USMLE QBank Review Flashcards
Scaphoid Fractures
- most common of carpal bone fractures
- from fall on outstretched hand
- pain and tenderness in the anatomical snuffbox (scaphoid and trapezium for the floor)
- scaphoid branch of radial artery supplies scaphoid
- fractures = avascular necrosis and nonunion
Dupuytren’s Contracture
- slowly progressive fibroproliferative disease of the palmar fascia
- nodules form on the fascia, eventually resulting in contractures that draw the fingers into flexion
Opiod analgesics Sideefects
- I.e. Morphine
- can cause contraction of smooth muscle cells in sphincter of oddi leading to spasm and an increase in common bile duct pressures
- cause histamine release leading to vasodilation of blood vessels and itching = can cause hypotension
- constipation
- no direct toxic effect to liver but is metabolized by liver
- increase somatostatin secretion from pancreas
Sarcomere
- A band = thick filaments in sarcomere and includes portions overlapped by thin filaments. H band is apart of the A band
- I band = contains the Z line and actin filaments that do not overlap with thick filaments
Oral vs Anal drug bioavailability
- when taking an oral drug there is first pass metabolism by the liver which diminshes drug concentration in the systemic circulation
- sublingual drug administration can help bypass first pass metabolism
- rectal drug administration partially bypasses the first pass metabolism because 2/3 of venous drainage goes straight to IVC while the other goes into the portal veinous system
- IV, sublingual, and rectal administration bypasses some or all first pass and allows more drug to reach systemic circulation
Anti-Smith Antibodies
- associated with SLS
- smith protein normally complexes with small nuclear RNA in cytoplasm that forms SnRNPs
- autoantibodies directed against SnRNP’s = anti-smith antibodies ==> defect in removal of introns from mRNA
RNA types
RNA polymerase 2 = mRNA and snRNA
- other types of RNA are rRNA and tRNA
Lesch Nyhan Syndrome
If purine salvage is impaired then the activity of PRPP amidotransferase will increase to supply de novo purine synthesis
- X linked recessive disorder
Southwestern Blot
Helps to identify DNA binding proteins
Uses double stranded DNA as a probe (compared to Southern and Northern blot that use single stranded DNA as probes)
-c-Jun and c-Fos are nuclear transcription factors that directly bind DNA via a leucine zipper motif
- Southwestern Blots are used to detect DNA binding proteins like transcription factors, nucleases, and histones
Lesch Nyhan Syndrome
If purine salvage is impaired then the activity of PRPP amidotransferase will increase to supply de novo purine synthesis
- X linked recessive disorder
Cystic Fibrosis
- mutation in CFTR gene due to phenylalanine deletion
- chronic pulmonary infections, bronchiectasis, pancreatic insufficiency, digital clubbing
- infertility due to absence of vas deferens bilaterally (azoospermia)
- meconium ileus in new born
- CFTR gene mutations are the most common cause of bilateral absence of the vas deferens
- can diagnose with elevated sweat chloride levels and measurement of nasal transpeithelial potential difference
Primary Ciliary Dyskinesia
- dynein arm defect - abnormal ciliary motion and impaired mucociliary clearance
- chronic pulmonary infections
- situs in versus
- infertility due to immotile spermatozoa
Diagnosis - low nasal nitric oxide levels
- genetic testing
Kleinfelter Syndrome
- most common meiosis nondisjunction
- the higher numbers of X chromosomes = more severe manifestations
Clinical features - primary testicular failure due to hyalinization and fibrosis of the seminiferous tubules ==> infertility and cryptorchidism
- testosterone deficiency causes eunuchoid body habits = tall stature and gynecomastia
- facial and body hair are sparse or absent
- mild intellectual disability
- gynecomastia
- long legs
Marfan Syndrome
- arachnodactyly, scoliosis, aortic root dilatation
- due to an inherited defect of the ECM protein fibrillin
Fragile X Mental Retardation
- Macroorchidism = enlarged testes
- large jaw and long face
- large Everett ears
- mitral valve prolapse, flat feet, and hypotonia
- intellectual disability
CGG repeat
X -linked = affects the methylation and expression of the FMR1 gene
Turner Syndrome
45 XO
- short stature
- broad chest
- primary amenorrhea
Bloom Syndrome
Premature aging due to shortened telomeres
Telomerase
- reverse transcriptase (RNA-dependent DNA polymerase)
- lengthens telomeres by adding TTAGGG repeats to the 3’ end of chromosomes
Insulin Biochemical Pathway
Anabolic hormone that acts via tyrosine kinase signaling to increase the synthesis of glycogen, proteins, fatty acids and nucleic acids
-Tyrosine kinase/phosphatidylinositol-3-kinase stimulation promotes glycogen synthesis by activating protein phosphatase, an enzyme that de phosphorylates (activates glycogen synthase)
Once pro insulin is made in the RER there is cleavage of pro insulin in the islet cell secretory granules that yields insulin and C-peptide which are stored in the granule until they are secreted in equimolar amounts
What is tetrahydrobiopterin a cofactor for?
Tetrahydrobiopterin (BH4) is a cofactor in the synthesis of serotonin, tyrosine, and DOPA
Phenylalanine –> Tyrosine –> DOPA –>Melanin or Catecholamines
Tryptophan –> 5 hydroxytryptophan –>Serotonin
- serotonin is formed via hydroxylation and decarboxylation of tryptophan
- Phenylketonuria can result from BH4 deficiency due to Dihydropyridine reductase deficiency ===> serotonin deficiency and hyperphenylalanemia. Treatment = low phenylalanine diet and BH4 supplementation
Ventricular Septal Defect
Low pitched holosystolic murmur heard best at the left sternal border with increase in hand grip
Atrial Septal Defect
- mid-systolic pulmonary ejection murmur that results from increased flow across the pulmonic valve
Aortic Regurgitation
Early diastolic murmur
Genital Ulcer Disease
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Mechanism of Action of Bacterial Toxins
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Water Soluble Vitamins
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Coronary Steal Syndrome
- collateral micro vessels form adjacent pathways for blood flow to areas distal to an occluded vessel
- Adenosine and dipyridamole are selective vasodilators of coronary vessels that can cause coronary steal = blood flow in ischemic areas is reduced due to arteriolar vasodilation in non ischemic areas because ischemic areas are already maximally vasodilated due to local vasodilators.
Coronary steal can lead to hypoperfusion and worsening of existing ischemia
Ehlers Danlos syndrome
- group of hereditary disorders characterized by defective collagen synthesis
- caused by procollagen peptidase deficiency which causes impaired cleavage of terminal propeptides in the extra cellular space
Clinical manifestation
- joint laxity
- hyper extensible skin
- tissue fragility due to the formation of soluble collagen that does not properly cross link
Uncomplicated umbilical Hernia
- defect at the linea covered by skin
- caused incomplete closure of the umbilical ring which allows for protrusion of bowel through the abdominal musculature
- most are reducible, asymptomatic, and resolve spontaneously in first few years of life
- reducible bulge at the umbilicus notably with increased abdominal pressure
Associated with Down syndrome, hypothyroidism, beck with-Wiedermann syndrome
Oomphalocele vs. Gastrochisis
O = midline herniation of abdominal contents contained within a membranous sac
G = full thickness abdominal wall defect that presents as intestines outside sac
Pharyngeal Arches
First = trigeminal nerve and maxillary artery Second = facial nerve, muscles of facial expression, and stapedial artery Third = glossopharyngeal nerve, parts of the hyoid bone and stylopharyngeous muscle, common and proximal internal carotid arteries Fourth = superior laryngeal nerve of the vagus, muscles of the pharynx and soft palate, and some laryngeal muscles. Aortic arch and subclavian arteries Fifth = obliterated during fetal development Sixth = recurrent laryngeal nerves of the vagus, muscles of larynx, pulmonary arteries and ductus arteriosus
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Prolactin facts
- manufactured due to stimulation by TRH and is inhibited by progesterone
Although prolactin secretion increases as pregnancy progresses, high progesterone levels inhibit lactation through negative feedback on prolactin on the anterior pituitary
Lactation during pregnancy is suppressed due to high progesterone levels inhibiting the anterior pituitary
Craniopharyngiomas
- supra stellar tumors found in children and composed of calcified cysts containing cholesterol crystals. They come from remnants of Rathke’s punch an embryonic precursor of anterior pituitary
Osteoporosis Facts
- African American women have higher bone density through out their lives than women of other ethnicities
Non Modifiable risk factors
- advanced age
- female sex
- white Hispanics or Asian ethnicity
- personal or family history of fractures
Modifiable Risk factors
- decreased physical activity
- Low BMI
- poor calcium and vitamin D intake
- excessive alcohol or tobacco use
- premature menopause
- glucocorticoid use
Rheumatoid Arthritis Complication
Long standing rheumatoid arthritis can affect the cervical spine and cause vertebral malalignment that can affect the atlantoaxial joint
- extension of the neck during endotracheal intubation can worsen the subluxation leading to acute compression of the spinal cord and vertebral arteries causing sudden areflexia of all extremities
Intra ventricular Hemorrhage
- blood in the ventricles of the brain
Common due to prematurity - Can be silent or present with altered level of consciousness, hypotonia, and decreased spontaneous movements
- Symptoms: bulging anterior Fontanelle, hypotension, decrebrate posturing, tonic-clinic seizures, irregular respirations, and coma
Usually originates from the germinal matrix
Increased frequency with decreasing age and birth weight
Clear Cell Carcinoma
Most common subtype of Renal Cell carcinoma
- appears as cuboidal or polygonal cells with clear abundant cytoplasm and eccentric nuclei
- golden yellow on microscope due to high glycogen and lipid content
- originates from proximal renal tubules
Risk factors include smoking and obesity
Renal oncocytomas = collecting duct cells (with numerous mitochondria)
Viral Myocarditis
Progressive onset of heart failure in the setting of a recent viral infection = dilated cardiomyopathy
Filtration Fraction
FF = GFR/RPF
Prokaryotic DNA polymerases
All 3 can remove mismatched nucleotides via their 3’-5’ exonuclease activity
Only DNA polymerase 1 has 5’ to 3’ exonuclease activity which is used to remove the RNA primer synthesized by RNA primase
Transketolase
Converts Fructose 6 phosphate to a ribose sugar in the non-oxidative part of the HMP Shunt
Phenylketonuria
Autosomal recessive defect of phenylalanine hydroxylase or BH4 (tetrahydrobiopterin)
- Children present with intellectual disability, seizures, eczema, light haiir/skin, and a musty Odor
Screening occurs 2-3 days after birth because the mother makes enzyme for fetus
Maternal PKU = lack of proper dietary therapy during pregnancy = microcephaly, intellectual disability , growth retardation, congenital heart defects in child
Treatment = restriction of phenylalanine intake and supplementation of tyrosine , must avoid artificial sweetener aspartame
Anaplastic Tumor Characteristics
Cells that demonstrate a complete lack of differentiation
- loss of cell polarity with complete disruption of normal tissue architecture, cells coalesce into sheets or islands in a disorganized fashion
- significant variation in the shape and size = cellular and nuclear pleomorphism
- Hyperchromatic nuclei with high N/C ratios
- Giant multinucleated tumor cells
Clinical Phenotypes of 21 Hydroxylase deficiency
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Common Causes of Myopathy
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Cardiac Tissue Conduction Velocity
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Acute Inferior Wall MI
Right Ventricular Myocardial Infarction
- presents with hypotension, elevated jugular pressure and clear lungs
- leads 2,3, and AVF
Amatoxins and Ricin
- from mushroom poisoning = Amanita phylloides or death cap
- potent inhibitors of RNA polymerase 2 (halting mRNA synthesis)
Ricin
- from the castor oil plant Ricinus communis
- potent toxin that inhibits protein synthesis by cleaving the rRNA component of the eukaryotic 60S subunit
Lymphatic Drainage of the Leg
- superficial lymphatic system is divided into medial and lateral tracks
Medial Track
- runs up to the superficial inguinal lymph nodes bypassing the popliteal nodes
- runs along the long sap heinous vein up the superficial inguinal lymph nodes and bypasses the popliteal nodes
- lesion on medial = inguinal lymphadenopathy
Lateral Track
- drain the lateral part of the leg and communicates with the popliteal and inguinal nodes
- lesions here = both popliteal and inguinal lymphadenopathy
Cytomegalovirus
- causes mononucleosis-like syndrome
- mono spot negative
- in immunocompromised = primary or reactivated CMV infection can result in severe retinitis, pneumonia, esophagitis, colitis, or hepatitis
Diabetes
Type 2
- excess visceral fat and limited subcutaneous fat
- waist circumference & waist to hip ratio is very profound
Type 1
- high ketone levels = DKA = no presence of insulin at all
Differential Diagnosis of Vaginosis
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Trichomonas = can be seen on wet mount Saline microscopy of vaginal discharge. Presents with yellow-green discharge and vaginal burning and is sexually transmitted
Systemic Mastocytosis
- colonal mast cell proliferation occurs in the bone marrow, skin, and other organs
- mast cell is associated with C-KIT receptor tyrosine kinase mutation
- these cells have a large expression of tryptase
- there is excessive histamine release from de granulation of the mast cells which causes syncope, flushing, hypotension, pruritus, and urticaria
- histamine also induces gastric acid secretion which can lead to gastric ulcers
- the excess acid inactivates pancreatic and intestinal enzyme causing diarrhea
- other GI symptoms include nausea, vomiting, and abdominal cramps
Overall causes Gastric hypersecretion
Hepatitis E Virus
Unenveloped single stranded RNA virus that spreads through fecal oral route
- cause high mortality in infected pregnant women
Osteoporosis
- Trabecular thinning with fewer interconnections
Osteitis Fibrosa Cystica
Skeletal Manifestation of Primary hyperparathyroidism
- presents with bone pain
- superiosteal erosions affecting the phalanges of the hand = affects mostly cortical (compact bone)
- salt and pepper skull
- brown tumor bone cysts
Osteoporosis
Persistence of primary spongiosa said in the medullary cavity with no mature trabeculae
- accumulation of woven bone and diffuse skeletal thickening
Common Causes of Nonvalvular Heart Failure
Look at picture
Diabetes
Type 2
- excess visceral fat and limited subcutaneous fat
- waist circumference & waist to hip ratio is very profound
Type 1
- high ketone levels = DKA = no presence of insulin at all
Differential Diagnosis of Vaginosis
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Trichomonas = can be seen on wet mount Saline microscopy of vaginal discharge. Presents with yellow-green discharge and vaginal burning and is sexually transmitted
SIADH
- low plasma sodium and osmolality
- concentrated urine
- normal body fluid volume due to ANP
- can be due to Small Cell lung cancer
The -omas
VIPoma
- diarrhea
- hypokalemia
- achlorhydria
Glucagonoma
Check Pictures
Somatostatinoma
- abdominal pain, gallbladder stones, constipation, hyperglycemia, and Steatorhea
- inhibition of GI motility
Superior Gluteal Nerve Lesion
- causes positive trandelenburg sign = hip drop observed contra lateral to lesion as the ipsilateral foot is lifted off the ground = superior gluteal nerve lesion or gluteus medius muscle
- weakened gluteus medius can’t contract
- caused by injection at superiomedial quadrant of the left buttock (proper placement should be in superiolateral quadrant of left buttockor even better the anterograde real gluteal region)
Injections to the superiomedial, inferomedial, and inferolateral regions of buttock risk injury to sciatic nerve
Superior gluteal nerve gives innervation to gluteus medius and minimus = hip abductors
inferior gluteal nerve = gluteus maximus = hip extender
Supine Hypotensive Syndrome
CHECK PICTURES
- occurs a lot to pregnant women supine
Types of Collagen
Type 1 = for mature scars
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Hypertrophic Cardiomyopathy Pulse
A bifid carotid pulse with brisk upstroke (spike and dome)
Central Vein Access via Femoral Vein
- the optimal site for obtaining vascular access in the lower extremity during cardiac catheterization is the common femoral artery below the inguinal ligament
- if going above the inguinal ligament this can significantly increase the risk of retroperitoneal hemorrhage
SHOCK
When it comes to hypovolemic shock
- IV fluids that are normal saline are given to increase the intravascular and left ventricular end diastolic volumes. The increase in preload stretches the myocardium and increases end diastolic sarcomere length leading to an increase in stroke volume and cardiac output.
Jervell and Lange-Nielsen Syndrome
Congenital Long QT syndrome
- autosomal recessive
- accompanied by congenital neuro sensory deafness
How do you decrease mitral regurgitation?
By decreasing left ventricular afterload = will increase the forward to regurgitation volume ratio
Sings of Reversible and Irreversible Injury
Reversible
- myofibril relaxation = cardiac myocytes occurs with severe ischemia
- dis aggregation of poly soles = ischemic injury
- dis aggregation of nuclear granules
- TAG accumulation
- Glycogen loss
Irreversible
- Mitochondrial vacuoles action = involved mitochondria is permanently damaged and can’t produce ATP
IL-10
Important anti-inflammatory cytokine that inhibits TH1 cells and reduce expression of MHC2 and suppresses the activation of macrophages and dendritic cells
Buerger’s Disease (Thromboangiitis Obliteran’s)
A vasculitis of medium and small sized arteries in the tibial and radial arteries
- there is acute and chronic inflammation of the arterial walls often with thrombosis of the lumen which can undergo organization and recanalization
- this segmental thrombosing vasculitis often extends into contiguous nerves and veins
- this condition can result from direct endothelial cell toxicity from tobacco products or from hypersensitivity to it
- usually seen among heavy cigarette smokers with onset before age 35 and is associated with hypersensitivity to intra dermal injections of tobacco extracts
Drug Treatments for TB
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Mycolic acids in the cell wall cause mycobacteria to be acid fast as they retain the carbolfuschin dye and resist decoloration by acid-alcohol de colorizing agent
Important GI Hormones & Impairments in Glycogenolysis
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Biotin Cofactors
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Neurophysins
- carrier proteins for oxytocin and vasopressin (ADH)
Act as chaperone molecules as they transport the hormones toward the nerve terminals in the posterior pituitary from their site of production in paraventricular and supraoptic nuclei
Point mutations in neurophysin 2 = hypothalamic diabetes insipidus
Phase 4 of SA node action potential
Acetylcholine and adenosine reduce the rate of depolarization by prolonging phase 4
Valsalva Maneuver
- can induce vagal stimulation to decrease tachycardia
- the rectus abdominus muscle is recruited in this process to achieve increased intra abdominal and intrathoracic pressure
Gonorrhea
- can cause urethritis (dyslexia and purulent urethral discharge)
- the nucleic acid amplification test is the diagnostic test of choice
- intra cellular diplococci
- dual therapy with ceftriaxone and azithromycin due to concerns about resistance and chlamydia co-infection
Common Clinical Disinfectants
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- formaldehyde and glutaraldehyde function by alkylation get and cross-linking DNA and proteins = most commonly used for sterilization of hospital instruments that cannot withstand autoclave temp
Binding Globulins
An increase in estrogen activity increases levels of TBG this leads to an increase in total thyroid hormone levels, but feedback control maintains normal levels of free thyroid hormone
- an increase in TBG leads to an increase in total T4 (bound T4 plus free T4) as well as total T3
Gestational Trophoblastic Disease
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Complete mole = snowstorm appearance
Primary Biliary Cholangitis
- chronic autoimmune liver disease characterized by lymphocytic infiltrates and destruction of small and mid-sized intrahepatic bile ducts
- common in middle aged women and is associated with other autoimmune disorders
- serum alkaline phosphate is elevated and AMA titers are positive
- granulomas and bile staining of hepatocytes are common
Erythema multiforme
- cell mediated inflammatory disorder of the skin
- erythematous papules that evolve into target lesions
- most commonly associated with HSV
DNA probes
- protein that must be able to bind DNA
- transcription factors, steroids, thyroid proteins, vitamin D receptors, retinoic acid receptors, DNA transcription and replication proteins
- N-myc and C-myc can bind DNA = transcription factors
Toxic Megacolon
- well recognized complication of ulcerative colitis
- patients typically present with abdominal pain/dissension, bloody diarrhea, fever, and signs of shock
- use abdominal X-Ray
- barium enema and colonoscopy are contraindicated due to risk of perforation
Differential diagnosis and features of chest pain
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Hypertensive disorders of pregnancy
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Hemicholinium
Inhibits the sodium co-transporter bringing choline and sodium into the neuron. Inhibits production of acetylcholine.
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The Pharyngeal Pouch Derivatives
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The floor of the foregut gives rise to the thyroid not the pharyngeal arches.
Enterobius vermicularis (enterobiasis) PINWORM
Occurs more frequently in school age children
- diagnosed by Scott tape test
First line treatment = Albendazole and second line is pharyngeal pamoate
What activates gaunylyl Cyclase?
ANP, BNPm NO
Chronic AV shunt
- increases cardiac output because of SNS
- decreases total peripheral resistance and increases venous return
- causes the venous return curve to shift right because ECV is increased through renal retention of fluids and because venous pooling is reduced by the increases SNS tone
Bones of Wrist and Hand
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Some Lovers Try Positions That They Can’t Handle
Nerve Distribution of the Leg
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Base Excision Repair and CaSr
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CaSr = G-protein coupled receptors that regulate the secretion of parathyroid hormone in response to changes in circulating calcium levels.
Central Retinal Artery Occlusion
Pale retina (due to ischemia and edema) and a cherry red macula
- sudden, painless, and permanent, monocular blindness
Trypsin Inactivation
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HLA proteins
Class 1 = HLA B27
- expressed by all nucleated cells
Class 2 = HLA DR, DP, DQ
- expressed by antigen presenting cells and present predominantly foreign antigens to CD4 helper T-cells
- conditions associated with HLA class 2 include rheumatoid arthritis, diabetes type and celiac disease
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Primary Aldosteronism
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Disease prevalence = q^2
For rare autosomal recessive disorders
2pq
P = 1
Side Effects of Corticosteroids
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- causes an increase in neutrophil count = demargination of neutrophils from their attachment on the vessel wall
Type 2 Diabetes
Pancreatic Islet amyloid deposition is characteristic
Ectopic Pregnancy
In an ectopic pregnancy the uterine specimen would reveal decidualized endometrium only
- consisting with dilated coiled endometrial glands and vascularized edematous stroma
These changes occur in the luteal phase of the menstrual cycle under the influence of progesterone as the endometrium prepares for implantation. Embryonic and trophoblastic tissue will be absent from the uterus
Type 4 hypersensitivity reactions
Key cells involved are the macrophages, CD4 helper T cells and CD8 helper T cells
- macrophages present the antigen to CD4 helper T cells
- then the CD4 helper T cells secrete cytokines that recruit CD8 T cells to the area and produce the characteristic signs of induration and erythema
Angioedema
Can be hereditary or acquired (ACE drugs)
- in hereditary = low C1 esterase inhibitor activity leads to increases in bradykinin levels
See Picture
Hormone regulation
Permissiveness = when one hormone allows another to exerts its maximal effect
- cortisol increases alpha 1 receptors on VSM to increase the effects of catecholamines
Synergistic = when the combined effect of both drugs exceeds the sum of the individual drug effects
Additive = when the combined effect of 2 drugs is equal to the sum of their individual effects
Tachypylaxis = decreased drug responsiveness in a short period following one or more doses (rapidly developing tolerance)
Drugs
Drug continuous infusion of a drug metabolized by first order kinetics, the steady state concentration is reached in 4-5 half lives.
HIV
- in the HIV replication cycle
- only the env gene polyprotein product is glycosylated to gp160 and is proteolytically cleaved within the endoplasmic reticulum and Golgi apparatus to form the envelope glycoproteins gp120 and gp41
Types of Exocrine Glands
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Bloom Syndrome
- autosomal recessive
- mutations in the BLM gene encoding helicase
- Patients present with growth retardation, facial anomalies, photosensitive skin rash, and immunodeficiency due to chromosomal instability and breakage
Patella Fractures
- due to a direct blow to the anterior aspect of the knee
- the patella can also be fractured indirectly due to excessive force transmitted through the quadriceps tendon
- patients develop acute swelling, tenderness, inability to extend the knee against gravity, and a palpable gap in the extensor mechanism
Mood Stabilizers in Bipolar Disorder & Antifungal Targets
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Biventricular Pacemakers
Has 3 leads
- first 2 are placed in the right atrium and right ventricle
- the third lead is used to pace the left ventricle and courses through the coronary sinus and resides in the anterioventricular groove in the posterior aspect of the heart
Elastin Production
- synthesized as a large polypeptide precursor composed of about 700 mostly no polar amino acids
- elastin contains proline and lysine residues but a few of these amino acids are hydroxylated
- after trophoblastic is formed it is secreted in the Extracellular space where it interacts with fibrillin that functions a scafold
- Then Lysil oxidase (requires copper) oxidatively delaminates some of the lysine residues of tropoelastin helping with the formation of desmosomes cross-links between neighboring polypeptides
- these cross links allow for the rubber like properties of elastin
The rubber like properties of elastin are due extensively cross-linking between elastin monomers, which is facilitated by Lysyl oxidase
Lead Time bias
- an artificial increase in survival time among tested patients who actually have an unchanged prognosis
- patients screened with more sensitive tests appear to live longer only because the disease was detected earlier than it would have been if diagnosed clinically
- the overall length of tie from disease onset to death actually remains the same in both groups
Beta blockers
- decrease AV nodal conduction
- leading to an increased AV nodal refractory period = PR interval prolongation
Cromolyn
And Nedocromil
- inhibit mast cell degranulation and prevent release of preformed chemical mediators
C. Diphtheria
The bacterium produces intra cellular poly phosphate granules that are called metachromic granules that can be detected on microscopy after methylene blue staining
Giardia Lambilia
- cause injury to the duodenal and jejunal mucosa by adhering to the intestinal brush border and releasing molecules that induce a mucosal inflammatory response
- Secretory IgA which impairs adherence is the major component of adaptive immunity against G. Lamblia
FYI
Eosinophils are used against worm infections only!
HIV
- the high mutability for the evasion of host humoral and cellular immune responses and the development of resistance to anti-retrovirus drugs
- Pol gene mutations are responsible for acquired resistance to HIV reverse transcriptase inhibitors and HIV protease inhibitors
- Env gene mutations enable escape from host neutralizing antibodies
Chest X Ray for Emphysema
Flattened Diaphragm!!!!
Cystic Fibrosis
Look at Pictures
- autosomal recessive disease that results from a mutation in the CFTR gene on chromosome 7
- The CFTR protein is a transmembrane ATP-gated channel
Acute Respiratory Distress Syndrome
Pg 613
Remember white out of lungs and thick hyaline membranes
- due to damage of type 1 pneumocytes
Restrictive Lung Diseases
Pg 611-612
Nephrogenic DI
Treated with Thiazides or indomethacin (to decrease synthesis of prostaglandins which inhibit ADH)
Interstitial Lung Disease
- associated with decreased lung volumes and increased lung elastic recoil caused by fibrotic interstitial tissue.
- the increased elastic recoil results in increased radial traction (outward pulling) on the airways leading to increased expiration flow rates when corrected for the low lung volume (opposite for emphysema)
Intestinal atresia
See picture
- in the jejunum/ileum are due to vascular injury
Bordatella Pertussis
- causes whooping cough
- clinical presentation is a paroxysmal cough lasting >2 weeks that is associated with post-tussive eyes is or inspiratory whoop after a severe coughing episode
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Mitochondrial DNA
- exists as a small circular chromosome
- codes for the rRNA and tRNA needed for mitochondrial protein synthesis
- each mitochondria contains 1-10 copies of maternally derived mtDNA
- mitochondria have a double membrane and wavy cristae
- it resembles prokaryotic DNA and is maternally derived
Left Renal Vein
- can be compressed by superior mesenteric artery
Pathogens responsible for secondary bacterial pneumonia after a viral infection
- S. Pneumonia
- S. Aureus
- H. Influenza
Psoriasis
- Can cause deforming joint disease
- common complications include arthritis, nail pitting, and uveitis
AV shunts
- increase cardiac preload by increasing the rate and volume of blood flow back to the heart
- because they bypass the arterioles, the TPR is reduced which decreases the after load as well
- AV fistula is an abnormal communication between an artery and a vein that bypasses the arterioles the major source of resistance in the vascular system = can reveal a pulsatile mass with a thrill on palpating over the site or a constant bruit
Rabies
- bats are main source of rabies
- agitation and spasms progressing to coma with weeks of exposure is strongly supportive of rabies encephalitis
- prophylactc vaccination is given for high risk people = inactivated vaccine
Recurrences of genital herpes
- can be reduced through daily treatment with oral valacyclovir, acyclovir, or farcical over
- condom use can help prevent a primary genital HSV infection but dose not prevent deactivation of latent infection
Polycythemia
- defined as a hematocrit level >52% in men and >48% in women
- it may be the result of a true increase in the red blood cell mass (absolute erythrocytosis) or decrease in the plasma volume (relative erythrocytosis)
Carotid Sinus
- dilation of the internal carotid artery located just above the bifurcation of the common carotid artery
- the carotid sinus reflex has an afferent limb that arises from the baroreceptors in the carotid sinus and travels to the vagal nucleus and medullary centers via the glossopharyngeal nerve
- the efferent limb carries parasympathetic impulses via the vagus nerve
To protect the thyroid from a nuclear accident
KI is given prophylactically to protect the thyroid from excessive accumulation of radioactive Iodide
Iron absorption
Occurs primarily in the duodenum and proximal jejunum
- bypass of the small bowel segment by gastrojejunostomy results in iron deficiency anemia
- malabsorption of vitamin B12, folate, and ADEK
Vitamin C = distal small bowel active process
- B6 = jejunum and ileum passive process
Biotin and pantothenic acid = small and large intestine via sodium dependent transporter
Thioamides
Methimazole and propylthiouracil
- decrease the formation of thyroid hormones by inhibition of thyroid per oxidase that is responsible for both iodine organification and coupling of iodotyrosines
- PTU also decreases the peripheral conversion of T4-T3
Treating Thromboembolisms in Pregnant women
- use low molecular weight heparin = enoxaprin (doesn’t cross the placenta like warfarin)
Veranicline
- partial agonist at the alpha4beta2 nicotinic acetylcholine receptor that reinforces the effects of nicotine in the CNS system
- this drug competes with nicotine and prevents its binding
- because it’s a partial agonist it helps reduce the symptoms of nicotine withdrawal by mildly stimulating the receptor
This drug assists patients with cessation of tobacco use by reducing withdrawal cravings and attenuating the rewards effects of nicotine
Piriform Recess
- where food can get caught
- a branch of the superior laryngeal vagus nerve is there which carries motor fibers to the muscles involved in vocal cord function
- the nerve mediates the afferent limb of the cough reflex by carrying sensation from the mucosa superior to the vocal cords
Henoch Schonlein purpura
- due to IgA immune complex
Post-Glomerular Strep GN
- granular deposition of IgG, IgM, and C3 in the mesangium and basement membrane
- starry sky appeared
- EM = sure epithelial humps
Bethancol
Used for postoperative urinary retention
- muscarinic agonist that will allow for urination
LaPlace’s law
See Picture
AV nodal Artery
- usually arises from the dominant coronary artery
Erythropoeisis Stimulating Agents
- are used to treat anemia of chronic kidney disease
- ESA’s can improve anemia without need for blood transfusions
There is a high risk thromboembolic events - due to increased blood viscosity as a result of the elevation in red cell mass
- increased risk for hypertension due to activation of erythropoietin receptors on vascular endothelial and smooth muscle cells
Green Color of pus and sputum from bacterial infections
- blue green heme based pigmented molecule contained within the azurophilic granules of neutrophils and catalyzes the production of hypochlorous acid (BLEACH) from chloride and H2O2 during the phagocytic respiratory burst ==> this is due to MYELOPEROXIDASE
Influenza Vaccine
- inactivated killed vaccine = injection
Function by inducing neutralizing antibodies against the hemagluttinin antigen in selected viral strains - Live attenuated vaccine = nasal spray
Generate a strong cell mediated immune response in addition to providing humoral immunity
Catalase Positive Organisms
- S. aureus
- Burkholderia Cetacea
- Serratia marcescens
- Nocardia
- Aspergillus
Crohn’s Disease
- due to a mutation in the NOD2 gene (expressed on epithelial cells and macrophages)
- the gene activates the NF-kB pathway = this is a pro inflammatory transcription factor that increases cytokine production
- In Crohn’s disease mutations in NOD2 result in decreased activity of NF-kB pathway which impairs the innate immune response of the intestinal mucosa and allows intestinal microbes to induce an exaggerated response by the adaptive immune system, resulting in chronic GI inflammation
Hepatic Abscesses
S. Aureus can cause this by hematogenous seeding of the liver
Enteric bacteria (E. Coli, Klebsiella, and enterococcus) can cause hepatic abscesses by ascending the biliary tract (ascending cholangitis), portal vein premix, or direct invasion from an adjacent area
FRC
- airway pressure equals zero
- but the intra pleural pressure is negative with a value of -5cm H20
Structures derived from neural crest cells
Melanocytes Odontoblasts Tracheal cartilage Enterochromaffin cells Laryngeal cartilage Parafollicular cells of the thyroid Adrenal medulla Schwann cells Spiral membrane
MOTEL PASS
Steroid Producing Cells
- cells in the adrenals, gonads, and liver
Pyelonephritis
- suppression of endogenous flora, colonization of the distal urethra by pathogenic gram negative rods and attachment of these pathogens to the bladder mucosa are the stages of pathogenesis in the lower urinary tract infections
- anatomical or functional vesicoureteral reflux is almost always necessary for the development of acute pyelonephritis
Klinfelter Syndrone
- primary hypogonadism
- elevated FSH and LH and low testosterone
- long lower extremities, small, firm testes, and azoospermia
Acute Tubular Necrosis
- due to decreased renal perfusion
- straight proximal tubules and the thick ascending limb of Henle are the most commonly affected portions
- muddy brown casts are seen
Heparin and Warfarin
Heparin = PTT watch Warfarin = PT watch and also check INR
Rebound Rhinorrhea
Topical preparations of alpha adrenergic agonists cause vasoconstriction of the nasal mucosa vessels and are used as decongestants
- Overuse of these drugs cause negative feedback resulting in decreased norepinephrine synthesis and release from nerve endings which diminishes their effects
Hemangioma
- never biopsy a hemangioma because it can lead to a fatal hemorrhage and has low diagnostic yield
What is the earliest sign of diabetic nephropathy?
- moderately increased albuminuria is the earliest sign of diabetic nephropathy and the leading cause of ESRD
- screening for early stage diabetic nephropathy is best achieved through the use of albumin urine dipsticks
Sirloimus
- binds to the immunophilin FK-506 binding protein in the cytoplasm, this forms a complex that binds and inhibits mTOR
- inhibition of mTOR signaling blocks IL2 signal transduction and prevents cell cycle progression and lymphocyte proliferation
Artery the true pelvis
The ureter lies medial to the ovarian vessels and anterior to the internal iliac artery
Increased intake of citrate and fluid help to prevent calculus formation
9,10,11 rib over lie the spleen
12th rib overlies the kidney
Grape fruit Juice
- slows the breakdown of drugs by inhibiting the CYP450 ==> CYP3A enzymes
Where does the most water reabsorption in occur in the nephron when there is 24 hours of water deprivation?
- The proximal tubules reabsorb >60% of the water filtered by the glomeruli, regardless of the patients hydration statu s
Ethical obligations for impaired colleagues
- non emergency situation a person should contact the designated hospital committee, commonly called a physician health program
- if this is not possible or such a body doesn’t exist then the state licensing board should be contacted
Linkage Disequilibrium
- a pair of alleles are inherited together in the same gamete more or less often than would be expected given random chance
- this can occur even if the genes are on different chromosomes
Pancreas
- the dorsal pancreatic bud = pancreatic tail, body, most of the head, and small accessory pancreatic duct
- the ventral bud = uncinate process, pancreatic head and proximal portion of the main pancreatic duct
Physicians and Gifts
- it is ethically problematic for physicians to accept expensive gifts as they may influence or appear to influence physician behavior
- these gifts should be declined after expression of appreciation
Osmotic Laxatives
Polyethylene glycol
Magnesium Hydroxide
Magnesium Citrate
Chronic Lung Transplant Rejection
- affects the small bronchioli producing the obstructive lung disease known as bronchiolitis obliterans
- characterized by lymphocytic inflammation, fibrosis, and ultimately destruction of the bronchioles
What increases risk of statin myopathy?
- use with gemfibrozil = impairs the hepatic clearance of statins if given together
Why does the myocardial cell swell during transient ischemia?
- ion pump failure due to ATP deficiency during cardiac ischemia causes intra cellular accumulation of Na+ and Ca2+
- this draws water into the cell causing the cellular and mitochondrial swelling
Hypertrophic Cardiomyopathy
- produces a systolic murmur
Contraindications for OCP use
- prior history of thromboembolic event or stroke
- history of an estrogen-dependent tumor
- women over age 35 years who smoke heavily
- hypertriglyceridemia
- decompensated or active liver disease
- pregnancy
Vasopressin and Desmopressin
- cause V2R mediated increase in water permeability in the cortical and medullary collecting ducts
- vasopressin activates urea transporters in the medullary collecting duct, increasing urea reabsorption and decreasing renal urea clearance e
- this increases the medullary osmotic gradient and allows for the production of maximally concentrated urine and
Acute Cholecystitis
- caused by gallstones obstructing the cystic duct
- the gallbladder will not be visualized due to the obstruction by a radio tracer
- ultrasound findings = gallbladder wall thickening, pericholecystic fluid, and a + Murphy sign
Cord Factor by Mycobacteria
- establishes virulence through neutrophil inhibition,
- mitochondrial destruction
- induced release of TNF
Diffuse Esophageal Spasm
- several segments of the esophagus contract inappropriately at the same time which appears as disorganized non-peristaltic contractions on esophageal manometers and corkscrew esophagus on barium
- pathogenesis = impaired inhibitory neurotransmission within the esophageal my enteric plexus
Lymph Node drainage
Above the dentate line = inferior mesenteric and internal iliac lymph nodes
Below the dentate line = inguinal nodes
Mesothelioma
- dyspnea and chest pain
- hemorrhagic pleural effusions are usually present
- Nodular or smooth pleural thickening with the lung parenchyma intact
- histopathology = tumor cells with numerous long slender micro villi and abundant toon filaments
- use pancytokeratin as immunohistochemical marker
Indicator of Obestity induced Restrictive Lung Disease
- reduction in expiratory reserve volume due to increased respiratory rates with reduced tidal volumes
- obesity has minimal effect on residual volume but FRC is the sum of RV + ERV
- so FRC is markedly decreased
Ecthyma gangrenosum
- cutaneous necrotic disease with a strong association with Pseudomonas
- occurs from peri vascular invasion and release of tissue-destructive exotoxins causing vascular destruction and insufficient blood flow to patches of skin that become edematous and necrosis
- pseudomonas infections are common in patient that are neutropenia, hospitalized, have burns or indwelling catheters
Acute Cholecystitis
- caused by gallstones obstructing the cystic duct
- the gallbladder will not be visualized due to the obstruction by a radio tracer
- ultrasound findings = gallbladder wall thickening, pericholecystic fluid, and a + Murphy sign
Cord Factor by Mycobacteria
- establishes virulence through neutrophil inhibition,
- mitochondrial destruction
- induced release of TNF
Diffuse Esophageal Spasm
- several segments of the esophagus contract inappropriately at the same time which appears as disorganized non-peristaltic contractions on esophageal manometers and corkscrew esophagus on barium
- pathogenesis = impaired inhibitory neurotransmission within the esophageal my enteric plexus
Lymph Node drainage
Above the dentate line = inferior mesenteric and internal iliac lymph nodes
Below the dentate line = inguinal nodes
Mesothelioma
- dyspnea and chest pain
- hemorrhagic pleural effusions are usually present
- Nodular or smooth pleural thickening with the lung parenchyma intact
- histopathology = tumor cells with numerous long slender micro villi and abundant toon filaments
- use pancytokeratin as immunohistochemical marker
Indicator of Obestity induced Restrictive Lung Disease
- reduction in expiratory reserve volume due to increased respiratory rates with reduced tidal volumes
- obesity has minimal effect on residual volume but FRC is the sum of RV + ERV
- so FRC is markedly decreased
Ecthyma gangrenosum
- cutaneous necrotic disease with a strong association with Pseudomonas
- occurs from peri vascular invasion and release of tissue-destructive exotoxins causing vascular destruction and insufficient blood flow to patches of skin that become edematous and necrosis
- pseudomonas infections are common in patient that are neutropenia, hospitalized, have burns or indwelling catheters
Acute Cholecystitis
- caused by gallstones obstructing the cystic duct
- the gallbladder will not be visualized due to the obstruction by a radio tracer
- ultrasound findings = gallbladder wall thickening, pericholecystic fluid, and a + Murphy sign
Cord Factor by Mycobacteria
- establishes virulence through neutrophil inhibition,
- mitochondrial destruction
- induced release of TNF
Diffuse Esophageal Spasm
- several segments of the esophagus contract inappropriately at the same time which appears as disorganized non-peristaltic contractions on esophageal manometers and corkscrew esophagus on barium
- pathogenesis = impaired inhibitory neurotransmission within the esophageal my enteric plexus
Lymph Node drainage
Above the dentate line = inferior mesenteric and internal iliac lymph nodes
Below the dentate line = inguinal nodes
Mesothelioma
- dyspnea and chest pain
- hemorrhagic pleural effusions are usually present
- Nodular or smooth pleural thickening with the lung parenchyma intact
- histopathology = tumor cells with numerous long slender micro villi and abundant toon filaments
- use pancytokeratin as immunohistochemical marker
Indicator of Obestity induced Restrictive Lung Disease
- reduction in expiratory reserve volume due to increased respiratory rates with reduced tidal volumes
- obesity has minimal effect on residual volume but FRC is the sum of RV + ERV
- so FRC is markedly decreased
Ecthyma gangrenosum
- cutaneous necrotic disease with a strong association with Pseudomonas
- occurs from peri vascular invasion and release of tissue-destructive exotoxins causing vascular destruction and insufficient blood flow to patches of skin that become edematous and necrosis
- pseudomonas infections are common in patient that are neutropenia, hospitalized, have burns or indwelling catheters
IL-2 Activity
- produced by Helper T cells and is the major growth factor for T lymphocytes
- stimulates the growth, differentiation, and survival of antigen-specific CD4 T cells and CD8 T-cells
- also promotes the growth of B cells and activates natural killer cells and monocytes
- Increased activity of T cells and NK cells are thought to be responsible for IL-2’s anti-tumor effects
- IL-2 is currently used as immunotherapy for metastatic melanoma and renal cell carcinoma
GERD histology finding
- basal Zone hyperplasia
- elongation of the lamina propria papillae and scattered eosinophils and neutrophils
Inferior Wall of the Heart
- supplied by the right coronary artery
- lead 2,3, AVF
Ecological Studies
- unit of analysis is populations and not individuals
- the frequency of a given characteristic and a given outcome are studied using population data
- useful for generating hypotheses but should not be used to make conclusions regarding individuals within these populations
Other EBM things to know
- Nested case control designs = start with cohort studies in which participants are followed over time and those participants who develop an outcome of interest become cases for a case-control study
- Qualitative Studies = use focused discussion groups, interviews, and other anthropological techniques to obtain narrative information that can be crucial in explaining quantitative results
Bisphosphonate
- have a similar structure to pyrophosphate and attach to hydroxyapatite binding sites on bony surfaces preferentially binding in areas of increased bone turnover
- induce osteoclast apoptosis
CCB
- The SA and AV node undergo diastolic depolarization during phase 4 due to a slow, inward sodium current
- verapamil slows the diastolic depolarization that occurs in phase 0 and the latter part of phase 4 = SA and AV node
- in cardiac muscle cells it decreases the excitation and contraction coupling
- pay attention to the CELL specified
Bradykinin
- hormone produced by the kidney
- acts locally to constrict veins and dilate arterioles to increase renal perfusion
Foscarnet
- pyrophosphate analog that is sometimes used for ganciclovir-resistant CMV infections
- can chelate calcium
- can cause renal hypomagnesemia and a reduction in the release of PTH which contributes to hypocalcemia
- the hypocalcemia and hypomagnesemia promotes seizures
Skull exits for the cranial nerves
Pg 475
Remember CN 5 mandibular exits through the foramen ovale
CN 5 maxillary exits through foramen rotund up
Ataxia Telangiectasias
- increased risk of sinopulmonary infections that constitute a characteristic triad of ataxia telangiectasia = cerebellar ataxia, Telangiectasias, and increased risk of sinopulmonary infections
- talengiectasia - superficial blanching nests of distended capillaries on sun exposed areas of the skin
- autosomal recessive inheritance
- defect in gene that codes for ATM gene that plays a role in DNA break repair
- the immune deficiency manifests as an IgA deficiency that predisposes to infections of the upper and lower airways
Patients with HIV
- headaches, seizures, and multiple ring enhancing CNS lesions on MRI = toxoplasmosis encephalitis
Horners Syndrome + Muscle weakness in ipsilateral arm
Think Pancoast tumors
Spinal accessory nerve
- made of fibers from cranial and cervical spinal nerve roots
- passes through the posterior triangle of the neck and provides innervation to the SCM and trapezius
- lesion = impaired abduction of the arm above horizontal and drooping of the shoulder
Polio vaccines
- The live attenuated Sabin vaccine produces a stronger mucosal secretory IgA immune response than the inactivated poliovirus vaccine
Glossopharyngeal Nerve
- causes loss of sensation in the upper pharynx, posterior tongue, tonsils, and middle ear cavity, and loss of taste sensation of the posterior third of tongue
Ethics
- Physicians are not required to provide medical services against their personal beliefs
- once a patient physician relationship is made the physician can refer the patient to another provider who can perform the requested medical service
- physicians should respond to disclosure of past sexual abuse with empathy and concern. Clearly acknowledging the trauma and communicating willingness to discuss it when the patient is ready
Possible Triggers for Prinzmetal angina
- cigarette smoking
- cocaine/amphetamines
- dihydroergotamine/Triptans = constricts vascular smooth muscle via stimulation of both alpha-adrenergic and serotonergic receptors
Heart Failure contributions
- RAAS activation and SNS activation results in increased after load, excessive fluid retention and deleterious cardiac remodeling
Places most susceptible to atherosclerosis
- lower abdominal aorta and coronary arteries
Candida
- Germ tubes at 37 degrees Celsius
Calcium efflux from cardiac cells prior to relaxation
- mediated by the Na/Ca exchange pump and Sarcoplasmic reticulum Ca-ATPase pump
Rifaximin
- nonabsorbable antibiotic that alters GI flora to decrease intestinal production and absorption of ammonia = decreases intra luminal ammonia production
- lactulose = increases conversion of ammonia to ammonium
Eosinophilic Damage
- major basic protein released by eosniophils normally functions to kill helminths
- it is also though to contribute to the bronchial epithelial damage sustained by patients with atopic (extrinsic allergic asthma)
Campylobacter
- can get from exposure to domestic animals (cattle, chickens, dogs) or contaminated food
Vibrio parahemolyticus = transmitted by contaminated shellfish
Exacerbation of myasthenia Travis
In a patient treated with long acting acetylcholinesterase inhibitors occurs due to myasthenic or cholinergic crisis
- The edrophonium (tension) test helps to differentiate
- Clinical improvement after the test indicates that the patient is under treated
Prokaryotic DNA polymerase
DNA Poly 1 = has both 5’–>3 ‘ and 3–>5’ exonuclease activity = which means it can remove the RNA primer created by RNA primate and repair damaged DNA sequences
DNA Poly 3 = only has 3’–>5’ activity
Multi factorial Inheritance
- the complex interaction of numerous genetic and environmental factors to determine phenotypic expression
- although the exact inheritance risk cannot be determined, the closer a relative is to the affected person, the more likely the relative is to develop the trait
Group B S. Agalacticae treatment
- Universal prenatal screening for group B strep colonization by vaginal-rectal culture at 35-37 weeks gestation is recommended to identify colonized women who require intrapartum antibiotics, most frequently with penicillin or ampicillin to prevent neonatal GBS sepsis pneumonia and meningitis
Don’t give penicillin earlier than 35 weeks because it will clear from the females system and can still come back again before delivery
Spread of different Bacteria
N. Meningitidis –> Pharynx -> blood -> choroid plexus -> meninges
H. influenza –> Pharynx -> lymphatics -> meninges
M. Tuberculosis –> primary lung focus –> blood –> meninges
Statins
- when it comes to Statins = hepatotoxicty is more of a fear than muscle
- so check LFT’s first before checking serum creatinine (for renal failure)
COPD and Fibrosis
The work of breathing is minimized in patients with increased elastic resistance when their respiratory rate is high and tidal volume is low
- patients with diseases that increase airflow resistance breathe at a lower rate/higher tidal volume in order to minimize the work of breathing
What drug helps with hair growth?
Finestaride
Dopamine Hydroxylase Deficiency
- causes dysautonomia which is ptosis, orthostatic hypotension, hypoglycemia, and hypothermia
Bacillus Anthracis
- found in soil and able to survive past the boiling point of water
At 100 - spore forming bacteria are able to survive high temperatures, desiccation, and chemical agents by forming spores
- Spore forming bacteria can be killed by autoclave
Atropine
- reverses the muscarinic symptoms of organophosphate poisoning but has no nicotinic effects
- so patients treated with atropine are still at risk of muscle paralysis
Alpha-1 antitrypsin
- associated with reddish-pink, periodic acid-Schiff positive granules of un-secreted polymerized AAT in the peri portal hepatocyte
Frontal Lobe lesions
- Left sided lesions = are associated with apathy and depression
- Rightsided lesions - disinhibition of behavior
Ureter blood supply
- proximal ureter to the kidney = renal artery
- distal ureter close to the bladder = superior vesical artery
- circulation to the middle portions are highly variable
Fat emboli in the pulmonary vasculature stain black with osmium tetroxide
TCA
-have anti muscarinic side effects = confusion, constipation, and urinary retention
Amityrptiline
Long Half life’s of Benzodiazepene
- chlordiazepoxide
- diazepam
- flurazepam
Intermediate half life = Alprazolam and Clonazepam
Short half life = Triazolam
Benzos that are preferred in patients with impaired hepatic metabolism that undergo glucoronidation directly and are not dependent on hepatic enzymes = Lorazepam, oxazepam, temazepam
Parkinson’s Disease On-Off phenomenon
- thought to be a consequence of progressive nigrostriatal neurodegeneration leading to a decreased therapeutic window for levodopa
- unpredictable
- this phenomenon does not resolve
Bilateral Anterior Cerebral Artery Occlusion
- behavioral symptoms (Abulia)
- urinary incontinence = micturition center = medial frontal lobe/cingulate gurus
Atropine
- can cause acute closed angle glaucoma by narrowing of the anterior chamber angle and diminished outflow of aqueous humor
First line treatment for essential tremor
- nonspecific Beta adrenergic antagonist
Myotonic Dystrophy
- autosomal dominant disorder
- increased number of trinucleotide repeats on myotonia proteins kinase gene
- sustained muscle contraction, along with weakness and atrophy
- cataracts are seen in almost all patients
- frontal balding and gonadal atrophy are other common features
Increasing Diffusion Rate
- increased with temperature due to increased molecular movement speed and increased macromolecule solubility
- larger membrane surface areas
- increased solubility of the diffusing substance
Neprilysin
- a metalloprotease that cleaves and I activates endogenous peptides including natriuretic peptides glucagon, oxytocin, and bradykinin
Herpesvirus Family
- the herpesvirus family bud through and acquire the lipid bilateral envelope from the host cell nuclear membrane
- But overall most enveloped nucleocapsid viruses acquire their lipid bilateral envelope by budding through the plasma membrane of the host cell
Nitrates
- patients taking daily maintenance nitrates need to have a nitrate free period every day to avoid tolerance to the drug
Delirium
- may manifest as acute changes in cognition and behavior
- low dose antipsychotics (haloperidol) are the medications of choice to treat the behavioral and psychotic manifestations of delirium
- do not give benzo’s because it can worsen the state unless it is in the case of alcohol withdrawal
Anti-Arrhythmics
Use dependence describes the phenomenon in which higher rates of depolarization leads to increased sodium channel blockade due to the channels spending less time in the rating state
- For Class 1 = sodium channel binding strength is 1C>1A>1B
- class 1C demonstrates the most use dependence and class 1B has the least
Bilateral Renal Artery Stenosis
- GFR is dependent on Angiotensin 2 mediated efferent arteriolar vasoconstriction in RAS
- ACE inhibitors or A2 receptor inhibitors will cause efferent arteriolar vasodilation that causes the GFR to fall and may lead to the development of acute renal failure
Features that Aid in Localizing a Transverse Spinal Cord
- moving roster ally spinal levels have increasing amounts of white matter, decreasing amount of gray matter and are more oval shaped
- lower cervical and limbo sacral regions have larger ventral horns because they innervated the limbs
- Thoracic and early lumbar sections contain lateral gray matter horns
- Gracile and cuneate fasiculiare present above the T7 spinal level, whereas only the gracile Fasciculus is present below this level.
Meningitis
- their outer membrane LOS is the same as LPS and it accounts for the morbidity and mortality in infected people
Rat Poison
- Same thing as warfarin
- to treat an overdose very quickly you must give fresh frozen plasma and also vitamin K
- FYI heparin overdose is treated with protamine sulfate
H. Influenza
- blood loving organism that gets its NAD+ from co-culture with S. Aureus and demonstrates the satellite phenomenon
K+ sparing diuretics
- work on the collecting duct = Late distal tubule and cortical collecting duct
Spontaneous intracranial hemorrhage
- most common cause in young adults are AV malformations, ruptured cerebral aneurysms, or sympathomimetic drugs like cocaine
- this can also occur due to coarctation of the aorta causing high pressures in the brain
Insulin Types
- Short acting insulin = best for post-meal hyperglycemia
- Regular insulin = best for DKA
- NPH = is given twice a day
- long acting insulin analogs = are best for basal levels
Renal Facts
- Drug induced tubular necrosis = aminoglycosides, radio contrast media, cisplatin, amphotericin B, and foscarnet
- Drug induced tubular obstruction may be due to intra tubular precipitation of tissue degradation products drugs, or drug metabolites ==> sulfonamides, methotrexate, IV acyclovir, and triamterene = can precipitate in renal tubules and cause renal failure
- Acute allergic interstitial nephritis = methicillin, cephalosporins, Acetozolamide, allopurinol, sulfonamides, and NSAIDs
- Chronic allergic interstitial nephritis = lithium and cyclosporine
ACE inhibitors can be bad by precipitating acute renal failure in those that have atherosclerotic disease and are dependent on efferent arterioles constriction to maintain renal perfusion (renal artery stenosis)
Subarachnoid Hemorrhage
- patients that survive the initial subarachnoid hemorrhage can have a number of complications
- some may develop secondary arterial vasospasm = this vasospasm occurs in the vessels surrounding the ruptured aneurysm
- the secondary vasospasm causes cerebral ischemia which presents as new-onset confusion and focal neurological deficit
- severe vasospasm 4-12 days after the initial insult is the major cause of morbidity and mortality in patients recovering from SAH
Rebleeding can also occur
- symptoms include the sudden development of a severe headache, severe nausea and vomiting, a change in the level of consciousness and the appearance of new neurological deficits
- if rebleeding occurs the CT scan can identify the newly extravasated blood
Toxic Shock Syndrome
- S. Aureus creates superantigen that activates large numbers of helper T cells
- super antigens interact with major histocompatibility complex molecules on antigen presenting cells and T cell raptors to cause a widespread activation of T lymphocytes
- activation of T cells is responsible for the release of IL2 from the T cells and IL-1 and TNF from macrophages
- these IL’s cause capillary leakage, circulatory collapse, hypotension, shock, fever, skin findings, and multi organ failure
Antipsychotic Side Effects
Extra pyramidal
- Acute dystonic reaction = sudden onset of sustained muscle contractions
- Akithisia = subjective restlessness with inability to sit still or stand in one position
- Drug induced Parkinsonism = tremor, rigidity, bradykinesia, masked facies
Tardive Dyskinesia
- involuntary movements after chronic use (ex: lip smacking, choreoathetoid movements)
- this is the only side effect that can worsen or persist following medication discontinuation
Neuroleptic malignant syndrome
- Fever, rigidity, mental status changes, autonomic instability
Lung Transplantation
Acute rejection = pulmonary and bronchial vessels are targets
Chronic rejection = small airways are affected causing bronchiolitis obliterans (inflammation and fibrosis of the bronchiolitis walls lead to narrowing and obstruction of the affected bronchioli)
Important
Cancers of the pelvis including the prostate spread to the lumbosacral spine via the vertebral venous plexus
= this is why the brain is the first metastasis site when it comes to prostate cancer
Respiratory acidosis
Acute = heroin overdose that causes Hypoventilation
Chronic = COPD allows enough time for renal compensation
Trigeminal Neuralgia
- Carbamezapine is the drug of choice
- Baclofen and Valproic acid are second line
The main cause of overdose death
Opioids = #1
Heroin = #2
Prescription Analgesics = #3
Pericarditis
Acute due to viral infection = friction rub
Constrictive pericarditis = kussmaul breathing and pericardial knock
- requires months or years to develop
LPS
In gram negative species is a very long heat stable molecule arranges into three regions
O antigen = cell wall outer membrane polysaccharide antigen used to classify gram negative bacteria
Core polysaccharide
Lipid A = responsible for the toxic properties of LPS that lead to gram negative sepsis and endotoxins septic shock. Causes widespread activation of macrophages leading to the widespread release of IL-1 and TNF-alpha
LPS is not actively secreted by bacteria
Tamoxifen
A selective estrogen receptor modulator used in the treatment of estrogen receptor positive breast cancer
- it is a prodrug metabolized by CYP2D to its active metabolite endoxifen
- patients with genetic polymorphism a resulting in poor CYP2D activity are exposed to decreased levels of the active metabolite and have a higher risk of disease relapse
Treatment for Transient Ischemic Attack
- blood pressure control
- statin
- low dose aspirin which selectively inhibits COX1 and can increase risk of GI bleeding
Nitric Oxide
Is found in the cortex, hippocampus, hypothalamus, cerebellum and olfactory system and is thought to participate in the formation of new memories
- it is a unique neurotransmitter because it freely diffuses across cell membranes and does not need to interact with other neurons via a synapse
Heart Failure cells
Hemosidierin macrophages
- macrophages containing golden cytoplasmic granules that turn dark blue with Prussian blue staining
- this means left ventricular dysfunction
- macrophages eat the red blood cells that come into the blood
Choleliathisis in Pregnancy
- Pregnancy and the usage of OCP’s predispose to gallstone formation
- Estrogen increases cholesterol synthesis by up regulating HMG-CoA reductase which causes the bile to become supersaturated with cholesterol
- Progesterone reduces bile acid secretion and slows gallbladder emptying
Gallstones are increased in women that are fat, fertile, female, and forty
Bacterioides Fragilis
- apart of the normal colonic flora
- can form abscesses within the GI tract
Pudendal nerve Block
- performed by injecting an anesthetic intravaginally
- medial to the ischial spine and through the sacrospinous ligament
- this provides anesthesia to most of the perineum
Lyme disease in pregnant women
- Ammoxicillin should be given instead of Doxycycline due to teratogenic effects
Important
- Never give a patient both an SSRI and a MAO inhibitor
- this is due to the risk of serotonin syndrome
This is why Patients must wait at least 2 weeks after MAO inhibitor discontinuation before initiating SSRI therapy allowing enough to time for regeneration of MAO
Cleft Lip and Cleft Palate
Cleft Lip = maxillary prominence fails to fuse with the intermaxillary segment during the 5th-6th week of development
Cleft Palate = palatine shelves fail to fuse with one another or with the primary palate.
Cleft lit and palate can occur together or in isolation
Protein Structue
Primary = covalent peptide bonds
Secondary = alpha helix or beta sheet with hydrogen bonding
Tertiary structure = overall shape a single polypeptide chain makes after compaction from secondary structure (ionic bonds, hydrophobic interactions, hydrogen bonds, and disulfide bonds
Liver Can’t use Ketone bodies
- Lacks the succinyl CoA transferase enzyme (thiophorase) to convert the ketone body to acetoacetyl CoA
S. Pyogenes
- Pyrrolidonyl arylamidase positive
Neutropenic Patients
- are at high risk for viral and fungal infections
- the most common fungal causes are Aspergillus and candida species
- invasive pulmonary aspergillosis presents with some combo of fever, chest pain, cough, dyspnea, and hemoptysis
Important
Changes in host range are most commonly caused by a mutation in the viral encoded surface glycoproteins that mediates virion attachment to targets host cell plasmalemma receptors
Nicotinic Receptors
- a type of inotropic receptor that doesn’t depend on 2nd messenger
- these receptors are ion channels that are comprised of 5 subunits with 2 ACh binding sites.
- if and only if both binding sites are filed, the ion channel will open
If a person is infected with Hep B
- and they have acute hepatitis with mild or sub clinical symptoms
- they will eventually completely resolve
3 types of Hep B infections
- acute hepatitis with complete resolution (>95 of cases)
- fulminant hepatitis with massive liver necrosis
- chronic hepatitis with or without cirrhosis
Normal Aging in the Heart
- include a decrease in left ventricular chamber apex to base dimension
- development of a sigmoid shaped ventricular septum
- myocardial atrophy with increased collagen deposition
- accumulation of cytoplasmic lipofuscin pigment within cardiomyocytes
Candida Infection
- Local defense = superficial infection is by T lymphocytes
- hematogenous defense for disseminated candidiasis = neutrophils
Kozak Sequence
- occurs on eukaryotic mRNA and is defined by gccRccAUGG in which R is either adenine or guanine. This sequence helps initiate translation at the methionine start codon.
Bleeding in Pateints kidney disease (Uremia)
Renal failure
- the accumulation of uremic toxins in the circulation impair platelet aggregation and adhesion resulting in a qualitative platelet disorder that only prolongs bleeding time
- Uremic bleeding can be improved with dialysis because it removes the toxins and partially reverses the bleeding abnormality
Acute Chest Syndrome
Occurs in sickle cell patients
- due to vaso-occlusive crisis localized to the pulmonary vasculature
-
Inflammatory Leukocyte Accumulation Steps
- Margination = increased vascular leakage in the micro vasculature leads to hemoconcentration and decreased wall shear stress, improving the contact of neutrophils with the endothelial lining
- Rolling = Neutrophils roll on the endothelium via the loose binding of sialylated carbohydrate groups to L-selectin on neutrophils or E-selecting/P-selection on endothelial cells. Cytokine stimulation increases expression of endothelial selectins
- Activation: slow rolling allows the leukocyte to sample the chemokines secreted by the inflamed tissue. This activates the integrins by inducing a signaling cascade that results in a conformational change in the integrins necessary for binding
- Tight adhesion and crawling: neutrophils become firmly attached to the endothelium via the binding of CD18 beta 2 integrins (Mac-1 and LFA1) to intercellular adhesion molecule 1 (ICAM-1) on endothelial cells
- Transmigration: after crawling to the endothelial cell periphery, neutrophils eventually migrate out of the vasculature by squeezing in between the cells via integrin attachments and adherence to platelet endothelial cell adhesion molecule 1 (PECAM-1). This protein is found primarily at the peripheral intercellular junctions of endothelial cells.
Dermatomyositis
- proximal muscle weakness
- heliotrope rash in the perioorbital area and cheeks along with got rods papules on the hands
- has a strong association with malignancy (lung, colorectal, and ovarian cancer)
Theophylline Intoxication
- Seizures are the major cause of morbidity and mortality
- Tachyarrhythmias are the major concern but do not usually cause QT prolongation
Treatment of theophylline intoxication includes administration of activated charcoal to reduce GI absorption.
Beta blockers are the drug of choice for theophylline induced Tachyarrhythmias
Seizures can be treat with benzo and barbituates
SAH
Sub arachnoid hemorrhage has a risk of vasospasm due to blood breakdown (4-10 days after hemorrhage)
= giving a patient a CCB can help in preventing these symptoms
Penicillins
Inhibit transpeptidases by binding covalently to their active site
Acute Compartment Syndrome
Most common in the anterior compartment of the leg
= includes the foot extensor muscles, anterior tibial artery, and the deep peroneal (fibular) nerve
- Injury to the deep peroneal nerve causes decreased sensation between the first and second toes, decreased dorsiflexion of the foot, foot drop, and claw foot
Health Risk Assessment
A questionnaire that uses demographic, medical, lifestyle, and family history information to calculate a patients risk age.
- A patient whose risk age is greater than chronological age has a higher risk of death than the average individual of that chronological age
Antioxidants
Superoxide dismutase in as an antioxidant that neutralizes reactive oxygen species, preventing cell injury
Placement of a Tracheal Tube
Between the superficial cervical fascia and cricothyroid membrane
It goes through the following structures
- Skin
- Superficial Cervical Fascia (including subcutaneous fat and platysma muscle)
- Investing and pre tracheal layers of the deep cervical fascia
- Cricothyroid membrane
Capitation
An arrangement in which a payor (individual, employer, or government entity) pays a fixed determined fee to cover all medical services required by a patient
- payment structure in HMO’s
- the payor can directly negotiate a capitated contract with an insurance company that then pays the providers, or a large medical group may negotiate directly with the payor
Lithium Toxicity
Can occur from thiazides, NSAIDs, or ACE inhbitors
Differentiating Between DIC and TTP
- both have schistocytes
- in DIC everything will be increased including PT, PTT, and BT
- in TTP only Bleeding Time will be increased
Transference
- unconscious shifting of emotions or desires associated with a person from the past to another person in the present
Cystathione Deficiency
Can present as marfinoid habits due to homocystinuria
= supplement B6 in diet
Affected people have marfinoid habitus, ectopia lentis, and development delay. High risk of thromboembolism
Opening Snap of Mitral Stenosis
- will get worse when A2 and OS gets closer together
- this tells you that the pressures in the left atria are very high
Emetic Center of the Brain
Area Postrema
- lies in the dorsal medulla near the fourth ventricle
Recombination vs. Reassortment
Recombination = exchange of genes between 2 chromosomes via crossing over within homologous regions. The resulting proveny will have recombined genomes with traits not present simultaneously in either parent virus = nonsegmented virus = 2 dsDNA strands
Reassortment = genetic composition that occurs when host cells are coinfected with 2 segmented viruses that exchange whole genome segments. (I.e. Influenza)
Propofol and other highly lipophilic drugs
- readily diffuse across membranes quickly accumulating in tissues receiving high blood flow, this accounts for their rapid onset of action.
- these compounds are then distributed to organs receiving less blood flow, which explains their short duration of action
Ganciclovir Therapy
- neutropenia is a significant adverse effect and is increased with co-administration of zidovudine or TMP-SMX
Graves Disease Exopthalmos
High dose glucocorticoids like prednisone are used to control severe Grave’s opthalmopathy
- they are helpful in decreasing the severity of inflammation and decreasing extra ocular volume
= Conventional anti thyroid drugs do not improve this
Acyclovir
- can cause crystalline nephropathy if adequate hydration is not provided
How to avoid wrong site surgery?
- Mark the operative site
- independent verification of the patient, procedure, and site by 2 health care workers (nurse and physician) should be performed
- the dual identifiers must perform the verification independently because 2 clinicians verifying identifiers together can result in replicating an error
- surgical timeout before the procedure in order to conduct a final verification of the patient, procedure and site
Important
When atherosclerotic occlusion develop slowly over time there can be compensation by the development of arterial collateral around the point of occlusion
- the collateral circulation can provide flow to the hypoperfused areas distal to the point of occlusion
Thin fibrous cap and increased lipid core and active inflammation = more likely to rupture
Lipofuscin
Yellow brown finely granular perinuclear pigment = produce of free radical injury and lipid peroxidation
= aging
Tuberculosis
Active TB is never treated with drug mono therapy due to the fast emergence of mycobacterial antibiotic resistance from rapid, selective gene mutations
- Isoniazid mono therapy may be used for patients who have a positive PPD and a negative chest X Ray
Medical Conditions that present as Anxiety
- hyperthyroidism
- hypoglycemia
- Pheochromocytoma
- hypercortisolism
- cardiac arrhythmia
Integrins
Bind to specific proteins = collagen, fibronectin, and laminins, cadherins, selectins, and Ig superfamily members
Aspergilloma
Colonize and develop in old lung cavities from TB, emphysema, and sarcoidosis
- forms fungus ball without lung tissue invasion
- radiopaque structure that shifts when the patient changes position
- might cause cough and hemoptysis
Q fever
- myalgia, fatigue, Fever >10 days
- retroorbital headache with a normal leukocyte count
- thrombocytopenia and increased liver enzymes
Tetralogy of Fallot
The degree of right ventricular outflow tract obstruction is the major determinant of the degree of right to left intra cardiac shunting and resultant cyanosis
G protein receptors and integral membrane proteins
Contain transmembrane domains composed of alpha helicase with hydrophobic amino acid residues (alanine, valine, isoleucine, phenylalanine, tryptophan, methionine, proline, glycine)
= these transmembrane domains help anchor the protein to the phospholipid bilayer of the cell membrane
Heparin
Both unfractionated heparin and LWMH (enoxaparin) can bind to antithrombin to increase its activity against Factor 10a
= but only unfractionated heparin is able to bind to both antithrombin and thrombin to allow antithrombin to inactivate thrombin
Obstructive Lesion in a Mainstem bronchus
Can prevent ventilation of an entire lung leading to obstructive atelectasis and complete lung collapse
Chest X Ray will show unilateral pulmonary opacification and deviation of the mediastinum toward the pacified lung
Demyelination Principles
Length constant = space constant
- measure of how far along an axon an electrical impulse can propagate
- demyelination will decrease the length constant and result in impaired stimulus transmission
HbS
Valine substitution promotes hydrophoic interaction among Hb molecules and results in HbS polymerization and erythrocytes sickling
Hydralazine Side Effect
- Reflex Sympathetic Activity
- causing fluid retention
Don’t give to angina/CAD patients - lupus like syndrome
LAD reconstruction
- if just one = use left internal mammary (thoracic) artery
- if multiple arteries need reconstruction = breath sap heinous vein
Great saphenous vein it’s located inferolateral to the pubic tubercle
- coarses anterior to the medial malleolus
Femoral triangle
- inguinal ligament superiority
- sartorious muscle laterally
- adductor long us muscle medially
Cystic Fibrosis AGAIN
In Respiratory and Gastric Glands
- impaired functioning of the CFTR protein reduces luminal chloride secretion and increases sodium and net water absorption, resulting in dehydrated mucus and a more negative transepithelial potential difference
In sweat glands
- abnormal CFTR function causes reduced salt absorption, leading to the production of hypertonic sweat with high chloride content.
Allergic Bronchopulmonary Asperfillosis
- occurs in 5-10% of corticosteroid dependent asthmatics
- patient have high serum IgE levels, eosinophilia, and IgE plus IgG antibodies to Aspergillus
- there is intense airway inflammation and mucus plugging with exacerbations and remissions
- repeated exacerbations may produce transient pulmonary infiltrates and proximal bronchiectasis
Polysaccharide capsular vaccines
- S. Pneumonia
- H. Influenza
- N. Meningitidis
Hepatocellular Carcinoma
- World wide, the countries that have high rates of hepatitis B virus (HBV) infection have more than 85% of all Hepatocellular carcinoma cases.
- The people that develop HCC in these countries usually have chronic HBV infection acquired through vertical transmission at childbirth, which increases their risk of developing HCC by early to middle adulthood 200-fold
- In these countries with high rates of HBV infection, HCC commonly presents in adults 20-40 years old
- So universal vaccination of children against HBV would be the one measure most likely to cause a steep decline in the incidence of Hepatocellular carcinoma worldwide
Primary Aldosteronism
- Hypernatremia never occurs due to aldosterone escape
ARea postrema
- the central emetic center is in the dorsal surface of the medulla at the caudal end of the 4th ventricle
IV drugs
Highly lipophilic drugs
- it is rapidly cleared from the plasma and preferentially distributed to organs receiving high blood flow (Brain, heart, liver, and kidneys)
- this initial distribution accounts for the rapid onset of sedation seen with administration
- over time propofol is redistributed to. Organs receiving less blood flow (skeletal muscle and skin)
- then lastly bone, adipose and connective tissue
IV anesthetics are eliminated through the liver
Inhaled anesthetics are eliminated through the lungs
The neuromuscular blocking agents spontaneously degrade in plasma and organ tissue, a type of metabolism known as Hoffman elimination
TMP-SMX
Is associated with bone marrow suppression
The treatment of Choice for Diabetic Ketoacidosis
- IV normal saline and insulin
- these therapies increase serum bicarbonate and sodium and decrease serum glucose, osmolarity and potassium
PCR
Used to amplify small fragments of DNA
- you first need a source DNA template that includes the target region to be amplified as well as flanking sequences adjacent to the target region
- the oligonucleotide sequence of these flanking regions must be known in order to make the primers necessary to start PCR
Left or Right nasal hemianopia
Will occur with aneurysm from internal carotid artery
- will cause ipsilateral nasal hemianopia by damaging uncrossed optic nerve fibers from the temporal portion of the retina
Calcium Channel Blocker Side effects
Include headache, flushing, dizziness, and peripheral edema
- development of peripheral edema occurs due to preferential dilation of pre capillary vessels (arteriolar dilation) this leads to increased capillary hydrostatic pressure and fluid extravasation into interstitium
Abdominal Aortic Aneurysms
Characterized by Transmural inflammation of the aortic wall
- chronic inflammation leads to degradation of elastin and collagen by proteases, resulting in loss of elastin and smooth muscle cells and abnormal collagen remodeling and cross-linking
- These changes lead to weakening and progressive expansion of the aortic wall resulting in aneurysm formation
Middle episiotomy
The perineal body is a fibrous ulnar tissue between the urogenital and anal triangle
- a midline episiotomy is a vertical incision from the posterior vaginal opening to the perineal body
- it transacts the vaginal submucosal tissue but not the external anal sphincter or the rectal mucosa
Nafcillin, Oxacillin, Methicillin, and Dicloxacillin
- Have bulky R groups that prevents Beta Lactamases
- the only way resistance can be conferred is if there is altered penicillin binding proteins which are resistant to the drug
- the penicillin binding protein is where it binds
Low Vd (3-5L)
- characteristics of a drug such as high molecular weight, high plasma protein binding, high charge, and hydrophilicity tend to trap the drug in the plasma compartment
Heparin Overdose
You can’t give fresh frozen plasma because it contains antithrombin 3 which enhances heparin effect
Give protamine = effective
Pre tibial Myxedema
Will cause lower leg skin thickening and induration
- seen in hyperthyroidism due to grave’s disease
Carpal Tunnel Syndrome
Associated with conditions that reduce carpal tunnel space, including pregnancy (fluid accumulation), hypothyroidism (GAG buildup), diabetes (connective tissue thickening), and rheumatoid arthritis (tendon inflammation)
- patients with a long history of hemodialysis can also develop median nerve compression through deposition of Beta 2 microglobulin in the carpal tunnel
Rickettsia and Chlamydia
Are intra cellular organisms because they can’t make their own ATP
Obligate Anaeorobes
Lack catalase and Superoxide dismutase
Mycobacterium Kasasii
Pulmonary TB-like symptoms in COPD patients
Mycobacterium scrofulaceum
Causes cervical lymphadenitis in children
Mycobacterium Marinum
Hand infection in aquarium
Hepatitis D
Considered replication defective because it must be coated by external coat hepatitis B surface antigen of HBV to penetrate the hepatocyte
-
CCL4 poisoning
CYP450 will produce free radicals that start a vicious cycle of hepatic injury = lipid peroxidation
CCL4 injury develops rapidly and leads to swelling of the ER, destruction of mitochondria, and increased permeability of cell membranes. This causes hepatocyte necrosis
Aspirin Toxicity
Would caused a mixed respiratory alkalosis and non anion gap metabolic acidosis so the pH would normal
Occulomotor Nerve
- Has parasympathetic fibers inside it
Uncal herniation will cause a dilated pupil
Gastric Bypass Surgery
Can cause small intestinal bacterial overgrowth (SIBO) due to excessive bacterial proliferation in the blind-ended GI segment.
SIBO results in deficiency of most vitamins (B12, A, D, and E) and iron, but increased production of folic acid and vitamin K
Varicose Veins
Can cause lower extremity edema due to venous stasis
- common complications resulting from poor blood flow include painful thromboses, stasis dermatitis, skin ulceration, poor wound healing, and superficial infections
- venous stasis ulcers often occur over the medial malleolus
- varicose vein thromboses are restricted to the superficial venous system
EBM
Reproducibility = reliability Validity = Accuracy
Common Peroneal Nerve Injury
Foot drop and stoppage gait
Recurrent C. Diff Infection Treatment
Fidaxomicin is used primarily in recurrent CDI and is bacteriocidal with minimal systemic absorption
- a macrocyclic antibiotic (related to macrolides) that inhibits the sigma subunit of RNA polymerase, leading to protein synthesis impairment and cell death
- it is an oral drug with bacteriocidal activity, minimal systemic absorption and a narrow spectrum it has less effect on normal colonic flora than either metronidazole or vancomycin
Lactase Deficiency
- elevated stool osmotic gap
- decrease in stool pH because the bacteria Ferment lactose to produce short chain fatty acids
- increase in hydrogen gas which causes flatulence
Nucleolus
All rRNA is made in the Nucleolus
Abetalipoproteinemia
- will see clear or foamy cytoplasm in the intestinal epithelium
Peripheral Neuropathy
Toxin penetration through the blood-nerve barrier leading to peripheral neuropathy occurs with diphtheria
Hyalinization of nerve arterioles is seen in diabetes mellitus (diabetic microangiopathy) = leads to the narrowing of the arterial lumen and ischemic nerve injury = one mechanism of diabetic neuropathy
Guillain barre = acute demyelination peripheral neuropathy. Segmental demyelination and an endometrial inflammatory infiltrate seen on light microscope
Digoxin
Used for ventricular rate control in atrial fibrillation as it decreases AV conduction by increasing PSNS vagal tone
- Digoxin slows the ventricular rate during atrial fibrillation by enhancing vagal tone which leads to the inhibition of AV nodal conduction
Succinylcholine
- can cause significant potassium release and life threatening arrhythmias in patients at high risk for hyperkalemia, including those with burns, myopathies, crush injuries, and denervation injuries or disease
Thiazide Diuretics
Can cause hypokalemia and lead to significant muscle weakness, cramps, and rhabdomyolysis
Cox 2
Is an inducible enzyme that is undetectable in most tissues except in cases of inflammatory cell activation
FYI COX1 creates constitutive prostaglandins
COX2 creates inducible prostaglandins
Her2
Oncogene
Tyrosine Kinase Receptor
185-kD transmembrane glycoprotein that has intra cellular tyrosine kinase activity
It is one of the epidermal growth factor receptors that play a role in the activation and control of epithelial growth and differentiation = increased rates of breast and ovarian cancer
Growth Factors that increase angiogenesis in neoplastic tissue
VEGF AND FGF
Also pro inflammatory cytokines IL-1 and IFN-gamma can indirectly promote angiogenesis through increased expression of VEGF
Roseola HHV6
Fever for 4-5 days then maculopapular rash.
Some may get seizures
Heterophile antibody negative mononucleosis like syndrome
Most likely it is cytomegalovirus
- CMV can be acquired via transfusions by leukocyte laden blood products because the virus infects leukocytes of granulocyte macrophage lineage
- other causes are HHV6, HIV, and toxoplasmosis
Tetanus Diagnosis
Pure Clinical via History and Exam
- no other way to diagnose
Pelvic Floor Muscles
Kegal exercises help strengthen the pelvic floor muscles
- levator ani = iliococcygeus, pubococcygeus, puborectalis
- these muscles hold the bladder and the urethra in the proper Anatomic position
- injury to these muscles can result in urethral hypermobility which can lead to stress incontinence
Non-small cell lung cancer
Some patients may have a chromosomal rearrangement that creates a fusion protein EML4 and ALK
THIS RESULTS IN CONSTANT TYROSINE KINASE THAT CAUSES MALIGNANCY
Supracondylar Fracture
Lateral displacement = radial nerve
Medial displacement = medial nerve and brachial artery
Telomerase
RNA DEPENDENT DNA POLYMERASE that consists of 2 components
- Telomerase reverse transcriptase
- Telomerase RNA
