The Big Doozie Flashcards
How do you differentiate between schizoaffective disorder and bipolar disorder with psychotic features?
In schizoaffective, psychoses happen in abscense of mood sx. In bipolar w/ psychotic, psychotic sx only happen during mood periods.
Pt has hx of rheumatic fever. What heart abnormality, and how does it present?
Mitral valve prolapse, LA enlargement, can compress esophagus (since LA is on posterior of heart against esophagus)
Attributes of right colon cancer, left colon cancer, and rectosigmoid cancer?
RCC=Weight loss, progressive fatigue, occult bleeding, B12 deficiency
LCC=Constipation/Diarrhea (obstructs the pathway more)
Rectosigmoid=hematochezia
For following structures, give embryologic origin: Kidneys Gi tract Liver Pancreas Spleen Adrenal Cortex Adrenal Medulla
Kidneys: Mesoderm GI tract: Endoderm Liver: Endoderm Pancreas: Endoderm Spleen: Mesoderm Adrenal Cortex: Mesoderm Adrenal Medulla: Neural crest (ectoderm)
Which l.n. drain the glans penis, the scrotum, and testes?
Penis: Deep inguinal
Scrotum: Superficial inguinal
Testes: Para-aortic
How is malignant hyperthermia treated and what is the MOA?
Treated w/ dantrolene.
It blocks intracellular calcium release, prevents further contraction
5 receptors involved in vomiting?
M1 muscarinic, D2 dopaminergic, H1 histaminic, 5HT3 serotinergic, Neurokinin 1 (NK1) receptors.
Fibrates MOA? Main use? What do they predidpose to?
MOA=upregulate lipoprotein lipase (LPL), increase triglyceride clearance (also causes decreased VLDL production). Main use=lower triglycerides.
Predispose: cholesterol gallstones (b/c decreased bile acid)
Does this by INHIBITING CHOLESTEROL 7-ALPHA HYDROXYLASE
Pt has large amplitude unvoluntary swinging movement of contralateral limb. Where has damage occurred? Potential cause?
This is hemiballismus. Location=subthalamic nucleus
Cause=Lacunar stroke.
Not Huntington’s those are low-amplitude movements (chorea). Caused by atrophy of caudate nucleus.
2 types of scleroderma and associated antibodies for each?
Diffuse: widespread, rapid. Scl-70 Ab (anti-DNA topoisomerase 1)
Limited: CREST syndrome. Anti-centromere Ab.
In someone who is starving, at one point does fuel source change from glycogenolysis to gluconeogenesis?
After 12-18 hours (so if past one day, it’s gluconeogenesis. Involves Oxaloacetate to phosphoenolpyruvate.
What happens once the ribosome interacts with the stop codon?
A release factor binds to the ribosome and the finished script is released from the ribosome.
How does mycoplasma pneumonia relate to erythrocytes?
Its cell membrane is similar to that of erythrocytes, so infection with this organism can lead to hemolytic anemia (which is complement-mediated and intravascular)
What is the positioning of the ureter in relation to:
Gonadal vessels
Internal iliac artery
Uterine artery
Posterior to gonadal vessels and uterine artery (water under the bridge).
Anterior to internal iliac artery.
Which subthalamic nucleus controls circadian rhythm and pineal gland function?
Suprachiasmatic
What is considered a normal A-a gradient?
5-15. If w/in those limits, it means that the problem is caused by alveolar hypoventilation, not the other 3 causes.
An ACTH suppression test doesn’t cause ACTH to decrease even at high doses. What is the likely cause?
Exogenous ACTH (such as from metastatic small cell lung cancer or something like that). It's not caused by a pituitary adenoma.
How is pulmonary arterial hypertension treated?
Definitively with transplant.
For the interim, with Bosentan (a competitive antagonist of endothelin receptors)
What 3 structures run along the anterior elbow?
Median nerve, Radial nerve, brachial artery.
Radial n. most likely injured w/ lateral displacement of fracture, Median n. injured w/ medial displacement
Where does the trachea lie in relation to the esophagus and vertebral bodies?
Between them. On CT, the esophagus doesn’t have a lumen (it’s usually compressed)
T or F?
Adenocarcinoma in situ of the lung involves invasion?
False.
No invasion of vascular or stromal tissue
Woman with Sjogrens (or RA) w/ pruritus and fatigue. Probable dx? Histologically looks like what other process?
Dx: Primary biliary cirrhosis (PBC)
Looks like Graft v. host disease
Both involve lymphocytic inflammation
Tetanus inhibits which neurotransmitters?
GABA and glycine.
Why do ppl w/ Crohn’s dx get gallstones?
Terminal ileum inflammation–>decreased bile reabsorption–>hyperconcentrated bile w/ cholesterol–> gall stones
A pt being treated w/ levodopa for Parkinson’s starts to have times when they freeze. Should you stop tx?
No. It’s hard to predict the response, but this is a side effect of tx and shouldn’t be stopped.
What causes glaucoma, and what is usually used to treat it?
Increased intraocular pressure due to increased aqueous humor production or decreased outflow. Aqueous humor is produced by the EPITHELIUM of the ciliary body. So tx targets that.
What functions as a glucose sensor within the cell?
Glucokinase. It detects glucose and signals for insulin release
Post MI, what is the most common cause of death?
Rupture of the ventricular wall which then leads to hypotension and cardiac tamponade.
What type of drug is neuroleptic malignancy syndrome caused by? What are some sx? Treatment?
Antipsychotic meds.
Fever, elevated Creatine kinase, muscle rigidity, autonomic dysregulation.
Treat w/ dantrolene (to antagonize ryanodine receptors)
What type of drugs (think receptor) are involved with orthostatic hypotension?
The alpha-1 adrenergic antagonists (-azosins)
What is the MOA of digoxin in treating atrial fibrillation?
It decreased AV node conduction by INCREASING PARASYMPATHETIC TONE.
It’s also a positive inotrope by inhibiting the sodium potassium ATPase pump
A previously healthy infant has an intracranial bleed. What is he likely low on, and what process is impaired?
Low on Vitamin K.
Impaired gamma carboxylation.
What’s the triad of Plummer-Vinson syndrome?
Iron deficiency anemia, esophageal webs, atrophic glossitis (DYSPHAGIA)
Also associated with shiny red tongue and spoon shaped nails (koilonychia).
Treat with iron supplementation
A child has a head MRI that shows intracranial calcifications. You were thinking a pituitary adenoma before that. Dx? Origin?
Dx: Craniopharyngioma.
Derived from remnants of Rathke pouch, which becomes the ANTERIOR PITUITARY
Most common childhood supratentorial tumor.
They commonly cause bitemporal hemianopia (blindness in the lateral half of both eyes) b/c they compress optic chiasm
Review sarcoidosis vs amyloidosis
Sarcoidosis: Lungs, African Americans, bilateral hilar adenopathy, constitutional sx, NON-caseating granulomas (vs TB which has caseating granulomas). HYPERCALCEMIA caused by activated neutrophils which cause increased intestinal absorption (PTH independent)–>the granulomas produce ACE 1,25 dihidroxy-cholecalciferol (active form of Vit D)
Amyloidosis: Kidneys
What properties of drugs make them more likely to be metabolized AND cleared by the liver?
Highly lipophilic with a high volume of distribution.
What structure do ACE inhibitors work on?
They work on the efferent arteriole (prevent them from constricting, thus decreasing the GFR)
What are the side effects of thiazolinediones (TDZs), used to treat diabetes by increasing insulin sensitivity?
Names of drugs and MOA?
Weight gain and edema (fluid retention)
Not the best for people with congestive heart failure.
Pioglitazone.
Reduce insulin resistance, bind peroxisome proliferator-activated-receptor-gamma, transcriptional regulation.
Take several days to weeks to kick in due to altered gene expression.
Where is a central line typically placed?
In the Superior Vena Cava
Mechanism of action of nitrates?
Common side effects of nitrates to take into account?
Activate guanylate cyclase and increase amounts of intracellular cGMP. These increased levels lead to dephosphorlyation of myosin light-chain, resulting in vascular smooth muscle relaxation.
Throbbing headache/flushing
What is Hartnup disease? How are neutral AAs involved?
AR disease, deficiency of neutral AA (tryptophan) leads to decreased absorption from gut, decreased niacin, pellagra-like symptoms.
Treat with niacin supplementation
How are CML and leukemoid reaction similar? How do they differ?
Both have increased myeloid precursor cells on blood smear. CML has low leukocyte alk phos level. Leukemoid reaction has normal or high leukocyte alk phos level.
CML-Philadelphia translocation (9:22), BCR-ABL.
If pt has carcinoid syndrome, where has metastasis had to have occurred?
What marker is diagnostic?
How is it treated?
To the liver (ie originate in intestine, but serotonin is metabolized there. If it metastasizes, then pt has symptoms).
Marker: 5-hydroxy… acid (5-HIAA)
Treated w Octreotide and surgery
Common cause of fecal incontinence post labor?
This nerve also senses pain involved w/ external hemmrhoids.
Pudendal nerve injury
Just think POOdendal
What part of brain determines personality?
Lesions to which side cause apathy/depression, and disinhibited behavior?
Frontal lobe=executive fnxn and personality.
Left sided=Apathy/depression
Right sided=Disinhibition
Benign disorder of sugar metabolism.
Which ones aren’t benign?
Benign=Fructokinase deficiency
Not benign=Aldolase B deficiency (hereditary fructose intolerance), Galactose-1-phosphate uridyl transferase deficiency (classic galactosemia)
Differentiate btwn 2 types of Chiari Malformations
Type 1: More mild. Low-lying cerebellar tonsils thru foramen magnum, headaches + cerebellar dysfnxn
Type 2: More severe. Downward displacement of cerebellum + medulla thru foramen magnum.
Kaposi Sarcoma shows what on biopsy?
Spindle cells, neovascularization, extravasation.
Causes diarrhea, esp in HIV pts.
What 3 changes pertaining to stool are seen in lactose intolerance?
Decreased pH (fermenting AAs), Increased breath hydrogen content, increased stool osmolality
What does silicosis impair?
It impairs the macrophages. Macrophages are necessary for fighting off TB.
A pt has breast cancer risk and osteoporosis. Best tx, tamoxifen or raloxifene?
Raloxifene–>opposes estrogen in breast, agonist at bone.
Tamoxifen–>also opposes estrogen in breast, some agonist at bone, but also creates risk for uterine cancer.
Where is contracture most likely to occur?
Palms, soles, anterior thorax, serious burns. Excess matrix metalloproteinase activity and myofibroblast accumulation.
Which portion of the spine does RA tend to affect?
The cervical spine.
If someone has hives, what would biopsy show?
Dermal edema
DS baby has an umbilical hernia. Normal? Tx?
Umbilical ring didn’t close properly. Usually self resolve.
What drugs should be avoided in ppl w/ decreased C1 esterase inhibitor levels?
ACE inhibitors.
Signs of C1 esterase inhibitor deficiency=angioedema
Differentiate btwn pathologic causes of U/L and B/L hearing loss.
U/L=Acoustic Schwannoma between Cerebellum and Lateral Pons.
B/L=Neurofibromatosis Type 2
What artery is occluded when a patient has either Broca or Wernicke aphasia?
Middle cerebral artery
What would cause longitudinal tears at the gastro-esophageal jxn?
Rapid changes in intra-abdominal pressure (ie lots of vomiting).
This is Mallory-Weiss tears. Seen in bulimics or alcoholics since they throw up a lot.
What role does cytochrome C play in apoptosis?
It’s a mitochondrial enzyme that activates caspases and indirectly brings about cell death via intrinsic apoptosis.
Do the campylobacter sketchy.
Do it!
What’s at the 3’ end of the tRNA?
CCA sequence
What is involved if there is skin necrosis after starting warfarin therapy?
A deficiency of Protein C (or Protein S). Due to a hypercoagulable state, and occlusion of the microvasculature
Differentiate btwn Niemann Pick and Tay-Sachs. What will accumulate in each?
Niemann-Pick: hepatosplenomegaly, cherry red spot. Sphingomyelin accumulates.
Tay-Sachs: NO hepatosplenomegaly, cherry red spot. GM2 ganglioside accumulates.
What is the mechanism of myasthenia gravis?
Autoantibodies against postsynaptic ach receptor. Reduced motor end plate potential
How do you treat people with overstimulation of muscarinic receptors in gut? (excessive cholinergic)
Scopalamine
Someone has excessive orotic acid. What is deficient?
Ornithine transcarbamylase. Most common Urea cycle disorder. X linked recessive. Interferes with ability to eliminate ammonia.
Will see increased orotic acid, decreased BUN, decreased citrulline, increased glutamine, NO MEGALOBLASTIC ANEMIA (vs orotic aciduria)
What is theophylline used for and what are the toxicities?
Not widely used, for asthma.
Toxicities: Seizures and arrhythmias (heart and brain)
In what situations can pulsus paradoxus be observed?
Cardiac tamponade, Asthma, Obstructive Sleep Apnea, Pericarditis, Croup
How are acute obstructive pulmonary exacerbations treated?
With beta-2-adrenergic receptor agonists.
Gs protein–>increased intracellular cAMP
How do methimazole and propylthiouracil both treat hyperthyroidism?
They both block the coupling. PTU also decreases peripheral conversion of T4 to T3.
Using gancicolvir and TMP-SMX increases odds of developing what?
Neutropenia.
Zidovudine does the same thing
What’s the pathogenesis of bacterial colonization on heart valves in strep viridans?
Fibrin deposition.
Sudden appearance of flat, dark cutaneous lesions on trunk and head. Dx? At risk of?
Dx: Seborrheic keratosis (common in old ppl)
Indicative of underlying malignancy
Hallmark of diastolic heart failure? Associations?
Elevated LV filling pressure. Associated w/ htn, obesity, infiltrative disorders (transthyretin-amyloidosis, sarcoidosis).
What muscle is innervated by the thoracodorsal nerve?
Latissimus Dorsi
What are hallmarks of anaplastic tumors?
They don’t have any resemblance to the tissue they originate from. Also contain numerous abnormal mitoses and giant tumor cells.
What’s the net effect of ribavirin? What is it used to treat?
Treats Hepatitis C.
It interferes with the duplication of viral genomic material.
How do dysplasia and carcinoma differ?
Dysplasia is reversible until it includes the basement membrane.
What structures are associated with the 1st, 2nd, and 3rd parts of the duodenum?
1st=1st lumbar verebra (only part that isn’t retroperitoneal)
2nd=head of pancreas, common bile duct
3rd=superior mesenteric vessels, uncinate process of pancreas
For what organism is dark-field microscopy used?
Treponema pallidum (which causes syphilis). Look for helical motile spirochetes.
What is etoposide used to treat? What is the difference between topoisomerase I and II?
Etoposide treats testicular and small cell lung cancer. It targets topoisomerase II.
Top I makes only nicks in a single strand of DNA.
Top II cuts both (to relieve tension). Etoposide prevents Top II from resealing the break, so the cells get killed b/c their DNA is chopped up. (Podophyllin does the same thing, but to treat genital warts)
What effect do nitrites have on hemoglobin?
In what situation would you give someone nitrites?
They cause it to switch to the methemoglobin form (which can’t carry O2, binds to cyanide). The partial pressure of O2 in blood remains same.
Give them nitrites in cyanide poisoning to get cyanide off of the cytochrome in mitochondria
What type of mutation causes HbS and HbC?
Missense mutations.
HbS=Glu->Val (even more positive)
HbC=Glu->Lys (even more positive)
Remember: Missense is when only one is substituted. Nonsense can’t make sense b/c it stops early. Missense is just a mistake.
All exclusively breastfed newborns should be supplemented with what vitamins? (hint, one is a one-time thing, one is continual for first 6 months)
Vitamin D supplementation
Vitamin K injection (one time)
What does leuprolide used for, and how does it work?
It’s a GnRH analog. It can either be pro-androgen (pulsatile therapy) or anti-androgen (continuous therapy ie for prostate cancer or precocious puberty).
Most common NNRTIs?
Nevirapine, Efavirenz
What eye finding would you expect to see with uncal herniation secondary to increased intracranial pressure?
CN III palsy. Fixed dilated pupil (damage to parasympathetic fibers)
Recurring calcium oxalate kidney stones. Tx?
Thiazide diuretics (increased calcium reabsorption). Don’t use if hypercalcemic.
Which cytokine is involved in cachexia? (Muscle wasting) What do the following do? Interferon alpha IL-3 TGF-beta
TNF-alpha.
Interferon alpha: synth by leukocytes. Antiviral and antitumor
IL-3: activated by CD4 cells. Myeloid cell growth (bone marrow stimulation)
TGF-beta: inhibits inflammatory response (T cells, cytokines)
Differentiate btwn:
Simple/Complex partial seizures
Partial/Generalized seizures
Simple: maintain consciousness
Complex: impaired consciousness
Partial: Only single area of brain (usually medial temporal lobe)
Generalized: Diffuse
What test is used to test for fat in stool?
Stool microscopy w/ Sudan III stain
Give quick summary of nephrotic syndrome.
Increased glomerular permeability–>major loss of protein–>drop in colloid osmotic pressure–>fluid moves into interstitium (edema)–>increased aldosterone (replenish fluid in vasculature)–>increased protein production in liver
Which drug should be used to treat atropine toxicity?
Physostigmine (Physostigmine “Phyxes” atropine overdose)–>penetrates CNS as well as periphery.
Neostigmine=NO CNS.
Bot are anticholinesterases
What is the cancer marker CA-125 strongly associated with?
Epithelial ovarian neoplasms (serous and mucinous cystadenocarcinomas).
MOA of anastrozole, used to treat breast cancer w/ ER mutation.
It’s an aromatase inhibitor–>decreases amount of estrogen, pretty effective.
Meds that diminish the degradation of Ach are beneficial in Alzheimer’s. Why?
Ach is decreased in basal nucleus of Meynert and hippocampus in Alz due to decreased act. of choline acetyltransferase.
What’s a scotoma?
It’s a visual defect that occurs due to pathological process.
Pt has swollen erythematous joint w/ fever and reduced ROM. Dx? Next steps?
Synovitis. Tap the joint and test it.
Don’t leave untreated–>fever and severe pain tip you off to serious process, NSAIDs won’t cut it.
Parakeratotic stratum corneum, esp. on elbows.
Psoriasis
What’s the mechanism of ionizing radiation?
It causes double-strand breaks in the DNA and formation of oxygen free radicals.
Differentiate btwn IL-4 and IL-5
IL-4: produced by Th2 helper cells. Facilitates growth of B cells and T helper lymphocytes. Stimulates antibody switching (esp IgE)
IL-5: B cell differentiation, stimulates IgA production and eosinophil activity. Important in parasitic infections
What is Corynebacterium diphtheriae grown on?
Cysteine-tellurite agar (grows black). Remember exudate is grayish color.
Carbidopa is added to levodopa. What side fx will get worse?
What is Entacapone used for?
Anxiety & agitation. Carbidopa increases availability in CNS, decreases in periphery. Improves most side fx. However, these get worse bc they are central
*entacapone is often added later on, it also decreases the peripheral conversion
White spots w/ erythematous center in buccal mucosa (Koplik spots).
Measles. Cough, Coryza, Conjunctivitis. Then spots. Then you get maculopapular rash that starts at head and moves down.
2 classes of dopamine agonists?
1) Ergot (bromocriptine)
2) Non-ergot (pramiprexole, ropinirole)
Why might a pregnant women have bad hypotension when supine?
Uterus compresses IVC, less venous return. Should lay on their left side.
What type of channel is blocked in CF?
ATP channel
Choosing between glipizide, glimepiride, and glyburide, which has lowest chance of causing hypoglycemia?
Glipizide (it’s short acting). Just gotta memorize that.
In EPI (exocrine pancreatic insufficiency), which process will still be normal?
The absorption of MONOSACCHARIDES (don’t require pancreatic enzymes to digest them).
Lipase, Amylase, trypsinogen, and stool fat content will all be irregular.
Between succinylcholine and the “curare” type drugs, which one is depolarizing and which is nondepolarizing?
Succinylcholine is depolarizing in phase I, then repolarized in phase II.
Curare drugs are nondepolarizing.
I don’t really understand this stuff.
When should you expect to hear a VSD, and what maneuver makes it more pronounced?
Hear a holosystolic murmur made worse by hand grip maneuver (increased systemic resistance, more left to right movement of blood)
Allopurinol is a chronic gout drug. It’s a xanthine oxidase inhibitor. What drugs does it increase concentration of?
Azathioprine and 6-Mercaptopurine (both metabolized by XO)
Why are beta-2 adrenergic agonists used in obstetrics?
Relaxes uterine muscle(tocolysis, inhibits contractions)–>can hold off labor for a little bit.
Which muscle(s) of rotator cuff cause ER?
Infraspinatus (and some teres minor).
Supraspinatus-abduction
teres minor-adduction/ER
Subscapularis-IR, adduction
Bell’s Palsy
Facial n paralysis. Unilateral paralysis.
Can’t smile, eyebrow sagging, can’t close eye. Decreased tear formation, decreased taste of ant 2/3 of tongue
For patients who don’t benefit more from meds in Parkinson’s, where should DBS be targeted?
To the subthalamic nucleus or globus pallidus INTERNUS
Pt with amenorrhea. Skinny, works out a lot. Why?
Decreased leptin, dysfunctional GnRH stimulation. Decreased LH, FSH, estradiol (Functional Hypothalamic Amenorrhea)
Which breast cancer marker is indicative of poor prognosis?
HER2
In which patients are corticoid tx first line for gout?
People w/ contraindications to cyclooxygenase inhibitors (NSAIDS) and colcichine (those are the usual first line treatments).
Differentiate b/w PDA and tetralogy of Fallot
PDA–>cyanosis in lower extremities.
Tetralogy–>the r-l shunt of VSD causes whole body cyanosis (problem is in the heart)
Patient has an elevated alk phos. What should you follow it up w/ to determine if liver is source?
gamma-glutamyl transpeptidase (this is specific to the liver)
Screen for this if looking for renal failure in diabetics
Albumin. Do serum dipstick looking for albumin.
Orotic acid, retardation, megaloblastic anemia. Dx, tx?
Dx: Orotic aciduria
Tx: Uridine supplementation
Most important opsonins
IgG and C3b
Thiazide diuretics lead to increased excretion of this. Causes…
Potassium. Causes hypokalemia and metabolic alkalosis (b/c hydrogen also excreted)
Puffer fish toxins block..
Depolarization (voltage gated sodium, blocks sodium influx)
RIght sided murmurs increase on…
lEft sided murmurs increase on…
rIght=Inspiration (tricuspid regurg)
lEft=Expiration (mitral regurg, VSD)
AST:ALT ratio in alcoholic pancreatitis? What else is indicative?
AST:ALT>2. Macrocytosis of RBCs is also indicative of alcoholic (vs acute pancreatitis)
Pt w/ RA, post intubation has flaccis paralysis. Cause?
Cerebral vertebrae subluxation
Hormone body produces that acts like diuretic.
ANP, released from atria
Where should thoracocentesis be performed?
Mid clavicular: between 6th and 8th rib
Mid axillary: between 8th and 10th
Paravertebral: btwn 10th and 12th
Glucocorticoid effect on liver?
Increased gluconeogensis and glycogenesis.
Biggest warning with lamotrigine (anti-epileptic)?
Steven Johnson syndrome-monitor for rash, more likely in kids.
What is blocked by a monoclonal antibody in HER2 mutations?
What is the name of the monoclonal antibody?
A tyrosine kinase receptor
Trastuzumab. It inhibits proliferation and promotes apoptosis
Nonsurgical management of gallstones?
Bile acid supplement–>more bile acid=less cholesterol concentration
TB drug that requires bacterial catalase peroxidase?
Isoniazid
Pt has urine that darkens upon it standing overnight, painful abd, polyneuropathy. Dx? Cause? When treated (w/ heme preparation), what is downregulated?
Acute intermittent porphyria, AD condition.
Porphobilinogen deficiency.
Give glucose or heme.
Heme downregulates aminolevulinate synthase (ALA synthase)
Pt has low EF. But then when bypass is performed, the function increases. What is likely cause?
Hibernating myocardium–>the dysfxn is resolved with revascularization
Cytokine crucial for wound healing
TGF-beta. It attracts fibroblasts.
Ristocetin shows decreased aggregation of platelets.
Von Willebrand factor deficiency
Urea cycle defect, increased ornithine. What should be limited in pt?
Protein
DS associated w/ what hematologic malignancy?
> 5 yrs old=ALL
<5 yrs old=Acute megakaryoblastic leukemia
What hormones are neurophysins involved with, and where are those hormones released from?
Involved with ADH (vasopressin) and oxytocin. Released from posterior pituitary.
Where do ACL and PCL originate and attach?
ACL: Orig @ ant lateral femoral condyle. Attach @ medial tibial plateau ANTERIOR to PCL. Prevents anterior movement of tibia related to femur.
PCL: Orig @ ant medial femoral condyle. Attach @ lateral tibial plateau POSTERIOR to ACL. Prevents posterior movement of tibia related to femur.
4 drugs for partial seizures, 4 for general seizures, 1 for absence.
Partial: CGPP (Carbamazepine, gabapentin, phenobarbital, pheytoin)
General: LLTV (Lamotrigine (stevn Johnson!), Levetiracetam, Topiramate, Valproate
Absence: Ethosuximide
Peripheral artery disease tx that blocks platelets and vasodilates.
Cilostazol.
Should also give aspirin or clopidogrel as antiplatelets to avoid coronary heart disease and stroke,
Hormone that keeps you thin, if you lose it you get obese?
Leptin–>the satiety hormone. LepTIN keeps you THIN
Ghrelin is the hunger hormone
Most common brain tumor in adults. Histology?
Glioblastoma multiforme (from asrocytes) Histo: Pseudopalisading pleomorphic tumor cells surround area of necrosis and hemorrhage
Acute bacterial arthritis in sexually active female. Cause?
N. Gonorrhea
If efferent arteriole constricts in kidney, what happens to GFR and FF?
GFR increases. FF increases.
Pt lost pain and temp sensation to UE. Dx? What is damaged?
Syringomyelia.
Central cystic dilation leads to damaged ventral white commissure and anterior horns. Associated w/ Chiari malformations.
Upper motor neuron signs w/ scoliosis would also indicate syringomyelia.
Antibiotic associated w/ reversible cytopenias and irreversible aplastic anemia.
Chloramphenicol. Binds bacterial 50s.
What are the following markers found on? CD4 CD8 CD15 CD16 CD19 and CD20
CD4: t helper cells
CD8: cytotoxic T cells
CD15: Granulocytes and Reed-Sternberg cells (Hodgkin Lymphoma)
CD16: Fc receptor on NK cells, neutrophils, macrophages.
CD 19 and 20: pre-B cells (19, 20 and 21 on mature B cells)
Wolf Parkinson White quick hits:
Delta wave, shortened PR interval, widened QRS.
Accessory pathway bypasses AV node, directly connects atria and ventricles.
Which drug classes prolong the QT interval? Of these, which is least likely to cause Torsades de Point?
Class IA sodim (Disopyramide, Procainamide, Quinidine) and Class III potassium (amiodarone, dronedarone) antiarrhythmics.
Amiodarone is least likely to cause Torsades de Point.
Clinical presentations of tertiary syphilis?
Cardiovascular symptoms, gummas.
Remember VDRL is indicative of syphilis
Neurotransmitter abnormalities in Huntington’s
Decreased Ach and GABA, Increased dopamine
remember atrophy of caudate nucleus
What type of drug metabolism would have bimodality?
Acetylation (there are slow and fast acetylators)
For the coronary arteries, give where you would see St elevations for MI:
LAD
Left Circumflex
Right Coronary
LAD: V1-V4, anteroseptal transmural ischemia
Left Circumflex: V5, V6 (possible I and aVL), transmural ischemia of lateral wall of LV
Right Coronary: II, III, aVF, posteroinferior wall of LV
Waxing and waning lymphadenopathy, most common indolent non-hodgkin lymphoma.
Follicular Lymphoma. B-cell origin.
t(14;18)
Overexpression of bcl-2 oncogene
Pt presents w/ jaundice and shortness of breath. Labs show both liver and lung abnormalities. Dx?
Alpha 1 antitrypsin deficiency. Cirrhosis and hepatocellular carcinoma are potential complications
What are bisphosphonates (-nates) similar in structure to? What is their MOA?
Similar to pyrophosphate
Disrupts osteoclast fxn by attaching to hydroxyapatite binding sites on bones (makes osteoclasts apoptose)
What are the targets of the following viruses?
CMV-->Cellular integrins EBV-->CR2 (CD21) HIV-->CD4/CXCR4/CCR5 Rabies-->Nicotinic Acetylcholine Receptor Rhinovirus-->ICAM1
Elevated propionic acid. Involved AA’s?
Valine, Isoleucine, Methionine, Threonine
Base excision repair sequence:
Glycosylase cleaves–>Endonuclease cleaves 5’ end–>Lyase cleaves 3’ end–>DNA Pol III–>Ligase
Sertoli cell fxn?
Produce inhibin–>suppress FSH
Also facilitate spermatogenesis. Loss of fxn would mean infertility
Difference between transference and displacement (psych)
Transference: Emotions for someone from the past moved to someone in present
Displacement: Emotions for someone in present moved to someone else in present
Alternate treatment for hypertriglyceridemia (besides fibrates)?
Niacin. It increases HDL, lowers LDL and triglycerides.
Side fx=increased prostaglandins (treated w/ aspirin)
Etanercept is a secondary treatment for rheumatoid arthritis. What is its MOA?
It is a soluble receptor decoy protein. It is a “deceptor”. Get it? Etanercept–>decept–>decoy?
What is a direct indicator of alveolar ventilation status?
PaCO2. If it is low, it means there is alveolar hyPER ventilation. If it’s high, it means there is alveolar hypoventilation.
What is the autonomic function of dopamine?
At low doses, dopamine binds to D1 receptors in renal vasculature and cause increases in GFR, RBF, and sodium excretion.
At higher doses, dopamine increases cardiac contracility by binding to beta-1 adrenergic receptors.
What do the vinca alkaloids (used as chemo) act on, and what phase of cell cycle do they lock cells in?
They act/inhibit microtubule formation. Thus, they arrest cells in M phase since the DNA can’t be pulled apart. Causes peripheral neuropathy.
MOA of benzodiazepines?
Open CNS GABAa receptor-chloride channels. (Keep open longer so choloride can move more).
Anticonvulsant, muscle relaxant, anxiolytic, hypnotic.
No bone marrow aspirated. Pancytopenia. Massive splenomegaly (red pulp). Dx? Histo findings?
Hairy cell leukemia.
Diagnosed by finding TRAP on flow cytometry.
Lymphocytes w/ cytoplasmic contractions on histo (like hair)
IV drug user dies. They have signs of endocarditis. What valve involed, and what would you expect to see on lungs?
Valve=Tricuspid valve
Lungs: Wedge shaped hemorrhagic lesions on periphery, secondary to septic pulmonary embolus.
The only place in GI tract where ulcers don’t have increased risk of carcinoma in same location.
Duodenum.
Type 1 error vs Type 2 error? How does power fit it?
Type 1 error (alpha): Probability of seeing a difference when there isn’t one in reality.
Type 2 error (beta): Probability of seeing no difference when one truly exists.
Power (1-beta): ability of a study to detect a difference when one really exists
Cardiac tissue conduction velocities, fastest to slowest.
Purkinje system–>atrial muscle–>ventricular muscle–>AV node.
“Park AT VENture AVenue”
Slowest in AV node so ventricle can fill during diastole.
Why are conjugate vaccines used?
To elicit a T cell response leading to long term immunity through memory B cells.
What are the source of amatoxins, and what do these toxins do?
Poisonous mushrooms. They inhibit RNA Pol II, thus preventing production of mRNA.
MOA and use of colcichine?
Acute gout and prophylactic gout drug.
It inhibits tubulin polymerization, messes up microtubules/cytoskeleton.
GI side effects
Brain mass causing early morning emesis and papilledema/headaches. Dx? Location?
Pineal gland tumor. Most likely a germinoma causing obstructive hydrocephalus. Suprasellar.
Potential problems w/ massive amounts of blood transfusion?
Citrate can chelate calcium, cause hypocalcemia.
Difference between heteroplasmy and penetrance?
Penetrance: Either you have the disease or you don’t.
Heteroplasmy: People have varying severities of the disease, seen in mitochondrial diseases b/c ppl inherit different amounts of maternal mitochondria
musculocutaneous n. muscles & sensory
forearm flexors (biceps, brachialis, coracobrachialis) sensory: lateral forearm
artery in head of femur, damage leads to avascular necrosis
medial circumflex a. (of profunda femoral)
What do LMW heparin and unfractionated heparin bind to?
LMW heparin (enoxaparin): antithrombin III, Factor Xa Unfractionated heparin: antithrombin III, Factor Xa, Thrombin (more effective)
Characteristics of ARPKD and ADPKD
ARPKD: Infantile. Congenital hepatic fibrosis. Can lead to Potter sequence. Systemic htn, progressive renal insufficiency, portal htn.
ADPKD: usually mutation in PKD1. Adult onset. Numerous huge cysts, flank pain, hematuria, htn. Extrarenal manifestation=Liver cysts (3rd to 4th decade)
Why is hydroxyurea used in sickle cell disease?
What about gardos channel blockers?
It leads to production of Hemoglobin F, less Hb S. Mechanism not understood. Used for pts with pain crises.
Gardos channel blockers block exit of water and potassium from cell, prevents dehydration and polymerization of RBCs.
Signs of Graves disease
exophthalmos (treated by high-dose GLUCOCORTICOIDS!), pretibial myxedema, periorbital edema, eye movement limitation.
In Graves, antibodies attack the TSH receptor in body.
Preferred treatment for open angle glaucoma
Topical prostaglandins–>they increase acqueous humor outflow
What blocks ascension of kidneys in horseshoe kidney? What is clinical sign of it?
The inferior mesenteric artery blocks it.
Frequent UTIs are a sign of it, associated w/ ureteropelvic obstruction, hydronephrosis, renal stones, infection, aneuploidy syndromes.
60 yo smoker hematuria, flank pain, polycythemia, palpable mass. Dx?
Renal cell carcinoma–>also one of the “silent” cancers, don’t catch it til it metastasizes.
Between polyclonal and monoclonal lymphocytic proliferation, which is most likely malignant?
Monoclonal–cells of one type are malignant.
Vitamin deficiency associated with eating too many egg whites.
Biotin (Vit B7). Avidin in egg whites binds biotin.
It’s a co-factor for carboxylation enzymes.
Used in conversion of pyruvate to oxaloacetate, results in lactic acidosis.
“Flame shaped retinal hemorrhage”
Caused by hypertension, causes unilateral vision problems.
Child, massive splenomegaly, pancytopenia, osteoporosis, macrophages w/ “wrinkled tissue paper.” Diagnosis? Deficiency?
Gaucher’s (high in Ashkenazi jews).
Beta-glucocerebrosidase deficiency.
AR lysosomal storage disorder.
Supplement with glucocerebrosidase.
Malignancy associated with myasthenia gravis
Thymoma
Vessels at risk after transverse cut in in rectus abdominis during C-section?
Inferior epigastric arteries (they are susceptible to hematoma)
Calcification of hilar l.n., birefringent particles visible, cmmon in certain industries.
Silicosis
What effect do beta blockers have on juxtaglomerular apparatus?
They block beta 1 receptors there. Normally those receptors release renin, but blockers block that and thus also lower Renin, Angiotensin II, Angiotensin I, and Aldosterone. They don’t have an effect on the ACE system, so don’t affect angiotensinogen or bradykinin..
Friederich Ataxia and Vitamin E deficiency look alike. What are the symptoms? (what kills ppl w/ friederich ataxia?)
Ataxia, Loss of position and vibration sense, loss of deep tendon reflexes.
Friederich Ataxia ppl die of heart issues (hypertrophic cardiomyopathy). It is caused by degeneration of spinocerebellar tracts.
What is it that makes methadone such an effective treatment for opioid addiction?
It’s a full mu-opioid agonist with a really long half life (less likely to have withdrawal symptoms)
Give 2 equations to calculate Renal Blood Flow
(Urine PAH*Urine flow rate)/Plasma PAH
or
(PAH clearance)/(1-hematocrit)
What is extramedullary hematopoiesis indicative of?
Some sort of hemolytic process (ie severe chronic hemolytic anemia, Beta-thalassemia)
Drug that slows heart rate with no effect on contractility or relaxation. Name of drug? MOA?
Ivabradine.
It selectively inhibits the funny channel (Na channel, Phase 4)
What causes greatest risk of death in Acute Rheumatic Fever?
Pancarditis–>myocarditis, cardiac dilation, heart failure, death.
What is RT-PCR used to detect?
Levels of mRNA in a sample.
Pathogenesis of black pigment gall stones?
Brown stones?
Increased amounts of unconjugated bilirubin in bile (ie secondary to chronic hemolysis, ileal disease).
Brown=biliary tract infections.
Mnemonic to differentiate between high and low potency antipsychotics?
TRy to Fly High (Trifluoperazine, Fluphenazine, Haloperiodol)–>neurologic side fx
Cheating THieves are low (Chlorpromazine, Thioridazine)–>non-neurologic side fx.
Crigler-Najjar vs Gilbert vs Dubin-Johnson
Crigler-Najjar: Unconjugated hyperbilirubinemia. Absent UDP (which converts unconj to conj bili). Jaundice w/ neuro symptoms (kernicterus=bilrubin deposits in brain)
Gilbert: Unconjugated hyperbilirubinemia, mild anemia, decreased levels of UDP.
Dubin-Johnson: Conjugated hyperbilirubinemia, defective liver excretion. Black liver. Benign. (Rotor’s=similar, milder, no black liver)
Mechanism of development of insulin resistance?
serine kinases in the beta subinit of insulin receptor get phosphorylated (induced by catecholamines, glucocorticoids, glucagon, TNF-alpha), which then prevents the downstream signaling that insulin binding to alpha receptors usually causes.
Head bobbing in cardiovascular problems
Widened pulse pressure, likely secondary to aortic regurgitation
Strawberry vs cherry hemangiomas
Strawberry=common in kids, they regress by age 5-7.
Cherry=most common in adults. Do not regress. Appear in adulthood.
Subarachnoid hemorrhage in pt w/ adult polycystic kidney disease. Give what to prevent cerebral vasospasm?
Berry aneurysm.
Give calcium channel blocker, specifically beine.
Berry aneurysm associated with ADPKD, Eherls Danlos Syndrome
Antifungal that changes composition of cell membrane, and involved CYP450
-Azole drugs.
Suppress synthesis of ergosterol. Also inhibit CYP450 oxidase system in humans.
Drug class used to lower LDL that causes hypertriglyceridemia?
Bile-acid binding resins. It’s b/c they inhibit the enterohepatic circulation of bile acids which increases production of triglycerides and causes hypertriglyceridemia
Cholestyramine, Colestipol, Colesevelam.
Signs of abusive head trauma (“shaking baby syndrome”)
Full anterior fontanelle, tearing of bridging veins and SAH, retinal hemorrhages, posterior rib fractures.
*note that if no Vit K supplementation occured, then that’s the leading differential
Which nerve (and subsequently muscle lesion) is at risk from thyroidectomy?
External branch of superior laryngeal nerve.
The cricothyroid muscle is at risk.
Relation of blood/gas coefficient to blood saturation and onset of action in inhaled anesthetics?
Lower blood/gas coef: High blood saturation, fast onset, lower potency
Higher blood/gas coef: Low blood sat, slow onset, high potency.
Why have monoclonal antibodies been devleoped to PD-1 and CTLA-4?
PD-1 and CTLA-4 are found on T cells and carry out cell death unless the cells they bind to have PD-L1 and B7 ligands that bind to those surface receptors. Cancerous cells overexpress PD-L1 and B7 to avoid immune system. By developing monoclonal antibodies to PD-1 and CTLA-4, it prevents tumor cells from being able to avoid the immune system.
Which arteries provide the lesser and greater curvatures of the stomach?
Lesser: Left and right gastric
Greater: Left and right gastroepiploic and short gastric
Differentiate between indirect and direct hernias.
Indirect: LATERAL to epigastric vessels. Protrude at deep inguinal ring.Continue into scrotum. Felt with tip of finger (thru external inguinal ring)
Direct: MEDIAL to vessels. Hesselbach triangle. Felt w/ pulp of finger.
MD’s don’t LIe.
Leukemia associated w/ 15:17 translocation and treatment.
APML (M3 version of AML).
Responds to all-trans retinoic acid.
Promyelocytes and intracytoplasmic Auer Rods, bleeding in setting of DIC, decreased fibrinogen
Also associated with promyelocyte leukemia gene (15:17)
Dry vs. wet age-related macular degeneration
Dry: gradual decrease in vision. Yellowish spots on pigment epithelum (“drusen spots”)
Wet: rapid loss of vision, neovascularization. Grayish green subretinal discoloration.
HLA Class I and II associated spondyloarthropathies:
Class I (HLA B27): Seronegative spondyloarthropathies-->Psoriatic arthritis, Ankylosing Spondylitis, IBD, Reactive Arthritis (PAIR) Class II: Rheumatoid Arthritis, T1DM, Celiac.
How do liver and skeletal muscle differ in terms of how glycogenolysis is initiated?
Liver: Epinephrine and glucagon bind Gs, increased cAMP phosphorylates PK which then activates glycogenolysis.
Skeletal Muscle: Contraction causes release of calcium which phosphorylates PK to activate glycogenolysis.
Rule of thumb for kidney function:
Creatinine doubles as GFR halves. (ie GFR 60—>30, Cr 1–>2).
Difference between paranoid and delusional personality disorder?
Paranoid: Distrusting, no specific delusions (ie don’t trust neighbors but don’t think they’re doing anything)
Delusional: Delusions for over a month, but otherwise functional. (ie don’t trust neighbors and think they are poisionig them)
Signs of mesothelioma:
Pleural effusion, pleural thickening, asbestos connection, psammoma bodies w/ numerous long slender microvilli and abundant tonofilaments.
Where does bleeding typically occur in intraventricular hemorrhage in premies?
The germinal matrix.
Hormone that is stored in liver that mobilizes fatty acids for metabolism in times of stress.
Hormone-sensitive lipase
Finger/thumb extension is weak, everything else ok. Nerve affected? Where does this nerve pass through?
Radial nerve. Passes through supinator canal.
Best drug for acute MI to slow down heart, decrease oxygen demand?
Cardioselective beta blocker (Beta-1 adrenergic blocker).
How to differentiate between all the types of beta blockers?
What is their general MOA?
Beta 1 selective antagonists: go from A to M (atenolol, betaxolol, esmolol, metoprolol.
Nonselective antagonists: go from N to Z (nadolol, pindolol, propranolol, timolol
Nonselective alpha and beta: Modifixed suffixes (-lol instead of -olol)
MOA: They inhibit the interaction between neurotransmitters and their receptors in adrenergic synapses.
Give vessels responsible for and characteristics of these issues: Epidural hematoma: Subdural hematoma: Subarachnoid hemorrhage: Intraparenchymal hemorrhage:
Epidural hematoma: middle meningeal artery. “Lucid interval”
Subdural hematoma: Bridging veins. Crescent-shaped hemorrhage. Midline shift.
Subarachnoid hemorrhage: Rupture of aneurysm (Berry aneurysm). “Worst headache of my life”. Treat with nimodipine (ca channel blocker)
Intraparenchymal hemorrhage: Systemic htn, amyloid angiopathy, recurrent lobar hemorrhagic stroke in elderly.
MOA of aspirin, NSAIDS, celecoxib, acetaminophen.
Aspirin: Irreversible COX1 and COX2 inhibition via acetylation.
NSAIDS: reversibly inhibit COX1 and COX2
Celecoxib: Reversibly inhibits COX2. Doesn’t cause GI side effects
Acetaminophen: reversibly inhibits COX, mainly in CNS (thus no anti-inflammatory effects)
Diuretic used for increased intracranial pressure. Toxicity?
Mannitol (acts on proximal straight tubule, an osmotic diuretic)
Toxicity: Pulmonary edema.
MOA of SSRIs?
Blockade of the serotonin transporter.
2nd generation antipsychotics are D2 and serotonin receptor antagonists.
Most common predisopsing factor for infective endocarditis?
Mitral valve prolapse (in developed countries) Rheumatic fever (in developing countries)
What motions do the cerebellar hemispheres control?
Ipsilateral motion. Lesions to a hemisphere would cause ipsilateral dysdiadokinesia
What are the cumulative effects of sickle cell disease on the spleen? Major sx of SCD?
Major atrophy and fibrosis due to repeated splenic infarctions (during times of crises).
Pain crises, dactylitis (swelling of hands and feet due to infarctions in bones of extremeties), intra and extravascular hemolysis.
How to keep where the branches of trigeminal nerve exit?
“Standing Room Only”
Superior orbital fissure (V1, CNIII, IV, VI)
Foramen Rotundum (CN V2)
Foramen Ovale (CN V3)
How to reverse atropine toxicity (excessive muscarinic activation)
Physostigmine (b/c it does both periphery and central)
Neostigmine has NO central.
What tissue are heart valves made of?
Connective tissue
Net effect of ACE inhibitors?
Increased Angiotensinogen, Angiotensin 1, Bradykinin (b/c ACE normally breaks down bradykinin)
Decreased Angiotensin II and Aldosterone.
Chronic lymphedema predisposes to…
Angiosarcoma (especially after mastectomy). Presents as firm violaceous nodules.
Distinguish between Th1 and Th2 helper cells.
Th1 cells: release IFN-gamma. Activate macrophages and cytotoxic T cells. Activated by IFN-gamma and IL-12 (from macrophages).
Involved in Crohn disease
Th2 cells: release IL-4, IL-5, IL-10, IL-13. Recruit eosinophils for parasite defense and promote IgE (from B cells). Activated by IL-4, inhibited by IFN-gamma.
Involved in Ulcerative Colitis
General mechanism of Regulatory T cells
They suppress CD4 and CD8 T-cell effector functions. Express CD3, CD4, CD25, and FOXP3.
When activated they produce anti-inflammatory cytokines (IL-10, TGF-beta)
Triad of McCune Albright Syndrome?
1) Endocrine disorders
2) Cafe au lait spots
3) Fibrous dysplasia of bone
International adoption (no newborn screening), blurry vision. Deficient enzyme?
Galactokinase deficiency–>accumulation of buildup of galactose and thus galactitol, which causes cataracts.
*remember that galactose-1-phosphate deficiency is the very serious galactosemia and present early 2o to consuming milk. Due to accumulation of galactose-1-phosphate.
In which part of bilirubin cycle is it green in color?
When it’s biliverdin.
RBCs–>Heme–>Biliverdin–>Unconjugated bilirubin–>Unconjugated bilirubin albumin complex–>Conjugated bilirubin–>Urobilinogen–>either urobilin (pee) or stercobilin (poop).
Heme oxidase changes from heme to biliverdin.
UGT changes from uncon. complex to conjugated bilirubin.
Which muscle type is used more for sustained things (ie posture)
Type 1 (like the paraspinal movements). Usually have lots of mitochondria, not much glycolysis occurs here
Net effects of parathyroid hormone?
Increased bone resorption of Ca and phosphate.
Increased kidney reabsorption of CALCIUM in DCT
Decreased reabsorption of PHOSPHATE in PCT.
Increased 1,25 OH D3 (calcitriol) production by kidney
Increased serum calcium, urinary phosphate
Decreased serum phosphate
By occluding the hepatoduodenal ligament (Pringle maneuever), which vessels are blocked?
If those vessels are occluded and bleeding still happens, what vessels are implicated?
Portal triad in hepatoduodenal ligament: Hepatic artery, portal vein, common bile duct.
If still bleeding, either the IVC or hepatic veins are injured.
What drug class does dobutamine fit into?
Beta 1 adrenergic agonist. Stimulates Gs, increased cAMP. Positive inotrope, chronotrope, vasodilator
Which structure makes up most of the anterior surface of the heart (ie susceptible to stab wounds from front)
Right ventricle
What is one of the key factors that contributes to insulin resistance?
Elevated fatty acid levels–>increased glucose uptake and gluconeogenesis.
Elevated insulin levels also contribute to insulin resistance.
What’s a cholesteatoma? Where would you expect to find it?
It’s a pearly mass in the inner ear (beyond the tympanic membrane) caused by squamous cell debris.
What is the drug class and MOA for both abortive and prophylactic migraine treatment?
Abortive: Triptans. They are 5-HT1B/1D agonists. They inhibit trigeminal nerve activation and prevent release of vasoactive substances.
Prophylactic: Tricyclic Antidepressants, inhibit presynaptic serotonin and norepinephrine (amitryptiline, venlafaxine).
Beta blockers, and anticonvulsants also used prophylactically.
Where do the following diuretics act?
1) Carbonic anhydrase inhibitor (Acetazolamide)
2) Osmotic diuretics (mannitol)
3) Loop diuretics (-ides)
4) Thiazide diuretics (hyrdochlorothiazide)
5) Potassium sparing diuretics (spironolactone, Triamterene, Amiloride)
1) Acetazolamide: Proximal tubule. Alkalinizes urine. Metabolic acidosis
2) Mannitol: Descending loop of Henle, proximal tubule. Hypernatremia, pulmonary edema
3) Loop diuretics: Thick ascending loop of Henle. Hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, ototoxicity
4) Thiazides: Distal convoluted tubule, Hyper GLUC, hypokalemia.
5) Spironolactone: Collecting duct. Hyperkalemia.
2 treatment options for CMV infections. One is activated intracellularly, one binds DNA pol and reverse transcriptase and does not require intracellular activation. What are they?
Main treatment: Ganciclovir, requires intracellular activation.
Second treatment: Foscarnet, used in gancicolovir resistant infections.
Remember that CMV can cause colitis, especially in HIV patients
Anemia, bite cells, Heinz bodies are associated with G6PD deficiency. What conditions predispose to G6PD deficiency?
1) Infections
2) Drugs (dapsone, antimalarials, TMP-SMX)
3) DKA
4) Eating fava beans
What would you expect to see on peripheral smear of someone with gram negative sepsis and signs of anemia?
Schistocytes. A sign of DIC
How to differentiate between pilocytic astrocytomas, medulloblastomas, and ependymomas?
1) Astrocytomas=most common. Low grade. Commonly in cerebellum. Solid AND cystic components on imaging.
2) Medulloblastomas: second most common. Malignant. ONLY cerebellum. Solids ONLY (NO cystic). Poor prognosis, severe headaches and cerebella dysfxn. Derived from primitive cells.
3) Ependymomas: Third most common. Hydrocephalus. gland like structures called “rosettes”
Decreased CMAP that then increases following rapid repetetive stimulation is indicative of what?
Botulism.
Also look for both nicotinic (diplopia, dysphagia) and cholinergic (dry mouth) blockade
Match each syndrome with its gene association: Lynch Syndrome Familial adenomatous polyposus Von-Hippel Lindau Li-Fraumeni Multiple endocrine neoplasia 1 Multiple endocrine neoplasia 2
Lynch: MSH2, MLH1, MSH6, PMS2 (colorecrtal, endometrial, ovarian)
FAP: APC (colorectal, brain)
VHL: VHL (pheo, hemangioblastomas, clear cell renal)
Li-Fraumeni: TP53 (sarcomas, breast, brain)
MEN1: MEN1 (parathyroid, pancreas, pituitary, “3 P’s”)
MEN2: RET (thyroid, pheochromocytoma, parathyroid hyperplasia)
MEN2B–>marfinoid habitus, mucosal neuromas
What parts of spinal cord does Vit B12 deficiency affect?
Dorsal columns (loss of position, vibration, Romberg sign) Lateral corticospinal tracts (spastic paresis)
Before starting someone on etanercept for RA, Psoriasis, or ankylosing spondylitis, what test should you perform?
A skin tuberculin test. Etanercept is a TNF-alpha inhibitor, and TNF-alpha is key for keeping latent TB at bay.
Remember that etanercept is a TNF decoy receptor (deCEPTor)
What are the 3 stop codons?
UAA, UGA, UAG
A metabolism issue that looks a lot like Marfan syndrome
Homocystinuria.
AR mutation causing cystathionine synthase deficiency.
Treat w Vit B6 (PYRIDOXINE) and decreased methionine intake w cysteine supplementation
Definition of pleiotropy
When one genetic defect causes multiple seemingly unrelated symptoms/phenotypic manifestations
Order of symptoms/signs of alcohol withdrawal
1) Tremors/Anxiety (6-24 hours)
2) Generalized tonic-clonic seizures (12-24 hours)
3) Hallucinations (12-48 hours)
4) Delirium tremens
How to differentiate between strep viridans and strep pneumo (both alpha hemolytic) in regards to optochin and bile.
S. Pneumo: Optochin sensitive, bile soluble (MOPS)
S. Viridans: Optochin resistant, bile insoluble (post dental caries)
In what condition are Auer rods present? How do they look on histology? What do they stain positive for?
Present in AML M3.
Present in myeloblasts (large cells that have abundant basophilic cytoplasm (blue outlines filled with pink).
Auer rods stain positive for peroxidase.
Intracellular and extracellular levels of potassium, sodium, and cloride.
Intracellular: High potassium, low sodium and chloride.
Extracellular: Low potassium, high sodium and chloride.
When ion channels open, chloride flows out of the cell.
Mom has rubella. Complications for mom and kid?
Mom: Polyarthralgias
Kid: sensorineural defects, cataracts, cardiac malformations.
Children and non-pregnant women of child bearing age should be vaccinated with LIVE vaccine
A patient has an occluded subclavian vein proximal to the left subclavian artery. How does the body compensate?
Subclavian steal syndrome. Blood will flow retrograde through the left vertebral artery to meet back with rest of circulation.
Symptoms include arm ischemia and dizzyness upon exercise.
Treatment of pregnant mothers with which drug will cause Ebstein anomaly in the baby?
Lithium (for bipolar disorder).
Ebstein anomaly is when there is apical displacement of the tricuspid leaflets, decreased volume of RV, and atrialization of RV.
First line treatment for general anxiety disorder?
SSRIs/SNRIs (ie citaprolam)
Benzodiazepines shouldn’t be used for long term treatment!
MOA of opioid analgesics?
Bind opioid receptor (mu, delta, kappa). They open potassium channels and close calcium channels, also block release of neurotransmitters from the presynaptic terminal.
All of it to make you feel no mo pain.
Naloxone/Naltrexone are used to reverse effects, opiod receptor antagonists.
Where are the pupillary light reflexes mediated and directed?
In the neural structures (optic nerve, oculomotor nerve, Edinger-Westphal nucleus) of the UPPER MIDBRAIN
What is responsible for the green color of sputum during common bacterial infections?
Myeloperoxidase released from neutrophil azurophilic granules that then form HCl.
Pt blood smear shows >30% plasma cells. What do they have, and what are they at risk of developing?
Have multiple myeloma.
At risk of develoing AL amyloidosis.
Amyloid is derived from monoclonal immunoglobulin light chains, deposits in kidneys, heart, tongue, and nervous system (unlike sarcoid which deposits in lungs)
Woman has itchy erythematous skin rash on breast. Diagnosis? Cause?
Inflammatory breast cancer.
Peau d’orange rash.
Caused by lymphatic obstruction (cancerous cells clog lymphatics)
MOA of SGLT-2 inhibitors (-liflozin) in management of diabetes?
Block reabsorption of glucose at PCT.
Check renal function before starting (Cuz glucosuria can be rough on kidneys)
Which ln drain medial and lateral aspects of foot?
Medial–>Superficial inguinal nodes (along with scrotum, buttocks, anterior abdominal wall, and skin of penis)
Lateral–>Popliteal–>deep inguinal nodes (along with glans of penis)
Tx for kid w/ both absence and tonic-clonic seizures?
What about tx for someone with epilepsy and bipolar?
Valproate (Ethosuximide ONLY treats absence)
Epilepsy and bipolar–>also valproate
First line treatment for RA? Side effects?
Methotrexate.
Side fx=Stomatitis (mouth sores), liver dysfxn, bone marrow suppression.
*takes a few weeks to kick in. So you should give corticosteroids or NSAIDS for acute management until methotrexate kicks in
Premie is given supplemental oxygen. Potential side effect?
Retinal hemorrhage, major cause of blindness in developed countries
Why is diarrhea a major sx of chronic pancreatitis?
Exocrine insufficiency (due to calcifications of ductal plugs, epigastric). Will have malabsorption. Associated w/ excessive alcohol.
In CNIII Palsy, why is there down and out gaze?
Because the superior oblique and lateral rectus muscles are unopposed. (The CNIII muscles are all messed up).
Remember, SO4 LR6 R3
Why does kidney failure lead to osteodystrophy?
When kidneys fail they produce less 1,25 di… and filter less phosphate, so there is decreased calcium and increased phopshate. Body responds by increasing PTH, more bone resorption and more PTH resistance. A vicious cycle that unleashes itself on the bone.
Autosomal dominant condition causing lots of telangiectasias and nosebleeds.
Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasias)
What is linkage disequilibrium?
It’s when alleles at 2 linked loci occur at a rate higher or lower than what would be expected. Ie if one gene has a freq of 0.2, another has 0.4, but together they appear 0.2 (should be 0.4*0.2)
What is usually deficient in chronic granulomatous disease? How is it diagnosed?
NADPH oxidase. Released from neutrophils. Recurrent infection with CATALASE POSITIVE bacteria/fungus.
Dx: Absence of green fluorescence on nitroblue tetrazolium test, or DHR flow cytometry.
Infectious causes and manifestations of esophagitis?
Candida: white pseudomembrane, pain with swallowing
HSV-1: Punched-out ulcers
CMV: Linear ulcers (look for enlarged cells with intranuclear inclusions)
What process is G6PD involved in? If there is a deficiency, what becomes deficient, and what processes are affected?
Involved in first step of pentose phosphate pathway (PPP). This produces NADPH, a key reducing agent (of glutathione).
If deficient, the biosynthesis of cholesterol, fatty acids, and steroids will all be affected.
What leads to lactic acidosis in hypoxic conditions?
Intracellular NADH inhibits pyruvate dehydrogenase (which normally converts pyruvate to acetyl coenzyme A for ox. phopsphorylation as part of glycolysis). As a result, pyruvate is instead converted to lactate by lactate dehydrogenase.
Why does glucosuria occur in situations of DKA?
Glucose is reabsorbed at PCT by carrier protein, thus it is saturable. If it becomes saturated, then theexcess glucose can’t be reabsorbed and is released in the urine.
Which substance is typically used to calculate GFR?
Inulin
Match each w/ site of release, net effect: Gastrin Somatostatin Cholecystokinin Secretin GIP VIP Motilin
Gastrin: G cells (stomach duodenum), increased gastric acid, mucosa, motility
Somatostatin: D cells (pancreatic islets, GI mucosa), decreased gastric acid, pepsinogen (octreotide is an analog)
Cholecystokinin: I cells (duo, jej), increased panc, gallbladder, decreased gastric empt
Secretin: S cells (duo), increased bicarb, decreased gastric acid
GIP: K cells (duo, jej), decreased gastric, increased insulin
VIP: parasymp sphincters, gallbladder, small intestin, increased intestinal water and relaxation
Motilin: Small intestine, Increased MMCs
Net effect of ezetimibe?
Inhibits cholesterol absorption at brush border of intestine, then liver increases LDL receptor expression, so serum cholesterol decreases
How to differentiate between different Class I sodium channel antiarrhythmics in terms of drug names, inhibition of phase 0 depol, and length of AP?
IA: “Queen PROClaims Diso’s pyramid” (Quinidine, Procainamide, Disopyramide). Intermediate phase 0 depol, lengthens AP.
IB: “I’d Buy Liddy’s Mexian Tacos” (Lidocaine, MexileTine). Weak phase 0 depol, SHORTENS AP.
IC: “Can I have Fries, Please” (Flecainide, Propafenone”. STRONG PHASE 0 DEPOL, no effect on AP.
Important cytokine involved in Giant Cell arteritis to which there is a monclonal antibody drug (tocilizumab)?
How to diagnose Giant Cell arteritis?
IL-6
Dx: Elevated ESR, CRP. Intimal thickening+giant cells on artery biopsy
2 major etiologies of angioedema?
1) Mast cell activation: Itching and hives involved. Type 1 hypersensitivity reactions, direct activation (opioids)
2) Excess bradykinin: No itching/hives. ACE inhibitors, C1 inhibitor deficiency
Sudden upward stretching of the arm causes damage to which part of brachial plexus? Signs?
The lower trunk. Paralysis of intrinsic hand muscles (Klumpke palsy), total claw hand deformity
Symptoms of congenital hydrocephalus?
Macrocephaly, full fontanelle, Muscle hypertonicity/hyperreflexia (from upper motor neuron injury)
How does aplastic anemia appear on histology?
Hypocellularity and an abundance of fat cells (with pancytopenia)
MOA and side fx of statins?
HMG-CoA reductase inhibitors. Toxicities: muscle and liver. Check hepatic transaminases prior to initiating therapy
Etiology of stress, urge, and overflow incontinence.
Stress: loss of urethral support, dysfnxnal urethral sphincter (pelvic floor laxity, urethral sphincter dysfxn)
Urge: Detrusor overactivity (uninhibited bladder contraction)
Overflow: Impaired detrusor contractility, bladder outlet obstruction (Detrusor muscle weakness)
What would be the physical findings if a ureter was accidentally injured during a pelvic surgery?
Flank pain radiating to the groin with ballotable mass that develops within a week. Likely due to an obstructive process that causes hydronephrosis
How do prolactinomas typically present in men/women?
Women: Menstrual irregularities/galactorrhea in premenopausal women, present later.
Men: present later, Headache, bitemporal field defects (clumsiness)
In which states do Rb proteins keep cells stuck in the G1 to S checkpoint?
When they’re hypOphosphorylated.
If hyperphosphorylated, they’re inactivated and let cells continue to replicate (can lead to tumor)
Which vitamin seres to maintain normal differentiation of epithelial cells?
Vitamin A
Most common cause of otitis externa. Characteristics of this bug?
Pseudomonas. It’s motile and oxidase positive.
Treat w/ aminoglycosides, piperacillin, quinolones.
Exotoxin inactivates EF2 by ribosylation (same as diptheriae)
Histo of Hashimoto’s?
Other features? Compare to subacute granulomatous thyroditis
Hashimoto’s: Dense lymphocytes (mononuclear), well developed Germinal centers. Autoimmune, PAINLESS, associated w HLA-DR5 and non-Hodgkin lymphoma. TPO antibody.
Granulomatous: Painful, post viral, transient hyperthyroid, increased ESR, giant cells.
Collagen synthesis:
Intracellular: Signal sequence–>hydroxylation (Vit. C/scurvy)–>Glycosylation (procollagen triple helix/Osteogenesis Imperfecta)
Extracelllar: Cleavage of disulfide-rich terminal regions–>Cross-linking (Ehler-Danlos syndrome, Menkes disease)
Difference in valve pahtology bwn rheumatic fever and infective endocarditis
Rheumatic Fever: Fibrosis, commissural fusion at edges
Infective Endocarditis: Large friable vegetations, destruction of valve leaflets
An IV anesthetic (propofol) has fast onset as well as wears off fast. Why?
Goes to brain fast initially, then redistributes to low blood flow tissues
What makes H flu virulent, and to what is vaccine developed?
Type B capsule. H flu is gram neg diplococci
Panic disorder treatment?
SSRI or benzo.
SSRI preferred b/c don’t have abuse potential
Tx for:
Oral candidiasis
Systemic candidiasis
Dermatophytoses
Oral candidiasis: Nystatin (similar mech to Amph B)
Systemic Candidiasis: Amph B
Dermatophytoses: Terbinafine (allylamine antifungal), Griseofulvin (inhibits fungal mitoses at metaphase)
Tx for bulimia nervosa?
SSRI–>specifically fluoxetine, also CBT and nutritional rehabilitation
Differentiate btwn common peroneal and tibial n injuries
Common peroneal: “Foot drop”, “steppage gait”, loss of eversion, dorsiflexion, dorsum of foot sensation lost.
Tibial: Loss of inversion, plantar flexion, sole of foot sensation, inability to curl toes. Passes through popliteal fossa
Hallmarks of obstructive and restrictive lung dseases on PFTs?
Obstructive: Decreased FEV1/FVC, maybe increased LVs
Restrictive: Increased FEV1/FVC, decreased lung volumes
Rat poison treatment (think warfarin overdose).
Tx for warfarin vs heparin overdose?
Warfarin: Vitamin K (takes days), Fresh Frozen Plasma (immediate)
Heparin: Protamine sulfate
Processes that occur to mRNA in cytoplasm?
Associate with ribosomes (translation), or P bodies (regulate mRNA translation and mRNA degradation)
Differentiate between 2 most common causes of CAH, including what the deficient enzymes do.
1) 21-hydroxylase deficiency. Salt wasting, decreased BP, XX virilization. Normally converts progesterone to 11-deoxycorticosterone and 17-OH progesterone to 11-deoxycortisol.
2) 11 beta-hydroxylase deficiency. INCREASED BP, virilization of XX. Normally converts 11-deoxycorticosterone to Corticosterone (precursor to aldosterone) and 11-deoxycortisol to cortisol.
What is the cause of gram negative sepsis (ie from e coli?)
Lipid A, the toxic component of LPS. Causes widespread release of IL-1, TNF alpha
Sudden cardiopulmonary arrest in a mom post-delivery (or during pregnancy). Likely cause and findings?
Amniotic fluid enters mom’s circulation, anapylaxis, hypoxia and hypotensive shock, possible death, DIC.
Will see fetal squamous cells on biopsy of pulmonary vasculature.
How is venous thromboembolism treated in pregnancy?
With low-molecular-weight heparins (enoxaparin, selteparin).
4 Glycogen Storage diseases: Von Gierke disease (Type 1) Pompe disease (Type II) Cori disease (Type III) McArdle disease (Type V)
Von Gierke: Fasting hypogly. Increased glycogen in liver, blood lactate, and triglycerides. G-6-Phosphatase def.
Pompe: Severe cardiomegaly, hypotonia, early death, glycogen in lysosomal vesicles. Acid alpha-glucosidase deficiency
Cori: Milder version of Type 1, w/ normal blood lactate. Deficient alpha-1,6-glucosidase
McArdle: Muscle issues (pain, myoglobinuria). Myophosphorylase deficiency–>failure of glycogenolysis
Tall young male unilateral chest pain, diminished tactile fremitus, hyperresonance, and diminished breath sounds on that side. Dx? Cause?
Dx: Primary spontaneous pneumothorax
Caused by rupture of apical blebs or cysts.
Compare how H flu and N mening both cause meningitis
H flu: Pharynx–>Lymphatics–>Meninges
N mening: Nasopharynx–>Blood–>choroid plexus–>Meninges
How to differentiate between phenoxybenzamine and phentolamine (nonselective alpha blockers)
Phenoxybenzamine: IRReversible, longer drug=longer. Treats pheochromocytoma to prevent hypertensive crisis.
Phentolamine: Reversible. Use for pts on MAO inhibitors eating tyramine foods
What type of incontinence is associated with T1DM?
Overflow incontinence (due to diabetic autonomic neuropathy), which also causes inability to sense a full bladder and incomplete bladder empyting.
Adverse effects of these drugs: Lithium Valproate Carbamazepine Lamotrigine
Lithium: Diabetes insipidus, hypothyroidism, Ebstein anomaly
Valproate: Hepatotoxicity, Neural tube defects
Carbamazepine: Agranulocytosis, hypnatremia, NTDs
Lamotrigine: Steven-Johnson syndrome, benign rash
Differentiate between upper and lower motor neuron injuries
Upper: Spastic paralysis, clasp-knife rigidity, Hyperreflexia, Babinski sign
Lower: Flaccid paralysis, Hypotonia, HypOreflexia, muscle atropy & fasciculations
What does vascular endothelium release to inhibit platelet aggregation?
Prostacyclin (PGI2). It opposes action of Thromboxane A2., and causes vasodilation and increased permeability.
Synthetic prostacyclin used in pulmonary htn, peripheral vascular disease, Raynaud syndrome.
Middle aged white male w/ diarrhea, weight loss, joint pain, neuro sx, and PAS (+) organism
Whipple disease (from gram (+) Tropheryma whipplei. Treat w/ antibiotics
Signs of marijuana use
Tachycardia, conjunctival injection (red eyes), inappropriate laughter, increased appetite, cognitive impairment, dry mouth
Relative sodium channel binding strength of IA, IB, and IC sodium channel blockers
IC>IA>IB
Drug type recommended for patients w/ systolic HF and past MI?
ACE inhibitors, providing a mortality benefit
Microscopic changes seen post ischemic stroke in brain?
12-24 hours: Eosinophils “red nuclei”
24-72 hrs: Neutrophilic infiltration
3-7 days: macrophage/microglia infiltration
1-2 weeks: reactive gliosis, vascular proliferation
>2 weeks: glial scar formation (astrocytes)
Differentiate btwn S3 and S4 sounds:
S3: Ventricular gallop. turbulent flow to ventricles due to increased volume. Normal in children, YOUNG ADULTS, and pregnancy. *if head in older adults, it’s a sign of LVF
S4: Atrial gallop. Heard after atrial contraction as blood is forced into stiff ventricle (reduced ventricular compliance). Normal in OLDER ADULTS
General features of Paroxysmal Hemoglobinuria
Uncontrolled complement mediated RBC lysis, impaired GPI anchor (due to mutated PIGA gene), CD55/CD59 deficiency. Aplastic Anemia.
Can lead to Budd-Chiari syndrome
Manifestations: fatigue, jaundice, hemoglobinuria, thrombosis at atypical sites, pancytopenia.
ALSO LEADS TO HEMOSIDEROSIS!
Virus associated with measles virus
Vitamin A. Supplementation recommended.
It prevents ocular complications, reduces recovery time and length of hospital stay.
Which l.n. drain the colon proximal to and distal to the dentate line?
Proximal: Inferior mesenteric and internal iliac
Distal: Inguinal
Patient’s hat size changes. What do you expect? On biopsy, bone shows cells with over 100 nuclei. What is the marker for that cell type?
Paget’s disease of bone (disorder of bone remodeling).
Nuclie>100=osteoclasts
Marker=RANK-L, M-CSF.
Look for mosaic pattern of lamelar bone (cement lines) on biopsy
Risk associated w/ cavernous hemangioma?
Intracerebral hemorrhage and seizure
Ghon complex associated w/ which stage of T B infection?
Primary TB infection
In lead poisoning, what is seen on RBCs on peripheral blood smear?
What enzyme is inhibited?
Basophilic stippling, microcytic anemia. Normal blood studies.
Ferrochelatase and delta-aminolevulinic acid dehydratase are inhibited.
Hallmark findings of MS?
Demyelination of CNS, IgG in CSF, Oligoclonal bands are diagnostic, Oligodendrocyte loss and reactive gliosis, destruction of axons. MRI is gold standard.
HIV patient gets a skin rash and associated virus?
Kaposi Sarcoma. Associated with HHV-8
Blue-violet or brown skin plaques, derived from primitive mesenchymal cells
Match each with its defective/important process:
Nucleotide Excision Repair–>Endonucleases
Base Excision Repair
Mismatch Repair
Nonhomologous end joining
Nucleotide Excision Repair: Xeroderma Pigmentosum
Base Excision Repair: Spntaneous/toxic deamination
Mismatch Repair: HNPCC (Hereditary nonpolyposis colorectal cancer–>MLH1 and MLH2 mutations
Nonhomologous end joining: Ataxia telangiectasia, Fanconi anemia
How does growth hormone mediate growth in the body?
It stimulates release of IGF-1 from liver (through JAK-STAT signaling pathway)
How is cholecystitis diagnosed?
1) Ultrasound that visualizes wall thickening or pericholecystic fluid (stones aren’t diagnostic)
2) Cholescintigraphy (failure to see gall bladder on radionuclide biliary scan
Why is butt chugging better than oral absorption?
It is more likely to bypass first pass metabolism in the liver and go straight to circulation
If something binds 2,3-bispohosphoglycerate, how does that affect hemoglobin binding affinity?
Has a greater hemoglobin binding affinity, more like fetal homeglobin.
Does the glossopharyngeal or hypoglossal nerve injury cause deviation of the tongue?
Hypoglossal nerve
Glossopharyngeal injury would cause loss of gag reflex, loss of sensation of upper pharynx, middle ear, and and tonsils, and loss of taste of posterior third of tongue
Young girl has a rash all over body that started as a “slap cheek” rash on face. Siblings had it.
Dx? Cause? Where does this replicate?
What effect does it have in adults?
Dx: Erythema Infectiosum, or Fifth Disease (from Parvovirus B19)
Replicates in the bone marrow (precursor of erythrocytes)
Causes arthritis in adults.
Neoplasm, most common cause of SIADH, neuroendocrine origin
Small cell lung cancer.
Euvolemic, hyponatremia, hyperosmolality of urine compared to serum (>100 mOsm, body can’t remove water)
Release of Ach from presynaptic terminal at NMJ is dependent upon what?
The influx of calcium into the presynaptic terminal.
Sensory and gustatory innervation of the tongue:
Sensory: Ant 2/3=mandibular branch of trigeminal (V3)
Post 1/3=glossopharyngeal nerve
Post area of tongue root=Vagus
Gustatory: Ant 2/3=maxillary branch of facial
Post 1/3=glossopharyngeal
Post area of tongue root: Vagus
Acute tubular necrosis quick hits
Granular “muddy brown” casts.
Increased FeNa.
3 phases: 1)Inciting Event 2) Maintenance phase(hyperkalemia) 3) Recovery phase (hypokalemia)
Can be caused by ischemia or neophrotoxic substances
Most commonly affects the PCT or thick ascending loop of Henle
Most common outcome is resolution w/ tubular re-epithelization.
Differentiate between Stanford Type A and B aortic dissection
Type A: Ascending aorta, just distal to aortic valve
Type B: Descending aorta, just distal to left subclavian artery
Differentiate between SER and RER. Which cells would have predominately SER?
RER: Site of synthesis of secretory, lysosomal, integral membrane proteins
SER: Steroid and phospholipid biosynthesis. (think adrenals, gonads, liver). Ex: ACTH which promote glucocorticoid production
What is edrophonium used for?
Increases Ach, diagnoses myasthenia gravis as well as checks levels of medication. If pt has symptoms that resolve w/ edophonium, their dose of Achesterase inhibitors (pyridostigmine) is too low. If not, their dose is too high
Which type of drug exacerbates hypoglycemia in diabetics?
Non-selective beta adrenergic blockers (-lols from N-Z, mask adrenergic sx). Should only prescribe B-1 blockers for diabetics.
Alzheimer drugs w/ MOA and toxicity?
Memantine: NMDA receptor antagonist, prevents excitotoxicity, Tox: confusion, dizziness
Donepezil, Galantamine, Rivastigmine, Tacrine: AchE inhibitors. Tox: Nausea, dizziness, insomnia
Also Vitamin E (antioxidant)
Remember, w/ Alz you’ll see cortical atrophy
Why can’t RBCs use ketones as energy?
They don’t have mitochondria
How do perfusion, ventilation, and V/Q change from apex to base in lung?
Perfusion is MUCH higher in base compared to apex
Ventilation is higher in base compared to apex, but not as much of a difference
V/Q is higher in apex than lung b/c of this (since perfusion is so much less there)
First step in the adenoma to carcinoma sequence?
APC inactivation.
p53 inactivation and K-ras activation happen much later in the process
K-RAS mutation increases size of adenoma (uninhibited proliferation).
TP53 is key in malignant transformation from adenoma into carcinoma.
This process is found most in sporadic colon cancer and pts with FAP
What test will be abnormal in Hemophilia?
PTT (everything else will be normal)
X-linked, prolonged bleeding after operations
Decreased Factor VIII (hemophilia A) or IX(Hemophilia B)
Net effect on cholesterol of statins and fibrates?
Statins: decrease hepatic cholesterol synthesis
Fibrates: increase hepatic cholesterol synthesis.
When used synergistically, they reduce cholesterol even more than statin monotherapy
Which medications cause IgE-INDEPENDENT mast cell degranulation, causing itching and swelling, pain, bronchspasm?
Opioids, radiocontrast agents, and some antibiotics (vancomycin)
Appendiceal carcinoids can cause appendicitis. What type of cells are they derived from?
Neuroendocrine cells
Match the following casts with their cause
RBC casts:
WBC casts:
Fatty casts ("oval fat bodies"):
Granular ("muddy brown") casts:
Waxy casts:
Hyaline casts:RBC casts: glomerulonephritis, malignant htn
WBC casts: Tubulointerstitial inflammation, acute pyelonephritis, transplant rejection
Fatty casts (“oval fat bodies”): Nephrotic syndrome
Granular (“muddy brown”) casts: ATN
Waxy casts: End-stage renal disease
Hyaline casts: Nonspecific, concentrated urine
Pathogenesis of minimal change disease?
Most common nephrotic in kiddos.
T cell dysfxn–>glomerular permeability factor (cytokine)–>podocyte foot process fusion (effacement)–>decreased anionic properties of glomerular basement membrane–>selective albuminuria
Responds excellently to corticosteroids
Where would PAH concentration be lowest?
In the Bowman Capsule (because it is secreted into nephron by PCT, and none of it is reabsorbed)
Which antibiotics bind 30S subunit and 50S subunit?
“Buy AT 30, CCEL (sell) at 50
30:
Aminoglycosides (-cin, but not clindamycin). Bactericidal, initiation complex.
Tetracyclines (-cycline). Static. Prevent tRNA attachment
50:
Chloramphenicol. Static. Blocks peptidyltransferase. Mengitis & Rocky Mountain Fever
Clindamycin. Static. Blocks peptide transfer. Anaerobes above diaphragm (vs metronidazole)
Macrolides (erythromycin). Static. 23rRNA of 50S subunit. Atypical pneumonias, pertussis.
Oxazolidinones (Linezolid). Initiation complex. Gram pos species including MRSA
How to diagnose mucormycosis? How does it differ from aspergillis on histo?
Get a mucosal biopsy and then look at it. It will have nonseptate hyphae with right angle branching.
Aspergillis has septate hypae with acute angle branching
MOA of antidepressant w/ no sexual side effects? Other use?
Bupropion. It’s a norepinephrine and dopamine reuptake inhibitor with no effect on serotonin.
Also used for smoking cessation
Causes of acne in adults?
Anabolic steroids (androgens) which boost sebum production, stimulate follicular epidermal hyperproliferation. In steroid use, also look for testicular atrophy, erythrocytosis, and virilization in females
Signs of riboflavin deficiency, and which process is messed up?
Inflammation of ips, scaling and fissures at corners of mouth, corneal vascularization.
FAD and FMN are derived from riboFlavin.
Redox reactions impaired–>particularly SUCCINATE DEHYDROGENASE rxn in TCA cycle (which converts succinate into fumarate)
What promotes sickling in sickle cell patients? Which organs are more likely to promote sickling?
How would 2,3 bis… fit in? pH?
Sickling associated with low oxygen levels (oxygen unloading). Organs that take lots of oxygen (brain, muscle, placenta) promote sickling.
2,3 bis causes lower O2 affinity. So decreased 2,3 bis would be better in sickle cell patients.
Decreased pH promotes sickling, so less acidic is better for sickle cell patients
Levels of TSH, T4, and T3 in hypothyroidism?
Elevated TSH, Decreased Free T4, and normal T3 until later on in the course of the disease (when it decreases).
T3 stays normal b/c it has a short-life and is converted in periphery
How to differentiate between central and nephrogenic Diabetes Insipidus?
Central: Lack of ADH being released from posterior pituitary. On water deprivation test, body responds to ADH analog.
Nephrogenic: Normal ADH levels, dilute urine, concentrated serum. No response to ADH analog
MOA and toxicity of these 3 MRSA drugs?
Vancomycin
Daptomycin
Linezolid
Vancomycin: blocks glycopeptide polymerization by binding to D-alanyl-D-alanine. Tox=Red man syndrome, nephrotoxicity
Daptomycin: Depolarizes cellular membrane (inserts channels). Tox=Myopathy & CPK elevation. Surfactant inhibits it
Linezolid: Binds 50S subunit. Tox=Thrombocytopenia, optic neuritis, serotonin syndrome
Diabetic mononeuropathy of CN III is caused by? Clinical findings?
Caused by central ischemia that affects somatic but not parasympathetic. As a result, you’ll see ptosis and down and out gaze, but normal light and accommodation reflexes.
Neuro complication of parotid gland tumor?
Facial nerve paralysis (the facial n. emerges within this gland and splits into its 5 branches here)
Pt has surgery in different country, then dies. Shrunken liver on autopsy. What tests would be expected?
This is due to inhaled anesthetic (halothane) induced lethal fulminant hepatitis. If tested before death they would show severely elevated AST/ALT and prolonged Prothrombin Time (PT)
Why does alcohol cause hypoglycemia after glycogen stores are depleted?
Ethanol inhibits gluconeogenesis, so once glycogen is depleted, there is no more.
This is b/c alcohol promotoes NAD–>NADH, so processes needing NAD+ are found lacking (lactate can’t be made into pyruvate)
Why do statins+fibrates make myopathy so much worse?
B/c fibrates inhibit the hepatic clearance of statins so their effects are more prolonged/pronounced.
What does Neer’s impingement test test?
Impingement of the supraspinatus tendon by acromion process
Rapidly progressive dementia, myoclonic jerks, vacuoles in gray matter.
Creutzfeld-Jakob disease–>prion disease
Differences between antipsychotics and atypical antipsychotics?
Antipsychotics: D2 receptor! Dystonia/extrapyramidal side effects! (involves nigrostriatial pathway)
Also cause increased prolactin b/c dopamine normally inhibits prolactin (will see amenorrhea, galactorrhea as side effect)
Atypical: 5H2A receptor. No dystonia/extrapyramidal
Local vs systemic defense against candida?
Local: T cells. Localized candida infxns in HIV pts
Systemic: Neutrophils. Systemic candidiasis in neutropenic pts
In Reye syndrome what histologic effect would you see on liver cells?
Fatty change–>microvesicular steatosis (no inflammation)
Would also see cerebral edema
General features of these different dementias: Alzheimer's Frontotemporal Lewy Body Creutzfeldt-Jakob
Alzheimer’s: Most common. DS more likely to have it. ApoE4=increased risk, ApoE2=decreased risk. APP, presenilin-1,2=earlier onset. Cortical atrophy, decreased Ach, amyloid plaques, neurofibrillary tangles
Frontotemporal (Pick disease): change in personality, aphasia, parkinsonian aspects. Frontotemporal atrophy, silver staining tau protein aggregates
Lewy Body: Dementia and hallucinations (“haLewycinations”), then parkinsonian. Lewy bodies, cortical. Alpha-synuclein defect
Creutzfeldt-Jakob: Rapidly progressive, myoclonus. Spongiform cortex, prions.
Best treatment for alcohol withdrawal?
Long-acting benzodiazepines (flurazepam, diazepam, chlordiazepoxide).
Remember, chlordiazepoxide is the outlier in terms of name structure, but it does have “diaze” in it.
What’s the phyisologic response to aplastic anemia?
Increased Erythropoietin
Which mutation makes tumors resistant to anti-EGFR drugs?
Activated KRAS gene, b/c it activates the EGFR pathway independent of the EGFR binding (uncontrolled proliferation)
Differentiate between saccular (Berry) and Charcot-Bouchard aneurysms
Berry: Located at circle of Willis, larger, associated with ADPKD and Ehlers-Danlos, Causes SAH which presents as major headache followed by neuro deficits.
Charcot-Bouchard: Located in basal ganglia/internal capsule/cerebellum/thalamus/pons, SMALL, associated w/ hypertension, INTRACEREBRAL hemorrhage, lenticulostriate vessels, neuro deficits followed by headache
What’s in Potter’s syndrome, and what causes it?
Oligohydramnios (renal agenesis)–>Compression of fetus–>limb deformities, pulmonary hypoplasia, facial deformities.
Causes: ARPKD, Obstructuve uropathy, bilateral renal agenesis.
Teratogen: ACE inhibitor
Common conditions that demonstrate polygenic inheritance? (ie some XLR, some AD within same disease constellation of symptoms)
Androgenic alopecia, epilepsy, glaucoma, hypertension, ischemic heart disease, schizophrenia, T2DM
Lipofuscin is the yellow brown “aging substance” found in cells. What causes the color?
Lipid peroxidation
What structure is responsible for removing RNA primers?
RNA Pol I (only one with 5’-3’ exonuclease activity)
Equation to calculate anion gap?
=Sodium-(Bicarb+Chloride)
Normal is between 10-14
In DKA, it’s normal for a patient to have really low bicarb, and they compensate by Kussmaul breathing (respiratory alkalosis). Thus, their PaCO2 should be in the 24-28 range. What does it mean if the PaCO2 is at 40 in the setting of DKA?
It means there is respiratory failure going on, and as a result there is respiratory acidosis on TOP of metabolic acidosis
Winter formula: PaCO2=(1.5*bicarb)+8+/-2
Formula to calculate net filtration pressure?
=(Hydrostatic pressure capillaries-interstitium)-(Oncotic pressure capillaries-intersitium)
Net effect of carotid massage? (used to end paroxysmal superventricular tachycardia)
Increased pressure on carotid sinus–>Increased stretch–>Increased afferent firing from carotid sinus–>Increased parasympathetic tone–>Increased AV node refractory period–>Decreased HR
MOA of methotrexate in treating ectopic pregnancy?
It is a folic acid analog that competitively inhibits dihydrofolate reductase. It blocks DHF–>THF synthesis, so DHF builds up in cells. THF is needed for lots of reactions in body (ie DNA synthesis).
Tox: Causes myelosuppression (reversible by leucovorin), hepatotoxicity, mucositis, pulmonary fibrosis.
Complications of succinylcholine
Hyperkalemia, Hypercalcemia, Malignant Hyperthermia
What is acidified glycerol lysis testing used to diagnose?
Heridtary spherocytosis (testing increased osmotic fragility). Red cell cytoskeleton abnormalities (spectrin, ankyrin). Hemolytic anemia, jaundice, splenomegaly. Tx: Splenectomy Complications: Pigment stones, aplastic crisis with parvovirus B19
Follicular lymphoma is a B cell origin lymphoma that overexpresses bcl-2 gene. What does bcl-2 normally do?
It normally inhibits apoptosis, so when overexpressed it’s keeping cancerous cells alive.
14:18 translocation
What do the a,c,x,v,and y waves correspond to?
A wave=Atrial contraction C wave=RV Contraction X descent=atrial relaXation v wave=right atrial "V"illing (filling), increased pressure y descent=RA emptYing into RV
During a-fib what determines the ventricular contraction rate?
The AV node refractory rate periods (remember, no P wave abnormal atrial contraction, so it all becomes dependent on the AV node)
Pt has pyruvate dehydrogenase complex deficiency (and elevated serum alanine). What diet, as well as specific amino acids, should you give them?
Ketogenic diet (to avoid having to convert pyruvate to acetyl-CoA, which they can't do).
AA's=lysine and leucine. ("Lysine and Leucine are the onLy pureLy ketogenic amino acids)Where’s the lesion in someone who can’t write, do a math calculation, tell left from right, and has finger agnosia?
In the angular gyrus of the dominant Parietal Lobe (called Gerstmann syndrome).
What do these 3 drugs bind to prevent platelet formation?
Abciximab
Aspirin
Clopidogrel
Abciximab: GpIIb/IIIa (deficiency=Glanzmann thrombasthenia, decreased platelet to platelet binding, prolonged bleeding time, mucosal bleeding)
Aspirin: COX/TXA2
Clopidogrel: ADP receptor
Cause of axillary nerve injury (deltoid flattening, decreased sensation)
Anterior dislocation of the humerus
Histologic differences between Crohn and Ulcerative colitis
Crohn: TRANSMURAL and is noncaseating granulomas, lymphoid aggregates (Th1 mediated)
UC: Crypt abscesses, NO granulomas (Th2 mediated). TOXIC MEGACOLON (diagnose with Xray)!
HFE gene mutation (the protein normally interacts with transferrin). Disease?
Primary hemochromatosis. Enterocytes and hepatocytes detect false low levels of iron. Triad: Micronodular cirrhosis, diabetes mellitus, skin pigmentation.
Due to excessive absorption of iron in the intestine.
Tx: phlebotomy, chelation with deferasirox
How does secretin help to distinguish gastrinomas (Zollinger Ellison) from H. pylori infections? Remember, both have duodenal ulcers.
Secretin normally inhibits gastrin secretion. If astrin continues to be released, it’s a neoplasm (b/c secretin paradoxically causes increased release from those neoplastic cells).
*Key distinction: H pylori infections are in stomach. Gastrinomas are often located in the pancreas/small intestine.
Lambert-Eaton Myasthenic Syndrome quick hits
Proximal muscle weakness, cranial nerve involvement, IMPOTENCE, DRY MOUTH, improves w/ muscle use.
Commonly associated w/ small cell lung cancer. DOESN’T improve w/ Achesterase inhibitor.
Cause=abs to presynaptic Ca channel–>decreased Ach release
If pt already has diphtheriae infection, what’s the tx?
1) Passive immunization
2) Antibiotics (Penicillin, erythromycin)
3) DPT vaccine (toxoid)
2 main causes of acute pancreatitis?
1) Gall stones
2) Alcoholism
* Other causes include hypertriglyceridemia, ERCP procedure, drugs, infections, surgery, hypercalcemia, structural irregularites
Hypercoagulability that is RESISTANT to protein C. Cause?
Inherited–>likely Factor V Leiden
Where should femoral nerve block be given?
At the inguinal crease
Compare/Contrast these muscular dystrophies:
Duchenne
Becker
Myotonic type 1
Duchenne: X linked frameshift disorder, truncated dystrophin protein. Pseudohypertrophy of calf muscles. Death by dilated cardiomyopathy. Increased CPK and aldolase. Onset before age 5. Muscles are invaded by fat and fibrous tissue. Beta-myosin heavy chain is affected
Becker: X linked non-frameshift, insertions in dystrophin. Less severe than Duchenne, later onset.
Myotonic: Autosomal Dominant. CTG trinucleotide repeat, expansion in DMPK gene. Myotonia, muscle wasting, cataracts, testicular atrophy, frontal balding. Can’t release doorknob.
MOA of calcineurin inhibitors?
Cyclosporine and Tacrolimus. They inhibit calcineurin, block T-cell activation by preventing IL-2 transcription (calcineurin is a key part of IL-2 activation).
Both are very nephrotoxic.
Antibiotic therapy for pelvic inflammatory disease?
Ceftriaxone + Azithromycin or Doxycycline
Pt from South America presents with dilated esophagus and uncoordinated peristalsis w/ dysphagia to solids a liquids. Dx?
T. Cruzi (Chaga’s disease)
This is achalasia. Normally it’s congenital, but if it’s in someone from South America, suspect infection first.
Treatment of psoriasis ranges from topical Vitamin D to biologics and other conventional drugs. Which treatment type activates a nuclear transcription factor?
Vitamin D analogs (calcipotriene, calcitriol, tacalcitol).
Pt has dark connective tissue, brown pigmented sclerae (and ear cartilage), urine turns black on prolonged exposure to air, debilitating arthralgias. Dx? Deficient enzyme?
Alkaptonuria (ochronosis).
Deficiency of homogentisate oxidase.
Degradative pathway of tyrosine to fumarate.
Pigment forming homogentisic acid accumulates in tissue. Autosomal recessive, typically benign
What vessels are involved for contralateral homonymous hemianopia with AND without macular sparing?
With macular sparing: Posterior cerebral artery (supplies occipital lobe). Spared due to collateral flow from middle cerebral artery
Without macular sparing: Middle cerebral artery (also contralateral motor and sensory deficits)
Changes seen in interstitial lung disease in terms of lung volume, lung elastic recoil, and radial traction.
Decreased lung volume, Increased elastic recoil, increased radial traction (which then causes increased expiratory flow rates)
*all of the opposites for emphysema
Who would you be likely to see meconeum ileus in?
Pts w/ cystic fibrosis. The meconium is dehydrated and causes distal small bowel obstruction.
What type of infection does Gastric Bypass predispose to? What will be deficient/in excess?
SIBO (Small Intestine Bacterial Overgrowth) due to excessive bacteria in the gastroduodenal blind pouch that was left behind.
Excess Vitamin K, Folate (produced by bacteria)
Deficiency of most vitamins and iron
Meds associated with osteoporotic fractures?
Anticonvulsants, aromatase inhibitors, medroxyprogesterone, GnRH agonists, PPIs, Glucocorticoids, Unfractionated Heparins, Thiazolidinediones.
Osteoporosis is common cause of pathogenic vertebral fractures
Which ion channel is involved in Congenital long QT syndrome?
Voltage gated potassium channels. Remember: Deaf-->autosomal recessive (Jervell and Lange-Nielsen syndrome) No deafness (only cardiac)-->Autosomal dominant (Romano-Ward Syndrome)
What causes photoaging (wrinkles)?
Ultraviolet A waves cause epidermal atrophy, flattening of rete edges, decreased collagen fibril production, increased degradation of collagen and elastin
Compare/Contrast Giant cell and Takayasu arteritis
Giant cell: Elderly females, unilateral headache, affects branches of carotid artery. FOCAL GRANULOMATOUS INFLAMMATION. Treat w/ high does corticosteroids. Increased ESR
Takayasu Arteritis: “Pulseless disease”, Asian females <40 yrs old. GRANULOMATOUS THICKENING AS WELL. Treat w/ corticosteroids. Increased ESR
Pts w/ Cystic Fibrosis can be both hyponatremic and hypochloremic. Which causes symptoms?
Hyponatremia causes symptoms (usually occurs at high temps or high exercise. Treat w/ salt supplementation).
Hypochloremia is usually asymptomatic
What drug should be used for beta-lactamase producing gram neg rods? *think diabetics w/ foul smelling ulcer
Extended spectrum penicillin w/ beta-lactamase inhibitor–>Piperacillin-tazobactam
How does UC related colon cancer differ from sporadic?
Duration and extent of UC most important. More likely to arise from non-polypoid lesions, be MULTIFOCAL, involve p53 EARLY and APC LATE, and have a higher histological grade
Best way to measure potency of inhaled anesthetic?
Minimal alveolar concentration (concentration of anesthetic needed to make 50% of patients unresponsive).
Potency is inversely proportional to MAC (Higher potency=lower MAC)
What are the medical indications for using cholinomimetics?
Non-obstructive urinary retention, parlytic ileus, and glaucoma.
Most effective treatment for hypertriglyceridemia?
Fibrates. If that’s not controlled, add fish oil supplements
What is the hormonal deficiency in Kallman syndrome?
Decreased synthesis of GnRH. Failure to develop secondary characteristics, no smelling.
Defective migration of GnRH cells and formation of olfactory bulb. Infertility
When are the permeance of sodium and potassium the highest during the neuronal action potential?
Sodium greatest during depolarization.
Potassium highest during repolarization
If there is folate deficiency, what substance can be given to prevent apoptosis and permit proliferation of erythroblasts?
Thymidine
Because thymidylate synthase converts dUMP to dTMP, also causes production dihydrofolate
4 drugs that are CYP 450 inhibitors (increase serum level) of theophylline
Cimetidine, ciprofloxacin, macrolides, verapamil
Baby leans head to one side. Palpable mass that doesn’t move w/ swallowing. Dx? Cause? tx?
Congenital torticollis. Develops by 2-4 wks of age. Caused by birth trauma (breech) or malposition of the head in utero (ie from oligohydramnios), cause SCM muscle injury.
Resolve w/ conservative therapy and stretching exercises
Most common cause of recurrent or spontaneous lobar hemorrhage in adults >60
Cerebral amyloid angiopathy.
Most common sites are occipital (w/ homonymous hemianopsia) and parietal (w/ contralateral hemisensory loss)
Why is blood in the left atrium less oxygenated than blood in the pulmonary capillaries?
B/c blood of the pulmonary veins mixes with deoxygenated blood from the bronchial circulation and thesbian veins
Quick hits for Henoch Schonlein Purpura
Most common childhood vasculitis (remember Kawasaki, Asians under 4, l.n. involvement)
Follows URI
Triad: Palpable purpura on butt/legs, Arthralgias, Abdominal pain.
Secondary to IgA immune complex deposition, associated w/ IgA nephropathy (Berger disease)
Malaria types and treatment
Plasmodium falciparum, vivax, and ovale. Look for trophozoites (small rings) in RBCs)
Falciparum: Treat w/ chloroquine, or mofloquin if chloroquine rsistant. Also atovaquone/proguanil
Vivax and Ovale: Dormant forms (hypnozoites), treated w/ primaquine
G-coupled protein receptors that bind glycoprotein hormons (FSH, TSH, LH) have 3 domains. What are they, and what do they contain?
1) Extracellular domain (binds ligand, hydrophilic amino acids)
2) Transmembrane domain (nonpolar, hydrophobic amino acids, alpha helix). Anchor the protein into the membrane
3) Intracellular C-terminus domain
Where des complement bind to immunoglobulin? Which Ig type is best for complement?
Binds it at the constant region near the hinge point. IgM is best b/c of its pentameric conformation
Rapid facts about the following liver tumors: Hepatocellular carcinoma: Cavernous hemangioma: Hepatic adenoma: Angiosarcoma: Metastases:
Hepatocellular Carinoma: Most common primary tumor, malignant. Associated with HBV and cirrhosis. Leads to Budd-Chiari Syndrome (thrombosis/congestion of hepatic veins). Elevated alpha-fetoprotein. Spreads hematogenously.
Cavernous hemangioma: Common, benign, 30-50yrs. Histo shows dilated blood vessels. Associated w/ Von-Hippel-Lindau dx
Hepatic adenoma: Bengn, oral contraceptives/steroids. Pain and shock if ruptures.
Angiosarcoma: Malignant tumor, endothelial origin. Aresenic, vinyl chloride.
Metastases: most common overall. GI, breast, lung mets.
What is the net effect of chloride, water, and sodium (in terms of secretion/reabsorption) in CF?
The CFTR channel is faulty. Normally, chloride is secreted out into the mucus which causes water and sodium to stay out there and not be reabsorbed. However, when the chloride can’t get out (b/c of faulty CFTR channel), there is INCREASED water and sodium REABSORPTION, making the mucus area a more negative environment
What is likely to be injured after a stab wound to the left anterior chest at the mid clavicular line at level of 5th rib?
The lung. The only part of the heart that is out that far laterally is the apex of the heart (the left ventricle), so theoretically that also could have been effected.
Review the primary cardiac tumors (adults and kids)
Myxoma: Adults. 90% in atria (mostly left). Diastolic “tumor plop” sound, “ball valve” obstruction. Scattered cells w/in a mucopolysaccharide stroma (on histo)
Rhabdomyomas: Children. Associated w/ tuberous sclerosis.
What do uric acid crystals have to do with Tumor Lysis Syndrome? Where will the crystals precipitate?
This syndrome is when there is excessive breakdown of tumor cells, so increased levels of uric acid (which tumor cells use).
Uric acid is mroe soluble in acidic environment, so precipitates in collecting duct and distal tubule, causing oliguria.
Treat w/ urine alkalnization and increased hydration as well as allopurinol (a xanthine oxidase inhibitor)
What does Multiple Myeloma cause in osteoclasts? How are PTH, calcium, and 1,25 hydroxy… and PTHRP levels changed?
MM causes increased osteoclast activation. As a result, there is hypercalcemia as WELL as hypercalciuria. PTH levels are DECREASED b/c of the increased calcium in blood, and same story with 1,25 hydroxy… PTHRP levels are unchanged.
Incretins are GI hormones that increase insulin regardless of blood glucose levels (respond to oral glucose). What 2 hormones have incretin activity?
GLP-1 (glucagon like peptide 1) and GIP (glucose-dependent insulinotropic peptide).
Pt presents w/ N/V, hypotension, diarrhea, and breath smells like garlic. Dx? Source? Tx?
Arsenic poisoning.
From insecticides or contaminated water.
Tx=Dimercaprol
Distinguish between Tinea (dermatophytes–capitis, corporis, cruris, pedis, unguium) and Tinea versicolor (Pityriasis versicolor)
Tinea: Dermatophytes. Caused by Microsporum, Trichophyton, and Epidermophyton. Brnaching septate hyphae, visible on KOH preparation with blue fungal stain. Ringworm, jock itch, athlete’s foot.
Tinea versicolor: Caused by Malassezia spp (or Pityrosporum sp). Yeast like fungus, not a dermatophyte. Damage MELANOCYTES and cause hypopigmentation/pink patches. Occur in summer. “Spaghetti and meatballs” appearance. Treat w/ topical or oral antifungals, selenium sulfide
Rank these diabetes meds from shortest to longest duration of action (or from highest to lowest peaks of plasma insulin levels:) Aspart/Lispro/glulisine NPH Regular Glargine Detemir
Aspart/Lispro/Glulisine (fast acting)–>Regular/Human recombinant–>NPH–>Detemir–>Glargine
Virchow Triad
Endothelial damage, venous stasis, hypercoagulability
Drugs that bind gp41 and gp120 block which HIV processes?
gp41–>Fusion to target cell membrane (enFUvirtide)
gp120–>inhibits HIV entry, allosteric binding (Maraviroc). CCR5 antagonist
Pt has nonspecific symptoms, fever, elevated ALT/AST, thrombocytopenia. Deals with cattle, including cleaning their waste from the barn. Dx?
Acute Q fever secondary to Coxiella Burnetii infection (from aerosols of cattle/sheep waste/amniotic fluid).
Chronic Q fever would present as infective endocarditis.
What is Kussmaul sign, and in what conditions would it be seen?
It’s when there is an increase in JVP on inspiration instead of the normal decrease. Seen with constrictive pericarditis, restrictive cardiomyopathies, right atrial or ventricular tumors
What are the malignant signs of polyps in colon? Which has highest malignant potential?
Serrated and adematous (tubular and villous) are all neoplastic.
Villous>tubular in terms of malignancy.
Tubulovillous has intermediate malignancy potential.
Non-neoplastic=hyperplastic, hamartomatous, and inflammatory.
Size increases risk (especially >4cm)
Stabilizing force for secondary structure of proteins
Hydrogen bonds
Patient w/ CF has steatorrhea. What drug should you give them?
Give them a pancreatic enzyme supplement, since they likely have pancreatic insufficiency.
Pts w/ CF have chronic productive cough, recurrent sinopulmonary infections, pancreatic insufficiency, and male infertility (bilateral absence of vas deferens)
BCR-ABL, HER2/neu, and RET all involve tyrosine kinase. Which cancers are each connected to?
BCR-ABL=CML, ALL
HER2/neu=Breast (poor prognosis), ovarian, and gastric carcinomas
RET=Medullary thyroid cancer (MEN2A, 2B)
Renal mass, malignant cells, oliguria. Likely dx? What gene is mutated, and on what chromosome/
Renal cell carcinoma.
Both sporadic and hereditary are associated with a VHL mutation on chromosome 3.
RCC=3 letters, on chromsome 3.
Hereditary also includes cerebellar hemangioblastomas and pheochromocytomas in addition to RCC.
A pt w/ asthma is always coming in. The treatment that they take at home isn’t really working. What is a good add-on treatment (along w/ MOA)?
Omalizumab. It’s an IgE monoclonal antibody. Binds mostly to unbound serum IgE.
Used in allergic asthma resistant to inhaled steroids and long-acting beta 2 agonists
What bug causes hemolytic-uremic syndrome? What does the toxin inhibit? How would you get this bug?
Comes from EHEC, which is usually from undercooked meat. It causes hemolytic uremic syndrome (anemia, thrombocytopenia, acute renal failure). Toxin inhibits 60S ribosomal subunit.
Patient w/ acute pancreatitis develops respiratory failure. Why?
Increased cytokines and pancreatic enzymes lead to neutrophilic invasion of alveolar membranes, leads to ARDS. In ARDS you would see waxy hyaline membranes.
How to differentiate between blasto, histo, coccidio, and paracocci on histo?
Blasto: Same size as RBCs, broad-based budding. Mississippi River and Central America
Histo: Smaller than RBCs, within macrophages. Mississippi and Ohio River valleys. Causes pneumonia. Bird/bat droppings
Cocci: Larger than RBCs, filled w/ endospores. Southwestern US/California
Paracocci: Latin America. Captain wheel formation
Most common cause of eye problems in patients with HIV?
CMV infection (CD4<50). Treat with ganciclovir
How to calculate the clearance of anything (from kidneys).
Which substances are used to calculculate GFR and RPF?
What should FF be in healthy patients?
Clearance=(Urine concentration of S*Urine flow rate)/Plasma Concentration of S
GFR=Inulin/Creatinine
RPF=PAH
FF should be 20%
Different bursae and associated activity causing injury
Prepatellar: “housemaid’s knee”. Repeated trauma or extensive kneeling
Baker cyst: Popliteal fluid collection, chronic joint disease
Suprapatellar: direct blow to distal thigh or repetetive extension (runners)
Anserine: Medial aspect of knee. Obesity or athletes
Characteristics of histo findings in hepatitis?
Panlobular lymphocytic infiltrates, ballooning hepatocytes, hepatocyte necrosis, hepatocyte apoptosis (w/ acidophilic councilman bodies, stain pink)
Dermatitis herpatiformis associated with which GI issue? Characteristics of both?
Dermatitis herpatiformis: bilaterl and symmetrical erythematous papules on extensor surfaces. Microabscesses and neutrophils at dermal papillae tips. Involves IgA antibodies against gliadin (part of wheat)
Celiac: Increased intraepithelial lymphocytes, loss of villus height, crypt hyperplasia (vs Crypt abscesses in Ulcerative Colitis)
What plays a key role in protecting elastin from being degraded (inhibits elastase)? In what patients would smoking dramatically increase the risk of panacinar emphysema?
Alpha 1 antitrypsin.
Smoking makes elastase even more unopposed in patients with antitrypsin deficiency, and thus they are much more likely to develop panacinar emphysema
Pt has severe aortic stenosis, then gets acute a-fib. What would you expect to happen?
BP would decrease because the LV is most likely hypertrophic and has lost compliance. If atrium isn’t contracting, the amount of LV preload decreases b/c LV depends on atrial kick to get blood into it, thus resulting in decreased SV and increased pulmonary htn.
Drug of choice for both paroxysmal superventricular tachycardia (PVST) and cardiac stress test? Die fx?
Adenosine (a rapid antiarrhythmic). It gets potassium out of cells.
Side fx: flushing, hypotension, chest pain, sense of impending doom.
Antiarrhythmic used in torsades de pointes and to reverse digoxin toxicity
Magnesium
Patient is on an ACE inhibitor but reports cough and angioedema (due to excess bradykinin). You decide to switch them to a different drug class. What do you choose?
ARB (angiotensin II receptor blockers).
They selectively block binding of angiotensin II to AT1 receptors. Don’t increase bradykinin, don’t cause cough or angioedema. They are teratogenic though, so keep those away from Rachelle.
Will see increased renin, angiotensin I and angiotensin II. Decreased aldosterone, no change in bradykinin
Evolution of extrapyramidal side effects for Antipsychotic drugs:
4 hrs–>Acute dystonia. Muscle spasm, stiffness, crisis
4 days–>Akathisia. Restlessness (inability to sit still) Don’t confuse w/ psychotic sx!
4 week–>Bradykinesia. Parkinsonism.
4 month–>Tardive dyskinesia
Papilledema, dry skin rash, hepatomegaly. Vitamin deficiency?
Vitamin A
Immune mediated demyelination of the peripheral nerves, along with perineural inflammation. Dx Clinical findings?
Guillain-Barre syndrome. Schwann cells are destroyed.
Symmetric ascending muscle weakness, areflexia.. Facial paralysis and autonomic dysregulation.
Associated w/ Campylobacter or viral infections.
The autoimmunity is thought to be due to mimicry
“Floppy child syndrome”
Werdnig Hoffman syndrome, damage to anterior horn
Lowe motor neuron sx.
Key growth factors that promote angiogenesis?
Vascular Endothelial Growth Factor (VEGF)
Fibroblast Growth Factor
Also TGF-beta
How are siRNAs and miRNAs used therapeutically?
They go and bind to parts of mRNA, and induce posttranslational gene silencing, thus blocking mRNA translation
Which cells are most susceptible to ischemia in the brain?
pyrmidal cells of hippocampus and neocortex, Purkinje cells of cerebellum.
Hippocampus=first area damaged
Abrupt onset gross hematuria in a healthy pt w/ history of sickle cell dx in family (or diabetes mellitus, analgesic use, severe obstructive pyelonephritis)
Renal Papillary necrosis. Gross hematuria and proteinuria
Distinguish btwn acute and chronic pyelonephritis
Acute: Neutrophil infiltrate, affects cortex, spares glomeruli. Fevers, flank pain, CVA tenderness.
Ascending UTI is cause. WBCs in urine +/- WBC casts. Striated parenchymal enhancement seen on CT
Chronic: Due to recurrent acute episodes. Associated with vesicoureteral reflux, chronic kidney stones. Assymetric corticomedullary scarring, blunted calyx.
Contain EOSINOPHILIC CASTS resembling thyroid tissue (thyroidization of kidney)
Mycobacteria that grow in parallel chains “serpentine cords.” What is that, and what does it mean?
It’s cord factor, what makes mycobacteria virulent. Without it they aren’t infective.
Cord factor inhibits macrophage maturation and induces the release of TNF alpha
Why don’t pregnant women lactate?
Because of high levels of progesterone.
Why is RPF used for FF and not RBF? How do you calculate RPF from PBF?
RBF includes space taken up by erythrocytes, which isn’t filtered.
To calculate RPF, do RBF*(1-hematocrit)
Pathogenesis of hepatic encephalopathy?
Treatment?
Advanced liver failure–>liver can’t metabolize nitrogenous waste products–>ammonia crosses BBB–>Excess glutamine accumulates in astrocytes–>less glutamine to convert to glutamate in brain–>Disruption of excitatory neurotransmission
Presentation: Disorientation/asterixis, difficult arousal or coma. Renal failure, diuretics, bypassed hepatic blood flow post-TIPS.
Treat with Lactulose (increases NH4) and Rifaximin
Best way to contrast between delirium and brief psychotic disorder?
Those with psychotic disorders are typically alert and oriented
Dating patients questions for boards?
Never ethical
Different types of hearing loss?
Conductive– Bone>air (abnormal Rinne test), localizes to affected ear.
Sensorineural–Air>bone, localizes to unaffected ear.
Noise-induced–Damage to steroiciliated cells in organ of Corti, lose high-frequency first.
*remember that high frequency in ear is heard at base of cochlea (thin and rigid, like high strings on guitar). Low frequency heard at apex near helicotrema, wide and flexible
How do the different white blood cell plasma cells appear on histo?
Neutrophil: Multilobed nucleus.
Monocyte: Kidney-shaped nucleus, only one nucleus
Macrophage: Eats things, so has crap in it.
Eosinophil: Pink. Large eosinophilic granules. Defends against helminthic infections (through major basic protein)
Basophil: Allergic reactions. Presence=CML. Basophilic granules
Mast cell: Allergic reaction in local tissues. Contain basophilic granules, look a lot like basophils
Progressive heart failure in someone w/ recent viral infection. What should you expect?
Dilated cardiomyopathy with systolic dysfunction (decreased ventricular contractility)
How to differentiated between rubella (a paramyxovirus) and rubeola (German measles, a togavirus)?
Rubella and rubeola are both febrile maculopapular rashes that start on the face and spread to trunk and extremities.
Rubeola (Togavirus) is more likely to have postauricular lymphadenopathy and tenderness.
Anemia with “helmet cells”, “burr cells” and RBC fragments are indicative of what?
Mechanical red cell destruction (prosthetic valves) or microangiopathic hemolytic anemia.
What is the MOA of NRTIs in HIV therapy?
They competitively inhibit nucleotide binding to reverse transcriptase, and terminate the DNA chain (b/c they lack a 3’ group, makes 5’to3’ bond formation impossible)
What are saddle anesthesia and loss of anocutaneous reflex indicative of?
Cauda equina syndrome. Involves S2-S4
Why are allopurinol and rasburicase often given in conjunction with cancer treatments?
Cancer treatment involves tumor lysis syndrome, when intracellular contents get dumped out into bloodstream. Uric acid is one of those.
Allopurinol and rasburicase make uric acid into more soluble metabolites, thus decreasing likelihood of renal failure due to excess uric acid.
Hydration is also really important.
MOA of phosphodiesterase-3 inhibitors (milrinone, inamrinone) on contractility of the heart and blood vessels.
Causes increased contractility (increased cAMP).
Also causes vasodilation, so shouldn’t be used in pts with hypotension
What kind of antihistamine should be avoided in elderly patients?
1st-generation H1 blockers should be avoided (diphenhydramine, dimenhydrinate, chlorpheniramine…contain -en/-ine or -en/-ate) because they cause significant side effects, also cross into CNS.
Use 2nd generation (end in -adine) ie loratadine, fexofenadine, desloratadine.
Ovarian mass in woman with irregular vaginal bleeding, thickened endometrium, yellow firm mass, eosinophilic center on histo?
Granulosa cell tumor
What precaution should be taken when treating someone with acyclovir?
Aggressive intravenous hydration to avoid crystallization occuring in the kidney.
What’s going on in presbyopia and myopia?
Presbyopia: Inability to see things up close. Image is focused behind the retina.
Myopia: Inability to see things far away. Image is focused in front of the retina.
Paradoxically, as we age we become more presbyopic. So ppl who are myopic might see improvements in their vision.
What structures are most likely absent or non-functional if someone can’t metabolize very long fatty acid chains or fatty acids with branch points at odd numbered carbons?
Peroxisomes.
Likely to see neurologic diseases from improper CNS myelination.
These are normally oxidized by beta (VLFAC) or alpha (branch point) oxidation in peroxisomes.
If Kupfer cells are seen, what process is most likely occurring?
Hemolytic anemia leading to deposition of hemosiderin in the liver. Yellow-brown cytoplasmic granules.
2 drugs most involved in drug-induced SLE?
Procainamide (Class 1 sodium channel blocker), and Hydralazine (vasodilator).
You will see ANa (anti nuclear antibodies) with both, but will not see anti-dsDNA.
Branches of the splenic artery?
Pancreatic branches (upper body & tail of panc) Short gastric (upper part of greater curvature, no real anastomoses) Left gastroepiploic (Middle part of greater curvature, anastomoses with right gastroepiploic)
If diaphragmatic contractions progressively weaken on maximal inspiration, what is implicated?
The neuromuscular junction is probably messed up or there is rapid muscle fatigue due to constrictive lung or chest wall.
The phrenic nerve would be implicated if they were uniformly weak contractions (not progessive)
Which type of DNA codes for proteins, tRNA, and ribosomal RNA?
Mitochondrial DNA.
Small circular DNA molecules that resemble bacterial plasmids.
Maternally inherited. Mitochondria are double membraned and wavy cristae.
Where is the synthesis and assembly of ribosomal components carried out?
In the nucleolus
White/yellow plaques on colonic mucosa, composed of fibrin and inflammatory cells?
C. diff infection
Pain upon hip extension, prefer to be in hip flexion with lumbar lordosis?
Psoas abscess (pain w/ hip extension=psoas sign)
T or F? Stop codons code for an AA
False. The last AA is from the codon before it. Stop codons only bind release factor and release it from ribosome
Which 2 cell types release bicarb to neutralize gastric acid?
Which will undergo hyperplasia?
1) Brunner’s glands (submucosal), which are most numerous at pylorus but also through proximal duodenum.
2) Epithelial cells of pancreatic ducts and ductules
* Brunner’s glands will undergo hyperplasia in the presence of excess gastric acid (ie H pylori infection)
Burkitt lymphoma quick hits.
Occurs in adolescents/young adults. 8:14 translocation (c-myc and heavy-chain Ig).
C-myc is a TRANSCRIPTION ACTIVATOR
“Starry sky” histo–>sheets of lymphocytes w/ interspersed macrophages
Associated w/ EBV.
Jaw lesion in African form, Pelvis/abdomen in sporadic form
Disease where women present much later than men w/ same disease?
Hemochromatosis (b/c women menstruate, takes them longer to get up to the 20g of accumulated iron).
Men in 40s, women later
Sudden, acute painless and permanent monocular blindness. Dx? Fundoscopic findings?
How does the clot get there?
Central retinal artery occlusion.
Pale retina, cherry red macula
Clot travels from internal carotid to ophthalmic to central retinal
How do nonvirulent forms of strep pneumo become virulent?
Through transformation. They require a capsule to become virulent. They can take up exogenous DNA and integrate it into their own to then become virulent.
Treatment for BPH that also causes hair growth?
What about prostate cancer treatment?
Treatment for breast cancer than involves aromatase?
Finasteride: 5-alpha-reductase inhibitor, decreases conversion of testosterone to DHT. Useful in BPH and male-pattern baldness.
Flutamide: Nonsteroidal competitive androgen receptor inhibitor. Prostate cancer treatment.
Anastrozole/Exemestane: Aromatase inhibitors, used in postmenopausal women with ER positive breast cancers
Anti-inflammatory drug that doesn’t impair platelet aggregation at all?
Celecoxib–>only blocks COX-2. COX-1 is the one involved in platelet formation. Also doesn’t cause GI side effects!
Hypertensive drug that causes peripheral edema?
Calcium channel blockers (-dipines, diltiazem, verapamil)
What type of reaction is poison ivy? What immune cell is involved?
Type 4 (Delayed type).
2 phases: 1) Sensitization phase. Takes 10-14 days. Initial exposure/development of immunity.
2) Elicitation Phase: 2-3 days following exposure.
T lymphoctyes are involved.
New onset neuro sx, anemia w/ schistocytes, thrombocytopenia, acute kidney injury. Dx? Pathogensis?
Thrombotic Thrombocytopenic Purpura (TTP).
Deficiency of ADAMTS13, a protease that normally cleaves VWF. Results in large, prothrombotic VWF that causes clots in microvessels, thrombocytopenia and schistocytes follow b/c they are sheared by platelet-rich thrombi.
Can also get Hemolytic Uremic syndrome secondary to this, caused by platelet rich thrombi in glomeruli and arterioles.
2 types of gastric cancer?
1) Intestinal adenoma. Solid mass, projects into lumen, glandular cells.
2) Diffuse Carcinoma: infiltrates stomach wall, signet ring cells (mucin filled). Stomach wall grossly thickened and leathery.
Most common lung cancer? Is it associated with smokers?
Adenocarcinoma is most common overall, and most common in women and non smokers. Not associated with smoking. Peripheral location, osteoarthropathy.
Other lung cancers:
Squamous: 2nd most common. Hypercalcemia. Central location.
Small cell: “Oat cell”. Most common. Central location. Cushing syndrome, SIADH, Lambert-Eaton syndrome.
Large cell: Least common. Peripheral. Galactorrhea and gynecomastia.
Nephrotic syndrome secondary to malignancy, infection, medication. Increased thickness of glomerular membrane. Spike and dome appearance w/ silver stain. Poor response to steroids. Dx?
Other nephrotic syndrome quick hits?
Membranous Nephropathy!
Focal segmental: Most common in African Americans/Hispanics. Effacement of foot process. Segmental sclerosis, hyalinosis, focal deposits of IgM, C1.
Minimal change: Most common in kiddos. Effacement of foot processes. Recent infection, good response to corticosteroids.
Amyloidosis: Apple-green birefringence. Chronic conditions (RA, TB, MM)
Diabetic Glomerulo-nephropathy: GBM thickening. Kimmelstiel-Wilson lesions (light pink mesangial expansion). Increased GFR.
Which tests are used to monitor warfarin and heparin?
Warfarin: Prothrombin Time (PT), INR. Remember it inhibits factors II, VII, IX, X.
Heparin: Activated partial thromboplastin time (aPTT)
Sharp pleuritic chest pain relieved by sitting up and leaning forward. Associated w/ SLE.
Pericarditis (most common cardiovascular manifestation of SLE)
Vaginitis: 3 causes. Quick hits.
1) Gardnerella. Thin gray discharge with fishy odor. pH>4.5, Clue cells, positive whiff test (w/ KOH). Treat w/ clindamycin or metronidazole
2) Trichomonas. Green smelly discharge, vaginal inflammation. pH>4.5, motile bugs. Treat pt and partner w/ metro.
3) Candida vaginitis: Cottage cheese discharge, vaginal inflammation. normal pH, pseudohyphae, Treat w fluconazole.
Features of cystic medial degeneration? What is it associated with?
Pooling of proteoglycans in the medial layer of of large arteries. Predisposes to aortic dissections and aneurysms. Seen in Marfan syndrome.
Difference between a true and false aneurysm?
True=within the 3 layers.
False=breach of all 3 layers, hematoma forms outside of the vessel, but then is contained within a sac of connective tissue.
Deficiency of this causes recurrent infections with neisseria species.
MAC (the membrane attack complex, C5b-C9)
Match necrosis type with where commonly seen. Coagulative Liquefactive Fat Caseous
Coagulative: Ischemic Injury (Anucleated, tissue structure preserved)
Liquefactive: Bacterial infections, CNS infarcts (viscous liquid mass, pus, abscess, CSF-filled)
Fat necrosis: Acute pancreatitis. Saponification (soap like)
Caseous necrosis: Tuberculous infection (cheesy, granulomas, also funcal infections)
What causes myofibril relaxation at the end of the excitation-contraction coupling?
Calcium efflux through the Na/Ca exchange pump and the sarcoplasmic reticulum Ca-ATPase pump (SERCA)
Which drugs have antimuscarinic effects?
Atropine, Tricyclic antidepressants (amitryptiline), H1 receptor antagonists (diphenhydramine), neuroleptics, antiparkinsonian drugs.
Enzymes that enable reversible conversion between ribose-5-phosphate (nucleotide synthesis) and fructose-6-phosphate (glycolysis)?
Transketolase and Transaldolase
Pt has MS. They have optic neuritis (demyelination of optic nerve CN II) of one side. What will be the effect on the light test?
On the affected side, there will be no light reflex in either eye (since CN II carries afferent signal). On normal side there will be normal constriction of both eyes b/c that nerve isn’t injured, and the efferent aspect of the light reflex travels with the oculomotor nerve.
Pt has Hemophilia A. Why does desmopressin work for tx?
It increases factor VIII.
It also stimulates secretion of vWF from cells.
Zollinger-Ellison is involved with which hereditary thing?
MEN1. Pancreatic, Pituitary tumors, and parathyroid adenomas.
20-30% of ppl w/ ZE will have MEN1
Tx for gonorrhea?
Ceftriaxone (3rd gen ceph) and Azithromycin (a macrolide), azithromycin is to treat concurrent chalmydia infection
Aortic arch derivatives
1st: Maxillary artery
2nd: Hyoid/Stapedial artery
3rd: Common carotid, proximal internal carotid
4th: Left–>aortic arch. Right–>Proximal right subclavian artery
6th: Left–>Ductus arteriosus, proximal pulmonary arteries
Sudden deceleration from MVA would cause damage to which part of aorta
Isthmus (just distal to left subclavian). It’s anchored here by ligamentum arteriosum here, makes it less mobile, more likely to be injured
Class of antiarrhythmics that cause increased affect at higher heart rates (use-dependence), and cause QRS prolongation.
Class IC (Flecainide, Propafenone) "Can I have Fries, Please."
What’s the purpose of inhibiting the proteasome?
When would it be used?
Cause increased apoptosis (since proteasome usually kills pro-apoptotic substances. Proteasomes also eat a lot of the toxic substances that are released by cancerous cells)
Used in MM.
Dangerous side effect of anti-thyroid medications?
Agranulocytosis.
Meds=PTU, Methimazole (used to treat Graves disease)
*remember, you also give corticosteroids to stop the exophthalmos and pretibial myxedema!
What’s cystinuria? Which AA are not absorbed correctly? What do these pts tend to develop?
Excess cysteine in urine due to defective transport that normally works in absorption of cysteine, ornithine, lysine, and arginine (COLA).
Patients get HEXAGONAL cysteine kidney stones.
Cause of hypochromic, microcytic anemia?
Iron deficiency. Could be nutritional or occult blood loss
Which enzyme helps out in someone w/ essential fructosuria (fructokinase deficiency)
Hexokinase
Purpose of carcinoembryonic antigen?
For colon cancer.
Associated w/ WORSE PROGNOSIS, if present following surgery it indicates RESIDUAL disease.
Also used to track RECURRENCE
Drug administered after nuclear accidents?
Potassium iodide. It gets in and inhibits thyroid uptake of radioactive iodine isotopes.
What is the NF-KB protein?
What keeps it inhibited?
It’s a proinflammatory transcription factor.
Repressed in Crohn disease, it results in reduced cytokine production. Impairs innate immunity when decreased
It’s inhibited by IKB. IKB is ubiquinated when an infection is detected and NF-KB goes and enters the nucleus to help the immune response
Criteria for Preeclampsia/Eclampsia?
HELLP syndrome?
Preeclampsia=NEW ONSET htn w/ proteinuria or end organ dysfxn after 20th wk gestation. Caused by abnormal placental spiral arteries, endothelial dysfxn, vasoconstriction, ischemia.
Eclampsia=Preeclampsia+maternal seizures
HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets. Schistocytes on blood smear.
Necrotizing vasculitis of respiratory tract plus progressive glomerulonephritis (crescentic)?
Wegener’s (granulomatosis with polyangiitis)
Associated with C-ANCA, which attacks neutrophils
Budding yeasts with thick capsules in HIV pt
Cryptococcus!
Porcelain gallbladder characteristics?
Calcified gallbladder (presents as sometimes asymptomatic firm mass in RUQ). Due to chronic cholecystitis. Treat w/ prophylactic cholecystectomy due to high rates of gallbladder carcinoma.
What is Kartagener syndrome and how does it present?
Defect of the dynein arm, results in defective cilia. Infertility in men AND women (immotile sperm, messed up cilia in fallopian tube), ectopic pregnancy, bronchiectasis, recurrent sinusitis, Dextrocardia (heart on other side).
Remember, dynein is RETROGRADE to microtubule (+to-), kinesin is ANTEROGRADE to microtubule (-to+)
Which process is responsible for most acid excretion in chronic acidosis?
Increased ammonium production in the kidneys. Renal tubular epithelial cells metabolize glutamine to glutamate and excrete it as ammonium in the urine.
In CAH, what are the relative levels of cortisol, aldosterone, ACTH, and 17-hydroxyprogesterone?
Cortisol: Decreased
Aldosterone: Decreased
ACTH: Increased
17-hyr..: Increased
How does capsaicin achieve its analgesic effect?
It causes release and then depletion of Substance P
Why do ACE inhibitors lead to increased creatinine?
They decrease the GFR (and thus the FF) by inhibiting efferent arteriole.
Should not be used in pts with renal artery stenosis.
For mitral regurgitation, what additional murmur is indicative of the severity?
An S3 sound
West-Nile virus quick hits?
Febrile illness with rash, neuro manifestations (flaccid paralysis, encephalitis).
Transmitted by female Culex mosquitoes in Summer.
Why do pts w/ Tetralogy of Fallot squat?
It increases systemic vascular resistance and decreases the R to L shunt (through the overriding aorta)
For extended spectrum beta lactamases (Which are resistant to penicillines and cephalosporins), what drug should be used?
Carbapenems
If on XRAY you see a completely opacified lung with deviation of structures towards that side, what is it indicative of?
Obstructive lesion in a mainstem bronchus
Agent used for raising HDL (although it doesn’t really improve outcomes)
Niacin (the vitamin) given at pharmaceutic doses
Histological picture of post-strep glomerulonephritis?
1) Enlarged, hypercellular lomeruli on light microscopy
2) “Lumpy-bumpy” IgG, C3 deposits on florescence (not linear!)
3) Electron-dense subepithelial humps on electron microscopy
Pre-malignant lesions on sun exposed areas that are erythematous papules with central scale and sandpaper texture?
Actinic Keratosis.
Potential to progress to squamous cell carcinoma
Prolonged NSAID use can cause renal injury. What are the findings?
Chronic interstitial nephritis and papillary necrosis. Bilateral shrunken kidneys with papillary necrosis.
Will see protein and WBCs in urine
What are TATA and CAAT boxes? What do they do?
They are promoters in eukaryotic cells. They promote initiation of transcription. usually found upstream
What process are pancreatic pseudocysts seen in?
Acute pancreatitis. Usually pop up around 4 weeks after acute pancreatitis. They are cysts filled with enzymes and inflammatory cells surrounded by GRANULATION TISSUE and FIBROSIS, not epithelium, thus making them psuedocysts.
They can rupture and cause hemorrhage
Moldy grain tends to grow aspergillus. What cancer is associated? Why?
Hepatocellular carcinoma.
B/c aspergillus produces aflatoxins which then cause mutations in the p53 gene, which allows for hepatocellular carcinoma to develop
Which vascular beds are most susceptible to atherosclerosis (highest burden)?
Abdominal aorta and coronary arteries
How does hypoxia cause different effects in pulmonary circulation vs systemic (in terms of vasculature)
In pulmonary circ, it causes vasoconstriction (to prevent blood from perfusing areas of poor ventilation).
In systemic, hypoxia leads to vasodilation to try and get oxygen to those areas
What does meningococcal septicemia lead to?
Hemorrhagic infarction of the adrenal glands, leading to acute renal crisis (Waterhouse-Freiderichson)
Why do reticulocytes stain blue on Wright-Giemsa stain?
They are immature and still have ribosomal RNA within them
Which bacteria species are spore forming and tend to be found in soil?
Bacillus and clostridia
In condition of pulmonary embolus, why does hypoxemia develop?
V/Q mismatch
What is the immediate treatment that should be given to patients with Addison’s?
Glucocorticoids (Dexamethasone or hydrocortisone)
What is the mechanism of action of interferon alpha and gamma, which are released by all cells in response to viral infection?
They suppress viral replication by HALTING PROTEIN SYNTHESIS and promoting apoptosis of INFECTED CELLS ONLY
how to differentiate btwen neuroleptic malignancy syndrome and serotonin syndrome?
Serotonin has neuromuscular hyperactivity, whereas NMS is a rigid paralysis
What stain is useful if you have someone who seems like the might have a MEN2 syndrome and you are looking at their thyroid cells?
A Congo Red stain, which will stain amyloid deposits (nests of polygonal cells, derived from calcitonin released by neoplastic C cells)
Suspected dx if a patient has thrombocytopenia, ecchimoses, mucosal bleeding, etc with no real other signs/explanations?
Immune thrombocytopenic purpura (ITP)
usually by IgG destruction of GPIIb/IIIa (target of Abciximab!)
What does a positive urea-test from gastric biopsy that raises pH indicate?
H pylori infection (b/c H pylori produces large amounts of urease)
HCG is indicative of what testicular tumor?
Testicular germ cell tumor.
Look for TSH activation (hyperthyroidism)
2 exceptions to the sympathetic neurotransmitter transmission (usually Ach from preganglionic, NE from postganglionic).
1) Adrenal medulla (NE directly into bloodstream after preganglionic stimulation)
2) Eccrine sweat glands (cholinergic both pre and post-ganglionic)
Pt presents in DKA. What treatment should you give them?
Insulin. It will increase serum bicarb and sodium and decrease serum glucose, potassium (b/c less lipolysis), and osmolality.
Treating a pt for alocohol intoxication. What should you do to prevent Wernicke encephalopathy?
Give thiamine supplementation BEFORE starting dextrose, otherwise dextrose alone will precipitate Wernicke encephalopathy.
Wernicke affects the MAMILLARY BODIES (part of Papez circuit) of the brain (drunk ppl love sex, want boobs. mamillary bodies are boobs of brain)
Which infections is reactive arthritis associated with?
Either GU or GI. Chlamydia, Campylobacter, Salmonella, Shigella, Yersinia.
Also associated with HLA-B27. Look for signs of arthritis after some sort of benign infection
Tx of Influenza A & b?
Oseltamavir–>neuraminidase inhibitor. Impairs release of newly formed virions.
If on TPN, why do you get gallstones?
B/c there is no enteric stimulation to cause release of CCK. Thus, gall bladder stasis.
Interscalene nerve block is used to block what? It also causes transient paralysis of which muscle?
Used to block brachial plexus.
Transient paralysis of diaphragm
Which cells sense hypoxia and as a response release EPO?
Peritubular cells in renal cortex (Kidneys).
EPO then stimulates erythrocyte production
When oxygen binds to hemoglobin, what does hemoglobin release?
Hydrogen ions and CO2. (Haldane effect)
In the peripheral tissue, high levels of CO2 and hydrogen cause hemoglobin to release O2 (Bohr effect)
Why do pregnancy and birth control pills predispose to gallstones?
Estrogen upregulates cholesterol synth (opposite of statins) and progesterone causes gall bladder hypomotility.
Pathogenesis of Wilson Disease
Inadequate hepatic copper excretion, failure of copper to enter circulation as CERULOPLASMIN.
You’ll see DECREASED ceruloplasmin, cirrhosis, corneal deposits, copper accumulation, hepatocellular carcinoma, hemoltyic anemia, basal ganglia degeneration, asterixis, dementia, dyskinesia, dysarthria.
Treat with D-penicillamine
Where would you want to biopsy in Hirschsprung disease?
Submucosa, looking for absence of submucosal (Meissner) and myenteric (Auerbach) plexi
Best med to slow down diabetic nephropathy?
ACE inhibitors or ARBs (they are blood pressure independent and anti-proteinuric)
In internuclear ophthalmoplegia, where does the lesion typically occur?
It’s in the medial longitudinal fasciculus (in the dorsal pons). Where one eye doesn’t do medial convergence.
An opioid drug that has partial affinity and works as an antagonist in the presence of other opioids (can precipitate withdrawal)
Buprenorphine (used in conjunction w/ naloxone for heroin addicts)
Patient found to have lipoprotein lipase deficiency. Dx? Risk of developing what?
They will have elevated chylomicrons, and are at risk of acute pancreatitis in the future due to hypertiglyceridemia.
H pylori is associated with what malignancy?
MALT lymphoma (mucosa associated lymphoid tissue) and gastric adenocarcinoma H pylori infection is typically in antrum of stomach.
Shigella gains access to the body how?
They bind selectively to Microfold M cells of Peyer’s patches and are then endocytosed
What value stays normal in ARDS?
The pulmonary capillary wedge pressure (pulmonary edema is noncardiogenic).
Capillary permeability, lung compliance, ventilation to perfusion matching, work of breathing would all be changed.
3 Trisomies:
1) 13. Patau syndrome. cleft liP/Palate. holoProsencephaly. Polydactyly. 13=Puberty=Patau. Decreased b-hcg, increased nuchal translucency.
2) 18. Edwards syndrome. low set Ears, clenched hands, prominent occiput. 18=Election=Edwards. Decreased b-hcg, alpha-fetoprotein, estriol, inhibin.
3) 21. Down syndrome
Most common cause of DIC in pregnant women?
Tissue of released tissue factor from placenta into maternal circulation
How does enterococcus gain resistance to aminoglycosides?
They produce enzymes that transfer different chemical groups to the aminoglycoside molecule
If a tumor stains positive for synaptophysin, what is it likely derived from?
What about GFAP?
Synaptophysin=Neuronal origin
GFAP=glial origin (astrocytomas, ependymomas, oligodendrogliomas)
What is the effect of arteriovenous shunts on pressure volume loops?
They increase preload and decrease afterload because they bypass the capillaries.
Causes high output cardiac failure
List of CYP450 inducers/inhibitors
Inducers: Carbamazepine, Phenytoin, Phenobarbitol, Rifampin, Griseofulvin
Inhibitors: Cimetidine, Ciprofloxacin, Erythromycin, Azole antifungals, Grapefruit juice, Isoniazid, Ritonavir (protease inhibitors)
2 calculations for cardiac output:
1) CO=SV*HR
2) CO=rate of O2 consumption/arteriovenous O2 content difference
How does hyperglycemia cause organ injury (like cataracts)?
1) It deposit on cells non-enzymatically (advanced glycosylation end products)
2) Glucose is converted to sorbitol (by aldolase reductase) too fast, so sorbitol accumulates and causes influx of water and osmotic injury. Aldol reductase also depletes NADPH, which predisposes to oxidative stress and damage
Who and where are most affected by osteomyelitis?
What about vertebral myelitis (in adults)?
Children (especially boys)
Metaphysis of long bone (slow blood flow, capillary fenestration)
MRI is best diagnostic tool for vertebral osteomyelitis?
Most common congenital heart defect associated w Down Syndrome?
Complete atrioventricular canal defect. Comprised of an ASD, a VSD, and a common AV valve
Muscle/nerve involved w/ winged scapula, and potential cause for it?
Muscle: Serratus anterior
Nerve: Long thoracic
Cause: Axillary node resection, penetrating trauma, chest tube placement
Levels of Ca, PTH, phosphorus in osteoporosis?
Normal!
Triple therapy for H pylori infection?
2 antibiotics (amoxicillin and clarithromycin) and 1 PPI (omeprazole)
What conditions cause haptoglobin to decrease?
Haptoglobin decreases when it binds to hemoglobin. It binds to free hemoglobin in the blood when hemolysis is occurring. So abnormal (low) haptoglobin is seen concurrent with hemolysis
Major toxicity associated w/ Amphotericin B?
Renal toxicity! Severe hypokalemia and hypomagnesemia are major side effects, often require supplementation
Give approximate V of distribution for these 3 scenarios:
Large molecular weight, hydrophilic.
Small molecular weight, hydrophilic.
Small molecular weight, hydrophobic.
Large molecular weight, hydrophilic: 3-5 L (plasma)
Small, hydrophilic: 14-16 liters (plasma + extracellular)
Small, hydrophobic: 41 L (plasma+interstitial+extracellular)
What’s it called when ppl have intense pain about 45 min after eating to the point that they have food aversion?
Mesenteric ischemia, similar to angina pectoris
Difference between small and large VSDs?
Small: blowing holosystolic murmur at mid/lower left sternal border. Murmur develops after about 4 days of life (b/c pulm resistance is high at birth). Insignificant, close spontaneously
Large: No murmur, presents w heart failure, failure to feed, failure to thrive. Require correction, if not can develop pulmonary htn and Eisenmenger syndrome
Sign of esophageal squamous cell cancer and major causes?
Involves upper 2/3 of esophagus, keratin pearls.
Causes: Smoking and drinking
MOA of Class II antiarrhythmics
They are beta blockers. Decrease SA and AV node activity by decreasing cAMP, decreasing calcium currents. Suppress normal pacemakers by decreasing slope of phase 4. Used for SVT and controlling afib and atril flutter.
-lol drugs
MOA of Class III antiarrhythmics
Potassium channel blockers. Amiodarone, Ibutilide, Dofetilide, Sotalol (AIDS).
Increase AP duration, ERP, and QT interval.
Markedly prolonged repolarization by blocking Ik channel (Phase 3)
Amiodarone is only one that doesn’t have risk for Torsades de pointes
How to differentiate between UTI and pyelonephritis?
Pyelonephritis will show WBC casts along with UTI sx.
Why can’t mycoplasma species be treating by penicillins, cephalosporins, carbapenems, vancomycin?
They don’t have peptidoglycan cell walls (which are the target of those drugs).
Mycoplasma species can be treated by anti-ribosomal drugs (macrolides, tetracycline)
Location and signs of Pancoast (superior sulcus) tumor?
Occurs in apex of lung. Invades local structures, causes Horner syndrome (ipsilateral ptosis, miosis, anhidrosis), SVC syndrome, rib destruction, atrophy of hand muscles, pain in distribution of C8 and T1-T2
Skin lesion secondary to medications that causes unblanchable violaceous raised lesions distributed over bilateral lower extremities? (they probably show histo image too)
Leukocytoclastic vasculitis
Histo shows perivascular inflammation of small vessels w/ fibrinoid necrosis and predominance of neutrophils
Hematuria, proteinuria, urine RBC casts, hypercellular glomeruli. Dx? Other lab findings?
Post strep glomerulonephritis
Expect to see ASO titers, elevated anti-DNase B titers, decreased C3 and total complement, and cryoglobulins. normal C4
Most common site of thrombus formation in afib?
Left atrial appendage
How is cirrhosis caused?
It’s diffuse hepatic fibrosis with replacement of the normal lobular architecture by fibrous-lined parenchymal nodules
Causes=Chronic hepatitis, alcohol, hemochromatosis, and NASH (non alcoholic steatohepatitis)
How is tuberculosis contained into granuloma?
By CD4+ T cells and macrophages
How do coagulation studies differ between HUS/TTP and DIC?
They are normal in HUS/TTP (b/c coag system is not activated)
Abnormal in DIC
Quick review of what happens with the different parts of kidney?
PCT-reabsorbs AAs, glucose, electrolytes
Descending loop- permeable to water, ions retained in lumen (fluid becomes hypertonic)
Ascending loop- impermeable to water. Na, Cl, K reabsorbed. urine less concentrated
Early DCT-reabsorbs Na, Cl. Urine most dilute here.
Collecting tubule- reabsorbs Na in exchange for H and K. Vasopressin inserts aquaporin here
How are glucose and cholesterol taken up into cells?
Glucose: facilitated diffusion (thru a carrier protein) that is stereoselective for D-glucose
Cholesterol: receptor-mediated (LDL receptor)
Why do sickle cells tend to polymerize?
The glu-val causes a change into a nonpolar, hydrophobic pocket in Hb. This causes Hb to polymerize thru hydrophobic interactions
Signs and greatest risk for pancreatic cancer?
Signs: Nontender enlarged gall bladder called Courvoisier sign (b/c pancreas head compresses the common bile duct), weight loss, obstructive jaundice. Weight loss.
Risks: Smoking, Age>50, Chronic pancreatitis, Diabetes.
CA19-9 is the cancer marker.
Bone signs of osteoporosis and hyperparathyroidism?
Osteoporosis: Loss of total bone mass, trabecular thinning with fewer interconnections
Hyperparathyroidism: Subperiosteal resorption with cystic degeneration
In a pt w/ history of major depressive episodes, what should be ruled out?
History of mania (looking for bipolar). You don’t want to put someone on antidepressants if they have bipolar disorder.
What causes beta-thalassemia?
Mutations that result in defective transcription, processing, and translation of beta-globin mRNA (NOT a folding issue!)
What is DRESS syndrome? In who should it be suspected?
Drug Related with Eosinophilia and Systemic Symptoms.
Typically occurs 2-8 weeks after starting anticonvulsants, allopurinol, sulfinamides, and antibiotics.
Fever, lymphadenopathy, facial edema, diffuse skin rash, eosinophilia, internal organ dysfxn
1) Treats both hypertension and BPH?
2) Coronary heart disease, heart failure, and hypertension?
3) Essential hypertension in general population?
1) Alpha-1 adrenergic blockers (-azosins)
2) Cardioselective B-1 blockers
3) Hydrochlorothiazide
Painful blue discoloration underneath fingernail. Dx?
Either:
1) Benign glomus tumor (from smooth muscle that controls temp regulation of dermal cells)
2) Melanoma (pigmentation derivative)
What causes anal fissures, and where do they usually occur?
Caused by passing hard stool with prolonged constipation, sx are pain while pooping and blood in stool.
Usually occur at posterior midline distal to dental line, due to poor blood flow
What lies immediately deep to 12th ribs?
Left and right kidney.
Spleen below left 10th and 11th
Which maneuvers will increase/decrease the murmur heard in hypertrophic cardiomyopathy?
Increase: Maneuvers that decrease preload (Valsalva, abrupt standing, nitroglycerin administration)
Decrease: Maneuvers that increase preload and afterload (Squatting, Sustained hand grip, Passive leg raise)
Drug that causes gingival hyperplasia?
Phenytoin–>this drug increases sodium channel inactivation. Causes a buttload of side fx (peripheral neruopathy, ataxia, hirsutism, megaloblastic anemia, teratogenesis, SLE like syndrome…
Mechanism of formation of uric acid stones?
They look like rhomboids.
Either increased uric acid (ie from leukemia treatment) or more acidic urine. In conditions of chronic metabolic acidosis, the kidneys increase excretion of hydrogen, making urine more acidic, where uric acid is more soluble
Watershed areas of colon susceptible to ischemic damage in hypotensive states?
The left splenic flexure and the rectosigmoid junction
Drug used in hypercholesterolemia or hypertriglyceridemia states that predisposes to gout?
Niacin (which decreases hepatic synthesis of triglycerides and VLDL and decreases HDL clearance).
Can cause renal excretion of uric acid, increasing chance for gout
What effect does cortisol display for lots of hormones, making them exert their maximal effect?
Permissiveness (ie increases glucose release from liver in response to glucagon)
Key players in Type IV hypersensitivity reactions?
Macrophages, CD4+ helper T cells, CD8+ cytotoxic T cells
Which drugs cause prolonged PT? Prolonged PTT? Both? Both PLUS prolonged thrombin time?
Prolonged PT=Extrinsic pathway drugs Prolonged PTT (aPTT)=Intrinsic pathway drugs Both=Common pathway, Factor Xa inhibitiors (-ban=direct, indirect=Fondparinux) Bot+prolonged TT=Direct thrombin inhibitors (Argatroban, Bivularivudn, Dabigatran)
Cardiac pacemaker action potential currents:
Phase 0
Phase 3
Phase 4
Phase 0: Calcium (prolonged by Class IV antiarrhythmics, calcium channel blockers, verapamil, diltiazem)
Phase 3: Potassium
Phase 4: Sodium (prolonged by Class II antiarrhythmics (beta blockers)
Pt has vertical diplopia (when close-reading, walking down stairs). Likely lesion?
Trochlear nerve palsy.
Deficient action of superior oblique muscle around eye
Pts typically tuck chin and tilt head away from bad eye
In pts with cirrhosis, what are 3 most important tests to run to check livery fxn?
1) Albumin levels (hypo=bad)
2) Prothrombin time (prolonged=bad)
3) Bilirubin levels (elevated=bad)
2 yo pt has bursts of non-rhythmic eye movements in various directions, hypotonia, myoclonus, and abdominal mass. Dx?
Neuroblastoma (excess N-myc!!)
Most common extracranial neoplasm in children, found on adrenal gland
Most common disorder of porphyrin synthesis. How does it manifest? What is deficient?
Porphyria Cutanea Tarda
Blistering cutaneous photosensitivity.
Uroporphyinogen decarboxylase is deficient.
*look at pg 396 to differentiate btwn porphyira probs
“Stabbing” or “electric shock” sensation on face. Dx and tx?
MOA of tx?
Trigeminal neuralgia. (in distribution of V2 and V3)
Carbamazepine is treatment of choice.
Carbamazepine inhibits sodium current on multiple levels, keeps nerves from being able to fire rapidly.
Can also cause bone marrow suppression
Why are beta blockers used in hyperthyroidism?
They block sympathetic affects and also decrease conversion from T4 to T3
MOA of ehtosuximide, phenytoin, carbamazepine, and valproic acid?
Ethosuximide: Blocks T-type calcium channels in thalamic neurons
Phenytoin, Carbamazepine, Valproic acid: Reduce ability of Na channels to recover from inactivation. Inhibit neuronal high frequency firing.
Herited disorder (AD w/ incomplete penetrance), prolonged PPT and prolonged bleeding time. dx?
Von Willebrand Factor deficiency.
Most common heritable bleeding disorder
Impaired platelet function and Factor VIII
In patients w/ heparin induced thromboctyopenia (HIT) what is the drug of choice for treatment?
Direct thrombin inhibitors (such as argatroban)
Which nerve detects carotid massage? Which nerve detects increased stretch in aortic arch?
Carotid: Glossopharyngeal
Aortic arch: Vagus
Sodium correction mnemonics in relation to pons?
Low to high, pons will die (osmotic demyelination syndrome)
High to low, brain will blow (cerebral edema, herniation)
Why are OCPs used in PCOS?
It lowers the amount of LH which in turn lowers the amount of ovarian androgen production, treats hirsuitsm
Characteristics of Dandy-Walker malformation?
Hypoplasia/absence of cerebellar vermis, dilation of fourth ventricle, developmental delay, large skull
How to monitor progression of ankylosing spondylitis?
Measure degree of chest expansion (thoracic spine can get involved, leading to hypoventilation).
Remember to look for bilateral sacroiliitis, HLA-B27 serotype, uveitis
What’s the Reid index and what is it used for?
It’s the ratio of the mucous gland layer thickness in broncial wall submucosa to the total thickness from the respiratory epithelium to the bronchial cartilage.
Used to monitor severity of chronic bronchitis.
Normally is about 40%, gets larger with bronchitis
Landmark used to find appendix in appendicitis?
Teniae coli. They’ll guide to the strt of the cecum where appendix is
Kawasaki disease quick hits
Kids 4 and under usually Fever>5 days, bilateral conjunctivitis, cervical lymphadenopathy, Mucocutaneous involvement. Treat w/ aspirin. "Strawberry tongue" Cause coronary atery aneurysms
Lab values for iron deficiency anemia?
Decreased ferritin, Increased TIBC ( and transferrin), and a microcytic anemia.
Why is there subacute cerebellar degeneration seen in some cancers (ie small cell lung cancer, breast/ovarian/uterine cancer)?
B/c the immune response against those cancers end up cross reacting with Purkinje neuron antigens. It’s an autoimmune process.
Triad of ataxia telangiectasia?
What DNA process is messed up?
Ataxia, cutaneous telangiectasias (esp in sun exposed areas) and recurrent sinopulmonary infections.
DNA break repair is messed up (non-homologous)
What are the auto-antibodies in Rhemautoid Arthritis?
Anti-citrullinated peptides and Rheumatoid Factor (which is specific for the Fc portion of IgG)
Differentiate between DIC and TTP-HUS.
DIC: Pts bleed, coag cascade activated, PT and PTT prolonged, Low fibrinogen, increased FDP.
TTP-HUS: Do not bleed, only platelets are activated, Normal Pt and PTT, normal fibrinogen
What is used to reverse or “save” cells in the case of too much methotrexate ingestion?
Folinic acid (leucovorin). It doesn’t require DHF reductase (which methotrexate inhibits)
Neurodegenerative diseases typically have what kind of hydrocephalus?
Hydrocephalus ex-vacuo (meaning that CSF expands but normal pressure is retained due to cortical atrophy).
Basically the CSF is justt aking the place of where the brain used to be.
An excessive rise in left atrial systolic pressure is due to?
Mitral regurgitation. Blood goes back into atrium during ventricular systole, increasing filling of the atrium. Seen as a large v wave peak
Risks of secondhand smoke around newborns?
Asthma, low birth weight, middle ear disease, SIDS
4 risk factors for developing renal calculi?
Hypercalcemia, Hyperoxaluria, Hyperuricosuria, hypocitraturia
Someone has platelet-rich thrombi with no bacterial growth on their mitral valve leaflets. Dx?
Nonbacterial thrombotic endocarditis.
Associated with advanced malignancy, chronic inflammatory disorders, and sepsis
Triad of normal pressure encephalitis?
1) Gait difficulties
2) Cognitive disturbances
3) Urinary incontinence.
Look for enlarged ventricles disproportionate to the size of the sulci enlargement
“Wet, wacky, and wobbly”
Enzyme that plays a key role in brown pigment stone formation?
Beta-glucoronidase. Released by injured hepatocytes and bacteria
Liver fluke Clonorchis sinensis have high prevalence in eastern asia and are common cause of brown pigment stones
Splinter hemorrhages underneath the fingernails are signs of…
Bacterial endocarditis (hemorrhages caused by microemboli from valvular vegetations). Auscultate for regurgitant murmur
Drug of choice for treatment resistant schizophrenia?
Clozapine (monitor neutrophil count due to risk of agranulocytosis!)
Carnitine deficiency is associated with deficiencies in the synthesis of what?
Ketone bodies (acetoacetate) Carnitine normally transports fatty acids into the mitochondria (it's the fat car). If no carnitine, then skeletal muscle and cardiac muscle can't use ketone bodies for energy when glucose is low, resulting in myopathy.
How to differentiate between delta-aminolevulinate synthase and reductase?
ALA synthase: requires Vit B6 as a cofactor, inhibited in B6 deficiency which leads to sideroblastic anemia.
ALA reductase: Inhibited by lead poisoning which in turn leads to anemia.
Why don’t PaO2 and PaCO2 change during exercise?
The majority of the change is seen in venous blood, whereas arterial blood levels stay close to normal
Match each of the following landmarks with the cranial nerves that pass through them: Cribriform plate Optic Canal SOF For Rotundum For Ovale For Spinosum Internal Acoustic Meatus Jugular foramen Hypoglossal canal Foramen magnum
Crib plate: CN I Optic Canal: CN II SOF: CN III, IV, V1, VI Rotundum: CN V2 Ovale: CN V3 Spinosum: middle meningeal artery/vein Internal acoustic meatu: CN VII, VIII Jugular foramen: CN IX, X, XI Hypoglossal canal: CN XII Foramen magnum: Spinal roots of XI, brainstem, vertebral arteries
Effect of carbon tetrachloride toxicity?
P450 microsomal oxidase system creates free radicals, cause hepatic injury
How does biliary atresia present?
Dark urine, jaundice, conjugated bilirubin within first 2 mos of life w clay colored stools.
Obstruction of bile ducts.
Intrahepatic bile duct proliferation, portal tract edema, fibrosis
Teratogenic antibiotics?
Tetracyclines-teeth staining
Chloramphenicol-“Gray baby” syndrome
TMP/SFX: Neural tube defects
Aminoglycosides: Ototoxicity
MOA of Raltegravir?
It’s an integrase inhibitor for HIV, disrupts HIV genome integration, prevents synthesis of viral RNA
Best drug to treat insomnia in elderly?
Ramelteon, a melatonin agonist with few side effects
Drug of choice for someone in hypertensive crisis w/ kidney issues?
Fenoldopam. It’s a dopamine-1 receptor agonist.
Causes arteriolar dilation, increased renal perfusion, and promotes diuresis and natriuresis
Why is thrombin given to patients with hemophilia who are bleeding?
*Hemophilia likely in pt who keeps bleeding after a dental procedure/hemarthrosis
They either lack Factor VIII or IX and can’t activate thrombin by themselves. If given thrombin they can then form clot.
MOA of vancomycin? How do resistant bacteria evade it?
Vancomycin binds to D-alanyl-D-alanine location in bacterial cell wall.
Resistance arises when bacteria substitute D-lactate for D-alanine, so vanco can’t bind anymore
Vasculitis found in heavy smokers.
Buerger’s disease (thromboangiitis obliterans). It’s a segmental thrombosing vasculitis that etends into veins and nerves, encases them in nerve tissues
What do the A band and the H band refer to when talking about the sarcomere?
The H band is the portion that contains ONLY thick filaments. It straddles the M line.
The A band refers to the length of the thick filaments, but contains some parts where thick and thin overlap. The A band never changes size, the H band does (gets smaller with contraction) b/c the actin filaments bind to the thick filaments
Between mitochondrial vacuolization and disaggregation of nuclear granules, which is an irreversible type of injury?
Mitochondrial vacuolization. It is a sign that those mitochondria are no longer capable of producing ATP
What are accessory nipples and why do they occur?
They are extra nipples along the mammary line. They are the most common congenital breast anomaly in men AND women.
Due to failed involution of the mammary ridge.
Usually asymptopmatic, may become tender with menses. Look like nipples
Buspirone MOA and why is it not a good treatment for acute anxiety?
It is a partial agonist at 5HT1A receptor.
It takes several weeks for the onset of its action, so not good in acute situations.
It’s a nonbenzodiazepine anxiolytic
Pancreatic islet amyloid deposition is characteristic of which type of diabetes?
Type 2 DM
Recurrent episodes of abdominal pain and facial swelling, as well as excessive cleaving of C2 and C4 by C1 are indicative of what?
C1 inhibitor deficiency.
C1 normally is inhibited from cleaving C2 and C4 by C1 inhibitor. C1 inhibitor also blocks the kallikrein-induced conversion of kininogen to bradykinin, so if you don’t have C1 you get excess bradykinin which leads to facial swelling.
What does the hypercoagulabe state of Factor V Leiden predispose to?
Deep vein thromboses
What do both nitrates and ED pills (phosphodiesterase inhibitors) lead to the accumulation of?
cGMP which increases vasodilation
What is octreotide and what is it used for?
It’s a somatostatin analog. Inhibits the actions of many splanchnic vasoconstriction hormones.
It is used to stop acute variceal bleeds, acromegaly, VIPomas, and carcinoid tumors.
Treatment for restless leg syndrome?
Dopamine agonists (ropinirole, pramipexole).
Treatment for narcolepsy?
Psychoactive stimulants such as modafinil.
Scheduled daytime naps are also good
MOA of these oral diabetes drugs: Biguanides (metformin): Sulfonylureas (chlorpropamide, glipizide): Thiazolidenediones (-glitazone): GLP-1 analogs (-tide): DPP-4 inhibitors (-gliptin) Amylin analogs (Pramlintide): SGLT-2 inhibitors (Canagliflozin): alpha-glucoside inhibitors (Acarbose):
Biguanides (metformin): MOA unknown. Increased insulin sensitivity.
Sulfonylureas (chlorpropamide, glipizide): Close K channels in beta cell membrane, increased insulin release due to calcium influx
Thiazolidenediones (-glitazone): Binds PPAR-yamma nuclear transcription regulator, increased insulin sens. Upregulate GLUT-4 and adiponectin
GLP-1 analogs (-tide): Increased insulin, decreased glucagon release
DPP-4 inhibitors (-gliptin): Increased insulin, decreased glucagon release
Amylin analogs (Pramlintide): Decreased gastric empyting, decreased glucagon
SGLT-2 inhibitors (Canagliflozin): Block reabsorption of glucose at PCT (sugar pee)
alpha-glucoside inhibitors (Acarbose): Inhibit intestinal alpha-glucosidases, delayed glucose absorption, decreased posprandial hyperglycemia
If lung abscess shows peptostreptococcus, prevotella, bacteroides, or fusobacterium what should you suspect?
Aspiration pneumonia (seizures can cause aspiration)
Examples of osteoblastic and osteolytic neoplasms?
Osteoblastic: Prostate cancer, small cell lung cancer, Hodgkin lymphoma
Osteolytic: Multiple myeloma, non-small cell lung cancer, Non-Hodgkin lymphoma, Renal Cell Carcinoma, Melanoma
Churg-Strauss (Eosinophilic granulomatosis with polyangiitis) quick hits:
Small to medium vessel vasculitis
Asymmetric multifocal neuropathy (due to the vasculitis)
Late-onset asthma, rhinosinusitis, eosinophilia
MPO-ANCA/p-ANCA
Pts with familial retinoblastoma have increased risk of what later on?
Secondary tumors, especially osteosarcoma.
What is tissue damage/subsequent abscess formation caused by?
Lysosomal enzyme release from neutrophils and macrophages
What gives elastin its elastic properties?
Cross linking between elastin monomers facilitated by lysyl oxidase (interchain cross links)
What type of receptors are calcium sensing receptors?
G-protein membrane bound receptors
Polymyositis vs Dermatomyositis
Polymyositis: Symmetric proximal muscle weakness, endomysial inflammation w CD8+ cells. Most often involves shoulders. Autoantibodies (ANA, anti-Jo-1, which are anti-histidyl-tRNA synthetase) present in most cases
Dermatomyositis: Involves malar rash, Gottron papules (on knuckles of hand), periorbital rash. Increased risk of occult malignancy (lung, colorectal, ovarian). Perimysial inflammation and atropy with CD4+ cells
What should people with heart failure due to LV dystolic dysfxn be treated with?
Beta blockers, ACE inhibitors, ARBs, and aldosterone antagonists.
What are the following amino acids precursors to?
Glutamic acid, Histidine, Methionine, Tyrosine, Tryptophan?
Glutamic acid: GABA
Histidine: Histamine
Methionine: Cysteine, Carnitine, Taurine, Lethicin
Tyrosine: Dopamine, norepinephrine, epinephrine, thyroxine, melanin
Tryptophan: Serotonin
Tx for serotonin syndrome?
Cyproheptadine–>it’s an antihistamine with anti-serotonergic activity
MOA of isoproterenol?
B-1 and B-2 adrenergic receptor, increased contractility with decreased vascular resistance
Damage to brainstem above red nucleus leads to what?
Damage to brainstem at/below red nucleus leads to what?
Above (Cerebral hemispheres, internal capsule): Decorticate FLEXOR posturing (activated flexors)
At/Below (midbrain tegmentum, pons): Decerebrate (EXTENSOR) posturing
Best treatment for treatment-resistant depression?
Characteristics of atypical depression?
Monoamine oxidase inhibitors (MAOIs) such as phenelzine, tranylcypromine, selegiline.
Atypical depression: mood reactivity, leaden paralysis, rejection sensitivity, increased sleep and appetite.
*Don’t use MAOIs with SSRIs!
Why is nephrotic syndrome a hypercoagulable state?
Due to the loss of anticoagulant factors, particularly antithrombin III. As a result, it’s common to see a left-sided varicocele indicative of renal vein thrombosis
Which endogenous molecule has been linked to colon cancer, which causes for the use of aspirin to be used for prophylactic treatment against adenomatous polyp formation?
Cyclooxygenase-2
Which inflammatory cells are involved in COPD development?
Neutrophils, macrophages, and CD8+ cells.
They cause both alveolar destruction (emphysema) and mucus hypersecretion (chronic bronchitis)
Drug that causes fat redistribution to the trunk and away from extremities?
HAART (highly-active anti-retroviral therapy).
Subcutaneous lipoatrophy in face and extremities is associated with NRTIs
Specific sign of left sided heart failure?
Orthopnea (supine dyspnea that is relieved by sitting up)
Where is CSF released from and absorbed? What path does it follow?
Differentiate between non-communicating and communicating hydrocephalus.
Released from choroid plexus in lateral and fourth ventricles.
Absorbed by arachnoid granulations in subarachnoid space.
Lateral ventricles–>interventricular foramen of Monro–>3rd ventricle–>Cerebral aqueduct–>Fourth ventricle–>Foramina of Luschka and Magendie–>Subarachnoid space.
Non-communicating: flow of CSF from ventricles to subarachnoid space obstructed. Caused by congenital anomalies (aqueductal stenosis, Chiari/Dandy-Walker malformations). Enlargement above obstruction, normal below it.
Communicating: No obstruction, usually failed absorption. All ventriculi are symmetrical in size.
Cytokine that is ONLY released by lymphocytes?
IL-2. Promotes growth and differentiation of T cells, B cells, NK cells, and macrophages
How do poxviruses appear on pathological studies?
Eosinophilic cytoplasmic inclusions
What structure is most likely to be damaged by posterior or anterior dislocation of the knee joint?
Popliteal artery.
Tibial nerve prone to damage from penetrative trauma
What is characteristic of tyrosine kinases (ie effect of ligand binding to receptor?)
Dimerization
Post nephrectomy, how does the other kidney compensate?
It eventually can perform 80% of the function of both kidneys after 6 weeks.
Schizophreniform vs schizophrenia?
Schizophreniform=same sx, just >1 mo, <6 mos. No functional decline required
Schizophrenia: Delusions, hallucinations, disorganized speech and behavior, negative symptoms for >6 mos, also requires functional decline
How do ARR and NNT relate?
NNT=1/ARR
ARR=Risk of 1-Risk of 2
Most common cause of viral encephalitis?
HSV!
Net effect of nitrates?
Increased cGMP, decreased intracellular calcium, myosin light chain dephosphorylation resulting in vascular smooth muscle relaxation.
They increase vasodilation, decreased end-diastolic volume thus requiring less oxygen of the heart
Gram positive catalase negative species able to grow in hypertonic saline and bile that would cause endocarditis?
Enterococcus.
Most likely to get it after cytoscopy (GU instrumentation of catheterization)
Also can cause UTI. Demonstrate gamma hemolysis (no hemolysis)
Baby is extremely cyanotic after 2 days of life, aorta doesn’t seem to be in right place. Cause? Reason?
Transposition of the aorta and pulmonary arteries due to defective spiraling of the fetal aorticopulmonary septum.
Don’t present for a few days because ductus arteriosus keeps them oxygenated, but once it closes it’s downhill fast
Most common cause of kidney infarction?
Systemic thromboembolism (most likely from afib). Kidney would have wedge shaped infarct
What does congenital prolonged QT syndrome predispose to?
Torsades de point!
When is S3 best heard?
At the end of expiration (lung has less volume, heart closer to chest wall)
What is S4 associated with?
Restrictive cardiomyopathy and left ventricular hypertrophy
Pt with atypical depression (and on treatment) eats food containing tyramine. What is likely to happen?
Tyramine hypertensive crisis. MAO normally detoxifies tyramine containing foods (aged cheeses, cured meats, craft beer). But if on MAO-I for atypical depression, you lose that and are susceptible.
Cause of outflow obstruction in hypertrophic cardiomyopathy?
It’s the mitral leaflet and the interventricular septum (which is hypertrophic) that cause a blockage of outflow
Which artery provides the interior surface of the heart?
The posterior descending artery, which branches from right coronary artery in 90% of people
Method to increase amount of blood going forward in mitral regurgitation?
Decrease afterload
One specific -lol drug that you should remember since it is a Class III antiarrhythmic and not a calcium channel blocker?
Sotalol (the S in AIDS)
Amiodarone, Ibutilide, Dofetilide, Sotalol
Drugs that cause coronary artery dilation and coronary steal (where blood moves away from ischemic areas blocked by atherosclerosis)
Adenosine and dipryamidole
Organ that has highest oxygen extraction in body
Heart
Holosystolic murmur that increases on inspiration?
Tricuspid regurg
Murmur that radiates to axilla
Mitral regurg
What causes beriberi? Difference between dry/wet?
Caused by thiamine deficiency (also causes Wernicke-Korsakoff).
Dry=symmetrical peripheral neuropathy.
Wet=add high-output congestive heart failure to the mix
What is the defense mechanism to diptheria?
How does diptheria get its virulence?
It’s IgG to the toxin that it releases to the circulatory system.
Diptheria becomes virulent by bacteriophage-mediated “infection” with the Tox gene, then it produces that bad toxin. This is called lysogenization
Cause of tetralogy of Fallot?
Anterior and cephalad deviation of the infundibular septum
Auscultation finding in ASD? (which can lead to paradoxical arterial clots?)
Fixed wide splitting of S2
Brief overview of the renin angiotensin system?
Renin converts angiotensinogen to angiotensin I in systemic circulation. ACE converts angiotensin I to angiotensin II in the lungs. Angiotensin II causes systemic vasoconstriction and efferent arteriole vasconstriction in kidney to maintain GFR. It also leads to aldosterone production, which increases sodium reabsorption
Most useful way of measuring degree of mitral stenosis?
A2 to opening snap time interval. Shorter interval means more sever stenosis (higher pressure)
An early diastolic murmur is characteristic of what?
Aortic regurg
Diuretic of choice for improved survival for patients w/ CHF and reduced LVEF?
Spironolactone, Eplerenone (mineralocorticoid receptor antagonists)
2 drugs of choice for managing ventricular arrhythmias during acute MI because they block inactivated sodium channels (ie ischemic myocardium)?
Amiodarone and lidocaine
Meds that are common causes of orthostatic hypotension?
alpha 1-adrenergic antagonists (b/c they decrease systemic vascular resistance and increase HR) and diuretics
Clinical signs of cardiac tampoade?
Beck’s triad (JVD, hypotension, diminished heart sounds) and Pulsus paradoxus (loss of pulse on inspiration)
What should you suspect if there is a post-MI pericarditis that sets in anywhere from a week to a few months after the MI?
Dressler’s Syndrome, an autoimmune reaction to antigens created by the infarction
Clinical signs of patent ductus arteriosus?
Continuous murmur over left infraclavicular region. Derived from 6th aortic arch.
Treat w/ indomethacin (block prostaglandins, close PDA) or surgery in older pts
Drug type that increases peripheral vascular resistance and systolic blood pressure and decreases pulse pressure and heart rate?
Alpha-1 adrenergic receptor AGONISTS (such as phenylephrine)
*remember, clonidine is a alpha-2 adrenergic receptor agonist
Drugs that have shown long-term improvement in patients with left ventricle systolic dysfunction?
Beta blockers, ACE inhibitors, ARBs, aldosterone antagonists
Net effect of norepinephrine?
Acts on alpha-1 adrenergic (increase IP3, peripheral vasoconstriction), alpha-2 adrenergic (decrease cAMP, decrease insulin and norepi release), and beta-1 adrenergic (increased cAMP, increased contractility)
Causes of diastolic heart failure?
Classic findings?
Hypertension, obesity, infiltrative disorders (eg transtyretin involved with amyloidosis)
Regular LV ejection fractio and end diastolic volume, HALLMARK=INCREASED END DIASTOLIC PRESSURE
Cancer associated with arsenic/polyvinyl chloride/thorotrast? What is the cancer marker?
Hepatic angiosarcoma.
Tumor marker=CD 31
Auscultory findings of PDA?
Continuous murmur heard best at left infraclavicular region, maximal intensity (and splitting) at S2
Reversal for TCAD overdose?
Sodium bicarb. It increases serum pH and extracellular sodium which is available to help overcome the fast sodium channel blockade
Differentiate between capillary hydrostatic pressure and plasma oncotic pressure
Hydrostatic pressure increases filtration by pushing fluid and solute OUT of the capillaries. Oncotic pressure (colloid osmotic pressure) pulls fluids INTO the capillaries. So edema would form in environments of INCREASED hydrostatic pressure or DECREASED oncotic pressure
What should you give to someone who has signs of norepinephrine extravasation (area around IV site becomes cold and clammy, denoting vasoconstriction)?
Alpha 1 blockers (such as phentolamine)
What is prinzmetal (variant) angina, and what can cause it?
It’s when you get angina at random times (such as at night or during rest)
Triggers include smoking, cocaine/amphetamines, and dihydroergotamine/triptan drugs
I have SIBO. What will I have excess of?
Vitamin K and folate (b/c bacteria produce it)
Main mechanism of defense against giardia (in terms of body’s immune defense)
Secretory IgA, which impedes adherence
What is systemic mastocytosis?
Abnormal proliferation of mast cells and histamine. In addition to flushing and pruritis, histamine causes hypersecretion of gastric acid
On which side do the gonadal veins drain into the renal vein?
The left side.
Right side drains right into the IVC
What is bilious emesis indicative of?
What are intestinal atresias of the midgut a sign of?
Obstruction below the 2nd part of the duodenum.
Intestinal atresias of the midgut (jejunum, ileum, proximal colon) are caused by vascular occlusion in utero. Forms “apple peel” or “Christmas tree” deformity
Someone takes an opioid med then has terrible stomach pains. What is happening?
Causes contraction of smooth muscle in Spincter of Odii, leading to increased pressure in gallbladder and common bile duct
Retroperitoneal organs?
SAD PUCKER Suprarenal adrenal glands Aorta & IVC Duodenum (not 1st part) Pancreas (head and body) Ureters and bladder Colon (ascending and descending) Kidneys Esophagus Rectum
What anatomic structures contain the superficial and deep inguinal rings?
Superficial-external oblique
Deep-transversalis fascia
Testi passes through superficial to get into scrotum
What is abetalipoproteinemia?
It’s an inherited inability to synthesize apolipoprotein B. Thus, lipids can’t be gled once they’ve been absorbed, so they stay in the intestine and intestine gets all fatty
What are AFP and CA 19-9 tumor markers of?
AFP=Germ cell tumors and hepatocellular tumors
CA 19-9=Pancreatic tumors
What role do E5 and E6 play in HPV infections?
They inhibit Rb and p53 so they inhibit apoptosis so that the infected cells can proliferate, leading to malignant transformation
Major side effect of 2nd generation antipsychotics?
Metabolic adverse effects (weight gain, dyslipidemia, hyperglycemia, increased risk of diabetes)
Cause of inflammatory diarrhea that can be passed from animals to humans?
Campylobacter. Associated with Guillan Barre
If you see an increased serum methionine, what should you suspect?
Homocystinuria. Cysteine becomes essential.
Difference between DNA Pol III and Pol I?
Both of them have 5’ to 3’ DNA synthesis and 3’ to 5’ exonuclease proofreading ability.
Only Pol I has 5’ to 3’ exonuclease activity to remove RNA primers
What are renal angiomyolipomas associated with?
Tuberous sclerosis, an autosomal dominant condition.
It is characterized by cortical tumors with subependymal hamartomas in the brain, with consequent seizures and cognitive disability. Also will see cardiac rhabdomyomas, facial angiofibromas, and leaf-shaped patches of skin lacking pigment
Fragile X syndrome quick hits?
Increased number of CGG repeats (>200) on FMR1 gene on long arm of chromosome X. This leads to hypermethylation and inactivation of FMR1.
Big testes, prominent forehead and chin
Triad of congenital toxoplasmosis?
Hydrocephalus, intracranial calcifications, chorioretinitis
Drug used to mitigate muscarinic overstimulation secondary to cholinesterase inhibitors?
Scopolamine, an antimuscarinic drug
Where are serotonin-releasing neurons located in the CNS?
In the raphe nucleus
What cell type is connected to primary central nervous system lymphoma (seen as ring enhancing lesions in brain)?
B cell–>a non Hodgkin lymphoma, associated with EBV
Major dopaminergic pathways in the brain and what do they control?
Mesolimbic (positive symptoms) and Mesocortical (negative sx) pathways: Cognition and behavior
Nigrostriatial: Substantia nigra to caudate nucleus, regulates coordination of voluntary movements
Tuberoinfundibular pathway: Connects pituitary to hypothalamus, regulates prolactin synthesis
Which hormone has a very similar structure to the endorphins (that act on opioid receptors)?
ACTH. This suggests a potential link between stress and opioid system
Major amino acid responsible for transferring nitrogen to the liver for disposal? Which enzyme is connected to this AA?
Alanine.
Alpha-ketoglutarate is connected b/c it’s involved in forming glutamate, which is then processed into urea which is how nitrogen is disposed of
What visual deficit does temporal lobe damage cause?
Contralateral superior quadrantanopia
Damage to which nuclei result in complete contralateral sensory loss?
Ventral posterior lateral nucleus and ventral posterior medial nucleus.
VPLN receives info from spinothalamic tract and dorsal columns, VPMN rexceives input from trigeminal pathway
Which enzymes use thiamine as a cofactor and are thus affected in thiamine deficiency?
Pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, transketolase.
How to differentiate between the way the lungs respond to foreign particles?
For big stuff, they are caught in mucus and then swept up through the cilia.
For really fine particles (think of the pneumoconioses) they are actually taken care of by macrophages within the lung
What is responsible for releasing proteases (like elastase) in the lungs?
Macrophages
Best treatment for bronchiole asthma and chronic airway obstruction?
Corticosteroids (Fluticasone)
What are the normal pO2 of the trachea and alveoli? In what condition would pO2 of the alveoli be elevated?
Trachea=150 mm Hg
Alveolar=104 mmHg
Elevated alveolar is due to impaired perfusion, meaning that it’s not given the chance to diffuse
Patients who have a CD4 count <50 should be treated with what prophylactically to avoid infection with Mycobacterium avian complex (MAC)?
Azithromycin.
Pts with infection treated with azithro/clarithromycin and Rifabutin or Ethambutol
At what point is pulmonary vascular resistance the lowest (in terms of Lung Volume)?
At the FRC. It peaks when at RV and TLC
In lung transplants what is affected by rejection?
Small airways, causing bronchiolitis obliterans syndrome
Which calcium channel blockers only have an effect on the vascular smooth muscle?
Dihydropyridines (-dipines), they cause peripheral vasodilation
Verapamil works ONLY on heart muscle, and Diltiazem works on BOTH heart and smooth muscle
Where is norepinephrine produced?
In the locus ceruleus, which is in the posterior rostral pons near the lateral floor of the fourth ventricle
Regardless of dehydration status, where is the majority of water absorbed in the kidney?
Where does ADH insert aquaporin channels?
60% of water is reabsorbed in the PCT.
ADH inserts aquaporin channels in the medullary portion of the collecting duct.
Which receptors sense PaCO2? What about PaO2?
PaCO2=Central chemoreceptors
PaO2=Peripheral chemoreceptors
This is bc CO2 can cross the BBB
Niacin is a precursor vitamin for the enzyme NAD and NADP. In pellagra, what is used to synthesize niacin?
Tryptophan
Catecholamine synthesis pathway?
Phenylalanine–(Phenyl.. hydroxylase)–>Tyrosine–(Tyrosine hydroxylase)–>DOPA–(Dopa decarboxylase)–>Dopamine–(dopamine beta hydroxylase)–>Norepinephrine–(Phenylethanolamine-N-methyltransferase)–>Epinephrine
*PNMT enzyme activity is increased by cortisol
Virus associated with aplastic crisis in sickle cell patients?
Parvovirus B19 (a nonenveloped single-stranded DNA virus)
RNA pol that only works in the nucleolus?
RNA pol I. It transcribes the 45S pre-rRNA that becomes 18S, 5.8S and 28S rRNAs.
Nucleolus stains basophilic
First thing you should give to someone in anaphylaxis?
Epinephrine (epi pen)
Antibiotic to be given to someone with aspiration pneumonia/lung abscesses?
Clindamycin
PCP MOA?
N-methyl-D-aspartate receptor antagonist
Uniformly enlarged uterus with normal-appearing endometrium?
Adenomyosis
In what form is ammonia secreted in the kidneys?
As glutamate. Renal tubular epithelial cells metabolize glutamine to glutamate
Type of antidepressant that has strong anticholinergic properties?
TCADs
Function of t-tubules in skeletal muscle?
transmit a depolarization from sarcolemma to sarcoplasmic reticulum as quickly and uniformly as possible
Something that involves chromosomes 15:17 and involve the retinoic acid receptor?
AML-particularly the M3 form APML
Which bugs are resistant to cephalosporin drugs?
Listeria (use ampicillin), MRSA, Enterococci, Atypicals (Mycoplasma, Chlamydia)
If hemoglobin becomes more likely to be saturated with oxygen, what is the adjustment made in the body?
You’ll have erythropoiesis because since O2 is more bound to Hemoglobin, it’s less likely to dissociate so the body will become more hypoxic (left shift on the curve)
Tx for essential tremor?
Beta blockers (specifically propranolol) or primidone. Don’t be tricked! They often self medicate with alcohol, but that or benzodiazepines are NOT the best treatment
Integrative vs proliferative phase of Hep B virus?
Proliferative=the virus infects hepatocytes which are attacked and destroyed by CD8+ T cells.
Integrative: Some of the HBV DNA integrates into the genome of the hepatocytes and predispose to hepatocellular carcinoma
Which apolipoprotein is NOT found on LDL?
Apo-E.
Quick hits on Type 1, Type IIa, and Type IV hyperlipidemias.
Type I: Increased chylomicrons. Lipoprotein lipase deficiency or altered apo-C2. Pruritic/eruptive xanthomas. NO ATHEROSCLEROSIS
Type IIa: AD. Defective LDL receptors. Tons of LDL, achilles tendon xanthomas, ACCELERATED ATHEROSCLEROSIS
Type IV: AD. Too much VLDL (hepatic production). Hypertriglyceridemia >1000, CAUSES PANCREATITIS
Virus type that acquire their envelope from the host membrane?
Herpes viruses
How to differentiate between the lactose fermenting gram negative rods, and also the lactose non-fermenting gram neg rods?
Lactose fermenting: Either by fast (E coli, Enterobacter, Klebsiella) or slow (Citrobacter, Serratia) fermenters.
Non-fermenters (white on MacConkie Agar): Oxidase positive (Pseudomonas). If ox neg, test for sulfur production (Salmonella, Proteus) or no sulfur production (Shigella)
T or F? Shigella toxin plays a vital role in infectivity?
False.
Nontoxigenic strains still produce shigellosis
Shigella invades the intestinal mucosa
What role do hemagglutinin and neuraminidase play in influenza virus?
Hemagglutinin: Promotes viral entry (blocked by inactivated vaccine)
Neuraminidase: Promotes progeny virion release (blocked by oseltamavir)
Hepatitis A infection here in the US. What is most likely cause?
Raw or steamed shellfish.
If other places, overcrowded areas with poor sanitation or contaminated water likely sources (Fecal/oral transmission)
3 thiazide diuretics?
Hydrochlorothiazide, Chlorthalidone, Chlorothiazide
Which molecule is the key regulator of iron homeostasis?
Hepcidin.
High iron and inflammation=high hepcidin. Hepcidin then binds to ferroportin and inhibits it from absorbing iron into the circulation.
Hypoxia and increased erythrocytosis=Low hepcidin, so more absorption of iron
Baby has urine-looking fluid leaking from the umbilicus. What is the likely cause?
A patent urachus (a remnant of the fetal allantois which connects the yolk sac to the bladder)
Name the fluids that are typically excreted/not reabsorbed by the kidney and those that are actively reabsorbed in the PCT?
Excreted: PAH, Creatinine, Inulin, Urea, Cl, K, Na (that’s the order from greatest to lowest amount excreted).
Reabsorbed: Bicarb, AAs, glucose (from least to greatest)
Salmonella is a common cause of osteomyelitis in sickle cell patients. What is its mechanism of resistance?
Vi antigen CAPSULE that keeps it from being opsonized (by C3a and IgG)
Clinical features of primary hyperaldosteronism?
Tx?
Hypertension, hypokalemic alkalosis (Muscle weakness and paresthesias).
Will have hypertension with low renin activity
Aldoesterone stays high after saline infusion
Tx: Aldosterone antagonists (spironolactone, eplerenone)
Clinical features of congenital hypothyroidism?
Not present at birth, presents after a few months once mom’s T4 has waned.
Constipation, lethargy, big/swollen tongue, hypotonia, umbilical hernia, large anterior fontanelle
How to differentiate between hyperkalemia caused by spironolactone and digoxin toxicity?
Digoxin will have ardiac arrhythmias, GI, neuro, and visual sx.
Spironolactone will have hyperkalemia, gynecomastia, impotence, decreased libido.
Digoxin more severe
Which familial type of cancer should you think of if you see pheochromocytoma?
MEN2
Cells that are derived rom the neural crest cell follow the mnemonic MOTEL PASS. What are they?
Melanocytes Odontoblasts Tracheal cartilage Enterochromaffin cells Laryngeal cartilage Parafollicular cells of thyroid Adrenal medulla and all ganglia Schwann cells Spiral membrane
Pt getting treated for breast cancer and gets hemorrhagic cystitis. What could have prevented that?
Mesna (sulfhydryl compound that binds acrolein)
Likely being treated with cyclophosphamide or ifosfamide which causes toxic metabolite acrolein which causes hemorrhagic cystitis.
Net effect of glucagon on cardiac muscle?
Activation of adenylate cyclase, increased cAMP, increased SA node firing
Ppl w/ antiphospholipid antibodies are in a hypercoagulable state. What are they at risk of, and what tests may come back with false positives?
Risk of thombotic related events and recurrent miscarriages.
Also come back with false positive syphilis tests
Difference between enhancers/promoters?
Enhancers: Upstream or downstream. Either increase or decrease transcription.
Promoters: 25-75 bases upstream, initiate transcription
Polycythemia vera pathogenesis?
Mutation of JAK2 gene, makes hematopoietic stem cells more sensitive to growth factors and EPO, so increased RBC mass.
JAK2 is a cytoplasmic tyrosine kinase
A myeloproliferative disease of pluripotent hematopoietic stem cells
EPO is low in these pts.
Aspirin intoxication quick facts?
First you get respiratory alkalosis.
After 12 hours it switches to anion gap metabolic acidosis.
In the mix between the 2, the pH will be fairly normal but with a low CO2 and low HCO3
What is idiopathic intracranial hypertension?
Something in young obese women that presents with daily headache (that worsens with Valsalva), papilledema, and transient visual disturbances. There is compression of the optic nerves resulting in impaired axoplasmic flow and optic disc edema
Drug recommended for patients with hypertension at risk of osteoporosis?
Thiazide diuretics because they increase calcum absorption at the DCT Hyper GLUC (glycemia, lipidemia, uricemia, calcemia)
Classification of pertussis?
It’s a gram negative coccobacillus.
A cough that lasts greater than 2 weeks, associated with post-tussive emesis.
Adults need to get boosters
What’s the marker for macrophages?
CD14
Translocation and gene associated with follicular lymphoma?
14:18
Bcl-2, a protooncogene that has anti-apoptotic effects
Muscles that pass through greater and lesser sciatic foramen?
Greater: Piriformis
Lesser: Obturator internus muscle
Is Meckel’s diverticulum a true or false diverticulum?
How is it diagnosed?
True.
It has mucosa, submucosa, and muscularis layers (false, such as Zenker’s esophageal, only have mucosa and submucosa).
Meckel’s diverticulum is a remnant of the vitelline duct and is attached to the ileum.
Diagnosed by increaed 99MTc-Pertechnetate uptake
Why does isoniazid lead to sideroblastic anemia?
It blocks the synthesis of pyridoxine. Pyridoxine is used as a cofactor for delta-amino… synthase, part of the heme pathway, so it stops heme sythesis and causes sideroblastic anemia.
What type of bug is gardnerella?
An anaerobic variable gram negative rod
Which cell types have insulin-dependent glucose transporters?
Muscle cells and adipocytes. GLUT-4.
Everything else is glucose independent GLUT 1, 2, 3, and 5
What are the virulence factors for each of the clinical manifestations of E coli infections? Bacteremia/Sepsis Neonatal meningitis Bloody diarrhea Watery diarrhea UTI
Bacteremia/Sepsis: LPS
Neonatal meningitis: K1 capsular polysaccharide
Bloody diarrhea: Shiga like toxin (Verotoxin)
Watery diarrhea: heat-stable/heat-labile enterotoxins
UTI: P fimbriae
What causes competitive inhibition of iodine transportation?
Perchlorate
How do you calculate net excretion rate of a substance?
Filtration rate of the substance minus the total tubular reabsorption rate
Gene mutation in both familial and sporadic renal cell carcinoma?
VHL gene mutation on chromosome 3p
MOA of flutamide?
It’s a competitive inhibitor of testosterone receptors, used in conjunction with leuprolide (a GnRH agonist) in the treatment of prostate cancer
T or F? Damage to posterior pituitary gland would cause permanent issues regarding ADH and oxytocin?
False.
Damage to the hypothalamus (where those hormones are produced) would cause permanent. Damage to posterior pituitary would be transient.
Typical consequences of left ventricular infarct?
LVF, Cardiogenic acute pulmonary edema, pulmonary venous hypertension (congestion), transudate of plasma into the interstitium and alveoli of the lung
What does the AV nodal refractory period correspond to on ECG?
The PR interval
Pt has necrolytic migratory erythema (erythematous papules on face, lesions enlarge and coalesce leaving bronze-colored central indurated area with peripheral blistering and scarring) on a backdrop of Diabetes. Probable dx?
Glucagonoma
Tumor of the alpha cells of the pancreatic islet of Langerhans.
4 D’s–>Dermatitis, Diabetes (hyperglycemia), DVT, depression
Diagnosed by looking at glucagon levels
Difference between transudate and exudate?
Transudate is fluid that is pushed through the capillaries by high pressure in capillary.
Exudate is fluid that leaks through the capillaries due to inflammation
What is it that initially fights off the development of edema in conditions of elevated CVP?
Increased lymphatic drainage
Tx to prevent herpes from reactivating?
Daily oral valacyclovir, acyclovir, famciclovir
What do RNA Pol I, II, and II do?
RNA Pol I: rRNA
RNA Pol II: mRNA
RNA Pol III: tRNA
What are the 3 beta lactamase inhibitors?
Clavulanic acid, Sulbactam, and Tazobactam
Triad of Wiskott Aldrich syndrome?
Eczema, Thrombocytopenia, combined T-lymphocyte and B-lymphocyte deficiency
3 ways that someone can inherit Down Syndrome?
1) Meiotic Nondisjunction (95% of cases)
2) Unbalanced translocation
3) Mosaicism (not all cells have extra chromosome 21)
Surface marker for monocytes/macrophages?
CD14
Effect of estrogen on thyroid hormones?
Estrogen increases Thyroid Binding Globulin levels, which means there is less free T3 and T4 (b/c it gets bound).
As a result the body produces more Total T3 and T4 to saturate the TBG and then have enough free, so the Total T3 and T4 pools increase, but the free levels remain normal
Result of going to high elevation?
Respiratory alkalosis (b/c there is hyperventilation, low CO2, and a resultant decrease in bicarb as well)
What is the effect of liver disease on BUN?
BUN is decreased because there is less conversion of ammonia to urea since the liver normally does that.
What antibody test is specific and sensitive for EBV?
Heterophile antibodies t sheep or horse erythrocytes.
EBV is oncogenic because it promotes continuour proliferation of B cells
How do we test for legionella, and how is it treated?
Test for it using urine sample (since gram staining is made ineffective by unique lipopolysaccharide chains on the outer membrane).
Treat it with fluoroquinolones (-floxacin) or newer macrolides (azithromycin)
What are the 5’ and 3’ ends of introns (that tell splicesomes to splice there)?
GU at 5’ end
AG at 3’ end
Where else can HPV warts infect in the body besides the genitals/anus?
The true vocal cords of respiratory tract b/c they are composed of stratified squamous epithelium
Why aren’t sodium levels really elevated in hyperaldosteronism? What happens to potassium and bicarb levels?
Lots of potassium is excreted (since reabsorbed sodium makes the lumen negative), so pts are hypokalemic. They also produce more bicarb, resulting in metabolic alkalosis.
Sodium is accounted for by increased renal blood flow and the action of ANP which limits sodium overload. This is called aldosterone escape
Why should you give pyridoxine supplementation concurrent with isoniazid treatment?
Because isoniazid competes with Vit B6 (pyridoxine) and causes a frank deficiency of Vit B6 which leads to defective synthesis of neurotrasmitters like GABA, causing neuropathy
What’s the underlying biochemical feature of megaloblastosis?
A defect in DNA synthesis–>ie if Vit B12 or folate are low, there is impaired purine and pyrimidine synthesis
List of the SSRIs and SNRIs?
SSRIs: Fluoxetine, Paroxetine, Sertraline, Citalopram (Flashbacks paralyze senior citizens)
SNRIs: Venlafaxine, Duloxetine
Steps of tumors becoming invasive?
1) Detach from neighboring cells, decreased expression of adhesion molecules (E-cadherins)
2) Adhesion to basement membrane, increased LAMININ
3) Invade basement membrane using proteolytic enzymes (metalloproteinases, Cathepsin D protease)
What does the Multi drug resistance gene (MDR1) in tumor cells do?
It codes for an ATP dependedent efflux pump that pumps drug out of the cytosol and blocks influx into the cell as well.
It causes resistance to chemo drugsa
Mnemonic for cancers that metastasize to bone?
“Lead kettle”, PB/KTL
Prostate, Breast, Kidney, Thyroid, Lung
General characteristics of V Cholera?
Comma shaped, ox positive gram neg bacillus.
Susceptible to acid, so pts with less acid (ie pts on PPIs) are more susceptible to cholera infections
What effect does nephrotic syndrome have on oncotic pressure?
It lowers it (b/c they will have hypoalbuminemia, and it will cause interstitial edema formation due to net plasma filtration)
Most common cause of death in TCAD overdose?
Cardiac arrhythmias and refractory hypotension. This is because they inhibit fast sodium channel conduction.
Serum marker for parotitis?
Elevated serum amylase (since the parotid gland secretes amylase). Lipase will be normal.
Most common in elderly patients who are intubated or dehydrated due to Staph Aureus infection
Signs of Krukenberg tumor?
Bilateral ovary masses (that are actually metastases from gastric tumors).
Unintentional weight loss, epigastric pain.
Tumor cells have large amount of mucin with a signet ring appearance
How to eosinophils work to kill helminths?
Stimulated by Il-5 (produced by Th2 and macrophages)
Via antibody-dependent cell-mediated cytoxicity.
They also are involved in Type I hypersnsitivty reactions
Composition of pseudogout crystals?
Calcium pyrophosphate, rhomboid shaped crystals
Drugs that cause atrioventricular conduction block?
Nondihydropyridine calcium channel blockers (Verapmil, Diltiazem)
What is indapamide?
A thiazide diuretic
Diabetes drug that increases insulin secretion regardless of glucose level in blood?
Sulfonylureas (Glipizide, glyburide, etc.)
They have a serious risk of causing hypoglycemia in patients that don’t eat.
What do MHC Class I proteins consist of?
Single heavy chain and associated B2-microglobulin
Which clotting factors are activated by Vitamin K?
Factors II, VII, IX, and X.
Factor VII has the shortest half life.
If Vitamin K is given and PT isn’t corrected, it means there is Factor VII deficiency and some sort of underlying liver disease
Multisystem involvement and biopsy showing segmental, transmural inflammation of the arterial wall with fibrinoid necrosis are characteristic of?
Polyarteritis nodosa
Predominately involves small to medium sized vessels. Clinical features are due to ischemia of the involved organs.
Associated with Hep B in 30% of cases
Patient develops fever, skin rash, renal issues after starting a beta lactam antibiotic. Diagnosis?
Acute interstitial nephritis
IgE mediated hypersensitivity
NSAIDs, rifampin, sulfonamides, and diuretics are also a common cause
What is the process that leads to insulin being released?
Glucose is metabolized in pancreatic beta cells and produces ATP. ATP then binds to ATP-sensitive K channel and leads to membrane depolarization and insulin release.
What is the role of homeobox genes?
Encode DNA-binding transcription factors that are important for the segmental organization of embryo along cranio-caudal axis
The one counter-insulin hormone that binds to receptors within the cell (not on outer membrane)?
Cortisol.
Epi, norepi, and glucagon all bind to membrane bound G protein receptors.
Growth hormone binds a membrane receptor that does JAK-STAT pathway
CAH type that impairs synthesis of estrogens, androgens, and cortisol but does not inhibit mineralocorticoid production. What enzyme is deficient?
17 alpha hydroxylase
Boys appear phenotypically female at birth, girls develop normal genitalia.
Patients have hypogonadism, hypertension, hypokalemia
Pseudomonas treatment?
Piperacillin, 3rd of 4th gen cephalosporins, cipro or levofloxacin, carbapenems (-penem), Aminoglycosides, Monobactams
What must Hep B virus do to Hep D virus for it to become virulent?
It Hep b surface antigen has to coat the Hep D surface antigen before the Hep D antigen can infiltrate the hepatocyte.
Why does prolonged glucocorticoid treatment cause hyperglycemia?
Increase hepatic glycogenolysis and gluconeogenesis, as well as antagonize insulin in the periphery
Inheritance pattern of G6PD?
X linked recessive
List of meds with negative chronotropic effects?
Beta blockers
Non dihydropyridine calcium channel blockers
Cardiac glycosides (digoxin)
Amiodarone and sotolol
Cholinergic agonists (pilocarpine, rivastigmine)
Treatment with anthracycline chemotherapeutics lead to what type of heart failure?
LVF and RVF, due to dilated cardiomyopathy caused by free radicals
Adverse effects associated with arteriolar vasodilators (such as hydralazine and minoxidil)?
Reflex sympathetic activation that causes increased CO, contractility, and HR as well as sodium and fluid retention.
Given in combination with sympatholytics and diuretics.
Useful acutely for patients with severely elevated blood pressure
Viruses that are segmented and can undergo reassortment?
Orthomyxoviruses (flu), Reoviruses (Rotavirus, coltivirus), Bunyaviruses (California encephalitis, sandfly/Rift valley fevers, Crimean-Congo hemorrhagic fever, Hantavirus), and arenaviruses (LCMV, Lassa fever encephalitis)
Leukemoid reaction quick hits
Increased WBC count with increased neutrophils and bands (left shift), Increased leukocyte alkaline phosphatase.
Smear shows basophilic oval inclusions in mature neutrophils (Dohle bodies)
Most common cause of unilateral fetal hydronephrosis?
Inadequate canalization of the ureteropelvic junction
Tx for drug-induced Parkinsonism
It’s a result of D2 receptor blockers (1st gen antipsychotics, antiemetics)
Either stop the offending drug or give them anticholinergic antiparkinsonian med (trihexiphenidyl, benztropine)
Hormones that use the Protein Kinase A G protein mediated adenylate cyclase system?
PTH, TSH, Glucagon
Bladder issue that pts w/ MS tend to get?
Bladder hypertonia, a spastic bladder with increased urinary frequency and urge incontinence. The bladder doesn’t relax
Pts w asplenia are susceptible to infection from what kinds of organisms?
Organisms that are encapsulated (S pneumo, h flu, N mening
What re the crescents associated with rapidly progressive glomerulonephritis made up of?
Glomerular parietal cells, Monocytes, macrophages, abundant fibrin
What is PRPP synthetase involved in?
Production of activated ribose necessary for de novo purine and pyrimidine synthesis.
Deficiency causes gout
Absent lactate dehydrogenase is associated with depleted intracellular amounts of what?
NAD+.
In anaerobic conditions, NAD+ s regenerated via lactate dehydrogenase.
In aerobic conditions, NAD+ is regenerated via the TCA cycle
What does the tetanus vaccination cause in the immune system?
Humoral antibodies are developed that neutralize the bacteria
PML/RARA, the mutation associated with AML 15:17, codes for an abnormal what?
Retinoic acid receptor. As a resultthe differentiation of myeloblasts is inhibited
MOA of Ipratropium?
Anticholinergic derivative of atropine. Blocks muscarinic receptors, prevents bronchoconstriction and reduces parasympathetic stimulation of tracheobronchial submucosal glands in lung
List of medically important dimorphic fungi?
Sporothrix Shenckii, Coccioidies, Histoplasma, Blastomyces, and Paracoccioides (also candida)
Carbolfuchsin is used in acid-fast stains. What does it stain in those specific specimens?
Mycolic acid
What’s the issue in osteogenesis imperfecta?
Defective synthesis of Type 1 collagen. This results in impaired bone matrix formation
Diuretic involved with increased calcium reabsorption (used in osteoporosis)
Thiazide diuretcs
Atropine is used to reverse cholinergic toxicity. However, it only blocks muscarinic effects, and leaves you susceptible to nicotinic effects such as muscular paralysis. What drug reverses all of the cholinergic toxiciy effects?
Pralidoxime.
It “restores” cholinesterase from its bond with organophosphates that cause cholinergic toxicity
What do sickling episodes in SCD result in?
Hemolysis
End results of pyruvate kinase deficiency?
Hemolysis due to failure of glycolysis and resultant failure to generate sufficient ATP to maintan erythrocyte structure
Spleen goes into overdrive to remove those deformed erythrocytes, so you’ll see red pulp hyperplasia
Drug used to treat pheochromocytoma prior to surgery?
Phenoxybenzamine (alpha blocker), it prevents hypertensive crisis
Chemo drug involved with ototoxicity?
Cisplatin
Drugs that cause interstitial lung disease?
Amiodarone, nitrofurantoin, methotrexate, bleomycin
What is Albright hereditary osteodystrophy?
It’s pseudohypoparathyroidism associated with short stature, short metacarpal and metatarsal bones, and is caused by end-organ resistance to parathyroid hormone
Mutation associated with achondroplasia?
Gain of function point mutation of fibroblast growth factor receptor 3 (FGFR3)
What maintains the high local level of testosterone that is needed for normal sperm production and maturation?
Androgen binding protein which is produced by the Sertoli cells
What does the safronin stain stain red?
Collagen, Mast cell granules, and mucin
What are norepinephrine and epinephrine metabolized to?
Vanillylmandelic acid. You’ll see elevated levels of this in patients with pheocrhomocytomas or other catecholamine secreting tumors
How to differentiate between Group A strep and other strep species?
Do a bacitracin test because Group A strep is bacitracin sensitive while the other strep species are bacitracin resistantResults in hyperuricemia and hyperuricaria
Lesch-Nyhan quick hits.
X linked recessive, HGPRT deficiency.
Self-mutilating behavior, dystonia, delayed development.
Results in hyperuricemia and hyperuricaria
Acanthosis nigricans is a sign of what things?
Insulin resistance, obesity, GI malignancy (all due to increased growth factor production)
What do people with mechanical heart valves have to go on indefinitely?
What is the MOA of this drug?
Anticoagulation therapy (WarfarIn) Warfarin inhibits Vitamin K Epoxide Reductase which is involved in activating Vitamin K so that it can perform gamma carboxylation on Factors II, VII, IX, and X
Where do melanocytes and germ cells originate from and migrate to?
Germ cells originate in yolk sac, migrate to the gonadal ridge.
Melanocytes originate in the neural crest and migrate to epidermis
DiGeorge syndrome associated with which cardiac anomaly?
Truncus arteriosus malformation. CATCH 22 Conotruncal cardiac defects Abnormal Facies Thymic aplasia/hypoplasia Cleft palate Hypocalcemia
Absence of CD40 ligand is diagnostic for what?
Hyper IgM syndrome CD40L is what the CD4 T cells use to invoke class switching
What are the 2 anti-TNF alpha drugs?
Infliximab and Etanercept
What is hand-foot-genital syndrome and what is it caused by?
Hypoplastic great toes and thumbs and dysmorphic genitalia, caused by a mutation in the homeobox gene HOXA13
What are mutations in ERBB22, PAX6, TP53, and VHL involved in?
ERBB22=Breast cancer, overepxressed epidermal growth factor
PAX6=Paired box, specification of certain tissues in embryo, involved in eye and brain development, presents with ocular defects such as aniridia (absent iris)
TP53=tumor suppression gene mutated in Li-Fraumeni syndrome. Breast cancer and sarcomas at young age.
VHL=Von-Hippel-Lindau syndrome. Retinal, cerebellar, spinal hemangioblastomas. Renal cell carcinoma, pheochromocytoma, pancreatic tumors
How do Vit D and PTH differ? Calcitonin?
Vit D causes increased absorption of calcium AND phosphate. Decreases PTH
PTH causes increased calcium, decreased phosphate.
Calcitonin decreases bone resorption and calcium reabsorption.
PCR quick hits
Heat for denaturation, cool for primer hybridization (binding to single stranded DNA), reheat for primer extension and DNA synthesis
Sinus that is most involved with acute rhinosinusitis?
Maxillary sinus, opens at middle nasal meatus
Ln that drains the abdomen
Left supraclavicular. Thoracic duct dumps into here
ATP of thiamine
Alpha-ketoglutarate, Transketolase, Pyruvate dehydrogenase
What is RiboFlavin (Vit B2) involved with?
FAD, FMN are derived from Flavin. Redox reactions, SUCCINATE DEHYDROGENASE!!!
2 C’s of B2=Cheilosis (lip inflammation and fissures at corner of mouth) and Corneal vascularization
Vitamin B3 (niacin) involved with?
NAD derived from Niacin (B3=3ATP)
Derived from TRYPTOPHAN
Treats DYSLIPIDEMIA (lowers VLDL, raises HDL)
3 D’s of B3=Dermatitis, Diarrhea, Dementia (Pellagra)
Hyperpigmentation of sun-exposed limbs
Excess causes flushing, hyperglycemia, hyperuricemia
Vit b5 associations?
B5 is “pento”thenic acid.
Component of coenzyme A and fatty acid sytnahse.
Deficiency=alopecia, adrenal insufficiency
Zinc fingers=?
A transcription factor motif
MOA of Fomepizole and Disulfiram in alcohol metabolism?
Fomepizole inhibits alcohol dehydrogenase, is an antidote for methanol or ethylene glycol poisoning
Disulfiram inhibits acetaldehyde dehydrogenase, causes aceltadehyde to accumulate and contributes to hangover symptoms.
Effects of ethanol metabolism in the liver?
Increased NADH/NAD ratio, increasing pyruvate–>lactate and oxaloacetate–>Malate (prevents gluconeogenesis, causes fasting hypoglycemia), also increased triglyceride production=hepatosteatosis.
FBPase-2 is related to….
PFK-1 is related to…
FBPase-2=fasting state, responds to glucagon, more gluconeogensis, less glycolysis, more cAMP.
PFK-2=Fed state, responds to insulin, more glycolysis, less gluconeogenesis
Mnemonic to remember Kreb’s cycle?
Citrate Is Kreb’s Starting Substrate For Making Oxaloacetate
I=Isocitrate, K=Alpha-ketoglutarate, S=Succinyl-CoA and Succinate, F=Fumarate, M=Malate
Mnemonic to remember urea cycle?
Ordinarily, Careless Crappers Are Also Frivolous About Urination
Ornithine, Carbamoyl Phosphate, Citrulline, Aspartate, Argininosuccinate, Arginine, Urea
Cahill Cycle Vs Cori Cycle
Cahill: Glucose–>Pyruvate–>alanine–> (Alanine + alpha-ketoglutarate)–>Pyruvate+Glutamate, glutamate–>urea
Cori: Pyruvate–>Lactate–>Pyruvate–>Glucose–>Pyruvate
What does N-acetylglutamate synthase deficiency cause?
Hyperammonemia. It’s b/c it is a required cofactor for carbamoyl phosphate synthetase I.
Presents as poorly regulated respiration and temp, poor feeding, velopmental/intellectual delay (identical to presentation of carbamoyl phosphate synthetase I deficiency)
Homocystinuria can be caused by 2 different defective enzymes. What are they?
Homocysteine methyltransferase (decreased methionine). Cystathionine synthase deficiency (decreased cysteine)
What is involved in fatty acid syntheisis and breakdown?
Synthesis: Citrate (SYtrate=SYnthesis)
Breakdown: Carnitine (CARnitine=CARnage)
3 conditions that make Tetralogy of Fallot worse?
Feeding, Crying, Exercise
What reaction can metronidazole cause with alcohol?
A disulfiram like reaction, inhibiting acetaldehyde dehydrogenase
