UWorld 2nd time incorrects Flashcards
cafe-au-lait spots
neurofibromas
Lisch nodules (pigmented, asymptomatic hamartomas of the iris)
congenital pseudoarthritis
other associated tumors: meningiomas, astrocytomas, glioma, pheochromocytomas
NF-1 (single gene autosomal dominant on chromosome 17)
what is the mechanism of insulin resistance
phosphorylation of serine and threonine residues of insulin receptor substrate by serine kinase
the serine and threonine on the beta subunit of the insulin receptor is phosphorylated in order to decrease the cellular cascade that allows the GLUT4 receptor to come to the cell surface
-this type of phosphorylation is induced by TNF-alpha , catecholamines, glucocorticoids, and glucagon
describe the structure of the insulin receptor
2alpha nd 2beta subunits
the 2 alpha are extracellular and act as binding sites for the insulin
the 2beta subunits act as intracellular and have tyrosine binding domains that are activated when insulin binds to the alpha subunits
-the insulin receptor is the autophosphorylated and GLUT4 is transported to the membrane to allow glucose into the cell
compare and contrast polymyalgia rheumatica vs fibromyalgia
PR–> pain and stiffness in proximal muscles with fever, malaise, and weight loss. no muscle weakness. women >50. associated with giant cell temporal arteritis. symptoms get better with steroids
FM–> women 20-50. chronic widespread musculoskeletal pain associated with tender points, stiffness, paresthesias, poor sleep, fatigue, cognitive disturbance (fibro fog). treat with regular exercise, antidepressants (TCAs and SNRIs), neuropathic pain agents (gabapentin)
list the retroperitoneal organs
SAD PUCKER
Suprarenal (adrenal) glands
Aorta & inferior vena cava
Duodenum (except first part)
Pancreas (head and body) Ureters & bladder Colon (ascending and descending) Kidneys Esophagus Rectum (mid and distal)
what are the symptoms and whats the pathogenesis of multiple myeloma
SYMPTOMS: renal insufficiency, back/bone pain, normocytic anemia, hypercalcemia
PATHOGENESIS: excessive production of monoclonal immunoglobulin (paraprotein), myeloma cells replicate in the bone marrow and release cytokines to activate osteoclasts and inhibit osteoblasts (via IL3, IL7, and Wnt pathway inhibition) leading to osteolytic (radiolucent) bone lesions
myeloma cells stimulate osteoclast maturation by producing RANKL and destroying OPG
this destruction of bone leads to the hypercalcemia seen
inheritance pattern of hemophilia a, b, and c
a (8) and b (9) –> x-linked recessive
c (11) –> autosomal recessive
pt with central venous catheter and parenteral nutrition (lots of pokes into their skin) are more likely to have what fungal infection and how does it look
candida –> pseudohyphae with blastoconidia
bacterial endotoxin
lipopolysaccharide found in gram negative bacteria that is released upon cell lysis
-in blood stream it causes severe inflammatory response mediated by TNF-alpha and IL-1 secreted by macrophages
stacked brick intestinal adhesion
enteroaggregative E.coli (adhere but dont invade intesintal mucosa)
-persistant diarrhea in infants in developing countries and in those with advanced AIDS
what to look out for in patients taking second generation atypical antipsychotics
-apines –> metabolic syndrome (weight gain, diabetes, hyperlipidemia)
clozapine –> agranulocytosis
risperidone –> hyperprolactinemia (amenorrhea, galactorrhea, gynecomastia)
what should you think of if you see ANA and anti-histone antibodies and whats implicated in this
drug induced lupus erythematous
- procainamide and hydralazine are the two most common
- isoniazid, minocycline, and quinidine are also implicated
circumferential laxity of phrenoesophageal membrane
sliding hiatal hernia
phrenoesophageal membrane defect can lead to what
paraesophageal hiatal hernia (herniated gastric fundus)
bochdalek hernia
failure of posterolateral diaphragmatic foramina to fuse
- congenital hernia diagnosed pre or perinatally
- pulmonary hypoplasia with neonatal respiratory distress is common
lesser sac hernia
herniation of viscera through omental foramen (foramen of winslow) causes intraabdominal hernia
-rare and usually involve small bowel and are very painful due to bowel strangulation
most common benign liver mass
cavernous hemangioma (venous malformation)
- usually occurs b/w ages 30-50
- usually filled with thrombus and incidentally found
- biopsy contraindicated due to risk of hemorrhage
female with pulse discrepancies in upper extremities, fever, night sweats, arthritis, myalgias, skin nodules, ocular disturbances
takayasu arteritis
- granulomatous thickening and narrowing of aortic arch and proximal great vessels
- increase in ESR
- treat with corticosteroids
pseudomembranous colitis (white yellow plaques with fibrin and inflammatory cells)
clostridium difficile
what two enzymes can act on homocysteine
- methionine synthase (requires B12)
- cystathionine synthase (requires B6) –> this defect is the most common cause of homocysteinuria (causing an increase in methionine)
-note: homocysteine is prothrombotic resulting in premature thromboembolic events (atherosclerosis and acute coronary syndrome)
young pt with heart attack, what do you think?
homocystinuria or kawasakis
how is scar tissue formed
macrophages secrete TGF-beta to stimulate fibroblasts to secrete collagen and form scar tissue
major component of eosinophilic granules
major basic protein that works against helminths
what class of medication should you not prescribe to a pt who has a history of gall stones
fibrates (reduce cholesterol solubility and promote gallstone formation by reducing bile acid synthesis)
what value is used to estimate GFR
inulin
what causes lacunar infarctions
- result of small vessel occlusion (due to lipohyalinosis and microatheroma formation) in penetrating vessels supplying the deep structures of the brain
- major risk factors –> uncontrolled hypertension and DM
altered mental status, hyperthermia, lead-pipe rigidity, and sympathetic hyperactivity
neuroleptic malignant syndrome
-get within 1-3 days of a dopamine antagonist (antipsychotic medication)
mass lesion involving hypothalamus of pituitary stalk would cause an increase in what hormone
prolactin
pathogenesis of neisseria meningitidis to get to the meninges
pharynx –> blood –> choroid plexus OR cerebral capillary endothelium –> meninges
what do you give to pt who has HIV (not on medication) to stop the virus from passing onto the child
zidovudine (NRTI) –> inhibits phosphodiester bond formation
what is derived from the ventral pancreatic bud vs the dorsal pancreatic duct
ventral: uncinate process and main pancreatic duct
dorsal: body, tail, isthmus, and accessory pancreatic duct
BOTH contribute to the pancreatic head
bosentan mechanism of action
endothelin receptor antagonist
pt just had long bone/pelvic surgery
explain why they might slowly develop hypoxemia and what other symptoms you would expect
fat embolism into pulmonary arteries
-expect to see the triad of hypoxemia, neurologic abnormalities, and petechiae
- hypoxemia due to fat microglobules lodging in the pulmonary arteries
- fat-emboli associated within the CNS
- fat-emboli associated within the dermal capillaries resulting in erythrocyte extravasation and a petechial rash
what interleukin stimulates the production of eosinophils?
IL-5
what do levels of acetoacetate tell you
used as a urine test for ketones
what differentials should you think of if a pt has hypoketotic hypoglycemia after fasting for 1-2days in adults or 8-10hrs in kids
NO detectable levels of acetoacetate after low/no calorie intake
- primary carnitine deficiency
- muscle weakness, cardiomyopathy, elevated muscle triglycerides - MCAD deficiency
- acyl-CoA dehydrogenase deficiency (first enzyme used in beta-oxidation)
- seizures and sudden death
what does acyl-CoA carboxylase do
rate limiting enzyme in fatty acid synthesis
what indicates a later stage of calcific aortic valve disease
think of this disease when looking at an elderly man with aortic stenosis (late peaking systolic murmur with soft S2)
-differentiation of valve fibroblasts into osteoblast-like cells
lymph drainage from glans penis and superficial nodes
deep inguinal nodes
what can you give a pt instead while they are agitated if haloperidol is not available
quetipine
high fever, severe polyarthralgias, headache, maculopapular rash, lymphopenia, thrombocytopenia, transaminitis
-tropical/subtropical parts of central/south america, africa, and asia
via aedes mosquito
Chikungunya fever
-chronic arthralgias may prequire methotrexate
how to confirm trichomoniasis
wet mount/ saline microscopy
CGG repeat
Chin Giant Gonads –> fragile X (due to gene methylation)
defects in DNA mismatch repair lead to what
lynch syndrome (nonpolyposis colorectal cancer) –> also gives you higher rate of endometrial cancer
jaundice, dark urine, acholic stools in first 2 months of life due to conjugated hyperbilirubinemia
biliary atresia
-on biopsy you will see intrahepatic bile duct proliferation portal tract edema, and fibrosis
path blood takes to get to the retinal artery
internal carotid artery –> ophthalmic artery –> retinal artery
what does an increase in prolactin do to levels of estrogen?
they decrease levels of estrogen
-women with prolactinomas are more likely to have decreased bone density, amenorrhea, and vaginal atrophy
what happens in a type I hypersensitivity response
interaction of allergen with preexisting IgE bound to basophils and mast cells –> this facilitates cross-linking of surface IgE molecules that signals cells to degranulate releasing chemical mediators (histamine and heparin)
what vitamin deficiency can lead to increased susceptibility to oxidative stress
vitamin E deficiency
symptom management of peripheral artery disease
graded exercise program and cilostazol (pde inhibitor that blocks platelet aggregation and acts as direct arterial vasodilator)
infant with pale skin and musty odor what do you think of?
phenylketonuria
-tyrosine is essential
what do you clamp to decrease uterine blood flow but to preserve fertility
internal iliac artery cause uterus still has collateral blood flow from the ovarian arteries
first line and second line medications for alcohol use disorder to help with cravings
- Naltrexone and Acamprostate –> opioid antagonists (preventing reinforcing effects of alcohol)
- Disulfiram –> aldehyde dehydrogenase inhibitor
what are the cutoff values for hypoxia
SaO2 < 92%
PaO2 <65mmHg
what stimulates the chromaffin cells in the adrenal medulla
acetylcholine
which DNA polymerase has exonuclease activity in both 5 to 3 and 3 to 5 directions?
DNA polymerase I (removes short fragments of RNA that are base paired to the DNA template)
DNA polymerase III only has 3 to 5 exonuclease activity
both have 5 to 3 polymerase activity
whats another name for the suspensory ligament of the ovary and whats placed here?
infundibulopelvic ligament (fold of peritoneum) -contains ovarian artery, vein, lymphatics, and nerves
- note: this whole ligament must be ligated to prevent heavy ovarian bleeding in an oophorectomy
- this is also affected in ovarian torsion
injury to meyers loop in the temporal lobe vs the dorsal optic radiation results in
meyers loop: contralateral superior quadrantanopia
optic tract: “pie on the floor”
what drugs target fungal cell wall vs fungal cell membrane integrity
cell wall –> “fungins” Anidulafungin, Caspofungin, Micafungin
cell membrane integrity –> amphotericin B and Nystatin (both bind ergosterol) and azoles (inhibit ergosterol synthesis)
how do corticosteroids affect your immune system
- immunosuppression with an increased risk of infection
- neutrophilia (increased number comes from neutrophil demargination of ones previously attached to vessel walls, this makes them less available for recruitment against infections)
genomic imprinting
occurs with uniparental disomy –> person receives 2 copies of a chromosome from the same parent (selective activation of gene expression
what is phosphatidylcholine and how do its levels affect gallstone formation
its a phospholipid
-decreased levels allow bile to become supersaturated with cholesterol and help lead to gallstone formation
what is contact dermatitis an example of
type IV (delayed type) hypersensitivity reaction -T lymphocytes
what are the two types of age-related macular degeneration and what will you see in both of them/how do you treat them
Degeneration of macula (central area of retina) causing distortion (metamorphopsia) and eventual loss of central vision (scotomas)
DRY –> Deposition of yellowish extracellular material (Drusen) in between Bruch membrane and retinal pigment epithelium with gradual decrease in vision.
prevent progression with multivitamin and antixoidants
WET –> rapid loss of vision due to bleeding secondary to choroidal neovascularization. you will see grayish discoloration of the macula with areas of adjacent hemorrhage. treat with anti-VEGF injections (bevacizumab and ranibizumab)
young boy with spastic diplegia, abnormal movements, and growth delay with increased arginine levels in plasma and CSF (mild or no hyperammonemia)
arginase deficiency –> it normally produces urea and ornithine
-treatment is a low protein/arginine free diet
what medications can you give a pregnant woman for hypertension
He Likes My Neonate Hydralazine Labetolol Methyldopa Nifedipine
*do not give ACEi or ARBs during pregnancy as this can affect the renal function of the fetus and cause potter sequence and hypercalvaria
ageusia
loss of taste which can occur in the setting of anosmia (loss of smell) which is a common complication of TBI
superior mesenteric artery syndrome
- occurs when aortomesenteric angle critically decreases due to rapid weight loss/loss of mesenteric fat, pronounced lordosis, or surgical correction of scoliosis
- transverse portion of duodenum is entrapped b/w SMA and aorta causing symptoms of partial intestinal obstruction
what glands secrete bicarb in the duodenum (specifically the first part)
brunners gland in the submucosal layer
in a patient with heart failure whats the cutoff number for a preserved ejection fraction
preserved is an LVEF >50% –> HFpEF
-this develops due to diastolic dysfunction which usually occurs due to systemic hypertension (low CO and high systemic vascular resistance)
what TB medication is dependent on bacterial catalase-peroxidase (KatG encoded)
isoniazid
generally speaking what do tyrosine kinase receptors do
mediate the effects of hormones that promote anabolism and cell growth
-ex: insulin, insulin-like growth factor 1, epidermal growth factor, and platelet derived growth factor
what are cell adhesion molecules (CAMs)
proteins located on cell surface that mediate binding with other cells or with the extracellular matrix
- ex: selectins, integrins, and cadherins
- generally downregulated in malignant tumors which allow these cells to spread from their site of origin
human multidrug resistance genes code for what
p-glycoprotein
- transmembrane ATP-dependent efflux pump protein that has a broad specificity for hydrophobic compounds
- reduces the influx of drugs into the cytosol and can increase efflux from the cytosol (preventing action of chemotherapeutic agents)
what does a1-antitrypsin deficiency do to carbon monoxide diffusion capacity
decreases it
what do LH and FSH do in males
LH stimulates leydig cells to secrete testosterone
FSH stimulates sertoli cells to secrete inhibinB
*note: sertoli cells also secrete mullerian inhibitory factor in utero
explain the action and purpose of SPINK1
serine peptidase inhibitor kazal type 1 –> secreted by pancreatic acinar cells to function as trypsin inhibitor so those enzymes dont get prematurely activated in the pancreas causing pancreatitis
what information does the carcinoembryonic antigen assay give you?
monitoring for tumor recurrence
febrile illness with meningitis and encephalitis in the summer months
arbovirus meningoencephalitis (west nile, la crosse, st louis, and eastern/western equine encephalitis viruses) –> due to infected mosquitos
signs of a VIPoma
WDHA syndrome
Watery Diarrhea
Hypokalemia
Achlorhydria
steps in base excision repair
- Glycosylase
- Endonuclease (cleaves 5’)
- Lyase (cleaves 3’ sugar phosphate)
- DNA Polymerase
- Ligase
low maternal serum alpha-fetoprotein and unconjugated estradiol
what would a high maternal serum alpha-fetoprotein indicate
aneuploidies (ex: trisomy 18 and 21)
-you will also see high beta-hCG and inhibin A
high maternal serum AFP: open neural tube defects, ventral/abdominal wall defects, multiple gestation
where in the cell does splicing occur
in the nucleus
what is formed from the paramesonephric ducts
they fuse to form the fallopian tubes, uterus, cervix, and upper vagina
- disruptions of the process can lead to mullerian tract anomalies
- incomplete lateral fusion of paramesonephric ducts results in a bicornulate uterus characterized by an indentation in the center of the fundus
mesonephric ducts vs paramesonephric ducts
mesonephric ducts –> men
paramesonephric ducts –> women
what does sodium nitroprusside do
short acting agent that causes balanced vasodilation of the veins and arteries to decrease BOTH left ventricular preload and afterload
-because the vasodilation is balanced stroke volume and cardiac output are maintained but even at a lower LV pressure (lower cardiac work)
sensorineural hearing loss, vertigo, tinnitus
- ear fullness/pain
- usually unilateral
Meniere disease
-increase endolymph in inner ear –> endolymphatic hydrops
explain vestibular neuritis and labyrinthitis
single episode of severe vertigo that can last days
-due to inflammation of vestibular nerve (viral or postviral)
labyrinthitis has hearing loss
vestibular neuritis has no hearing loss
brief episodes of vertigo brought on by head movement and no auditory symptoms
Benign paroxysmal positional vertigo (BPPV)
-otoliths in semicircular canals
inactivated/killed versions of the influenza vaccine do what
stimulate formation of neutralizing antibodies against hemagglutinin antigens of included strains
-humoral response
if someone has a pyruvate dehydrogenase deficiency… what should you give them and why
implement a ketogenic diet (high fat, low carb, moderate protein)
- forces body into ketogenesis and does not use glucose which allows lactic acid levels to decrease back to normal
- the two exclusively ketogenic amino acids are Lysine and Leucine (cause we Like fats)
glucogenic amino acids
I MET HIS VALentine and shes so sweet (glucogenic)
met, his, val
what is the most common cause of nipple discharge (serous or bloody)
intraductal papilloma (small fibroepithelial tumor with lactiferous ducts typically beneath areola) –> papillary cells with fibrovascular core
what is the first thing that changes drastically in the progression of diabetic nephropathy
GFR increases a lot then wanes down
Albuminuria very slowly rises throughout the process/development
what chemotherapeutic agent can cause pulmonary fibrosis
bleomycin which induces free radical formation
how are sarcomeres being added in both concentric and eccentric hypertrophy of the heart?
concentric –> parallel
eccentric –> series
inheritance pattern of PKU
autosomal recessive
what drains to the superficial inguinal nodes vs the deep inguinal nodes
superficial –> cutaneous lymph from umbilicus down, including anus below dentate line
EXCEPT glans penis and posterior calf drain to deep inguinal nodes
what do you have to cut through as part of a cricothyrotomy
incision through superficial cervical fascia, pretracheal fascia, and cricothyroid membrane
explain the actions of dopamine at both low and high doses
D1 > B1 > a1
LOW DOSES: decrease in blood pressure due to selective vasodilation
HIGH DOSES: increase in BP, HR, CO, and renal blood flow
buprenorphine
partial opioid receptor agonist that bind with a high affinity and can displace other opioids
what do you use as a landmark for lumbar punctures
iliac crest (needle placed b/w 3rd and 4th OR b/w 5th and 6th lumbar vertebrae)
what type of reaction is it if you give the wrong type of blood
type II hypersensitivity reaction–> complement mediated cell lysis
Periodic acid-schiff (PAS)
stains glycogen and mucopolysaccharides
used to diagnose Whipple disease (Tropheryma whipplei)
pressure to what can cause common peroneal nerve injury
fibular neck –> weakness on foot dorsiflexion/eversion and impaired sensation over lateral shin and dorsal foot and b/w first and second toes
how do you measure fetal lung maturity
L/S ratio should be roughly 2:1 by 35weeks gestation
Lecithin/Sphingomyelin
Lecithin = phosphatidylcholine
tetrodotoxin (puffer fish) and saxitoxin (red tide)
bind to Na+ channels, inhibiting Na+ influx and preventing action potential conduction
ciguatoxin (exotic fish/moray eel) and batrachotoxin (south american frogs)
bind to Na+ channel, keeping it open and causing persistent depolarization
transthyretin
protein tetramer produced in the liver and it acts as a carrier of thyroxine and retinol
- mutations in the TTR gene can increase the tendency to misfold producing an amyloid protein that infiltrates the myocardium and cause an infiltrative cardiomyopathy
- CARDIAC AMYLOIDOSIS
what is the pathogenesis of extra nipples
failed involution of the mammary ridge
explain lights criteria
pleural fluid is exudative if 1 or more of the following criteria is met:
- pleural fluid protein/serum ratio is >0.5
- pleural fluid LDH/serum ratio is >0.6
- pleural fluid LDH > 2/3 of upper limit of normal for serum LDH
EXudate = EXcess protein, LDH, and hypercellular (cloudy)
*also note transudate is hypocellular
if you are shown a gel electrophoresis WITH NUMBERS included what should you do
check to see if the difference between the two numbers is divisible by 3
- if it is then you know its an in frame mutation, nonsense, or missense mutation
- if it is NOT then you know its a frameshift mutation
*also make sure to look at what is being used… mRNA or DNA? if its cDNA then the length will tell you how long the mature RNA transcript will be… not how long the protein will be
wound dehiscence
rupturing of previously closed wound and can result from insufficient granulation and scar tissue formation, inadequate wound contraction, or excessive mechanical stress
-usually in abdominal wounds subjected to an increase in abdominal pressure
what are contractures
produce deformities of wound and surrounding tissues
-most often on palms, soles, anterior thorax, or at serious burn sites
myofibroblasts accumulate during wound healing to initiate what
initiate wound contraction during healing by second intention
what are the antibodies in the in individuals with type A, B, AB, and O blood to attack other blood types?
blood groups A and B have the IgM antibodies to other blood types
AB has no antibodies
O has IgG antibodies to both A and B blood products
*note only IgG can cross the placenta and can cause hemolysis in the baby
what is the only enzyme that creates GTP in the krebs cycle
succinate thiokinase
Succinyl-CoA —-> Succinate
explain the difference between the weber test and the rinne test
weber test (tuning fork on the head) –> conductive localizes to affected ear // sensorineural hearing localizes to unaffected ear
rinne test (tests bone conduction by putting tuning fork behind ear) –> conductive hearing loss (bone > air) // sensoryneural hearing loss (reduced bilaterally and air > bone)
what is supposed to correct tRNAs that have incorrect amino acids placed on them
aminoacyl-tRNA synthetase are supposed to make sure that correct pairs are made
damage to one of the temporal hemiretinas will cause what
disrupt transmission of the ispilateral optic nerve, lateral optic chiasm, optic tract, lateral geniculate body, optic radiations, and primary visual cortex
what cells secrete mullerian inhibitory factor
sertoli cells
*absence of sertoli cells or lack of mullerian inhibitory factor leads to development of both male and female internal genitalia with male external genetalia
what part of the lungs are affected by asbestos, silica, beryllium, and coal and what will you see for each one
- asbestos is from the roof but affects the base of the lungs (lower lobes)
- silica, beryllium and coal are from the base (earth), but affect the roof of the lungs (upper lobes)
asbestosis: ferruginous bodies and interstitial/pleural plaques
berylliosis: granulomatous noncaseating granulomas
coal: carbon laden macrophages and black lung
silica: microphages, hilar lymph node calcified, birefringent silicate particles… eventual collagen deposition leading to pulmonary fibrosis
pathogenesis of nonbacterial thrombotic endocarditis
- valvular endothelial injury caused by circulating inflammatory cytokines
- triggers platelet deposition in the setting of an underlying hypercoagulable state
- libman sacks endocarditis is most commonly seen with underlying malignancy and/or SLE
how do neoplastic cells use the PD-1 receptor to help evade the immune system
PD-1 = programmed death receptor
neoplastic cells can create the ligand for this receptor on their surface and then bind to these receptors and block the apoptosis of these cells causing T-cell exhaustion
*you can give a pt monoclonal antibodies against PD-1 (pembrolizumad, nivolumab) or PD-L1 (atezolizumab) resulting in T cell disinhibition and restoration of cytotoxic response
pt with significant renal dysfunction (like right before a transplant/dialysis type of dysfunction) starts to bleed from cut or catheter site
uremic platelet dysfunction
- abnormal (increased) bleeding time only, everything else is normal
- pt has uremia (and subsequent uremic toxins in blood) which causes a qualitative platelet disorder
underlying mechanism of a Zenker diverticulum (aka. false diverticulum)
abnormal spasm or diminished relaxation of cricopharyngeal muscles during swallowing
-cricopharyngeal motor dysfunction
what will you see in the skin lesions of a pt who has leprosy
IL-2 and IFN-gamma
Jarisch-Herxheimer reaction
systemic inflammatory response that occurs within hours of antibiotic initiation for spirochetal infections (syphlis, lyme disease, leptospirosis)
- due to rapid lysis of spirochetes which spills bacterial lipoproteins into the bloodstream triggering a strong immunologic response
- most cases are self limited and do not require intervention
if you have loss of the patellar reflex OR achilles reflex… which nerve roots are affected?
patellar: L4
achilles: S1
first line therapy for schizophrenia
antipsychotics (D2 antagonists)
what does proinsulin have in it
c-peptide and insulin both of which are packaged in vesicles and secreted from the cell
what cycle does hyperammonia affect?
glutamate-glutamine cycle
reasons for increased renin and increased aldosterone
secondary hyperaldosteronism
- renovascular hypertension
- malignant hypertension
- renin secreting tumor
- diuretic use
reasons for low renin and high aldosterone
primary hyperaldosteronism
- aldosterone secreting tumor
- bilateral adrenal hyperplasia
reasons for low renin and low aldosterone
- CAH
- deoxycorticosterone-producing adrenal tumor
- cushing syndrome
- exogenous mineralocorticoids
what muscle does the musculocutaneous nerve cross through and what does it innervate
corachobrachialis
-forearm flexors and sensory for the lateral forearm
cavernous carotid aneurysm
- if small then usually asymptomatic
- if large it can compress the abducens nerve and mess up the lateral rectus nerve on the ipsilateral eye as well as diplopia that is worse when looking to the side of the lesion
what is the most common cause of aortic stenosis
extensive valve calcification with impaired leaflet mobility
-you will hear ejection systolic murmur with a diminished S2 heart sound
what nerve can be electrically stimulated to help with obstructive sleep apnea
hypoglossal nerve
how to explain what happens as a result of myasthenia gravis
reduction amplitude of motor end plate potential
- autosomal recessive mutation of ATP7B
- hepatic, neurologic, and psychiatric problems
- decreased ceruloplasmin
wilson disease
insulin secretagogues
sulfonylureas and meglitinides
what causes primary amebic meningoencephalitis
naegleria fowleri
- free living, motile, protozoan parasite
- lives in warm water and soil worldwide
- nearly all cases are fatal but you can try to give amphotericin B
virus associated with birds…. what is it and what are the symptoms
west nile virus (via culex mosquito)
- fever, headache, rash
- meningitis, encephalitis, acute symmetric flaccid paralysis
blanching of a vein into which norepinephrine is being infused together with induration and pallor of the tissues surrounding the IV site….
signs of NE extravasation leading to vasoconstriction
-prevent tissue necrosis by local injection of an alpha 1 blocking drug (ex: phentolamine)
S-100 positive tumor in the brain
+S-100 means its of neural crest origin
schwannoma in the brain and it can also be a melanocyte if elsewhere/symptoms match or langerhans histiocytosis
how do most sarcomas spread and how to most carcinomas spread… what are the exceptions?
Sarcomas: spread hematogenously Carcinomas: spread lymphatically -------- except Four Carcinomas Route Hematogenously: Follicular thyroid carcinoma Choriocarcinoma Renal cell carcinoma Hepatocellular carcinoma
if you see a psammoma body what could that indicate
PSaMMOM
Papillary carcinoma of the thyroid Somatostatinoma Meningioma Malignant Mesothelioma Ovarian serous papillary cystadenocarcinoma Milk (prolactinoma)
immunosuppressed pts with febrile neutropenia, sepsis would lead to what broad differential….
what if the pt also had ecthyma gangrenosum
these pts are more susceptible to gram - bacteria
with EG then you can pretty strongly go with pseudomonas aeruginosa
ecthyma gangrenosum
rapidly progressive, nectrotic cutaneous lesion caused by pseudomonas bacteremia typically seen in immunocompromised pts
metabolic fuel use
1g CARB/protein/whey = 4kcal
1g ALCOHOL = 7kcal
1g FATTY ACID = 9kcal
(# of letters = # kcal)
what affect does acetyl-coA have on certain enzymes
pyruvate gets converted to acetyl-coA
acetyl-coA stimulates gluconeogenesis via upregulation of pyruvate carboxylase (which takes you straight from pyruvate to oxaloacetate so it can be converted to PEP)
acetyl-coA inhibits pyruvate dehydrogenase
what does secretin do
increases pancreatic HCO3- and bile secretion
decreases gastric acid secretion
what are the requirements for hospice care
meant to provide comfort and providing palliation instead of definitive care
- only requirement is life expectancy <6 months
- during end of life care priority is given to improving pts comfort and relieving pain
- principle of double effect (ex: prioritizing lack of pain over side effects of medications like respiratory depression)
*note that a DNR is NOT required
what happens to UV damaged DNA
endonuclease nicking of damaged DNA strand
sputum gram stain for legionella
sputum gram stain shows many neutrophils and few/no bacterial organisms
-dx via urine antigen test
what can result in glycogen deficiency in the vaginal epithelium
estrogen deficiency from premature ovarian failure or menopause (resulting in flattening of labial folds and vaginal rugae causing dyspareunia
endometrial hyperplasia
increased endometrial gland to stroma ratio due to excess estrogen stimulation
-pts present with irregular menses
endometrium glands within uterine myometrium
adenomyosis –> leads to abnormal uterine bleeding and painful menses with an enlarged uterus
risk factors for abdominal aortic aneurysm
smoking, increased age, male sex, family history
what can occur due to chronic alcoholism independently of folate deficiency
macrocytosis
steps in wound healing… explain.
- Inflammatory (up to 3 days after wound): platelets, pmns, macrophages
- clot formation, increase vessel permeability and pmn migration into tissue then macrophages clear debris 2 days later - Proliferative (day 3-weeks after wound): fibroblasts, myofibroblasts, endothelial cells, keratinocytes, macrophages
- granuation deposition, type III collagen, angiogenesis, epithelial cell proliferation, dissolution of clot, wound contraction
- delayed second phase wound healing in vitamin C and copper deficiency - Remodeling (1 week-6+months after wound): fibroblasts
- type III collagen replaced by type I collagen, increased tensile strength of tissue, collagenases (require zinc) break down type III collagen
pharyngeal pouches and derivatives
FIRST –> ear // tympanic cleft = acoustic meatus and tympanic membrane
SECOND –> tonsils
THIRD –> inferior parathyroids (dorsal wings), thymus (ventral wings)
FOURTH –> superior parathyroids (dorsal wings), ultimopharyngeal body and parafollicular cells of thyroid (ventral wings)
pharyngeal arches and derivatives
FIRST –> Maxillary and Mandibular processes: mastication, masseter, lateral/medial pterygoids, mylohyoid, anterior belly of digastric, tensor tympani, anterior 2/3 of tongue, tensor veli palatini (CN V3 and V2)
SECOND –> Reichert cartilage: muscles of facial expression, stapedius, stylohoid, platysma, posterior belly of digastric (CN 7– facial expression smile)
THIRD –> greater horn of hyoid, stylopharyngeus (stylopharyngeus innervated by glossopharyngeal nerve)– CN9
FOUR - SIX –> arytenoids, cricoid, corniculate, cuneiform, thyroid (CN10)
*5 disappears)
what does folate deficiency inhibit
synthesis of nucleic acids, particularly formation of dTMP —> defective DNA synthesis and can lead to apoptosis of hemopoietic cells and megaloblastic anemia
*note that supplementing thymidine bypasses dihydrofolate reductase (by using thymidylate synthase) and can reduce erythroid apoptosis
what acid-base problems should you think of acutely in a pt who is suffering from a pulmonary embolism
hypoxemia due to v/p mismatch respiratory alkalosis (hypocapnia) due to hyperventilation
t-test vs anova vs chi-square
t-test checks differences b/w means of 2 groups
anova checks differences b/w means of 3+ groups
chi-square checks difference b/w 2+ percentages or proportions of categorical outcomes (not mean values)
specifically… what does the acid-fast stain actually stain
mycolic acids
what does strep viridans do
capable of producing extracellular polysaccharides (dextrans) using sucrose as a substrate
-dextrans facilitates the adherence of strep viridans to fibrin —> in pts with pre-existing valvular lesions, they can adhere to fibrin-platelet aggregates and establish infection that leads to endocarditis
compare and contrast NF1 and NF2
NF1 (von reckinghausen)
- neurofibromin mutation on chromosome 17
- cafe-au-lait, neurofibromas, lisch nodules
NF2 (central neurofibromatosis)
- merlin mutation on chromosome 22
- bilateral acoustic neuromas
explain the progression of types of hemoglobin
first few weeks of embryogenesis: zeta and epsilon globin chains (made by yolk sac)
AFTER THAT now every Hb must have 2alpha and 2non-alpha chains
8 weeks gestation: HbF (2alpha2gamma) begins to forms and is the only hb type by week 14
term new born: HbF is 60-80% of all Hb and is gradually replaced by HbA (2alpha2beta)
6months+: HbA composes vast majority
what is the most common cause of oropharyngeal carcinoma (presenting as persistent throat pain, tonsil ulcer)
-biopsy shows proliferative cytokeratin-positive cells
HPV
-cytokeratin+ cells indicate a squamous cell carcinoma
dermatologic fungal infections where the initial lesion is a reddish nodule that later ulcerates
-spreads along the lymphatics
appears at site of thorn prick —-> Sporothrix Schenckii
how is excess copper removed from the body
hepatic excretion into bile
-note that 5-15% of copper excretion comes from renal tubular secretion
niacin
aka nicotinic acid
- raises HDL, lowers TG, lowers LDL
- side effects: cutaneous flushing, warmth, and itching (all mediated by PGE2 and PGD2) —> you can pretreat with aspirin to stop these effects
leiomyoma (fibroids)
- most common tumor in females (AA females)
- multiple discrete tumors, benign smooth muscle
- estrogen sensitive
- may be asymptomatic, cause abnormal uterine bleeding, or result in miscarriage
- severe bleeding may lead to iron deficiency anemia
*Note: you will see a whorled pattern of smooth muscle bundles with well demarcated boarders
how to differentiate leukemoid reaction vs CML
symptoms present similarly: leukocytosis
but…
leukemoid reaction has a normal-elevated leukocoyte/neutrophil alk phos
CML has a low leukocyte/neutrophil alk phos
how do estrogen levels affect TBG
increase in estrogen increases level of TBG –> leads to increase in total thyroid hormone levels but feedback control maintains normal levels of free (biologically active) thyroid hormone
explain the difference between a case-control study and a cohort study
case-control study: compares a group of people with disease to a group without the disease and asks what happened? (Odds ratio)
cohort study: compares a group with a given exposure to a group without an exposure and asks who will develop a certain disease or not (relative risk)
crossover study
participants work as their own controls to see what treatments work better (washout period b/w each treatment)
case series study
collects detailed information about people who are thought to have the same disease/condition
what drugs have zero-order elimination
PEA
Phenytoin
Ethanol
Aspirin
what is the mechanism of action of typical vs atypical antipsychotics and what’re the bases you should you for their names
TYPICAL
- haloperidol, pimozide, “azine”s
- block dopamine D2 receptor (increase cAMP)
ATYPICAL
- aripiprazole (partial D2 agonist), “apine”, “peridone”
- serotonin and D2 antagonists, varied effects on alpha and H1 receptors
how can crohns disease cause ecchymoses/easy bruising
crohns mainly affects the terminal ileum
bile is primarily taken up in the ileium (Iron Fist Bro)
if you dont take up bile you cant reabsorb as many fats and fat soluble vitamins
the fat soluble vitamins are A, D, E, and K…. you need vitamin K for clotting
less vitamin K = ecchymoses and easy bruising
annular pancreas
pancreatic tissue encircling the descending duodenum caused by failure of ventral pancreatic duct to properly migrate and fuse with the dorsal bud during the 7th and 8th week of fetal development
-usually asymptomatic but may present with duodenal obstruction or pancreatitis
what is the most frequent mechanism of sudden cardiac death in the first 48hrs after an acute MI
ventricular fibrillation
-related to electrical instability due to lack of perfusion in the ischemic myocardium
retinal lesions, hydrocephalus, jaundice, and hepatosplenomegaly in a newborn… what does the mom have?
toxoplasmosis
what can excessive vitamin D intake cause
hypercalcemia, mental status changes, muscle weakness, constipation, polyuria/polydipsia
normal values for PaO2 and PAO2
PaO2 = 100 mmHg PAO2 = 104 mmHg
A-a gradient is normally around 4 (normal is b/w 4-15 mmHg)
what comes from tyrosine and tryptophan respectively?
phenylalanine –> TYROSINE (makes T4) – tyrosine hydroxylase–> Dopa (makes melanin) – dopa decarboxylase–> Dopamine –dopamine beta-hydroxylase–> NE –PNMT–> Epi
TRYPTOPHAN –> niacin (makes NAD+ and NADP+) and serotonin (makes melatonin)
what does arginine make
creatinine, urea, and nitric oxide
what is polyhydramnios and what causes it
too much amniotic fluid
- often idiopathic but could also be associated with certain fetal malformations (esophageal/duodenal atresia, anencephaly —> both cause inability to swallow amniotic fluid), maternal diabetes, fetal anemia, multiple gestations
- either cause too much to be made or not enough being swallowed by the baby or gi obstruction so it cant go through the baby fully
subacute granulomatous thyroiditis (de Quervian) vs hashimotos thyroiditis
SGT (dQ): onset following viral illness, painful thyroid, transient hyperthyroid symptoms, increase ESR and CRP, decreased radioiodine uptake, inflammatory infiltrate with macrophages and giant cells
HT: autoimmune, painless thyroid enlargement, hypothyroid features, positive TPO antibody, lymphocytic infiltrate with well developed germinal centers and Hurthle cells (eosinophilic epithelial cells)
what is the single strongest risk factor for further attempts and completed suicide
a history of previous suicide attempts
pathogenesis of RA
- activation of T lymphocytes in response to rheumatoid antigens (citrillunated proteins and type II collagen)
- activated T cells release cytokines that cause synovial hyperplasia with recruitment of mononuclear cells
- accelerated metabolic rate of inflamed synovial tissue leads to local hypoxia and increased production of hypoxia inducible factor-1 and VEGF by local macrophages and fibroblasts (resulting in synovial angiogenesis/neovascularization)
- as the disease progresses into late RA these new blood vessels expand the inflammation into a rheumatoid pannus (invasive mass composed of fibroblast-like synovial cells, granulation tissue, and inflammatory cells)
- overtime this pannus destroys articular cartilage and erodes the underlying subcondral bone
if you have an increase in osteoblastic activity what should increase in your serum… like what correlates with osteoblastic activity in the blood
alk phos
what triggers myocyte relaxation
calcium efflux from the cytoplasm that occurs as a result of the Na/Ca exchanger and sarcoplasmic reticulum Ca-ATPase pump
where do carbonic anhydrase inhibitors work and how
acetazolamide works at the proximal tubules
- inhibits HCO3- absorption and H+ secretion
- also reduces NH4+ excretion
where do thiazide diuretics work
hydrochlorothiazide works at the distal convoluted tubule
where do the potassium sparing diuretics work
amiloride (Na blocker) and spironolactone (aldosterone antagonist) works at the cortical collecting duct
where do ACEi and ARBs work on the kidney
they BLOCK the constriction of the efferent arteriole so that it stays open (they block angiotensin II)
-in pts with bilateral renal artery stenosis this can precipitate acute renal failure cause neither kidney can compensate and GFR decreases dramatically
how to treat status epilepticus (single seizure lasting >5mins or occurrence of multiple discrete seizures with incomplete recovery of consciousness between episodes)
IV benzos (usually lorazepam) to potentiate GABA and you also want to concurrently administer phenytoin (or fosphenytoin) to prevent recurrence
phenytoin works by blocking Na+ channels
puncture above the inguinal ligament will likely cause what
retroperitoneal hematoma
what is the main factor that predisposes to aortic dissection
hypertension
inherited defects regarding what pathway results in disseminated mycobacterial disease in infancy or early childhood
interferon-gamma
-pts require lifelong treatment with antimycobacterials
child with vomiting lethargy, jaundice, and ecoli sepsis during breastfeeding
classic galactosemia (deficiency of galactose-1-phosphate uridyl transferase
-switching to soy milk based formula is recommended
how do you diagnose EBV
detecting heterogeneous group of heterophile IgM antibodies that react with antigens on horse or sheep erythrocytes
what does anaphylaxis do to your blood vessels
widespread venous and arteriolar dilation along with increased capillary permeability and third-spacing of fluids (drop in venous return)
why should you co-administer mesna/have the pt excessively hydrated with both cyclophosphamide and ifosfamide
to stop hemorrhagic cystitis because these metabolites are broken down in the kidneys to acrolein which is then excreted in the urine
acrolein –> toxic to uroepithelial cells causing cell death and necrosis
mesna (sulfhydryl compound) binds to and inactivates toxic metabolites
what causes hypotension when supine
compression of IVC –> reduced venous return –> reduced preload –> decreased cardiac output –> hypotension
where is the great saphenous vein
superficial vein of the leg that originates on the medial side of the foot, courses anterior to the medial malleolus, travels up the medial aspect of the leg and thigh
-drains the femoral vein within the region of the femoral triangle…. a few centimeters inferolateral to the pubic tubercle
what does CN7 do
- motor output to facial muscles
- parasympathetic innervation to lacrimal, submandibular, sublingual salivary glands
- special afferent fibers for taste of anterior 2/3 of tongue
- somatic afferent from pinna and external auditory canal –> innervates stapedius muscle (stabilizes stapes and damage causes hyperacusis)
becks triad in cardiac tamponade
- hypotension with pulsus paradoxus (decrease in systolic blood pressure >10mmHg on inspiration)
- elevated JVP
- muffled heart sounds
