U-World (advanced editing) Flashcards
PECAM-1 is a molecule that allows for what step of neutrophil migration?
Transmigration (getting the neutrophil across the endothelial cell).
*remember the steps are: (1) marination, (2) rolling, (3) adhesion, (4) transmigration and chemotaxis, (5) phagocytosis
Explain the mechanism as to how pancreatic beta cells release insulin into the bloodstream in response to elevated glucose levels.
- Glucose comes into the pancreatic beta cells via the GLUT 2 transporter
- Glucose is broken down into ATP by glycolysis
- The increased ATP level within the cell causes closure of the K+ channel
- Since the K+ channel is closed, K+ cannot get out—> inc K+ within the cell, so it gets de polarized (anytime there’s inc positive charge into a cell that’s depolarization)
- The depolarization stimulates Calcium influx into the cell
- The calcium allows for insulin vesicles to get exocytosed and insulin + c-peptide are released out of the cell into the bloodstream
Where is the most common ectopic thyroid tissue site?
the tongue (lingual thyroid)
*The thyroid gland starts as the thyroid diverticulum in the pharynx and descends into the neck. Failure for the thyroid to fully migrate on down to the neck can interfere with swallowing, etc.
Think about the synthesis of the catecholamine epinephrine (epi). What amino acid is it synthesized from? What is the enzyme that converts NE—> epi? What hormone promotes this conversion?
Epi is made from Tyrosine. NE—> epi by PNMT (phenylethanolamine-N-methyltransferase) and cortisol stimulates this conversion.
Hydrophobic amino acid residues like Ala, Val, Leu, I’ll, Phe, Trp, Met, Pro, and Gly serve what function for proteins?
Anchor proteins to the phospholipid membrane
Besides letting glucose into cells to regulate blood sugar, what does insulin do?
Cell growth and DNA synthesis and promotes synthesis of glycogen, lipids, and proteins.
(*It specifically promotes glycogen synthesis by activating protein phosphatase.)
What glucose transporters are represented by the circles? Triangles?
circles (more insulin binding—> more expression of these receptors): GLUT 4 (the insulin-dependent channel- needs insulin to get expressed and allow glucose into the skeletal/ fat cells)
triangles (more insulin binding—> no change in expression of these receptors): GLUT 1, 2, 3, 5 (insulin-independent channels on other cells)
Turner syndrome presents with what findings in the: neck, nipples, height, aorta (2 things), kidneys, and ovaries?
neck is wide
nipples are spread far apart
short stature
coarctation of the aorta and bicuspid aortic valve
horshoe Kidney
streak ovaries (don’t get a period)
Patient presents with lips that look like this. He also had his thyroid removed after a mass was discovered. What is the most likely diagnosis and what gene is most likely mutated causing this?
MEN 2b
(multiple endocrine neoplasia: mucosal neuroma, thyroid medullary carcinoma, and pheochromocytoma)
*mucosal neuroma means these lesions on the lips and mouth
What biochemical change (also mention the specific amino acid residues) will occur on insulin receptors leading to insulin resistance?
Phosphorylation of serine and threonine residues on insulin receptors (by serine kinase)—> insulin resistance (insulin binds to receptor–> but less glucose is able to come into the cell)
(*this type of phosphorylation can be induced by TNF-alpha, catecholamines, glucocorticoids, and glucagon).
Patient has high free thyroid hormone, low TSH. Shins look like this. What is the disease? Explain the finding on the shins.
Graves’ disease (most common cause of hyperthyroidism).
In Graves you have an antibody that stimulates TSH receptors on the thyroid—> causes the thyroid gland to produce too much TH= hyperthyroidism. But since you also have TSH receptors on your shins and on optic muscles, the disease affects these places. Stimulation of receptors in shins and eyes—> increased production of GAGs—> non-pitting edema in shins and thickened ocular muscles that push the eyeballs out.
What causes gigantism?
Excess growth hormone (GH)—> excess liver production of IGF-1 acting on growth plates of bones.
What effect does estrogen have on bones? What does this mean for post-menopausal women?
Estrogen decreases osteoclast activity, so there’s less breaking down of bone.
Post-menopause: decreased estrogen—> more osteoclast activity (don’t have the protective estrogen to keep osteoclasts in check)—> increased risk for osteoporosis and fractures of the bones
Name which enzymatic step in this vitamin D activation pathway the following things will have an affect on.
- Getting some sunlight
- Increasing vitamin D in your diet
- Increase in PTH
- Increase in Calcium
- Sunlight: Step A (7-dehydrocholesterol—> cholecalciferol)
- Diet: Step B (cholecalciferol—> 25-hydroxyvitamin D3)
- PTH: Step C (25 vitamin D—> 1,25 vitamin D)
- Calcium: INHIBITS step C (if you have inc Calcium, you don’t want to activate vitamin D into 1,25 to inc Calcium more)
You give a hypOthyroid patient T3 for treatment. What will happen to the patient’s T4 levels and rT3 levels after treatment (increase, decrease, or stay the same)?
Since T4–> T3 (active) and you now have increased T3, T4 levels will GO DOWN (negative feedback). Since T4 is used to make rT3 and there’s less of it available, rT3 levels will also GO DOWN.
What is this describing?
Klinefelter syndrome
Label the parts of the breast.
(Sinuses- collecting reservoirs for milk during lactation)
A 14 year old girl just had menarche (started her periods) 1 year ago. She complains of irregular periods (doesn’t have them every month), and when she has them she bleeds heavily for 7-10 days. She also has spotting when she’s not on her period. What is most likely the issue?
girls just starting their periods and women getting ready to end their periods often have irregular cycles. What’s going on is an ANOVULATORY CYCLE. Estrogen builds up, thickening the endometrium, but PG does not come into play to shed the lining when pregnancy does not occur. So bleeding does not happen until the endometrium becomes so thick that some cells will shed at once—> heavy bleeding.
An episiotomy is performed on a women to expediate childbirth. An incision is made at the posterior vaginal opening. What pelvic floor muscle was cut into?
The perineal body
What is postpartum ovarian vein thrombosis? Where could the clot go from the right ovarian vein (more common)? How about from the left ovarian vein?
Increased coagulation from pregnancy + endothelial damage from delivery—> ovarian vein thrombosis. This would present as fever and flank pain (no specimens detected if UTI is suspected).
Right ovarian vein—> IVC
left ovarian vein—> left renal vein
What causes a septate uterus?
The septum doesn’t completely go away/ resorb/ involute.
What causes a bicornuate uterus?
Mullerian ducts don’t completely fuse.
What causes a didelphys uterus?
Mullerian ducts don’t fuse at all.
What branch off the common iliac artery goes down to the leg as the femoral artery? What branch off the common iliac artery branches into smaller arteries to feed a bunch of pelvic structures?
external iliac—> goes down leg as femoral artery
internal iliac—> branches to feed pelvic structures
Took antibiotics 2 weeks ago. Now has thick white vaginal discharge. Budding cells are seen. What is it?
Candida vaginitis (the antibiotic use killed bacteria and altered the normal vaginal flora, allowing for colonization of the Candida fungi).
Postpartum hemorrhage can be controlled by medical management- uterine massage (squeezing the uterus to contract vessels and decrease blood flow) or uterotonic meds (to maintain blood flow). However, if these interventions do not work to control bleeding, we will bilaterally legate what artery to stop bleeding?
The INTERNAL ILIAC ARTERY
(external iliac—> goes down leg as femoral artery
internal iliac—> branches to feed pelvic structures)
Girl who doesn’t always use condoms presents with yellow-green vaginal discharge. How can you confirm the diagnosis?
Saline microscopy. (Watch the Trichemonas organisms move around the slide with their flagella)
If breast cancer spreads to __________, you would see overlying skin retractions/ skin dimpling.
Malignant infiltration of suspensory ligaments of the breast (Cooper’s ligament)
Baby favors turning head 1 way (cries if you turn their head the other way). Has neck swelling on 1 side. What is this? What’s it caused by?
Congenital Torticollis
(injured SCM muscle in neck from intrauterine malposition or birth trauma)
30 year old with breast mass. You see this on histology. Most likely diagnosis?
Fibroadenoma (remember, this is the most common benign neoplasm of the breast and you see fibroblasts here…if it were like Paget disease of the nipple, we’d expect to see the surface epithelium bc it travels out to the nipple and if it were ductal carcinoma in Situ we’d see a clearly defined duct with malignant cells only within it…)
Lady presents with unexplained weight loss and getting full fast. Bilateral ovarian masses and stomach wall thickening are seen on CT. What is it? What are these histo cells?
Krukenburg tumor
(stomach CA—> goes to ovaries)
”Signet ring cells” (mucus pushes the nucleus to the side)
What kind of ovarian cancer is this?
mature teratoma (appreciate the different kinds of cells in there coming from different embryologic origins)
In chronic kidney disease, what happens to Phosphate levels, calcium levels, and PTH levels? Explain.
phosphate goes UP
calcium goes DOWN
PTH goes UP
Guy gets stabbed laterally at the 5th intercostal space, midclavicular line. What structure is most likely to be hit?
The left lung (right ventricle would be spared since the knife went in laterally and mid-clavicular)
Which part of the male urogenitary tract is most likely to be damaged from trauma (for example from a car accident causing a pelvic fracture)?
Posterior urethra (labeled “C”)
(This part of the urethra has less support. The prostatic urethra on the other hand, is surrounded by the prostate “cushion” so is not likely to be damaged in a urethral injury.)
Which segment of the male urethra is most commonly injured in straddle injuries? How about in a pelvic fracture?
Straddle injury—> Anterior urethra injury
Fractured pelvis—> Posterior urethra injury
Failure of the urethral folds to fuse results in what in a male?
hypospadias (urethra opens on bottom of the penis shaft)
What’s the first line medication therapy for BPH?
Where’s the prostate?
Where’s the bladder in this CT of a male?
Nerves are injured during a prostatectomy (removal of the prostate gland, probably bc the guy has prostate cancer. What is the most likely complication? Explain.
Erectile dysfunction
(The prostatic plexus of nerves in the fascia of the prostate innervate the corpus cavernosa of the penis—> erection. So, if these nerves are damaged, ED will result.)
What structure is cut in a vasectomy?
The vas deferens
A man and his wife don’t want more kids so the guy gets a vasectomy. Is it possible for them to get pregnant afterward?
yes. Although you cut the vas deferens (route for sperm), there can still be viable sperm that were already there distal to where you cut and they can chill there for 3 months. You have to tell the patient this and advice the couple to use contraception for 3 months following the procedure and until a semen analysis confirms azoospermia (no sperm).
Which lymph nodes does the scrotum drain into?
superficial inguinal lymph nodes
Which lymph nodes does the glans penis drain into?
Deep inguinal lymph nodes
Which lymph nodes do the testes drain into?
para-aortic lymph nodes
TZDs (like Pioglitazone) bind to what receptor located where?
PPAR-gamma, an intracellular nuclear receptor.
What are the 3 main organs located in the RUQ?
liver, gallbladder, and colon
What are the 4 main organs located in the RLQ?
Appendix, colon, ureter, and ovary
What are the 3 main organs located in the LUQ?
Spleen, stomach, and colon
What are the 3 main organs located in the LLQ?
Colon, ureter, and ovary
What are the 4 main organs located in the epigastric region?
stomach, liver, colon, and pancreas
What are the 2 main organs located in the hypogastric/ suprapubic region?
bladder and uterus
A man presents with a painless testicular mass. His testicular tumor is most likely to spread to which group of lymph nodes?
para-aortic
(remember, lymph node drainage tends to follow blood supply. The testes develop from the retroperitoneum and establish their arterial blood supply from the abdominal aorta. Even though they descend, their blood supply and lymph drainage still comes from up there.)
Where do the gonadal (testicular and ovarian) arteries and veins branch from?
right gonadal (testicular/ ovarian) vein—> comes off the IVC
left gonadal (testicular/ ovarian) vein—> comes off the left renal vein
right and left gonadal (testicualr/ ovarian) artery—> comes off the abdominal aorta
Baby boy has painless scrotal swelling that transilluminates. What is this and where specifically is the swelling/ accumulation of fluid?
Hydrocele
Tunica vaginalis
(note: it is due to failure of the processus vaginalis to obliterate)
What 3 pathogens can cause esophagitis in an HIV patient?
- Candida (most common)
- Herpes simplex virus-1 (HSV-1)
- Cytomegalovirus (CMV)
What are all the retroperitoneal structures?
Lady has a 2 day hx of crampy abdominal pain and vomiting. Months ago had an episode of acute calculous cholecystitis that was managed. She is presenting to you with a distended abdomen, high-pitched bowel sounds, and X-ray that shows air in the gallbladder. What’s going on?
Gallstone Ileus (this is a complication of gallstones)
*her gallbladder became inflamed to the point that it ruptured/ inflammation ate away at the gallbladder and formed a connection (fistula) with the duodenum. This allowed the gallstone to move into the duodenum—> most commonly lodges in the iliocecal valve, causing small bowel obstruction.
Pancreatic tissue is circling the duodenum and constricting it so that baby is fussy when fed and vomits. What is this called? What is it due to?
annular pancreas
due to abnormal migration of ventral pancreatic bud
Children with watery diarrhea should be treated with what type of solution?
Oral rehydration solutions= Sodium- glucose solutions (to prevent dehydration and electrolyte abnormalities)
What’s wrong with this liver?
Cirrhosis
(disruption of normal hepatic parenchyma by bands of fibrosis and regenerative nodules of hepatocytes)
Absent liver conjugation enzymes and jaundice. What is it? What does this condition lead to?
Crigler Najjar syndrome
Kernicturus: accumulation of bilirubin (UCB) in brain—> neurological deficit—> death
Decreased liver conjugation enzymes and jaundice in an adult. What is it?
Gilbert syndrome
Deficient bilirubin excretion into bile caniculi and dark liver. What is it? What would it be if the liver were not dark?
Dubin-Johnson syndrome (black liver)
Rotor syndrome
Explain the adenoma-carcinoma sequence of how most people get colon cancer.
Increased pressure in what vein can cause gastric varices (dilated veins) in the fundus of the stomach?
splenic vein (it runs over the fundus *not left gastric vein bc that vein runs along the lesser curvature of the stomach)
An actress comes into the office with nausea and bilious vomiting. She recently went on a diet to lose 25 lbs quickly for role. You hear high-pitched bowel sounds on physical exam. Diagnosis?
SMA (superior mesenteric artery) syndrome
Rapid weight loss—> loss of fat pad cushioning where the duodenum is sandwiched between the aorta and SMA—> SMA compresses down on the duodenum. (Note that high-pitched bowel sounds means small bowel obstruction.)
SMA syndrome compresses which part of the duodenum?
The 3rd part/ horizontal part/ TRANSVERSE duodenum
What is this?
Cavernous hemangioma
(most common benign liver tumor)
Explain the lifecycle of Strondyloides Stercoralis. How is it diagnosed?
(remember, Strondyloides S. Is the roundworm “strong guy” in Sketchy)
penetrates soles of feet—> goes to lungs, then bronchial tree—> gets swallowed—> enters GI tract—> lays eggs in intestinal wall—> those eggs hatch and the worms re-penetrate the intestinal wall—> enter bloodstream—> go to lungs (cycle continues)
*since the victim is being re-penetrated with the same organism, it gets widespread and can lead to hyperinfection (multiorgan dysfunction and septic shock)
You would only find larvae in stools (no eggs because they laid them into intestinal walls—> already hatched and crawled out)
Lady has an inflammed terminal ilium and this histology picture from it. What is the diagnosis?
Crohn’s disease
(affects anywhere in the GI tract, skip lesions, but most common site is terminal ilium. Characterized by non-caseating granulomas that are Th1-mediated.)
What are the 2 main vessels that supply the small and large intestines? What vessel bridges these 2 vessels together, creating an anastomosis?
SMA and IMA
marginal artery of Drummond creates an anastomosis between these arteries to continue to supply the intestines even in ischemic injury to one vessel
What effect does CCK (Cholecystokinin) have on the pancreas and gallbladder?
Increases gallbladder and pancreatic secretion (promotes contraction of the gallbladder and relaxation of the sphincter of Oddi for bile and pancreatic enzymes to get released and enter the duodenum)
A patient has appendicitis and you are doing surgery to remove their appendix. What anatomy structure is most helpful in localizing the appendix?
Tenia coli
(Longitudinal ribbons of smooth muscle on the ascending, transverse, descending, and sigmoid parts of the colon. All 3 “ribbons” come together at the appendix.)
*note: colon haustra (the bumps/ segments) are helpful in distinguishing the colon/ large intestine from the small intestine (no haustra), but not the BEST landmark for finding the appendix.
- Name thes 4 vessels.
- Which one would have an increased pressure in a patient with cirrhosis prior to giving diuretics?
- The portal vein (C) would have an increased pressure in a patient with cirrhosis (cirrhosis—> increased hydrostatic pressure in the portal vein—> ascites/ fluid leakage into abdomen)
Appendicitis-like symptoms, but further evaluation of tissue reveals this histology. What is it?
Carcinoid tumor (malignant proliferation of neuroendocrine cells) *can tell by this classical rosette appearance like flowers
*These tumors can occur anywhere along the gut (small bowel most common) and if they release serotonin and cause bronchospasm, diarrhea, and flushing symptoms, we call it carcinoid syndrome
Unintentional weight loss, early satiety. Stomach biopsy shows this. What is it?
Diffuse gastric adenocarcinoma
(note: signet-ring cells and leathery “linitis plastica” appearance)
RUQ pain associated with eating fatty meals. Upon CCK stimulation test, there is slow/ incomplete gallbladder emptying. What does the patient probably have?
Biliary sludge.
This means there is hypOmotility of the gallbladder (it’s not contracting as well as it should to get all the bile out)—> stasis of bile and more opportunity for the bile contents to precipitate out and form stones and the bile to thicken (viscous)
An abdominal cyst is found in a kid with fibrous bands connecting it to the ileum and to the umbilicus. What is it?
Omphalomesenteric (Vitelline duct) cyst
due to failure of the Vitelline duct to completely obliterate (go away)
Besides Meckel diverticulum, what other abnormalities can occur if the Vitelline duct fails to completely obliterate?
(See pic)
*remember that the Vitelline duct connects the Yolk sac to the midgut in embryo. Note that no obliteration at all means urine will be coming out of the belly button.
Where does the splenic artery branch from? What 2 arteries does the splenic artery branch into? If the splenic artery were occluded, lack of blood flow through which of those 2 arteries would become a problem?
Splenic artery branches off the celiac trunk
splenic artery—> short gastric artery and left gastroepiploic (gasto-omental) artery
splenic artery blocked—> lack of blood flow through the short gastric artery would be a problem for the organs it supplies (fundus of the stomach), not so much a problem if there’s lack of blood flow through the left gastroepiploic artery bc it forms a strong anastomoses with the right gastroepiploic artery
How can Crohn’s disease lead to fat and fat-soluble vitamin malabsorption? Explain in context of bile acid absorption and recycling.
Guy with Crohn’s disease is bruising easily. Does not have a coagulation disorder. Why is he bruising easily?
Bile acid malabsroption
Crohn’s most often affects the terminal ileum, which is also the site of bile acid absorption into the blood. Inflammation there from Chron’s—> bile acid malabsorption—> fat and fat-soluble vitamin (A, D, E, K) malabsorption (bc you need the bile acids to help reabsorb these guys)—> vitamin K deficiency will lead to easy bruising, given that vit K is needed to activate many coagulation factors
Explain how Crohn’s disease can lead to gallstones.
Inflammation in terminal ileum (most common place Crohn’s affects)—> decreased absorption of bile acids into blood—> less bile acids received to liver and added to bile—> more cholesterol in proportion to bile acids in the bile stored in the gallbladder—> precipitation of cholesterol—> gallstones
Explain how Crohn’s disease can lead to Calcium oxalate kidney stones (most common type of kidney stone in Crohn’s disease).
Inflammation in terminal ileum (most common place affected by Crohn’s)—> decreased absorption of bile acids into the blood (the site where they get reabsorbed)—> less bile acids recycled to liver and added to bile—> decreased absorption of fat—> increased FAs (fatty acids) in lumen of intestines (because they can’t get absorbed)—> calcium (normally bound to oxalate) will bind those FAs—> increased free oxalate absorption—> filtered thru kidneys—> inc chance for calcium-oxalate kidney stones
Where is the cardia of the stomach? (Invision picture in head)
Intussusception (telescoping of the bowel)
What’s wrong with this sigmoid colon?
diverticulosis
What is this?
Metastatic liver CA
(not primary liver CA bc there are multiple liver tumors)
What is this? How would it present? What defect caused it?
Zenker diverticulum (false diverticulum, outpouching of the mucosal layer of the esophagus)
presents with dysphasia (difficulty swallowing), bad breath (trapped food)
caused by a defect in the esophageal muscular wall
Where does H.Pylori usually affect? Where does is most commonly cause ulcers? Explain the process of how this happens.
H. Pylori usually affects the antrum of the stomach and causes ulcers in the duodenum.
The infection/ inflammation in the antrum of the stomach decreases somatostatin from D-cells (also in the antrum)—> increases gastrin release—> promotes parietal cells to release more HCl acid
Lady gets a C-section and due to high birth weight of baby, the surgeon also has to cut the rectus abdominis muscle laterally. What vessel is at greatest risk of injury?
inferioir epigastric artery
What are the watershed areas of the colon? Why are they more susceptible to ischemia?
- Splenic flexure
- Rectosigmoid colon
- Hepatic flexure
They are the curves of the colon that are furthest away from the main blood supply to the colon (SMA/ IMA), so if there’s is decreased blood flow, they will be the first areas to suffer ischemic damage (splenic flexure and rectosgimoid colon would be worse off, then hepatic flexure would suffer)
What artery supplies the right half of the colon? Left half?
Right half of colon—> supplied by SMA
Left half of colon—> supplied by IMA
This is a histo picture of the esophagus. What is the pathology?
Squamous cell carcinoma of the esophagus
Mucoid diarrhea, mass in sigmoid colon on colonoscopy. What is this?
Villous adenoma
(“villous is the villan”- worse type of pre-cancerous adenomatous polyp, most likely to become malignant, can produce PG-E2–> mucusy secretory diarrhea—> hypokalemia and hypoproteinemia)
32 year old woman. Diarrhea. Draining fistula near coccyx. What is the diagnosis?
Crohn’s disease
(remember the most common location it affects is the terminal ileum, where the small bowel meets the large bowel near the coccyx. Also, fistula aka abnormal connections can from with the bowel wall that inflammation has eaten into.)
How does right-sided/ ascending colon CA present vs. left-sided/ descending colon CA?
Which description is consistent with Crohn’s disease? Caseating granulomas in all intestinal layers. OR thickening of muscularis mucosa.
Thickening of muscularis mucosa (remember, Crohn’s disease has NON-Caseating granulomas, not caseating)
Old lady. On/ off abdominal pain. High-pitched bowel sounds heard on auscultation. She has a hard cholesterol-filled mass obstructing the iliocecal valve. Diagnosis?
gallstone ileus
(complication of a gallstone, in this case a cholesterol gallstone. Inflammation breaks down gallbladder wall—> forms fistula/ connection with duodenum—> stone moves into iliocecal valve. Pneumobilia= air from intestines in gallbladder.)
What cardiac problem occurs in acromegaly?
LV hypertrophy/ cardiomyopathy
Label these in head. All curves correspond to insulin types.
