow due to the extremely tight binding of the toxin to the Na+ channels; but once dissociated, it can be excreted in the urine.
phentolamine
when is it given?
a1 blocking drug - usually leads to vasodilation
usually given to coutneract the NE-mediated vasoconstriction
patient w/ R leg numbness lifts R foot higher than he does on the L; R foot slaps to the ground w/ each step.
PE: unable to evert R foot (keeps foot plantarflexed + inverted)
damaged nerve?
common peroneal n.
paralysis of peroneus longus + brevis (mediates foot eversion)
paralysis of tibialis anterior (mediates dorsiflexion)
paralysis of extrinsic extensors of the toes
loss of sensation to the anterolateral leg
NET: foot drop + high stepping gait
patients w/ HTN and dyslipidemia has total occlusion of L main coronary artery + diffuse atherosclerotic disease characterized by intimal thickening + collagen deposition. What cells produce this intimal response?
smooth muscle cells - migrate from the media, across the IEL, into the intima where they proliferate and produce collagen to produce a neointima (in respons eto intimal injury)
why is pregnancy an independent risk factor for DVTs?
increased production of clotting factors
decreased fibrinolysis
reduced protein S
pressure of gravid uterus on IVC -> venous stasis
∆ btwn cherry hemangioma and strawberry hemangioma?
cherry: adults, #’s often increase and do not regress
strawberry: kids; size often increases, but spontaneously regresses
Lead inhibits
ALAD + ferrochetolase
2 risk factors for infective endocarditis
prosthetic valves prior valvular inflammation and scarring (FIBRIN deposition allows bacteria to bind to it)…duh
why does prolactin cause vaginal dryness and bone fractures?
it inhibits GnRH –> hypogonadism –> anovulation, amenorrhea
low extrogen –> vaginal dryness, low bone density
amytriptyline
ADR
**potent anti-cholinergic effects **
(may mimic atropine toxicity - fever, mucosal/axillary dryness, cutaneous flushing, mydriasis, and cycloplegia an delirium)
medical student begins to dress and act like an attending physician
identification
patient presents w/ difficulty swallowing and this (see pic)
diagnosis + treatment?
koilonychia (spoon nails) + difficulty swallowing (dysphagia) are specific for IDA - iron deficiency anemia
treatment: Fe prep
cleft palate results from
occurs hwen the palatine shelves of the maxillary prominence fails to properly fuse with one another or with the primary palate
Tadalafil is indicated for two diseases. What are they?
erectile dysfunction
pulmonary artery HTN
Fredreich ataxia chromosome
9p (drawing out 9P looks like a walker)
what is myelophthisic anemia?
space-occupying lesion in bone marrow -> pancytopenia
(most common = metz to the bone with associated fibrosis)
MTX treatment
causes an accumulation of..
prevents synthesis of..
accumulated substrate: Dihydrofolate polyglutamate
(polyglutamation prevents movement of these substrates out of the cell)
prevents synthesis of: purines + thymidlyate synthesis
decreased lung compliance is caused by…3
pulmonary fibrosis
insufficient surfactant
pulmonary edema
type II cytotoxic hypersensitivity
autoantibodies that bind to specific tissues or cells and cause destruction (ie rheumatic fever, hemolytic disease of newborn)
difference btwn communicating + non-communicating hydrocephalus?
communicating: no obstruction to CSF flow; usually occurs 2˚ to dysfunction or obliteration of subarachnoid villi that is caused by meningeal infections or subarachnoid/IVH. ALL ventricles are enlarged
non-communicating - ventricles above the obstruction are enlraged, those below are normal (usually due to aqueductal stenosis, arnoid chiaris or dandy walker malformations)
marker of high infectivity in Hepatitis B? low infectivity?
- high infectivity = HBeAg (e for elevated, emergency)
- low infectivity = anti-HBeAg
Cimetidine
MoA
ADR
MoA: H2 receptor antagonist –> decreass HCl production
ADR: gynecomastia, inhibits P450 and may increase levels of warfarnin, phenytoin, propranolol, metoprolol, quinidine, and theophylline
F w/ ambigious genitalia, hypotension, and hyperkalemia
deficient enzyme?
21-hydroxylase deficiency
- decreases cortisol production
- decreased mineralocorticoid production -> hypotension+hypokalemia
- increased androgen production -> F have ambigious genitalia
how does citrate work in treating calcium kidney stones?
citrate = binds to free (ionized) Ca and prevent its precipitation, thereby allowing it to be excreted.
where is amyloid (AA) made? AL?
AA = liver
AL = bone marrow (Ig light chains)
Niacin
Clinical Use
MoA
ADR
- clinical use: hyperTg – 2nd line, or** low HDL**
- MoA: decrease VLDL + Tg (by suppressing FFA release from peripheral tissues and by decreasing VLDL conversion to LDL), **increase **HDL
- ADR:
- Flushing, itchiness (prevent w/ aspirin)
- Hepatotoxicity
- Hyperglycemia (acanthosis nigricans)
- increase uric acid (gout)
Clozapine
Clinical use
ADR
helpful in treating NEGATIVE symptoms of schizophrenia
ADR: agranulocytosis and seizures
3 drugs that inhibit dihydrofolate reductase
Trimethoprim
MTX
Pyrimethamine
TMP
intracellular signaling factors for a1, a2, ß1, ß2
a1 = increase IP3 -> vasoconstriction
a2 = decrease cAMP -> decrease NE/insulin release
ß1 = increase cAMP -> increase contractility
ß2 = increase cAMP -> bronchodilation/vasodilation
most internal component fo the anterior abdominal wall musculature
transversus abdominis (transversalis)
(lies immediately deep to the internal oblique)
which monosaccharide has the highest rate of metabolism in the glycolytic pathway and why?
**F-1-P **(derived from dietary frutose) is rapidly metabolized because it bypasses PFK-1, the rate limiting enzyme of glycolysis
(other sugars enter glycolysis before this rate limiting step and are therefore metabolized more slowly due to the regulation of PFK-1)
what should patients be tested for prior to starting hydroxychloriquine?
baseline + follow-up ophthalmologic exams since it can result in irreversible retinal damage w/ long-term use
patients with influenza is at risk for what and why?
What pathogens are most common in this particular illness?
bacterial pneumonia (recurrent fever, dyspnea, and productive cough) because influenza damages the mucociliary clearance mxns of the respiratory epitehlium
S. pneumo > S. aureus, > H. influenza
most specific marker for diagnosing acute hepB infection?
most specific marker of viral replication/increased infectivity?
IgM anti-HBc - remains elevated during the window period (disappearance of HBsAg and appearance of anti-HBs)
HBeAg = e for emergency!!
bioavailability fraction for an IV drug
1
3 main causes of HIV-associated esophagitis - how do you tell them apart?
- candida - white pseudomembrane; yeast cells + pseudohyphae that invades mucosal cells
- HSV1 - small vesicles that evolve to “punched out” ulcers; forms Cowdry type intranuclear inclusions in multi-nuclear squamous cells at the margins of ulcers
- CMV - LINEAR ulceration (intranuclear + cytoplasmic inclusions)
what kind of withdrawal: Sweating, dilated pupils, piloerection (“cold turkey”), fever, rhinorrhea, yawning, nausea, stomach cramps, diarrhea (“flu-like” symptoms).
heroin withdrawal
what should you monitor for patients on Thiazolidinediones?
LFTs, specifically ALT, because they cause severe hepatotoxicity (although the newere versions do not)
cardiac findings in friedreich’s ataxia
other findings?
hypertrophic cardiomyopathy, CHF “big heart”
**kyphoscoliosis, pes cavus **(foot defomities), diabetes mellitus
**ataxia **(degeneration of ascending + descending spinocerebellar tracts)
(note that this is a trinucleotide d/o on chromosome 9 that results in degeneration of the posterior columns and spinocerebellar tracts)
patient in the ER with complaints of increasing SOB - treat w/…?
high dose IV glucocorticoids - used for acute asthma exacerbations that cause patients to end up in the ER
Albuterol is good for mild episodic symptoms
65yo w/ sudden onset of L eye blindness and L jaw pain that starts in the middle of a meal
temporal arteritis - arterial lumens narrow and cannot respond to increased blood requirements during the meal.
patients may also experience muscle pain + morning stiffness (polymyalgia rheumatica)
get ESR!!
polyarteritis nodosa (PAN) affects which arteries?
spares which arteries?
histology?
cause?
affects: medium - small size arteries (kidneys, heart, liver, GI tract)
spares: pulmonary arteries
histology: transmural inflammation w/ fibrinoid necrosis
cause: **HepB **
Nesiritide
What is it? Who do you use it in?
recombinant BNP (brain natriuretic peptide)
CHF due to decompensated LV dysfunction
what can reverse vagally-mediated bronchoconstriction?
anti-muscarinics (ipratropium)
milrinone
MoA
clinical uses?
phosphodiesterase inhibitor -> increases cAMP
in heart: increased cAMP -> increased Ca -> increased cardiac contractility
in VSM: increased cAMP -> vasodilation
central DI usually results from damage to:
hypothalamic nuclei or pituitary stalk (don’t answer posterior pituitary because the neuron axons project there, but it’s not actually made there…)
Nitroprusside
clinical use?
General Metabolism?
OD trmt
anti-HTN w/ mixed arterial + venous vasodilatory effects
metabolized to cyanide w/ subsequent conversion to thiocyanate (via rhodanase)
OD: thiosulfate - donates sulfur to liver rhodanase to enhance conversion of cyanide -> thiocyanate
Nifedipine, Verpamil, and Diltiazem are all Ca channel blockers
- Nifedipine - similar to nitrates in effect - it causes peripheral vasodilation (vasculature-specific effects), which may result in reflex tachycardia. Good anti-HTN agent for patients with bradycardia
- verapamil and diltiazem - similar to ß blockers in effect - slows conduction through the AV node (cardiac-specific effects) and is used for rate control in a-fib w/ rapid ventricular response
battery factory should make you think of what type of poisoning
LEAD - abd colic, constipation, HA, lead line, peripheral neuropathy, microcytic hypochromic anemia + basophilic stippling
how does resistance to penicillins, aminopenicillins, cephalosporins, and monobactams occur?
- penicillin: upregulation of ß lactamase (penicillinase) that destroy the ß-lactam ring of penicillins
- cephalosporins + penicillinase-resistant penicillin (nafcillin/methicillin): modified penicillin binding proteins (PBP) that prevent the binding
- (thus infections caused by organisms expressing ß lactamases require a ß lactamase inhibitor (ie clavulanic acid, sulbactam, or tazobactam)
part of the placenta that is derived from fetal origin
cytotrophoblast syncytiotrophoblast (both form the chorion) primary villi = earliest projection of the chorion
why is surgery not indicated for small cell carcinoma of the lungs?
it is highly invasive and the majority have distant metz at the time of diagnosis and surgery proves futile. These tumors are sensitive to chemoRx and radiation.
how does glucocorticoids cause hyperglycemia? 2
it it increases hepatic synthesis of enzymes involved in gluconeogenesis + glycogenolysis
it antagonises the effect of insulin in muscle + adipose tissue, thus favoring catabolism in these tissues (to ultimately provide substrates for gluconeogenesis + glycogenolysis in the liver)
an undescended testes is at risk of what later on in life?
testicular carcinoma
MALES
FSH is to _________ as LH is to _________
FSH is to Inhibin B AND Androgen Binding Protein, Sertolic cells** **
as LH is to testosterone, Leydig cells
serum sodium levels for someone with
central DI
nephrogenic DI
primary polydipsia
central: >142
nephrogenic: >142
primary polydipsia:
what should be considered before **ramipril **is prescirbed to a patient w/ a hx of MI + coronary artery bypass surgery for stable angina?
if the patient has bilateral RAS. Why?
patients w/ atherosclerotic cardiovascular + peripheral vascular disease can also develop renovascular disease (RAS). Patients w/ RAS are dependent on ACE-mediated efferent arteriole vasoconstriction to maintain renal perfusion + GFR. Use of ACEi will block this effect and reduce renal perfusion, potentially leading to ARF.
“wrist drop” is usually due to compression of which nerve?
what type of injury usually causes this?
radial n.
improperly fit crutches or mid-shaft humerus fracture
antibiotic that causes red man syndrome + nephrotoxicity
vancomycin - blocks glycopeptide polymerization by binding tightly to D-ala/D-ala
pulmonary hamartoma
aka coin lesions
excessive growth of a tissue type native to the organ of involvement
hx: popcorn calcifications, islands of mature hyaline cartilage, fat, smooth muscle cells and clefts lined by respiratory epithelium
reverse NE effects (intense vasoconstriction)
phentolamine mesylate (a-receptor blocker)
52 F w/ a hand tremor that is alleviated by drinking small amounts of alcohol.
Dx, best treatment for this patient and why?
- Dx: essential tremor (AD, + family history)
- treatment: **propranolol ** - non-selective ß receptor antagonist is throught to lessen the tremor via its CNS efffects
low potency anti-psychotics
ADR?
chlorpromazine, thirordazine
anticholinergic effects (confusion, dry mouth, urinary retention) due to their strong blockade of central + peripheral muscarinic cholinergic receptors
what is the purpose of adding carbidopa to levodopa?
what ADRs will improve?remain the same?
carbidopa inhibits peripheral decarboxylase, thereby reducing peripheral conversion of levodopa, making more of it available to the brain and less peripheral ADR
improve: N/V, tachyarrhythmias, postural hypotension + hot flashes
remain the same or worsen: anxiety + agitation (since more dopamine becomes available to the brain)
diuretics that cause hypercalcemia?
hypocalcemia?
hyper: thiazides
hypo: loops
what is a ghon complex? when does it occur?
when the lower lobe lesion (ghon focus) is accompanied by ipsilateral hilar adenopathy = ghon complex
occurs during initial infection with MTB
causes of Mitral valve prolapse
sporadic myxomatous degeneration of the mitral valve
Marfan
Ehlers-Danlos
a1 blockers are generally used for?
treatment of concomitant BPH + HTN
examples are prazosin, terazosin, doxazosin
23yo F in her 3rd trimester develops fever, weakness, and diarrhea; delivers baby at 34wks.
Physical exam of the neonate shows disseminated granulomas.
Culprit? Treatment?
Listeria Monocytogenes - cause of granulomas in-utero; fatal
GPR that is acquired by eating delicatessan food
Trmt: Ampicillin
patient w/ Conn syndrome
spironolactone
eplerone
genetic cause of familial hypercholesterolemia
hepatocyte under-expression of functional LDL receptors
how does panic attack affect PaO2 and PaCO2?
raises HR and CO via sympathetic stimulation of the heart; however, there is an associated hyperventilation and respiratory alkalosis, thus a slight rise in PaO2 and fall in PaCO2
eye field looks like this:
where is the lesion?
R optic nerve
B
Alz treatment
Cholinesterase inhibitor - Donepezil
Antioxidants - Vit E
NMDA receptor antagonist - memantine
how does HRT affect thyroid hormone levels?
serum levels of TSH is normal
serum levels of T4 and T3 are also normal
increase TBG levels
increased total T4 and total T3
PREGNANCY/oral coontraceptives also do the same thing…
Amantidine has 3 clinical uses. What are they?
what is its MoA?
ADR?
Parkinson’s - increase DA release
Influenza - impairs uncoating of virus after host-cell endocytosis (note that this is no longer used due to increased resistance)
Rubella
MoA: inhibits M2 ion channel, thereby blocking viral uncoating after host cell endocytosis
ADR: ataxia
where is iron absorbed?
where cells regulate the total iron content of the body?
duodenum
hepatic cells - secretes hepcidin (APR)
Enfuvirtide
fusion inhibitor - binds Gp41 and blocks conformational changes necessary for fusion of viral + cellular membranes
FUSION FUVVVV GP-FOUR-1
woman treated with x hormone - FSH declines initially but later dramatically increases. What is hormone X?
Estrogen
low levels inihibit FSH secretion via negative feedback, higher sustained estrogen levels produce (+) feedback, leading to estrogen surges in FSH/LH secretion.
LH surge induces ovulation
tremors, agitation, anxiety, delirium, psychosis
patient is undergoing withdrawal of…?
PE findings?
OH
PE: seizures, tachycardia, palpitations
STEMI in V4-V6 leads
anterolateral wall (LAD or LCX)
lancet-shaped Gram (+) diplococci
s. penumo
carnitine function
deficiency will cause what to happen?
patient will also be deficient in what substrate?
transport long-chain FA into mitochondria
deficiency: impaired FA transport into the mitochondria, restricting ketone body production
patient will also be deficient in acetoacetate
how does resistance to fluoroquinolones develop?
structural alterations in topoisomerases II /DNA gyrase
ab with two epsilon chains
IgE
key anatomic landmarks for locating the trigeminal nerve
middle cerebellar peduncles
student stealing from a wealthy friend and thinking that he is rich enough that he can afford to lose it
rationalization
patient has esophageal varices + splenic enlargement + normal liver histology. What’s going on?
portal vein thrombosis
patient w/ difficulty walking; leands towards R while walking. When asked to stand on his L foot, his R hip tilts downards.
(+) Trendelenburg sign - hip dips towards the unaffected side when the patient stands on the affected leg.
superior gluteal n. - innervates the gluteus medius + gluteus minimus (both function to pull the pelvis down and abduct the thigh)
reginal adenopathy with LNs containing granulomas filled with necrotic debris
causal agent + treatment?
bartonella henslae
trmt: azithromycin or dox
achondroplasia - mutation and effect?
FGF-receptor 3 gene -> abnormal chondrocyte proliferation at the growth plates of long bones
result: short-limb dwarfism
Patient on Isoniazid develops peripheral neuropathy. Why?
how do you prevent this?
Isoniazid is structurally similar to B6 and therefore causes
- “extra B6” to be excreted, often resulting in B6 deficiency.
- compete with B6 in the synthesis of multiple neurotransmitters, resulting in defective end products (NTs that do not work)
prevent w/ B6 supplementation
Suggest antibiotics that work at each step of mRNA synthesis
formation of initiation complex
Aminoacyl-tRNA binding
Peptide bond formation
translocation
- Initiation complex = **Aminoglycosides **(gentamicin, amikacin, tobramycin, streptomycin), Linezolids
- Aminoacyl-tRNA binding **= Tetracyclines **(doxycyline)
- Peptide bond formation = Chloramphenicol (inhibits peptidyltransferase)
- translocation = Macrolides (azithromycin, erythromycin), clindamycin
terbinafine
MoA
inhibits squalene epoxidase
“TSE” = Tiffany’s aunt last name
what Rx is best used to address the infertility issues in patients with PCOS?
Clomiphene - a SERM that prevents negative feedback on the hypothalamus by circulating estrogen -> results in increased LH/FSH production and subsequent ovulation
brain tumor that has sheets of small, blue cells
medulloblastoma - located in teh cerebellum
role of cyclin D1
present in what dz
promotes G1->S transition
present in mantle cell lymphoma
How does BNP work?
acts along with ANP to cause vasodilation (and decreased preload) and diuresis; both ANP + BNP activate guanylate cyclase, which induces an increase in cGMP
how do these factors change with vWF d/o?
Platelet Count
Bleeding time
PT
PTT
plasma fibrinogen levels
ristocetin challenge
smear
Platelet Count = NC
Bleeding time = increased (differentiates it from vWF)
PT = NC
PTT = increase
plasma fibrinogen values = normal
ristocetin = abnormal
smear = normal
IM injection into the buttocks result in ispilateral hip drop every time the ipsilateral foot is raised. where was the injection done and what causes these sx?
**gluteus medius gait - **caused by injury to the superior gluteal n. (L4-S1) or injury to the gluteus medius
Injection was probably done in the supero-medial quadrant of the gluteal region, which caused damage to the gluteal n.
All injections are usually done in the superolateral quadrant to avoid this
Zafirlukast and Montelukast
MoA and use
inhibit leukotriene-receptors
chronic asthma prophylaxis
diphenoxylate MoA
use?
why is it manufactured with atropine?
opiate binds to µ opiate receptors in GI tract -> slows motility
use: anti-diarrhea (low doses)
manufactured w/ atropine because it discourages abuse - patients who decide to take higher doses of diphenoxylate wil result in higher doses of atropine, which will produce adverse sx (dry mouth, blurry vision, nausea)
what factor causes an increase in the thermoregulatory set point in the anterior hypothalamus (results in a higher core body temperature)
PGE2
MEN 2B
gene mutation?
what does it affect?
activating mutation of RET protooncogene
pheochromocytoma
Medullary thyroid cancer (MTC, calcitonin)
oral/intestinal ganglioneuromatosis (mucosal neuromas)
marfanoid habitus
in 90% of patients, the posterioinferior wall of the L ventricle is supplied by?
posterior descending branch of R coronary artery (RCA)
marker of pancreatic cancer
CA 19-9
what forms the SVC
L/R brachiocephalic v.
drug that causes a dose-dependent increase in cardiac contractility + dose-dependent decrease in systemic vascular resistance
isoproterenol
- increases cardiac contractility via ß1 receptors
- at lower doses, it selectively binds to ß2 receptors, causing relaxation of VSM
- negligible effects on a-receptors
hemolytic anemia is usually due to defects in these two pathways.
Associated enzymes?
glycolysis = pyruvate kinase
pentose phosphate shunt = Glucose-6-phosphate DH
blotchy red muscle fibers on Gomori trichome stain are buzzwords for this particular d/o
mitochondrial myopathies
why is propranolol given to patients with thyrotoxicosis?
why is it never given to patients with diabetes? (what are some alternate options)
ß blockers like propranolol has dual effects in thyrotoxicosis
- decreased effect of sympathetic adrenergic impulses reaching target organs
- decreased rate of peripheral conversion of T4 -> T3
in patients with diabetes, non-specific ß blockers like propranolol can
- inhibit the Epi/NE-mediated compensatory reactions to hypoglycemia (tremor, palpitations, sweating)
- blockade of ß2 receptors inhibit hepatic gluconeogenesis + peripheral glycogenolysis and lipolysis
- treat w/ SELECTIVE ß1 blockers instead because they do not block metabolic sympathetic effects
what should you consider when initiating chronic hypouricemic therapy with either xanthine oxidase inhibitors (allopurinol) or uricosuric agents (probenecid or sulfinpyrazone)?
it may precipitate an acute gouty arthritis attack, thereofre it is advisable to initiate chronic NSAID therapy to prevent this.
how does typical antipsychotics differ from atypical antipsychotics?
typical: haliperidol, trifluoperazine, fluphenazine, etc
typical = only + sx of schizo
ex: clozapine, risperidone, olanzapine, quetiapine
atypical = both + and - sx of schizo
leptin and adiponectin
where is it from? what type of factor is it? what does it do?
what happens if you have a mutation in leptin?
both are secreted from fat cells
-
leptin = hormone –> decreases food intake via
- decrease production of neuropeptide Y (appetite stimulant) in the arcuate nucleus
- stimulate production of POMC (appetite suppression)
- decrease insulin resistance
- ∆ leptin = hyperphagia + obesity
- adiponectin = cytokine, decrease insulin resistance
how do various parts of the choclea differ in terms of their fluid content?
scala vestibuli** + tympani** = perilymph (high Na)
scala media = endolymph (high K)
patient w/ acute epididymitis and orchitis w/ white discharge. Culprit?
Neisseria gonorrhoeae - can cause abscesses within the epididymis (white discharge)
GN (diplo)cocci
cardiac findings marfan’s syndrome
cystic medial necrosis of the aorta
lamellar bodies of type II pneumocytes
store and release pulmonary surfactant; deficiency can result in patchy atelectasis
neonatal jaundice should be given what therapy + vitamin supplement?
likely due to conjugation problem (think Craig Najjar or Gilbert d/o)
trmt: phototherapy (but this can destroy riboflavin, so you need to supplement this!!)
stimulating afferent portions of CN9 and CN10 will cause what to HR and BP?
bradycardia + hypotension
CN 9 and CN 10 carry afferent information from carotid sinus + aortic arch baroreceptors, respectively, to the medulla. Both receive input from the NTS
by incresaing the firing rate of these neurons, the NTS receives a “false signal” that the “BP is too high”, resulting in a baroreceptor reflex, resulting in decreased sympathetic outflow and increase parasympathetic outflow.
Net: bradycarida + hypotension
reaction formation
replacement of an unpleasant or unacceptable thought or desire (recovering drug addict who wants to use drugs) w/ an emphasis on its opposite (advocating against drug use)
onset of BP 160/110 and 3+ proteinuria at 16wks gestation suggests:
Hydatidiform mole
note that diagnostic criteria for pre-eclampsia is after 20 weeks gestation; before this, the sx are likely due to the hydatidiform mole
dysphoria, irritability, anxiety, increased appetite
patient is undergoing withdrawal of…?
PE findings?
OH
PE: seizures, tachycardia, palpitations
facial swelling and dark urine following a recent skin infection
post-strep GN
bipolar patient presents w/ polydipsia, polyuria, and very low specific gravity after water restriction should make you think of…
ADR of this Rx? 3 major ones
LITHIUM
antagonizes ADH -> nephrogenic DI
hypothyroidism
Ebstein’s anonmaly of the tricuspid valve
patient started on an antiplatelet drug comes in with fever + mouth ulcers. the first drug that should come to mind is…
ticlopidine - neutropenia (often presents as mouth ulcers + fever)
37yo w/ fibrocystic changes of her breast is at increased risk of breast cancer when there is….
**epithelial hyperplasia **
(ie florid hyperplasia, atypical ductal hyperplasia, and ductal carcinoma in situ, all of which have increasing risks of invasive ductal carcinoma)
pericardial knock
occurs in constrictive pericarditis, where there is reduced ventricular compliance via an external force (sharper, more accenutated heart sound that is heard earlier in diastole than S3)
what antihypertensive Rx can cause this?
ß blockers
ex: metoprolol - selective ß1 antagonist, which can cause bradycardia + varying degrees of AV block (in this case, a 2nd deg. AV block of 2:1 or 3:1)
Rifampin
MoA
how is resistance acquired?
MoA: inhibits DNA-dependent RNA-polymersase (prevents transcription)
Resistance: modification of the rifampin binding site on the bacterial DNA-dependent RNA polymerase, thereby preventing transcription of DNA -> mRNA
cause of greenish sputum in a patient with high fever, chills, and productive cough
myeloperoxidase - blue-green heme-based pigmented molecule
(don’t confuse with pseudomonas sputum, which is blue-green)
Purpose of using desmopressin in patients with hemophilia A
XLR d/o in Factor 8
DDVAP stimulates release of Factor 8 and vWF from endothelial cells
C1 esterase inhibitor deficiency
what Rx is absolutely contraindicated?
Hereditary angioedema
C1 esterase inhibitor normally degrades C1 and prevents excessive complement activation and inflammation; also inactivates kallikrein (which converts kiniogen -> bradykinin).
ø C1 esterase = active kallikrein + bradykinin are increased
**bradykinin + C3a + C5a cause angioedema via ** vasodilation/vascular permeability
contraindicated: Captopril (since ACEi can result in bradykinin accumulation)
NT responsible for induction of REM sleep
ACh
Nystatin MoA
binds to ergosterol in the fungal cell membrane and causes pore-formation and subsequent leakage of fungal cell contents
L homonymous superior quandrantanopia has damage to
R temporal lobe (meyer’s loop)
how do these factors change with HUS d/o?
Platelet Count
Bleeding time
PT
PTT
plasma fibrinogen levels
smear
Platelet Count = decrease
Bleeding time = increase
PT = NC
PTT = NC
plasma fibrinogen levels = normal
smear = RBC fragmentation
follows infection with shigella or Ecoli 0157:H7
what bony landmark would be most appropriate to locate the pudendal nerve.
ischial spine
pudendal nerve innervates the perineum; originates from S2, S3, S4 and leaves through the pelvis through the greater sciatic foramen and then wraps around the ischeal spine and sacrospinous ligament to enter the lesser sciatic foramen and eventually reach the perineum.
buzzword: mucicarmine stain
CRYPTOCOCCUS neoformans - it’s the only fungus that contains a polysaccharide capsule.
can also use silver stain
virulence factor of s. epidermidis
ability to form biofilms (extracellular polysaccharide matrix) on fibrinogen, fibronectin, prosthetic devices, IV catheters
biofilms functions as a barrier to antibiotic penetration, interferes with host defenses (opsonization, neutrophilm igration, even T cell activation)
5mo boy with sx consistent w/ viral bronchiolitis (low grade fever, runny nose, progressive cough, tachypnea, agitation)
bug?
treatment?
what other disease can you use this treatment for?
**Ribavirin - **nucleoside analog that inhibits synthesis of guanine nucleotides; active aganist RSV + HepC
how does MTB cause tissue distruction?
result of host immune response via Type IV **DTH HSR **- **Th1 specific cells - **results in granulomatous inflammation + caseous necrosis
PDA is common in…
premature infants, esp. those with RDS
no PERIPHERAL CD19+ cells
Bruton X-linked agammaglobulinemia - bc the cells in circulation (though there are immature CD19+ cells in the bone marrow)
Where nodes do the prostate gland drain into?
internal iliac nodes
minor drainage into external iliac + sacral nodes
ADR of carbamazepine
agranulocytosis or aplastic anemia
biochemical profile of 1˚ adrenal insufficiency in terms of Na, K, Cl, and HCO3
what does this patient look like?
what would cause this patient to suddenly undergo adrenal crisis? what would you give this person?
ø aldosterone** **or cortisol: Hyponatremia, Hyperkalemia, Metabolic Acidosis, HypOchloremia
signs of adrenal insufficiency: hyperpigmentation, vomiting, weight loss, abd pain
crisis: stressful situations (infection, surgery) normally cause adrenals to screte large quantities of cortisol, since it is essential to cardiovascular + metabolic adaptations to stress; but since this patient can’t mount that response -> hypotensive, tachycardic, hypoglycemic “shock-like states”
treatment: corticosteroid
Rx that requires an acidic environment to kill mycobacterium tuberculosis
**pyrazinamide (PZA) - **works best in acidic pH (ie phagolysosome); best for intracellular MTB
(compare to rifampin, isoniazid, and ethambutol, which have better activity against extracellular MTB
what does this patient have and which area corresponds to the opening snap?
Mitral Stenosis
OS occurs at the point where the LAP line first crosses w/ LV line - when the LV pressure drops below the LAP (towards the L side of the graph)
diastolic murmur
2yo F (46XX) w/ ambigious genitalia, clitoral enlargement and partial fusion of labioscrotal folds.
high BP, hypokalemia
enzyme deficiency?
net effects of this enzyme deficiency?
11 hydroxylase deficiency ->
- excessive adrenal androgen -> ambigious genitalia, etc
- excessive 11-DOC production -> hypokalemia, high BP
- high ACTH (due to ø cortisol), which further augments the production of T and 11-DOC
- ø aldosterone
note that this enzyme mutation is the second most common cause of CAH
L homonymous inferior quandrantanopia is due to a lesion in..
R parietal lobe (dorsal optic radiation)
tenderness of the calf muscle on dorsiflexion of the foot
Homan’s sign = DVT
MoA of rifampin?
blocks protein synthesis by inhibiting DNA -dependent RNA polymerase, thereby preventing transcription of DNA -> mRNA
I decrease GI absorption of calcium, inhibit collagen synthesis by osteoblast, decrease gonadotropin releasing hormone, and increase urinary calcium loss.
What am I
glucocorticoids
description describes a side effect of glucocorticoids: lower bone mineral density
what is lysyl oxidase?
enzyme that catalyzes the conversion of lysine residues to an aldehyde in collagen fibers (thus strengthening collagen fibers)
role of bcl-2
mutated in what disease
apoptosis inhibitor
follicular lymphoma
Schwannoma
Appearance
Prognosis, presentation
S100(+)
Acoustic schwannoma, (if bilateral gNF2)
Adults
8yoF w/ breast development + pubic hair
PE shows mass in RLQ, CT shows ovarian mass.
Dx?
Granulosa cell tumor - sex-cord/stromal tumor - produce excess estrogen hormones that can cause precocious sexual development, as seen in this child
Meckel diverticulum is caused by:
where is it generally located?
is it a true or false diverticula?
most common sx?
diagnostic test?
failure of obliteration of the omphalomesenteric duct (vitelline duct)
located 2 feet from ileocecal valve (distal ileum)
true diverticula = covered by all 3 layers (mucosa, submucosa, muscularis)
RLQ pain + lower GI bleed (black, tarry stool) due to presence of ectopic gastric (or pancreatic) mucosa; can cause ulceration of adjacent mucosa
pertechnetate study - accumulates in RLQ
Why are patients on ACEi predisposed to angioedema and cough?
bradykinin (produced by the kidney when RAAS is activated) acts locally to
- constrict veins and dilate arterioles to increase renal perfusion
- induce dry cough
normally metabolized by ACE; ACEi prevent its metabolism and increases bradykinin’s persistence in the body.
condylomata acuminata
genital warts due to HPV 6, 11
diuretic that causes pulmonary edema
mannitol
Charcot-Bouchard aneurysms
why do they form?
where are they located?
rupturing of these results in…
occur due to long-standing HTN
basal ganglia, pons, internal capsule, pons
intracerebral hemorrage
hCG is most similar to these 3 hormones
TSH, LH, FSH
oocyte surrounded by one or several cuboidal follicular cells
secondary follcile
what does this patient have?
mitral regurgitation
40F with worsening fatigue, no remarkable medical/social/family history, vitals and PE are normal, lab shows alk phos level of 180 U/L
What is the next step in evaluation? Justify.
AlkPhos is present in bone and liver and therefore you want to determine origin of the elevated AlkPhos by assessing GGT levels, which is present in the liver, but not in the bone
bacillis anthracis virulence factor has the similar mechanism of action as…
- b. anthracis - edema factor acts as an adenylate cyclase -> increased cAMP -> edema + phagocyte dysfunction
- bordetella pertussis - pertussis toxin disables Gi -> disinhibits adenyl cylase -> increased cAMP levels -> edema + phagocyte dysfunction
burkett lymphoma translocation
burkitt t8;14
∆ = 6 looks like a b
what do each one represent?
W = hCG
X = hPL
Y = CRH
middle aged women with Sjogren’s complains of severe pruritis over the palms and soles and is unbearable during the night. Diagnosis? labs? typical associations?
**1˚ biliary cirrhosis (PBC) - **autoimmune rxn that results in destruction of intralobular bile ducts and subsequent cholestasis
labs: anti-mitochondrial antibodies; elevated conjugated bilirubin, elevated Alk phos
associations: middle aged women with insidious onset of pruritis, esp at night. autoimmune conditions (CREST, Sjogrens, RA, Celiacs’)
marker for monitoring cystadenocarcinoma (serous and mucinous) recurrence
CA-125
unilateral swollen, tender and erythematous breast w/ an induration present at the edge of the erythematous area.
Dx + Hx changes?
**inflammatory breast cancer **
hx: dermal lymphatic invasion by cancer cells -> blocked lymphatic drainage -> lymphedema and w/ overlying skin swollen, red, tender, and peau d’orange appearance
presbyopia
what is it?
what causes it?
what does it develop into?
age-related condition in which the lens is unable to focus on near objects because of denaturation of structural proteins within the lens, leading to loss of lens elasticity (difficulty w/ reading fine print, eye strain after reading, need to hold objects farther from the eye in order to see them clearly)
presbyopia develops into myopia** (near-sightededness),** where patients retain teh ability to see up close and can also experience some improvement in distance vision
only antidepressant that does not cause sexual dysfunction
buopropion
(but ADRs include agitation, insomnia, and seizures)
why do patients w/ Klinefelter’s syndrome have mild mental retardation?
risk and severity of mental retardation increases with each additional X chromosome
(what does that say about women?!)
R homonymous hemianopia has damage to
L optic tracts
patient with painful palpable masses in the grown. PE shows multiple enlarged, abscessed LN draining through the skin through indolent sinuses. dx?
buboes = lymphogranuloma venereum - chlamydia trachomatis
1˚ lesion = PAINLESS self-healing papule or shallow ulcer, but draining LN becomes really PAINFUL
woman complaining of diarrhea containing a lot of mucoid material. colonoscopy shows cauliflower-like mass in the sigmoid colon. she also has hypoK. what does she have?
villous adenoma - large + sessile (compared to tubular adenomas that tend to be smaller + pedunculated)
- can cause lower intestinal bleeding + microcytic hypochromic anemia
- partial intestinal obstruction -> crampy abd. pain, constipation, distension
- can secrete lots of mucus, leading to secretory diarrhea (if stool volume is large –> hypovolemia + electrolyte imbalances
- risk of adenocarcinoma
how is potency measured?
1/MAC
potent anesthetics have low MAC
name this please
blastomycosis
large, round yeast w/ doubly refractile wall and broad-based bud
common in Ohio / Mississippi River Valleys, Great Lakes
Pulmonary form: pneumonia
disseminated form: severe…
what is this?
downey cell (infectious mono, EBV)
valproate
MoA
major ADR
Increase Na channel inactivation; Increase GABA concentration
neural tube defects - it inhibits intestinal folic acid absorption
hepatotoxicity (get LFTs)
weight gain
use: tonic clonic seizure (genearlized) and myoclonic seizures
what exits the foramen spinosum?
MMA
HFMD
coxsackie type A - a PERCH (picornavirus)
platelets - contents of:
alpha granules
dense granules
alpha granules - Fibrinogen, vWF “FaV”
dense granules - ADP, Calcium “CAD”
patient w/ a crush injury receives a skeletal m. relaxant for resusscitation and undergoes cardiac arrest (v-fib); serum K levels are 10mEq/L. What was he given and why does this occur?
what would’ve been a better Rx to give this patient?
**Succinylcholine **
- depolarizing neuromuscular-blocking agent; not degraded by AChE
- binds **nACh-R (non-selective cation channel that will allow Na influx/K efflux) **and causes continuous end-plate stimulation that ultimately results in inactivation of these channels
better to give vercuronium + rocuronium, which are non-depolarizing agents
patient with increased AG acidosis was given treatment X.
within several hrs, the patient’s mental status improves, serum HCO3 + Na levels increase, serum osmolality decrease, and K decreases.
Which was the dx? treatment?
DKA (most common)
trmt: hydration + insulin
<em>insulin</em>
- <em>allows cells to use glucose as an energy source, thereby decreasing lipolysis and the production of ketone bodies. Decreased ketone production -> increase plasma HCO3</em>
- <em>intracellular shift of K -> decrease serum K</em>
<em>rehydration - normalize serum Na and decrease serum osmolality</em>
cause of kidney stones in crohns ileocolitis
type of stones?
oxalate kidney stones
impaired bile acid absorption in the terminal ileum, leading to the loss of bile acids in the feces w/ subseqent fat malabsorption
fat binds Ca -> soap complex
free oxalate is absorbed and is filtered and collected in the kidneys –> urinary calculi
∆ between thrush and leukoplakia
thrush = can be scraped off; usually due to candida
leukoplakia = precancerous, cannot be scraped off
F w/ stretching/pulling sensation in her groin with R pleural effusion + SOB and fluid in her abdominal cavities. Dx?
Meigs’ Syndrome - triad of hydrothorax, ascites, and ovarian tumor (Ovarian Fibroma)
high potency anti-psychotics
ADR?
trmt for ADR?
haloperidol, fluphenazine
extrapyramidal sx due to D2 blockade (inhibition of the inhibitory effects of dopaminergic neurons, resulting in unopposed M1 cholinergic activation)
trmt: M1 receptor antagonists (diphenhydramine and benztropine) to re-establish balance
45F w/ hx of SLE is generally treated with what?
what do you expect her body habitus to be?
what do you expect her adrenal glands to be?
if she suddenly stopped her Rx, what do you think will happen?
- usually treated w/ glucocorticoids
- body habitus - Cushing syndrome - truncal obesity, mild hirsutism, facial plethora, proximal muscle weakness
- adrenals: bilateral cortical atrophy due to suppression of the HPA axis by the glucocorticoids
- sudden cessation after prolonged use -> adrenocortical insufficiency + adrenal crisis
What should you give a patient w/ rabies?
Killed vaccine (of entire viral particles)
how does nephritic and nephrotic syndrome differ in term of proteinuria + RBC casts + lipiduria + renal function
nephritic:
nephrotic: >3.5g/day, ø RBC casts, lipiduria, normal renal function
acute onset of neurologic ∆s, hypoxemia, and petechial rash in a patient w/ severe long bone or pelvic fractures
fat embolism syndrome
neonate w/ a continuous machine like murmur + an ECHO that shows an aorta lying anterior to and to the right of the pulmonary artery is diagnostic of….
transposition of the great arteries - failure of aorticopulmonary septum to spiral normally during fetal development.
continuous machine like murmur is due to PDA - connection that allows this neonate to survive
Why is primaquine often added to chloroquine?
vivax or ovale = both establish a latent hepatic infection in the form of hypnozoites.
chloroquine = kills plasmodia in the blood stream
primaquine kills the hyponozoites and prevents relapses
why are reticulocytes “bluer” than a mature RBC?
the basophilic reticular mesh-like network is **residual ribosomal RBA **(stained with Wright-Giemsa stain)
effets of anti-cholinergic toxicity
examples of Rx that does this?
fever, mucosal/axillary dryness, cutaneous flushing, mydriasis, and cycloplegia an ddelirium
hot as a hare
dry as a bone
red as a beet
blind as a bat
mad as a hatter
examples: BIOGAS: benztropine, ipratropium, oxybutynin, glycopyrrolate, atropine, scopolamine
Match choice w/ each line:
Normal enzyme control
Mutation producing increased Km
Mutation decreasing amt of functional enzyme
X = mutation decreasing amt of functional enzyme
Y = Mutation producing increased Km
Z = Normal enzyme control
lesions of these 2 areas of the brain are responsible for the confabulation + memory loss
mammillary bodies = memory loss
anterior + dorsomedial thalamic nuclei = confabulation (when unsure of a fact, they fill in the memory gap w/ a fabricated story they themselves believe to be true)
MTB isolateds treated w/ Rx lose their acid-fast rapidly and stop porliferating. What Rx?
isoniazid - blocks mycolic acid synthesis
short-acting insulin (post-prandial
regular (best for DKA)
Lispro
Aspart
Glulisine
No “LAG” *be careful not to mix Glulisine with Glargine - remember “Glaarrrrrrrrrrr” sounds long
causes of low Ca, low PTH?
Hypoparathyroidism
(surgical removal, autoimmune destruction)
dobutamine
MoA
clinical use
ß adrenergic agonist (mostly ß1; little ß2 and a1)
ß1 = incr. cAMP -> (+) ionotropy/contractility (incr MVO2, HR)
ß2 = = decrease peripheral vascular resistance
clinical use: acute heart failure due to cardiogenic shock (decreased myocardial contractility)
biochemical features of Alzheimers
decreased ACh
decreased GABA
WBC casts are pathognomonic for…
pyelonephritis (UTI)
37yo w/ cyclic pelvic pain, normal sized uterus, dyschezia
endometriosis - presence of normal endometrial tissue in abnormal locations (outside uterus) which undergo menstrual type bleeding to form chocolate cysts
“normal size”
what Rx should you prescribe to a patient w/ an acute gouty attack?
What dont you want to prescribe in these cases?
colchicine
inhibits microtubule formation in leukocytes, thereby reducing neutrophil chemotaxis and migration to inflammatory sites
impairs GI mucosal function (due to microtubule disruption), leading to D, N, V, abd. pain
DO NOT prescribe allopurinol or probenecid since they can mobilize tissue stores of uric acid and precipitate/worsen acute attacks
someone who undergoes excessive weight loss by consuming water and vitamin pills only will have an increased of what in their serum?
ketone bodies - acetoacetate + 3-hydroxybutyrate
name this please
mucormycosis - broad, non-septate hyphae that branch at right angles
(+) VDRL + pleocytosis of CSF is diagnostic of:
neurosyphilis (3˚ syphilis!!)
presence of gumma
Pancreatic cancer chromosome
18q (patrick swayze died of this - he was born 8-18)
in 10% of cases, chronic aortic stenosis can preciptiate into…
a-fib. Why? Cause the atrial contraction is impt for maintaining adequate filling of a non-compliant LV (sequelae of aortic stenosis)
reducing LV preload + CO –> systemic hypotension
decreased forward filling of LV -> increased LAP -> acute pulmonary edema
∆ btwn icteric vs anicteric viral infection
anicteric = silent or subclinical; ø jaundice observed
icteric = jaundice, malaise, fatigue, etc
what should patients be tested for prior to starting enteracept?
PPD - latent TB (since TNFa inhibitors can cause reactivation)
newborn w/ flaccid lower extremities and bilateral absent ankle reflexes. XRay shows poorly developed lumbar spine + sacrum.
Diagnosis? What causes this?
Caudal regression syndrome - sacral agenesis causing lower extremity paralysis and urinary incontinence (hard to tell in an infant…)
due to poorly controlled-MATERNAL DIABETES
how do these factors change with liver disease?
Platelet Count
Bleeding time
PT
PTT
clotting factors
Platelet Count = NC
Bleeding time = NC
PT = increase
PTT = increase
(decreased all clotting factors)
Diagnosis
cause?
commin in what patient population?
Dupuytren’s contracture - benign and slowly progressive fibro-proliferative d/o of the palmar fascia. As the scarring progresses, nodules form on the palmar fascia and the fingers gradually lose their flexibility, eventually resulting in contractures that draw the finger into flexion
common in: ALCOHOLICS
difficulty of plantar flexion is usually due to damage to which nerve?
tibial nerve (branch of sciatic nerve; provides innervation for popliteus + flexors of the foot)
33 yo sexually active woman develops painful, swollen right knee. What should you consider and what is the pathogenic feature of this organism?
septic arthritis, likely due to neisseria gonorrhoeae; major pathogenic feature = **PILI **(convers adherence properties, protects aganist phagocytosis, and undergoes antigenic variation)
mental retardation, eczema, musty body odor in toddler
PKU
patient who receives several units of packed RBC begins to complain of tingling sensation in his toes and fingers. Ca levels are 7.2mg/dL (normal 8.4-10) Why?
paresthesias due to hypocalcemia.
Packed RBCs contain citrate anticoagulant, which chelates serum Ca + Mg; usually occurs with multiple transfusions of more than 5-6L of blood.
patient w/ fever, fatigue, joint pain, and urticaria-type skin rash suddenly develops a surge of serum ALT and AST
what is the diagnosis?
Hep B
say wha….blows my mind, but according to Uworld:
prodromal period: “serum sickness-like” w/ patients experiencing malaise, fever, rash, pruritis, lymphadenopathy, and joint pain
acute viral hepatitis: significant rise in ALT, AST (followed by rise in bilirubin and AlkPhos)
NOT hepC infection because it is usually asymptomatic, though some may complain of malaise, nausea, or RUQ pain
patient w/ R foot that is dorsiflexed and everted and is unable to stand on tip toes. What nerve is affected + what is the likely area of sensory loss
tibial nerve - innervations/fxns
- gastrocnemius, soleus, plantaris -> plantar flexion of the foot
- digitorum longus + flexor hallucis longus -> toe flexion
- tibialis posterior muscle -> inversion of the foot
- area of sensory loss: skin of the distal plantar surface of the foot
fomepizole - when is it used?
antidote in suspected MeOH or ethylene glycol poisioning
acts as a competitive antagonist of alcohol dehydrogenase and thereby prevents the conversion of methanol/ethanol into their toxic metabolites
diagnose
cowdry type A inclusions - herpes virus
ab with shortest half-life
IgD
arachnodactyly, scoliosis, aortic root dilation
Marfan (fibrillin1 defect)
acarbose
MoA
ADR
clinical use
acarbose - decreases activity of a-glucosidase on the intestinal brush border -> prevents hydrolysis of disaccharides, thereby allowing delayed carbohydrate absorption (remember that carbs are absorbed as monosacchardies)
Same class: miglitol
ADR: flatulence, bloating, abd. pain, rash
clinical use: type II DM
CN 3 emerges between these two vessels
posterior cerebral (PCA)
superior cerebellar (SCA)
stylopharyngeus m. is derived from?
3rd branchial arch - innervated by the CN9
also from this arch is portions of hyoid bone and posterior 1/3 of the tongue
interpret this
HBsAg positive
anti-HBc positive
IgM anti-HBc negative
anti-HBs negative
Chronically infected
nausea, vomiting, abd. cramps, muscle aches, dilated pupils, yawning, piloerection, lacrimation, hyperactive bowel sounds
patient is undergoing withdrawal of…?
PE findings?
Heroin
ABG typically seen of heroin overdose
pH
pCO2
HCO3
heroin suppresses respiratory centers, resulting in hypoventilation with retention of Co2. An overdose is an acute event.
pH = low pCO2 = high HCO3 = normal
what would increase one’s susceptibility to an organism that GP, oxidase + that grows on highly alkaline media?
omeprazole/PPI’s
vibrio cholera - note that it grows well on highly alkaline media and it must survive passage through the acidic pH of the stomach to colonize the small intestines to cause disease
what nodes drain the testes?
what nodes drain the scrotum?
testes: paraaortic nodes
scrotum: superficial inguinal nodes
autopsy of 21yo shows atrophy of basal ganglia, increased brain Cu
dx?
Wilson’s disease - Cu accumulates within organ tissues (esp. liver, brain, and eye; at risk for:
hepatitis, cirrhosis, portal HTN
neuropsychiatric sequelae: basal ganglia atrophy - parkinson-like tremor, rigidity, ataxia, slurred speech, personality ∆s, depression or paranoia
what is the basis behind warfarin-induced skin necrosis?
Protein C levels has a shorter half-life than the other vitamin K dependent factors (2, 9, 10), resulting in a transient hypercoagulable state
patient w/ dorsiflexed + everted foot w/ sensory loss over the sole of the foot
injured nerve?
tibial
drugs w/ high intrinsic hepatic metabolism + hepatic clearance tend to have these two properties:
high lipophilicity (allows Rx to cross cell membranes and enter hepatocytes and then excreted into bile)
**high volume of distribution **(wide distribution to many different tissues, such as the brain, liver, adipose)
malar rash on cheeks appearance followed by a an erythematous rahs in a reticular pattern on the trunk + extremeities
parvoB19 (erythema infectiosum)
infarcts involving anterior pons results in…
corticospinal tract damage: contralateral hemiparesis + babinski
corticobulbar tract damage: contralateral lower face palsy + dysarthria
pontine nuclei + pontocerebellar fibers damage: contralateral dysmetria + dysdiadochokinesia
ATAXIC HEMIPARESIS
honey + constipation, mild weakness, lethargy, poor feeding should make you think of this
infant botulism - spores in honey
chemoRx associated with burning on urination + urgency
cyclophosphamide, ifosfamide
hemorrhagic cystitis
reverse w/ mesna
What is a “lucid interval” and it is often seen in what type of brain injury
transient period of feeling well after the head injury followed by a rapid declind in mental function that can progress to coma/death
epidural hematoma
organism associated w. progressive difficulty walking, weakness in lower extremities and absent DTR + recent hx of diarrhea
campylobacter
GN, motile, corkscrew appearance; oxidase +
43yo African American F complains of bilateral paresthesias of her thumbs, index, and middle fingers; no problems w/ legs. Hx of chronic renal failure due to uncontrolled HTN and requires hemodialysis on a regular basis
Dx?? (be specific)
carpal tunel syndrome due to ß2 mucroglobulin deposition (dialysis associated amyloidosis)
most common cardiac cause of sudden death in young, seemingly healthy individuals w/o signs
pathophysiology behind this?
murmur that is associated with this d/o?
hypertrophic cardiomyopathy
dynamic ventricular outflow tract obstruction caused by abnormal systolic anterior motion of the anterior leaflet of the mitral valve toward the hypertrophied interventricular septum
systolic ejection murmur produced by the LV outflow tract obstruction
cardiac findings in down syndrome
endocardial cushion defects (ASD, regurgitant AV valves)
lung bx shows alveolar growth pattern w/o invasion.
dx?
bronchioloalveolar carcinoma (variant of adenocarcinoma)
arises along alveolar septae w/o vascular or stromal invasion
on cxr, it appears as a peripheral mass or pneumonia-like consolidation
how do you differentiate btwn chronic HepB hepatitis of low or high infectivity?
- low - low or undetectable levels of HBeAg (marker of high infectivity) and detectable anti-HBeAg
- high - high or persistent levels of HBeAg and low or undetectable levels of anti-HBeAg
in other words, HBeAg is a marker of high infectivity
32 yoF w/ LN that fluctuates in size over time. Dx?
Follicular lymphoma (t14;18, bcl-2) - indolent non-Hodgkins lymphoma; indolent course marked by painless waxing and waning lymphadenopathy (ie remissions and recurrences)
what is the purpose of the washout period between treatment w/ MAOi and treatment w/ SSRI??
allow for MAO regeneration, since MAOi (ie tranylcypromine, phenelzine, and selegiline) irreversibly inhibit MAO (whhch normally functions to breakdown monoamine neurotransmitters ie serotonin)
eosinophil infiltrates in bronchial bx should make you think of..
allergic asthma
patient w/ difficulty rising from seated position and climbing stairs. injury to what nerve?
inferior gluteal n. - innervates the gluteus maximus
what happens to bile acids before they are secreted into the canaliculi?
they are conjugated to glycine or taurine (improves solubility/emulsifying ability) to create bile salts, which are actively secreted into the bile canaliculi
Medulloblastoma
Location
Appearance
Prognosis, presentation
Cerebellar vermis (posterior fossa)
Solid tumor w/ sheets of small blue, hyperchromatic nuclei + scant cytoplasm; homer-wright rosettes can be seen in 1/5 of cases
Kids
Malignant
hemosiderosis vs hemochromatosis
hemosiderosis - iron accumulation in parenchymal tissues
hemochromatosis - defect that results in abnormally high Fe absorption of dietary iron that results in
- mildly elevated LFTs
- elevated plasma Fe w/ >50% TIBC
- elevated serum ferritin (storage)
TTP is due to
typical labs?
∆ ADAMTS13, which cleaves vWF multimers
labs:
increased bleeding time
decreased platelet count
**increased indirect bilirubin and **LDH
schistocytes
ø fibrin split products (d-dimers, DIC would have elevated levels), PT/PTT is normal (whereas in DIC, both are prolonged)
patient develops HIT after given heparin for DVT (platelets are 85k). What is an alternative?
Argatroban, bivalirudin or lepirudin
BM splitting is seen in which two renal disease
membranoproliferative glomerulonephritis and Alport Syndrome
where does the scala vestibuli and scala tympani meet?
helicotrema
gram (+) filamentous rod in sulfur granules
actinomyces isrealii
1yo african american boy who acutely developed tender swelling of both hands and feet.
think sickle cell - dactylitis (painful swelling of hands/feet)
AR d/o in african americans
combination of
low MCV
low serum Iron
high TIBC
should make you think of…
iron deficiency anemia - body iron stores are reduced and the TIBC increases as the body attempts to accumulate more Fe
MEN 2A
gene mutation?
what does it affect?
activating mutation of RET protooncogene
parathyroids (hyperplasia)
pheochromocytoma
Medullary thyroid cancer (MTC, calcitonin)
flung transplant - chronic rejection affects which part of the transplant specifically and presents with what sx?
small airways - causes bronchiolitits obliteratans syndrome
sx: dyspnea, wheezing
pathophysiology of direct inguinal hernias
protrusion of abd. contents through the Hesselbach ∆ on the anterior abdominal wall
macrophages with Pas(+) granules in the lamina propria of the GI is indicative of? how should you treat it?
infection with tropheryma whippelii (GPR actinomycete) - affects small intestines, joints, and CNS
trmt: obviously antibiotics..
High MCV
Normal Serum Fe
Normal TIBC
should make you think of..
megaloblastic anemia due to folate or B12 deficiency - DNA synthesis lags behind cytoplasm formation so mitosis is relatively delayed and RBCs are larger than normal. Iron metabolism is usually not directly affected
anaplasia v. dysplasia vs. neoplasia vs metaplasia
neoplastic - morphologically and architecturally similar to normal cells; usually in well-differentiated/low grade tumors
dysplastic - REVERSIBLE expansion of immature cells that is confined to the epithelium
anaplastic - neoplastic cells that demonstrate a complete lack of differentiation; may contain abnormal mitoses + giant tumor cells
metaplasia - reversible differentiation of cells
active immunity vs. artificial active immunity
when one is stimulated to produce their own immune response artificial - stimulus (vaccination) was medically applied to induce immune response
severe starvation effect on a.a. levels
essential amino acids become deficient PVT TIM HALL
T/F - adults can have anti-HAV IgG antibodies without ever experiencing an icteric illness (jaundice, malaise, fatigue, anorexia, etc)
T.
how do differentiate CMT from friederich ataxia?
- charcot marie tooth
- scoliosis
- pes cavus
- muscle wasting of the anterior compartment of the lower limbs due to dis-myelination of the deep peroneal nerve
- friedrich ataxia
- kyphoscoliosis
- pes cavus
- ataxic gait, freqent falling
- cardiomyopathy = frequent cause of death
GLP-1 (exenatide)
clinical use
MoA
incretin hormone; secreted by intestinal L cells in response to food intake; clinically used for Type II DM
acts through GPCR -> decreases blood glucose by
inducing satiety
decreasing gastric emptying
increasing insulin release from pancreatic ß cells
This is a lung biopsy. What’s the diagnosis?
pulmonary chondroma (hamartoma; coin lesion)
contain islands of mature hyaline cartilage, fat, smooth muscle, and clefts lined by respiratory epithelum
radial n. pierces through this structure
injury to this nerve results in:
supinator
injury: wrist drop (innervates extensors of the hand)
Pt w/ BPH has allergies and wants Rx.
What drugs are appropriate and why?
H1 blockers
- 1st gen: Diphenhydramine, dimenhydrinate, chlorpheniramine.
- 2nd gen: Loratadine, fexofenadine, desloratadine, cetirizine.
but 1st gen has anti-muscarinic and anti-alpha side** **effects should be avoided since it reduces the contractility of bladder smooth muscle –> acute urinary retention
Also - decongestants with alpha-1 agonist ativity (pseudoephedrine) should also be avoided for the same reason
Argatroban, Bivalirudin, Dabigatran
MoA?
inhibits **thrombin (IIa) **directly
23yoM w/ myoclonic epilepsy of recent onset has a muscle bx that shows blotchy red muscle fibers on Gomori trichome stain. Risk of transmission to his offspring?
0% - this is a mitochondrial myopathy “MERRF” and only maternal mitochondria are transmitted to the fetus.
feature that is common to both sickle cell anemia + ß thalassemia
bone marrow expansion in the calvarium
aachondroplasia
what is it?
defect in?
what type of inheritance pattern does it follow?
“midgets” - disproportionately short arms and legs, large head, saddle nose
defect: activating mutation in FGF-R3
Autosomal Dominant or Sporadic Mutation
genetically female fetus w/ virilized genitalia + hyponatremia + hyperkalemia + hypotension should make you think of…
21 hydroxylase deficiency (corticosteroid precursors are shunted toward androgen production)
definition of interference
inhibition of one viruse’s replication and/or release of a second virus that is infecting the same cell; doe snot result in new progeny phenotype
why is it that central retinal artery occlusion results in a pale retina w/ a “cherry-red” spot on the macula?
macula has a separate blood supply from the choroid artery, while the rest of the retina is supplied by the central retinal artery (arises from the ophthalmic artery, which arises from the ICA)
amphotericin B
MoA
ADR
binds to ergosterol (fungal version of cholesterol; present on cell membranes)
<strong>a</strong>mph<strong>o</strong> and <strong>e</strong>rg<strong>o</strong> both start w/ vowels + have “O” as their second syllable
however, they can also bind to human cholesterol to some degree and cause toxicity to human tissues and result in nephrotoxcity -> hypokalemia + hypomagnesemia occur due to increased distal tubular membrane permeability
(hypokalemia manifests as weakness and arrhythmias; ECGs show T-wave flattening, ST-depression, prominent U waves, and premature atrial/ventricular contractions)
∆ between condyloma lata and condyloma acuminata
condyloma lata = 2˚ syphilis (large gray wart-like growths)
condyloma acuminata = anogenital warts caused by HPV 6/11
∆ between chancre, condyloma lata, gumma?
chancre = 1˚ syphillis = painless ulcer w/ raised borders
condyloma lata = 2˚ syphilis (large gray wart-like growths)
gumma = 3˚ syphilis = painless, granulomatous lesions that progress to gray-white rubbery lesions that may ulcerate
antibiotic that causes myopathy and CPK elevation and is inactivated by pulmonary surfactant
daptomycin - depolarizes the cellular membrane
cytokeratin is a marker of
epithelial origins
(keratin-containing intermediate filaments that make up the cytoskeleton of almost all epithelial cells)
myoclonic seizure
description (consciousness)?
first line treatment?
brief arrythmic jerking movements; no loss of consciousness
valproate
what thyroid state causes myopathy (increase CPK)?? and why?
HYPOTHYROID - get serum TSH levels
BM that shows this is indicative of…
ALL - hypercellular bone marrow with a high % of lymphoblasts
Caspofungin MoA
blocks synthesis of ß (1,3)-D-glucan
(main component of Candida + Aspergillus)
CaB (candida+aspergillus, **ß **(1,3)-D-glucan)
L-selectin
Siaylyl-Lewis
E-selectin
P-selectin
Selectins = involved in rolling & margination
(selectin’ a place to bind to!)
NeutrophiLs = L-selectin, Siaylyl-Lewis
Endothelial cells = E-selectin, P-selectin
greatest regulator of cerebral circulation
CO2 - potent cerebral vasodilator
someone who hyperventilates (panic attacks) - develops hypocapnia, which can cause cerebral vasoconsriction –> neurological sx
serum findings for exercise-induced amenorrhea in terms of
FSH
LH
Estrogen
all decreased bc this is a form of hypothalamic amenorrhea
pt w/ holosystoic mumur w/ blowing quality over the cardiac apex w/ hemorrhagic macules on the sole of the feet
mitral regurg
janeway lesions - septic embolization from infected cardiac valve vegetations. tends to localize on palms and soles. painless
pulsus paradoxus
cardiac tamponade (also presents with hypotension)
tonic clonic seizure
description (consciousness, post-ictal state)?
first line treatment?
generalized tonic extension of the extremities, followed by clonic rhythmic movements; loss of conscious + prolonged post-ictal confusion
phenytoin, carbamazepine, valproate
antidepressant that can induce mania
Venlafaxine (SNRI) or any antidepressants
breast tumor with “indian file” cell organization
Invasive lobular breast tumor; bilateral, multiple lesions
in what cases would you give rifampin as a monotherapy? or multi-agent therapy?
monotherapy: H influenza or N. meningitidis exposure
multi-agent therapy: mycobacterial exposure
How does the L/R testicular vein differ in terms of their drainage?
What about the L/R suprarenal veins?
- Testicular vein
- L = L renal vein
- R = IVC
- suprarenal vein
- L = L renal vein
- R = IVC
summary: L = L renal vein, R = IVC
midshaft humeral fracture can damage these 2 structures
radial n. + deep brachial a.
(results in wrist-drop due to paralysis of the forearm extensors and wrist)
poliomyelitis
what is another d/o that can present the same way?
symptoms of fever, malaise, aseptic meningitis occur first, followed by loss of neurons in the anterior horn of the spinal cord (LMN lesion -> flaccid paralysis, atrophy, areflexia, and muscle fasciculations
Werdnig-Hoffman Syndrome - congenital degeneration of anterior horn of spinal cord.
tamoxifen effects
SERM (selective estrogen receptor modulator - antagonist effects in breast - agonist effects in endometrium -> endometrial cancer - decrease bone loss
how does an indirect inguinal hernia occur?
enters via internal/deep inguinal ring (Lateral to inferior epigastric vessels; above the inguinal ligament) and exit out the external inguinal ring; can continue into scrotum!
caused by failure of the processus vaginalis ot obliterate
common in male infants
rust colored urine, facial swelling (periorbital edema), BP 150/90, elevated BUN/creatinine, urinalysis w/ hematuria, RBC casts, mild proteinuria (1+ = 1g/day)
what determines prognosis?
PIGN
prognosis determined by **AGE!! **
young children = good; most recover completely w/ conservative Tx
adults = not so good; only 50% will resolve completely; rest will develop chronic GN or RPGN
how does non-pathogenic strains of S. pneumo acquire pathogenicity?
transformation
eye field looks like this:
where is the lesion?
optic chiasm
C
cytarabine
leukemia, lymphomas (ie AML)
inhibits DNA polymerase
ADR: leukopenia, anemia, megaloblastic anemia
how does sleep patterns change with the elderly?
more awakenings and arousal at night
awakens earlier
less total sleep
REM remains constant up to around 80yo and then declines
Stage 4 and then stage 3 NREM (slow wave) vanishes
what drains into the superficial inguinal nodes?
all skin from the umbilicus down (external genitalia, anus (up to pectinate line)), but excluding the posterior calf
purpose of using glucose + heme in the treatment of acute intermittent porphyria
both lead to ALAS inhibition
34 M with bitemporal visual deficit; labs show elevated prolactin.
how do you expect these to change: GnRH, LH, T
suspect pituitary tumor, most likely prolactinoma - inhibits entire axis of GnRH-LH/FSH, causing impotence in men, amenorrhea in women of reproductive age
GnRH = decrease
LH = decrease
T = decrease
MoA of dopamine in the H-P axis
inhibits prolactin
role of c-myc
mutated in what dz
nuclear transcrptional activator of genes involved in proliferation, differentiation, and apoptosis
burkitts
of these, which one has the highest oral bioavailability? NTG isosorbide dinitrate isosorbide mononitrate amyl nitrate Na nitroprusside
isosorbide mononitrate
severing the glossopharyngeal afferent fibers will cause what to HR and BP?
HTN w/ tachycardia
CN9 and CN10 carry afferent informaton to the medulla from teh carotid sinus and aortic arch baroreceptors, respectively; firing rate of these neurons increase w/ increasing BP
severing either one of these -> false signal to the medulla, signaling that the animal suddenly had a decrease in BP, thus eliciting a baroreceptor reflex that results in an increase in sympathetic outflow and decrease in parasympathetic outflow
net: HTN + tachycardia
ATP yield from conversion of glucose to 2 pyruvates
ATP yield if you add arsenic?
2 ATP / glucose molecule
w/ Arsenic: 0 ATP/ glucose because it competes w/ glyceraldehyde-3-phosphate dehydrogenase
“moldy” grains in china should make you think of what bug?
what do these bugs produce?
what is this person at risk for?
Aspergillus flavus and Aspergillus parasiticus
produces aflatoxins, which produces p53 mutations
hepatocellular carcinoma
pathophysiology of claudication
atherosclerosis (lipid filled intimal plaque)
diuretics that cause angioedema
ACEi
pregnant woman in her 2nd trimester has glucose in her urine and glucose levels of 147mg/dL, with no hx of diabetes. what factor is responsible for this?
increased hGH - growth hormone variant produced by the placenta (that acts like GH) to
- stimulate IGF-1 in the mother and largely regulates maternal intermediary metabolism to allow the fetus to receive more glucose and a.a.
- has anti-insulin effects, resulting in increased circulating glucose levels in the mother
What does this represent? (choose one)
Increase preload
Increase afterload
Systolic dysfunction
Increased ejection Fraction
Normal Saline Infusion
Increased preload
purpose of N-acetylcysteine in CF patients
mucolytic agent - cleaves disulfide bonds within mucus glycoproteins
most common location for colorectal cancer
rectosigmoid colon (followed by ascending colon)
2 yo w/ spontaneous bursts of non-rhythmic conjugate eye movements + hypotonia + myoclonus. has an abdominal mass. dx?
markers?
histology?
neuroblastoma - common extracranial tumor that develops from neuroblasts in the adrenal medulla. associated with N-myc amplification
markers: neuropil, S100, synaptophysin, chromogranin
hx: looks like solids sheets of small cells w/ dark nuclei and scant round cells
labs: incr. homovanillic acid (HVA) +/- vanillylmandelic acid (VMA)
retropertional abdominal mass, HTN, anorexia, weight loss
treatment for acromeagly or gigantism
octreotide (somatostatin analog) pegvisomant (GH receptor antagonist)
“presence of smoothly marginated, submucosal, rounded 5cm mass in the uterus fundus”
dx + histological pattern?
leiomyomas - whorled pattern of smooth muscle in bundles w/ well-demarcated borders
patient w/ fever, thrombocytopenia, microangiopathic hemolytic anemia (schistocytes on smear), renal insufficiency, and neurological manifestations have..?
TTP - likely caused by antibodies that recognize the metalloprotease (ADAMST13) that cleaves vWF multimers
all 5 sx are not often seen, but the most common triad is
thrombocytopenia
microangiopathic hemolytic anemia (schistocytes on smear)
neurological manifestations
cleft lip results when
maxillary prominences fail to fuse properly w/ the intermaxillary segment (philtrum) during early embryonic development
Erythematous ulcerating lesion of nipple has a bx that shows large, clear mucin-filled cells w/ abundant cytoplasm w/ intraepidermal spread of these cells. Dx?
Paget disease - ductal carcinoma in situ - malignant cells (paget cells) extnd intraepidermally within the ductal system into the nipple w/o crossing the BM
what would you do if someone needed an emergency airway but couldn’t be intubated?
perform a cricothyrotomy - involves making an incision of superficial fascia, pretracheal fasica, and cricothyroid membrane (between thyroid + cricoid cartilages)
15 yo boy dies in a car accident, his younger brother begins to wear his jacket all of the time, no matter how warm the weather is
identification - unconscious adoption of the characteristics or activities of another person (often a mxn for reducing the pain of separation or loss)
Clinical use + ADR of acyclovir
HSV 1/2
VZV
ADR: crystal nephropathy (renal toxicity), neurotoxicity (delirium + tremor)
thrombasthenia
AR - defective platelet aggregation that causes
prolonged bleeding time
normal # of platelets
34yoM died of internal hemorrage inherited a defect of an elastin-associated glycoprotein that is abundant in zonular fibers of the lens, periosteum, and aortic media. Dx?
Marfans - fibrillin-1
fibrillin1 is a major component of the microfibrils that forms a sheath around elastin fibers; serves as a scaffold for elastin deposition.
macrophage marker
CD14
sudden upward jerking of the hand at the level of the shoulder can cause injury to which part of the brachial plexus?
lower trunk of the brachial plexus (C8-T1) - both of which contribute to the median + ulnar nerves (together, these nerves innervate all of the intrinsic muscles of the hand)
results in “hand clumsiness or paralysis”
Rivaroxaban, Apixaban
MoA?
inhibits Factor Xa directly
diabetic Rx that causes increased insulin release
sulfonylurea (Glyburide, Glipizide) - causes K channel closure in ß cells
ADR: disulfram-like rxn
patient with ø T tubules in some muscle fibers will experience what?
uncoordinate contraction of myofibrils
of these, which ions are intracellular? extracellular?
Na, Cl, Ca, K
**only K is intracellular! **
rest is extracellular
Trousseau sign
occlusion of brachial artery with BP cuff (triceps)–> carpal spasms
VHL chromosome
3p (3 letter word, as siedlecki said..)
net vasopressin effects
V2-receptor mediated increase in H2O and urea in the CD (ie renal clearance of these substances are reduced!)
**Gemfibrozil, **Fenofibrate
Clinical Use
MoA
ADR
What increases ADR?
- Clinical use: HyperTG (hVLDL) – 1st line
- MoA: Actvate PPAR-a ****(and somehow suppresses cholesterol 7a-hydroxylase activity), ultimately reducing the conversion of cholesterol into bile acids)
- ADR: Gallstones (since it increases cholesterol content of bile!),
- increased risk of cholesterol gallstones w/ concomitant use of bile-acid binding resins
how does leuprolide affect testosterone and DHT levels?
how does this compare to finasteride?
- Leuprolide - transient increase, then decrease in both T and DHT
- Finasteride - decrease in DHT
serotonin syndrome caused by:
anti-emetic?
analgesic?
antibiotic?
migraine Rx?
cancer?
ondansetron
tramadol
linezolid
triptans
carcinoid tumor when it metz the the liver (b/c secretory products are no longer degraded)
staghorn calculi seen in
ammonium mg phophsate (struvite) stones
cysteine stones
bone marrow that shows this should make you think of..
myelophthisic anemia - anemia caused by space-occupying lesions (fibrosis, granuomas, etc) in the bone marrow. all lineages are affected -> pancytopenia.
how does dehydration affect RPF, GFR and FF?
dehydration –> decr. RPF + decr. GFR
RAAS activation –> efferent arteriole constriction to maintain GFR
FF = GFR/RPF = increases (bc RPF drops proportionately more than GFR)
mucicarmine staining of bronchoalveolar fluid shows budding yeast forms w/ thick capsules
at risk for what?
cryptococcus neoformans - stains red on mucicarmine stain
at risk for meningitis - esp those with HIV, sarcoidosis, or leukemia, immunocompromised
biopsy of the myocardium is indicative of..
viral myocarditis - lymphocytic interstitial infiltrate w/ focal necrosis of myocytes adjacent to to the inflammatory cells
JVD , hypotension, tachycardia could be either one of two things
cardiac tamponade
(look for Beck’s triad: hypotension, distended neck veins, distant or muffled heart sounds, as well as tachycardia; also pulsus paradoxus)
tension pneumothorax
elevated JVP + low BP + tachycardia
cardiac tamponade
What’s estrogen’s effect on bone?
anabolic effect: increase osteoBlastic and decrease osteoClastic activity
decreased lung compliance may be caused by these 3 factors
pulmonary fibrosis
pulmonary edema (L ventricular failure, inflammation)
insufficient surfactant
cardiac manifestation of lupus
inflammation of serous membranes (pericardial inflammation)
- results in chest pain that radiates to the neck and shoulders/back, increases with inspiration, and is relieved by sitting up auscultate by having the patient sit upright and leaning forward
- should hear a scratchy sound
CF patients are most likely to die from..?
pneumonia
NOT malabosrption due to pancreatic insufficiency b/c this can be fixed w/ pancreatic enzyme supplemnetation
what would be a potential cause for variegated, mottled appearance of the liver (hemorrhage + necrosis in the centrilobular regions)?
**Chronic CHF **- causes blood stasis in the central veins and central sinusoids of hepatic lobules + subsequent central hemorrahgic necrosis.
not acute RHF because this typically leads to acute congestion of the liver, which does not cause the typical nutmeg appearance of chronic congestion
What is primidone?
antiepileptic that is metabolized to phenobarbital + phenylethylmalonamide (PEMA), both of which are also anticonvulsants.
consider this Rx when a patient has elevated blood phenobarbital levels
verapamil
MoA / ADR
Ca channel blocker - slows diastolic depolarization that occurs in phase 0 and the latter part of phase 4 -> decreased** rate of firing of the SA nodeandslows** AV node conduction
ADR
- cause prolongation of PR interval and as well as AV block (1st, 2nd, or 3rd)
- gingival hyperplasia
- constipation
point of takeing nitrates at AM, noon, but NOT PM
wavoid tolerance development (decreased vascular sensitivity to nitrates)
patient w/ persistent cough + pulmonary infiltrate has cold agglutinins
Mycoplasma pneumoniae - causes high levels of IgM that clumb when exposed to cold temperatures
other d/o that cause cold agglutinin formation: EBV or hematologic malignancies
what will continuous administration of leuprolide do?
GnRH agonists - continuous infusion -> inhibit LH/FSH -> diminished testosterone production
Zileuton
Use and MoA
inhibits 5-lipooxygenase (prevents conversion of arachadonic acid to LT)
mono-like sx can be caused by which two bugs?
CMV (-) or EBV (+)
differentiate with monospot test
Bony metz = if osteoblastic, you should think of…
prostate cancer
bone marrow that shows this is indicative of…
myelodysplastic syndrome - BM shows disordered/dysplastic differentiation affecting all non-lymphoid (erythryoid, granulocytic, monocytic, and megakaryocyte lineages)
calculation for loading dose?
Vd * CP / bioavailability fraction
in patients w/ renal or hepatic impairment: loading dose = unchanged, maintenance dose = decreased
damage to superior gluteal nerve (L4-S1) can result in what motor deficit?
weak thigh abduction
only difference btwn minute ventilation and alveolar ventilation calculations?
dead space
minute ventilation: Vt * RR
alveolar ventilation: (VT-VD)*RR
liver cells that have a high concentration of fructose-2,6-bisphosphate will have a low rate of conversion of…
fructose-2,6-bisphosphate helps to control the balance between gluconeogenesis + glycolysis via
activates PFK1 -> glycolysis
inhibits fructose-1,6-bisphosphatase -> ø gluconeogenesis
net: decreases gluconeogenesis (ie conversion of alanine to glucose)
destruction of the hypothalamus results in elevation of which hormone?
prolactin (since it is no longer under the inhibitory effects of dopamine produced by the hypothalamus)
Rapid association: Mitral Stenosis
chronic rheumatic heart disease
∆ btwn first-order kinetics and 0-order kinetics
- first-order kinetics = constant fraction (proportion) of drug that is metabolized per unit time based on the serum concentration
- zero-order kinetics = constant amount of drug metabolized per unit time, independent of concentration
What is the ortner syndrome?
Mitral stenosis that causes LA dilation sufficient enough to impinge on the L recurrent laryngeal n., resulting in hoarseness
(remember, this nerve innervates all of the intrinsic muscles of the larynx except the cricothryoid)
cytogenetic defect: ‘immature myeloid cells with giant cytoplasmic granules’
acute promyelocytic leukemia (APL) - subtype of AML
cytoplasmic granules = auer rods
t15;17 chromosomal translocation that causes fusion of alpha retinoic acid receptor gene to PML gene
cyclin D1, CD5
mantle cell lymphoma t11;14
diagnose
negri bodies - rabies virus
ulcer location that is least least likely to be associated with malignancy:
esophagus
stomach
duodenum
sigmoid
rectum
duodenum - most ulcers here are due to H pylori or NSAIDs and are rarely associated wiht malignancy
alcoholic w/ poor dentition and a foul smelling sputum. CT shows lung abscess. what should you treat him with?
think aspiration pneumonia
clindamycin - oral anerobes and gram + aerobes (ie S. penumo); binds to the 50S subunit and disrupts protein synthesis
how does a PE cause hypoxemia
V/Q mismatch - because it creates a sudden drop in perfusion of the corresponding areas of the lung parenchyma, therefore while air enters the alveoli, the amt of blood that passes through the affected areas is not sufficient for normal gas exchange
what is physiologic jaundice?
occurs after the first 24hrs of life and subsides by the end of the first week; associated with a relatively mild unconjugated hyperbilirubinemia
lung mass for which surgery is NOT indicated
small cell carcinoma - it is the most aggressive, highly invasive and most patients have metz at the time of diagnosis
BUT they are SENSITIVE to chemoRx and radiation
what is a porcelain gallbladder? Patients w/ this particular Xray finding are at risk of…?
rim of Ca deposits that outline the gallbladder
condition is associated with chronic cholecystitis; can progress to gallbladder carcinoma
46XY infant w/ small phallus, hypospadias, and testes that reside in the inguinal area. BP + serum T is normal.
Deficient enzyme?
5a reductase - converts T -> DHT
T -> male internal reproductive system
DHT -> development of external genitalia
ø 5a reductase = internal genitalia develop normally under influence of T, but external genitalia do not develop properly due to lack of DHT -> female pseudohermaphroditism
what does it mean when the arteriovenous concentration gradient of a gas anesthetic is HIGH in terms of
tissue solubility
time to reach blood saturation
brain saturation
- HIGH tissue solubility (ie a large amt of anesthetic is taken up from arterial blood, which results in a low venous concentration)
- time to reach blood saturation = longer
- brain saturation = delayed because of the factors above
weak R forearm flexion + absent biceps reflex will develop a loss of sensation where?
lateral forearm - bc the patient has sx consistent w/ musculocutaneous n. injury (C5-C7) - innervates the upper major arm flexors + forms the lateral cutaneous nerve of the forearm (sensory information to the skin of the lateral forearm)
dipyridamole + adenosine
Rx used in myocardial perfusion imaging studies selective vasodilators of coronary vessels –> redistributes flow away from ischemic areas, thus exacerbating the MI
giant cell arteritis
clinical sx
treatment
histological findings
>50yo, HA, facial pain, jaw claudication, vision loss (due to ophthalmic artery occlusion, increased ESR
trmt: prednisone
hx: granulomatous inflammation of the media w/ fragmentation of the internal elastic lamina (IEL) branches of the carotid artery
Which one does this graph represent? (choose one)
Aortic insufficiency
Aortic Stenosis
Mitral Stenosis
Mitral regurgitation
Aortic Insufficiency
why is it that IgG against HepC envelop do not conver effective immunity against the infection?
HepC envelop proteins vary in their antigenic structure b/c there is no proofreading 3’-5’ exonuclease activity built into the virion-encoded RNA polymerase!!
Why are those with A1AT deficiency strongly adviced to avoid smoking?
smoking plays a synergistic role in the disease process by pemanently inactivating A1AT through oxidation of a methionine residue, resulting in dyspnea decades earlier
EMG reading that is DECREASED by multiple sclerosis (demyelination)
INCREASE?
decrease: length constant = measure of how far along an axon an electrical impulase can propagate
increase: time constant - time it takes for a charge in the membrane to achieve 63% of its original value (lower value = faster ∆’s in membrane potential = faster conduction speed)
*myelination increases length constant and decreases time constant
anastrozole
MoA
clinical use
decreases androgen (androstenedione) aromatization to estrone (in liver, muscle, fat), thereby minimizing the growth and development of malignant breast tumors
trmt: post-menopausal women w/ breast cancer
atherosclerotic plaques
where are mostly develop?
what factors determine their ability to produce acute coronary syndrome?
develop in large elastic arteries + large/med sized muscular arteries
(abdominal, coronary, popliteal, internal carotids, circle of willis)
plaque stability, which depends on the mechanical strength of the overlying fibrous cap (which is continuously being remodeled by macrophages via collagen synthesis and degradation/MMPs)
“patient complains of a dark tan despite avoiding sun exposure” should make you think of…
Hemochromatosis
AR, ø HFE (normally regulates transferrin/Fe uptake) = unregulated uptake of dietary Fe = abnormally high levels of intestinal absorption = mildly elevated LFTs, elevated plasma Fe w. >50% TIBC, elevated serum ferritin
presentation: skin pigmentation, DM secondary to pancreatic islet destruction, pigment cirrhosis w/ hepatomeagly
Complications: cirrhosis, HCC
Women tend to present later due to blood loss during menstruation + pregnancy
pathophysiology of gallstone ileus?
what are some physical findings of this?
occurs when a large gall stone erodes into the intestinal lumen through a cholecysto-enteric fistula, thereby allowing
- air from the lumen to enter the biliary tree “pneumobilia”
- the stone to travel down the intestines, causing a waxing and waning of abdominal pain, nausea, vomiting
immunity to reinfection with influenza is predominately mediated by
anti-HEMAGGLUTININ IgA and IgG
Methotrexate
ADR
How to reduce ADR?
somatitis (painful mouth ulcers)
hepatotoxicity (hepatitis, fibrosis, cirrhosis)
myelosuppression (increased risk of opportunistic infections)
Alopecia
reverse effects w/ folinic acid
which of these proteins are outside the nucleosome core that faciliate nucleosome packaging into a more compact structure?
TopoII
snRNP
Ubiquitin
HIstone H1
Histone H3
HIstone H4
Histone H1
NO is derived from which a.a.?
Arginine
brain tumors that are prevalent in kids
pilocytic astrocytoma
medulloblastoma
ependymoma
PEM
37yoF at 12 weeks gestation comes in with elevated glucose and Tgs. Why is this?
human placental lactogen (hPL) is to blame - it is secreted from syncytiotrophoblasts and has similar biologic properties to prolactin + growth hormone. It functions to maintain adeqate fetal glucose supply via:
- increases insulin resistance (so that more glucose can be shunted towards the fetus
- **stimulates proteolysis + lipolysis - ** resulting FFA + ketones provide energy to the mother, thus freeing more glucose for fetal use
- inhibits gluconeogenesis
before alanine is converted to glucose, its amino group is transferred to what molecule?
alpha-ketoglutarate
(note that this molecule is the key amino-group acceptor in transamination reactions)
occurs via transamination reaction that requires B6
17yo boy begins to develop enuresis
regression
purpose of extracellular polysaccharides (dextrans) produced by strep viridans
dextrans facilitate adherence to fibrin platelet aggregates deposited at sites of endothelial trauma (provides a site for bacterial adherence and colonization during bacteremia)
sweating, dilated pupils, piloerection, yawning, fever/rhinnorhea
patient is undergoing withdrawal of…?
PE findings?
opioids
patients undergoing total gastrectomy will require life-long supplementation with what nutrient??
water soluble vitamins = B12 due to IF deficiency
daycare center where several children develop dysuria and hematuria. Genome of pathogen?
hematuria indicates hemorrhagic cystitis due to adenovirus
genome: linear dsDNA, non-enveloped
person with aggressive impulses participates in contact sports
sublimation - diversion of unacceptable impulses into acceptable outlets
rapid association: mitral regurgitation
infective endocarditis (leads to destruction of the valve leaflets)
VSD is common in…
Down syndrome patients
chemoRx associated w/ abd. pain and jaundice
mercaptopurine (causes cholestasis + hepatitis)
benz(o)pyrene - what is it and what does it do?
pro-carcinogen that is metabolized by P450 MICROSOMAL MONOOXYGENASE into a carcinogen; cause lung cancers etc
what maintains progesterone during the first trimester of pregnancy?
what happens if there is a deficiency of this enzyme?
hCG - secreted by syncytiotrophoblasts lining the placental villi; deficiency –> increased risk of miscarriage
what is ceruloplasmin and how is it affected in Wilson diseae?
major copper-carrying protein in the blood (also plays a role in iron metabolism)
Wilson’s disease = LOW
floppy baby + mild jaundice + enlarged tongue + general hypotonia + umbilical hernia
congenital hypothyroidism - T4 is impt for normal brain development and myelination during early life and undiagnosed congenital hypothyroidism produces irrversible mental retardation.
what kind of withdrawal: prolonged anxiety, irritability, depression
cannabis
renal plasma flow equation
RPF can be calculated as (1-hct)/RBF
or use clearance of PAH
Filtration fraction equation
be specfic in terms of how you calculate each term
FF = GFR/RPF
FF is essentially = creatinine or inulin clearance / PAH clearance
OR
RPF can be calculated as (1-hct)/RBF
why are nitroglycerin administered sublingually?
because it has a very high first-pass metabolism and not enough of the drug reaches the systemic circulation to be effective.
therefore it is administered sublingually, where it enters the systemic circulation directly via sublingual capillaries and arterioles
(same for propranolol and lidocaine)
hemisphere dominant for visual-spatial functions (map reading, locating oneself in space)
Right hemisphere
hypoglossal nerve innervates all intrinsic muscles of the tongue EXCEPT
palatoglossus muscle (innervated by vagus, CN10)
5HT and melatonin are derived from which a.a.?
tryptophan
∆ in intestinal absorption of cystine, ornithine, arginine, and lysine is indicative of which dz? What is the clinical manifestation of this d/o?
**Cystinuria - **inborn defect of the transporter responsible for transporting these 4 dibasic a.a.; as a result, these 4 substances are excreted via urine and feces
clinical manifestation: **hexagonal cystine stones **(presents as renal colic)
Patient comes in complaining of a sensory deficit (green). What is the nerve injury and accompanying motor deficits? What is the usual cause of injury?
Obturator n.
∆ thigh adduction
anterior hip dislocation, or iatrogenic (pelvic surgery)
treatment for trigeminal neuralgia
carbamazepine
(also used in seizure d/o, and bipolar d/o)
cardiac findings in tuberous sclerosis
valvular obstruction due to cardiac rhabdomyomas
diabetic Rx that increases insulin sensitivity
Glitazones (TZD) - binds PPAR-gamma transcription factor
Metformin - exact mxn unknown
common sx in temporal arteritis
histological findings?
polymyalgia rheumatica (AM stiffness, pain in torso, shoulder, pelvic girdle)
monocular vision loss (permanent)
segmental GRANULOMATOUS inflammation of the media (abnormal areas interspersed w/ segmental normal appearing arterial walls); commonly involves branches of the carotid a., esp the temporal arteries!
38 F w/ sudden severe episodes of severe R sided facial pain, usually precipitated by a meal or teeth-brushing.
Dx and trmt?
Trigeminal neuralgia (tic douloureux) - sudden + severe pain, usually in the distribution of CN V (esp. V2, V3) triggered by any stimulus to CN V
Carbamazepine
patient w/ gonorrhea should be treated with …
ceftriaxone **PLUS Azithromycin or Doxycycline **for chlamydia trachomatis since co-infection is VERY common
major limiting factor for coronary blood flow under normal conditions
since most of blood flow to the heart occurs during diastole, the duration or length of diastole determines CBF
eye field looks like this:
where is the lesion?
R peri-chiasmal lesion (usually due to calcification or aneurysm of the ICA impinging on the uncrossed, lateral retinal fibers)
D
renal interstitial infiltrate w/ plasma cells + eosinophils should make you think of…
drugs that can cause this?
acute interstitial nephritis - likely due to drug-induced HSR such as
ß lactam abx, rifampin, NSAIDs, Diuretics, Sulfonamides
BRaNDS
Pituitary Adenoma
Prognosis, presentation
Prolactinoma, bitemporal hemianopia
Adults
mediator of niacin-induced skin flushing and warmth
how to avoid this?
prostaglandins
evidenced by the fact that aspirin taken 30-60min before administration significantly reduces these symptoms (however, note that over time, patients develop a tachyphylactic response, and pretreatment w/ aspirin becomes unnecessary)
methimazole
MoA
ADR
inhibits TH synthesis by suppressing iodination and coupling of iodine
agranulocytosis, edema, rash
bioavailability fraction for an oral drug
depends on the absorptive properties and first-pass metabolism
measure of fraction of administered Rx that reaches systemic circulation
how much was delivered orally
Myeloperoxidase is a marker of….
myeloid cells
treatment for chlamydia trachomatis
Azithromycin or **Doxycycline **
but must **ADD CEFTRIAXONE **for potential Neisseria coinfection
15 yo M w/ kyphoscoliosis + high plantar arch
dx?
pathophysiology?
what other sx does this normally present w/?
Friedriech ataxia - AR, trinucleotide repeat d/o (GAA) on chromosome 9 in frataxin gene (Fe binding protein)
also presents with degeneration of **spinocerebellar tracts **->
muscle weakness + ø DTR, vibratory sense, and proprioception
staggering gait, frequent falls
hypertrophic cardiomyopathy
mantle cell lymphoma translocation
mantle cell lymphoma, t11;14
∆ = 3 rotated 90˚ will look like an m. Also, m forms two semi-circles = cyclin (bicycle wheel)
ETEC virulence factor has the similar mechanism of action as…
- ETEC: Heat-labile toxin activates adenylate cyclase -> increase cAMP -> increase Cl/H2O efflux
- Vibrio cholera - cholera toxin activates Gs -> increase cAMP -> increase Cl/H2O efflux
neutrophil rich discharge + erosions of the vaginal mucosa
Neisseria gonorrhoeae
What pathogens produce a factor that inactivate EF-2 via ribosylation?
Corynebacterium diphtheriae + Pseudomonas Aeruginosa
in general, how many bands would show on an RFLP analysis if non-dysunction occured in meiosis I vs meiosis II?
meiosis I = 3 bands
**meiosis II **= 2 bands, with one band darker
(either from mother or father, signifies inheritance of 2 sister chromatids)
patients w/ influenza are at increased risk of?
secondary bacterial pneumonia caused by
S. pneumo, S. aureus, and H. influenza
F w/ microcalcifications seen on mammography. Pathology indicates that she has what type of breast cancer?
DCIS - Neoplastic cells confined to ductal lumen (ø BM penetration)
L hemonymous hemianopia has damage to:
R optic tract or optic radiation
male w/ undervirilized and does not undergo puberty. develops HTN and hypokalemia
enzyme deficiency?
17a-hydroxylase deficiency
- ø sex steroid production -> females are OK, males are undervirilized, both do not undergo puberty (no sex steroids)
- ø cortisol synthesis
- increased production of mineralocorticoids -> HTN, hypokalemia
ECG shows QT prolongation and polymorphic complexes that change in amplitude and cycle length
what drugs normally cause this?
torsades de pointes
quinidine, procainamide, disopyramide (class IA)
ibutilide, defetilide, and sotalol (class III)
cause of urinary incontinence in a elderly patient with enlarged ventricular system, poor memory, and gait abnormalities
distortion of periventricular WM
bladder controlled by descending cortical fibers that run in the paraventricular area. Loss of these fibers as a result of the hydrocephalus results in urge incontinence
What should you do before initiating therapy with either infliximab, entanercept, or adalimumab?
get a PPD to screen for latent TB since treatment with these can cause reactivation!
definition of an erosion vs ulcer
- EROSIONS - defects limited to mucosa only (do not fully extend through the muscularis mucosa)
- ULCERS - can extend through the muscularis layer
oocyte surrounded by a single layer of flattened follicular cells
primordial follicle
isoproterenol
non-selective ß agonist
increases HR, CO, PP
decreases PVR and diastolic BP
drug of choice for ß blocker OD
glucagon acts on GPCRs to increase cAMP and thus increase intracellular Ca during muscle contraction -> incr HR and cardiac contractility
mitral stenosis is common in..
rheumatic heart dz
How is it that a patient receiving TPN after extensive jejunal resection develops biliary stones?
TPN causes
- since nutrients are administered via IV, there is no enteral stimulation (ø food passing through GI = ø CCK = biliary stasis)
- ileal resection may disrupt enterohepatic bile acid circulation, resulting in supersaturation of hepatic bile with cholesterol.
patient on anti-pyschotics develops prolonged QT.
Rx?
Ziprasidone
small bluish lesions under the nail of finger that is extremely tender to touch. what is it?
glomus tumor (glomangioma) or sub-ungual melanoma (pigmentation)
depends on the answer choices
if patient has elevated HbA2, what should that make you think of?
ß thalassemia
normal adults: there is 97% HbA1 , 2.5% HbA2, and 1% HbF
HbA2 is elevated in ß thalassemia (trait or intermedia) to compensate for the decreased synthesis of HbA1 that results from ß globin chain underproduction
name this please
aspergillus - acute V shaped angles
patients w/ suspected MEN 2 (A/B) has likely has a thyroid that has these histological features
MTC of thyroid gland = extracellular amyloid deposits formed by calcitonin secreted from neoplastic parafollicular C-cells
How does AST, ALT levels change in alcoholics?
AST is >> ALT
26yoF new onset of constipation, dry skin, hair loss, weight gain and fatigue, BP 110/70, P 55 after starting Rx for her mood swings and sleep problems should make you think of this particular drug.
What are other ADRs of this drug?
hypothyroidism due to lithium therapy
other ADR: nephrogenic DI, Ebstein’s anomaly of tricuspid valve
What is DHEA sulfate?
weak androgen produced by the adrenal cortex.
fetus with 46XY has functioning Leydig cells but total absence of Sertoli cells. will the internal + external genitalia develop?
internal: M + F reproductive organs
- <em>sertoli cells produce MIF, which cause paramesonephric ducts to involute; absence of this causes persistence and subsequent development into female internal genitalia</em>
- presence of Y chromosome = SRY - produces testes determining factor, which causes gonadal differentiation into testes.
- *Leydig cells secrete T, which stimulates the Wolffian ducts to develop into the male internal genitalia. It is also converted to DHT, which induces development of male external genitalia *
external: **M **
where is the main site of digestion of dietary lipids? absorption?
digestion = duodenum
absorption = jejunum
20yo M w/ testicular torsion - due to occlusion what arteries?
spermatic cord w/ occlusion of testicular arteries, both which originate directly from the aorta
R testicular v -> IVC
L testicular v -> L renal vein
compare DIC to TTP/HUS in terms of
whether patients bleed
what’s activated
PT/PTT
fibrinogen levels, FDP levels
- DIC
- patients bleed
- coagulation cascade is activated
- PT/PTT prolonged
- low fibrinogen + increased FDP
- TTP-HUS
- usually ø bleeding
- only platelets are activated
- normal PT/PTT
- normal fibrinogen
dx and tumor marker?
seminoma
elevated levels of placental ALP
clinical/laboratory indication of premature menopause
reduced inhibin levels - ovary fails to respond to pituitary hormones and secrete hormones.
hypoglycemia, lactic acidosis, hyperlipidemia, hyperuricemia.
hx: hepatic steatosis
Von Gierke’s - ∆ glucose-6-phosphatase deficiency
how to identify patient with primary polydipsia
urine osmolarit is >500 (compared to normal >800 and compared to nephrogenic and central DI, whose urine osmoarlity is
steady, reliable and prompt increase in urine osmolarity during a water deprivation study
paltry response to vasopressin administration (
(ADH normally increases aquaporin channels)
trmt: water restriction
T/F patient w/ Bell’s palsy do not have problems w/ tearing, as it is not a function of CN 7
FALSE. paresiss of CN 7 will affect tearing, as well other processes
- motor output to facial m -> facial drooping
- parasympathetic innervation to lacrimal, submandibular, and sublingual salivary glands (7-LSS) -> decreased tearing, salivation
- taste afferent fibers from anterior 2/3 of tongue -> **loss of taste sensation **
- somatic afferent from pinna and external auditory canal -> hyeracusis
MoA for methyldopa and clonidine
a2 receptors -> decreased sympathetic outflow -> decreased BP
Interpret this
HBsAg negative
anti-HBc positive
anti-HBs negative
Interpretation unclear; four possibilities:
- Resolved infection (most common)
- False-positive anti-HBc, thus susceptible
- “Low level” chronic infection
- Resolving acute infection
diuretic that causes hyperkalemia
anything that acts on the CD
- K sparing diuretics
- ACEi/ARBs
how does craigler-najjar syndrome affect these labs:
haptoglobin
total bilirubin
direct bilirubin
haptoglobin = normal
total bilirubin = high
direct bilirubin = low
(means that bilirubin is mostly unconjugated)
What are H2 receptor antagonists commonly used for?
block gastric acid secretion by parietal cells
patient w/ a lesion that impinges upon the superior orbital fissure will result in what type of sx?
- diplopia (due to CN 3, 4, 6)
- loss of ipsilateral corneal reflex - afferent sensory via nasociliary branch of CN V1 (opthalmic br.)
- superior ophthalmic v.
what is the purpose of drug suppositories?
ewwwww
partially bypasses first-pass metabolism
Superior rectal veins –> inferior mesenteric vein –> portal circulation
————————————–pectinate line—————————————
middle rectal vein –> internal iliac –> systemic circulation
inferior rectal vein –> internal pudendal vein –> systemic circulation
patient on anti-pyschotics develops extrapryamidal sx/Drug-induced parkinsonism
What was he treated with?
Treatment for this?
Rx: 1st generation antipsychotics that cause D2 receptor blockade in the nigrostriatal pathway (ie haloperidol)
Trmt: Benztropine or Trihexyphenidyl
DO NOT treat w/ levodopa or bromocriptine - both can precipitate or exacerbate psychosis
Patient comes in complaining of a sensory deficit (green). What is the nerve injury and accompanying motor deficits?
Tibial nerve (L4-S3)
∆ = foot inversion, plantar flexion, toe flexion
diabetic patient treated with amitriptyline for peripheral neuropathy can suddenly develop what?
acute urinary retention due to anticholinergic effects of this drug (same as other TCAs); must use with caution in pts with BPH
how does non-pathogenic strains of C. diphtheriae acquire pathogenicity?
bacteriophage-mediated integration of the Tox gene (encodes for diphtheria AB exotoxin) into the genome = lysogenization
“myxomatous changes” in arteries should make you think of…
aortic aneurysm in Marfans
myxomatous ∆s in media of large arteries = cystic medial degeneration due to lack of fibrillin-1 (major component of ECM microfibrils that form the scaffolding for elastic fibers)
precursor for serotonin
diagnostic test for patients w/ serotonin syndrome
tryptophan
test for serotonin metabolite 5-HIAA (5-hydroxyindoleacetic acid) in a 24hr urine sample
patient w/ poorly managed ulcerative colitis comes in w/ fever, bloody diarrhea, abd. distension. what is the next best step in the patient’s workup?
toxic megacolon - get xray to diagnose
(not colonoscopy or barium contrast studies b/c it may cause perforation of TMC)
pulsus parvus et tardus
aortic stenosis - pulse of low magnitude w/ a delayed peak
RItonavir
what is this drug used for other than HIV?
ADR??
**protease inhibitor - **prevents assembly and maturation of the virus, thereby non-functional, non-infectious forms are produced instead. RT is not affected
inhibits CYP450 - therefore it is manufactured as a single drug w. lopinavir to reduce dosing frequency! (can also increase concentrations of drugs metabolized by the same enzyme)
ADR
- Lipodystrophy - increased fat deposition on the back and abdomen “buffalo humb” with decreased adipose adipose tissue on the extremities “peripheral wasting
- Hyperglycemia - due to increased insulin resistance
puncture wound into the posterior fornix of the vagina enters what space
rectourterine space (pouch of douglas) - located between the uterus and rectum
how to accentuate S3 sound?
having the patient lie in the L lateral and decubitus position and fully exhale
presence of a S3 is common in patients with LV systolic failure
SIADH in terms of
plasma Na
plasma osmolality
urine concentration
urine Na
body fluid volume
- plasma Na: LOW
- plasma osmolality: low
- urine concentration: very concentrated
- urine Na: very high
- body fluid volume: normal
patient w/ HTN and ADPKD should be place on what drug?A
ACE inhibitor or ARBs
pts w/ ADPKD has cysts that impair glomeruli perfusion, which triggers RAAS. ACEi not only interrupts this system, but also increases RBF and may provide renoprotective effects
it is important to have high _________ in all screening tests
sensitivity
atropine binds to these receptors
competitive antagonist at post-junctional muscarinic receptors
(in the heart, it would block vagal influences, thereby increasing HR)
cardiac tamponade findings
pulsus paradoxus
arterial hypotension
when pericardial P >10mmHg -> collapsed atria -> increased systemic venous pressure -> reduced ventricular preload -> decreased CO
death due to cardiogenic shock
how does estrogen influence cholesterol synthesis?
how does giving a women fibrates for dyslipidemia preciptate the risk of gall stones?
increases hepatic HMG-CoA reductase activity -> net increase in cholesterol biosynthesis
fibrates can suppress cholesterol 7a-hydroxylase activity, which reduces the conversion of cholesterol to bile acids, thereby resulting in excess cholesterol secretion into bile and subsequent gallstone formation!!
during starvation, 2 substrates required for gluconeogenesis
what is an allosteric activator of this process?
glycerol from fat breakdown
glucogenic a.a. + lactate -> oxaloacetate + pyruvate
allosteric activator of gluconeogenesis: acetyl-coA - increases activity of pyruvate carboxylase (B7)
∆ btwn suppression and repression?
- suppression = voluntary withholding of unpleasant thoughts or feelings from one’s mind
- repression = unconscious removal of disturbing psychologic material from conscious awareness
patient with hypothyroidism (high TSH, low T4 and low T3) is given T3 supplements. how will TSH, T3, rT3, and T4 change?
most sensitive test to assess hypothyroidism?
high TSH, low T4, low T3 indicates inadequate thyroid response to circulating TSH (1˚ hypothyroidism)
- TSH = decrease (T3 feedsback to inhibit release)
- **T3 = increase **(duh)
- rT3 = decrease (due to inhibited TSH release)
- **T4 = decrease **(due to inhibited TSH release)
*T3 cannot be converted into T4 or rT3; but T4 can be converted into T3 or rT3. T3 supplementation will reduce TSH levels and therefore cause decreased secretion of T4 from the thyroid gland, which will also reduce levels of rT3.
TEST: **serum TSH **
why would opioid analgesics cause severe abd pain shortly after administration?
because it causes contraction of smoot muscles cells in the sphincter of oddi, leading to constriction and spasm -> increased CBD pressures -> biliary coli
causes of high Ca, low PTH?
PTH-independent hypercalcemia
(e.g., excess Ca2+ ingestion, cancer)
hyperkinetic pulse
rapid ejection of a large stroke volume aganist a decreased afterload
can occur during fever or exercise in normal subjects, or in patients with high output conditions (PDA, AV fistula)
parotitis, orchitis, aspetic meningitis.
genome of pathogen that does this
mumps
paramyxovirus: (-) ssRNA, linear, enveloped
“bag of worms”
varicocele (pooling of blood into testicles); usually due to upstream compression of the veins that drain the testes by abd. or pelvic masses.
L testicle is usually more affected, bc the L renal vein passes between the aorta and the SMA; if there is an enlargement or hardening of the SMA, this may cause compression of the L renal vein, ultimately leading to pooling of blood in the testicle
cardiac findings in turner syndrome
coarctation of aorta
organism cultured on charcoal yeast extract w/ cysteine
legionella pneumophilia
outbreaks have been associated w/ contaminated water that is used to humidfy air (in a commercial, residential, or hospital setting)
µ receptors
excessive stimulation (ie via opiates) will result in
best treatment?
physical dependence
euphoria
sedation
respiratory + cardiac depression
reduced GI motility
naloxone - high affinity for µ opioid receptors; for opiate OD
“black liver” should make you think of this dx
Dubin-Johnson
- defect in hepatic excretion of bilirubin glucuronides across the canalicular membrane
- patients usually have conjugated hyperbuilirubinemia (direct bilirubin fraction >50% of total; normal LFT)
- hx: dense pigment composed of epinephrine metabolites within lysosomes of the liver
2 treatment of Burrelia burgdorferi
doxycycline
Ceftriaxone
ingestion of raw oysters
Vibrio vulnificus
black pigment stones within the gallbladder is evidence of
CHRONIC hemolysis
increased unconjugated bilirbuin precipitates in bile as Ca-bilirubinate
usually associated w/ sickle cell anemia, ß thalassemia, hereditary spherocytosis
purpose of giving heme prep to patients with recurrent abd. pain, anxiety? dx?
Acute intermittent porphyria
can be precipitated by Rx such as phenobarbital, griseofulvin, and phenytoin, OH, or low calorie diet; all of which can be precipitated by increasing ALAS, which decrease the hepatic concentration of
heme inhibits the synthesis of ALAS
arthroconidia
dermatophytes that cause ringworm or tinea
R/L confusion, dysgraphia, dyscalculia, and finger agnosia
dx? damage to which hemisphere? part of the brain?
Gerstmann Syndrome
damage to parietal-temporal lobe of dominant (L) hemisphere
(note that damage to the R parietal-temporal cortex will result in spatial neglect syndrome - ie agnosia of the contralateral side of the world)
bone changes consistent w/ Vitamin D deficiency?
excessive unmineralized osteoid and widened osteoid seams; low bone mineral densities
what is the genome of this?
CMV - enveloped dsDNA virus
see epithelial cell w. intranuclear + cytoplasmic inclusions
bone-specific alkaline phosphatase reflects activity of which cell type?
osteoBlasts
in the late follicular stage, what happens?
(be specific in terms of cell type + receptors)
granulosa cells increase expression of receptors for LH
widow who takes over her husband’s voluntary work after he dies
identification - unconscious adoption of the characteristics or activities of another person (often a mxn for reducing the pain of separation or loss)
where are parietal cells relative to chief cells in the gastric mucosa?
parietal cells are more superficial to chief cells
parietal cells - oxyntic pale pink, round pink like cells - secrete HCl and IF
chief cells - more basophilic, granular - secrete pepsinogen
tzanck smear is used for…
diagnosing HSV - should see multi-nucleated giant cells
14yoF w/ failure to menstruate.
PE: downy hair in armpits and genital area, no breast development.
Pelvic E: vagina but no palpable uterus.
Genetic studies: 46XY
dx?
Male pseudohermaphrodite
most are due to testicular feminization (T is produced but the body fails to respond to it). Patients usually have testes, epididymis, vas deferens, and seminal vesicles and a prostate that remain small in the absence of T stimulation
3yo M w/ spastic paresis of lower extremities and choreoathetoid movements has very high argninine levels in plasma + CSF. Deficient enzyme?
**∆ Arginase **- urea cycle enzyme that converts arginine -> urea and ornithine
bronchiectasis
what is it and what is it associated with?
chronic necrotizing infection of bronchi -> permanently dilated airways, purulent sputum, recurrent infections, hemoptysis
associations: bronchial obstruction, smoking (poor ciliary motility), Kartagener’s, CF, ABPA
6mo w/ hypoglycemia, hyperTg, ketoacidosis
PE shows: hepatomeagly
hx: accumulation of small-chain dextrin-like material within the cytosol
dx? mutated enzyme?
Cori disease - ∆ debranching enzyme
ketoconazole
MoA
weak anti-androgen that decreases production of steroid hormones in gonads and adrenals
chromolyn
MoA and use
bronchial asthma - prevention
MoA: inhibit mast cell degranulation
other Rx: nedocromil
drug used to stimulate peristalsis in postop ileus
side effects?
bethanechol - cholinergic agonist for
- post-op ileus
- atonic bladder (non-obstr. urinary retention)
ADR: nausea, vomiting, abd. cramps, diarrhea, dyspnea, increased secretions (sweating, lacrimation, salivation)
a rare metabolic dz, if detected early, can be treated effectively and the severe sequelae can be prevented. It is most important for a test to be used in all newborns to have high ..
PPV
sensitivity
specificity
**sensitivity - **represents the ability of a test to r/o those with the disease
impt in screening!! test with high senstivity is one which identifies most patients w/ the disease (ie most sick patients will have a + test result)
(not PPV because it measures the test’s ability to correctly identify those with the disease from all those who had (+) test results; depends on disease prevalence)
56yo w/ hx of gallstones has cramping + mid-ab pain, ab distension + vomiting for 12 hrs.
xray reveals air in GB + biliary tree - where is gallstone most likely lodged?
Ileum
gallstone ileus occurs in patients w/ longstanding cholelithliasis, where a large gallstone in the GB causes persistent pressure on the GB wall and results in the formation of a cholecystenteric fistula btwn the GB and adjoining adjoining gut tissue, thereby
1) air from the gut to enter the GB and biliary tree
2) allowing the gallstone to enter the Gut.
gallstone gets stuck at ileocecal valve -> abd pain + distension + vomiting + tenderness, + tinkling bowel sounds
palpable but non-tender gall bladder + weight loss + jaundice + anorexia + dark urine + pale stool
dx si vous plait
enlarged but non-tender GB = courvoisier sign
with the other signs, this points to adenocarcinoma of the head of the pancreas compressing the bile duct
origin of Krukenberg tumor
typical cells seen w/ this type of tumor?
GI, usually the stomach
signet ring cells
HBV antigen that poorly correlates with viral replication
HBsAg - non-infective envelope glycoproteins that forms spheres
injecting 2L of saline into a pt w/ hypovolemic shock would increase which of the following factors:
- TPR
- ventricular muscle contraction velocity
- end diastolic sarcomere length
- HR
- Diastolic ventricular compliance
- TPR/ventricular contraction velocity is high in a pt w/ hypovolemic shock due to sympathetic activation to maintain organ perfusion and to shunt blood towards vital organs. Adding 2L of fluids will reduce sympathetic activation and decrease both
- end diastolic sarcomere length - fluid resuscitation increases preload , which extends the end diastolic sarcomere length in the ventricles, incraesing SV and CO
- HR will decrease due to fluid resuscitation
- diastolic ventricular compliance - unaffected (since compliance is affected by things affecting the myocardium itself)
bug that requires cholesterol to grow
MYCOPLASMA PNEUMONIAE - becasue their cell membrane is composed of cholesterol
gram negative, curved rod grown on alkaline medium
Vibrio vulnificus
marker produced by malignant ovarian epithelial tumors
CA-125
why does a 65yo M lose consciousness while buttoning a tight shirt collar?
external pressure on the carotid sinus causes:
- > baroreceptors to react as if there was a systemic BP increase
- > increase inhibitory discharge in response
- > bradycardia, hypotension, syncope
Bony metz = if osteolytic, you should think of…
lung, renal, thyroid cancer
69yoF w/ a past medical hx of MI 3 years ago has SOB + swelling of the legs, generalized weakness, and a S3 heart sound after starting a 3rd anti-hypertensive Rx. What could this agent be?
patient likely has CHF, which is a complication of both her past MI and verapamil, a Ca blocker w/ strong negative ionotropic effects that has been associated w/ an accelerated progression/exacerbation of heart failure in certain patients
trmt for acute asthma exacerbations
ß adrenergic agonists - stimulate ß2 receptors (Gs) -> activates adenylyl cyclase -> incr. intracellular cAMP
What does this represent? (choose one)
Increase preload
Increase afterload
Systolic dysfunction
Increased ejection Fraction
Normal Saline Infusion
Increased ejection fraction
va
3 month old boy with delayed motor development. 9 months later develops spasticity and writhing movements and exhibits compulsive biting of fingers and lips and constantly bangs his head. teens - develops arthritis and renal failure
Lesch Nyhan syndrome - increased monosodium urate
endotoxin
LPS
IM injection into the buttocks result in weak knee flexion, weak foot movements, difficulty in foot inversion and weak plantar flexion . where was the injection done and what causes these sx?
sciatic n. injury
Injection was probably done in the inferior-medial quadrant of the gluteal region, which caused damage to the sciatic n.
All injections are usually done in the superolateral quadrant to avoid this
myotonia definition
abnormally slow relaxation of muscles (or sustained muscle contraction)
recent oliguria + high serum creatinine + intranasal ulcer that failed to heal
Dx?
Labs?
dx: Wegener’s, c-ANCA (neutrophil proteinase 3)
nasal mucosal ulcerations, sinusitis, hemoptysis + glomerulonephritis
how do differentiate between PIGN and pyelonephritis?
- PIGN
- enlarged glomeruli w/ infiltrating leukocytes
- tubular infiltration w/ inflammatory cells is NOT seen
- pyelonephritis
- interstitial + tubular lumen infiltration by PMNs
- tubular epithelial disruption may be seen
- microabscesses in the interstitium may be seen
- WBC casts
- interstitial + tubular lumen infiltration by PMNs
when do glycogen stores become depleted? (ie at what point does the switch from glycogenolysis -> gluconeogenesis occurs?)
after 12-18hrs of fasting
patient with a hct of 64% and platelets
genetic mutation associated with this?
Jak2 - mutation - a non-receptor tyrosine kinase (meaning it’s an cytoplasmic kinase)
**polycythemia vera **
CN 9 and CN 10 carry afferent information from…
CN 9 = carotid sinus
CN 10 = aortic arch baroreceptors
firing rate of these neurons increases with increasing BP
hepatosplenomeagly + retinal pallor sparing of the macula in the L eye. Enzyme?
Niemann Pick Disease
∆ lysosomal Sphingomyelinase in histiocytes
“NPS = National Park Service”
LDH inhibited in strenuously exercising muscle would eventually lead to an inhibition of glycolysis due to an intracellular depletion of..
NAD+
present in limited amts in most cells; must be regenerated from NADH for glycolysis to continue (so that G3P DH can convert G3P -> 1,3-BPG via NAD+ -> NADH)
Anaerobic glycolysis: NAD+ is regenerated via LDH conversion of pyruvate -> lactate
M w/ hx of ulcerative colitis that presents w/ fatigue + high alkaline phosphatase
primary sclerosing cholangitis
unknown cause of “onion skin” bile duct fibrosis -> alternating strictures and dilation w/ beading of intra- and extra-hepatic bile ducts
hypergammaglobulinemia (IgM)
can lead to 2˚ biliary cirrhosis and cholangiocaricinoma
role of bcr-abl
present in what disease
fusion protein that inhibits apoptosis while promoting mitogenesis and increased TK activity
CML
Which one corresponds to this graph?
Acute GI bleed
Pyschogenic polydipsia
Diabetes insipidus
Hypertonic saline infusion
Diabetes Insipidus - see hyperosmotic volume contraction when the loss of free H2O exceeds the loss of electrolytes, resulting in increased osmolarity, decreased volumes in ICF and ECF
similar graphs with profuse sweating (due to hypotonic nature of sweat)
macroorchidism, law jaw, mental retardation
Fragile X
(X-linked)
surgical removal of a R ovarian mass - involves ligation of what structure? what must you be careful of?
suspensory ligament of the ovary (aka infundibulopelvic ligament) - carries the nerves/blood vessels that supply the ovary
be careful not to ligate the ureter!! (otherwise can lead to hydronephrosis….bad)
ethambutol
MoA?
clinical use?
ADR?
how does resistance to ethambutol develop?
clincal use: TB
MoA: inhibits synthesis of the CELL WALL (ie polymerization of the carbohydrates, NOT the mycolic acid synthesis)
side effect: optic neuritis (use an ethane-butane torch to my eye)
Resistance: increased production/activity of arabinosyl transferase (involved in cell wall synthesis)
(remember that ethambutol intereferes specifically w/ mycobacterial peptidoglycan cell wall synthesis via an unknown mxn that appears to differ from that of isoniazid)
important cytokine mediator of sepsis
TNFa
how do these factors change with Vit K deficiency?
Platelet Count
Bleeding time
PT
PTT
Platelet Count = NC
Bleeding time = NC
PT = increase
PTT = increase
ristocetin = abnormal
RBC - why is Cl levels much lower in arterial blood than in venous blood?
cause in venous blood, CO diffuses into RBC -> converted to carbonic acid -> spontaneous conversion to HCO3- and H+. As the bicarb diffuses out of the RBC into the plasma, Cl diffuses into the cell to maintain electroneutrality “chloride shift”
myocardial biopsy is indicative of
recent bacterial infection - see “interstitial granuomas” - presence of anitschkow cells (plump, red macrophages) + aschoff giant cells (multinucleated cells) surrounded by fibrosis in the interstitium
usually due to acute rheumatic fever
N-acetylcysteine (NAC) - when is it used?
- acetaminophen OD - enhances glutathione production and conjugation of toxic NAPQI metabolite
- mucolytic agent (CF, bronchitis, influenza)
- radiocontrast-induced nephropathy
dicrotic pulse
pulse w/ two distinct peaks - one during systole, other during diastole.
best palpated at the carotid arteries
typically occurs in patients w/ severe systolic dysfunction
cabergoline
dopamine agonist to treat prolactinoma
how does resistance to nafcillin develop?
(ie MRSA)
alterations in penicillin binding proteins (PBP)
(NOT due to ß lactamases because these semi-synthetic drugs have more complex (bulky) side chains and therefore prevent access of ß lactamases to the ß lactam ring)
other semi-synthetics: dicloxacillin, oxacillin, methicillin
what is somatomedin C
= IGF-1; serves to stimulate cell growth and multiplication
ADR of thiazides
HYPER-CLUG
- hyperuricemia -> gouty arthritis
- hypercalcemia -> good for treating nephrolithiasis secondary to hypercalcicuria
- **hyperglycemia **
- hyperlipidemia (cholesterol + LDL)
HYPO-NMTK
- hypokalemia/hypomagnesemia
- hyponatremia
- hypotension ((via decreasing blood volume and PVR)
Gag reflex involves which two nerves?
if the L afferent is defective, what will happen if you stimulate that side? the opposite side?
if the L efferent is defective, what will happen if you stimulate that side? the opposite side?
afferent: CN 9
efferent: CN 10
- L afferent is defective:
- stimulate ispilateral side –> no gag, no uvula response - logical cause no signals are going through
- stimulate opposite side –> gag w/o uvula deviation
- L efferent is defective:
- stimulate ispilateral side –> uvula deviates away from lesion
- stimulate opposite side –> uvula deviates away from lesion
case-control study
compares group of ppl w. and w.o disease to LOOK FOR PRIOR EXPOSURE or RISK FACTOR
use Odds Ratio
sx of L sided CHF
dyspnea on exertion orthopnea PND (waking from sleep gasping for air)
why do patients have low-intracellular K and normal-high extracellular K levels?
because they lose significant amts of K in the urine, primarily through
- glycosuria-induced osmotic diuresis
- hypovolemia-mediated increase in aldosterone secretion
patient w/ paroxysmal supraventricular tachycardia can be treated with what manual manuevers and why?
- Valsalva manuever
- carotid massage
both increase vagal tone to increase the refractory period in the AV node to prevent a reentrant circuit from conducting.
ab with valence of 10
IgM
how do these factors change with DIC?
FDP
fibrinogen
PT
PTT
platelet count
Total bleeding time
smear
FDP = increase (also known as D-dimer)
fibrinogen = decrease
PT = prolonged
PTT = prolonged
plaetlet count = decrease
Total bleeding time = increase
smear: RBC fragmentation
this a.a. is a precursor for epinephrine, norepinephrine, and melanin
tyrosine
otitis media pathogens
otitis externa pathogens
media = strep pneumo, h. influenza, moraxella
externa = pseudomonas (esp. in diabetics)
best anticoagulant for DVTs?
what if the patient is pregnant?
warfarin
pregnant? heparin
46 M that does not seem to care about his family anymore and smoetimes becomes aggressive. Also have periodic jerky momvents of his arms.
Hungtington - loss of GABA-containing neurons - bilateral atrophy of the caudate + putamen ( = striatum)
how many half-lives does it take for a drug to reach steady state concentration?
4-5 half-lives
patients w/ evidence of prolonged cholestasis (pale grey stool, bile deposition within the hepatic parenchyma, presence of green-brown plugs in teh dilated bile canaliculi) will usually suffer from…
intestinal fat malabsorption + nutritional deficiencies (esp. D, E, A, K) due to reduction in bile flow
osteomalacia (usually due to Vit. D deficiency)
viral protein p24 and p7
viral protein p120 and gp41
HIV
gag (p24, p7) = nucleoside capsid proteins
env (gp120, gp41) = envelope proteins
apoptotic cell histology
cytoplasmic blebbing + nuclear blabbing
examples of k-sparing diuretics?
Spironolactone
Eplerone
Amiloride
Triamterene
torticollis (acute dystonic reaction) is likely due to:
treatment?
high potency antipsychotic Rx (haliperidol, fluphenazine) use - inhibition of Dopaminergic D2 Receptors
inhibition effects of D2 neurons are balanced by the excitatory cholinergic M1 neurons, therefore blockade of dopaminergic neurons result in unopposed cholinergic stimulation, resulting in extrapyramidal ADR (torticollis, akathisia, parkinsonism)
(therefore M1 receptor antagonists - diphenhydramine, benztropine) re-establish dopaminergic-cholinergic balance and are effective remedies for acute extrapyramidal symptoms)
morphine mOA
binds to µ receptors that cause GPCR activation of K channels to increase K efflux –> hyperpolarization of post-synaptic neurons and termination of pain transmission
Why do patients w/ sarciodsis have elevated Ca levels?
in patients w/ granulomatous d/o (ie sarcoidosis or NHL), the activated T cells secrete IFNg, which increases the activity of 1-alpha hydroxylase in macrophages, thus resulting in an inappropriate elevation of 1,25-dihydroxy Vitamin D; the rest is history…
when does secondary erythrocytosis due to hypoxia usually occur?
when SaO2
acute viral hepatitis is characterized by 3 histological features
1) diffuse ballooning degeneration (hepatocyte swelling)
2) Councilman bodies (eosinophilic apoptotic hepatocytes)
3) mononuclear cell infiltrates
name the 3 walls of the orbit
which ones are the weakest ones (ie the ones that are most likely to fracture w/ blunt trauma0
superior wall: thick orbital plate of frontal bone
inferior wall: thin bone separating the orbit from maxillary sinus
lateral wall: thick bone of zygoma + sphenoid
medial wall: thin ethmoid + lacrimal
congenital QT prolongation causes these 2 things
sudden death
neurosensory deafness
what kind of withdrawal: flashbacks
hallucinogenic - can occur later in life even when no additional Rx has been taken
37yo F w/ abd. discomfort has a uniformly enlarged uterus + normal appearing endometrial glands
adenomyosis - presence of endometrial glandular tissue within the myometrium; sx: menorrhagia and dysmenorrhea
“size is added to the uterus”
in what diseases would you see an elevated ßhCG? (3)
hydatidiform moles
choriocarcinomas
gestational trophoblastic tumor
oval-to-round intracytoplasmic hepatocyte inclusions that appear eosinophilic on H&E should make you think of this d/o
A1AT deficiency
What is biliary sludge? What causes it?
Who is at greatest risk of this?
mixture of particulate solids that have preciptated from bile; usually caused by gallbladder hypomotility (ie slow/incomplete response to CCK)
at risk: pregnancy, rapid weight loss, octreotide (somatostation analog), high spinal cord injuries
Causes of low Ca, high PTH?
2˚ hyperparathyroidism
(vitamin D deficiency, chronic renal failure)
how does the liver take up and secrete bilirubin?
take up: organic anion transporting polypeptide (OATP)
secretes: MRP2 (an ATP-dependent organic anion transporter)
Role of Golgi-tendon organs?
Golgi-tendon organs (GTO) - receptors at the junction of muscle + tendon; innervated by sensory axons (Grp Ib)
GTOs are activated when a muscle actively contracts against resistance, results in stimulation of inhibitory interneurons in the spinal cord, which inhibit contraction of the m. -> results in sudden muscle relaxation (prevents damage to musculoskeletal system, esp when a muscle exerts too much force)
test used to dx confirm cystinuria
sodium-nitroprusside test (+)
H band of the sarcomere contains________ while the A band corresponds to ________
H band of the sarcomere contains only myosin thick filaments while the A band corresponds to** length of the whole myosin filament (including those overlapped by thin actin filaments)**
SIADH treatment
fluid restriction
IV hypertonic saline
vaptans
demeclocycline (ADH antagonist)
general antipsychotic effects on prolactin
dopamine antagonist -> galactorrhea
why are oral hypoglycemic Rx generally avoided in gestational diabetes mellitus (GDM)
risk of fetal hyperinsulinemia and hypoglycemia
Bosentan MoA and clinical use
competitive antagonist of endothelin receptors -> vasodilation -> decrease pulmonary arterial pressure (thereby lessening risk of RHF)
clinical use: 1˚ (idiopathic) pumonary arterial HTN
giving patients gangciclovir + zidovudine is likely to preciptate what?
neutropenia and anemia
Ganciclovir = neutropenia, anemia, thrombocytopenia, impaired renal function
zidovudine = bone marrow suppression (anemia, granulocytopenia)
complex partial seizure
description (consciousness, postictal state)?
first line treatment?
almost always originates from the temporal lobe (mood ∆, illusions, hallucinations); impaired consciousness + post-ictal state
carbamazepine
PDA originates from which embryonic aortic arch?
carotid arteries?
subclavian arteries
PDA: 6th (also the pulmonary arteries)
carotid arteries: 3rd
subclavian arteries: 4th
posterior stimulation of the external auditory meatus results in syncope. why?
vagal stimulation –> decreased HR and BP –> faint
bone marrow that shows this is indicative of
aplastic anemia - BM is devoid of hematopoietic elements and is filled with fat, fibrous stroma, and scattered clusters of lymphocytes and palsma cells that replace the normal tissue.
name this please
mucormycosis - broad, non-septate hypahe that branch at right angles (90˚)
papillary necrosis of the kidneys can be due to these 5 things
histologically, what does it look like?
sickle cell anemia
phenacetin (analgesic)
pyelonephritis (acute)
urinary tract obstruction
diabetes
SPPUD
hx: coagulative infarct necrosis w/ preserved tubule outlines
recurrent nephrolithiasis in a young patient should alert the doc of…
Cystinuria - defect in the PCT, which causes decreased reabsorption of COLA; though only the cystine precipitates into hexagonal stones (pathognomonic for this dz)
diagnose w/ Na (cyanide) nitroprusside solution, which turns purple
patients with what type of d/o tend to have hypercalcemia and hypercalciuria?
granulomatous d/o
sarcoidosis
tuberculosis
hodgkins
non-hodgkins
what nodes do the bladder drain into?
superior portion = external iliac nodes
inferior portion = internal iliac nodes
disease prevalence affects what epidemilogical parameter?
PPV
patient with persistent foot drop after prolonged compression of which nerve
common peroneal n.
<em>lateral br. of sciatic n.; splits into the deep + superficial n.</em>
<em>deep -> extensor + great dorsiflexors (<strong>inability to dorsiflex the foot = foot drop)</strong></em>
<em>superficial -> peroneal muscles + skin of most of the toes</em>
How does 15 minutes/day in the sun help with Vitamin D metabolism?
It promotes conversion of:
provitamin D3 (7-dehydrocholesterol) –> vitamin D3 (cholecalciferol)
the latter gets shunted to the liver, where 25-hydroxylation occurs, and then to the kidneys, where alpha-hydroxylation catalyzes the second hydroxylation step to make active 1,25 OH Vitamin D3
Which one corresponds to this graph?
Acute GI bleed
Pyschogenic polydipsia
Diabetes insipidus
Hypertonic saline infusion
psychogenic polydipsia - causes ECF+ICF expansion and a decreased osmolarity of both (hypo-osmotic volume expansion of both ICF, ECF)
before starting Rx w/ alendronate, what must you caution the patient?
bisphophonates - alendronate, risedronate, ibandronate
makes hydroxyapatite more insoluble; decrease bone resorption by interfering w/ osteoclasts function
*patients must stay upright for at least 30 minutes to prevent reflux because these agents can cause stomach/esophageal inflammation + erosions*
most common cause of fetal hydronephorsis?
ureteropelvic junction (btwn kidney and ureter) - failure to recanalize
match afferents
carotid sinus CN9
aortic arch baroreceptors CN10
- carotid sinus - CN 9/glossopharyngeal
- aortic arch - CN 10/vagus
How does TNFa decrease glucose uptake by cells?
TNFa - proinflammatory cytokine that induces insulin resistance via activation of serine kinases, which result in phosphorylation of
- IRS-1 serine residues, thereby preventing IRS-1 interaction with the insulin receptor
- ß subunit of insulin receptors, thereby hindering downstream signaling
catecholamines, glucocorticoids, and glucagon also induce insulin resistance by this mechanism.
Rx that are selective vasodilators of coronary arterioles
adenosine + dipyridamole
abduct arms to 90˚, flex them to 30˚, thumbs down, and apply downward on warms force to elicit pain and weakness
What muscle is this manuever called and what is it testing?
supraspinatus m. - tendon is vulnerable to injury due to its positioning btwn the acromion and head of humerus
this is called the “empty-can supraspinatus test”
TdT (+), CD1, CD2, CD5
ALL - precursor T cell leukemia
urea’s nitrogen is derived from what?
NH3 + aspartate
what vitamin should not be taken by those on levodopa therapy?
B6 - it increases the peripheral metabolism of levodopa and decreases its effectiveness
meckel’s diverticulum is a remnant of what?
omphalomesenteric /vitelline duct
2 ft from ileocecal valve, 2”, males are 2x more likely to be affected
doxazosin
MoA
clinical use
**a1 blocker **- smooth muscle relaxation
same as prazosin, terazosin
leads to
- decreased PVR -> can lead to orthostatic hypotension/vertigo (can cause first-dose effect; therefore should start with a small first dose)
- decreased urinary obstruction caused by BPH
clinical use: HTN + BPH
Zidouvine (AZT), Zalcitabine
MoA, ADR
NRTI - must be converted to its monophosphate form by cellular thymidine kinase before it can be converted into a pharmacologically active triphoshate form
AZT MoA: RT transcriptase inhibitor - competitively binds to RT and is incorporated into the viral genome as a thymidine analog, has an 3’ “azido” group (instead of the usual 3’OH group), thereby blocking 3’-5’ phosphodiesterase bond formation and ultimately DNA chain elongation
AZT ADR: bone marrow toxicity + anemia
vaginal Rx that contains prostaglandin E2 induce cervical softening
Dinoprostone (prostaglandin E2)
do not confuse with
- Misoprostol (Prostglandin E1)
- Alprosta dil (prostaglandin E1), a vasodilator used to treat erectile dysfunction
- Latanoprost (prostaglandin F2a) - for glaucoma
- Epoprostenol (prostaglandin I2) - trmt for pulmonary HTN
patient undergoes surgery for open cholecystectomy but 2 days later, she develops sudden nausea, fatigue, and anorexia and is slightly icteric. She worsens acutely and dies 3 d later.
What happened?
What labs do you expect?
key *buzz* words = surgery
patient presents w/ HSR drug reaction (likely HALOTHANE), and is presenting of signs of hepatotoxicity, where the liver rapidly atrophies and has widespread CENTRI-lobular hepatocellular necrosis and inflammation of the portal tracts and parenchyma
labs of liver failure: markedly elevated AST/ALT, prolonged PT, leukocytosis, eosinophilia
unilateral renal artery stenosis is usually due to…
atherosclerotic changes in the arterial intima
fibromuscular dysplasia
causes of high PTH, high Ca?
1˚ hyperparathyroidism
(hyperplasia, adenoma, carcinoma)
where is bile/ B12 absorbed?
ileum
when are rank receptors overexpressed?
HYPO-estrogenic states - causes increased bone resorption due to increased osteoclastic activity
low estrogen = low bone mass
ß blockers affect which part of the EKG?
ß blockers slow AV conduction -> prolonged PR interval (p to beginning of q)
what innervates the parotid gland?
CN 9
lungs - small cell carcinoma stains + for what IHC marker
these cells secrete ACTH, ADH, and antibodies against presynaptic Ca channels (LES)
chromogranin and synaptophysin neuroendocrine marker
hx: kulchitsky cells (small dark blue cells)
<em>Note: bronchial carcinoid lung tumor is also + for chromogranin (neuroendocrine tumor)</em>
Statins
Clinical Use
MoA
ADR
What increases ADR?
- Clinical use: Hyper-LDL – 1st line
- MoA: Inhibit HMG CoA reductase (hepatocytes respond by increasing LDL-R to increase uptake of circulating LDL)
- ADR: Myositis (increase CK), Hepatitis
- increased risk of myopathy w/ concomitant use of fibrates or niacin, since fibrates increase the concentrations of most statins
indicator of severity in mitral stenosis
S2-to-opening snap interval - the shorter the interval, the more severe the stenosis
ø hx of major medical illness but develops heavy menstrual periods + mucosal petectiae + non-palpable ecchymoses in legs from trauma.
Labs show decreased platelets.
Smear shows normal cell morphology in other lines and few large young platelets
think ITP - anti-platelet antibodies
does NOT cause splenomeagly
non-septate hyphae should make you think of…
Mucor + Rhizopus species - both cause mucormycosis in immunosuppressed patients
branches at 90˚
(compared to aspergillus, which branches at 45˚)
type of necrosis that happens in the brain? all other tissues?
brain: liquefactive
other: coagulative
patient’s w/ paroxysmal episodes of breathlessnes + wheezing has suptum that shows many “granule containing cells and crystalloid masses” - what cytokine is involved?
eosinophilic bronchitis
eosinophils + charcot-leyden crystals
infiltrates are due to IL-5 secreted by Th2 cells
SPINK1 mutation results in…?
hereditary pancreatitis
SPINK1 prevents trypsinogen from being prematurely activated in the pancreas
distal ileum winding down a thin vascular stalk “apple core peel” due to
vascular occlusion - diminished intestinal perfusion leads to ischemia of bowel + subsequent narrowing of lumen
torticollis (twisting of neck) - cause and treatment
acute dystonic reaction - usually occurs within 5d of taking a new antipsychotic Rx (D2 receptor antagonist - haloperidol, fluphenazine) trmt: benztropine (anti-muscarinic)
elderly patients presenting with chronic anemia w/o any identifiable underlying cause (ie they eat a balanced diet, they have no relevant surgical history)
assume B12 deficiency, since elderly patients may have poor absoprtion secondary to gastric atrophy, causing achlorhydria and decreased release of B12 from food proteins.
Other potential causes: Pernicious anemia, terminal ileal disease (IBD, ileal resection, etc)
62yo w/ uterine bleeding and L solid, ovarian mass has an endometrial bx that shows marked endometrial hyperplasia
granulosa cell tumor
(how we can figure out that is beyond my knowledge, perhaps age + solid tumor??)
Maraviroc
CCR5 receptor inhibitor - prevents HIV from binding to the host cell
how does serum Mg affect PTH
low levels of Mg stimulate PTH secretion very low levels of Mg inhibit PTH secretion
role of BRCA
tumor suppressor gene; encodes a protein that acts to control the cell cycle and play a role in gene repair and transcription.
warfarin affects PT or PTT?
Heparin affects PT or PTT?
warfarin = PT
Heparin = PTT
remember that Audrey Hepburn HITs on Brad PiTT
naloxone has the greatest affinity for what type of receptors?
clinical use?
antagonizes µ opioid receptors
opioid OD - competes w/ narcotics and displaces them from the opioid receptors
case series
observational study that uses a group (all with the disease) and does NOT include control
drugs used to treat BPH
alpha blockers - terazosin, doxazosin, tamulosin
alpha-reductase inhibitors - finasteride
what kind of withdrawal: depression, hypersomnolence, fatigue, increased appetite over several days, and nightmares
cocaine
Foscarnet
MoA
clinical use, ADR
pyrophosphate analog that is commonly used to treat HIV patients w/ acyclovir-resistant herpesvirus or gangciclovir-resistant CMV infections
does NOT require cellular or viral activation, but it inhibits DNA polymerase and reverse transcriptase in HIV
ADR: nephrotoxicity, reduce PTH secretion, electrolyte ∆ (hypo-Ca, Mg, K), which can cause generalized seizures
how do you tell based on measuring pressure differences that a patient has mitral stenosis?
normally, the PWP (measure of LAP) is equal to the LV-EDP.
A pressure gradient of >25mmHg across the mitral valve is a clear indication of stenosis
metroprolol effects
ß1 selective - activates ß1 receptors on - heart -> decr. HR - JG cells -> decr. renin
diuretics that cause hyperuricemia?
loop diuretics and HCTZ
complication of hydatidiform mole
choriocarcinoma - abnormal proliferation of trophoblastic tissue - 2% risk of development
pt w/ anemia, bone marrow biopsy that shows ø erythroid precursors but preserved myeloid + megakaryocytic elements
dx? associations?
pure red cell aplasia - due to inhibition of erythropoietic precursors and progenitors by IgG autoantibodies or cytotoxic T cells (associated w/ thymomas + lymphocytic leukemia)
patient with this kind of bone marrow is at risk of what?
multiple myeloma - pt is at risk of
- amyloidsois due to AL amyloid
- anemia (due to bone marrow infilration)
- bone resorption (lytic leions) w/ resultant osteopenia
- hypercalcemia
- increased suceptibility to infection
- renal failure
28 yo F who is 28 wks pregnant develops a flu-like illnes w/ fever, HA, and myalgias. Several days later, she has a spontaneous aborption that shows severe amnionitis. Most likely cause:
handling cats
eating soft cheese
rat bite
STD
Tick bite
eating soft cheese - Listeria monocytogenes
trmt: ampicillin or TMP/SMX in patients w/ penicillin allergy
hypospadias is due to
incomplete closure of the urethral folds, resulting in urethral opening that is located on the ventral surface of the penis
pathologic process of sheehan syndrome?
why does this occur?
ISCHEMIC NECROSIS of the pituitary.
high Estrogen levels during pregnancy stimulates growth of the pituitary, causing it to enlarge and become more vascular. If significant hypotension occurs (ie after giving birth) while the pituitary is still enlarged, Sheehan syndrome can result.
do not confuse w/ pituitary apoplexy - hemorrage into a preexisting adenoma
5yo M treated for allergic rhinitis has flushed cheeks and dilated pupils. What was he treated with?
**H1 receptor antagonists **- binds to receptors on the vascular endothelium and bronchial smooth muscle, where it helps to mediate vascular permeability and bronchoconstriction
note that this class also has anti-cholinergic effects (ie antagnoist of muscarinic receptors
inhibition of eccrine sweat glands -> fever
inhibition of pupillary constrictor + ciliary muscles -> pupil dilation
sx of R sided CHF
lower extremity edema hepatomeagly commonly due to LHF
increased total bilirubin + LDH + decreased haptoglobin after TMP-SMX. Smear shows RBC w/ inclusions. What are these inclusions?
acute hemolysis, likely related to sulfonamide ingestion.
inclusions: oxidized and denatured hemoglobin “Heinz bodies’, indicates G6PD deficiency, in which hemolysis occurs following exposure to oxidants or infections
Type I HSR - cytokine involved
IL4 (produced by TH2) induced isotype switching in B cells
Patient comes in complaining of a sensory deficit (green). What is the nerve injury and accompanying motor deficits?
Common Peroneal (L4-S2)
∆ foot eversion, dorsiflexion, toe extension
( superficial peroneal n. provides sensory innervation to the majority of the foot; deep peroneal n. provides sensory innervation only to the region btwn the 1st and 2nd digits of the foot)
name this please
candida albicans - budding yeast with pseudohyphae “germ tubes”
most important prognostic factor in breast cancers
axially LN involvement (indicates metz)
54yo smoker w/ recent weight gain despite no changes to his diet/exercise reports bruses + darker skin + epigastric pain. CXR shows mass in R lung field.
Dx? what is responsible for his sx?
small cell carcinoma - produces ACTH + vasopressin
excess ACTH
- excess cortisol production (Cushing syndrome)
- melanotropin receptors activation (a-MSH homology) -> skin hyperpigmentation
why is it that an Rx of a specific dose is
subtherapeutic w/ oral ingestion
therapeutic w/ rectal administration
?
because oral bioavailability of an Rx depends on the absorptive properties of the Rx as well as the first pass metabolism
(hepatic metabolism after gaining access to the systemic circulation from the GI tract)
brain histology - what does this patient have?
Pick disease - note the circular cytoplasmic inclusions of the microtubule associated protein tau)
labetalol
non-selective ß blocker that also has alpha1-recepter blocking effects; both contractility and SVR would decrease
how does a direct inguinal hernia occur?
buldges through hesselbach’s ∆, due to weakness in transversalis fascia, and out the superficial inguinal ring
(medial to inferior epigastric vessels, above the inguinal ligament lateral to rectus abdominis m.); do not protrude into the scrotum
common in older men
What part of the spinal cord are we in?
cervical
What part of the spinal cord are we in?
thoracic
What part of the spinal cord are we in?
lumbar
What part of the spinal cord are we in?
sacral
What part of the spinal cord are we in?
cervical
8 yo M presents w/ recurrent multiple respiratory + skin infections.
PE shows light skin with silvery hair, photophobia, nystagmus
labs show pancytopenia and increased PTT
dx and pathophysiology of the defect?
Chediak-Higashi Syndrome
∆LYST - defect in lysosomal trafficking and phagosome-lysosome fusion; also causes abnormal melanin storage in melanocytes
leads to recurrent pyogenic infections (Staph + Strep)
middle ear cavity, eustachian tube, mastoid air cells derives from what embryological orign?Add
1st pouch
epithelial lining of palatine tonsil derives from what embryological origin?
2nd pouch
in what situations can the equilibration of O2 and CO2 becomes perfusion limited? what does this mean anyway?
perfusion-limited gas = rate of alveolar capillary perfusion determines the speed with which the alveolar air equilibrates with venous blood gases
ex; pulmonary embolism (results in tracheal pO2 ~ alveolar pO2)
in what situations can the equilibration of O2 and CO2 becomes diffusion limited? what does this mean anyway?
diffusion-limited gas = alveolar gas does not equilibrate with the blood gas by the time that a given volume of blood reaches teh end of the alveolar capillary.
ex; emphysema, pulmonary fibrosis, exercise
why do patients with silicosis have higher rates of TB infection?
macrophages ingest the inhaled silica particles, which then affect the macrophage’s phagolysosomes by causing it to
release both the silica particles and mycobacteria
macrophage autolysis -> release of lysosomal enzymes contributes to alveolar + interstitial lung injury.
how do you calculate the absolute rate reduction?
ARR = Event Ratecontrol - Event Ratetreatment
Event Rate (%) = # events/ total # arm subjects
which one is more important to have in a screening test?
sensistivity? specificity? PPV? NPV?
high sensitivity = want to make sure the test will identify the most patients with the disease
high serum alkaline phosphatase in a patient w/ Paget’s disease of the bone is mediated by which cell type?
these patients are at increased risk of? 2
osteoClast = high AP
**osteosarcoma + fractures **
CAP OF Paget’s
virluence factor of E. coli that invades the blood stream? uropathogenic strains or diarrhoegenic E. coli?
- blood stream: K1 capsule - inhibits complement, phagocytosis, etc.
- uropathogenic/diarrheogenic: pili
Verotoxin?
shiga-like toxin that is made by EHEC
how does lipid A cause septic shock?
it activates macrophages, leading to a widespread release of IL-1 and TNFa, which causes the signs + sx of septic shock
HgA2 is indicative of?
HgA1 is indicative of?
A2 = (a2d2) = ß thalassemia
A1 = (a2b2) = glycemic control
patients w/ aldolase B deficiency should avoid what?
fructose + sucrose (glucose+fructose dipeptide)
acoustic neuromas usually arise from which CN? where is this intracranial mass usually located? what other nerves may be affected?
CN8
CN7, and CN5 may also be affected via compression due to its proximity
found btwn cerebellum + lateral pons
what innervates the supinator m?
radial n.
person receives several units of blood and develops signs of hypocalcemia. why?
whole blood contains citrate, which chelates Ca, resulting in hypocalcemia
vancomycin
MoA?
ADR?
how does resistance develop?
binds to **D-alanyl-D-alanine **in the cell wall peptide precursors and prevents formation of peptidoglycan
ADR: Red man syndrome, nephrotoxicity
resistance: VRE - changes in the peptide precursors from D-alanyl-D-alanine to D-alanyl-D-lactate
Name + MoA antibiotic that causes myopathy and CPK elevation
Daptomycin
creates transmembrane channels, which causes leakage of intracellular ions, leading to Depolarization of the membrane; does not work against GN infections since it can’t permeate LPS!
inactivated by pulmonary surfactant (not good for treating pneumonias)
name + MoA antibiotic that causes optic neuritis + thrombocytopenia
Linezolid
binds 50S (by at 30, CEL**L **at 50)
also increases risk of serotonin syndrome
ApoA-1 function
∆ results in?
LCAT actviation (leads to cholesterol esterification)
∆ results in low HDL and increased circulating free cholesterol levels
ApoB48 function
chyloµ assembly and secretion by the intestines
ApoB100 function
LDL particle uptake by extrahepatic cells
ApoCII function
∆ results in?
Lipoprotein lipase activation
∆ results in hyperchylomicronemia
ApoE3 and ApoE4 function
VLDL and chyloµ remnant uptake by liver cells
(∆ = liver can’t remove chyloµ+VLDL remnants from circulation, causing their accumulation in the serum, resulting in elevated cholesterol + Tg levels)
patient treated w/ an antibiotic that develops pancytopenia (aplastic anemia)
chloramphenicol - binds 50S subunit and inhibits the peptidyl transferase enzyme, thereby suppressing bacterial protein synthesis.
continual use of opioids can result in tolerance (decrease in effectiveiness + physiological response). What two side effects are most resistant to tolerance development?
constipation = due to opioid stimulation of µ receptors in the GI tract, causing decreased secretions + gastric motility
miosis = due to opioid stimulation of parasympathetic tracts of the pupil, leading to pupil constriction
gentamicin
MoA + ADR
how is resistance acquired?
binds to 30S subunit
vestibular + choclear ototoxicity
**nephrotoxicity, neuromuscular paralysis **
resistance - acquired plasmid/transposons that modify the aminoglycoside Rx via acetylation, adenylation, phosphorylation
67yo w/ trouble seeing an a gray subretinal membrane. dx & trmt?
age-related “wet” macular degeneration - abnormal BV w/ subretinal fluid/hemorrhage, gray subretinal membrane, or neovascularization
trmt: anti-VEGF, laser, or phototherapy - limits the choroidal neovascular membrane formation
compared to dry MD = subretinal drusen deposits or pigment ∆s, usually progresses to wet
how to determine the prognosis of a patient w/ N. meningitidis?
serum **lipooligosaccharide (LOS) **= endotoxin; plasma levels are closely associated with morbidity and mortality of the disease
LOS activates TLR4, resulting in production of TNFa, IL1ß, IL6, and IL8, resulting in sepsis
LOS also causes cutaneous pepteciae + hemorrhagic bullae + bilateral adrenal cortical hemorrhage (Waterhouse-Friderichsen Syndrome)
signs of HSV encephalitis?
affects TEMPORAL lobe, therefore can result in
aphasia (damage to speech area)
olfactory hallucination (olfactory cortex involvement)
personality ∆ (amygdala involvement)
parotitis is associated with which viral infection?
mumps
calculation of A-a gradient?
normal values?
Aa = PAO2 - PaO2
PAO2 = 150 - (PaCO2 / 0.8)
(bolded = what is normally given)
normal values are 10-15mmHg
shingles is due to what type of virus?
histology should show what?
trmt?
herpes - VZV - enveloped, dsDNA virus
hx: intranuclear inclusions in keratinocytes + multinucleated giant cells (+Tzanck smear), acantholysis (loss of intercellular connections ) of keratinocytes and intraepidermal vesicles
trmt: gabapentin for post-herpetic neuralgia
dermatitis herpetiformis presents with what kind of physically? histology?
PE: pruritic grouped vesicles on extensor surfaces
hx: PMN accumulations at the tips of dermal papillae (microabscesses)
males = bifid scrotum is due to malformation of?
what does this strcture form in females?
failure of the labioscrotal folds to come together, resulting in two separate scrotal sacs…
in females, this forms the labia majora
causes of:
hypospadias
epispadias
hypospadias: incomplete fusion of urethral (urogenital) folds, resulting in an opening of the urethra along the ventral shaft of the penis
epispadias:
loss of this protein is associated with metastasis
e-cadherin
what is alpha-amanitin?
produced by in Amanita phalloides (aka death cap mushrooms)
inhibits RNA pol III (makes tRNAs), therefore no mRNA is made. Can cause severe hepatotoxicity if ingested
which part of the tRNA carries the CCA sequence? amino acid?
both at the 3’ end
(the CCA is where the actual tRNA binds)
what is reponsible for making sure that the tRNAs are charged with the right a.a.?
aminoacyl-tRNA synthetase (each a.a. has its own!) - scrutinizes a.a. before AND after it binds to tRNA and if it is incorrect it hydrolyzes the bond and replaces it for the right one.
what cytoskeletal element comprises
microvilli
cilia
flagella
microvilli = actin + myosin “m&m”
cilia + flagella = microtubules
what type of collagen are these made of?
granulation tissue
scar tissue
granulation = type III
scar = type I
the cornea, lens, and vitreous body of the eye are all made of different types of collagen. what are they?
cornea = Type I ( I looks like a cob of corn)
vitreous body = Type II (two words!)
lens = Type III (lens = 3 letters)
pupil deviations occur in 3 CN palsies and what are they?
CN 3 = down and out
CN 4 = upward
CN 6 = medially
lens subluxation occur in 3 disorders. what are they?
upward and temporally = Marfan
down and inward = homocystinuria
lens disolocation (ectopia lentis) = marfans
why do CF patients present with contraction alkalosis + hypokalemia
whenever you see alkalosis + hypokalemia in the same sentence, consider the presence of aldosterone
CF patients lose a lot of fluids due to Na/H2O losses in their sweat (remember, usually Na is reabsorbed and water follows but in CF patients this does not occur)
Decr. ECV -> RAAS -> Aldosterone -> Na/H2O reuptake + H/K excretion
what drug do you want to avoid using in a patient with **azathioprine **and why?
xanthine oxidase inhibitors - since 6MP is degraded by it! Using it will increase toxicity of pancytopenia (leukopenia,
symptoms associated wtih cholinergic agonists?
- increase nausea, vomiting, abd. cramps, diarrhea by increasing GI smooth muscle tone
- cause dyspnea via bronchoconstriction by increasing bronchial smooth muscle tone
- cause bradycardia, hypotension (perpiheral vasodilation)
- incraese secretions: sweating, salivation, lacrimation, bronchial secretions
- cause: miosis
basically, PARASYMPATHETHIC EFFECTS (rest & digest)
drug that is usually administered post-op - causes flushing, diaphoresis and nausea, miosis, HR55, BP 100/70
bethanchol - cholinergic agonist used to stimulate peristalsis in post-op ileus; also used to treat non-obstructive urinary retention (atonic bladder)
how do benzodiazepines + barbiturates similar in terms of their MoA? how are they different?
how does tolerance to either drug work?
both bind to GABAA (ion channels) to increase flux of Cl- ions, thereby hyperpolarizing the cell and stablizing the cell membrane, rendering it less excitable.
Benzos - increase frequency of Cl- channel openings
barbiturates - prolongs duration of Cl- channel opening
tolerance: prolonged stimulation -> decrease # of GABAA receptors in the synaptic clefts
inactivated/killed vaccines
Cholera
HepA
Influenza (Inj)
Rabies
Polio (salK)
kill that CHIRPing bird
(rest are inactivated)
clues on CT scan for
constrictive pericarditis
aortic dissection
ischemic heart disease
- constrictive pericarditis - thickening/calcifications of the pericardium
- aortic dissection - double aortic lumen
- ischemic heart disease - calcifications in the coronary arteries + aorta
∆ btwn conversion d/o and somatization d/o?
conversion = somatoform d/o where there are motor/sensory deficits (ie symptoms are neurologic in nature - blindness, aphonia, weakness, pseudoseizure) that suggest a neurologic or general medical illness, even though all of the appropriate tests and labs are normal
- typically affect young women who with an emotional stress
somatization = somatform d/o where there are numerous** physical complaints** over where there are no physical explanations for (ie pain sx, GI sx, sexual sx, pseudoneurologic sx) and have impacted their social or occupational functioning
- patients typically have a high use of medical resoruces
patient presents to be a hemiplegic to get disability benefits
malingering - purpose of faking symptoms for secondary gain (financial)
woman with gas pain is convinced that she has colon cancer
Hypochondriasis - somatoform d/o that refers to the irrational fear of having or belief that one has a serious physical disease; usually due to misinterpretation of bodily sx or normal functions
typically seen in patients with anxiety d/o
patient w/ hx of HTN, asthma, diabetes that comes to ER w/ chest pain is treated. Chest pain disappears, but SOB develops. What was he given specifically?
Non-selective ß blocker
ß1 blockade - decreases HR
ß2 blockade = bronchoconstriction + wheezing
virus with phopholipid composition that resembles the host cell nuclear membrane
HERPESviruses - unique among viruses in that it buds through and acquire the lipid bilayer envelope from the host cell nuclear membrane
what is this ECG a description of?
“polymorphic QRS complexes of varying amplitude and cycle length with evidence of QT prolongation”
what can cause this?
Torsades “twisting of points” - type of v-tach that is always associated with an underlying QT prolongation
Class IA - quinidine, procainamide, disopyramide)
Class III (K channel blockers - ibutilide, dofetilide, sotalol - dis-K)
TCAs
most common location of colon cancers?
- **rectosigmoid **- most common - tend to presesent with obstructing sx (∆ bowel habits, constipation, abd. distension, N, V)
- ascending - 2nd most common - tend to present with iron deficient anemia, anorexia/weight loss, malaise
- descending + transverse - relatively rare
buzzwords
HBsAg
first virological marker detected in the serum after inoculation; suggests infectivity
HBeAg
antigen detectable shortly after the appearance of HBsAg; indicates active viral replication and infectivity and is associated w/ the presence of HBV DNA
if it persists for >3mo, there is an increased likelihood of chronic HepB
Anti-HBc
IgM = acute phase of disease; present during the window period!
IgG = recovery from disease
Anti-HBe
Anti-HBs
indicates successful vaccination OR clearance of HBsAg
remains detectable for life; indicator of immunity
lag period from which HBsAg disappears and anti-HBs appears = WINDOW period
Colonic diverticulum
true or false diverticula?
false diverticula - contains only mucosa and submucosa since these layers herniate through defects in the muscularis layer
(compared to Meckels, which contain mucosa, submucosa, and muscularis)
sequences involved in transcription initiation? translation initation?
transcription initiation = TATA
translation initation = AUG
ADR of furosemide
hypoK, hypoMg, hypoCa
volume depletion, hypoNa, decreased GFR, hypotension, ototoxicity
otoxic agents 5
salicyclates
cisplatin
aminoglycosides
loop diuretics (ethacrynic acid, furosemide)
SCALE-F
Triamterene
K sparing diuretic - blocks the ENaC in the DCT and CD, thereby resulting in increased Na/H2O loss and hyperkalemia
what is effect modification?
occurs when the effect of a main exposure on an outcome is modified by another variable
(ex: effect: SERM on DVT; variable: smoking status)
NOTE can be confused with confounding - if the variable was a confounding factor, then when the data is stratified in terms of the variable (SERM on DVT in smokers and non-smokers), then the effect should either be greater or disappear
what are these nuclei involved in
nucleus ceruleus
raphe nucleus
nucleus basalis of meynert
red nucleus
caudate nucleus
substantia nigra
- nucleus ceruleus - NE secreting neurons that participiate in the fight or flight response; located in dorsal pons
- raphe nucleus - serotonin secreting neurons, sleep wake cycle, arousal; lesions can result in insomnia and depression
- nucleus basalis of meynert - cholinergic neurons; in Alzheimers, these neurons secrete very low levels of ACh
- red nucleus - anterior midbrain, participate in motor coordination
- caudate nucleus - functions in motor activities; in huntingtons, there is a loss of cholinergic + GABA neurons
- substantia nigra - dopaminergic neurons; in parkinsons, these neurons are gone
first-line Rx in treating HTN during pregnancy
methyldopa
what provides innervation to the lacrimal glands? ie stimulation of what nerve will make you cry?
CN 7
also provides motor output to facial muscles
parasympathetic innervation to submandibular + sublingual glands
taste from anterior 2/3 of tongue
somatic afferents from the pinna + external auditory canal
patient is lying supine with R knee flexed and externally rotated
and resists extension of the leg and thigh, esp at the hip
what muscle is affected?
Psoas major
injury to this muscle (ie abscess) will cause patients to be in a position that will minimize stretching (supine w/ knees bent); most likely wont allow you to extend the muscle via extension of the hip
stop codons
UGA = u go away
UAG = u are gone
UAA = u are away
why is it that someone who drinks often have low glucose levels and fatty liver?
EtOH conversion to acetaldehyde and acetate requires reduction of NAD+ -> NADH
excess NADH favors conversion of
- pyruvate -> lactate
- oxaloacetate to malate
- glyceraldehyde-3-phosphate -> glycerol-3-phosphate
(thus regenerating NAD+)
the first two reactions prevent gluconeogenesis from occuring, thus resulting in fasting hypoglycemia
the last reaction combines with FA to make TGs, resulting in hepatosteatosis
Herpes
diagnostic test?
treatment?
Tzanck test (tzanck god I dont have herpes!!)
acyclovir -nucleoside analogs, that when incorporated into newly replicating viral DNA, terminates DNA synthesis
Benzodiazepines (BDZ) have various half-lives and people take them depending on their symptom severity.
Which ones are short-acting?
Which ones are intermediate acting?
Which ones are long-acting?
Short acting: Triazolam, Alprazolam, and Oxazepam = TAO
Intermediate acting: Lorazepam, Estazolam, and Temazepam = LET
Long acting: Chlordiazepoxide, Clorazepate, Diazepam, and Flurazepam
TAO - LET - the CDC Fail
Benzodiazepines (BDZ) have various half-lives and people take them depending on their symptom severity.
Which BDZ should one take to avoid to minimize risk of falling?
Which BDZ should one take to avoid day-time drowsiness?
Which ones put the patient at highest risk of physical dependence?
which ones are best?
in all 3 cases, the short acting ones (Triazolam, Alprazolam, and Oxazepam = TAO) have relatively short half-lives and therefore cause less daytime drowsiness + less risk of falls.
However, rapid clearance of th edrug can leads to severe withdrawal sx and therefore increase the risk of physical dependence!!
Best ones to use are the intermediate ones: Lorazepam, Estazolam, and Temazepam = LET
Longacting ones are Chlordiazepoxide, Clorazepate, Diazepam, and Flurazepam are associated wtih daytime somlence
TAO LET the CDC Fail
non-compliant HIV+ patient comes in with a single ulcerated mass in the anal canal; no palpable regional lympadenopathy
dx and pathogen?
squamous cell carcinoma of the anus - HPV 16/18
immunodeficiency states increase the host’s susceptiblity to HPV infection and a more severe infection
HIV homosexual males are more prone to developing <strong>anal</strong>squamous cell carcinoma
HIV females are more prone to developing<strong>cervical</strong> squamous cell carcinoma
where is most of the fluid filtered by the glomerulus reabsorbed?
PCT - duh!!!!!!! >60% of the fluid filtered by the glomerulus is reabsorbed in the PCT regardless of the patient’s hydration status
not the CD - even when the patient is suffering from dehydration; only 20% of the original fluid filtered is reabsorbed here.
lacunar infarcts
what are they and what are they caused by?
where are they typically located?
histological findings?
small, ~5mm cavities caused by occlusion of small penetrating arteries (lenticulostriate arteries) in the basal ganglia, internal capsule, pons, usually 2˚ to unmanaged HTN and DM
Hx: lipohalinosis (wall necrosis) and microatheromas (accumulation of lipid-laden macrophages within the intimal layer of the vessel wall)
what the heck is the difference btwn tight junctions, intermediate junctions, and gap junctions
- tight = zonula occludens - tightly adheres the membrane of two cells together
- intermediate = zonula adherens - cytoplasmic filaments that radiate from the cell membrane to hold adjacent cells together
- gap = how cells communicate with each other
which dietary substrate has the highest rate of metabolism in the glycolytic pathway?
glucose
mannose
galactose
fructose
fructose
it bypasses PFK-1 (rate limiting enzyme of glycolysis), while other sugars enter glycolysis before this rate limiting enzyme and are therefore metabolized more slowly due to regulation of PFK-1
how do differentiate btwn anorexia nervosa (binge-purge type) vs bulimia nervosa? 2
in binge-purge anorexia nervosa, there are two distinguishing features:
abnormally low body weight <85% of ideal
amenorrhea
febrile respiratory illness followed by the sudden appearance of red, flushed cheeks approx 2-5d later is characteristic of
virus?
genome?
where does it like to replicate?
erythema infectiosum - parvovirus B19
non-enveloped, ss DNA
(highly tropic for erythroid precursor cells and replicates predominantly in the bone marrow)
concomitant use of statins + gemfibrozil increases one’s risk of?
myopathy + hepatitis
gemfibrozil inhibits CYP450, thereby resulting in an increased serum levels of statins
concomitant use of fibrates with a bile acid binding resin increase one’s risk of?
cholesterol gallstones
which statin is NOT metabolized by cytochrome P450?
pravastatin
1 mo with mild jaundice, enlarged tongue, general hypotonia and an umbilical hernia is brought into the ER. Parents also complain that the baby seems “floppy” and has not been feeding well
dx?
congenital hypothyroidism
key: hypotonia, enlarged tongue, umbilical hernia, myxedema, mental retardation
difference btwn facticious d/o and malingering d/o?
facticious - intentional production or feigning of physical or psychological sx for the purpose of assuming the sick role
malingering - voluntary fabrication of sx for the purpose of obtaining an external reward (avoiding difficult situations, obtaining Rx, acquiring financial compensation)
what kind of gene are these and what diseases are they implicated in?
c-myc
bcl2
c-abl
cyclin D1
- c-myc = oncogene - Burkitts - inhibits apotosis
- bcl2 = oncogene - Follicular - inhibits apotosis
- c-abl = oncogene - CML - inhibits apotosis
- cyclin D1 = promotes G1-S - mantle
homeless alcoholic brougth to teh ER w/ vomiting and prolonged oliguria has a renal bx that shows ballooning + vacuolar degeneration of PCT + multiple oxaalate crystals.
what should you think of?
ETHYLENE GLYCOL
rapidly absorbed in the GI tract; metabolized to glycolic acid (toxic to renal tubules) and oxalic acid (preciptates as CaOx crystals in the renal tubules)
signs of high AG acidosis + high osmolar gap
granular casts are pathognomonic for
typical signs?
also known as muddy brown casts
Acute Tubular Necrosis (ATN)
due to prolonged hypotension that triggers hypoxic changes in tubular epithelial cells (esp the PCT and TALH)
signs: increased BUN, creatinine, and oliguria
muddy brown casts are pathognomonic for
typical signs?
can also be called “granular casts”
Acute Tubular Necrosis (ATN)
due to prolonged hypotension that triggers hypoxic changes in tubular epithelial cells (esp the PCT and TALH)
signs: increased BUN, creatinine, and oliguria
RBC casts are pathognomonic for 3 things
Glomerulonephritis
ischemia
malignant HTN
WBC casts are pathognomonic for 3 things
tubulointerstitial inflammation
acute pyelonephritis
transplant rejection
fatty casts are pathognomonic for 3 things
nephrotic syndrome
waxy casts are pathognomonic for 2 things
advanced renal disease
chronic renal failure
which is more common in alcoholics: folate or B12 deficiency
folate deficiency is more common
both show hypersegmented PMNs
(if the patient description says that the patient has DCML-sx, then consider B12 deficiency)
esophageal cancer
squamous cell is usually due to:
adenocarcinoma is usually due to:
squamous cell
- EtOH use
- tobacco
- N-nitroso-containing foods
Adenocarcinoma
- Barrett’s esophagus
- GERD
- obesity
- tobacco
5’-phosphoribosyl-1’-pyrophosphate synthetase (PRPP)
activating mutation in this gene results in?
PRPP = de novo purnine synthesis
activating mutation results in increased purine production -> hyperuricemia
tenderness of the calf muscle on dorsiflexion of the foot is a sign of?
homan’s sign - DVT!!
trmt: heparin
define and give an example of each
spongiosis
acanthosis
dyskeratosis
hyperparakeratosis
hypergranulosis
-
spongiosis - epidermal accumulation of edematous fluid in intercellular spaces; intercellular bridges become more distinctive
- eczematous dermatitis/contact dermatitis
-
acanthosis - increase thickness of stratum spinosum
- psoriasis
-
dyskeratosis - abnormal, premature keratinization of individual keratinocytes
- squamous cell carcinoma
-
hyperparakeratosis - retention of nuclei in the stratum corneum, which signals incomplete keratinization
- normal on mucous membranes
- actinic keratosis
-
hypergranulosis - excessive granulation in the stratum granulosum of the epidermis
- lichen planus
Pathogenesis btwn rheumatic fever vs PIGN (even though they’re caused by the same pathogen?
rheumatic fever = shared bacterial + human epitope homology that results in formation of autoantibodies against self
PIGN = immune complex deposition w/ subsequent complement fixation (Type III HSR)
what are the processes involved in apoptosis?
why is there no inflammation observed in apoptosis?
2 pathways
- intrinsic pathway - mitochondria becomes more permeable and releases caspase-actvating substances (ie cytochrome C)
- extrinisic pathway - TNFR1 or FasL (CD95) activation with subsequent FADD formation and caspase activation
ø inflammation because
- cell membrane remains intact and no cell contents are leaked into the surrounding tissue
how to caclculate false negative ratio?
1-sensitivity
Laron dwarfism is due to what?
typical lab findings in these patients?
defective GH receptors - leading to a decrease in linear growth
GH = high
IGF1 = low
major functions of these hypothalamic nuclei:
ventromedial
lateral
anterior
posterior
-
ventromedial - satiety; if you stimulate this constantly, you will grow ventrally and medially (skinnier)
- destruction -> hyperphagia
-
lateral - hunger; if you stimulate this constantly, you will grow laterally (fatter)
- *destruction -> anorexia *
-
anterior - heat dissipation (cooler) = AC
- destruction -> hyperthermia
-
posterior - heat conservation (warmth)
- destruction -> hypothermia
major functions of these hypothalamic nuclei:
arcuate
paraventricular
supraoptic
suprachiasmatic
- arcuate - dopamine, GHRH, gonadotropin secretion
- paraventricular - ADH, oxytocin, CRH, thyrotropin-releasing hormone** **
- **supraoptic **- ADH,oxytocin
- suprachiasmatic - circadian rhythm regulation + pineal gland function
crohns
vs
ulcerative colitis
in terms of location, wall involvement, and clinical manifestations
Crohns
- anywhere from mouth-anus (skipped)
- transmural inflammation + noncaseating granulomas
- Abd pain + diarrhea
Ulcerative Colitis
- colorectal (continuous)
- mucosal + submucosal inflammation
- bloody diarrhea + abd pain
complications of
crohns
vs
ulcerative colitis
crohns = fistulas and intestinal strictures
- fistulas can form btwn two adjacent bowel loops or in between the bowel and another organ (ie bladder, vagina, skin). Perianal fistulas and abscesses are common!!
- intestinal strictures can lead to intestinal strictures
ulcerative colitis = toxic megacolon
∆ btwn tetanospasmin and botulinum toxin? similarities?
both are proteases that cleave SNARE proteins required for NT release
- tetanospasmin = prevents release of inhibitory (GABA + glycine) NTs from inhibitory Renshaw cells in the spinal cord -> spasticity, risus sardonicus, and lockjaw
- botulinum = prevents release of stimulatory (ACh) NT at NMJ -> flaccid
for each one, name the culprit
wound -> neuron axons -> salivary gland
wound -> motor neurons -> spinal cord
fibrinous exudate -> systemic circulation -> cortical neurons
food -> systemic circulation -> meninges
food -> systemic circulation -> peripheral nerves
wound -> neuron axons -> salivary gland: rabies
wound -> motor neurons -> spinal cord: C tetani
fibrinous exudate -> systemic circ. -> cortical neurons:** C diphtheria**
food -> systemic circ. -> meninges: L. monocytogenes
food -> systemic circ. -> peripheral nerves: botulinum
varenicline
MoA
clinical use?
partial agonist of nicotinic ACh receptors
assist patients w/ smoking cessation by reducing withdrawal cravings and attenuating the rewarding effects of nicotine (ie its partial agonist activity causes minimal DA release, resulting in less stimulation of the reward pathway than nicotine)
patients with retinoblastoma are at increased risk of?
osteosarcomas
SVC syndrome is commonly associated with?
how does it present?
small cell lung cancer
HA, facial + upper extremity edema + dilated veins of upper torso
what is lipofuscin?
how does it develop?
“wear and tear” pigment
yellowish-brown, perinuclear pigment composed of lipid polymers and protein-complexed phospholipids; is the product of free radical injury and lipid peroxidation
differentiate btwn delusional d/o and paranoid personality d/o
- delusional d/o - one or more delusions in the absence of other psychotic symptoms; behaviors are not obviously bizzare; functioning is not significantly impaired apart from the direct impact of the delusions
- paranoid d/o - persistant patterns of behavior that are pervasive across a broad range of situations; characterized by suspiciousness or distrust
two cytokines involved in PMN recruitment
IL-8 and C5a
organ that is not a forgut derivative but is supplied by an artery of the foregut
spleen - mesoderm-derived organ that originates from dorsal mesentary
supplied by splenic artery - branch of celiac trunk (artery of the foregut)
why not treat a patient w/ sx of c. diphtheriae infection with antibiotics, such as penicillin or erythromycin first?
antibiotics kill the bacteria, thereby halting the release of new exotoxin into the blood stream, but it doesn’t affect the toxins that may have already gained access to the blood stream
the antitoxin is a neutralizing antibody (passive immunization) that sequesters the toxin that may have already gained access into the blood stream
diphtheria AB exotoxin = predilection for neural + cardiac tissue; it ribosylates and deactivates EF-2 in these tissues, therefore inhibiting protein synthesis
acute manic episode is treated with
mood stabilizing agent (lithium, valproate, carbamazepine) + atypical antipsychotic (olanzapine)
∆ btwn first and second generation antihistamines?
- 1st generation = lipophilic/can cross BBBand blockmuscarinic(blurry vision, dry mouth, urinary retention),sertonergic (appetite stimulation), anda-adrenergic (postural dizziness) pathways, and can cause sedation
- diphenhydramine, chlorpheniramine, dimenhydrinate, promethazine, hydroxyzine
- 2nd generation = do not cross the BBB and therefore have minimial sedative and anti-muscarinic effects and are usually non-sedating
- fexofenadine, loratadine, desloratadine, cetirizine
Zollinger-Ellison Syndrome is due to a tumor that develops in what organ?
pancreatic islet cell tumor
is a gastrin secreting tumor that causes hypersecretion of gastric acid, leading to peptic ulcers commonly in the duodenum, abd pain, GERD, and diarrhea
infant w/ dystonia, poor feeding, and urine that smells of burnt sugar should avoid which 3 amino acids?
leucine, isoleucine, and valine
∆ a-keto acid dehydrogenase -> inability to degrade branched chain a.a. -> accumulation can lead to neurotoxicity
definition of a permissive Rx vs additive Rx vs synergistic Rx
- permissive - Rx1 itself does not have an effect, but when it is added to another Rx2, it augments the effect of Rx2 (ie allows it to reach its full potential)
- additive - combined effect of Rx1 + Rx2 is equal to the sum of the effects expected from the individual Rx effects
- synergistic = combined effects of Rx1 + Rx2 exceeds the sum of the effects expected from the individual Rx effects
∆ btwn Myasthenia gravis and Lambert Eaton Syndrome in terms of the muscles affected?
MG: extraocular muscles are affected first (ptosis, diplopia)
LES: proximal muscles (hip girdle weakness)
histology of a vessel in a patient with buerger’s disease is likely to show what
segmental thrombosing vasculitis that extends into contiguous veins and nerves; due to direct endothelial cell toxicity from tobacco products or hypersensitivity to them
inflammation may eventually encase all 3 structures (NAV) in fibrous tissue (unique!!)
artery damaged in:
epidural hematoma
subdural hematoma
subarachnoid hematoma
hypertensive strokes
epidural hematoma = MMA
subdural hematoma = bridging cortiacl veins
subarachnoid hematoma = berry aneurysms
hypertensive strokes = lateral striate “penetrating arteries”
stimulation of acid secretion in the stomach is caused by these 3 phases.
what mediates each phase and what are their appropriate triggers?
1) cephalic stage - stimulate gastric acid secretion - mediated by vagal + cholinergic mxns; triggered by thought, sight, smell, taste of food
2) gastric phase = stimulate gastric acid secretion mediated by gastrin, which stimulates histamine secretion, and therefore acid secretion; triggered by chemical stimulus of food and stomach distension
3) intestinal phase = downregulate acid secretion after a meal via Peptide YY, which binds to ECL cells and inhibiting thier release of histamine
diffuse increased thickness of the glomeruluar BM w/o increase in cellularity; “spike and dome” apperance on silver stain, granular deposits on immunofluorescence
membranous glomerulopathy
thickness is caused by irregular dense deposits laid btwn the BM and the epithelial cells - resemble spikes when stained with silver
(nephrotic syndrome)
cardinal manifestations in patients with 1˚ hyperparathyroidism
bone loss = **bones **
subperiosteal thinning of cortical (ie compact) bone in the appendicular skeleton;<br></br>and w/ salt + pepper appearance of the skull
renal stones = stones
GI upset (ulcers) = groans
psychiatric d/o = **psychiatric overtones **
HIDA scan - what is it used for?
radionuclide scan that visualizes hepatic uptake of the radionuclide + excretion into the CBD and proximal small bowel
in patients w/ acute calculous cholecystitis (stone that impacts the cystic duct), you will see an absence of radionuclide filling in the GB
cytokines involved in sarcoidosis?
sarcoidosis = formation of non-caseating granulomas w/ a central collection of epithelioid macrophages (+ giant cells) surrounded by a rim of monocytes
Th1 CD4+ cells - secrete IL2, IFNg
IL2 -> stimulates proliferation of TH1
**IFNg -> stimulates macrophages **(only TH1 secrete IFNg)
patient receiving an agent that inhibits glucose reabsorption in the PCT will have a glucose clearance that approximates…
Inulin or mannitol
(the agent will basically cause all of the filtered glucose to be excreted; thus the glucose = GFR)
GLUT4 is the only transporter that is responsive to insulin. where is it predominately expressed?
muscle cells + adipocytes
∆ btwn
physiological dead space
anatomic dead space
alveolar dead space
physiological = anatomic + alveolar
anatomic = volume of air in conducting airway that is not available for gas exchange
alveolar = volume of air in alveoli that does not participate in gas exchange due to insufficient blood flow (perfusion limited)
how does **hereditary spherocytosis **affect MCHC?
increase MCHC - indicates membrane loss and RBC dehydration
patients w/ “burning feet syndrome” is usually deficient in what vitamin?
What is this vitamin used for?
It is also important in this one particular biochem pathway (of all the ones we have to know…)
pantothenic acid (B5) - cofactor in CoA and fatty acid synthase; impt in the first step of the TCA cycle where it binds with oxaloacetate to form citrate + succinyl CoA
what Rx would you use in a patient w/ thymidine-kinase deficient VZV isolate?
Pyrophosphate analog - foscarnet
no phosphorylation necessary: Tenofovir + Cidofovir
phosphorylation is necessary for acyclovir, valacyclovir, famciclovir, gangciclovir, and would therefore not be effective in this patient
patient w/ mild heaptomeagly, pancreatic calcifications, and macrocytic anemia should make you think of…
Alcoholism
heaptomeagly (steatosis) + pancreatic calcifications (chronic pancreatitis) = both most commonly caused by ethanol abuse)
macrocytic anemia = folate deficiency -> diminished Thymidine synthesis
“pruritus after showering” + “ruddy appearance” should make you think of..
typical blood findings?
polycythemia vera - JAK2 mutation that causes hematopoietic cells more sensitive to growth factors (EPO + thrombopoietin)
increased: RBC mass, plasma volume, platelet/WBC count, thrombotic events (hyperviscosity), peptic ulceration, pruritus, gouty arthritis (incerased cell turnover)
decreased: EPO levels
dapsone clinical use and ADR
clincal use: leprosy, PCJ
ADR: agranulocytosis
leading cause of chronic bronchitis
smoking
others (inhaled substances - air pollutants, grain, cotton, silica dust)
(note: genetic factors are not known to strongly predispose one to chronic bronchitis)
fungal antibiotics - which one affects
DNA & RNA synthesis?
cell membrane synthesis?
cell wall synthesis?
DNA & RNA synthesis (the nucleotide is part of the name)
- flucytosine
cell membrane synthesis “tears a-hole finely”
- amphotericin B + Nystatin bind ergosterol -> pore formation
- -azoles + terbina**fine **- inhibit synthesis of ergosterol
cell wall (1,3-ß-D-glucan) synthesis “casper the friendly ghost can go through the great wall”
- caspofungin
mutation in trypsin that prevents it from being permanently degraded will increase one’s risk to?
hereditary pancreatitis - due to mutation in SPINK1
all pancreatic enzymes (except amylase + lipase) are synthesized + secreted in inactive form to protect the pancreas from autodigestion and are activated by trypsin in duodenal lumen (after trypsinogen is converted to its active form, trypsin, by enterokinase)
SPINK1 acts as a trypsin inhibitor in the pancreas (prevents trypsin-mediated activation of other zymogens; ie it prevents autodigestion of pancreatic tissue)
trypsin also inhibits itself by cleaving other trypsin molecules (and therefore preventing active trypsin from forming within the pancreatic tissue)
depressed person started on this antibiotic experiences these sx:
agitation + confusion
severe abd cramps + diarrhea
increased T + BP + HR, regular
tremulous
dilated pupils
bilateral hyperreflexia + ankle clonus
Linezolid
ADR: serotonin syndrome - neuromuscular excitation, autonomic stimulation, altered mental status
these are the two main factors that can cause the bronchoconstriction that is seen in allergic asthma
What drug targets them to relieve these patients?
leukotrienes - zafirlukast, montelukast
ACh - ipratropium
how does acute salicyclate intoxication affect
pH
PaCO2
plasma HCO3
respiratory alkalosis - it stimulates the medullary respiratory center, resulting in hyperventilation -> CO2 loss, increase pH
**AG metabolic acidosis - **accumulation of organic acids in the blood = decrease pH, low HCO3
net: pH = close to normal, slightly acidic
net: PaCO2 = low
plasma HCO3 =
6 mo infant w/ poor feeding + irritability has diffuse skin erythema with + Nikolsky sign. What is the diagnosis?
SSSS - caused by exfoliatin exotoxin, which cleaves desmoglein
patient with pancytopenia, very low reticulocyte count, and normal PE should make you think of…
aplastic anemia - causes pancytopenia as the BM is replaced by fat cells and fibrous stroma; **an absence of splenomeagly is characteristic. **
other causes: B12/Folate deficiency, aleukemic leukemia, myelodysplastic syndrome
how does afferent arteriole constriction affect
GFR
FF
RPF
bonus: how do you calculate FF?
GFR = decrease
RPF = decreases
FF = unchanged
(afferent afteriole constriction results in relatively equal decreases in GFR and RPF)
remember that FF = GFR / RPF
how does efferent arteriole constriction affect
GFR
FF
RPF
bonus: how do you calculate FF?
GFR = increase
RPF = decerase
FF = increase
remember that FF = GFR / RPF
antibodies against polyribitol ribose phosphate will protect against what?
H. influenza - type B
what part of the GI tract do these appear?
Brunner glands
Peyer’s patches
crypts of lieberkuhn
largest # of goblet cells
Brunner glands = duodenum = “Brudder”
Peyer’s patches = **Ileum = “Pi” **
crypts of lieberkuhn = duodenum –> colon
largest # of goblet cells = **Ileum / colon **
Sx that occur w/ occlusion of the MCA on the L side of the brain? R side?
LEFT side (dominant hemisphere): hemiparesis w/ the arms affected more than the legs + APHASIA
RIGHT side (dominant hemisphere): hemiparesis w/ the arms affected more than the legs
Zollinger Ellison Syndrome
Diagnostic test?
Secretin injection
normally will inhibit gastrin secretion, but in ZES, there is a paradoxical increase in gastrin secretion
GI ligaments
which one contains the portal triad?
which one may be cut during surgery to visualize the pancreatic head?
which one contains the short gastrics?
which one contains the ligamentum teres hepatis?
which one is a part of the greater omentum?
which one contains the splenic artery?
portal triad = hepatoduodenal
cut to visualize the pancreatic head = gastrohepatic
short gastrics = gastrosplenic
ligamentum teres hepatis = falciform
part of the greater omentum = gastrocolic
splenic artery = splenorenal
where are these structures located and what is their function?
meissner’s plexus
auerbach’s plexus
MeiSSner’s plexus
- Submucosa
- controls Secretory activity
Auerbach (aka Myenteric) plexus
- Muscularis externa
- controls Muscle contractions
at what level of the spinal column is the
celiac trunk
SMA + L renal arteries
IMA
Aortic bifurcation
celiac trunk = T12
SMA + L renal arteries = L1
<<skip l2>
<p>IMA = L3</p>
<p>Aortic bifurcation = L4</p>
</skip>
posterior duodenal ulcer is likely to erode into which artery?
gastroduodenal a. - lies along the posterior wall of the duodenal bulb
which part of the stomach is the most vulnerable to ischemia bc it does not have a strong anastomatic arterial supply?
short gastric a.
How does the vagus n. affect stomach secretions?
be specific w/ the type of NT used
ACh -> M3 receptor -> stimulates parietal cells to secrete HCl and IF
GRP -> stimulates G cells to secrete gastrin (which stimulates ECL cells to produce histamine to ultimately stimulate parietal cells)
what is the pectinate line?
what are some pathologies above/below this line?
formed where endoderm meets ectoderm
above: internal hemorrhoids, adenocarcinoma
below: external hemorrhoids, squamous cell carcinoma, anal fissures
patient w/ steatorrhea is given a d-xylose test
what do low urine excreton values mean? 5
normal urine values?
D-xylose is a monosaccharide that is absorbed in the intestines, mostly in duodenum and jejeunum (ie it requires a normal, intact mucosal wall for absorption)
-
low values = defect in intestinal wall that leads to malabsorption
- baterial overgrowth -> corrects w/ antibiotics
- tropical sprue -> correct w/ antibiotics
- whipple -> does not correct w/ antibiotics
- celiacs -> does not correct w/ antibiotics
- crohns = affects w/ bile salt reabsorption and therefore fat malabsorption
-
normal values = intestinal wall is intact; malabsorption is due to other factors
- pancreatic insufficiency
peyer’s patches
where are they found?
what cells are present and what do they produce?
there is one specific bug that likes to infect these cells in particular - what is it?
sumucosa of ileum
contain M cells (APC) and B cells (-> plasma cells that produce IgA)
Shigella infects M cells via endocytosis and causes death of these cells -> ulceration w/ hemorrhage and diarrhea
mechanism of cholesterol excretion in the body?
mechanism of Fe excretion in the body?
mechanism of bilibrubin excretion in the body?
cholesterol = bile
Fe = enterocytes store Fe as ferritin but are sloughed off adn elimited
bilirubin = conjugated w/ glucuronate; bile
esophagitis is associated w/ reflux infection in immunocompromised. What would you see specifically for these bugs?
Candida
HSV1
CMV
Candida = white pseudomembrane - duh
HSV1 = punched out ulcers (herpes produces vesicles that when pierced -> “punched out lesions”)
CMV = linear ulcers
how is LES pressure affected in patients w/ achalasia? Scleroderma?
achalasia = increased (failure of relaxation)
scleroderma = decrease (smooth muscle atrophy due to replacement w/ collagen)
pentagastrin test is used for?
tests gastric acid secretion by parietal cells
(remember that gastrin stimulates both 1) gastric acid release by parietal cells directly and 2) histamine release from ECL cells (which stimulates parietal cells to secrete gastric acid)
low-than-expected increase in gastric acid secretion is indicative of gastritis because there is a loss of parietal cells (therefore less H+ is secreted)
2 yo w/ failure to thrive, steatorrhea, acanthosis, ataxia, night blindness
Diagnosis?
aß lipoproteinemia
loss of MTP gene - decrease synthesis of aß-lipoprotein B -> inability to generate chyloµ -> decrease cholesterol + VLDL into blood stream -> fat accumulates in enterocytes
ddx of pneumaturia
ddx of brownish yellow urine + GN rods/mixed flora
- **passage of gas in urine = **ddx: diverticulitus = **colonic diverticulitis that formed a fistula w/ the bladder
- ** brownish yellow urine + GN rods/mixed flora = ddx: crohns** = transmural inflammation that formed a fistula btwn the bowel wall and bladder
newborn infant w/ bilious vomiting, progressive abdominal distension w/ multiple air fluid levels and fecal obstruction should make you think of?
CF patient - meconium plug obstructs intestines, preventing stool passage at birth
elderly patient who present w/ abrupt severe abdominal pain should make you think of….
ischemic colitis - due to reduction of intestinal blood flow that results in ischemia; common at the splenic flexture + distal colon
when would you expect
AST > ALT
ALT > AST
AST > ALT = Alcoholic hepatitis (toast w/ alcohol)
ALT > AST = NASH - due to metabolic syndrome (insulin resistance and subsequent fatty infiltration of hepatocytes) (L = lipids)
budd-chiari syndrome
physical exam finding?
associations?
IVC occlusion (post-hepatic) w/ centrilobular congestion + necrosis
PE: ABSENT JVD
associations: hypercoagulable states, polycythemia vera, pregnancy, HCC
primary sclerosing cholangitis
histological features
lab findings?
associations?
risks?
concentric onion skinning of bile ducts -> alternating strictures and dilation w/ beading of intra- and extra-hepatic bile ducts on ERCP
labs: increased conj. bilirubin, cholesterol, ALP, hyper-IgM
associations: ulcerative colitis
2˚ biliary cirrhosis + cholangiocarcinoma
patient comes with jaundice, fever, RUQ pain
cholangitis - infection of biliary tree proximal to an obstruction
air in the biliary tree
sequelae?
fistula formed btwn the gall bladder and small intestines caused by gallstone
may lead to obstruction of the ilecocecal valve “gallstone ileus”
MoA of Shiga toxin + Shiga-like toxin (EHEC)?
inactivates 60S ribosomal subunit in human cells, leading to an inhibition of protein synthesis and eventual cell death
ductus arteriosus is a remnant of which embryological derivative?
6th aortic arch
delta wave
what is the d/o?
what else would you see?
what do patients usually complain of?
Wolff-Parkinson-White Syndrome - accessory conduction pathway (Bundle of Kent) that allows recurrent temporary tachyarrhythmias due to an re-entry circuit that involves the AV node and accessory pathway
should also see a shortened PR-interval and a widended QRS interval
patients complain of repeated episodes of palpitations that start and stop abruptly “recurrent temporarly arrhythmias”
what are janeway lesions?
painless lesions that are the result of septic embolization from infected cardiac valve vegetations; tend to localize on the palms and soles
found in bacterial endocarditis
IgA protease - produced by…
**S. pneumo + N. gonorrhoeae **
causes cleavage of IgA, therefore preventing them from interfering wtih bacterial adhesions to mucous membranes
virulence factor of staph aureus
protein A
part of the outer peptidoglycan layer that binds Fc of IgG at the complement binding site, therefore preventing complment binding and activation
4yo w/ difficulty walking + hx of respiratory infections.
cells demonstrate high rate of radiation-induced genetic mutations.
dx?
**ataxia-telangiectasia - **AR d/o that causes
cerebellar atrophy -> ataxia
telangiectasia -> shows up later in life
severe immunodeficiency -> repeated sinopulmonary infections
ineffective DNA repair -> increased risk of cancer
how much energy (kcal) per gram does each one of these yield?
protein
fat
ethanol
protein = 4
fat = 9
ethanol = 7
what is the length constant? time constant?
how does demyelination affect these values?
length constant - measure of how far along an axon an electrical impulse can propagate (ie distance at which the original potential decreases to 37% of its original amplitude
demylination decreases the length constant since there is increased charge dissipation along a nerve axon (myelin normally reduces charges from dissipating); net: it reduces the distance an impulse can travel
time constant - time it takes for a change in membrane potential to achieve 63% of its new value
demyelination increases the time constant (leads to a slower impulse conducton since it takes longer for the membrane to build up charges)
most abundant a.a. in collagen and its function?
two other a.a. that are abundant and their functions?
glycine (impt for triple helix to form)
other - proline (impt for a-helix formation) and lysine (impt for hydrophobic interactions)
true vocal cords are covered by what type of epithelium?
2 studies w/ similar RR values, but p values are different. What can account for this?
sample size - the power of a study increases proportionally w/ the same size. the larger a sample size, the greater the ability to detect a difference when one truly exists.
13C-labeled urea is used for what?
detect H pylori infection - breath is monitored for 13C-labeled CO2, which would indicate the presence of urease in the stomach
patients taking hydroxychloroquine should be monitored for?
who should you avoid giving choroquine to? Rx alternatives?
irreversible retinal damage - get baseline+followup eye exams
avoid giving hydroxychloroquine to patients w/ psoriasis - can make it worse! Alternative is to give atovaquone or proguanil
infant w/ recurrent otitis media, bronchiolitis, candidiasis, and poor growth suggests what d/o?
SCID
recurrent otitis media (bacterial), bronchiolitis (viral), candidiasis, and poor growth suggests** defect in both cell mediated (T cells) AND humoral (B cells) immunity**
consider DiGeorge if there are other features (facial abnormalities, hypoparathyroidism, cardiac defects) are present
∆ btwn CVID and SCID?
-
CVID - ∆ Igs secondary to failed B cell differentiation (cell mediated immunity is not severely impaired)
- frequent bacterial infections
-
SCID - ∆ B cells + ∆ T cells
- frequent bacterial, viral, and fungal infections
reliable vs accurate
precise vs accurate
reliable vs precise
reliable = precise = measure of reproducibility
accuracy = degree to which the measured value matches that of the gold standard
what are ephelides?
what are polythelia?
ephelides = freckles
polythelia = accessory nipple
due to failure of involution of the mammary ridge
bilateral parotid gland enlargement in a young woman should make you think of….
bulimia nervosa
muffled heart sounds, elevated JVP, profound hypotension
pericardial tamponade - usually due to rupture of the ventricular free wall as a consequence of a transmural MI
usually occurs 3-7d after MI, when coagulative necrosis, neutrophil infiltration, and enzymatic lysis of CT have sufficiently weakened the myocardium
B cell development
where does VD/VDJ recombination occur?
where does isotype switching occur?
where does somatic hypermutation occur?
VD/VDJ recombination = bone marrow
isotype switching = germinal centers in LN
somatic hypermutation = germinal centers in LN
where does the ascending aorta lie?
descending aorta?
ascending = posterior and to the right of the main pulmonary artery
descending = abuts the L anterior surface of the vertebral column and lies posterior to the esophagus and the L atrium
GN rods that are oxidase positive and non-lactose fermenting
trmt?
psuedomonas
penicllins: Ticarcillin, Piperacillin
Cephalosporins: Ceftaxidime, Cefepime
aminoglycosides: amikacin, gentamicin, tobramycin
Fluoroquinolones: ciprofloxacin, levofloxacin
monobactams: azetreonam
carbapenems: imipenem, meropenem
why is it that someone infected w/ mycoplasma pneumonia has mild anemia + serum LDH?
due to antigenic similarity btwn antigens in mycoplasma pneumoniae and the RBC cell membrane - immune system mounts a response “Cold agglutinins” aganist pathogen also destroys RBCs, resulting in mild anemia.
remember that cold agglutinins can agglutinate RBCs in vitro at low temps
ecthyma gangrenosum
bacteremia/septicemia w/ pseudomonas aeruginosa - lesions result from perivascular bacterial invasion of arteries/veins in the dermis + subcu tissue w/ subsequent release of exotoxins that are destructive to the tissue; usually in neutropenic patients, hospitalized patients, burns, chronic indwelling catheters
Exotoxin A, Elastase, Phospholipase C, Pyocanin
methacholine
muscarinic cholinergic receptor agonist - causes bronchoconstriction and increased airway secretions
used to dx asthma - decrease in FEV1 by >20% indicates bronchial asthma
bethany please call me
thiopental
how are its effects terminated?
barbituate - GABAa action - increase duration of Cl- opening
general anesthetic that is administered IV; highly lipid soluble (high potentcy) and equilibrates w/ the brain within 1 min of administration; and is used for the induction of anesthesia for short procedures
rapid redistribution into skeletal m. + adipose -> awakening…eek..
short-acting barbiturate - acts at GABA receptors and increases their inhibitory potential
woman w/ hx of PID, hypothyroidism, and appendectomy has LMP 9 weeks ago has abd pain, vaginal bleeding, signs of hemorrhagic shock (low BP, tachycardia, clammy hands, oliguria). endometrial bx will show..
decidual (gestational changes in the endometrium (no chorionic villi) because she has an ectopic pregnancy that probably ruptured
earliest lesion of atherosclerosis
intimal fatty streak
composed of intimal lipid filled foam cells (macrophages + smooth muscles filled with LDL) that insudate into the intima through an injured/leaky endothelium
earliest lesion of dissecting aortic aneurysm
intimal tear
trmt for patients w/ CAH
ACTH
why? because dececreased cortisol levels is sensed by the hypothalamus, which causes a consequential increase in ACTH production by the anterior pituitary, which further drives the conversion of cholesterol -> T
by giving exogenous steroids, this suppresses the HPA axis, thereby reducing this conversion!
equation for filtration rate of a substance X
Net excretion rate of a substance?
filtration rate of a substance X = GFR x plasma concentration of X
(GFR = inulin clearance)
Net excretion rate of a substance X = GFR x plasma concentration of X - tubular reabsorption of substance X
someone with sudden onset of transient numbness and tingling that resolves within 20 minutes should make you think of?
what should you treat these patients w/?
TIA
trmt: low dose aspirin - prevents coronary events and ischemic strokes
ADR: GI bleeds (inhibition of COX1 -> lack of PGI2 + decreased mucous production)
what happens when aspirin is used in asthmatics?
MAKES IT WORSE because aspirin blocks the COX pathways, leading to the overproduction of LTs that cause bronchoconstriction
pathophysiology of narcolepsy
trmt?
depletion of hypocretin1-secreting neurons in the lateral hypothalamus involved in maintaining wakefulness
net: shortened sleep latency + **entry REM sleep immediately, **hypnagogic + hypnopompic hallcuinations + sleep paralysis
trmt: scheduled daytime naps + psychostimulants (modafinil - 1st line, amphetamines - 2nd line)
hydrocele vs indirect hernia?
both caused by an incomplete obliteration of the processus vaginalis
- hydrocele - connection btwn the scrotum and abdominal cavity that allows for the leakage of fluid
- hernia - opening allows for the protrusion of abdominal organs along the inguinal canal
Schizoaffective d/o diagnostic criteria - 3
patient must meet criteria for
1) major depressive or manic episode
CONCURRENT w/
2) active symptoms of schizophrenia
AND
3) period in which schizophrenia occurs in the absence of mood sx
neisseria gonorrhoeae
why is it that patients keep getting re-infectioned w/ the same bug? 2
trmt?
1) n. gonorrhoeae can undergo a high frequency of antigenic variation of their gonococcal surface antigens (not due to resistance to antibiotics)
2) patient can be deficient in C5-C9, and is unable to form MAC complex
trmt: ceftriaxone
recurrent otitis media suggests
chronic mucocutaneous candidiasis suggests
pneumocystis infection suggests
patient that has all 3?
recurrent otitis media = ∆ humoral immunity
chronic mucocutaneous candidiasis = ∆ T cell deficiency
pneumocystis infection = ∆ T cell deficiency
patient w/ all 3 = SCID = typically present w/ failure to thrive and chronic diarrhea within the first year of life
ape hand deformity
denervation of the median nerve
also - sensation is lost on the palmar surface of the first 3 1/2 fingers
inability to flex the forearm
damage to the musculocutaneous nerve - paralysis of biceps + brachialis
claw hand deformity
ulnar n. damage - paralysis of most of the intrinsic muscles of the hand
wrist drop
damage to radial n. - innervates the extensors of the hand at the forearm
∆ btwn these
holocrine
eccrine
apocrine
merocrine
paracrine
**holocrine **- found in sebaceous glands; cells breakdown to release product; think “holocrine = holocaust = death of cells”
**eccrine **= **merocrine **= present throughout most of the body; secrete watery fluid in Na/Cl directly onto the skin surface (guessing these cells contain CFTR!!!)
apocrine - dermis + subcu fat of breast areolae, axilla, genitals - secrete into the hair follicles rather than directly to the skin surface; undergo cyclical ∆s secondary to hormonal fluctuations; odorless when secreted, but becomes malodorous due to skin flora
**paracrine **= secretions reach target cells via diffusion through the extracellular space (similar to endocrine glands)
patient w/ heavy calcification of the aortic valve w/o any other significant findings
dystrophic calcification due to cell injury + necrosis
role of alanine + glutamine in metabolism
alanine transports nitrogen to the liver (to alpha-ketoglutarate to form glutamate) for disposal
glutamate is processed in the liver to form urea (primary disposal form of nitrogen)
∆ btwn arnold chiari type I and type II?
type I - tonsils herniate below foramen magnum into the vertebral canal; manifests w/ HA and cerebellar sx (ataxia)
type II - cerebellum + medulla herniate below the foramen magnum; results in aqueductal stenosis
- **difficulty swallowing, dysphonia, stridor, apnea (due to compression of the medulla) **
- leg paralysis (due to lumbar myelomeningocele)
common complication of hemolytic anemia
pigmented gallstones - increased bilirubin from lysed RBC preciptates as Ca bilirubinate, forming pigmented stones in the GB
infant w/ recurrent otitis media, muco-candidiasis + chronic diarrhea + failure to thrive within the first year of life
SCID - ∆ humoral + ∆ cell-mediated immunity
Candida skin guages what type of HSR reaction?
what cell types are involved in this reaction?
failure to generate a response to this test indicates?
Type IV HSR
macrophages, CD4/8, and NK cells
failure to response = anergy/ø cell mediated immune response
failure is expected in SCID, where there is a hypoplasia of both B and T cells
“refractory” peptic ulcer dx should make you think of..
gross examination of the stomach should look…
Zollinger-Ellison
excessive gastrin causes
- increased gastric acid secretion from parietal cells -> PUD + diarrhea
- induces parietal cell proliferation/hyperplasia -> increased mass of fundic glands (gastric rugal folds look like brain gyri
important determinant of insulin resistance
visceral deposition of fat - ie fat surrounding internal organs, measured as waist:hip ratio
increase in liver fat suggests
increase in liver glycogen suggests
liver fat = insulin resistance
live glycogen = increased insulin action, since insulin increases glycogen synthesis in the liver and skeletal muscles
where should a thoracentesis be performed if done at the
mid clavicular line?
mid axillary line?
paravertebral line?
where should the needle be inserted at the ribs?
mid clavicular line = 1 rib above 7
mid axillary line = 1 rib above 9
paravertebral line = 1 rib above 11
needle should be inserted along the UPPER border, since insertion of the needle on the inferior margin of the rib risks striking the subcostal neurovascular bundle
any higher = risk of penetrating lungs
any lower = risk of penetrating abdominal organs
viruses that have polycistronic sequences (ie it generates a polyprotein product that must be cleaved into monocistronic mRNA)
ss (+) RNA viruses, non-segmented
Echovirus (picornavirus)
where are these normally seen in the lung
asbestosis
slicosis
berylliosis
coal workers
organic dust
LASU = SULA dunno** **
asbestosis = LOWER lobe, interstitial plaques w/ ferruginous bodies
slicosis = UPPER lobe - calcified hilar nodes w/ birefringent particles surrounded by dense collagen fibers
berylliosis = hypersensitivity pneumonoitis = non-caseating granulomas
coal workers = perilymphatic accumulation of coal dust-laden macrophages
organic dust = hypersensitivity pneumonitis = non-caseating granulomas
galactosyl ß-1,4-glucose is also known as?
LACTOSE
∆ in ß galactosidease (converts galactosyl ß-1,4-glucose -> galactose + glucose) = lactose intolerance
can be due to: genetics (1˚) or viral gastroenteritis/celiac sprue (2˚)
transient central DI
vs
permanent central DI
transient central DI = damage to the pituitary gland; temporary because the surviving neurons undergo hypertrophy and axonal regeneration, allowing them to produce and release functional quantities of ADH into the criculation after a certain period of time
permanent central DI = damage to hypothalamic nuclei (SOVP nuclei) or pituitary stalk
trmt for acute opioid withdrawal in neonates
tincture of opium - contains morphine; titrated to the patient’s sx and eventually tapered off
do not use nalxone since that is a pure opioid receptor antagonist; rather this is used in acute opioid intoxication, overdose, or for diagnosing opioid dependence. Administering this to a patient going through opioid withdrawal can result in even more severe withdrawal sx (ie seizures)
diplopia, dysphagia, dysphonia
3 D’s of botulism
trmt: antitoxin - blocks effect of circulating toxin, supportive (intubation/mechanical ventilation for diaphragmatic
ejection fraction is synonymous with
stroke volume
twinning
cleavage on d2?
cleavage on d5?
cleavage on d9?
cleavage on d2 = dichorionic - diamniotic
cleavage on d5 = monochorionic - diamniotic
cleavage on d9 = monochorionic -monoamniotic
impt dates to note:
chorion forms on D3, amnion forms on d8 (C3, A8)
justification for giving glucagon for ß blocker OD?
glucagon - acts on GPCR to increase cAMP, thereby releasing intracellular Ca -> increases contractility + HR; improves within minutes
brain tumor that has S100 positivity
schwannomas
tumor of the PNS that arise from schwann cells; usually occur within a few mm from the surface of the brain and spinal cord (common at the cerebellopontine angle at CN 8 - at this location it is called an “acoustic neuroma” and can cause tinnitus, vertigo, and sensorineural hearing loss)
(other S100+ tumor = melanoma; both derived from neural crest cells)
why would a patient w/ sickle disease develop macrocytosis?
what role does extramedullary erythropoiesis have?
predisposed to folic acid (B9) deficiency due to increased RBC turnover
extramedullary erythropoiesis should be considered when the reticulocyte count is really high (indicates that the bones are producing RBC as fast as they can pump them out)
if the reticulocyte count is low <5%, then consider B9 deficiency
pathophysiology of liquefactive necrosis in the brain
irreversible ischemic neurons release lysosomal enzymes that results in the degradation of tissues in the ischemic region
phagocytic cells migrate into the area and remove the necrotic tissue, leaving a cavity
astrocytes proliferate around necrotic area with the formation of a gliotic scar
acetaminophen
how is it metabolized and eliminated?
acetaminophen
hepatic metabolized via sulfation + glucuronide conjugation; remainder is eliminated via oxidation by CYP450 pathway (generates NAPQI - a highly toxic and reactive compound) and by urinary excretion by unmetabolized drugs.
Excess doses saturates the normal hepatic in excess NAPQI
cardiac bx shows: myofibrillar disarray + fibrosis
hypertrophic cardiomyopathy
3 sx of RHF?
LHF?
RHF: Hepatomeagly, peripheral edema, JVD
LHF: pulmonary edema (hemosiderin-laden macrophages), orthopnea, paroxysmal nocturnal dyspnea
what do these terms with regard to anesthetic properties:
low solubility in blood
low solubility in lipids
low solubility in blood = rapid induction + recovery times
low solubility in lipids = low potency = higher MAC (conc. needed to basically induce sedation)
N2O has a low blood and lipid solubility. what does this mean in terms of induction, potency, and MAC?
Halothane has a high blood and lipid solubility. what does this mean in terms of induction, potency, and MAC?
slow induction
high potency
lower MAC
Risperidone
ADR
atypical antipsychotic that has anti-dopaminergic actions
Hyperprolactinemia (galactorrhea + amenorrhea)
risPeridone
neurophysin
where are they producd and what are their functions?
produced in hypothalamic **SO (ADH) PV (oxytocin) **nuclei
involved in the post-translational processing of oxytocin + vasopressin (ADH) while it’s traveling down from the hypothalamus to the posterior pituitary; released into circulation
exogenous T use
LH
FSH
T
Sperm count
LH = decreased
FSH = normal
T = increased
Sperm count = decreased
(high LOCAL androgns are necessary for spermatogenesis)
central hypogonadism
LH
FSH
T
Sperm count
LH = decreased
FSH = decreased
T = decreased
Sperm count = decreased
cryptorchidism/orchitis
LH
FSH
T
Sperm count
damages ONLY the seminiferious tubules (Leydig cells are fine)
LH = normal
FSH = increased
T = normal
Sperm count = low
kleinfelter
LH
FSH
T
Sperm count
hypogonadism (damage to both leydig + seminiferous tubules)
LH = increased
FSH = increased
T = decreased
Sperm count = decreased
rationale of prescribing potassium-citrate to patients w/ recurrent kidney stones?
citrate binds to free (ionized) calcium, preventing its precipitation and facilitating its excretion
Anti-arrhythmia that has an ADR of transitory flushing, chest burning in the chest and SOB
adenosine
woman with pale conjunctivae, fatigue, irregular menstrual cycles, and Hb of 9.2 g/dL and no other findings
ferritin
transferrin
MCV
Hypersegmented PMN?
serum folate
suspect iron deficiency
ferritin: low
transferrin: high
MCV: low/microcytic
Hypersegmented PMN: none
serum folate: normal
Alzheimer Rx?
Donepezil (AChEi - enhances cholinergic neurotransmission)
Vit E (antioxidants - neuroprotection)
Memantine (NMDA receptor antagonist)
E. coli virulence factors for
UTI
Watery Gastroenteritis
Bloody Gastroenteritis
Bacteremia/Septic Shock
Neonatal meningitis
UTI: P. fimbrae* (adherence to epithelial cells, uroepithelial cells, and enterocytes)*
Watery Gastroenteritis: heat-stable (ST-cGMP), heat-labile (LT-cAMP) enterotoxins
Bloody Gastroenteritis: Verotoxin (shiga-like toxin)
Bacteremia/Septic Shock: LPS-Lipid A
Neonatal meningitis: K1 capsular polysaccharide
why would someone w/ aortic stenosis suddenly develop syncope + acute pulmonary edema?
a-fib
the LA can’t pump sufficient blood into the LV, which resulted in
- decrease in LV preload -> severe hypotension
- increased mean pulmonary venous pressure due to backup of fluids -> pulmonary edema
CMV features
enveloped, dsDNA
3 week old infant has dark urine, light colored stools, and palpable enlarged and firm liver
dx?
what would labs show in terms of bilirubin, AP, GGT?
what will liver biopsy show?
sequelae if not treated
biliary atresia
labs: increased bilirubin, AP, GGT
biopsy: cholestasis, intrahepatic bile duct proliferation, portal tract edema + fibrosis
sequelae if not treated: biliary cirrhosis
bilirubin
conjugation d/o?
secretory d/o?
ConjuGation d/o
- Craig Najjar
- Gilbert
Secretory d/o
- Dubin Johnson
- Rotor
Scleroderma
antibodies found in limited? diffuse?
limited (CREST): anti-centromere
diffuse: anti-topo I (Scl-70)
where in the nephron does uric acid preciptation tend to occur?
distal tubules + CD because these have the lowest pH (acidic)
Jullet’s mnemonic for stones that preciptiate at low pH: OUCH!
Oxalate
Uric acid
Cysteine
H = H+
47 M w/ sinusitis treated w/ ampicillin develops fever, maculopapular rash, and oliguria; creatinine is 2.4mg/mL. Urine sediment shows RBC, PMN, and eosinophils.
Dx?
other drugs that can do the same?
Drug-induced **Acute Interstitial Nephritis (AIN) **that is causing his acute renal failure
damage to the interstitium results in interstitial edema + inflammatory infiltrate
diagnostic: eosinophils and IgE in serum
NSAIDs, Sulfonamides, Rifampin, Diuretics
Type of cells that Shigella likes to infect
M cells in Peyer’s patches in the ileum
once endocytosed into the cell, shigella lyses the endosomes, multiplies, and spreads laterally into other epithelial cells, causing death and ulceration w/ hemorrhage and diarrhea
Asplenic patients are prone to infections by _______ organisms because…
encapsulated organisms (S. pneumo, H. influenza, N. meningitidis)
SpHiNE
spleen serves as a site of antibody synthesis and reservoir of phagocytic cells capable of removing circulating pathogens
49 M patient w/ STEMI is treated w/ streptokinase, IV fluids, and low dose ß blocker. Several hours later, he develops asymmetric pupils and irregular breathing pattern. Why?
common ADR of streptokinase is **hemorrhage. **
patient described has signs of intracerebral hemorrhage (decreased level of consciousness, asymmetric pupils, irregular breathing).
Don’t confuse the symptoms with an embolic stroke - dude was treated w/ thrombolytic, and therefore no clots should theoretically form - making hemorrhage a more likely possibility
Patients w/ ADPKD tend to have this in addition to their renal cysts
outcome of this dz?
LIVER cysts
diagnosed on a CT scan - see multiple renal + hepatic cysts that are homogenous w/ regular outline + non-enhancing w/ contrast CT (differentiates it from a solid metz)
outcome: ESRD
Anytime you see PrP, what disease should you think of?
Prion protein (PrP)
Creutzfeldt-Jakob Disease
Bovine Spongiform Encephalopathy
features: vacuoles in gray matter (spongiform encephalopathy) w/ NO inflammatory changes
painless gross hematuria should make you think of?
most important factor for prognosis?
“urothelial” or transitional cell carcinoma of the bladder; often grows as a papillary or sessile mass
stage - depends on the degree of its invasion into the bladder wall and adjacnent tissues
patient w/ CD4 count of 40cells/µL has elevated AP, LDH, and hepatosplenomeagly
Dx?
What could’ve prevented this?
MAC
acid-fast bacteria that grows optimally at 41˚C
Azithromycin
How do catecholamines, glucocorticoids, and glucagon, TNFa induce insulin resistance?
Insulin receptor (IR) is a TYROSINE KINASE receptor - binding insulin to its receptor on target cells causes auto-phosphorylation of IR, followed by phosphorylation of IRS, which goes on to activate PI3K and RAS/MAP pathways involved in cell growth
These factors all activate SERINE kinases, which phosphorylate IR (prevents downstream signaling) and IRS1 (prevents it from being phosphorylated by IR); net: insulin resistance
bilateral renal masses compsed of fat, smooth muscle, and blood vessels should cue you to which d/o?
TUBEROUS SCLEROSIS - AD d/o - renal angiomyolipomas is a benign tumor of BV, smooth muscle, and fat.
other findings: cortical tubers, subependymal hamartomas, seizures, mental retardation, ash leaf patches
(be careful not to confuse them with pheochromocytomas in NF1)
patient w/ RA that is refractory to treatment develops exertional dyspnea and cough; CXR shows reticulonodular pattern of opacities that are most pronounced in the lower lobes
Pulmonary fibrosis - restrictive lung d/o
sx: gradual-onset of dyspnea, first w/ exertion -> at rest
Labs: normal-increased FEV1/FVC ratio, dcreased DLCO
CXR: reticulonodular opacities; most pronounced in the lower lobes
progressive fibrosis can lead to the formation of cysts that later coalesce to form “honeycomb” lung appearance on CXR and histopathology
picornavirus that is the most acid labile
Rhinovirus
only PERCH virus that is inactivated in the stomach and therefore infection is limited to the upper respiratory tract (all others can pass through the stomach and into the small intestines w/o being degraded in the acid environment and colonize the GI tract)
patient w/ a history of well-controlled hyperthyroidism comes in complaining of fever + sore throat. What labs should you order?
WBC count w/ differential
why? **PTU and Methimazole - **both inhibit thyroid peroxidase (responsible for iodine organification + coupling of iodotyrosinase), but both can cause agranulocytosis
because
where do most duodenal ulcers occur?
what if they’re found in an aytpical location?
most occur in the duodenal bulb = peptic ulcer disease
ulcer found in the distal duodenum or atypical location = ZES (pancreatic gastrinomas that stimulate gastric acid secretion by parietal cells and increases parietal cell volume)
chronic gastritis w/ antral sparing
vs
chronic gastritis w/ antral involvement
chronic gastritis w/ antral sparing = autoimmune gastritis (may lead to pernicious anemia)
vs
chronic gastritis w/ antral involvement = H. pylori infection (also causes PUD)
sigmoid shaped ventricular septum in a 78yo M
part of aging…
reduced partoid gland secretion is due to which CN?
CN 9
pathophysiology of Myasthenia Gravis?
trmt?
what if the patient accidently took too much?
autoantibodies aganist post-synaptic nicotinic ACh receptors, resulting in decreased # of functional ACh receptors at the NMJ
net: reduces end plate potential following ACh release - ie the threshold potential is not reached, therefore the muscle clls do not polarize.
Trmt: AChE inhibitors
too much? treat with anti-muscarinics (ie scopolamine)
∆ btwn Mallory-Weiss tear and Boerhaave Syndrome in terms of
etiology?
clinical presentation?
Mallory-Weiss tear
- upper GI mucosal tear that occur secondary to rapid increase of intra-abdominal + intra-luminal gastric pressure
- presentation
- vomiting and retching (loss of gastric acid -> metabolic alkalosis)
- hematemesis
- epigastric pain
Boerhaave Syndrome?
- esophageal transmural tear
- vomiting and retching
- chest + upper abd. pain
- fever, dyspnea, and septic shock rapidly ensues
Sorbitol is metabolized to _______ in the seminal vesicles?
Sorbitol is metabolized to _______ in the lens?
Sorbitol is metabolized to _______ in the retina?
Sorbitol is metabolized to _______ in the renal papilla?
Sorbitol is metabolized to _______ in the schwann cells?
seminal vesicles, lens: Sorbitol is metabolized to fructose via action of sorbitol dehydrogenase
**retina, **renal papilla, schwann cells: sorbitol is not metabolized because there is much less sorbitol dehydrogenase activity in these tissues
volume status in a patient with SIADH
EUVOLEMIC HYPONATREMIA
Why? excess ADH causes excess water reabsorption -> hypervolemia, which leads to decreased RAAS + increased ANP -> Na excretion in urine
low plasma Na
low osmolality
inappropriately concentrated urine
increased urine Na
∆ btwn bethanechol, oxybutynin and phenylephrine in the treatmetn of bladder dysfunction??
bethanechol = muscarinic agonist - stimulates contraction of the detrusor muscle, therefore iimproving bladder emptying in patients w/ post-op urinary retention “blessing that you can go!”
**oxybutynin = anti-muscarinic agent - **used for urge incontinence (ie promotes urinary retention)
phenylephrine = alpha1 agonist = stimulation of a1 receptors in the bladder causes the trigone and sphincter to contract, thereby promoting urinary retention
- a1 blocking agent would improve bladder emptying
nucleolus
site of ribosomal subunit maturation + assembly
RNA pol I synthesizes the majority of rRNA from within the nucleolus
drug that you can use to prevent NSAID-induced ulcer disease
misoprostol - prostaglandin E1 analog
Quick associations:
joint pain + cardiac murmur
nasal ulcer + hematuria
malar rash + pleural effusion
hemoptysis + oliguria
dysphagia + sclerodactyly
-
joint pain + cardiac murmur = rheumatic heart disease
- ab against M proteins that cross-react w/ glycoproteins in the heart and joints
-
nasal ulcer + hemoptysis + hematuria = Wegener’s polyangiitis
- cANCA; pauci-immune staining in kidneys
-
malar rash + pleural effusion = SLE
- immune complex d/o; ANA (+), anti-dsDNA, anti-smith
-
hemoptysis + oliguria = Goodpasture
- anti-GBM (alpha3 chain of collagen type IV)
-
dysphagia + sclerodactyly = CREST
- anti-centromere
3 treatments for hirsutism?
- spirnolactone - K sparing diuretic + anti-androgen effects (receptor blocker, decreases T production)
- flutamide - inhibits binding to T receptors
- **finasteride **- 5a reductase inhibitor
Schistosomiasis that can cause:
squamous cell of the bladder?
intestinal ulceration?
liver cirrhosis (periportal pipestem fibrosis)
squamous cell of the bladder = S. Haematobium
- acquired via freshwater snails
intestinal ulceration + liver cirrhosis (periportal pipestem fibrosis) = S. mansoni
- periportal pipestem fibrosis
clinical manifestations of both result from a Th2 mediated immune response directed against the eggs, resulting in a **granulomatous **inflammation and fibrosis, which causes ulceration + scarring of the bowel or bladder/ureters
worm that causes B12 deficiency and megaloblastic anemia
Diphyllobothrium latum
ingestion of larvae from raw freshwater fish
cysticercosis
taenia solium - human tapeworm
consumption of infected, undercooked pork
“moldy grain” - aflatoxin exposure
bug?
MoA of the toxin?
sequelae?
Aspergillus flavus + Aspergillus parasiticus
aflatoxin causes a mutation in p53
sequelae: hepatocellular carcinoma
PAS(+) granules in macrophages found in an intestinal bx
Tropheryma whippelii - Whipple disease
hx: enlarged, foamy macrophages packed w/ rod shaped bacilli and PAS+, diastase-resistant granules
presentation: diarrhea and weight loss due to malabsorption
arthropathy, polyarthritis, psychiatric, and cardiac ∆s
trmt: antibiotic
∆ btwn metanephric blastema and metanephric diverticula?
metanephric blastema = glomeruli -> DCT
metanephric diverticula (aka ureteric bud) = collecting ducts -> ureters
What d/o these related to?
Kussmaul’s sign
Pulsus Paradoxus
Friction rub
Pericardial knock
which ones are acute? chronic?
Kussmaul’s sign (paradoxical increase in JVP w/ inspiration)
- usually in patients w/ chronic constrictive pericarditis
Pulsus Paradoxus (∆ systolic BP >10mmHg during inspiration)
- cor pulmonale, constrictive chronic pericarditis, pericardial disease, and cardiac tamponade
- patients usually have muffled heart sounds, JVD, and hypotension
Friction rub (high pitched, leathery, scratchy sound)
- acute pericarditis
- sharp, pleuritic and decreases when the patient sits up and leans forward (to decrease pressure on the parietal pericardium)
Pericardial knock (early diastole precordial sound)
- constrictive chronic pericarditis
middle meningeal artery branches off of what artery?
where does this enter the skull?
maxillary a., which itself is a branch of the external carotid a.
mma enters the skull at foramen spinosum
slowly growing mass that drains yellow pus in the setting of a recent oral trauma
dx and treatment?
actinomyces israelii
GP that is notorious for causing cervicofacial actinomycosis in patients following dental mainpulation; trmt: pencillin + surgical debridement
5a reductase deficiency
who does it affect; typical phenotypical presentation
5a-reductase deficiency
DHT normally mediates the development of the external genitalia (penis+scrotum) in the embryo, growth of prostate, facial hair, and temporal recession of the hairline
46XY infant w/ small phallus + hypospadias + testes in the inguinal area. Serum BP + T are normal
21 hydroxylase deficiency
who does it affect; typical phenotypical presentation
salt wasting and hypotension + hyperkalemia
XX = virilized
11ß hydroxylase deficiency
who does it affect; typical phenotypical presentation
HTN, salt wasting
XX = virlization
17a hydroxylase deficiency
who does it affect; typical phenotypical presentation
XY = undervirilized
Aromatase deficiency
who does it affect; typical phenotypical presentation
XY = virlized
d/o’s that have “endomysial” vs “endoneural” inflammatory infiltrate
- “endomysial” = polymyositis - inflammatory dz of skeletal muscle; bilateral symmetric weakness of proximal muscles w/ normal reflexes
- “endoneural” = Guillain Barre - acute demyelinating peripheral neuropathy that results in ascending paralysis + areflexia
acute onset JVD + 80/60mmHg + pulse of 120bpm
cardiac tamponade or tension pneumothorax
hx of chest trauma + abnormal lung auscultation -> TP
hx of viral infection-> CT
What does this dude have?
How do you know?
Myasthenia Gravis
see decreasing amplitude of cyclic intrapleural pressure changes during deep, rapid breathing (ie progressively weakening diaphragmatic contractions during maximal voluntary ventilation) with intact phrenic nerve stimulation
cells involved in local defense aganist candida?
systemic defense?
Local: T cells
Systemic: PMN
- HIV patients have localizd candidiasis but not systemic candidiasis
- Neutropenic patients are more likely to have systemic disease
Hemoglobin C vs Hemoglobin S
which one causes a more serious disease and why?
Hemoglobin S
charged glutamic acid -> hydrophobic valine
causes aggregation of hemoglobin molecules under anoxic conditions
(compare to HbC, where glumatic acid is replaced w/ lysine, a basic a.a.)
rationale for treating female infertility w/ menotropins followed by ßhCG?
menotropins = human menopausal gonadotropin - acts like FSH and leads to the development of a dominant ovarian follicle
ßhCG = simulates the LH surge
what confers elastin its plasticity and ability to recoil upon release of tension?
desmosine cross-linking btwn lysine residues on four different elastin chains (via lysyl hydroxylase, Cu)
which part of the heart forms the most diaphragmatic surface of the heart?
what artery supplies this area? In most individuals, what artery does this derive from?
inferior wall of the LV
PDA
derived from RCA
3 mo infant - irritable, feeds poorly, vomits frequently
PE: large head circumference, white-yellow chorioretinal lesions, enlarged ventricles w/ scattered intracranial calcifications
Toxo - usually acquired in utero (transplacental infection - mother likely infected during the first 6 mo of pregnancy)
expecting mothers should avoid cat feces to help prevent exposure to toxo
How does NTG lead to vasodilation?
NTG is converted to NO in cells
- > NO stimulates guanylate cyclase
- > increased cGMP
- > decreased Ca
- > decrease MCLK activity
- > decreased MLC phosphorylated
- > smooth muscle relaxation
what does a cavernous hemangioma of the liver look like?
let the name tell you
cavernous, blood filled vascular spaces of variable sizes lined by a single epithelial layer
most common benign liver tumor
bx is NOT recommended due to risk of fatal hemorrhage
Antidepressant ADRs
SSRIs
TCAs (imipramine, doxepin, amitriptyline, clomipramine)
SSRIs = sexual dysfunction
TCAs (imipramine, doxepin, amitriptyline, clomipramine) = LOTS
- urinary retention due to anticholinergic effects (TCAs relax the bladder)
- cardiac arrhythmias (QT prolongation)
- seizures = comipramine, bupropion
- orthostatic hypotension
class IA anti-arrhythmics?
class IB anti-arrhythmics?
class IC anti-arrhythmics?
**class IA anti-arrhythmics** = Disopyramide, Quinidine, Procainamide Double Quarter Pounder; some K channel interaction
**class IB anti-arrhythmics** = Lidocaine, Tocainide, Mexiletine Lettuce, Tomato, Mayo; come Ca channel interaction
**class IC anti-arrhythmics** = Moricizine, Flecainide, Propafenone More Fries Please; pure Na channel interaction
Lethal side effects associated w/
PCP
cocaine
opioids
PCP = trauma due to violent behavior
cocaine = stroke, MI
opioids = respiratory depression
patient w/ dyspnea, distended JVD, pitting edema, and fatigue has activation of these two processes
think of congestive heart failure
sympathetic + RAAS activation
enzyme involved in the breakdown of heme -> biliverdin
Heme oxygenase
Ca and PTH levels in a patient w/ chronic renal failure (BUN 75, creatinine 5.8)??
think 2˚ hyperparathyroidism due to CRF
decreased renal activity of 1a hydroxylase -> less 1,25-VitD3 made
less 1,25-Vit D3 -> decreased intestinal absorption of Ca
decreased serum Ca -> PTH elevates in response
impaired renal excretion of PO3 -> elevated serum PO3
osteoclasts differentiate under these two factors:
what do these osteoclasts look like?
RANKL + MCSF
osteoclasts in paget’s disease are (+) for tartrate-resitant acid phosphatase and are multinucleated (up to >100 nuclei)
how to calculate OR?
how to calculate RR? RRR?
OR = a/c / b/d = ad/bc
RR = a/(a+b) / c/(c+d)
RR reduction = 1 - RR
what does the carotid massage to the AV node?
prolongs the AV node refractory period
patient w/ impaired transport of ornithine from the cytosol to the mitochondria should restrict what in their diet?
restrict proteins from diet
ornithine transport into mitochondria is an essential step for urea formation (ornithine combines w/ carbamoyl phosphate to form citrulline in the urea cycle)
patient w/ hypoglycemia after a prolonged fasting period w/ inappropriately low ketone bodies
impaired ß oxidation due to **∆ acyl-coA dehydrogenase **- catalyzes the first step in the ß oxidation pathway
prolonged >3mo consumption of appetite suppressants (dexfenfluramine, fenfluramine, or phentermine) causes what? associated sx?
pulmonary HTN
manifests as dyspnea on exertion and can progress to cor pulmonale w/ RVH, potentially leading to sudden cardiac death
what bugs do these make you think of?
rhabditiform larvae in stool
parasite eggs in stool
perianal egg deposition
proglottids in stool
trophozoites and cysts in stool
-
rhabditiform larvae in stool - Strongyloides stercoralis
- can cause hyperinfection syndrome (massive dissemination of the organisms, leading to multiorgan dysfunction and septic shock)
-
parasite eggs in stool = schistosoma mansoni or japonicum
- s. stercoralis eggs hatch in the intestinal mucosa and are not found in stool
- perianal egg deposition = enterobius vermicularis
- proglottids in stool = Taenia solium, Diphyllobothrium latum
- trophozoites and cysts in stool = Giardia lamblia, Entamoeba histolytica
∆ btwn phenoxybenzamine vs phentolamine in terms of their effects on norepinephrine on the dose response curve?
phenoxybenzamine - irreversible, non-compettive antagonist - even very high NE concentrations cannot overcome its inhibitory effects, therefore the dose-response curves, pretreatment w/ phenoxybenzamine will cause the graph to shift down
phentolamine - reversible, competitive antagonist; high doses of NE can overcome its inhibitory effects, therefore the graphs will shift right
phenoxybenzamine, irreversible = LONGER words
phentolamine, reversible = SHORTER words
man with weight loss + epigastric discomfort after meals w/ occasional nausea should make you think of?
signet ring carcinoma of the stomach
cells contain lots of mucin droplets that push the nucleus to the side; often infiltrate the stomach wall
patients present w/ signs of acute decompensated CHF (SOB, inability to lie down, edema, lung crackles).
which diuretic to use?
ADR of this particular class of diuretics?
Loop diuretics = agent of choice in acute settings because it has potent diuretic effects
ADR: hypoK, hypoMg, hypoCa
second most common cause of all UTIs
what tests can you use to differentiate it from other bacteria?
S. saprophyticus
GP cocci
catalase +, coagulase -, novobicin resistant
dantrolene
what is it used for?
how does it work?
- used to treat malignant hyperthermia (fever+muscle rigidity) that occurs after administration of inhalation anesthetics +/- succinylcholine in susceptible individuals
- Malignant hyperthermia is caused by defective ryanodine (Ca) receptors on the sarcoplasma reticulum
- ryanodine receptors normally release small amounts of Ca into the cytoplasm during muscle contraction
- abnormal ryanodine receptors release large amounts of Ca, which stimulates ATP-dependent reuptake by the SR, where the excess ATP consumption -> generates heat + muscle damage
- muscle damage -> release of K, myoglobin, and CK into circulation
- Dantrolene acts on the ryanodine receptor and prevents further Ca release into the cytoplasm
GNR, oxidase +, pigment
Pseudomonas
DUH
patient w/ well-controlled HTN develops hypercalcemia and low PTH levels. Why?
thiazides - increases distal tubular reabsorption of Ca, leading to HyperCa, which leads to a suppressed PTH
what is 2-PAM and what is it used in?
pralidoxime - muscarinic receptor antagonist; used in organophosphate (AChEi) poisoning to reverse the effects of both N + M overstimulation
pathophysiology of vitiligo vs abinism?
- vitiligo - autoimmune destruction of melanocytes in the epidermis, resulting in lower #s of melanocytes
- **albinism **- decreased tyrosinase activity or defective trysoine transport, or normal neural crest cell migration, results in **normal # of melanocytes w/ decreased melanin production **
damage to Brocas Area or Wernicke’s area is likely due to occlusion of this artery
MIDDLE CEREBRAL ARTERY
trendelenburg gait
cause?
what does it look like?
injury to** superior gluteal n.** or gluteus medius m.
when one lifts the leg contralateral to the injury, the hip (on the same side as the leg lift) drops down because the **ipsilateral gluteus medius + gluteus minimus cannot contract **
best Rx to prevent recurrent Ca-Oxalate stone formation
ADR of this Rx?
Thiazides - inhibits apical NaCl cotransporter, which decreases intracellular Na. this ativates the basolateral Na/Ca antiporter, which pumps Na into the cell in exchange for Ca, thereby enhancing the luminal Ca absorption thorugh an ion channel on the apical membrane
net: decreases urine Ca excertion
ADR: hypONa, hypOK, metabolic alkalosis, hypER-Ca
patients w/ galactosemia without any other defect have cataract formation due to activity of which enzyme?
d/o?
trmt?
enzyme: **Aldose reductase - **converts galactose -> galacticol, which accumulates and cause osmotic damage in the lens
d/o: mild galactosemia (∆ galactokinase)
trmt: avoid lactose (metabolized to galactose + glucose)
DiGeorge vs Agammaglobulinemia
what cells are affected?
where in the LN does it affect?
DiGeorge
- ø T cells
- ø paracorTex
Agammaglobulinemia
- ø B cells
- ø 1˚ lymphoid follicles and germinal centers
patient prescribed diphenhydramine for skin rash subsequently experiences blurred vision. Why?
diphenhydramine (as well as chlorpheniramine) are 1st generation antihistamines (block H1 receptors) that ALSO have
anti-muscarinic, anti-alpha adrenergic, and anti-serotonergic properties that are responsible for the majority of their side effects
patients on typical antipsychotics develop extrapyramidal side effects - what do you treat them with?
benztropine or diphenhydramine
maple syrup urine disease
a.a. affected?
isoleucine, leucine, and valine
trmt: high-dose thiamine
45yo w/ 20pack history comes in with low PaO2 and low PaCO2
dx?
PE or pneumonia - both which can lead to hypoxemia
hypoxemia stimulates peripheral arterial chemoreceptors to increase respiratory drive, resulting in hypocapnia
however, the hypoxia continues due to the underlying disease process
result: increased Aa
trmt: O2 and correction of underlying dz process
In elderly patients presenting with anemia w/o any identifiable underlying cause, assume this vitamin deficiency
B12
F neonate swelling of hands + posterior neck mass that is composed of cystic spaces separated by CT rich in lymphoid aggregates
Turner Syndrome - lymphadema and cystic hygromas are common manifestations
ataxia, episodic erythematous and pruritic skin lesions and loose stools. Lab shows loss of neutral a.a. in urine
Hartnup disease - pellagra - 3 D’s of B3 (niacin):
diarrhea
dementia (ataxia)
dermatitis
Ristocetin aggregation test
how does it work?
it is used to measure vWF dependent platelet aggregation
activates GP 1b-IX on platelets, making them available for vWF binding
if vWF is decreased, there is poor platelet aggregation in the presence of ristocetin
why is it that NSAIDs can decrease the effects of loop diuretics?
loop diuretics inhibit NaK2Cl symporters in TALH and stimulate prostaglandin release to increase RBF/GFR
NAIDs inhibit the prostaglandin synthesis, therefore resulting in a decreased loop diuretic effect (also prostaglandins vasodilate the afferent arteriole; decreasing the production will result in afferent arteriole constriction, resulting in decreased RBF/GFR as well)
Patient receiving TMP/SMX complains of joint pain and pruritic skin rash. Areas of fibrinoid necrosis + PMN infiltration in his arteries and small arterioles.
Dx?
lab findings?
Serum sickness - Type III HSR
formation of ICs (IgG/IgM w/ antigens) w/ complement activation wherever the ICs deposit - thus results in hypOcomplementemia (decreased C3 level)
typically occurs 5-10d after exposure
common culprits: sulfonamide Rx
what is sydenham chorea?
patients w/ this are at increased risk of?
hyperkinetic extrapyramidal movement d/o - a neurologic manifestation of acute rheumatic fever (grp A ß hemolytic stre) caused by autoimmune rxn to neurons in the caudate and subthalamic nuclei; usually occurs after a latency of 2-3 mo post-strep throat
increased risk of rheumatic heart disease (mitra/aortic valve involvement)
cocaine
MoA
inhibits presynaptic reuptake of NE, Dopamine, and serotonin
net: increased BP, HR, chest pain secondary to coronary artery vasoconstriction, agitation from CNS activation, and symmetric pupil dilation that is responsive to light (mydriasis)
treatment for diabetic peripheral neuropathy
what would patients normally complain of?
**Amytriptyline - TCAs - ** has anticholinergic ADRs, so patients will complain of urinary retention
other option:
Duloxetine - SSRI - do not cause obstructive voiding symptoms
patient w/ double vision can’t adduct his left eye and has no corneal reflex
where is the lesion located?
CN III = loss of eye adduction via MR
CN V1 / VII = loss of corneal reflex
lesion: superior orbital fissure, where CN 3, V1, IV, VI and superior ophthalmic vein enters the orbit
Treatment for normal patients with isolated systolic HTN (ie 170/70)
Treatment for diabetic patients with isolated systolic HTN (ie 170/70)
normal patients: thiazides or dihydropyridine Ca antagonists (amlodipine)
diabetic patients: ACEi or ARB
general ADR of non-selective ß blockers
exacerbate
broncial asthma
perpiheral vascular disease
bradycardia
mask hypoglycemic symptoms of diabetic Rx
patients recovering from ATN may encounter this complication
dehydrated + hypokalemia
due to high volume diuresis + renal tubules that are not yet fully functional (thereby resulting in altered electrolyte balances)
treatment for bradycardia
ADR of this Rx?
atropine - decreases vagal influences on the SA/AV nodes
common ADR: increased intraocular pressure (may precipitate acute closed-angle glaucoma since it causes mydriasis, which narrows the angle of the anterior chamber and diminishes outflow of the aqueous humor)
broad based buds
vs
narrow based buds
broad based buds = blastomyces dermatitidis
narrow based buds = cryptococcus
hyponatremia, hyperkalemia, hypoglycemia
**Adrenal Crisis **
∆ aldosterone -> hyponatremia, hyperkalemia
∆ cortisol -> hypoglycemia
attributable risk %
excess risk in a population that can be explained by exposure to a particular risk factor
ARP = (risk in exposed - risk in unexposed) / risk in exposed
or
ARP = (RR - 1) / RR
45yo man w/ chronic fatigability, mild weight gain, and elevated CK
dx?
hypothyroidism (say wha…?)
hypothyroid myopathy is a common manifestation of hypothyroidism and can sometimes be the first manifestation!
prostate drains into these LN
internal iliacs
bladder LN drainage
superior portion - external iliac
inferior portion - internal iliac
what happens if you correct serum Na too fast in these scenarios
from low -> high
from high -> low
from low -> high: your pons will die - central pontine myelinolysis
from high -> low: your brains will blow - cerebral edema, herniation
2 reasons why the HMP shunt exist
produce NADPH for
1) anabolic reactions - **cholesterol + fatty acids **synthesis
2) reduce glutathione (thus repairing oxidative damage) in RBC
2 causes of locked in syndrome
1) central pontine myelinolysis - overly rapid correction of Na
* (usually from low->>high “your pons will die”)*
2) basilar artery infarction
clomiphene
MoA
clinical use
SERM - selective estrogen receptor modulator that prevents negative feedback inhibition on the hypothalamus by circulating estrogen ->> increased gonadotropin production (FSH/LH) and ovulation
clinical use: infertility (esp in PCOS patients)
vertebral artery can be accessed via which triangle?
suboccipital ∆
circle of willis develops from which two pharyngeal arches?
3 (ICA)
4 (Subclavian)
occlusion of this artery will cause lateral inferior pontine syndrome
symptoms?
AICA - anterior inferior cerebellar artery
vomiting, vertigo, nystagmus
**face - paralysis, decreased pain/T **
decreased lacrimation, salivation, taste, corneal reflex, hearing
islateral horner syndrome, ataxia, dysmetria
*bold - differentiating sx from PICA*
AICA = LIPS = facial droop (including the LIPS) means AICA’s pooped - all facial functions are impaired)
occlusion of this artery will cause lateral medullary syndrome
symptoms?
PICA - posterior inferior cerebellar
vomiting, vertigo, nystagmus
decreased pain T from ispilateral face + contralateral body
dysphagia, hoarseness, loss of gag reflex
islateral horner syndrome, ataxia, dysmetria
*bold - differentiating sx from AICA*
“Don’t PICA horse that can’t eat”
occlusion of this artery will cause medial medullary syndrome
symptoms?
ASA - anterior medullary syndrome
tongue deviation towards injured side
contralateral hemiparesis + loss of proprioception
ASA = MMS = Tongue
signs of MCA occlusion on the dominant hemisphere? non-dominant hemisphere?
dominant hemisphere (L): **aphasia **
non-dominant (R): hemi-neglect
direct vs indirect pathway
receptors
excitatory or inhibitory
net influence on motion
How does Parkinsons affect these pathways?
Direct
- D1 receptors
- excitatory - increase motion
INdirect
- D2 receptors
- INhibitory - decrease motion
Substantia nigra (SN) has a (+) effect on the direct pathway and an (-) effect on the indirect pathway. In Parkinsons, loss of the SN results in a loss of direct pathway activation and an uninhibited inhibitory effect of the indirect pathway, resulting in akinesia, shuffling gait, rigidity, cogwheel tremor
patient presents w/ fever, night sweats, weight loss, and painless waxing and waning lymphadenopathy that developed over the last few months
Follicular lymphoma (NHL - t14;18; bcl2)
key to diagnosis is the painless waxing/waning of lymphadenopathy
∆ btwn nucleus solitarius and nucleus ambiguus in terms of the information they carry and the CNs involved?
nucleus solitarius
- carries sensory information (taste, baroreceptors, gut distension)
- CN 7, 8, 10
nucleus ambiguus
- carries motor innervation of the pharynx, larynx, and upper esophagus (swallowing, palate elevation)
- CN 9, 10, 11
what do each of these carry?
optic canal
superior orbital fissure
formanen rotundum
foramen ovale
foramen spinosum
optic canal = CN 2, opthalmic artery, central retinal vein
Superior orbital fissure = CN 3, 4, V1, 6, opthalmic vein
note the contents are very similar to the cavernous, except the cavernous also has the addition of V2
formanen Rotundum = V2
foramen Ovale = V3
foramen spinosum = middle meningeal artery
Standing Room Only = V1, V2, V3
what are the contents of the cavernous sinus?
which nerve is most susceptible to injury and why?
CN 3, 4, V1, V2, 6, and ICA
most susceptible is CN6 because it’s is most central
similar contents to superior orbital fissure, except it doesn’t contain V2
* (note that they both begin with S?!)*
what do these d/o affect?
astigmatism
glacuoma
cataract
papilledema
scotoma
astigmatism = cornea
glacuoma = optic disk atrophy
papilledema = optic disk swelling (due to increased ICP)
cataract = lens
scotoma = macula
∆ btwn open and closed angle glaucoma in terms of:
cause
pain
treatment
open-angle
- cause: blocked trabcecular meshwork due to WBC/RBC or retinal elements
- painLESS
- trmt: latanprost or epinephrine
closed angle glaucoma
- cause: iris bows forward and blocks fluid access to the trabecular meshwork- fluid builds up behind iris, pushing it forward and against the cornea
- painFUL
- trmt: acetazolamide, mannitol, ß blocker, pilocarpine
- do NOT give epinephrine due to its mydriatic effects
Lesion in CN3
Lesion in CN4
Lesion in CN6
CN 3 = down and out pupil, ptosis, pupil dilation, ø accomodation
CN 4 = eye moves upward w/ contralateral gaze; head tilt toward side of lesion
problem going down stairs; may present w/ compensatory head tilt toward the opposite side
CN 6 = pupil directed medially
Pathophysiology of Marcus Gunn Pupil
damage to OPTIC NERVE or SEVERE RETINAL INJURY
therefore there is no afferent signaling = no bilateral constriction when light is shown in the affected eye
INO
what disease is it in?
what CN are involved?
what structure is involved?
what happens?
MS
CN 3, 6
MLF lesion
when looking left, CN 6 activates the ipsi LR, but contralateral CN 3 does not stimulate contra MR to fire, therefore contra eye (abducting eye) undergoes nystagmus (since CN 7 overfires in attempt to stimulate CN 3)
net: nystagmus in ipsilateral eye, ø movement in contralateral eye
note: convergence is OK
buzzwords: leukemia w/ lots of lymphoblasts
age?
type of cells?
associations?
trmt?
ALL
kids disease
high B or T lymphoblasts in circulation
TDT+
(T lymphoblasts present as a mediastinal mass -> hoarsness/dysphagia sx)
associated w/ Down syndrome; t12:21 = better prognosis
trmt: chemo
buzzwords: leukemia w/ smudge cells
age?
type of cells?
trmt?
CLL
elderly
B cell neoplasm (CD19, CD20, CD5)
trmt: alemtuzumab (binds CD52)
buzzwords: TRAP (+)
age?
type of cells?
trmt?
Haircy cell leukemia
adults
mature B cell neoplasm - hairy cells
trmt: cladribine (2-CDA adenosine analog)
buzzwords: leukemia w/ myeloblasts w/ rods
age?
type of cells?
associations?
trmt?
AML - M3 subtype (t15;17)
>60
myeloblast neoplasm w/ auerods (peroxidase +)
associations: alkylating chemRx, radiation, Downs, myeloproliferative d/o
trmt: Vitamin A
(DO NOT USE CHEMO bc that can cause the rods to lyse -> DIC)
buzzwords: leukemia w/ high basophils
age?
type of cells?
associations
trmt?
CML
elderly
myeloid stem cell proliferation due to 9;22 bcr-abl (increased tyrosine kinase)
results in lots of basophils, PMNs (but very low activity of leukocyte AP), metamyeloblasts
can transform to AML or ALL “blast crisis”
trmt: imatinib (Gleevec - TK inhibitor)
leukemia?
age?
type of cells?
associations?
trmt?
ALL
kids disease
high B or T lymphoblasts in circulation
TDT+
(T lymphoblasts present as a mediastinal mass -> hoarsness/dysphagia sx)
associated w/ Down syndrome; t12:21 = better prognosis
trmt: chemo
leukemia?
age?
type of cells?
associations?
trmt?
CLL
elderly
B cell neoplasm (CD19, CD20, CD5)
trmt: alemtuzumab (binds CD52)
leukemia?
age?
type of cells?
trmt?
Haircy cell leukemia
adults
mature B cell neoplasm - hairy cells
trmt: cladribine (2-CDA adenosine analog)
leukemia?
age?
type of cells?
associations?
trmt?
AML - M3 subtype (t15;17)
>60
myeloblast neoplasm w/ auerods (peroxidase +)
associations: alkylating chemRx, radiation, Downs, myeloproliferative d/o
trmt: Vitamin A
(DO NOT USE CHEMO bc that can cause the rods to lyse -> DIC)
leukemia?
age?
type of cells?
associations
trmt?
CML
elderly
myeloid stem cell proliferation due to 9;22 bcr-abl (increased tyrosine kinase)
results in lots of basophils, PMNs (but very low activity of leukocyte AP), metamyeloblasts
can transform to AML or ALL “blast crisis”
trmt: imatinib (Gleevec - TK inhibitor)
Diagnosis?
5 typical findings associated w/ this?
Multiple Myeloma
- CRABi
- HyperCalcemia
- Renal insufficiency
- Anemia
- Bone lytic lesions/Back pain
- Iinfections
- Multiple Myeloma: Monoclonal M protein spike
RA: patient lies in the L lateral decubitus position and exhales fully - you hear a low-pitched sound, mid-diastolic murmur at the cardiac apex
mitral stenosis
=
RHEUMATIC FEVER
systolic crescendo-decrescendo mumur along the L sternal border that intensifies upon standing; radiates to the suprasternal notch
becomes quieter w/ increased preload
hypertrophic cardiomyopathy (HCM)
AD, mutation in ß-myosin heavy chain protein that results in hypertrophy of the LV and disordered arrangement of cardiac myofibrils, which can cause
diastolic dysfunction
LV outflow obstruction
increased cardiac work/myocardial ischemia
patients usually present during physical activity because HR is incrased and the time provided for diastolic filling is insufficient to maintain an apporpiate CO
intracellular accumulation of what ion is the hallmark of ischemic injury?
cytoplasmic **Ca **accumulation
(should also see high extracellular K due to reduced fxn of Na/K ATPase and subsequent leak of K and low extracellular Na, Ca, HCO3)
Tamm-Horsfall glycoprotein
secreted by renal tubular epithelial cells in the TALH; aggregates to form hyaline casts in patients w/ pre-renal azotemia and low urine flow rate
presence of AChE in amniotic fluid indicates this
open neural tube defects (AChE is present in blood cells, muscle, and nerve tisuse)
cystathione-ß-synthase
defect in this enzyme causes what disease?
what is this enzyme important for?
what two factors accumulate in this d/o?
what becomes an essential a.a. in these patients?
Homocystinuria
enzyme is essential for degradation of methionine
accumulation of Methionine + homocysteine
Cysteine becomes an essential a.a.
virluence factor for neisseria gonorrhoeae
**pili **- adherence factor that is required for N. Gonorrhoeae to establish an infection
(do not confuse w/ the virulence factor of N. meningitidis, which has an anti-phagocytic capsule that enhances its survival to epithelial cells)
RA: peaked T waves + loss of P waves + prolonged PR interval, widening of QRS complex + slow HR
hyperkalemia
Rx that increases PVR and systolic BP, decreases PP and HR
phenylephrine - selective a-1 agonist
causes arterial vasoconstriction -> increased PVR and systolic BP
baroreceptor mediated increase in vagal tone -> decrease SV + HR
PP (Systolic - Diastolic) = decreased bc of the reflex decrease in stroke volume and the increased afterload
where can you find GI stem cells?
Crypts of Lieberkuhn
stem cells reside in the deepest parts of these crypts; functions to regenerate mucosal epithelium
Thiamine deficiency, as that seen in chronic alcoholics, can damage what two structures in the brain?
FA: mamillary bodies + medial dorsal nucleus of thalamus –> triad of **confusion, ophthalmoplegia, ataxia **
Uworld: cerebellum - loss of Purkinje cells in the anterior lobs + cerebellar vermis –> wide-based gait ataxia, truncal instability, intention tremor of hands and fingers, rhythmic postural tremor of hands and fingers
erythromycin
MoA
how does resistance to this Rx develop?
binds to the 23S rRNA component of the 50S ribosome and block translocation of the ribosome on the mRNA, thereby inhibiting protein synthesis
resistance: methylation of 23s rRNA hinders macrolide binding
chloramphenicol
MoA
how does resistance to this Rx develop?
binds 50S ribosome and inhibits the 50S peptidyltranserase
resistance: acetylation of the antibiotic (methylation of the 50S subunit is not a major mxn of resistance)
aminoglycosides
MoA
how does resistance to this Rx develop?
binds 30S ribosome and inhibits formation of initiation complex
resistance: acetylation, adenylation, or phosphorylation of the antibiotic
Tetracycline
MoA
Resistance?
bind 30S subunit and prevent aminoacyl-tRNA from binding to the A site on the ribosome, thereby inhibiting elongation
Resistance: decreased uptake + increased efflux of the antibiotic
linear erythematous rash on hands, legs, and arms that develops shortly after a hiking trip. patient had sore throat 1 wk ago and took penicillin
clue: LINEAR
Type IV HSR - DTH due to poison ivy/oak exposure
53 yo w/ hx of radiation therapy for enlarged adenoids as a child is at greatest risk of?
thyroid neoplasm
thyroid is the most sensitive to radiation: see a linear dose-response relationship btwn external radiation exposure and the development of thyroid cysts, nodules, and cancer
exit point of urea in the urea cycle?
arginase-mediated hydrolysis of arginine to form ornithine + urea
urea is excreted
ornithine is recycled back into the urea cycle, where it combines w/ carbamoyl phosphate (via ornithine transcarbamoylase, OTC) to generate L-citrulline
tardive dyskinesia is seen w/ typical antipsychotics. why is this?
antipsyhotics antagonize D receptors, thereby causing an upregulation of D receptors, which result in a concomitant decrease in cholinergic tone in the striatum
∆ btwn oral and inactivated polio vaccine
-
inactivated/killed polio (Salk)
- cannot cause vaccine-associated paralytic poliomyelitis
- intramsucular vaccine
-
live attenuated polio (Sabin)
- can revert to virulent form
- oral vaccine - better at inducing a prolonged mucosal IgA secretion
adenovirus
enveloped?
genome?
what does it use to replicate its genome?
dsDNA virus, non-enveloped
DNA-dependent DNA polymerase
reducing renal artery by 75% will do what to the FF?
FF increases when renal blood flow decreases
rationale behind administering penicillin + gentamicin together
pencillin impair cell wall synthesis, thereby resulting in membrane instability. by disrupting the cell wall, ß lactam drugs can allow aminoglycosides to enter the cell and exert their bactericidal effects (binds 30S ribosome = ø protein synthesis)
patient w/ DKA complains of face pain + bloody nasal discharge. Ocular movement is reduced and there is necrosis of nasal turbinates.
dx? complications?
dx: mucurmycosis
complication: cavernous sinus thrombosis
only dural sinus that can receive blood from the cerebral veins AND facial veins (superior + inferior ophthalmic veins)
acute infection of the central face may spread through the valveless facial veinous sytem into the cavernous sinus, resulting in inflammation + thrombosis. Lateral gaze palsy (∆CN6) is one of the first signs of this disease
someone with severe hypothyroidism can experience this
galactorrhea due to TRH (stimulates prolactin release)
24yoM w/ fever, malaise, bilateral parotid gland swelling + swollen tender scrotum. Later states that he has no interest in sex
dx?
at risk of?
Mumps (parotitis + orchitis)
orchitis = tender swelling of the testes, often results in seminiferous tubule atrophy, which can cause infertility and Leydig cell atrophy, which causes decreased T production -> sexual dysfunction
lumbar lordosis is caused by excessive contraction of?
hip flexors
why is it that oral glucose results in higher insulin levels than IV glucose?
GLP1 = incretin produced by gut mucosa that stimulate pancreatic insulin secretion in response to sugar containing meals
where is ApoB100 produced? ApoB48?
ApoB100 = liver
ApoB48 = intestinal cells<br></br>(truncated version)
gram stain of urethral discharge that reveals PMNs but no organisms
dx? trmt?
dx: chlamydia trachomatis - obligate intracellular org that does not stain w/ gram stain
trmt: azithromycin
(note: must also give a ceftriaxone for n. gonorrhoe, cause coinfections are high)
purpose of giving imipenem w/ cilastatin?
imipenem is a ßlactam antibiotic
cilastatin prevents renal tubules from hydrolyzing imipenem, thereby prolonging the antibacterial effects
note that this has the similar moa to probenecid, where the latter inhibits renal tubular secretion of pencillin, cephalosporins
RA: lymphocytes w/ “cleaved nuclei”
Follicular lymphoma - t14;18, overexpression of bcl-2 protein, which inhibits tumor cell apoptosis
crypt abscesses
Ulcerative colitis
(2 words)
pathogenesis of atretic follicles in ovaries in a 43yo
without adequate FSH, the oocytes + granulosa cells within primordial follicles undergo apoptosis
urine is added to a glass containing anti-hCG antibodies; latex particles coated w/ bhCG is added to the urine and agglutination is observed. interpretation?
(+) agglutination inhibition test = not pregnant
if pregnant, then urine contains ßhCG, the anti-hCG antibodies will bind the ßhCG and the latex agglutination will not occur because there aren’t any anti-hCG antibodies remaining to react with the ß-hCG coated latex particles
paclitaxel
MoA
why is it present on coronary artery stents?
paclitaxel - antineoplastic agent that binds ß tubulin and prevents microtubule braekdown, thereby causing arrest of the cell cycle in M phase
present on coronary stents to prevent retenosis due to intimal hyperplasia (common complication of stents)
only two RNA viruses that replicate in the nucleus
influenza
HIV
abnormal proline hydroxylation will result in
abnormal triple helix formation of collagen molecules
hydroxylation is essential for proper association of pro-alpha chains into procollagen chains
T/F ranitidine (H2 blockers) used to treat peptic ulcers, gastritis, etc are associated with hip fractures
FALSE -
hip fractures are actually associated w/ proton pump inhibitors (omeprazole, lansoprazole, etc, etc)
patient w/ psoriasis catches malaria while traveling through africa
trmt?
Atovaquone or Proguanil
(chloroquine can aggravate the psoriasis)
43 yo F presents w/ shingles. why?
advanging age or immunosuppression (HIV) increases risk of VZV reactivation
cause of microstatellite instability
d/o that this is present in?
HNPCC (lynch syndrome) - caused by ∆ mismatch repair genes that result in microsatellite instability (repeating sequences of bases - CACACACACA)
9p21
dysplastic nevi syndrome - numerous dysplastic nevi in a young person who has a family hx of melanoma in >3 1˚ relatives
due to mutations in CDKN2A gene on chromosome9p21
dx me please
Aortic dissection
note the cardiomeagly, abnormal aortic contour, wide superior mediastinum
predisposing factors: chronic HTN, marfans
which two drugs increase chloride conductance by binding to the GABAa receptor on neurons?
which one is inhibited by flumazenil?
Benzodiazepines **inhibited by flumazenil*
Barbiturates
how does pregnancy, OCP, or estrogen use affect:
sex hormone-binding glboulins?
Thyroxine-binding globulin?
sex hormone-binding glboulins = decrease
(SHBG normally binds testosterone; free estrogen is unchanged)
Thyroxine-binding globulin = decrease
in women, a lower SHBG = increased free Testosterone = more converted to DHT = hirsutism!
function of thyroid hormones? 4
incr ß1 receptors on heart -> incr HR
incr. Na/K ATPase -> incr. basal metabolic rate (incr. O2, incr. RR, incr T)
incr bone growth
incr brain maturation
why is it that peripheral edema is not seen in Conn syndrome? 2
aldosterone escape
- excess aldo -> excess Na/H2O reabsorption -> volume expansion -> increase renal perfusion pressure -> decrease PCT Na reabsorption = increased Na delivery to the distal nephron -> increased delivery of Na overrides the enhanced aldosterone-mediated Na reabsorption
- volume expansion -> increases ANP/BNP -> both have an inhibitory effect on Na reabsorption in the collecting duct
alcoholic w/ horizontal nystagmus + broad-based, undsteady gait
damage to where?
what embryological part of the brain does it derive from?
alcoholic cerebellar degeneration - condition caused by Purkinje cell degeneration within the cerebellar vermis and anterior cerebllar lobes
signs: wide based gait, truncal instability, ataxia, nystagmus, dyarthria
derived from rhombencephalun (metencephalon + myelencephalon)
how do these factors ∆ with excercise?
HR
LV ESV
LV EDV
LV EDP
HR = increased = increased sympathetic stimulation
**LV ESV = decreased = **because PVR (afterload) is reduced during exercise as a result of vasodilation in muscles, thereby allowing the heart to empty more completely during systole
LV EDV = **increased **= if HR increases to increase CO, then stroke volume must also increase (remember that CO = HR*SV)
LV EDP = unchanged = increased CO cancels out the vasodilation in exercising muscles
how does EDV and ESV change with LV systolic dysfunction
large dilated ventricles - CO is limited
EDV = increased
ESV = increased
how does EDV and ESV change with LV diastolic dysfunction
thickened ventricular walls; filling is limited due to decreased compliance
EDV = decreased
ESV = decreased
how does EDV and ESV change with global LV ischemia
decreased contractility of LV myocardium
EDV = increased
ESV = increased
how does HR, EDV and ESV change with pericardial constriction
decreased ability of the heart to expand during diastole
EDV = decreased
ESV = decreased due to low EDV
HR = increased in order to maintain CO in the setting of decreased preload
30 a.a. fragment of a nuclear protein w/ a coiled structure similar to an alpha helix; contains repeated leucine residues at every 7th position. What am I?
key word to note: nuclear
this is a leucine zipper domain found in transcription factors (TF); functions in facilitating the interaction of the TF with DNA to allow for ∆s in gene expression
similar examples - helix-loop-helix and zinc finger motifs
Initial reactants, enzyme, and location involved in the first step of
pyrimidine synthesis?
urea cycle?
Pyrimidine synthesis = **Carbomoyl phosphate synthase II **
- **CO2 **+ glutamine + 2ATP -> carbomyl phosphate
- cytosolic
**Urea cycle = Carbomoyl phosphate synthase I **
- NH3 + CO2 + 2ATP -> carbomyl phosphate
- mitochondria
radiolabeled CO2 molecules are incorporated into nuclear DNA. How is this possible?
**Carbomoyl phosphate synthase II **
cytosolic enzyme that catalyzes initial step in pyrimidine synthesis (CO2+glutamine ->carbomyl phosphate)
Flexon of the hip against resistance (applied by examiner) causes extreme pain. Dx?
iliopsoas test
(+) psoas sign = usually the result of inflammation of psoas muscle (psoas abscess) or its overlying peritoneum (appendicitis)
what structures pass through the diaphragm?
I ate (8) 10 EGGs AAT =_ 12_
T8 = IVC
T10 = Esophagus, Vagus
T12 = Aorta, Azygous, Thoracic duct
24 yo has moderate post-prandial hyperglycemia bc his pancreatic islet cells have a high set point for insulin secretion in response to blood glucose levels
dx? what enzyme is involved?
MODY
∆ glucokinase
- present on the pancreas + liver
- catalyzes 1st step in glycolysis (glucose -> G6P, which then allows it to be metabolized in glycolysis/TCA to produce ATP, which causes insulin release)
- has a high Km and therefore requires a higher glucose conc. for activation
- functions as the glucose sensor for insulin secretion
infant w/ hypotonia involving bulbar muscles, macroglossia, and enlarged + systolic murmur heard over the apex. Muscles reveal abundant PAS+ intracellular granules.
Dx? enzyme deficient?
Pompe disease
∆ lysosomal enzyme a-1,4-glucosidase
findings: hypotonia, macroglossia, massive hypertrophic cardiomyopathy, early death
patient w/ dark discoloration of sclera and knee cartilage/ligaments that appear dark brown in color
dx? impairment of what process?
Alkaptonuria - AR, ∆ homogentisic acid oxidase (enz. required for degradation of tyrosine and phenylalaine)
most common cause of osteomyelitis in
the general population?
patients w/ sickle cell?
the general population = S. aureus (GPC)
patients w/ sickle cell = Salmonella (GNR)
how can brain neoplasms increase ICP? 2
1) mass effect that cuases obstruction of normal CSF flow
2) disruption in the BBB, leading to increased vascular permeability and plasma infiltration into the cerebral interstitum “vasogenic edema”
what part of the female reproductive system has both columnar + stratified squamous epithelium?
cervix
the site described is the squamocolumnar junction; most common site of cervical malignancy (HPV loves this area for some reason….)
construction worker w/ TMJ
diagnosis?
clostridium tetani (GPR, spore forming)
usually contracted via puncture wound from a **rusty nail **
fungus - where is the cell wall relative to the cell membrane??
bonus - what antifungal agents work on both
Cell wall = OUTSIDE
(think of it as the great wall, protecting everything on the inside)
Rx: caspofungin
Cell membrane = INSIDE
Rx: amphotericin B, nyastatin - bind ergosterol;
azoles inhibit ergosterol synthesis
what drug is a short peptide medication that is an analog of the carboxy terminal of the delta chain of fibrinogen?
in other words, what rx looks like fibrinogen? and what is its role?
know that GP IIb/IIIa (an integrin receptor) present on platelets that binds to fibrinogen to enable a bridge to form btwn 2 platelets
GP IIb/IIIa inhibitors bind to GP IIb/IIIa receptors, thereby preventing fibrinogen from binding and preventing platelet aggregation
why does administering omeprazole + clopidogrel result in an increased risk of thrombosis?
clopidogrel is a prodrug that must be activated by CYP450 in order for it to exert its antiplatelet effects
coadministration with an inhibitor of CYP450 results in a decreased conversion of the inactive prodrug to its active metabolite, thereby increasing the patients risk of thrombosis.
how does the JG cells differ than the Macula densa
JG = modified SM of the afferent arteriole; secretes renin
MD = NaCl sensor on the DCT
RTA
Type I
Type II
Type IV
what are the defects and what is the net effect on K?
all result in NON-AG hyperchloremic metabolic acidosis:
- Type I - CD - a-ICC can’t secrete H (therefore new HCO3 is not generated); hypokalemia, increased risk of stones
- Type II - PCT - defect in HCO3 reabsorption; hypokalemia (more Na/ions delivered distally)
- Type IV - PCT - hypoaldosteronism; hyperkalemia
gingival ulcers, swollen gums, cervical lymphadeophaty
Herpes
should see multi-nucleated giant cells w/ intranuclear inclusions on oral ucler base scrapings on Tzanck preparation
AIDs patients are at greatest risk of which viral-induced malignancy?
EBV-associated NHL lymphoma
(aggressive diffuse large B cell lymphoma and Burkitt’s lymphoma)
which NT has been shown to modulate morphine tolerance?
what can reverse this tolerance?
glutamate - excitatory NT -> activates NMDA receptors -> increased phosphorylation** **of opioid receptors -> increased NO levels ->>> morphine/opioid tolerance
dextromethorphan - NMDA-receptor antagonist -> reverse opioid tolerance
patient w/ low serum Na and low osmolarity + low urine osmolarity should make you suspicious of…..
what should you see on the water deprivation test?
psychogenic polydipsia - excessive H2O intake
steady, reliable increase in urine Osm + paltry response <10% to vasopressin administration
how to differentiate btwn partial and complete central DI using the water restriction test?
complete central DI = the rise in urine osmolality is >50% after vasopressin is administered
(ie it will go from 160 –> 550 Osm)
neurofibromas found in NF-1 are derived from what embryological structure
Schwann cells - neural crest cells
ESRD patients are at greatest risk of..?
renal osteodystrophy - renal retention of PO4 + decreased renal synthesis of 1,25OH D3 (+ resultant hyperPTH)
patient w/ 101˚F, leukocytosis, BP 78/62, pulse 125/min, and lactic acidosis should make you think of?
101˚F, leukocytosis, BP 78/62, pulse 125/min = SEPTIC SHOCK
lactic acidosis = due to either overproduction or impaired clearance; in the case of septic shock, there is impaired tissue oxygenation, which decreases oxidative phosphorylation. This causes the shunting of ** pyruvate -> lactate** after glycolysis
most common cause of aortic stenosis in patients over 70 yo
senile, degenerative calcification of the aortic valve
DONT confuse w/:
1) rheumatic heart disease, which presents at an earlier age and usually the mitral valve is afected
2) infective endocarditis - targets abnormal aortic valves (bicuspid, calcified, prosthetic, or valves deformed by chronic rheumatic heart disease) and causes<u>aortic regurgitation</u> due to valve leaflet destruction
90yo M w/ amyloid deposits in cardiac atria; no other organs are involved. What are the deposits made of?
abnormally folded ANP - results in localized amyloidosis confined to the cardiac atria.
bupropion
benefits over other Rx?
ADR?
excellent alternative Rx for treatment of depression since it does not cause sexual dysfunction (like SSRis)
increased risk of seizures, esp in a patient who is anorexic
15yo CF patient w/ decreased proprioception and hyporeflexia over lower extremities with labs that show mild hemolytic anemia. Cause?
Vitamin E deficiency
∆G˚ = + 400 will have a Keq of
>1
<1
0
1
** Less than 1 **
if ∆G˚ was a negative #, then Keq wil be greater than 1
if ∆G˚ was 0, then Keq wil be 1
Keq of 0 is not mathematically possible
patient develops diabetes, anemia, and an erythematous indurated rash w/ crusting and scaling. What does she have?
glucagonoma - pancreatic tumor
PCOS patients are at risk of?
developing endometrial adenocarcinoma and type II DM
anaphylaxis is mediated through which cell + cytokine?
mast cell degranulation + histamine (also tryptase)
Primary CNS lymphomas in HIV patient are typically of what cell type?
B cells
latent EBV is strongly associated w/ AIDs-related primary CNS lymphoma
rationale behind giving spironolactone to a patient with CHF?
prevents aldosterone-mediated ventricular remodeling (that leads to cardiac fibrosis)
why would someone 1˚ biliary cirrhosis develop xanthelasmas?
chronic cholestatic processes (ie obstructive biliary lesions or 1˚ biliary cirrhosis) results in subsequent hypercholesterolemia, leading to the formation of xanthelasmas
patient involved in a car accident is obtunded but responds to painful stimuli. BP is 160/90, pulse is 72/min, respirations are 10/min
Few hours after initial treatment and stabilization, he develops severe tachypnea and decreased O2. CXR shows pulmonary edema.
Drug?
mannitol - osmotic diuretic used to treat cerebral edema and increased ICP; works by
- rapidly increasing plasma or tubular fluid osmolality, which causes H2O to move from the interstitial space into the vascular space or tubular lumen (mannitol can’t cross BBB, therefore water is drawn out from the brain, thereby reducing cerebral edema)
- osmotic diuretics work in the PCT and LOH to produce diuresis
ADR: pulmonary edema - occurs
pt w/ abd. distension, periodic diarrhea, difficulty gaining weight has a duodenal biopsy that looks like the bottom picture. History and PE is unremarkable otherwise. Diagnosis?
(top is normal for comparison)
celiac’s disease
patient w/ hypochromic microcytic anemia is treated w/ Fe. Several weeks later, blood smear shows numerous enlarged RBC that appear blue on the wright-giemsa stain.
What are these cells and why are they blue?
reticulocytes
contain a basophilic, reticular (mesh-like) network of residual ribosomal RNA
most common reasons for elevated AFP in a pregnant woman
dating error - underestimation of gestional age
∆ btwn aspirin, ibuprofen, and acetaminophen?
OD treatments for all 3?
-
aspirin = acetylsalicyclic acid = IRREVERSIBLE cox1/cox2 inhibitor
- activated charcoal - absorbs it before it can enter the systemic circulation
- HCO3 - combines w/ the acid to form a salt
-
ibuprofen = REVERSIBLE cox1/cox2 inhibitor
- active charcoal - absorbs it before it can enter the systemic circulation
-
acetaminophen = MoA is unknown but it is metabolized by glutathione;
- N-acetylcysteine
anticoagulant taht prolongs both PTT and PT, but not the TT
direct factor Xa inhibitors (idraparinux, rivaroxaban, apixaban) without significant anti-thrombin activity - therefore only affect PT and PTT but not TT (thrombin time)
patient w/ acute rheumatic fever develops a new holosystolic murmur. If she dies, what is the most likely cause of death?
severe myocarditis - may produce cardiac dilation that can evolve into functional mitral regurgitation (as is what is present in this patient) and even heart failure
where is very-long chain FA acids metabolized?
sequelae if this system malfunctions?
peroxisomes
these do NOT undergo mitochondrial ß-oxidation
dz lead to neurological defects from improper CNS myelination
hepatic encephalopathy - what two factors are depleted? what is the net effect of this?
hyperammonemia in hepatic encephalopathy leads to a depletion
a-KG, resulting in inhibition of Krebs cycle
glutamate, resulting in **glutamine accumulation **and subsequent astrocyte swelling and dysfunction
logic behind using IL2 to treat melanomas and RCC?
trade name of this drug??
aldesleukin
stimulates growth of CD4, CD8, B cells, NK cells, and monocytes
increased activity of T cells and monocytes -> responsible for IL2’s anti-cancer effect on metastatic melanoma and RCC, resulting in tumor regression
what are the names of the NNTRIs?
what is soooooooo special about these guys?
Delavirdine
Efavirenz
Nevirapine
spells “DEN”
these DEN’ require intracellular phosphorylation!
hemosiderin
what is it
common in what patients
treatment?
yellow-brown pigment that is composed of an aggregation of ferritin micelles in resident mononuclear phagocytes in tissues involved in RBC degradation (LN, BM, spleen, liver); marker of Fe accumulation
patients w/ hemolytic anemia or receive many blood transfusions
Iron chelation therapy
56yoM has a brain biopsy done 1 week after his stroke. myelin stain of the infarcted area has large cells stained w/ pink (myelin+). what are they?
microglia presents 3-5d after the onset of ischemia (note the timing of the bx) and engulf the disintegrated myein
34yo w/ membranous glomerulopathy suddenly experiences a L sided varicocele. Why?
Renal vein thrombosis on the L side
why? hallmark feature of nephrotic syndrome: proteinuria
how? increased permeability of the glomerular capillary wall results in a loss of lots of proteins, including the anticoagulant factors, especially antithrombin III, which is responsible for the thrombotic complications.
why do patients w/ membranous glomerulopathy experience increased risk of thromboembolism?
hallmark feature of nephrotic syndrome: proteinuria
increased permeability of the glomerular capillary wall results in a loss of lots of proteins, including the anticoagulant factors, especially antithrombin III, which is responsible for the thrombotic complications.
initial evaluation of patient who presents w/ signs of iron deficiency anemia should include:
looking for blood loss (esp in the GI tract)
person has this type of breathing pattern.
dx?
Cheyne Stokes - cyclic breathing in which apnea is followed by gradually increasing tidal volumes and then gradually decreasing tidal volumes until the next apneic period
common in patients w/ CHF or neurologic diseases (stroke, brain tumor, TBI)
(compare to normal below)
Patient being treated for allergic rhinitis has flushed skin + pupil dilation. What drug was he given?
Rx with anticholinergic effects (mostly muscarinic receptors)
inhibition of eccrine sweat glands can result in fever + compensatory cutaneous vasodilation
inhibition of pupillary constrictor and ciliary muscles can cause pupillary dilation
5 classes of drugs with anti-muscarinic effects?
atropine
TCAs
H1 receptor antagonist (diphenhydramine)
neuroleptics
antiparkinsonian Rx
morphine
what channels does it bind to?
which ions does it increase the flux of?
µ receptors (GPCR) activation -> activation of K channels -> increase K efflux -> hyperpolarization of post-synaptic neurons and termination of pain transmission
amatoxins found in amanita phalloides (wild poisonous mushrooms) can affect synthesis of this particular molecule in the cell
amatoxins are potent inhibitors of RNA pol II, thereby inhibiting mRNA synthesis
pramipexole and ropinirole
what is it and what is it used for?
dopamine agonists that preferentially stimulate D2 receptors
do not have to be metabolized in order to be active, plus they have a long half-life and prolong the effects of methyldopa, thus limiting motor fluctuations
do cholinergics agonists cause vasoconstriction or vasodilation?
what signaling factors do they mediate this through?
vasodilation
binds to muscarinic receptors on endothelial cells and promote the relelase of NO (EDRF), which activates guanylate cyclase and diminishes endothelium Ca concentration
infant w/ delayed separation of the umbilical cord should cue you into this disease
sequelae of this dz?
**Leukocyte Adhesion Deficiency **
inability to synthesize integrins, which are necessary for leukocytes to exit the blood stream
sequelae: recurrent skin infections WITHOUT pus formation, delayed detachment of the umbilical cord and poor wound healing
Downey cells seen in EBV are what cells?
Activated Cytotoxic CD8+ T cells - function to destroy virally-infected B cells
cause of cyanotic toe discoloration and increased creatinine in an elderly patient following a coronary angioplasty
atheroembolic disease caused by cholesterol-containing debris (needle shaped crystals) that gets pushed from larger arteries and lodges in smaller vessels, causing ischemia and decreased perfusion
patients w/ abetalipoproteinemia is likely to have what kind of small intestinal histology?
inherited ability to synthesize apolipoprotein B (component of chyloµ and VLDL)
lipids absorbed by the small intestines can’t be transported into the blood and accumulate in the intestinal epithelium, resulting in enterocytes w/ clear or foamy cytoplasm
drugs that block skeletal muscle nicotinic cholinergic receptors
tubocurarine
succinylcholine
patient has double vision when coming down the stairs.
which CN is affected?
CN 4 - Trochlear nerve
MHC I and MHC II are made up of what chains?
MHC I - heavy chain + ß2 microglobulin
MHC II - alpha + ß polypeptide chains
Pathogens with really low infectious dose
Shigella
Campylobacter
Entamoeba histolytica
Giardia
54yo smoker comes in with
recent weight gain despite no changes in diet/exercise
unusually large # of bruises
skin seems to be getting darker
epigastric abd pain that is relieved by OTC antacids
BP is 160/100mmHg, pulse is 90/min
CXR has an irregular mass in R lung field
Diagnosis?
Cushings Syndrome due to Small Cell Carcinoma
excess ACTH directly stimulates
- melanotropin receptors due to significant sequence homology w/ a-MSH (darker skin)
- adrenals to release excess cortisol (weight gain, bruising) and mineralocorticoids (note his high BP)
defense? directing anger toward a family member toward a hard workout at the gym
sublimation
mixed cryoglobulinemia is associated with which d/o?
Hep C
likely due to IgM deposits that lead to BM thickening and cellular proliferation
IgG4 antibodies against the phospholipase A1 receptor (PLA2R) is associated with which disease?
Idiopathic membranous nephropathy (glomerulonephritis)
how does timolol work?
ß blocker used in glaucoma (increased IOP) to decrease aqueous humor production by the ciliary epithelium
narrow angle glaucoma
what causes it?
what can precipitate painful attacks?
occurs when the anterior chamber of the eye narrows, obstructing the trabecular meshwork
preciptated by anti-cholinergics
(anti-parasympathetic = sympathetic = pupil dilation)
CSF features of
bacterial meningitis
viral meningitis
bacterial meningitis
- low glucose (bacterias got to eat)
- high protein
- PMN predominance
viral meningitis
- normal glucose
- high protein
- lymphocytic predominance
60yo M smoker comes in w/ high fever, confusion, HA, watery diarrhea, and mildly productive cough. Sputum gram stain shows numerous neutrophils but ø bacteria.
Dz? What can you use to diagnose this patient?
Treatment?
Fever + pneumonia + GI sx = Legionella pneumophilia (GNR)
Gram stain often shows few or no bacteria since a unique polysaccharide chain on the outer membrane inhibits gram staining
dx test: urine antigen
circulating RBCs are unable to synthesize heme. why?
because they lack a mitochondria, which is necessary for the last 3 steps of heme synthesis
(they obv. dont have a nucleus, but the mitochondria is the location of the heme biosynthetic pathway and I guess the most important??)
A 78yo patient w/ a BP of 180/70 should make you consider what?
A 78yo patient w/ a BP of 180/140 should make you consider what?
180/70 = diastolic BP is within normal range, so he has **isolated systolic HTN **caused by age-related decreases in the compliance of the aorta and its proximal major branches
180/140 = consider renal artery stenosis, since excess RAAS activation will result in hypervolemia +/- incrased TPR, which would increase both systolic + diastolic
patient w/ testicular malignancy + elevated T3 and T4
dx?
teratoma - elevated hCG
hCG is similar to FSH, LH, and TSH, therefore elevating the T3/T4 levels
patients w/ sickle cell anemia are at risk of infections with which organisms?
encapsulated organisms
- SEPSIS = think S. penumo (most common) or H. influenza (second most common)
- OSTEOMYELITIS = think Salmonella
How would these factors change with 1˚ mineralocorticoid excess?
Na
K
HCO3
when should you suspect this?
Na = normal (due to aldosterone escape)
K = low
HCO3 = high
(since K and H+ are being excreted in exchange for Na uptake - base must be high)
suspect when patients present w/ HTN in the setting of suppressed renin
1 week old neonate w/ HBsAg and HBeAg
Risk of chronic infection?
Viral replication rate?
Lab markers of liver injury?
HBsAg + HBeAg suggests acute hepatitis infection likely acquired during pregnancy
Risk of chronic infection = high
Viral replication rate = high (due to immaturity of the infant’s immune system to defend against the virus)
Lab markers of liver injury = **low **(HBV infects cells, but rarely causes hepatocyte damage - it is the T cells cause hepatocyte injury. since the immune system is immature at this time, there is minimal hepatic damage)
How do OCPs prevent pregnancy? 3
- suppress FSH/LH, which inhibits ovulation (ø LH surge)
- thickening of cervical mucus - prevents sperm from accessing the uterus
- progestin - prevents growth of the endometrium, making it unsuitable for embryo implantation
RA: amyloid deposition in the temporal cortex, hippocampus, and cerebral arteries
Alzheimers - amyloid is actually Aß amyloid, a product synthesized by the cleavage of APP (a normal component of neuronal membranes)
forms senile plaques and amyloid angiopathy (amyloid deposition in the media and adventitia
SLE patient has cushing-like symptoms is found dead at home.
Why? What do you expect her adrenal glands to look like?
SLE patients are likely to be treated with high doses of glucocorticoids, which can suppress the entire HPA axis (low CRH, ACTH, and cortisol), resulting in bilateral atrophy of adrenal cortices
sudden cessation of glucocorticoids after prolonged use can cause adrenocortical insufficiency and adrenal crisis
SLE patient being treated with chronic corticosteroid therapy suddenly develops a BP of 70/40 and pulse 120/min
What’s going on and what do you expect her CRH, ACTH and Cortisol to be?
Acute adrenal crisis - caused by suppressed HPA axis (values below) that occurs as a result of chronic steroid use - return to normal function takes weeks-months after withdrawal of corticosteroid
CRH = decreased
ACTH = decreased
Cortisol = decreased
These are pathognomonic for which type of vasculitis?
tranasmural inflammation with fibrinoid necrosis
granulomatous inflammation of the media
- tranasmural inflammation with fibrinoid necrosis = polyarteritis nodosa
- granulomatous inflammation of the media = temporal (giant cell) arteritis (giant cells are common in granulomas….duhhhh)
Excess Hydration
Acute Hemorrhage
Chronic Anemia
MI
Anaphylaxis
Anaphylaxis
widespread venous + arteriolar dilation w/ increased capillary permeability and 3rd spacing of fluid; results in a serious drop in VR (shifted down and leftwrd) and an increased cardiac contractility as the body attempts to maintain BP
Excess Hydration
Acute Hemorrhage
Chronic Anemia
MI
Anaphylaxis
increase in blood volume
causes an increase in the circulatory capacity of the system (therefore, increased MSFP)
Excess Hydration
Acute Hemorrhage
Chronic Anemia
MI
Anaphylaxis
acute hemorrhage
decreased blood volume decreases the degree of filling in the circulatory system
Excess Hydration
Acute Hemorrhage
Chronic Anemia
MI
Anaphylaxis
MI
sharp decrease in CO due to loss of function in a zone of the myocardium
Excess Hydration
Acute Hemorrhage
Chronic Anemia
MI
Anaphylaxis
Chronic Anemia
incrase in CO in an effort to meet metabolic demands of the tissues
VR also increases a little bit due to decreased blood viscosity
ligament that attaches to the cervical region of the uterus and extends posteriorly?
ureterosacral ligament
brown pigment gallstones should make you think of….
infection of the biliary tract with either E. coli, Ascaris lumbricoides, or Opisthorchis sinensis
all cause release of ß glucuronidase by injured hepatocytes and bacteria, which hydrolyzes the bilirubin glucuronides and increases the amt of unconjugated bilirubin in bile, leading to an increased risk of developing brown pigment stones
patient w/ HbA = 60% and HbS = 40%
is he homozygous or heterozygous for the sickle cell??
what are they normally protected from?
heterozygous for sickle cell trait
patients w/ sickle cell trait are protected from features that are common to sickle cell disease (sickle cell crises, aplastic crises and sequestration crisis) as well as protection from plasmodium falciparum
Hepatitis virus associated with pregnant woman
Genome of this?
how is it spread?
biggest concern about this?
HepE
ssRNA, unenveloped
spread via F/O
big concern: high mortality rate
Portacaval anastomoses in cirrhosis
Esophageal varices
Hemorrhoids
caput medusae
Esophageal varices = L gastric
Hemorrhoids = superior rectal vein
caput medusae = paraumbilical veins
MoA of sumitriptans?
5HT1B/1D agonist - post-synaptic receptor stimulation to
inhibit trigenminal n. activation (blocks pain pathways in brainstem)
prevent vasoactive peptide release
induce vasoconstriction
32yoF w/ persistent tea-colored and odorless diarrhea has no gastric acid secretion. Somatostatin trmt relieves the diarrhea. Why?
VIPoma - increases Cl loss in the stool, which causes:
- an excess loss of accompanying H2O, Na, and K
- inhibits gastric acid secretion
somatostatin administration inhibits VIP secretion
Top 3 Major risk factors for adenocarcinoma of the pancreas head?
Age (highest incidence at 65-75yo)
Smoking (doubles the risk)
Diabetes (risk increases w/ duration)
diagnosis?
MTB
serpentine cords - indicates the presence of cord factor, which correlates with virulence because it inactivates neutrophils, damages mitochondria, and induces release of TNF
pure RBC aplasia (ie only RBC counts are low; all other cell types are fine) is due to? 3
IgG autoantibodies, cytotoxic T cells, and ParvoB19 that inhibit precursors and progenitors; often associated w/ thymomas & lymphocytic leukemias
definition of dysuria
what is it associated with?
painful urination
associated with UTIs
Best Rx for a patient w/ HTN and concomitant renal insufficiency?
Fenolodopam - selective D1 receptor agonist
D1 receptor stimulation activates adenylyl cyclase and raises intracellular cAMP, resulting in vasodilation of most arterial beds, esp renal + coronary + mesenteric arteries; results in:
causes arteriolar dilation + natriuresis -> decrease SVR + BP
improves renal perfusion
expected ABG of someone with a acute PE?
acute PE -> hypoxemia -> hyperventilate -> respiratory alkalosis
high pH >7.4
low CO2
low O2 (due to VQ mismatch)
HCO3 22-26 (takes a few days for the kidneys to compensate)
pancreatic pseudocyts
occur due to?
are lined by what?
complication of pancreatitis, where the proteolytic enzymes disrput the walls of pancreatic ducts and cause leakage of pancreatic secretions into the peripancreatic space w/ subsequent inflammatory rxn in the walls of the surrounding organs
granulation tissue forms to encapsulate the fluid collection to form a pseudocyst
why is it that patients with Crohns develop multiple kidney stones?
b/c there is reduced CaOx binding within the intestines
why? bc most bile acids are lost in the feces, which impairs fat absorption; excess lipids in the bowel lumen bind to Ca2+ and the soap complexes are then excreted into feces. Free oxalate (normally bound by Ca ions to form an unabsorbable complex) is absorbed, filtered, and forms urinary calculi
why is it that MEN 2A have problems with both pheochromocytoma AND parathyroid gland?
chromaffin cells of the adrenal medulla and parafollicular cells of the thyroid originate from the neural crest cells
hyperacusis is due to?
hyperacusis = increased sensitivity to sound
paralysis of stapedius muscle, which is innervated by CN 7
stapedius stamps on sounds to make it softer.<br></br>staples look like two 7’s put together
∆ btwn clonidine, a-methyldopa, and mirtazapine?
clonidine, a-methyldopa = STIMULATE a2
used in HTN (clonidine) and HTN during pregnancy (a-methyldopa)
mirtazapine = BLOCK a2
used in depression
type of nerve damage in diabetic neuropathy
**ischemia of somatic nerve fibers **
(usually with preservation of parasympathetic fibers)
name the disease where there is pathology in the spinal cord, specifically in:
posterior columns + lateral corticospinal tracts
dorsal columns + dorsal roots of the spinal cord
lateral cortical spinal tracts + anterior horns
anterior horns
- posterior columns + lateral corticospinal tracts = B12 deficiency (or when B12 is given to a folate-deficient patient)
- **dorsal columns + dorsal roots of the spinal cord = tabes dorsalis **
- lateral cortical spinal tracts + anterior horns = ALS
- anterior horns = poliomyelitis
why is methadone the drug of choice for treating heroin addicts and abuse?
potent, long-acting w/ good oral bioavailability
long half life = prolonged effects to suppress withdrawal sx
How are these levels affected by OC use or pregnancy?
TBG
total T4
total T3
free TH
TBG = increased
total T4 = increased
total T3 = increased
free TH = normal
rose-colored spots on the periumbilical area is pathognomonic for which bug?
Salmonella typhi
other fun facts about this bug: carrier state in GALL BLADDER
(think of the spotted salmon swimming in the small fish tank “gall bladder”)
Rx to prevent HIV transmission from infected mother to infant?
ZIDOVUDINE (ZDV, AZT)
nucleoside analog that inhibits RT
which part of the bone aids in the healing of fractures
PERIOSTEUM
contains fibroblasts + progenitor cells that develop into osteoblasts and chondroblasts that aid in healing
treatment of premature ejaculations?
(sucks for the girl….)
SSRI - causes anorgasmnia + delayed ejaculation
