test #37 4.27 Flashcards
where are B1 receptors located
cardiac tissue and renal juxtaglomerular cells
main effect of beta blockers on blood pressure?
reduced renin release from juxtaglomerular cells in kidney
three presentations of ascension of gonorrhea / chlamydia..
- PID: purulent cervical discharge and cervical motion tenderness
- salpingitis & tubo-ovarian abscess
- peritoneal inflammation, including Fitz-Hugh-Curtis syndrome – from inflammation of hepatic capsule
Fitz-Hugh-capsule
associated w/ PID (gonorrhea / chlamydia ascension).
infection of liver capsule and “violin-string” adhesions of peritoneum to liver
two options for treating chlamydia
azithromycin or doxycycline
how long should people attempt to conceive before seeking medical intervention?
at least 1 year
when does advanced maternal age become a factor in ability to conceive
after 35 y/o
aging of oocytes & decreased ovarian reserve of oocytes
normal thickness of right ventricle? left?
right: 3-4mm
left: 1cm
definition of cor pulmonale
right ventricular hypertrophy caused by pulmonary HTN
w/ or w/o congestive heart failure
most common cause of pulmonary HTN
obliteration of segments of pulmonary vasculature by COPD
primary pulmonary HTN
young women, between 20-40y.o
mutation in BMPR2.
can no longer limit progressive proliferation of endothelial, smooth muscle, and intimal cells.
striking medial hypertrophy or arterioles and small arteries, as well as concentric laminar intimal fibrosis
what does the hemiazygous drain
blood from posterior walls of the thorax and abdomen
azygous + hemiazygous + accessory hemiazygous provide alternate path for blood to return to HEART, bypassing IVC
right gonadal vein & adrenal vein & renal vein drain? left?
right gonadal, renal, and adrenal drain directly into IVC
left gonadal and adrenal drain into RENAL VEIN, which passes between aorta & SMA into IVC
heteroplasmy refers to..
condition of having different organellar genomes within a single cell (mutated and wild-type)
MELAS
mitochondrial encephalopathy, lactic acidosis, stroke-like symptoms
mitochondrial disease (heteroplasmy)
Leber hereditary optic neuropathy
mitochondrial disease (heteroplasmy)
MERRF
myoclonic epilepsy, ragged red fibers (gomori trichrome stain)
Mccune-Albright syndrome inheritence
precocious puberty
polyostotic fibrous dysplasia
unilateral cafe au lait spot
mosaicism: post-zygotic mutation in somatic cells in GNAS-1
when a patient has hypertension, hyperlipidemia, coronary artery bypass surgery, and carotid endartectomy history.. suggests he suffers from..
generalized atherosclerosis
presentation of chronic mesenteric ischemia? due to? light microscopy
atherosclerotic narrowing of celiac trunk, SMA, and IMA
- epigastric or periumbilical abdominal pain (30-60min after food intake)
- - atherosclerotic arteries not able to dilate in response to increased blood flow requirements during digestion/absorption of food. - weight loss: hurts so bad, avoid eating.
pain out of proportion to exam! physical exam will seem bland
light microscopy: hypoperfused areas show mucosal atrophy and loss of villi. atherosclerotic plaques.
[similar pathogenesis to angina pectoris]
epigastric pain 30-40min post meal. weight loss b/c hurts so much to eat. in hyperlipidemic person.
chronic mesenteric ischemia
bony matrix consists of..
- inorganic: hydroxyapatite crystals
2. organic: type 1 collagen
osteogenesis imperfecta has an abnormality in which part of bone
bony MATRIX
supposed to give flexibility
autosomal dominant
complexity of eukaryotic genome due to..
presence of large number of non-coding DNA regions between coding regions (not just size)
glucokinase is located in..
pancreatic B cells and liver
glucokinase vs. hexokinase
glucokinase (pancreatic beta cell): higher Km, less sensitive to allosteric inhibition
[less affinity for glucose than hexokinase]
glucokinase deficiency in beta pancreatic cells
impaired glucose sensor in beta-pancreatic cells.
beta cells can’t convert glucose -> ATP -> close K+ channels -> depol and release INSULIN
—> insulin deficiency –> diabetes!
inactivating mutations in glucokinase can be exacerbated in..
pregnancy! one cause of gestational diabetes
(MODY) maturity onset diabetes of the young
MODY
maturity onset diabetes of the young.
exacerbated by pregnancy
inactivating mutation in glucokinase.
poor glucose sensor in pancreatic beta cells, poor insulin release –> diabetes!
all cutaneous lymph from umbillicus to feet (including external genitalia & anus up to dentate line) drain to..
superficial inguinal nodes
NOT testes, glans penis, and cutaneous portion of posterior calf
branches of IMA
left colic, sigmoid, and superior rectal
how much vibrio does one need to ingest for infection?
a lot, 10^10 from water (bc acid sensitive)
recall: likes alkaline environment!
10^6 if from food bc buffering capacity.
if achlorydia, i.e. on omeprazole, need far less vibrio
ADH is made in..
supraoptic nucleus
oxytocin production is made in..
paraventricular
how are posterior pituitary hormones released into systemic circulation
BOTH hormones and neurphysins secreted into hypohysial vein to enter systemic circulation
(intravesicular protein used to transport hormones from hypothalamus into posterior pituitary)
anterior to pituitary? posterior?
anterior: optic chiasm
posterior: mamillary body
neurphysins
proteins involved in posttranslational processing of oxytocin and vasopressin.
released into circulation w/ posterior pituitary hormones (hypophyseal vein)
how does chloramphenicol work? major side effect?
binding to ribosomal 50S subunit, inhibits peptidyl-transferase
side effect: aplastic anemia
major side effect of clindamycin
pseudomembranous colitis (c. diff)
disulfram-like rxn post which drug?
metronidazole
AV fistula
abnormal communication between artery & vein, bypassing arteriole (major source of resistance in vascular system)
allows blood under ARTERIAL pressure –> venous system
presentation: pulsatile mass w/ thrill on palpitation. auscultation -> constant bruit.
AV shunt on pressure-volume loop in left ventricle
- increased preload (increased rate and volume of blood flow)
- reduced afterload (bypass arteriole)
true vs. false diverticula
true: all 3 layers: have mucosa, submucosa, muscularis, and serosa layers
false: mucosa & submucosa only. protrustion through wall
true or false diverticulum: Meckel’s? Zenkers?
Meckels: true (also appendix)
Zenker’s: false (also common colonic diverticula)
when does the vitillene (omphalomesenteric) duct normally obliterate
7th week of fetal life
rule of 2’s w/ Meckel’s diverticulum?
2% of population 2 feet from ileocecal valve 2 inches in length 2% asymptomatic male 2x more affect 2 types of tissue possible: gastric / pancreatic
false / pulsion diverticulum are missing..
muscularis
only has mucosa and submucosa
usu herniation through muscularis layer
dysmenorrhea, dyspareunia, dyschezia with normal sized uterus? large uterus?
regular sized uterus: endometriosis
enlarged uterus: consider adenomyosis
adenomyosis
extension of endometrial tissue into uterine myometrium
dysmenorrhia, menorrhagia.
uniformed ENLARGED, SOFT globular uterus
tx: hysterectomy
physical exam of endometriosis?
ectopic collections of blood. blood undergoes hemolysis –> inflammation –> adhesions & distortion of organs
physical exam:
- nodularity of uterosacral ligaments
- fixed retroversion of uterus
explain symptoms of endometriosis
dysmenorrhea: shedding of ectopic tissue causes pain
dyspareunia: due to retroversion of uterus & endometrial implants on uterosacral ligaments
dyschezia: painful defecation due to pelvic adhesions
difficulty conceiving: adhesions in ovaries & fallopian tubes
note: ectopic endometrial tissue also interferes w/ ovulation & tubal function.
uterine malposition
retroversion is most common type. usu asymptomatic.
presentation of adenomyosis
dysmenorrhea (painful menses), abnormal bleeding, w/ LARGER uterus
major side effect of SSRI
sexual dysfunction
urinary retention is a side effect of drugs w/
antimuscarinic effects (i.e. TCA)
how to TCA’s lead to orthostatic hypotension
anti alpha adrenergic effects
TCA side effects
- antimuscarinic: urinary retention
- anti alpha adrenergic: orthostatic hypotension
- antihistamine: sedation
- cardiac arrythmia
- seizure (antihstamine, antimuscarinic, anesthetic)
what contains dihydrouracil, thymidine, acetylcytosine residues? significance?
tRNA
T arm: important for tRNA binding to ribosome.
3’ end of tRNA
CCA
links to amino acids via aminoacetylation
D arm of tRNA
dihydrouracil residues
important for tRNA recognition by correct aminoacyl tRNA synthetases
what is the only RNA species that contains thymidine
tRNA
t arm
(thymidine, pseudouracil, acetylcysteine)
TATA box
binding of transcription factors: unwinding DNA and initiate separation of strands
what drug is contraindicated in individuals with low C1 esterase inhibitor?
ace inhibitors, worry about angioedema
hereditary angioedema
autosomal DOMINANT.
C1 esterase inhibitor deficiency
episodes of painless, non-putting, well-circumscribed edema
usu face, neck, lips and tongue.
internal organs may be involved.
angioedema of tracheobronchial tree can cause respiratory obstruction. potentially fatal.
angioedema of GI tract: abdominal pain, vomiting, and diarrhea
normal function of c1 esterase inhibitor (2). problem in c1 esterase inhibitor deficiency
- block c1 complement activation
- inhibits kallikrein
(prevents kallikrein from converting kininogen –> bradykinin)
in deficient state, kallikrein is high, leading to elevated bradykinin.
bradykinin + c3a + c5a –> angioedema
kallikrein 2 roles
- convert plasminogen -> plasmin. which converts fibrin -> fibrin split products. which activates C1
- convert kininogen -> bradykinin -> angioedema
why are ace inhibitors contraindicated in c1 esterase inhibitor deficiency?
c1 esterase inhibitor deficiency has elevated bradykinin
ACE inhibitors elevate bradykinin
both -> angioedema
toxicity of methotrexate (3)
hepatitis, pulmonary fibrosis, bone marrow suppression
most commonly dislocated joint in body?
glenohumeral joint, esp anterior.
shallow articulation between humeral head and glenoid fossa of scapula
anterior dislocation of humerus
results from forceful external rotation and abduction of arm at shoulder.
axillary n damage –> teres minor, deltoid, and cutaneous lateral aspect of arm
acromioclavicular joint subluxation
downward blow on tip of shoulder. produces swelling and upward displacement of clavicle. not associated w/ specific nerve injury
spiral humeral midshaft fracture
result from torsion produce from fall on outstretched hand
radial n damage
fracture of coracoid process
rare. usu people who engage in shotgun or rifle-related shorts
efficacy of oral contraceptives
MOSTLY bc estrogen blocks midcycle gonadotropin surge, inhibiting ovulation.
progesterone: 1. counteract increased risk of endometrial cancer w/ unopposed estrogen 2. also decreases permeability of cervical mucus to sperm 3. also inhibits endometrial proliferation needed for implantation
serious risk w/ oral contraception
deep vein thrombosis, PE, ischemic stroke, MI
increased in SMOKERS over the age of 35. ESPECIALLY smoking status.
absolute contraindications to use of OCP (6)
- prior history of thromboemolic event/stroke
- history of estrogen-dependent tunmor
- over 35 y/o & smoke heavily
- hypertriglyceridemia
- decompensated or active liver disease (impair steroid metabolism)
- pregnancy
4 signs of lead poisioning
LEAD Sucks\
lead lines, encephalopathy & erythrocyte stippling, abdominal colic and sideroblastic anemia, drops: foot and wrist, rx: dimercaprol and edta. succimer for kids
- colicky abdominal pain, constipation, headaches, impaired concentration, defecits in short-term memory.
- bluish pigmentation at gum-tooth line & metaphyses of long bones (bruton lines)
- wrist drop or foot drop due to peripheral neuropathy
- microcytic hypochromic anemia & basophilic stippling on peripheral smear.
ways to be exposed to lead
manufacture of batteries, alloys, ammunition.
mining, smelting, chemical processing, recycling, spray painting, radiator repair
4 stages of iron poisioning
- nausea, diarrhea, abdominal pain. w/ hemorrhage, hypovolemia, and shock in severe cases.
- GI symptoms resolve, patient seems better
- metabolic acidosis, hepatic dysfunction, hypoglycemia
- scarring o the recovering GI tract
toxic metabolite of methanol
formaldehyde, formic acid
toxic metabolite of ethylene glycol
oxalic acid
cause of on-off phenomenon of L-dopa/carbidopa
unpredictable, dose-independent
describe on-off phenomenon of L-dopa/carbidopa
dyskinesia after dose, akinesia between doses
sudden loss of anti-parkinsonian effects of L-dopa –> hypokinesia and rigidity.
usu after long-term administration
wearing off phenomenon of L-dopa/carbidopa
progressive destruction of striatonigral dopaminergic neurons over a period of time.
dose dependent & predictable (vs. on off phenomenon)
histology of both lymphatics and glomerular capillaries
SINGLE layer of endothelial cells. junction between –> allow passage of molecules, fluid, and electrolytes.
[podocytes also there in glomerulus]
rx for borrelia burgdorferi (2)
doxycylcine or ceftriaxone (penicillin-type antibiotics)
phases of lyme disease
(1) early localized: days to weeks post exposure: flu like symptoms, characterestic erythema migrans
(2) early disseminated: CNS or cardiac (bell’s palsy, AV block)
(3) chronic: months to years, if not given antibiotics, asymmetric arthritis (usu involving single knee joint) and/or subacute encephalopathy (decreased memory, somnolence, mood change)
excessive dopamin blockade in striatum leads to excessive..
excitatory cholinergic M1 activity
rx: acute dystonia etc: benztropine adnd diphenhydramine
antipsychotic w/ highest H1 blockade
chlorpromazine and clozapine
low potency antipsychotics. greater risk of..
chlorpromazine, thioridazine
lower potency at D2 receptors.
– nonneurologic side effects: anticholinergic, antihistamine, anti-alpha1 adrenergic
high potency antipsychotics. greater risk of
trifluoperazine, fluphenazine, haloperidol
higher potency at D2 receptors
more EPS symptoms
testing for t. pallidium
first: RPR/VDRL
mixes pt serum w/ cardiolipin, cholesterol and lecithin.
[these are human cellular lipids released into blood stream after cell destruction by t. pallidum
nonspecific: positive in all subspecies of t. pallidum (yaws, pintal, bejel..)
also VDRL: common false positives
Viruses (EBV, hepatitis), drugs, rheumatic fever, lupus
second: specific.
FTA-ABs
indirect immunofluorescence of patients serum mixed w/ whole killed T. pallidum.
common false positives w/ VDRL?
virus (EBV, hepatitis)
drugs
rheumatic fever
lupus
rheumatoid factor
anti-Fc IgM.
positive in most cases of rheumatoid arthritis,
presence does not definitively established.
absence does not definitively exclude.
cold agglutins test for..
mycoplasma infection
blood added to a tube w/ EDTA, placed in ice –> agglutinate
most common cause of death in patient hospitalized for MI
ventricular failure (cardiogenic shock)
what might be protective against ventricular free wall rupture 3-7 days post MI?
LV hypertrophy and prior MI
crystals in pseudogout? aspirate shows? joint involved
rhomboid weakly + birefringent (blue) in polarized light & neutrophils
calcium pyrophosphate
often large joint (knee)
parinaud syndrome (dorsal midbrain synrdrome)
paralysis of upward gaze
consistent w/ tumor in pineal region
most common tumor of pineal gland
GERMINOMA; originate from embryonic germ cells.
usu kids, strong male preponderance.
secrete b-hCG –> precocious puberty
presentation of pineal germinoma
(1) precocious puberty in male, due to b-hCG
(2) obstructive hydrocephalus (aqueductal stenosis)
(3) parinaud syndrome: paralysis of upward gaze and convergence, compression of tectal (superior colliculus)
presentation of locked-in syndrome
spastic quadriplegia (loss of upper motor neurons in pons)
paralysis of most cranial nerves (damage to nuclei)
basic lateral medullary syndrome
contralateral loss of pain & temperature
ipsilateral paralysis of CN V, IX, X, XI
dysphagia and hoarseness
don’t PICA hoarse that can’t eat
basic medial medullary syndrome
contralateral spastic paralysis
ipsilateral flaccid paralysis of tongue
most common location for brain germinomas
pineal gland (histologically similar to testicular seminomas)
lateral pontine syndrome
AICA lesion
facial droop means AICA is pooped
test for prinzmetal angina
ergonovine.
most sensitive provative diagnostic test for coronary vasospasm.
ergot alkaloid, constricts vascular smooth muscle by stimulating both alpha-adrenergic and 5-HT receptors.
induces coronary spasm, chest pain, and ST-segment elevation
rx for prinzmetal angina
amlodipine
calcium channel blocker
3 morphologic variants of pneumonia
bronchopneumonia
- patchy inflammation of a number of lobules
interstitial pneumonia
- inflammatory infiltrate in alveolar walls
lobar pneumonia
- involves entire loung lobe
4 stages of lobar pneumonia
congestion (24 hr)
- red heavy boggy
- vascular dilation
- alveolar BACTERIAL exudate
red hepatization (day 2-3)
- red, firm lobe (liver-like)
- alveolar exudate: erythrocytes, neutrophils, fibrin
gray hepatization (day 4-6)
- gray-brown, firm lobe
- RBC disintegrate
- alveolar exudate contains neutrophils and fibrin
resolution
- restoration of normal architecture
- enzymatic digestion of exudate
[fibrinous exudates may not resorb completely –> REORGANIZATION: may lead to development of pleural adhesions
acute pyelo normally caused by
e. coli
klebsiella
proteus
enerococci
defense mechanism of bladder
- bladder mucosa normally does not allow bacterial attachment
- normal urine is bactericidal (high urea, high osmolarity
- urine flow washes bacteria downstream
cystitis: disruption of these mechanisms or overcome by bacterial virulence factors
pathogenesis of lower UTI (3)
development of acute pyelo?
lower UTI:
- supression of endogenous flora
- colonization of distal urethra by pathogenic gram negative rods
- attachment to bladder mucosa
pyelo: anatomic / functional vesicuuretral reflux! (hematogenous spread less common)
cystitis, and urine has ammonia scent –>
suggests proteus mirabilis infxn
thyroidization of the kidney suggests
chronic pyelonephritis
tubules w/ eosinophilic casts.
location of gastrinomas
neuroendocrine tumor pancreas peripancreatic tissue around head duodenum. results in gastrointestinal ulcers in unusual locations (i.e. postbulbal duodenum and jejuneum
newly diagnosed gastrinoma must be worked up for..
serum calcium, PTH, and pituitary hormones
bc of association with MEN-1
necrolytic migratory erythema
raised erythematous rash, typically in groin area.
associated w/ pancreatic glucagonoma
measure of visceral fat to subcutaneous fat?
waist-to-hip ratio
waist: viscera
hip: subcutaneous fat
high ratio, associated w/ insulin resistance
presentation of bronchioloalveolar carcinoma
uncommon, 10% of all
pneumonia-like consolidation. can expectorate pale tan fluid
rheumatoid lung disease
pulmonary fibrosis
auscultation of pulmonary fibrosis
end inspiratory rales at lung bases
etiology of pulmonary HTN in patient secondatry to left-sided heart failure
reactive vasoconstriction due to venous congestion
increase pulmonary venous congestion –> capillary leak (increased hydrostatic pressure) –> pulmonary edema.
edema causes alveolar collapse & decreased ventilation –> hypoxemia.
reactive vasoconstriction occurs in order to shunt blood to areas w/ better ventilation.
most common cause of left ventricular diastolic dysfunction?
chronic HTN.
concentric LV hypertrophy, decreases LV diastolic compliance.
as a result: steady state LV filling pressures rise to maintain SV & CO –> LA pressure elevation –> pulmonary venous congestion
etiology of pulmonary HTN secondary to COPD
respiratory hypoxia-induced vasoconstriction
leads to polycythemia and obliteration of vasculature –> compounding increased pulmonary aterial pressure.
increased flow volume and pressure in pulmonary vasculature results secondary to..
left-to-right shunt
large VSD or ASF
–> pulmonary HTN
pyruvate kinase
converts PEP to pyruvate
phosphoenolpyruvate –> pyruvate\
allosterically stimulated by F1,6BP (made from F6P from PFK), says: glycolysis is happening
pyruvate kinase deficicency
can’t get maximal ATP from glycolysis (no TCA)
defective maintenance of RBC architecture bc low ATP.
splenomegaly – work hypertrophy
work hypertrophy of spleen
hypertrophy of reticuloendothelial cells of splenic parenchyma (involved in removal of damaged RBC)
skeletal abnormalities of marfans
long extremities
long tapering fingers
spinal scoliosis and/or kyphosis
1st cause of death in Marfan’s. 2nd?
1: aortic dissection
2. cardiac failure (secondary to mitral and/or aortic regurg from prolapse or dilation of aorta)
receptor changes w/ long-tern ethanol use (3)
- downregulation of GABA
- normally binds & potentiates effects - upregulation of NMDA receptor
- normally inhibits NMDA - increase synthesis of excitatory mediaors: NE, 5-HT, dopamine
leads to tolerance (need to increase dose to get desirable effect) and withdrawal upon cessation. –> substance dependence
timing of alcohol withdrawal.
starts 5-10 hours after last drink
intensifies in 2-3 days
subside by 4-5
most common manifestation of alcohol withdrawal?
the shakes – tremulousness
also:
- autonomic dysfunction (increased HR, respiration, body temp)
- GI distress (nausea, vomiting)
- insomnia, agitation, anxiety
tonic clonic seizure in alcohol withdrawal
in <5% of people.
occur within 48 hours
delirium tremens
fluctuant arousal levels, potentially FATAL.
begin 48-72 hours after last drink.
also: severe sympathetic hyperactivity (BP, body temp, perspiration), hallucinations: like FORMICATION, and confusion
alcoholic hallucinations
affect <25% of alcoholics in withdrawal
carcinoid tumors arise from
enterochromaffin (endocrine) cells of intestinal mucosa
to be symptomatic from carcinoid tumor..
it must have metastazied to liver OR be extraintestinal
if GI only, will be metabolized to inactive pieces.
symptoms of metastasized /extraintestinal carcinoid tumor
- vasomotor instability: cutaneous flushing, instability
- GI symptoms: secretory diarrhea, crampy abdominal pain
- bronchoconstriction
- right sided valvular heart disease
why are there no left sided heart issues w/ metastatic / extraintestinal carcinoid tumor?
lung has MAO – degraded vasoactive substances.
biliary atresia
complete obstruction of extrahepatic bile ducts
presents 3-4th week of life
dark urine, acholic stool, conjugated hyperbillirubinemia
liver biopsy:
- intrahepatic ductular proliferation
- portal tract edema
- parenchymal cholestasis
D-isoimmunization
hemolytic disease of newborn
Rh+ infant w/ Rh- mothers.
jaundice within 24 hrs of birth.
lab: unconjugated hyperbilirubinemia, hemolytic anemia, positive Coombs test
jaundice within 24 hrs of birth
hemolytic disease of newborn, D-isoimmunication (Rh+ infant w/ Rh- mama)
jaundice in 3-4th week of life
biliary atresia
jaundice AFTER 1st day of life, SUBSIDES 1 week later
physiologic jaundice
jaundice w/ stress (fasting, illness)
gilbert syndrome
reduced UDP-glucoronyl transferase
physiologic jaundice
after 1st day of life.
subsides after 1st week.
relatively mild unconjugated hyperbillirubinemia
cystic duct obstruction often leads to.. describe. complications
acute cholecystitis.
obstruction. fatty meal –> CCK –> contraction against obstruction –> tissue becomes inflamed (as a result of prostaglandin release and stony disruption to mucosal layer)
–> ischemic changes in edematous & distended organ –> followed by bacterial invasion
complications: gangrene and perforation w/ generalized peritonitis or well-circumscribed abscess
what does failed gallbladder visualization on HIDA (radionucleotide billary scan) suggest?
cannot visualize gallbladder: CYSTIC DUCT.
goes from liver –> bowel
suggests stone obstructing cystic duct.
bile cannot go from liver -> hepatic duct -> cystic duct
instead liver -> hepatic duct -> bile duct -> bowel
what does filling of gallbladder on HIDA but poor ejection suggest?
obstruction in common bile duct
cystic duct clear, bc liver bile -> hepatic duct -> cystic duct fine
gallstone visualization
ULTRASOUND
not enough calcium for X-ray
definitive diagnosis of acute cholecystitis
HIDA SCAN!
- lack of filling (cystic duct obst)
- lack of ejection (common duct obst)
just STONES on ultrasound is NOT sufficient (many have and are asymptomatic)
need: distended gallbladder, wall thickening, pericholescystic fluid, positive sonographic murphy
