Step Flashcards
Most reliable ausculatory finding indicating mitral stenosis severity
A2-OS interval. As the pressure increases it becomes more difficult to push blood out of the LA, so the OS occurs sooner to provide more time to generate the pressure.
Chemoprophylaxis for meningococcal disease, Mechanism
1) Rifampin -penetrates well into all tissues. Inhibits DNA dependent RNA polymerase
2) Ciprofloxacin -risk of CT pathology
3) IM ceftriaxone -pnful route
4) sulfamethoxazole- Resistance
Bounding femoral and carotid pulses w/ head bobbing
Early blowing, diastolic decrescendo murmur best at left 3 or 4 ICS
Aortic Regurgitation
Wide pulse pressure (water-hammer)
Stroke volume increases due to increased preload, when the LV relaxes during diastole blood flows backwards and out of the arteries (collapsing arteries)
Lithium interaction with a hypertensive med leading to nonspecific T wave abnormalities
Hydrochlorothiazide
Volume depletion leads to increased reabsorption of Lithium in the PCT.
Chronic Lithium toxicity DDI
(volume depletion) Thiazides, ACEI, and NSAIDS
confusion, ataxia, neuromuscular excitability
Hyperosmotic volume contraction
osmol increase, ECF decreased, ICF decreased
Diabetes insipidus or decreased fluid intake, increased sweating
Central DI
Decreased ADH released -> water is not reabsorbed and the urine is very dilute
Isosmotic volume contraction
osmol same, ECF decreased, ICF same
osmol same, ECF decreased, ICF same
Acute GI hemorrhage or diarrhea -fluid is only lost from the ECF (blood vessels)
Hyposmotic volume contraction
osmol decreased, ECF decreased, ICF increased
Adrenal insufficency - lack of aldosterone
NaCl not reabsorbed-> ECF decreased.
ECF is low on solutes, so water shifts into cells (ICF)
Hypertonic volume expansion
osmol increased, ECF increased, ICF decreased
Hypertonic saline infusion- ECF volume and osmolarity increase
Water leaves the ICF to dilute the ECF
Hyposmotic volume expansion
osmol decrease, ICF increase, ECF same
Primary polydipsia and SIADH
Increased water intake or reabsorption shifts into ICF to dilute with the ECF staying the same. The increased water leads to overall decreased osmolarity
Onion-like concentric thickening of arteriolar walls
Hyperplastic arteriolosclerosis
Malignant HTN pathology
Homogenous acellular thickening of arteriolar walls
Hyaline arteriosclerosis
Lower HTN
Granulomatous inflammation of the media
Giant cell arteritis
Transmural inflammation of the arterial wall w/ fibrinoid necrosis
Polyarteritis nodosa
Smooth transition for impatient to outpatient
Discharge checklist
Down Syndrome Fetal Markers
AFP low
B-Hcg high
Inhibin A high
Chediak Higashi: What is it? Signs
Microtubule Disorder of neutrophil phagolysosome fusion
Partial albinism, peripheral neuropathy, recurrent pyogenic infxns
Proximal muscle weakness and Gottron’s papules (ertythematous plaques over hand joints)
Dermatomyositis
Dermatomyositis association
Often paraneoplastic to lung, colorectal, and ovarian CA
Blistering cutaneous photosensitivity
Uroporphorinogen decarboxylase deficency
Porphyria cutaenous tardia
Paraventricular tumor
Perivascular rosettes
Ependymoma
Cerebral hemisphere tumor
Hypercellular areas of atypical astrocytes bordering regions of necrosis (pseudopalisading)
Glioblastoma
Cerebellar tumor in kids
Small blue cells surrounding a neurophil
Homer-Wright Rosettes
Medulloblastoma
White matter of cerebral hemispheres
Round nuclei w/ halo of clear cytoplasm (Fried egg cells)
Oligodendroglioma
Cerebellar tumor in kids
eosinophilic granular bodies and elongated hairlike fibers (Rosenthal fibers)
Pilocytic astroocytoma
Spindle cells w/ palisading nuclei arranged around Verocay bodies composed of eosinophilic cores (antoni A)
Cerebelloponite angle
Schwannoma
Benign suprasellar tumor in kids
cords/nests of palisading squamous epithelium w/ internal areas of lamellar “wet keratin”
Adamantinomatous craniopharyngioma
Moldy grains in China w/ substance causing G to T mutation in p53 increase risk of what cancer?
Aflatoxins from aspergillus -> increased risk of HCC
Lac P
Promoter region where RNA polymerase binds
Lac I
gene for repressor -binds operator to prevent RNA polymerase binding. Constitutively on
Lac O
Operator- where the repressor binds, downstream of promoter region
Lactose (inducer)
Binds to the repressor to prevent it from binding to the operator and preventing RNA polymerase
Lac operon regulation
1) negative - repressor binds to operator preventing RNA polymerase from binding the promoter
2) cAMP-CAP binding upstream from the promoter. High glucose-> decreased cAMP.
Low glucose-> high cAMP-> binding to CAP-> cAMP-CAP binding to promoter
Patient is using herbal supplements that have not caused them SE
Advise on safety, quality, and efficacy
Conduct Disorder vs. Antisocial personality disorder
Conduct before 18, antisocial after 18
Persistent pattern of violating societal norms and other’s rights
Ligated IMA, which artery provides collateral circulation to the descending colon (not rectum)
SMA via marginal artery of Drummond
AIDS pt w/ working memory problem, executive dysfxn, and slow information processing
HIV associated dementia
HIV associated dementia histology
Microglial nodules, groups of activating macrophages and microglial cells around small areas of necrosis. They may fuse to form multinucleated giant cells
Mycobacterial Drug resistance due to non-expression of catalase-peroxidase enzyme
Resistance to INH. INH must be processed by mycobacterial catalase-peroxidase to be activated
Post-streptococcal glomerulonephritis complication risk increases for which pts?
Adults have poor prognosis due to higher risk of chronic HTN and renal insufficiency
Enzyme deficiencies of early steps in porphyrin synthesis
Neuropsych w/o photosensitivity due to metabolite accumulation
Uroporphyrinogen decarboxylase deficiency
Vesicles and blisters on sun exposed areas, edema, pruritus, pain, and erythema
Inflammatory arthritis, ulcer of the hard palate, butterfly rash
SLE-
ANA, anti-smith (spliceosome snRNP), anti-dsDNA
ALS microscopic
Loss of anterior horn - LMN lesions - muscle weakness and atrophy
Demyelnation of lateral corticospinal tracts - UMN lesion -spasticity and hyperreflexia
Can affect CN 5,9,10,12
ALS mutation
SOD1 -gene that codes for copper-zinc superoxide dismutase
Synovial WBC >100,000 and no crystals
Septic arthritis Tx w/ abx to prevent joint destruction, osteomyelitis, and sepsis
Acutr tx of gout when pt has peptic ulcer dz
Colchicine
Colchicine mechanism
Binds to intracellular tubulin and inhibits MT polymerizaton. Disrupts chemotaxis and phagocytosis
Colchicine SE
diarrhea, nausea, abd pn
Primary biliary cirrhosis classic pt
Pruritus and fatigue in middle aged woman
Cholestasis - jaundice, pale stool, dark urine
hypercholesterolemia - xanthelesmas
What does spironolactone due with K and H
Spironolactone blocks Na reabsorption and increases K and H reabsorption.
Fewer hydrogen ions are secreted from the collecting tubules
PCT osmolarity
300 isotonic w/ plasma regardless of final urine concentration
Descending loop of Henle osmolarity
Water leaves the tubule and the filtrate becomes concentrated, >300. ADH is high it will =1200
Ascending loop of henle osmolarity
Water comes back in to dilute the filtrate. <300
Distal convoluted tubule osmolarity
Most dilute section, impermeable to water, 100 osmol
Collecting duct osmolarity
Water leaves the tubule to dilute the hypertonic interstitium. So the somolarity is around 1200
Thyroid cytology - clusters of overlapping cells w/ large nuclei containing sparse, finely dispersed chromatin
Intranuclear inclusion bodies and grooves
Thyroid papillary carcinoma
Ground glass -Orphan Annie eyes
Psammoma bodies
Thyroid cytology - markedly pleomorphic cells, including irregular giant cells and biphasic spindle cells
Anaplastic cancer
Thyroid cytology - colloid nodule
Benign hyperplasia
Thyroid histology- Polygonal to spindle shaped cells w/ slightly granular cytoplasm.
Stains for calcitonin.
Adjacent amyloid deposits
Medullary thyroid cancer - from parafollicular C cells
MEN 2A and 2B
Homeless male w/ abd pn,
Develops acute confusion, nystagmus and b/l abducens palsy
b/l lesions in the mamillary body and Periaqueductal gray matter in the hospital
Wernicke’s encephalopathy triad - ataxia, ophthalmoplegia, confusion
Thiamine deficient pt given glucose
Develop Wernicke encephalopathy -added glucose worsens thiamine deficiency. Thiamine is cofactor for glucose metabolism (decarboxylase rxns)
Car accident pt develops excessive thirst and frequent urination that continues weeks later
Central DI - hypothalmic nuclei injury. Posterior pituitary injury would be transient
How is INH metabolized?
Acetylation to N-acetyl-INH
Bimodal distribution of metabolism
Fast and slow acetylators
Large mass surrounding the intestines
Uniform, round, medium-sized tumor cells w/ basophilic cytoplasm and proliferation fraction (Ki-67 fraction) of >99%
EBV - Burkitt Lymphoma (starry sky)
Chronic non-atrophic gastritis affecting the antrum: cause
H. Pylori infxn
Atrophic chronic gastritis of the body
Pernicious anemia
Most common benign liver tumor
Cavernous hemangioma - cavernous blood filled vascular spaces lined by a single epithelial layer
Which liver tumor can regress w/ d/c OC
hepatic adenoma
NOD2 mutation -> NF -KB decrease. What will be impaired
Cytokine production will be impaired -> impaired innate barrier fxn
Bugs get in and cause exagerated immune response
Fever, neuro sx (progressive lethargy), renal failure, anemia, and thrombocytopenia in setting of GI illness
Classic pentad of thrombocytopenic thrombotic purpura
Plt activation in arterioles and capillaries
Diffuse microvascular thrombosis
Microangiopathic hemolytic anemia w/ schistocytes
Thrombocytopenia
Clinical and pathologic features of thromobocytopenic thrombotic purpura
S-shaped bacteria causes decreased somatostatin-producing antral cells, what will this lead to
Duodenal ulcer as decreased somatostatin will lead to decreased inhibition of gastrin. The loss of somatostatin does not lead to gastric lymphoma, even though MALTs are possible with prolonged infxn
s/p coronary artery stent, livedo reticularis, hx of hyperlipidemia and CAD. What does biopsy of the kidney look like?
Cholesterol clefts in the arterial lumen. Cholesterol debris gets lodged leaving needle shaped clefts in intralobular renal arteries
Polycystic kidney dz w/ bone pn and weakness - Levels of Phosphate, PTH, and Calcitriol
-Phosphate is increased due to decreased GFR (less phosphorus filtered)
-Calcitriol is decreased, Hyperphosphatemia stims osteoclasts to secrete FGF, which is meant to decrease Phosphate reabsorption, but also decreases calcitriol synthesis
PTH is increase due to low Ca and high phosphate
Pulmonary histology - columnar mucin secreting cells that line the alveolar spaces w/o invading the stroma. How would you classify?
Malignant neoplasm, adenocarcinoma in situ (formerly bronchioalveolar carcinoma)
Why does a rt mainstem bronchus obstruction present as a u/l completely opacified lung
All of the alveoli collapse (atelectasis) - there is no air in the lung. It condenses into what looks like a solid organ.
Why is pancreatitis a risk factor for ARDS?
Pancreatitis leads to release of inflammatory cytokines and pancreatic enzymes that lead to neutrophils attacking the pulmonary interstitium and alveoli
ARDS Pathology
interstitial and alveolar edema, inflammation, and fibrin deposition cause the alveoli to become lined with waxy hyaline membranes
ARDS impact on the lungs: capillary permeability, lung compliance, WOB, V/Q match, PCWP
Decreased capillary permeability-> edema and decrease lung compliance, increased WOB, and atelectasis->V/Q mismatch, not ventilated, but perfused (shunt)
PCWP is NL
Why is Pulmonary capillary wedge pressure NL in ARDS
Noncardiogenic pulmonary edema
The problem is in the lungs not the heart, so the LA pressure is NL
Bright red hematemesis, splenomegaly, no liver biopsy abnormalities
Hepatic vein thrombosis - The obstruction is before the liver, so it is not affected. Blood spills back into anastamoses w/ systemic circulation
Budd-Chiari liver biopsy
Occlusion of hepatic vein leaving the liver. Centrilobular congestion and fibrosis
Porcelain gallbladder pathology
Chronic cholecystitis. Dystrophic intramural deposition of Ca salts.
Porcelain gallbladder increases risk of what?
Galbladder adenocarcinoma
Anti- tissue transglutaminase, where do you biopsy to confirm dx?
Celiac dz, biopsy the duodenum.
Duodenum and jejunum see highest level of gliadin
Crohn dz, where do you biopsy?
terminal ileum
Ischemia induced ventricular arrhythmias, tx w/?
Class IB antiarrhythmics,
mexiletine
lidocaine
Weakest Na channel blocker, dissociates the fastest, small effect on QRS, prefer inactivated channels
Class IB antiarrhythmics
mexiletine
lidocaine
Hypotension baroreceptor response
Low BP -> decreased stretch -> decreased baroreceptor signal -> increased SNS stimulation -> increased HR, increased contractility, increased bp
HTN baroreceptor response Carotid massage
High BP -> increased stretch -> increased baroreceptor signal -> increased PNS stim -> decreased HR, decreased contractility, decreased bp
Arteriolar vasodilators
minoxidil and hydralazine
SE of hydralazine and minoxidil
Na and fluid retention
Arteriolar vasodilators cause hypotension -> decreased stretch -> increase SNS -> increase RAAS -> increased Na and water reabsorption
Maintenance dose formula
MD = (Cpss X Cl)/bioavailability fraction
Half life formula
t1/2= (0.7 X Vd) / Cl
Loading dose formula
LD = (Cpss X Vd)/ bioavailability fraction
Overweight woman OD on antiseizure meds w/ PMH of abortion of fetus w/ spina bifida. She is confused. What lab abnormaltiy would you expect?
Increased liver transaminases. Rare, but fatal hepatotoxicity (measure LFTs)
Would cause respiratory depression -> respiratory acidosis
Valproic acid SE
Teratogenic -NTD Hepatotoxicity Pancreatitis tremors wt gain
Mechanism of nitrates
NO activates guanylate cyclase -> increased cGMP-> activates myosin light chain phosphatase (MLCP) -> vascular smooth muscle relaxation
Also increased cGMP decreases intracellular Ca
NL Smoothe muscle contraction
Ca flows in and binds to myosin light chain kinase (MLCK) -> smooth muscle contraction
Phentolamine mechanism
Blocks alpha 1 -> vasodilation
Class 1 Na channel binding strength
1C>1A>1B
1B has the weakest Na binding. Dissociates quickly. Prefers ischemic tissue due to delayed switch from inactivated to resting state
Class 1C properties
Most use dependence
Has the greatest binding to Na channels
Slow dissociation allows the effects to accumulate -> arrhythmias
Opioid MOA - pre-synapse
Opiods bind to Mu receptors on presynaptic - block Ca channels -> decreased Ca-> decreased NT release
Opioid MOA post synapse
Bind to Mu receptors
Stimulate K efflux out of the cell -> hyperpolarization ( less likely to depolarize
Increased release of DA and NE from presynaptic nerve terminals. SE due to increased NE. Which sympathetic output will be affected: adrenal, eccrine sweat glands, bladder?
Sympathetic output to the bladder will be most affected.
Eccrine sweat glands and the adrenals get Ach released presynaptically to stimulate them. Other visceral organs get NE released presynaptically to stimulate them
Acute MI tx leads to wheezing. Which part of NT release is affected?
Epi is prevented from binding to B2-R to stimulate bronchodilation
B blockers block B2 -> bronchoconstriction -> asthma exacerbation
Nitroglycerin primarily affects which vessels
Large veins
Primary venodilator -> decreased preload
Constipation, bradycardia, AV block, and worsening heart failure after Afib txmnt
nondihydropyridine CCB (diltiazem and verapamil) SE AV block (chronotropic effect) worse Hf- negative inotropic effect
Dilitiazem and verapamil MOA
Block L-type Ca channels-> decrease phase 0. Slow Av conduction -> AV block
Canagliflozin MOA
blocks SGLT, which normally would reabsorb glucose
What should be checked before starting canagliflozin?
Check serum CR, should be avoided in pts w/ moderate or severe renal impairment
SE of SGLT inhibitors
UTI, increased sugar in the urine for bugs
Pt undergoes general anesthesia and has fever, jaundice, tender HM, centrilobular necrosis, and elevated LFT, and bili. What med caused this?
Desflurane, halothane, enflurane
Metabolized by CYP450 in the liver that creates active metabolites or immune-mediated hepatocellular damage
anti-u1RNP
MCTD -mixed connective tissue dz
Mixed connective tissue disease
Sx of SLE, systemic sclerosis, RA and polymyositis
Anti-La
anti SSB
Sjogren’s
anti ro
anti-SSA
Sjogrens
Pulsus alterans: What is it? What causes it?
Beat to beat variation in pulse amplitude
Commonly severe LV dysfxn
Dicrotic pulse: What is it? What causes it?
Pulse w/ 2 peaks, 1 for systole and 1 for diastole
Severe systolic dysfxn and high systemic arterial resistance
Hyperkinetic pulse: What is it? What causes it?
Rapidly rising pulse w/ high amplitude. Large SV against decreased afterload
Aortic regurg, AVM
Pulsus parvus et tardus What is it? What causes it?
Diminished SV (parvus) and prolonged LV ejection time (tardus) LVOT obstruction - Aortic stenosis
What causes angioedema in a woman who just started taking lisinopril?
ACEI leads to increased bradykinin, which increases vascular permeability
What should you suspect in a kid w/ angioedema?
C1 esterase inhibitor deficiency. Complement is hyperactive-> unregulated activation of kallikrein-> increased bradykinin
Kawasaki dz complication
coronary artery aneurysms
Rt arm and rt side of face swelling
Brachiocephalic vein obstruction
Face and arms swelling b/l
SVC syndrome
What defects can lead to a paradoxical embolus?
PFO, ASD, VSD
Why does a reperfusion injury lead to increased creatinine kinase
The cell membrane is damaged by reactive oxygen species and creatinin kinase is able to leak out of the cell
Murmur at the apex radiates to the axilla
Mitral regurg. The blood flows back to the pulmonary vessels
Murmur at the RSB radiates to the neck
Aorti stenosis- Increased flow of blood out to the carotids
Aorti regurg sound
Diastolic high pitched=twangy
“blowing” murmur. The blowing is subtle
What is transthyretin’s normal role?
Transport thyroxine and retinol
What can a mutation of TTR lead to?
Transthyretin can then misfold and become an amyloid that causes restrictive dz in the heart
3 day onset of progressive cough, orthopnea, dyspnea, and LE edema
Acute decompensated heart failure
CXR: Cephalization of pulmonary vessels, perihilar alveolar edema (batwing), costophrenic angle blunting, Kerley B lines
Acute decompensated heart failure w/ secondary pulmonary edema
Causes of ADHF
MI, severe HTN, valvular abnl, arrhtymias, cocaine
AV Fistula - Preload and afterload
Preload is increased - more blood coming back to the heart
Afterload is decreased - the fistula allows for some of the arterial pressure to be transferred to veins
What medication can increase peripheral vascular resistance, increase systolic bp, decrease pulse pressure, and decrease HR?
Phenylephrine (Alpha 1 agonist)
Vasoconstricts to increase peripheral resistance and systolic bp.
The HTN is sensed by baroreceptors, which activate PNS to decrease HR and SV -> decreased pulse pressure (smaller difference btwn systolic and diastolic)
What is decreased in the post-synaptic cells of pts w/ Myasthenia gravis?
The have Ab against Ach-R, so fewer ACh-R exist (removed due to complement) -> decreased motor end plat potential. A synapse still has the same potential, but the potential of the whole end-plate is reduced.
What would you use to improve diarrhea, nausea and abd cramping in a MG patient given pyridostigmine?
Scopolamine (anti-cholinergic)
Pilocarpine MOA
Muscarinic agonist
Hyoscamine MOA
Muscarinic antagonist like scopolamine
Carbonic monoxide findings: Carboxy Hgb, PaO2, methemoglobin
Carboxy Hgb increased
PaO2 NL
Methemoglobin NL
What can cause methemoglobinemia?
Dapsone (Dihydropteroate synthesis inhibitor-similar to sulfonamides. Use in leprosy), nitrites
RPF equation
RPF = RBF X (1-hematocrit)
Length constant of an AP?
Distance at which the originating potential decreases to 37% of its original amplitude
What does myelination do to the length constant?
Myelination lengthens the length constant so that a potential can get farther before it dissipates
Why would you hypoventilate a pt w/ cerebral edema?
Hypoventilation would decrease PaCO2, which is a potent vasodilatoer. Decreasing PaCO2 -> vasoconstriction and increased cerebral vascular resistance, Preventing further edema
Major causes of hypoxemia:
alveolar hypoventilation
NL A-a gradient, there is not enough O2 inspired in the air
Cause of hypoxemia:
V/Q mismatch
Increased A-a gradient. Obstruction in airway leads to decreased ventilation w/ NL perfusion
Cause of hypoxemia: Diffusion impairment
ie. alveolar hyaline membrane dz. Diffusion is prevented by a thickened alveolar capillary membrane
Cause of hypoxemia: right to left shunt
Deoxygenated blood from the right heart flows into systemic circulation -> decreased PaO2
In what cases is PaO2 decreased?
It is decreased in high altitude. There is less oxygen in the blood. Anemia, CO, and CN poisoning have nl PaO2
In what cases is SaO2 decreased?
CO poisoning and high altitude
CO competes with the O2 binding
High altitude there is just very little O2 to bind
Nl in anemia, CN poisoning, and polycythemia
In what cases is oxygen content (Hgb content and oxygen saturation) decreased?
High altitude - low O2 able to bind available Hgb
CO poisoning - Hgb is bound to CO, so very little O2 is bound to Hgb
Anemia - There is a low amount of Hgb, so even though O2 may be available there isn’t Hgb to bind to
Conductive hearing loss in right ear (describe PE)
BC>AC -abnl Rinne. The ear drum does not vibrate when the fork is put in the air, but does vibrate when put on the mastoid bone.
Localize to the right - Weber
The rt ear does not get ambient noise conduction and so it is better able to hear the resonation through bone
Sensorineural hearing loss on the right ear
AC> BC - NL Rinne Test. The nerve hears the sound just as poorly from the ear drum as direct contact
Localizes to the left -Weber
The rt ear has a damaged nerve, so it does not transmit the nerve impulse from bone conduction as well as the Nl ear
K percentages in Bowman’s, PCT, ascending loop, and collecting duct in NL person
Bowman’s -100%
PCT- 35%
Ascending- 10%
Collecting duct - 110%
What kind of receptors are Ca sensing receptors? What is a disorder of these receptors?
GPCR
Familial hypocalciuric hypercalcemia
Ca binds to CaSR and inhibits PTH Normally
Intrinsic Tyrosine kinase Receptors
Insulin
IGF- Insulin like growth factor
JAK STAT receptors
EPO
GH
cytokines
PRL
Marker of osteoblast activity
Bone specific alkaline phosphatase- synthesizing bone matrix leads to release of alkaline phosphatase
Markers of osteoclast activity
Tartrate resistant acid phosphatase
Urinary hydroxyproline
Urinary deoxypyridinoline
What does increased lung volume due to alveolar resistance?
Increased lung volume lengthens and narrows the alveoli - > increased alveolar vessel resistance
What does decreased lung volume due to extra-alveolar resistance?
Decreased lung volume
Extraalveolar lung vessels narrow due to chest cavity compression -> increased extra-alveolar resistance
Pulmonary vascular resistance equation
PVR= alveolar + extra-alveolar resistance
increased or decreased lung volumes increase PVR, lowest at FRC
RBF equation
RPF/ (1-hematocrit)
Deficient IL-12 would lead to a decrease in which cells and what cytokine could make up for it?
IL-12 activates Th1 cells. You could give IFN-gamma, which helps stimulate differentiation to Th1 and also is secreted by Th1
Nitroprusside’s effects on preload and afterload
Nitroprusside decreases preload and afterload through equal arteriole and vein dilation
Oval or round yeasts inside macrophages, Many small yeasts
Histoplasmosis is smallest btwn blasto and coccidiodes
Milrinone MOA
PDE-3 Inhibitor
Cardiac - Increased cAMP leads to increased cardiac muscle contraction
Vasculature - Increased cAMP leads to vasodilation
Which med would cause a greater increase in QRS complex at a higher HR?
Class 1C has the greatest use dependence. Will block Na channels more rapidly at higher HR and lengthen the QRS more at higher HR
22 yo ruptured cerebral anuerysm w/ extensive intracranial hemorrhage? Most likely congenital cardiac anomaly/
Adult type Aortic coarctation
increased risk of berry aneursyms and aortic HTN
Hyperlipidemia drug causes flushing, what mediates the SE?
Niacin causes flushing via PGD2 and PGE2. Give aspirin (Cox inhibitor) before niacin to decrease flushing
How to prevent Group B strep in an infant?
There is no vaccine for GBS. You give the mom ampicillin to clear the infxn during pregnancy
Bosentan MOA
Endothelin receptor antagonist. Blocks vasoconstricting effects of endothelin
Bosentan used for?
Idiopathic Pulmonary artery HTN
What pt dz would cause anaphylaxis when giving O negative RBCs?
IgA deficiency
Develop IgE against IgA (anti-IgA). The RBCS may have a small amount of IgG that triggers anaphylaxis
Chronic rejection of a lung allograft damages where?
Small airways, Bronchiolitis obliterans. Solid organs-vascular obliteration
Which segment in the lungs has the greatest airway resistance?
The medium sized bronchioles - due to highly turbulent flow
Which segment has the lowest airway resistance?
Terminal bronchioles - increased cross-sectional area
Cough reflex afferent and efferent
Afferent is internal laryngeal n. (sensory-branch of CN 10) in piriform recess
Efferent is CN 10
Hyperoxia in COPD pt leads to what effect on V/Q?
Hyperoxia leads to vasodilation, which creates alveoli that are now ventilated with poor perfusion. Increased physiologic dead space
Hypoxia affect in COPD on vasculature
Hypoxia causes vasoconstriction of vessels supplying alveoli w/ low O2 content, perfusion is saved for the alveoli that are well ventillated
Whats causes a brown pigment stone?
Biliary tract infxn
Injured hepatocytes and bacteria release beta-glucuronidase, which breaks down bilirubin glucuronide ->increased Unconjugated bili
What causes black pigment stones?
Chronic hemolysis (SCA or spherocytosis) Ileal dz - increased enterohepatic cycling of bili
Inhibition of 7 alpha hydroxylase, what drug and MOA?
Fibrates inhibit 7-alpha-hydroxylase
Reduce conversion of cholesterol to bile acids -> lower solubility of cholesterol stones
What kind of liver dz has decreased serum albumin?
Chronic end stage liver dz
The remaining hepatocytes have reduced fxn, albumin has long half life (20 days)
What kind of liver dz causes distended abdominal veins, ascites, and palmar erythema?
End stage liver dz (cirrhosis), due to portal HTN and increased estrogen
What kind of liver dz causes splenomegaly?
Portal HTN causes blood to flow to Splenic vein since portal vein is blocked
What kind of liver dz causes a prolonged PT time, elevated aminotransferases, leukocytosis, and eosinophilia, and NL albumin?
Acute fulminant hepatitis
Halothane hepatotoxicity is indistinguishable from acute fulminant viral hepatitis on histology
Pt has any kind of surgery somewhere besides USA and develops and dies from liver issues. What pattern of injury?
Hepatocellular pattern
Rapid liver atrophy (shrunken)
Hepatocellular pattern of injury on histo
Widespread centrilobular necrosis
Inflammation of the portal tracts and parenchyma
Mechanism of halogenated anesthetic heptotoxicity
Hypersensitivity to the drug causes immune mediated attack against hepatocytes
Nerves innervating EAC
Posterior is auricular branch of vagus, and the rest is auriculotemporal of mandibular (V3)
Medical Tx of biliary colic
Ursodeoxycholic acid (hydrophilic bile acids) increase bile solubility and reduce cholesterol secretion
Cholestyramine and risk of gallstones
No net risk
Decrease enterohepatic recirculation of bile acids (less soluble cholesterol increased risk)
Stim conversion of cholesterol to bile acid and increase gallbladder motility (decreased risk)
Fibrate MOA
Upregulate LPL -> clear LDL
Activate PPAR-gamma to increase HDL synthesis
Inhibit 7-alpha-hydroxylase -> decreased conversion of cholesterol to bile acid (increased cholesterol stone risk)
Diphenoxylate MOA
Mu opioid -decrease GI motility
What drugs is diphenoxylate combine with? Why?
It is combined w/ atropine to cause dry mouth, blurry vision, and nausea (anticholinergic) at high doses to discourage excessive use
Meperidine MOA
Mu opioid- decrease GI motility
Loperamide MOA
Low dose Mu opioid agonist
Hepatic abscess via hematogenous seeding, what bug
Staph Aureus
Total gastrectomy requires lifelong administration of?
Vitamin B12 (water soluble) Lack of IF to bind B12 and facilitate absorption
Kid gets recurring giardiasis what enzyme will be deficient due to inflammation and infxn?
Secondary lactase deficiency
Also possible w/ celiac dz
Theophylline MOA and toxicity
PDEI - similar to cortical stimulant effects of caffeine, used for bronchodilation
Can cause sz and tachyarrhythmia due to caffeine like effects
Months of fatigue, rash (worse after hot showers), flushing, abd cramps, dizziness, syncope, and mast cells positive for KIT
Systemic mastoytosis
Increased mast cells w/ KIT (tyrosine kinase) mutation. Excessive tryptase and histamine
What does excess histamine cause in systemic mastocytosis?
Syncope, flushing, hypotension, pruritus, urticaria, and increased gastric acid secretion
What is the mechanism behind Zenker’s diverticulum?
Cricopharyngeal motor dysfxn
Cricopharyngeus doesn’t relax leading to increased oropharyngeal intraluminal pressure-> herniation-> false diverticulum
Anti-mitochondrial Ab
Primary biliary cholangitis
Lymphocytic infiltration and destruction of small intrahepatic bile ducts (2 possible causes)
Primary biliary cirrhosis
Graft versus host dz
Acetaminophen OD histo
Centrilobular necrosis that can extend to include the entire lobe
Acetaminophen OD tx
N-acetyl-cysteine, regenerates the decreased glutathione
Acetaminophen common drug name and where it acts
Tylenol, mostly in the CNS Cox3, less GI SE
Acetaminophen OD pathology
Acetaminophen metabolite (NAPQI) depletes glutathione and forms toxic byproducts in the liver
Hepatocellular swelling and necrosis, Mallory bodies, neutrophilic infiltration, and fibrosis. What caused this?
Alcoholoic hepatitis
What is a mallory body?
Cytoplasmic inclusion in heptocytes made up of damaged intermediate filament
Hepatomegaly w/ tense capsule and reddish-purple parenchyma, severe centrilobular congestion and necrosis
Budd-Chiari Syndrome
Hepatic vein obstruction
Non-inflammatory hepatocyte necrosis w/ fibrosis
Hemochromatosis
Liver histo - Panlobular microvesicular steatosis
Reye Syndrome
What is reye syndrome?
Give aspirin to a kid w/ a viral infxn
encephalopathy and liver dz
Reye syndrome mechanism
Aspirin metabolites decrease beta oxidation by reversible inhibition of mitochondrial enzymes
Reye Syndrome findings
Mitochondrial abnormalities, microvesicular fatty liver, hypoglycemia, vomiting, hepatomegaly, coma
What viruses is Reye syndrome associated with?
VZV and Influenza B
Pernicious anemia effect on gastrin, gastric pH, and parietal cell mass
Parietal cell mass low -> decreased gastric acid (high gastric pH) and decreased IF (B12 deficiency)
Leads to increased gastrin secretion from gastric G cells
What part of HDV life cycle is supported by previous HBV?
HBV provides the coating of HDV particles allowing it to penetrate a hepatocyte
Name products of TCA cycle
Pyruvate -> acetyl CoA-> citrate->isocitrate->alpha-ketoglutarate->succinyl Coa->succinate-> fumarate->malate-> oxaloacetate
Pyruvate kinase
PEP to pyruvate
Pyruvate dehydrogenase and what cofactors are required
Pyruvate to acetyl CoA
requires thiamine (decarboxylase)
B2-riboflavin, B3- niacin, B5-pantothenic acid, lipoic acid
Citrate Synthase
Oxaloacetate + acetyl CoA to citrate
Aconitase
Citrate to isocitrate
Isocitrate dehydrogenase
What Cofactor
Isocitrate to alpha-ketoglutarate
requires niacin as NAD+ -> NADH
Alpha-ketoglutarate dehydrogenase. What cofactors?
Alpha-ketoglutarate to succinyl CoA
Requires Thiamine(B1)
B2-riboflavin, B3-niacin (NAD+-> NADH), B5-patothenic acid, and lipoic aicd
Succinate thiokinase
Cofactor
AKA Succinyl-CoA synthetase
Succinyl-CoA to succinate
Requires GDP-> GTP
Succinate dehydrogenase
What Cofactor
Succinate to fumarate
Requires B2-riboflavin
FAD+->FADH
Fumarase
Fumarate to malate
Malate dehydrogenase
Cofactor?
Malate to oxaloacetate Requires niacin (NAD+-> NADH)
Pyruvate carboxylase
Cofactor?
Pyruvate to oxaloacetate for gluconeogenesis Requires Biotin (carboxylase)
What are the defense mechanisms against giardiasis?
IgA prevents adherence
and CD4 Th Cells
2 Major causes of polyhydramnios
Impaired fetal swallowing or increased fetal urination
2 main Causes of decreased fetal swallowing leading to polyhydramnios
GI obstruction - esophageal, duodenal, or intestinal atresia
Anencephaly - No brain to coordinate swallowing
Pregnant pt w/ epilepsy what is the baby at risk for
Valproate, carbamazepine, phenytoin -> increase risk of NTD
Pulmonary hyoplasia is cause or result of what?
It is a result of oligohydramnios, possibly due to renal agenesis. Low volume of urine made leads to low amount of amniotic fluid-> poor lung development
Ipratropium MOA
Anti-muscarinic - bronchodilation
Magnesium sulfate in asthma MOA
Inhibits Ca influx -> bronchodilation
Stabilizes T cells
Inhibits mast cell degranulation
What does pulmonary edema due to compliance and surface tension, and FRC?
Fluid in the alveoli increases air resistance -> decreased compliance
Surface tension increases w/ fluid in the alveoli->decreased compliance-> alveoli more likely to collapse -atelectasis
The decreased compliance means the lungs can’t fill as well-> decreased FRC and decreased TLC
Atrialization of the right ventricle (Epstein’s anomaly) is associated with what med?
Lithium used for bipolar
General classes used to treat bipolar disorder, schizophrenia, and epilepsy
Bipolar - lithium and mood stabilizers like valproic acid, carbamazepine, and atypical antipsychotics
Schizophrenia - antipsychotics (haloperidol, fluphenazine) atypicals (aripiprizole, clozapine)
Epilepsy (valproate, phenytoin, carbamazepine)
Bipolar tx
Lithium
Carbamazepine
Valproate
Atypical antipsychotics(aripiprazole and zapines)
Schizophrenia Tx
Haloperidol, fluphenazine
atypical - apiprazole, clozapine
Epilepsy Tx
Valproate, carbamazepine, phenytoin
Child has vascular lesions w/ IgA and C3 deposition
Henloch Schonlein Purpura -
Purpuric rash (butt)
colicky abd pn, polyarthralgia
Vasculitis: Saddle nose and olguria
Granulamatosis with polyangitis
Vasculitis: Weak upper extremity pulses
Takayasu arteritis - aorta and its branches
Vasculitis: HA and blurred vision
GCA
What cells release histamine and tryptase?
Histamine- basophils and mast cells
Tryptase - Mast cells only
Multiple cystic edematous hydropic villi, P57 negative
Complete mole,p57 negative=absence of maternal genome, all dad
Carcinoembryonic antigen
colorectal maliignancy
CA-125
Ovarian CA
Sarcoma botryoides in a young girl
Bunch of grapes out of vagina
rhabdomyosarcoma arising from the bladdeer or vaginal mucosa
CA 19-9
Pancreatic CA
C3b fxn
Opsonin and activates MAC
5-HETE (5-hydroxyicosatetraenoic acid) fxn
LT and lipoxin precursor
Neutrophil and Macrophage chemotaxis
Neutrophil degranulation
C5A fxn
Chemotaxis and increased phagocytosis directly
LTB4
Chemotaxis
Opsonins
IgG, C3B, CRP, and mannose binding lectin
Which hormones have the same alpha subunit?
Hcg, TSH, FSH, LH
Which hormones have beta subunits with significant homology?
Hcg and TSH
Painless scrotal mass, increased sweating and heat intolerance, increased T4 and T3, hypoechoic mass w/in the testicle
Testicular germ cell tumor secreting Hcg which can bind TSH -R if excessive enough
How do cancers met to the skeletal system?
Hematogeneous spread not lymphatic
Prostatic venous plexus receives blood from where?
Prostate, penis, bladder
Preventable adverse event
Harm to pt due to failure to follow EBM
Near miss
No harm to pt, prevented before harm could take place
Atypical endometrial cells, disorganized glands, and multiple mitoses
Endometrial adenocarcinoma commonly in post-menopausal women
Dilated, coiled endometrial glands and edematous stroma
Common during the luteal phase
Pathologic- ectopic pregnancy will stimulate this luteal phase due to the corpus luteum, but no implantation in the uterus
Enlarged chorionic villi and avascular edematous stroma
Molar pregnancy
Inflammatory infiltration of endometrial glands
Endometritis -infxn of the decidua
Straight, short endometrial glands, and compact stroma
Proliferative phase of the menstrual cycle
Anaphylactic schock tx
1-epinephrine - Alpha 1 vasoconstricts to increase bp
B1- Increases cardiac contractility, HR, and AV conduction
B2-bronchodilates -improving breathing
2-Diphenhydramine
Why not use NE to tx anaphylaxis?
Mostly an alpha 1 agonist - high vasoconstriction can limit CO stimulate carotid sinus to decrease bp and HR
Aspirin intoxication (acute salicylate toxicity) ABG
1) Respiratory alkalosis - stim medullary respiratory center to increase ventilation leading to decreased PaCO2
2) After 12 hrs - metabolic acidosis- salicylates uncouple oxidative phosphorylation leading to increased organic acids-> decreased bicarb
Aspirin intoxication ABG
1) 1st 12 hours respiratory alkalosis, pH up, PaCO2 down, HCO3 NL
2) after 12 hours mixed respiratory alkalosis and metabolic acidosis
pH close to NL, PaCO2 down (not compensated), HCO3 down
Layers in cricothyrotomy
Skin
superficial cervical fascia (SQ fat and platysma)
Deep cervical fascia (investing and pretracheal layers)
Cricothyroid membrane
What is RT-PCR used to detect?
mRNA, you take the RNA and RT back to DNA (cDNA) and make copies of mRNA containing exons w/o introns
CML RT-PCR
would show mRNA with both BCR and ABL exons
What do Southwestern blots detect?
Proteins that bind DNA
What does RAS code for?
Codes for GPCR, activates MAP kinase pathway -> affects transcription
What are c-Jun and c-Phos?
Nuclear transcription factors that bind DNA via a leucine zipper motif
Proto-oncogenes
S-100 marks waht cells?
Neural crest cells
Melanocytes, Schwann cells, Langerhans (DC)
Why eat carb rich food before workout?
Increased Ca release from SR->activate phosphorylase kinase to stim glycogen phosphorylase to break down glycogen
Synchronizes muscle contraction w/ glycogen breakdown, less anaerobic metabolism
3 fluid compartments and volumes
Total body water = 41 L
ECF= 14L
Plasma 3L
Low molecular weight molecule, which compartment
ECF 14L
Lipophilic molecule, which compartment
Total body water 41L
Not bound to albumin
Not in Plasma, ECF or TBW
Most abundant AA in collagen
glycine (Gly-X-Y)
also proline and lysine
DNA Pol I
Old school, It synthesizes the lagging strand and has 5’-3’ and 3’ to 5’ exonuclease proofreading
DNA pol III
New kid, Synthesizes leading strand and has 3’-5’ exonuclease proofreading
To avoid wrong site surgery
2 separate people identify the site individually
On effect/drug concentation grafts what do x and y axis mean?
X axis -lower the value the greater the affinity and potency
y axis- higher the value the greater the efficacy
Potency and affinity go together, what does not necessarily mean increased affinity?
lower Km does not necessarily mean that affinity is greater
CMV in a pregnant women can lead to a child w/
chorioretinitis
Ataxia, telangectasia, and sinopulmonary infxns are classic triad
Ataxia telangectasia
ATM gene mutation -> DNA break repair
IgA deficiency
Fragile X syndrome
What is the mutation and what does it do to DNA?
FMR mutation leads to FMR1 hypermethylation
How would you determine methylation and number of repeats?
Use Southern blot to determine number of CGG
MOA of botulinum toxin
Cleaves SNAREs preventing NT release from vesicles (pre-synaptic)
Antipsychotic OD - diffuse muscle rigidity, high fever, tachycardia, HTN, and altered sensorium
Name syndrome and tx
Neuroleptic malignant syndrome
Tx w/ dantrolene to block Ryanodine receptors
What NT is produced in the posterior rostral pons at the lateral floor of the fourth ventricle?
Locus ceruleus produces NE
What NT at ventral tegmental area and substantia nigra pars compacta
DA
3 DA pathways
Mesolimbic and mesocortical - cognition and behavior
Nigrostriatal - coordination of voluntary movements
Tuberoinfundibular - inhibit PRL
NT produced from Periaqueductal gray, rostral ventral medulla, and dorsal horn of the spinal cord
Dynorphin (opioid)
NT from posterior hypothalamus
Histamine and orexin - arousal and wakefulness
Transamination rxns require which vitamin?
Vit B6
What is the major AA responsible for transferring nitrogen to the liver?
alanine
What happens to alanine once it reaches the liver?
Alanine transfers the amino group to alpha ketoglutarate to form glutamate
What happens to glutamate in the liver?
Glutamate is transformed to regenerate alpha ketoglutarate and free ammonia by glutamate dehydrogenase
Morbilliform rash on trunk and arms, fever, encephalitis, and flaccid paralysis in the summer
WNV - Positive sense ssRNA flavivirus transmitted by Culex female mosquitos
Main features of a glucagonoma
Diabetes
GI- diarrhea, anorexia, abd pn
Necrolytic migratory erythema
Describe necrolytic migratory erythema
Erythematous plaques/papules on face. perineum, and extremities
Lesions coalesce leaving bronze colored, central indurated area w/ peripheral blistering and scaling
What is arginine a substrate for?
Arginase producing urea
Spastic diplegia, abnl movements, and growth delay
Arginase deficiency- arginine is not changed to ornithine and urea
Arginase deficiency- hyperammonemia?
Mild or no hyperammonemia
Thyroid histo: Nests of polygonal cells with Congo red positive deposits
Medullary thyroid CA
Why does medullary thyroid CA have Congo red positive deposits?
Tumor from calcitionin secreting C cells. The amyloid depositis are calcitonin secreted from the c cells
Thyroid histo: branching structures with interspersed calcified bodies
Papillary thyroid CA
calcified bodies are psammoma bodies
Follicular hyperplasia with tall cells forming intrafollicular projections
Papillary thyroid CA - intrafollicular projections = papilla. Don’t forget Orphn annie eyes- pale nuclei with thin rim of peripheral chromatin
Pleomorphic giant cell nests w/ occasional multinucleated cells
Anaplastic thyroid carcinoma
Sheets of uniform cells forming small follicles
Benign follicular adenom
Neonatal intraventricular hemorrhage in premature baby will have bleeding from where?
Germinal matrix - highly cellular and vascularized layer in the subventricular zone. neuron an glial cells migrate out of during development
What adrenergic receptor affects uterine contractions?
B2 agonists -decreases uterine contractions, tocolytic
What adrenergic receptor causes mydriasis?
Alpha 1 agonists-> mydriasis
In DKA which enzyme provides substrate for gluconeogenesis?
Glycerol kinase
TG breakdown in DKA
FA undergo beta oxidation to provide energy and ketone bodies, but not glucose
The glycerol backbone goes to DHAP to provide energy and glucose
Manifestations of pineal tumor (germinoma)
Obstructive hydrocephalus and dorsal midbrain syndrome (Parinaud)
What is Parinaud syndrome?
Limited upward gaze, downward gaze preference, b/l eyelid retraction and accomodation w/o pupil rxn
What is required for glycolysis? Glyceraldehyde-3-phosphate to 1,3-bisphosphoglycerate
NAD+
In anaerobic conditions what does pyruvate to lactate accomplish?
NADH transfers e- to pyruvate to make lactate and regenerates NAD+ to continue glycolysis
What substrate activates pyruvate carboxylase and inhibits pyruvate dehydrogenase? Promotes gluconeogenesis over TCA cycle
Acetyl CoA
When Acetyl CoA is low pyruvate dehydrogenase is disinhibited to make more
When Acetyl-CoA is high it prevents more by activating pyruvate carboxylase
Trazodone MOA
5HT modulator
5HT post-synaptic blocker and inhibits 5HT reuptake
Besides 5HT what does trazodone act on?
Alpha 1 block - orthostatic hyypotension
H1 block- sedation
5HT - insomnia associated w depression
Trazodone SE
TrazoBONE- priapism
orthostatic hypotension
Gastric erosions, what layer
Up to but not throught muscularis mucosa
Gastric ulcers, what layer?
Extend into submucosa or deeper
Duration of trazolam, oxazepam, and midazolam
Short acting < 6 hrs half-life
Duration of alprazolam, lorazepam, and temazepam
Intermediate 6-24 hrs half-life
Duration of chlordiazepoxide, diazepam, and flurazepam
Long > 24 hr half-life
To avoid undesirable daytime effects take short or intermediate acting benzos
short- oxazepam, midazolam, trazolam
intermediate - alprazolam, lorazepam, and temazepam
Narcolepsy tx
Psychostimulant like modafinil
Modafinil MOA
Non-amphetamine psychostimulant thought to enhance DA signaling
Tx of tx-resistant schizophrenia
Clozapine - 2nd gen antipsychotic
Clozapine SE
Agranulocytosis, metabolic syndrome, seizures, myocarditis
Aripiprazole and ziprasidone, risperidone
2nd gen antipsychotics
Tx of drug-induced Parkinsonism
D/c drug and centrally acting anti-muscarinic - benztropine
Don’t use carbidopa/levodopa - could precipitate psychosis
Most common cause of death in TCA OD
arrhythmia from inhibtion of fast acting Na channels in cardiac myocytes
TCA effects what receptors
Presynaptic NE and 5HT prevent reuptake - antidepressant
Muscarinic Ach-R block- tachycardia, hyperthermia
H1 -sedation
Alpha 1 block- vasodilation
Cardiac Na channels
Panic disorder tx emergent and long term
Emergent- benzo
Long term SSRI/SNRI
TCA blocks what receptors
NE and 5HT reuptake H1 Alpha 1 Muscarinic Cardiac fast acting Na channels
Venlafaxine, duloxetine, ddesvenlafaxine, levomilnacipran, milnacipram MOA
SNRI
High potency 1st gen antipsychotics
Haloperidol and fluphenazine - more likely EPSE
Low potency 1st gen antipsychotics
Chlorpormazine and thioradizine -more likely sedation (H1), orthostatic hypotension (Alpha 1), anticholinergic (muscarinic)SE
11-beta hydroxylase deficiency (hypokalemic metabolic acidosis) : cortisol, renin, and aldosterone
Cortisol is low as 11-deoxycortisol can’t become cortisol -> Increased ACTH -> increased 11-deoxycorticosterone (MC) -> increased Na reabsorption -> HTN
Renin and aldosterone would be low as the pt is HTN
What family of virus does RSV fall in?
Paramyxovirus - Negative sense ssRNA helical w/o envelope
dsDNA, enveloped, icosahedral
Hepadnavirus-HBV
Herpes virus - HSV
dsDNA, naked, icosahedral
Adenovirus - conjunctivitis, pharyngitis
Papillomavirus- warts
Polyomavirus- JC-progressive multifocal leukoencephalopathy (PML) in AIDS
BK-transplant pt, targets kidneys
ssDNA, naked, icosahedral
Parvovirus- B19 targets RBC- hydrops fetalis or aplastic crisis in SCA
Negative sense ssRNA, bullet shaped, enveloped virus
Rhabdovirus - Rabies
Negative sense ssRNA, helical enveloped virus in kid w/ wheezes
Paramyxovirus - measles, mumps, parainfluenza-croup, and RSV
Positive sense ssRNA, icosahedral, enveloped virus
Togavirus - Rubella, equine encephalitis
Flavivirus- Hep C, WNV, Dengue
Coronavirus - common cold, SERS
Retrovirus - HIV, HTLV
Positive sense ssRNA, icosahedral, naked
Calicivirus - Norovirus
Picornavirus (PERCH) - Polio, echo, rhino, cocksackie, and HAV
Picornaviruses (PERCH)
Polio Echo Rhino Cocksackie HAV
D-ALA dehydratase and ferrochetalase are affected
Lead poisoning - microcytic anemia, Basophilic stippling, GI and kidney dz
Uroporphorinogen decarboxylase is affected
Porphyria cutanea tarda - blistering cutaneous photosensitivity
Porphobilinogen deaminase is affected
Acute intermittent porphyria - Pnful abd, psycho disturbance, port wine stain, polyneuropathy
D-ALA synthase is affected
Sideroblastic anemia (X-linked) or B6 (pyridoxine) deficiency
What substrates accumulate in lead poisoning?
Protoporphyrin, D-ALA in the blood
What substrates accumulate in acute intermittent porphyria?
Porphobilinogen, D-ALA, coporphobilinogen (urine)
What substrates accumulate in porphyria cutanea tarda?
Uroporphyrin (tea colored pee)
What is believed to be the cause of endometrial carcinoma in post-menopausal women? tX
Unopposed estrogen
Tx w/ estrogen combined with progesterone to dampen the effects of estrogen
Diphenhydramine MOA and receptors affected
H1 blocker
anti-muscarinic
anti-alpha
Why would diphenydramine cause vision issues?
anti-muscarinic properties cause mydriasis aggravating acute angle-closure glaucoma. Alpha block would cause miosis not mydriasis
Things that can cause digoxin toxicity
Quinidine, amiodarone, verapamil - displace digoxin and decrease clearance
Hypokalemia
Yellow vision, premature ventricular contractions, curved ST segment
Digoxin toxicity
Kidney: Filter load equation
FL=GFR (L/day) X plasma concentration (mEq/L)
Kidney: Fractional excretion equation
FE = Excretion rate (mEq/day)/ filtered load
mEq/day
To get the fraction excreted
how much is secreted over how much is filtered - how much is in the plasma times the GFR
Fluphenazine vs phenelzine
Fluphenazine - 2nd gen antipsychotic
phenelzine - MAOI
Meperidine MOA
Opioid that also blocks 5HT reuptake. Can cause Serotonin syndrome when combined w/ MAOI
What does partial emancipation at age 15 allow for?
STI screening and tx -including HIV
substance abuse tx
Prenatal care and birth control
Agents that can cause lupus
Hydralazine - arteriole dilation
Procainamide - Class 1A anti-arrhythmic
INH - Prevents mycolic acid synthesis
Methyldopa - alpha 2 agonist (pregos)
Chlorpromazine - 1st gen low potency antipsychotic
Quinidine - Class 1A anti-arrhythmic
Minocycline - tetracycline
Terbinafine - Inhibits fungal squalene epoxide
Phenytoin - Anti-sz, blocks Na channels, also Class 1B antiarrhythmic
Sulfasalzine-Combo of sulfapyridine (anti-bx) and 5-aminosalicylic acid (anti-inflamm)
Treating HTN and pt gets SLE, what drug. What if the pt is pregnant?
Hydralazine -arteriole vasodilator
Methyldopa- alpha 2 agonist -decrease adrenergic
Treating an atrial arrythmia and the pt gets SLE, what if you were treating a ventricular arrhythmia post-MI
Class 1A anti-arrythmics
Quinidine or procainamide
Post-MI likely Class 1B - phenytoin
Treating a tonic-clonic sz and pt gets SLE
Phenytoin
Treating tuberculosis and pt gets SLE
Isoniazid
Tx pt for schizophrenia and pt gets SLE
Chlorpromazine
Tx for borrelia burgdorferi and pt gets SLE
minocycline
Tx for onchomycosis (nail fungus) and pt gets SLE
Terbinafine
Tx UC or Crohn dz and pt gets SLE
Sulfalazine
The most common solid tumor in childhood
Wilms tumor not neuroblastoma appear the same on CT -heterogeneous
3 Syndromes associated w/ Wilms tumor
Denys-Drash - gonadal dysgenesis, early-onset nephropathy
Beckwith-Wiedmann-organomegaly, macroglossia, hemihypertrophy, omphalocele
WAGR- WT, aniridia, GU malformation, retardation
Acid fast organisms
Mycobacteria (TB, leprosy)
Nocardia
Cryptosporidium
What characteristic is most important to the spread of cryptosporidium?
Resistance to Cl
How do you tx Cryptosporidium parvum?
Nitozoxanide - healthy
Azithromycin - immunocompromised
Posterior dislocation of the femur at the hip, what nerve is injured and what muscles would be weak?
Inferior gluteal n.
Loss of hip extension and lateral rotation of the thigh -gluteus maximus
Superior gluteal n injury. What movement is affected and which muscles
gluteus medius, gluteus minimus, and tensor fascia latae
Abduction of the hip
What characteristics of a protein make it more likely to be filtered?
small 7,000 Da
neutral - negative proteins get repelled by heparan
Alpha-synuclein is found in what?
Lewy bodies
Anemia compared to NL: CO, arterial PO2, Mixed venous PO2, 2,3-DPG
Right shift
CO increased to make up for low O2 delivery due to low Hgb
Arterial PO2 and arterial oxygen concentration -NL (independent of Hgb)
Mixed venous PO2 - increased O2 extraction by the tissues due to right shift
2,3-DPG increased to increased O2 extraction
What is chylothorax?
Accumulation of lymph in pleural space
Acute pleural masses w/ effusion w/ hx of installing fire-resistant tiles
Mesothelioma due to asbestos
Silicosis doesn’t have acute pleural masses or effusions
What is a carbuncle?
Cluster of boils draining pus to the skin, S. Aureus. Neck, face, and chest, doesn’t persist for years
What is a furuncle?
Painful boil due to hair follicle inflammation. Neck, face, and chest, doesn’t persist for years
What is an erythrasma?
Scaling, fissuring, and maceration. Brown scaly superficial infxn
What is hidradenitis suppuritiva
Local inflamm of apocrine sweat glands-> obstruction and rupture of ducts. Persists for decades. No abx
What kind of hypersensitivity is contact dermatitis and what things are important to that kind of rxn?
Secretion of Th1 cytokines like IFN gamma and TNF-alpha
Anti-microsomal Ab
Hashimoto’s thyroditis also anti-thyroglobulin
What type of hypersensitivity is Hashimoto’s thyroiditis?
Type 4- T cells get sensitized to antigens
Poultry processing worker w/ flu sx and elevated LFT, What dz and what tx
Chlamydophila psittaci
tx w/ tetracycline
Hypothyroid w/ breast d/c. Is TRH or TSH low?
If there is breast d/c then PRL is being stimulated by TRH, so the hypothyroidism must be at the level of the pituitary, TSH is low, but TRH is high
O father, B daughter, and A mother. What’s up?
Dad is not the father, could not have given B. Keep it simple
Chemotaxis agents
C5A, LTB4, IL-8
Cleft lip/palate, omphalocele, polydactyly, and cutis aplasia
Patau Syndrome Trisomy 13
VACTERL is an association what does it stand for?
Vertebral defects Anal atresia Cardiac defects Tracheo-esophageal fistula Renal anomalies Limb anomalies
Nontender GB, obstructive jaundice, and wt loss
Pancreatic adenocarcinoma at the head
Greatest risk factor for pancreatitis
Smoking
What happens to copper in the body?
In the liver it is incorporated into alpha2 globulin to form ceruloplasmin, which is then resecreted in the plasma
How is copper eliminated?
Secreted into the bile and out through the stool
RAS MAPK pathway
GF ligand binds receptor tyrosine kinase->autophosphorylation-> GTP binding->MAPK influencing gene expression in the nucleus
How is RAS regulated?
RAS has its own GTPase to remove GTP so that too much RAS doesn’t build up. RAS mutations -> decreased GTPase activity -> more activated RAS
Lost in desert for 3 days:
ADH, plasma osmolarity, and water excretion
ADH up
Plasma osmolarity up
water excretion down
Water continues to get lost even w/ low water excretion, so the plasma osmolarity increases w/ low volume and ADH increases to compensate
Buprenorphine characteristics
Partial Mu agonist
Why would using morphine not be effective after buprenorphine had been administered?
Buprenorphine is less efficacious as a partial agonist so it takes up receptors preventing morphine from having full effects
HA, vision problems, frontal bossing, sausage fingers, diaphoresis, hypoglycemia, sx improve w/ octreotide
Acromegaly- excess GH
GH antgonizes insulin
Professor has trouble speaking in front of people, NL in other situations
Social phobia-specific situations are stressful
Complications of multiple myeloma
Frequent sever infxns (monoclonal plasma cells), renal failure, anemia, and neuro dz
Pacemaker lead becomes dislodged into adjacent artery, which artery runs alongside the coronary sinus?
LCA - circumflex runs with coronary sinus
What kind of lung dz is asbestosis?
Restrictive, FEV1/FVC is close to nl. Make sure to look at FEV1 and FVC in graphs
Colicky RUQ pn, xanthomas, scleral icterus, hypercholesterolemia, prolonged PT, elevated conjugated bili, decreased Vit D
Extrahepatic cholestasis
Bile is not making it to the small intestine to help absorb fat soluble vitamins, Vit K, so you get prolonged PT, Low Vit D absorption
Too much bile so synthesis is turned off, cholesterol builds up in the liver, and LDL-R decrease
Constant severe RUQ pn, fever, nausea, vomiting, elevated WBC, and slightly elevated LFTs
Acute cholecystitis -
stone lodged in the cystic duct
Postprandial Colicky RUQ pn radiating to the rt shoulder, jaundice, and elevated alk phos, slightly elevated LFT
Choledochlithiasis -stone in CBD
Choledocholithiasis vs cholecystitis
In the CBD the pn occurs after eating when CCK is secreted. In the cystic duct it hurts continually
Leading cause of death in a AA male police officer age 25-34
Unintended accident, doesn’t matter that he’s a cop
Leading cause of death in AA male age 15-24
Homicide
Goal of Tx in Wolf-Parkinson White
Stop conduction of accessory pathway, not AV conduction-this will push more signal through accessory pathway
Goal of txing Isolated supraventricular arrythmias
Block AV node so atrial arrythmia is not transferred to the ventricle
Shortened PR interval, wide QRS, and delta wave
WPW- Myocyte loop in the bundle of Kent
Shortened PR interval as atria fire more quickly, ventricles start to fire sooner (delta wave) and the QRS gets lengthened due to the presence of multiple pathways
What medications should be used to prevent v-fib in WPW?
Class 1A - relatively nonselective (diffuse mycoytes) and dissociate slowly. Something that does not affect the AV node (rhythm control) No class 2 or 4, digoxin, or adenosine
Adenosine MOA
Increased K+ out of pacemaker cells leads to hyperpolarization. Slows AV conduction through pacemaker cells
Digoxin CI in which heart pts
V-fib and WPW
Digoxin MOA
Inhibits Na/K pump so Na and then Ca build up in the cell-> increased contractility
Stims vagus n to decrease HR at the AV node
1st degree heart block
PR interval is lengthened, it takes longer for atrial depolarization has delay to ventricle
Mobitz Type 1 Heart block (2nd degree)
The PR lengthens progressively until a beat is dropped and a QRS is not transmitted.
Mobitz Type 2 Heart Block (2nd degree)
PR interval is constant and then there is a sudden dropped beat (no QRS)
3rd degree heart block (complete)
Atria and ventricle beat independently. Possible w/ myomectomy
Drugs that can exacerbate MG
aminoglycosides-decreased presynaptic release and decreased post-synaptic sensitivity
Pregnant teen, what do you tell her
You can do prenatal care w/o informing pts, encourage to talk to parents, but don’t insist
Alcoholism, anterograde amnesia, and confabulations
Korsakoff syndrome-neuropsych manifestation o Wernicke Encephalopathy
Lesion of the mamillary bodies
Where is the lesion in Wernicke aphasia?
Superior temporal gyrus of the temporal lobe
AL amyloidosis (primary or secondary) what disease is an example
AL amyloidosis is primary like multiple myeloma
Made up of Ig Light chains
AA amyloidosis (primary or secondary) what dz is an example
Secondary amyloidosis
Chronic inflammatory dzs like RA, IBD. Fibrils made of Amyloid A
Kappa, Lambda, and M proteins
Products of whole Ig released by plasma cells
Seen in primary amyloidosis and MM
Multiple discrete lesions in the brain
Likely metastasis. Often located at gray-white jxn
Limited oxygen uptake (peak oxygen uptake of 15 mL/kg/min) and increased bp during stress test indicate what?
The pt has stable HF/deconditioning. Fatigue is a direct result of deconditioning
Tx for ischemic cardiomyopathy/stable HF/deconditioning
Closely monitored exercise regimen
Posterior stab in the 8th ICS , hydropneumothorax w/ high TG
Thoracic duct injury- leaks TG
Adrenal medulla vs. adrenal cortex
Medulla has glomerulosa, fasciculata, and reticularis
Cortex has NE and Epi
Elderly person w/ pneumonia. Hypofxn of what endo organ prevents improvement?
Thyroid-hypothyroidism
Adrenal cortex-cortisol deficiency
Kid w/ posterior fossa tumor and Rosenthal (corkscrew fibers)
Pilocytic astrocytoma also has pink blobs
Kid w/ posterior fossa tumor, small blue cells and Homer-Wright rosettes
Medulloblastoma
Radiodense bony spike covered with a radiolucent cap
Osteochondroma
Arterial O2 saturation, what does it mean
The % of Hgb that is saturated. NL in anemia, as the Hgb available has Nl binding
Arterial PO2, what does it mean
The partial pressure of O2 in the blood. Unaffected by Hgb. This is dissolved O2
Arterial O2 content, what does it mean
It includes Hgb O2 saturation (saO2) and PaO2. Decreased in anemia
Anemia: SaO2, PaO2, Arterial O2 content, venous O2
SaO2 - Nl, the available Hgb bin NLy
PaO2-NL independent of Hgb
Arterial O2 content - decreased as it depends on Hgb
Venous O2- decreased as more O2 will be extracted due to low Hgb
What is similar and different btwn Squamous cell CA and keratoacanthoma?
Both: abnl epithelial maturation, acanthosis, loss of basal cell layer
Different: Keratoacanthomas have central crater (volcano)
Low IFG binding protein, what will happen to IGF?
IGF will also be decreased. Low GH -> Low IGF and IGFBP
Lethargy, constipation, depression, shortened QT, ocular band keratopathy, HTN, duodenal ulcer, and pancreatitis. What could be a cause?
Primary hyperPTH
All signs of hypercalcemia from PTH excess
What condition is often associated with Meneire’s dz?
Permanent low frequency hearing loss
Dry, yellowish skin, low pulse, and slow shallow respirations, low sodium, low glucose, high cholesterol. What hormone is deficient?
T4
Decreased cardiac stim
Decreased LDL-R
Decreased GFR
What keeps RBF and GFR constant from 80 to 180 mmHG?
Changes in glomerular vascular resistance (constricting or dilating glomerular arterioles)
Metoclopramide MOA
Increase tone, contractility, and motility
Facilitates cholinergic effect
D2-R block
With what kind of vomiting would you use ondansetron?
Cancer chemotherapy and hyperemesis w/ pregnancy
5HT block
Tx diabetic gastroparesis with?
Metoclopramide- D2-R blocker w/ cholinergic effect- facilitates motility
MAP equation
MAP = SVR X CO
Lymphocytes that are most increased in the blood in EBV are?
T cells attacking EBV
They are the atypical lymphocytes
CYP450 Inhibitors -> increased drug level in blood
Acute alcohol abuse Ritonavir Amiodarone Cimetidine/ciprofloxacin Ketoconazole Sulfonamides Isoniazid Grapefruit Quinidine Macrolides (erythro and clarithromycin)
CYP450 Inducers
Chronic alcoholics St Johns wort Phenytoin Phenobarbital Nevirapine Rifampin Griseofulvin Carbamazepine
Nizatadine MOA
H2 blocker used for GERD. No CYP450 interaction like cimetidine
Sucralfate MOA
Form polymer that protects stomach from acid. Not compatible w/ acid lowering meds. It needs the acidic environment
What type of selection? T cells w/ thymic cortical epithelial cells.
Positive selection in the cortex, must have affinity for self-MHC
What type of selection? T cells w/ thymic medullary epithelial and DC.
Negative selection in the medulla, not too strong an affinity for self-MHC
How does INH lead to microcytic, sideroblastic anemia?
INH decreases B6, which is a cofactor for D-ALA synthase. Low D-ALA synthase means low production of heme and the iron builds inside the RBC
Poor Plt aggregation in the presence of ristocetin
VWF deficiency. Ristocetin activates Gp1 for NL VWF to bind. low VWF leads to low aggregation
What does GpIIb/IIIa bind to?
Binds to fibrinogen, which can bind to another Plt via gpIIb/IIIa
Lithium SE
Hypothyroidism
Nephrogenic DI
Tremor
Ebstein anomaly- atrialization of RV
Valproate SE
NTD
hepatotoxicity
Carbamazepine SE
Agranulocytosis
SIADH
NTD
Lamotrigine SE
Steven-Johnson syndrome
benign rash
Fxn of the proteasome
Recycle proteins, breakdown apoptotic proteins
Bortezomib MOA
Boronic acid dipeptide that inhbits the proteasome -> increased pro-apoptotic proteins and toxic proteins-> apoptosis
Severe hypoplasia of erythroid precursors w. NL granulopoeisis and thrombopoiesis
Pure red cell aplasia
Caused by thymomas
lymphocytic leukemia, and parvovirus B19
What occurs in the nucleolus?
Ribosomal subunit maturation and assembly
Which RNA Polymerase fxns exclusively in the nucleolus
RNA Pol I - transcibre 45S pre-rRNA gene that codes for most of the RNA components
RNA Pol II synthesizes what?
mRNA
snRNA
miRNA
most highly regulated of the RNA polymerases
RNA polymerase III synthesizes what>
tRNA and 5s rRNA (genes of this part of rRNA are made outside the nucleus)
Cause of megaloblastic anemia in chronic alcoholic?
Diminished thymidine synthesis due to folic acid and B12 deficiency ( also deficient due to pancreatitis)
Citalopram MOA
SSRI
Bupropion MOA
NDRI- smoking cessation and MDD. Not used for GAD
Buspirone tx what
Tx GAD. 5HT activator
SE of olanzapine and clozapine
Metabolic - wt gain, dyslipidemia, hyperglycemia, increased risk of diabetes
Cloazpine 1% SE
Agranulocytosis, not seen w/ olanzapine
Mycoplasma pneumonia and cold agglutinins whats the link?
Mycoplasma has antigen in cell membrane that is similar to I antigen in RBC membranes, cross-rxn occurs w/ IgM (cold agglutinins)
Tx of alcoholism
Disulfiram- inhibits aldehyde dehydrogenase leading to build up of aldehydes, which makes you feel sick
Acamprosate - Modulates glutamate at NMDA-R (once abstinent)
Naltrexone- block mu opioid-R inhibiting rewarding effects
PR interval 0.09
widened QRS
WPW, short PR and wide QRS
Nl PR interval is <200 ms
QRS complexes followed by inverted P waves?
AV reentry tachycardia due to WPW. signal travels down AV node and back up Bundle of Kent to the atrium, where the atria are stimulated after the ventricles in retrograde fashion-Inverted P
Bx reducing nitrate to nitrite means what?
Oxidase negative bacteria
enterobacteria. Don’t use oxidative phosphorylation
Pseudomonas makes what?
glycocalyx and blue-green pigment pyocyanin
Encapsulated organism
Why would opioid administration cause RUQ pn?
Contracts smooth muscle of sphincter of Oddi (spasm) increasing CBD and GB pressure. Opioids inhibit release of Ach
b/l lens opacities in a kid w/o other sx
Galactokinase deficiency-> increased galactitol, which accumulates in the lens
Rhabditiform larvae in the stool and eggs and adult parasites on an intestinal biopsy. Tx?
Strongyloides stercoralis
Tx w/ ivermectin
Parasite eggs in the stool?
Schistosoma mansoni or japonicum
Perianal egg deposition?
Enterobius vermicularis (scotch tape) Pinworms
Proglottids in the stool
Intestinal tapeworms (flatworms) made of multiple segments (proglottids) Taenia solium, T saginata, and diphyllobothrium lata
Trophozoites and cysts in the stool
Giardia lamblia and entamoeba histolytica
Oxidase +, Gram -, comma shaped rods that can survive on alkaline media
Vibrio cholera
S-shaped, motile, gram -, oxidase + rod, grows at 42 degrees
C. jejuni
microaerophilic and thermophilic
Most likely hepatitis from sexual transmission
HBV more commonly than HCV (usually asx and not very efficient sexual transmission)-more commonly IVDU
Serum sickness-like syndrome: joint pain lymphadenopathy, pruritic urticarial rash, RUQ pn, hepatomegaly, elevated LFTs
HBV
HCV is usually asx and transmitted by IVDU, less commonly sex
Asterixis
flapping tremor commonly seen in cirrhosis
Elevated LFTs mean what?
Hepatocyte injury
Elevated alk phos and GGT (gamma glutamyl peptidase) mean what?
Biliary injury or cholestasis
Elevated bilirubin means what?
Impaired transport and metabolic capacity
Elevated PT time and hypoalbuminemia mean what?
Impaired biosynthetic capacity
What labs predict prognosis in cirrhosis?
Indicators of liver fxn
Low albumin
Prolonged PT
Elevated bilirubin
Glutamine-glutamatae cycle w/ hyperammonemia
Nl: astrocyte takes up glutamate from the synapse (preventing excess excitation) and ammonia from the blood to make glutamine via glutamine synthase
Too much ammonia causes accumulation of glutamine and swelling of the astrocyte so it no longer takes up glutamate -> excess excitation (asterixis)
What do amatoxins in poisonous mushrooms do?
Inhibit RNA polymerase II (mRNA)
Colonoscopy- multiple polypoidal, hemorrhagic lesions.
Biopsy-spindle cells w/ surrounding blood vessel proliferation
Kaposi’s sarcoma
Colonoscopy: non-ulcerative inflammation
Biopsy: basophilic cluster seen on the surface of intestinal mucosal cells
Cyptosporidium
Ribavirin MOA
- Hypermutation during RNA dependent RNA replication
- Direct inhibition of HCV RNA polymerase by ribavirin triphosphate
- Inhibit IMP dehydrogenase
- Defective 5’ cap formation
- Enhance Th1>Th2 for more effective immune response
Why does signet ring gastric adenocarcinoma have diffuse infiltration?
Loss of E-cadherin
linitis plastica
HypoPTH - where is phos reabsorption increased and the absorption of Ca decreased
Phos has increased reabsorption in the PCT, so phos increases
Ca is not reabsorbed in the Distal convoluted tubule so Ca decreases
Why would uric acid stones form in a pt who has an ileostomy and is dehydrated and has chronic diarrhea?
Dehydration and chronic diarrhea lead to decreased HCO3 reabsorption from the gut, kidney excretes more H+ and reabsorbs more HCO3. So the tubule becomes acidic allowing for the formation of uric acid crystals
What type of cell does renal cell carcinoma originate from?
Epithelial cells of the proximal convoluted tubule
4 y/o girl, colicky abd pn, vomiting, and loose bloody stools. Red urine, anemic, thrombocytopenia
Hemolytic uremic syndrome like due to O157:H7
What is the mechanism of AKI in HUS?
Shig toxin injures endothelium of preglomerular arterioles -> Plt activation and microthrombi
HUS triad
Microangipathic hemolytic anemia
thrombocytopenia
Acute kidney injury (microthrobi in the renal vasculature)
Henloch Schonlein Purpura presentation
Abd pn, palpable purpura, arthralgias, acute glomerulonephritis, Nl Plt and coagulation studies
Non-lactose fermenting gram - rod causing pyelonephritis in a man w/ urinary catheter
Psuedomonas aeruginosa - Oxidase +
Enterobacter cloacae, What is it?
Gram - rod, lactose fermenter, extensive abx resistance
What does increased selective filtration of proteins mean in the kidney?
Increased filtration of proteins, ignore selective. It means more protein is filtered due to foot process effacement
Sodium cyanide-nitroprusside test on the urine, what dx?
Cystinuria
Detects cystine in the urine
How is digoxin eliminated?
Renally, decreased clearance in elderly
What do anti-phospholipid Ab due to coagulation studies?
Prolong PTT on lab test, but the pt is actually hypercoagulable
What causes muscle weakness and cramps in pt taking chlorthalidone?
Hypokalemia from thiazide diuretic. Also, causes metabolic alkalosis. Does not effect phosphate
Where are the JG cells?
The JG cells are modified smooth muscle cells around the afferent arteriole that secrete renin when stimulated by macula densa cells that surround the DCT
Which arteriole is affected by the RAAS system?
The efferent arteriole. Don’t get confused that JG cells are around the afferent arteriole and secrete renin
Multiple injuries in MVA gets txed w/ a diuretic and develops pulmonary edema, what was the med?
Mannitol. helps decrease cerebral edema by drawing fluid into the vasculature. If too aggressive the fluid will start to leak in the lungs and cause pulmonary edema
Bumetanide MOA
Loop diuretic
Clinical manifestations of schistomosiasis result from what immune response
Th2 granulomatous response to the eggs-> marked fibrosis, ulceration and scarring of the bladder or bowel
Where else can shistosoma deposit in the body besides the bladder?
Presinusoidal radicals of the portal vein -> periportal “pipestem” fibrosis
DM1, Inability to sense a full bladder, difficult starting and maintaining urine, nocturnal enuresis? What kind of incontinence and what other finding?
Overflow incontinence
Increased post-void residual volume
What causes overflow incontinence in a DM1?
DM autonomic neuropathy
impaired detrusor contractility
Loss of autonomic afferents telling the brain the bladder is full
What does increased post-void residual volume tell you?
Weak detrusor contraction
What kind of depression should you definitely use MAOI for?
Treatment resistant Atypical depression - increased appetite and sleep, leaden paralysis, mood reactivity, and rejection sensitivity.
Increased urinary frequency and not controlling urge to urinate w/ MS and other UMN signs
Urge incontinence - overactive or spastic bladder
Urodynamic studies of urge incontinence in MS
Little or no urine after void. Nl contraction, but poor distensability -
Why does the bladder have poor ability to distend in MS?
Loss of descending inhibitory control from UMN. Once it starts to fill it is hyperreactive and contracts the detrusor.
Earliest manifestation of diabetic nephropathy
Microalbuminuria, glycosuria comes later
What happens to the kidneys w/ acyclovir tx?
Acyclovir gets concentrated in the collecting duct and forms crystals causing renal tubular damage
How do you prevent nephrotoxicity from acyclovir?
Aggressive IV hydration
What does acidosis cause in the kidney?
Stimulates renal ammoniagenesis
Renal tubular epithelial cells take glutamine and make ammonium and bicarb (CO2 comes from alpha ketoglutarate as it gets broken down, which acts against the acidosis)
Skin biopsy- scattered areas of fibrinoid necrosis and neutrophil infiltration involving small blood vessels
Serum sickness - Type III hypersensitivity
Also hypocomplement, low C3 and C4
Signs of serum sickness
Fever, pruritic skin rash,and arthralgias 7-14 after antigen exposure
Causes of serum sickness
chimeric mabs -rituximab and inflixamab
nonhuman Ig - venom antitoxins
Non protein drugs - TMP/SMX, penicillin
Ankylosing spondylitis complications of: respiratory, cardio, eye
Respiratory: costovertebral and costernal jxn enthesopathies can limit chest wall expansion
Cardio: ascending aortitis
Eye: Anterior uveitis
What should be monitored to track disease progression in ankylosing spondylitis?
Chest wall expansion
Drug induced lupus is more common in what kind of pt?
Slow acetylators
What drugs commonly cause drug induce SLE in slow acetylators?
INH
procainamide
Hydralazine
Acute right knee pain with swelling and redness that has happened before, polycythemia vera. What would you see in the synovial fluid?
Monosodium urate crystals -Gout- polycythemia vera (myeloproliferative disorder will increase urate production predisposing to gout)
Synovium shows numerous RBCs, nontraumatic
Hemophilia or pts taking warfarin
mab to Il-6
Tocilizumab
Ab to myeloperoxidase and proteinase-3
ANCA associated vasculitides
B cell activating factor belongs to what family
TNF family
Muscle biopsy: transmural inflammation of mid-sized arteries w/ areas of amorphous, eosin-staining arterial wall necrosis (fibrinoid necrosis), and internal elastica lamina disruption
Polyartertitis nodosa
What is the most likely predisposing factor for PAN?
HBV infxn
Nervous system clinical features of PAN
Mononeuritis multiplex
2 mo baby, progressives floppiness and poor feeding, sleepy, constipated, large anterior fontanelle, large tongue, reducible umbilical hernia
Congenital hypothyroidism
What dz process in mom is associated w/ caudal regression syndrome?
Uncontrolled DM
agenesis of sacrum and lumbar spine, LE paralysis
Action of supraspinatus and innervation
Abduction (initiates)
suprascapular n.
Action of infraspinatus and innervation
External rotation
suprascapular n.
Action of teres minor
Adduction and external rotation
Axillary n.
Action of subscapularis and innervation
Adduction and internal rotation
upper and lower subscapular n.
Anteromedial displacement of supracondylar humeral fracture. What n. is injured?
median n. crosses over anteromedial aspect of humerus
Anterolateral displacement of supracondylar humeral fracture. What n. is injured?
Radial n. crosses anterolateral aspect of humerus
Medication given in gout that selectively binds to an Il-1 inducible enzyme highly expressed by inflammatory cells exclusively
Cox-2 inhibitor - celecoxib
Also induced by TNF-alpha
Preferred if pt has PUD
Which Cox is secreted by all cells and which one is only secreted by inflammatory cells?
Cox-1 -all cells used for housekeeping fxns
Cox-2 secreted by inflammatory cells after being induced by Il-1 and TNF -alpha
What will parvovirus in a kid look like?
Slapped cheek-bright red rash on the cheeks w/ circumoral pallor and fever
Generalized reticular rash on trunk, arms, and legs
Erythema infectiosum
Parvovirus in an adult
Acute arthropathy
Symmetric polyarthritis
RA-like
Sarcomere: H band A band M line I band Z line
H- myosin only (heavy chain)-shrinks
A- all myosin including overlap w/ actin (heavy chain)-constant length
M- Where the myosin anchors to structural filaments
I- Actin only (light chain)- shrinks
Z- Where actin binds structural elements (Z-Z shrinks)
Difficulty combing hair, endomysial mononuclear infiltrate, patchy muscle fiber fibrosis, what dz and what Ab
Polymyositis
ANA
Anti-Jo-1 = anti-histidyl tRNA synthase
What enzymes are increased in polymyositis?
Creatinine kinase
Aldolase
Anti-mitochondrial Ab
Primary biliary cirrhosis-pruritus, jaundice, diarrhea
Anti-smooth muscle Ab
Autoimmune hepatitis - middle aged women w/ chronic progressive hepatitis
Anti-CCP (most specific) and Anti-IgG Ab
Rheumatoid arthritis
Inflammation causes arginine to be converted to citrulline. The citrullinated proteins trigger immune response
Anti-centromere Ab
CREST syndrome C-calcinosis Raynaud phenomenon Esophageal dysmotility Sclerodactyl Telangiectasia
Anti-dsDNA
SLE (specific)
3 drugs that decrease bone formation
Glucocorticoids
unfractionated heparin
Thiazolidinediones
Drug that decreases calcium absorption
Long term PPI
Drugs that increase Vit D catabolism via CYP450 induction
Phenobarbital
phenytoin
carbamazepine
New back pain, fever, recent endocarditis or bacteremia. What is it and what is the initial evaluation?
Vertebral osteomyelitis
Blood cultures and spinal MRI to visualize the bacteria
3 phases of Lyme dz
Early: Erythrema chronicum migrans (bulls eye)
Early disseminated: facial palsy and AV nodal block
Late (mo or yrs) asymmetric arthritis or subacute encephalopathy
Tx of lyme dz
Doxycylcine or ceftriaxone
Osteoid matrix accumulation around trabeculae
Vit D deficiency
Increased osteoid w/o mineralization
Trabecular thinning w/ fewer interconnections
Osteoporosis-decrease in osteoblasts and increase in osteoclasts
Subperiosteal resorption w/ cystic degeneration
HyperPTH- subperiosteal thinning is classic
Lamellar bone structure resembling a mosaic
Paget’s dz
Irregular sections of bone linked by cement lines
Spongiosa filling the medullary canal w/ no mature trabeculae
Osteopetrosis-defective osteoclasts, CA mutation
Too much osteoblast activity
What does digital clubbing signify?
Chronic hypoxemia Large cell lung CA TB CF Empyema Bronchiectasis Chronic lung abscess
Adverse effects of succinylcholine
Malignant hyperthermia
Severe hyperkalemia - burns, crush injuries, and denervation- upregulated AchR during stage II block -> increased K efflux
Bradycardia or tachycardia
Which class I antiarrhythmics prefer activated or inactivated cells?
All 3 types of class I prefer activated or inactivated. Class Ib prefers ischemic, because it is slower to go to resting and it has the fastes dissociation
What cell jxn uses connexins?
Gap junctions-connects
What cell jxn uses claudins and occludins?
Tight junctions-occludes
What cell junctions use cadherins?
Adherens junctions and desmosmomes
Adhere cells together
What cells jxn uses integrins?
Hemidesmosomes-integrates cell into BM
Atypical cells infiltrating the nipple skin
Paget dz of the nipple-ductal spread of malignant cells
Cysts lined by metaplastic aprocrine cells
Fibrocystic change of the breast
Liquefactive necrosis of the adipocytes w/ hemorrhage
Fat necrosis due to trauma
Stroml proliferation compressing the ducts to slits
Fibroadenoma
Papillary cells w/ fibrovascular core
Intraductal papilloma
blood d/c due to twisting of vascular stalk of the papilloma in the duct
Benign myometrial smooth muscle cell proliferation
leiomyoma-uterus irregularly enlarged. irregular bleeding
Blastocyst implantation in the fallopian tube
Ectopic pregnancy
+ pregnancy test
Amenorrhea w/ or w/o abd pn
Endometrial tissue in the myometrium, uniformly enlarged uterus, secretory endometrium
Adenomyosis-middle aged parous females w/ heavy menstrual bleeding
Secretory endometrium is a NL finding
Hyperplastic growth of tissue from endometrial surface
Endometrial polyps
Greater increase in endometrial gland proliferation compared to the stroma
Endometrial hyperplasia-irregular but not painful menstrual bleed
Fever, abd pn, uterine tenderness, foul-smelling d/c after pregnancy termination
Septic abortion
Instrumentation S. Aureus and E. coli
Edema: capillary hydrostatic pressure, plasma oncotic pressure, sodium and water and lymphatics
More fluid in the capillaries, increases volue and dilutes osmolarity Increased capillary hydrostatic pressure Decreased plasma oncotic pressure Na and H20 retention Lymphatic obstruction
If there is increased CVP what prevents peripheral edema?
Lymphatic drainage works against edema until it becomes overrun
Clomiphene MOA
Blocks estrogen-R in the hypothalamus so pituitary continues to produce FSH and LH -> promotes fertility in PCOS
PCOS tx for pt wanting pregnancy and not wanting pregnancy
Pregnancy- clomiphene to stim FSH and LH
Non-pregnancy - Estrogen and progestin OC-reduced androgens and endometrial proliferation
Where will blood pool if you puncture the common femoral artery above the inguinal ligament?
It will pool in the retroperitoneum.The vessel sits just under the peritoneum
Sebaceous glands in acne are what kind of glands?
Holocrine glands
Salivary and eccrine glands are what kind of glands?
Merocrine
DCIS ductal carcinoma in situ looks like
Swollen mushroom hat
Breast: orderly row of cells due to decrease E-cadherin
Invasive Lobular carcinoma
15 yo female w/ amenorrhea, fully developed secondary sexual characteristics (pubic hair), shortened vaginal canal w/ rudimentary uterus
Mullerian aplasia
Mayer-Rokitansky-Kuster-Hauser
No upper vagina (short vagina)
Variable uterus and NL ovaries
Does androgen insensitivity have a uterus?
No uterus, XY, Mullerian duct is degraded
Vagina has what kind of cells
Squamous epithelial cells
Cervix has what kind of cells
Ectocervix-squamoues
Endocervix-columnar
Fallopian tube has what kind of cells?
Columnar w/ cilia
Ovaries have what kind of cells?
Cuboidal (germinal) rapidly proliferate
Hemosiderin deposits and endometrial glands or stroma outside the uterus
Endometriosis
Most important risk factor for intimal tears like aortic dissection
HTN
Copious green vaginal discharge burning on urination w/o CMT
Trichomonas vaginalis
How to confirm trichomonas vaginalis?
Saline microscopy- wet mount to identify trichomonads
What do you use cervial cytology to identify?
HPV
KOH test reveal what?
Amine-whiff test confirms gardnerella vaginosis
How do combined OC prevent pregnancy?
Reduce gonadotropin levels
prevent LH spike
How do locally acting progestins prevent pregnancy?
Thickens cervical mucus and impair sperm penetration
Common dermal finding of ulcerative colitis
Erythema nodosum
Pyoderma gangrenosum
Derm findings of DM
skin tags, acanthosis nigricans, and necrobiosis lipoidica diabeticorum
How does INH lead to sensory ataxia and decreased pain sensation in the distal extremities
INH decreasese B6, which is a part of the synthesis of NT
Deficiency of methylmalonyl-CoA mutase
Lethargy, vomiting, tachypnea of the newborn,
Hyperammonemia, ketotic hypoeglycemia, and metabolic acidosis
Elevated urine methylmalonic acid and propionic acid
Methylmalonic acidemia
Pathway for Threonine, methionine, valine, and isoleucine to enter TCA
All converted to propionyl CoA-> methylmalonyl CoA via propionyl CoA carboxylase w/ biotin (CO2)
Methylmaonyl CoA goes to succinyl CoA via methylmalonyl CoA mutase w/ Vit B12. Succinyl Coa cna enter TCA
Where is atrophy most pronounced in Alzheimer’s dz?
Temporoparietal lobes and hippocampus
Clasp-knife spasticity, what is it?
Initial resistance to passive extension followed by a sudden release of resistance
What does clasp-knife spasticity mean?
UMN lesion
Internal capsule stroke would have what signs?
Pure motor weakness affecting the c/l arm, leg, and lower face, c/l clasp-knife spasticity and hyperreflexia
Putamen lesion signs
C/l tremor, bradykinesia, and rigidity
Globus pallidus external segment lesion
Decreased movement, external segment inhibits STN which stims Gpi to inhibit the thalamus
Gpe Lesion: STN is not inhibited so it stims Gpi to inhibit the thalamus. no motion
Globus palidus internal segment lesion
Excessive movement
Internal segment inhibits thalamus, so lesion would disinhibit thalamus
Direct pathway does what to Gpi?
Inhibits Gpi-> disinhibits thalamus to move
Indirect pathway does what to Gpi?
Decreases stim of Gpi-> disinhibits thalamus to move
Direct pathway of basal ganglia
Substantia nigra -> increase (+) putamen -> increase (-) Gpi -> decrease (-) thalamus -> motion
Indirect pathway of basal ganglia
Substantia nigra -> increase (-) putamen -> decrease (-) Gpe -> increase (-) STN -> decrease (+) Gpi -> decrease (-) Thalamus
Spastic diplegia, growth delay, frequent choreoathetoid movements
Arginase deficiency - Increase urea and ornithine from arginine
What is the adrenergic receptor on the uterus?
B2 agonists relax uterine muscle
What nerves innervates the external genitalia, the perineum, and the anus ?
Pudendal n.
What nerve innervates the pelvic floor muscles, external anal and urethral sphincters
Pudendal n.
Fecal and urinary incontinence following prolonged delivery due to what?
Pudendal n. stretch
Horner’s syndrome w/ u/l arm pn
Pancoast tumor
Which RNA polymerase is responsible for many mistakes in HCV?
RNA Pol III
Decreased 3’-5’ exonuclease proofreading
Prevent cerebral vasospasm following SAH w/ what med?
Nimodipine (CCB)
AchE in the amniotic fluid means what?
NTD, AchE and AFP are leaking out of the CSF
Tetrodotoxin MOA
Binds NA channels in nerve and cardiac cells. Flaccid paralysis
Tx of tetrodotoxin
Gut lavage and charcoal
What immune cells protect from local candidiasis?
T cells
What immune cells protect from systemic candidiasis?
Neutrophils
Result of Liddle Syndrome
Gain of fxn of ENaC in collecting duct HTN Hypokalemia Metabolic alkalosis Low aldosterone
ENac in collecting duct is constitutively turned on, what will be the level of aldosterone and the tx
Aldosterone will be low as Liddle syndrome acts like hyperaldosteronism, so RAAS is turned down
Tx w/ amiloride, which blocks ENac
What is in the capsule of pseudomonas?
P. aeruginosa has exopolysaccharide capsule (alginate)
What does alginate form pseudomonas do?
Inhibits ciliary clearance, allows for bacteria to adhere to one another and prevents phagocytosis. Ab to alginate do not clear it
X, Y, and Z in the kidney, the plasma conc is increased, The clearance changes with constant GFR: X up, Y constant, Z down. What are the substances
X- As glucose plasma conc increases the glucose transporter becomes saturated (limited reabsorption) and more glucose gets filtered
Y- Inulin, not secreted or reabsorbed, independent of plasma concentration, only depends on GFR
Z- PAH, secreted into the lumen, when plasma conc increases the secretion transporter gets saturated and clearance decreases
What part of the esophagus is affected in dermatomyositis?
Upper 1/3 of the esophagus. Preference for striated muscle under voluntary control
