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
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
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)
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>)
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
eye field looks like this:
where is the lesion?
R optic nerve
B
patient has esophageal varices + splenic enlargement + normal liver histology. What’s going on?
portal vein thrombosis
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
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
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)
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
oocyte surrounded by one or several cuboidal follicular cells
secondary follcile
what does this patient have?
mitral regurgitation
what do each one represent?
W = hCG
X = hPL
Y = CRH
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)
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
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
causes of low Ca, low PTH?
Hypoparathyroidism
(surgical removal, autoimmune destruction)
name this please
mucormycosis - broad, non-septate hyphae that branch at right angles
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
diagnose
cowdry type A inclusions - herpes virus
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
MEN 2A
gene mutation?
what does it affect?
activating mutation of RET protooncogene
parathyroids (hyperplasia)
pheochromocytoma
Medullary thyroid cancer (MTC, calcitonin)
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
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
BM that shows this is indicative of…
ALL - hypercellular bone marrow with a high % of lymphoblasts
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
eye field looks like this:
where is the lesion?
optic chiasm
C
What does this represent? (choose one)
Increase preload
Increase afterload
Systolic dysfunction
Increased ejection Fraction
Normal Saline Infusion
Increased preload
cleft lip results when
maxillary prominences fail to fuse properly w/ the intermaxillary segment (philtrum) during early embryonic development
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)
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.
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
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)
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)
diagnose
negri bodies - rabies virus
Which one does this graph represent? (choose one)
Aortic insufficiency
Aortic Stenosis
Mitral Stenosis
Mitral regurgitation
Aortic Insufficiency
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)
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
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)
oocyte surrounded by a single layer of flattened follicular cells
primordial follicle
name this please
aspergillus - acute V shaped angles
dx and tumor marker?
seminoma
elevated levels of placental ALP
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
puncture wound into the posterior fornix of the vagina enters what space
rectourterine space (pouch of douglas) - located between the uterus and rectum
causes of high Ca, low PTH?
PTH-independent hypercalcemia
(e.g., excess Ca2+ ingestion, cancer)
what is the genome of this?
CMV - enveloped dsDNA virus
see epithelial cell w. intranuclear + cytoplasmic inclusions
in the late follicular stage, what happens?
(be specific in terms of cell type + receptors)
granulosa cells increase expression of receptors for LH
HBV antigen that poorly correlates with viral replication
HBsAg - non-infective envelope glycoproteins that forms spheres
What does this represent? (choose one)
Increase preload
Increase afterload
Systolic dysfunction
Increased ejection Fraction
Normal Saline Infusion
Increased ejection fraction
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)
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)
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
Causes of low Ca, high PTH?
2˚ hyperparathyroidism
(vitamin D deficiency, chronic renal failure)
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)
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˚)
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)
urea’s nitrogen is derived from what?
NH3 + aspartate
causes of high PTH, high Ca?
1˚ hyperparathyroidism
(hyperplasia, adenoma, carcinoma)
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
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”
brain histology - what does this patient have?
Pick disease - note the circular cytoplasmic inclusions of the microtubule associated protein tau)
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)
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
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
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
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
dx me please
Aortic dissection
note the cardiomeagly, abnormal aortic contour, wide superior mediastinum
predisposing factors: chronic HTN, marfans
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
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)
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
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
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”)
