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
how does resistance to cephalosporins occur
change in penicillin binding proteins (transpeptidases)
what nerves lie next to the prostate
prostatic plexus –> originates from inferior hypogastric plexus but from the prostatic plexus it goes to become to the greater and lesser cavernous nerves which innervate the corpus cavernosa of the penis and urethra
pharmacodynamic potentiation
greater than additive effect that occurs when 2 different drugs are administered simultaneously due to functional interactions within target tissues
procalcitonin
unique acute phase reactant
increases with bacteria
decreases with viruses
list the normal cardiac pressures in the compartments of the heart
RA: < 5 RV: 25/5 PA: 25/10 (PCWP --> essentially LA pressure = 4-12) LA: < 12 LV: 130/10 Aorta: 130/90
inheritance pattern of sickle cell
AR
what type of rash do you see in chlamydia vs syphilis
chlamydia –> vesicular rash
syphilis –> maculopapular or pustular rash
what do nitrites do to the body
iron is normally in Fe2+ state but nitrite converts it to the Fe3+ state —-> methemoglobin
methemoglobin
- binds tightly to cyanide
- dusky skin discoloration
- cannot carry oxygen
*note: partial pressure of O2 in the blood remains the same cause this is referring to amount of O2 dissolved in the plasma
acantholysis
loss of cohesion b/w keratinocytes in the epidermis (ex: in pemphigus disorders)
in a suprapubic cystostomy what gets pierced
aponeurosis of abdominal wall muscles, superficial fascia, transversalis fascia, and extraperitoneal fat
-no peritoneum affected
first line treatment for iron overdose
deferoxamine –> chelating agent that binds ferric iron to convert it to ferrioxamine (water soluble form to be excreted in the urine)
what should be on your differential if you see target RBCs
HALT
HbC disease
Asplenia
Liver disease
Thalassemia
microcytic anemia and increased hemoglobinA2 or fetal hemoglobin
beta-thalassemia minor
- usually caused by DNA mutations affecting transcription, processing, and/or translation of beta-globin mRNA
- most commonly due to aberrant precursor mRNA splicing or premature chain termination during mRNA translation
-thalassemias are due to decreased amount of otherwise normal beta globin chains
treatment of congenital adrenal hyperplasia
low doses of exogenous corticosteroids to suppress excessive ACTH secretion and reduce stimulation of the adrenal cortex
minimal change disease IM, LM, and EM
IM: no immune deposits
LM: normal glomeruli
EM: diffuse podocyte process effacement
benign prostatic hyperplasia can do what
if it gets bad enough it can cause a bladder outlet obstruction and the subsequent hydronephrosis can cause significant pressure-induced parenchymal atrophy with scarring and eventual chronic kidney disease
why would you hear a 3rd or 4th heart sound
3rd: ventricular gallop sound, heard during rapid passive filling of ventricles in diastole, sudden cessation of filling as ventricle reaches elastic limit
4th: atrial gallop sound, heard immediately after atrial contraction as blood is forced into a stiff ventricle
details about adjustment disorder
occurs within 3 months of identifiable event and lasts < 6 months once stressor has ended
-treat with CBT and SSRIs
-if symptoms persist for > 6 months after stressor then its GAD
what type of T cell is important in granuloma formation
CD4+ T cells which then release IFN-gamma (increasing ability to kill phagocytosed material)
pt with marfanoid habitus and vision problems… what do they have and what can you give them
pt has homocystinuria (AR)
-B6 is required for cystathionine synthase and many pts respond well to B6 supplementation
- vision problems: lese subluxes (down and in)
- pt can also suffer from ectopia lentis
what does carnitine do
assists with long chain fatty acid transport into mitochondria
what vitamins should be supplemented to infants who are exclusively breastfed
vitamin D and K
- especially D in pts with darker skin pigmentation
- also you may wanna give iron to infants who are preterm and have a low birth weight
Charcot-Bouchard aneurysm
associated with chronic hypertension
- affects small vessels of brain (lenticulostriate arteries in basal ganglia and thalamus)
- can cause intraparenchymal hemorrhage within deep brain structures
- not visible on angiography but you can see a big intraparenchymal hemorrhage on CT
what type of tumor can cause female virilization
sertoli-leydig tumors cause they secrete androgens causing clitoromegaly and hirsutism
what murmur causes an increased stroke volume with abrupt distension and rapid falloff of peripheral arterial pulses, resulting in a wide pulse pressure
-leads to bounding peripheral pulses and head bobbing with each heartbeat
aortic regurgitation
what organ is immediately deep to the tip of the 12th rib
kidney
visceral pleura
envelops the lungs and damage to ribs 1-6 have the greatest risk of damaging the visceral pleura
sputum and blood cultures with large, gram + rods that form colonies resembling a medusa head (clinically you will see lung infiltrates with mediastinum widening)
bacillus anthracis (antiphagocytic D-glutamate capsule + edema factor + lethal factor)
where do most aspiration pneumonias occur
right lung b/c the right bronchus is straighter than the left
what are the two types of aspiration syndromes
- Pneumonia
- lung parenchyma infection
- aspiration of upper airway or stomach microbes (anaerobes)
- presents days after event with fever, cough, increased sputum
- cxr infiltrate in RLL (can progress to abscess)
- antibiotics: clindamycin or beta-lactams and beta-lactam inhibitors - Pneumonitis
- lung parenchyma inflammation and aspiration of gastric acid with direct tissue injury
- presents hours after aspiration event
- range from no symptoms to nonproductive cough, decrease O2 respiratory distress
- cxr infiltrates (one or both lower lobes) resolve without antibiotics
- supportive (no antibiotics)
ideal anticoagulants for pregnant women
heparins keep mom and baby heppy (happy) –> do not cross BBB
-low molecular weight heparins are best
what innervates the deltoid muscle
axillary nerve
what is the pathogenesis of cleft lip
failure of fusion of the maxillary prominence and intermaxillary segment
ferritin vs transferrin
ferritin is iron storage levels in body
transferrin is serum total binding iron capacity
*note –> these values are always opposite!!
what does the C1 inhibitor do
- blocks cleavage of C2 and C4 (limiting complement cascade)
- blocks kallikrein-induced conversion of kininogen to bradykinin (vasodilator that causes increased vascular permeability)
*If you have C1 inhibitor deficiency then DONT give pt ACEi and and expect excessively cleaved C2 and C4 (cause the inhibitor isnt there to block it) as well as high levels of bradykinin (causing angioedema)
leukocyte migration and inflammatory accumulation (p.216 of FA)
- margination –> increased vascular leakage in microvasculature leads to hemoconcentration and decreased wall shear stress improving contact of neutrophils with endothelial lining
- rolling –> neutrophils roll via loose binding via sialylated carbohydrate groups (sialyl lewis X or PSGL-1 to L-selectin on neutrophils or E/P-selectin on endothelial cells)
- activation –> slow rolling allows leukocytes to sample the chemokines secreted by the inflamed tissue. this activates 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 epithelium via binding of CD18 beta 2 integrins (MAC-1 and LFA-1) to intercellular adhesion molecule-1 (ICAM-1) on endothelial cells
- transmigration –> migrate out of vasculature by squeezing between the cells via integrin attachments and adherence to platelet endothelial cell adhesion molecule-1 (PECAM-1): found at peripheral intercellular junctions of endothelial cells
adverse effects of levothyroxine and liothyronine
tachycardia, heat intolerance, tremors, arrhythmias all due to thyrotoxicosis
explain ventilation vs perfusion in the lungs
ventilation and perfusion are both the highest at the base of the lung
- as you move up the lung they both decrease
- perfusion is decreased more than ventilation as you move up the lung so the ratio of V/Q is increased
temporomandibular disorder
unilateral facial pain that worsens with jaw movement, headache, ear discomfort
- occur due to TMJ derangement
- involvement of mandibular nerve from trigeminal (supplies middle ear-tensor tympani and muscles of mastication)
thinning of outer third of eyebrow, fatigue, weight gain, goiter, and antithyroid peroxidase antibodies
hashimotos thyroiditis
- can have high prolactin due to stimulation of lactotrophs by thyrotropin-releasing hormone (TRH)
- intense lymphoplasmacytic infiltrate with active germinal centers
note: thyroid peroxidase iodinates thyroglobulin
whats the most common development of paroxysmal afib
- structural and electrical changes that predispose the heart to initiation and maintenance of electrical reentrant circuits and/or ectopic foci (atrial remodeling) –> can be due to normal aging or diseases causing atrial dilation
- remodeling leads to shortening of atrial refractory period and heterogeneity in localized electrical conduction b/w atrial myocytes creating substrate for development of afib
- afib can be triggered by excessive alcohol and certain electrical discharges
* note that the most common trigger of afib is aberrant electrical foci in pulmonary veins
best indicator of degree of mitral stenosis
A2-OS interval
what is NADPH used in
- reducing glutathione to protect from oxidative stress
- biosynthesis of cholesterol, fatty acids, and steroids
tocolysis
uterine relaxation due to B2 agonistic effects (used to defer premature labor)
what to think of on the differential when bats are involved
histoplasma and rabies
rabies pathogenesis
painful spasms –> progressive paralysis –> coma/death
-can give a pt post-exposure prophylaxis (rabies immune globulin and rabies inactivated vaccine) immediately after exposure to high-risk wild animal
stress-induced (takotsubo) cardiomyopathy
caused by catecholamine surge in setting of physical/emotional stress
- T-wave inversion, decreased LV ejection fraction
- balloon shaped echocardiogram
what is the predominant component of eosinophils
major basic protein which helps eliminate parasites
chiari I vs chiari II vs dandy-walker
chiari I –> ectopia of cerebellar tonsils inferior to foramen magnum (1 structure)
- asymptomatic in children and adults have headaches and cerebellar symptoms
- associated with spinal cavitations (syringomyelia)
chiari II –> herniation of cerebellar vermis and tonsils (2 structures) through foramen magnum with aqueductal stenosis causing a noncommunicating hydrocephalus
-associated with lumbosacral myelomeningocele (may present as paralysis/sensory loss at and below the level of the lesion)
Dandy-Walker –> agenesis of cerebellar vermis leads to cystic enlargement of 4th ventricle that fills the enlarged posterior fossa
-associated with noncommunicating hydrocephalus and spina bifida
where does lactase function
intestinal brush boarder
subclavian steal syndrome
stenosis of proximal subclavian artery leads to reversal in blood flow from contralateral vertebral artery to ipsilateral vertebral artery
- symptoms of arm ischemia in affected extremity –> exercise induced fatigue, pain, paresthesias
- vertebrobasilar insufficiency –> dizziness and vertigo
what causes false diverticula and what are the symptoms
develop due to exaggerated contractions of colonic smooth muscle segments resulting in an increase in intraluminal pressure leading to outpouchings of mucosa and submucosa through focal areas of weakness in muscularis (false diverticula)
usually if acquired later in life they are considered false diverticula
- usually pts > 60yo and most commonly affects sigmoid colon
- may be asymptomatic or have hematochezia or diverticulitis
*note true diverticula are most commonly found in the small intestine
what does bile soluble mean and name an example of a bacteria that is bile soluble
bile soluble = bile sensitive/dissolves/CANT grow in bile
strep pneumo is bile soluble cause the horses feet are covered
list the four glycogen storage diseases and their associated information
- Von Gierke disease (I) –> no glucose-6-phosphase
- hepatomegaly, steatosis, lactic acidosis, fasting hypoglycemia, hyperuricemia, hyperlipidemia - Pompe disease (II) –> no lysosomal acid a-1,4-glucosidase
- glycogen accumulation in lysosomes and cardiomegaly - Cori disease (III) –> no debranching enzyme (a-1,6-glucosidase)
- hepatomegaly, ketotic hypoglycemia, hypotonia, weakness, abnormal glycogen with short outer chains - McArdle disease (V) –> no myophosphorylase
- weakness and fatigue with exercise
describe the difference between zero order and first order kinetics
zero –> same amount gets metabolized no matter what you put into the body
first –> constant proportion of drug gets metabolized per unit time so amount metabolized changes based on serum concentration
what are the drugs you give for graves and whats a rare adverse effect
thionamides (propylthiouracil and methimazole)
-agranulocytosis
signs of toxic alcohol ingestion and how to treat it
- anion gap metabolic acidosis and elevated osmolar gap
- normal glucose and normal lactate
-give fomepizole (competitive inhibitor of alcohol dehydrogenase to prevent the toxic metabolite from forming)
if you see auer rods what do those cells stain positive for
myeloperoxidase
seen in AML
what endogenously blocks portal flow
somatostatin
what causes an increase in glycogenolysis within myocytes during active skeletal muscle contraction
calcium
-increased intracellular calcium causes activation of phosphorylase to increase glycogenolysis
what is the main part of the heart that gets its blood during diastole
left ventricle cause the pressure in the other parts of the heart are low enough that they can be pretty consistently perfused throughout the cardiac cycle but the pressure in the left ventricle is too high for this
thoracic outlet syndrome
caused by compression of brachial plexus as it passes through the scalene triangle
- space bordered by anterior and middle scalene muscles and the first rib
- symptoms typically include upper extremity numbness, tingling, and weakness that worsens with repetitive overarm movements (like baseball player throwing ball over and over again), diminished radial pulse on the affected side
- presence of anomolous cervical rib is a risk factor
*note that when you cut the scalene muscle to relieve the symptoms you can also potentially damage the phrenic nerve b/c it lies on top of the anterior scalene muscle
pancytopenia, hepatosplenomegaly, and teardrop cells on peripheral blood smear
primary myelofibrosis
-diffusely fibrotic marrow with clusters of megakaryocytes
- hematopoietic stem cell malignancy associated with clonal expansion of megakaryocytes
- neoplastic megakaryocytes secrete TGF-B stimulating bone marrow fibroblasts to fill medullary space with collagen
- bone marrow fibrosis leads to: extramedullary hematopoiesis, splenomegaly, cytopenias, and dacrocytes (teardrop cells)
- dry tap
what causes xeroderma pigmentosum vs lynch syndrome vs ataxia-telangiectasia vs BRCA1/Fanconi
XP: single stranded DNA nucleotide excision repair defect, endonuclease problem
Lynch: single stranded DNA mismatch repair defect
AT: double stranded DNA nonhomologous end joining defect
BRCA1/Fanconi: double stranded homologous recombination defect
what drugs improve survival in pts with congestive heart failure and reduced left ventricular ejection fraction, improve ventricular remodeling
mineralocorticoid receptor antagonists (Spironolactone and eplerenone)
-prevent aldosterone from binding
where are MHC Class I vs II expressed
I –> all nucleated cells, APCs, platelets (except RBCs)– associated protein is B2-microglobulin
II –> APCs only (associated protein is invariant chain)
subacute cerebellar degeneration in pt with a tumor as well
tumor is likely either small cell lung cancer, breast, ovarian, or uterine cancer
-etiology is autoimmune due to anti-yo, anti-p/q, and anti-hu antibodies
what will you see on a pt with medullary carcinoma
from parafollicular C cells
- produce calcitonin
- sheets of cells in amyloid stroma (stains with congo red)
in the event of a nuclear accident what should be given to everyone prophylactically
potassium iodide to protect the thyroid from excess accumulation of radioactive iodide
-potassium iodide will competitively inhibit thyroid uptake of radioactive iodine isotopes to prevent thyroid carcinoma
what comes from the right and left horns of the sinus venosus respectively (cardio embryology)
right –> smooth part of right atrium
left –> coronary sinus
what is the pentad for thrombotic thrombocytopenic purpura and whats absolutely required for the diagnosis*
- hemolytic anemia with schistocytes (MAHA)****
- thrombocytopenia***
- renal failure
- neurologic manifestations
- fever
what type of heart attack of the LAD would spare leads V1-V2
distal LAD
normal pressure hydrocephalus
triad of ataxic gait, urinary incontinence, then dementia
- due to distortion of periventricular white matter
- bladder control is influenced by descending cortical fibers that run in the distended paraventricular area
sacral vs pontine micturition center vs cerebral cortex and peeing
sacral –> S2-S4 responsible for bladder contraction, parasympathetic fibers travel from S2-S4 ventral white matter within pelvic nerves and stimulate cholinergic receptors in bladder wall
pontine –> located within pontine reticular formation, coordinates relaxation of external urethral sphincter within bladder contraction during voiding
cerebral cortex –> inhibits sacral micturition center
spelunking
exploration of caves
septic abortion
staph aureus or gram negative bacilli
risk factor for cervical dysplasia
- multiple sexual partners (#1) – also lack of barrier contraceptives
- smoking
- early coitarche
- DES exposure in utero
- immunocompromised (HIV or transplant pts) cause this increases your risk of HPV
what inhibits fatty acid oxidation
malonyl-coa (blocks carnitine acetyltransferase)
histology of condyloma lata
- its part of secondary syphilis
- intense plasma cell-rich infiltrate with proliferative endarteritis
what types of tumors are associated with alpha-fetoprotein
hepatocellular carcinoma and germ cell tumor
TdT+, CD10+, CD19+
all immature B-cell leukemias
complications of sjogren syndrome
non-hodgkin lymphoma, corneal damage, dental caries
how to reverse warfarin
to do it quickly give fresh frozen plasma and to do it but kinda slowly give vitamin K
Cataracts, Toupee, Gonadal atrophy
myotonic dystrophy type 1 (mainly of type 1 fibers)
- AD
- CTG trinucleotide repeat in DMPK gene
what are the selective arteriolar vasodilators
hydralazine and minoxidil
- this dilation causes the sympathetic system to ramp up and stimulate the baroreceptors
- increases CO, HR, contractility, and sodium/fluid retention
fractures to the orbital floor
this is where the infraorbital nerve runs (along the orbital floor in a groove in the maxilla before exiting the skull just inferior to the orbit)
- damage can result in parasthesia of the upper cheek, upper lip, and upper gingiva
- the inferior rectus muscle may also become entrapped, limiting vertical gaze
hematomas over the mastoid process along with periorbital ecchymosis and clear otorrhea
basilar skull fracture
what are the major hip flexors
iliopsoas, rectus femoris, and tensor fascia lata
hip abduction
gluteus medius and minimus
hip extensors
gluteus maximus
semitendinosus
semimembranosus
biceps femoris - long head
what leads to an abdominal aortic aneurysm
- occurs below renal arteries
- associated with increased age, smoking, hypertension, male, and family history —> these all lead to chronic transmural inflammation leading to the AAA
chest/back pain, cough, dysphagia, hoarseness, dyspnea
thoracic aortic aneurysm
kid with recent onset of gait instability and ataxia with biopsy of brain mass involving sheets of primitive cells and many mitotic figures
medulloblastoma
what is the major tropic/regulatory hormone of the zona fasciculata and reticularis
ACTH
-if a pt has ACTH dependent cushings they will have an increased level of ACTH that is not suppressed by dexamethasone and you will see bilateral hyperplasia of the F and R layer of the adrenal glands
how to accentuate an S3/S4
listen to it while the pt is at the end of expiration in the left lateral decubitus position
cystatin c
filtered at the glomerulus and no active reabsorption occurs and metabolized by kidney tubules so amount of excretion is variable
transport maximum in the kidney
limit to the rate at which a substance can be reabsorbed by the kidney
- so the kidney will absorb everything until it gets to the transport maximum then it will start excreting it in the urine
- glucose starts getting excreted at 200mg/dl and the Tm of glucose is 375mg/dl
how to treat a pt with turner syndrome
growth hormone which activates IGF-1 via the JAK-STAT pathway
selective medium containing vancomycin, colistin, nystatin, and trimethoprim
thayer martin medium
- selective chocolate sheep blood agar infused with…
- vancomycin–> inhibit gram +
- colistin and trimethoprim–> other gram negatives
- nystatin–> inhibit yeast
-selective for neisseria
what lab value is associated with placental abnormalities and fetal growth restriction in the fetus… also what would cause this
decreased estriol levels
-caused by tobacco smoking during pregnancy
explain the mechanism of carotid massage
increases pressure on carotid sinus –> increases stretch –> increases afferent baroreceptor firing –> increases AV node refractory period –> decreases HR
-NOTE: baroreceptors increase in firing in response to an increased pressure placed on them/the vessel wall and vice versa
where do you see endoneurial inflammation vs endomysial inflammation
endoneurial –> guillan-barre
endomysial –> polymyositis
organophosphates
these are typically found in pesticides used by farmers and are cholinesterase inhibitors
bromocriptine
BRO work on the boobs and youll be able to have a baby
-dopamine agonist that inhibits pituitary prolactin secretion to restore fertility in women with hyperprolactinemia
flaccid paralysis, parkinsonian features, and lymphocytic pleocytosis
west nile virus (via insect bite)
-usually also presents with flu-like illness and maculopapular/morbilliform rash
what can you give to pt with deficient IL-12
IFN-gamma to help fight the granulomatous mycobacterial infections
st johns wort
induces cytochrome p450 and can decrease the activity/efficacy of warfarin
-cause they metabolize warfarin faster
mneumonic for cyp450 inducers
MOst CHRONIC ALCOHOLics STeal PHEN-PHEN and NEVer Refuse GReasy CARBs
- Modafinil
- chronic alcoholism
- st. johns wort
- phenytoin
- phenobarbital
- nevirapine
- rifampin
- griseofulvin
- carbamazepine
*these metabolize the drugs faster and cause a decrease in their efficacy
anastrozole, letrozole, and exemestane
aromatase inhibitors
- reduce synthesis of estrogens from androgens
- you can give these to pts with estrogen receptor positive tumors to slow their growth
*note: in a premenopausal pt you can give goserelin (long acting GnRH analog to decrease follicle stimulation) for ER+ tumors
adult primary brain tumors
NOTE: these are all above the tentorium
Ms (meninges/myelin)
- oligodendroma
- schwannoma
- meningioma
blastomas
- glioblastoma multiforme
- hemangioblastoma
-Pituitary adenoma
childhood primary brain tumors
NOTE: these are all below the tentorium
Even Children Pick My Pears
- Ependymoma
- Craniopharyngioma
- Pilocytic astrocytoma
- Medulloblastoma (M-blast)
- Pinealoma
how do sex hormones effect bone development
initially increase linear growth but eventually encourage closure of epiphyseal growth plate
what is somatomedin C
IGF-1 (secreted by liver)
what type of cancer is likely to arise from acitinic keratosis (think of uworld bald man head pic)… what will you see on histology
squamous cell carcinoma
histologic findings: keratinocyte atypia, parakeratosis, hyperkeratosis
basal cell carcinoma phenotype and histology
most common skin cancer
- phenotype: pearly papules with central depression or ulceration
- histo: nests of basaloid cells and peripheral palisading of nuclei
what increases bleeding time and PTT
von Willebrand disease
pathology of buerger disease
segmental thrombosing vasculitis with vein and nerve involvement
granulomatous thickening and narrowing of aortic arch and proximal great vessels
takayasu arteritis
transmural inflammation of arterial wall with fibrinoid necrosis possibly at different stages of inflammation
polyarteritis nodosa
-may also present with innumerable renal microaneyrysms and spasms on arteriogram
fine needle aspiration of thyroid tumor showing clusters of large overlapping nuclei containing sparse, finely dispersed chromatin with numerous intranuclear inclusion bodies and grooves
papillary carcinoma
- orphan annie nuclei
- psammoma bodies
- increased risk with RET/PTC rearrangements and BRAF mutations
anaplastic carcinoma
older pt with rapidly enlarging neck mass taht compresses recurrent largyngeal nerve and other things to cause problems
- poor prognosis
- tp53 mutations
medullary carcinoma
parafollicular c cell tumor that produces calcitonin and has amyloid stroma and stains with congo red
what medication exacerbates hypoglycemia and masks its symptoms …. what mediates this
nonselective beta blockers (use in caution with pts using insulin)
mediated by norepinephrine and epinephrine
how is ascaris lumbricoides transmitted
contaminated food and water
loeffler syndrome
early pulmonary manifestations of worm infections that go to your alveoli to mature
cholesteatomas vs cholesterol granulomas
-both leading to conductive hearing loss
Cholesteatomas
- collections of squamous cell debris that form a pearly mass behind the tympanic membrane
- can be congenital or acquired
- can cause hearing loss due to erosion into auditory ossicles (conductive hearing loss)
Cholesterol granulomas
- form in middle ear after hemorrhage (less common)
- bluish-black gelatinous material behind tympanic membrane
- cholesterol and lipid accumulation
tumor that crosses the corpus callosum and has EGFR overexpression
glioblastoma multiforme
what can cause vesicoureteral reflux
usually occurs in pts where the ureters enter the bladder at a more perpendicular angle causing inflammation due to bacteria build up in the ureters/kidneys with the refluxed urine
-kidney will have dilated calyces with overlying renal cortical scarring
medial rectus palsy (this being the only problem) with normal convergence
medial longitudinal fasciculus impaired
-ipsilateral dorsal pons problem
recurrent episodes of hematuria concurrently with respiratory or GI tract infections
IgA nephropathy (due to circulating immune complexes)
- LM –> mesangial hypercellularity
- IF –> IgA in mesangium
porcelain gallbladder
manifestation of chronic cholecystitis and is often found associated with multiple gallstones
- due to dystrophic intramural deposition of calcium salts in the setting of chronic inflammation
- increased risk of adenocarcinoma of the gallbladder
what gets activated in smoking induced emphysema
macrophages and neutrophils release proteases (like elastase)
what are the 5 most common problems that can be developed in atheroembolic disease
stoke renal ischemia bowel ischemia livedo reticularis (purple discoloration of skin) blue toe syndrome
*you will see cholesterol deposits
which enzymes in the TCA cycle require vitamin B3
- these steps need NAD+
- pts present with the three Ds: dermatitis, diarrhea, dementia
pyruvate dehydrogenase
isocitrate dehydrogenase
alpha-ketoglutarate
malate dehydrogenase
histologically differentiate choriocarcinoma with moles
moles have villi and choriocarcinoma do not
what stage do people have parasomnias (sleepwalking and night terrors)
Non-REM 3
what cells trigger granuloma formation
Th1, IL-12, IFN-gamma
Th1 secretes IL-17 and TNF-alpha
what decreases during exercise compared to other variables like heart rate and afterload
total vascular resistance decreases because all of the vasculature constricts except for whats going to your skeletal/working muscles (those are preferentially dilated to shunt more blood to them)
peptostreptococcus, fusobacterium, prevotella, and bacteroidies are associated with what pathology
aspiration of anaerobic bacteria which can cause lung abscesses
-risk factors for abscesses: alcoholism, drug abuse, seizure disorder, previous stroke, and dementia
if a hospitalized pt is doing ok then suddenly develops difficulty breathing and hypoxemia what should you think of
acute respiratory distress syndrome
permethrin mechanism of action
used for lice and it blocks sodium ion conductivitiy in their neurons and paralyzes then kills the louse
embryonically derived from cardinal veins
superior vena cava (used as central line placement)
orotic acid increased with normal ammonia levels
orotic acid increased with hyperammonemia
normal ammonia: orotic aciduria (UMP synthase defect)
hyperammonemia: ornithine transcarbamylase deficiency
how to acutely treat a thyroid storm
3 Ps
Propranolol
Propothiouracil
Prednisolone
councilman bodies
cytotoxic T-cell mediated apoptotic bodies appearing as round acidophilic (pink on hematoxilin and eosin staining) on hepatocyte cell surface due to presence of viral antigens
three phases of ARDS
- exudative: inflammatory cytokines and leakage of fluid into alveoli with hyaline membranes
- proliferative: collagen deposited and edema reabsorbed
- fibrotic: minority of pts have too much collagen deposition and they get fibrotic scarring
short stature, absent thumbs, aplastic anemia
fanconi anemia
-inherited and increases the risk of malignancy, myelodysplastic syndrome, and AML
what phases increase gastric acid secretion and which decrease it
cephalic and gastric phases increase gastric acid secretion
intestinal influences/phase decreases it
vecuronium mechanism of action
competative antagonists of acetylcholine receptors
yeast, psuedohyphae, and positive germ tube test (see both line tubes and circles in the histo picture)
candida albicans
-common in pts getting chemo/immuunocompromised
diabetic ketoacidosis + black necrotic eschar is highly suggestive of what
mucomycosis
-treat with antifungals and surgical removal of the necrotic areas
what would increase the sound of a VSD
maneuvers that increase afterload (handgrip)
in diabetic neuropathy what occurs with small vs large fiber neuropathies
small –> predominance of positive symptoms like pain
large –> predominance of negative symptoms like numbness
*usually long axons are first messed up due to metabolic disturbances
what drug can you give to treat infertility in a pt with PCOS
clomiphene
diffuse fibrous thickening and distortion of mitral valve leaflet edges and narrowing of mitral valve orifice
mitral stenosis due to acute rheumatic fever
5-hydroxyicosatetraenoic acid (5-HETE)
produced by variety of immune cells and serves as leukotriene and lipoxin precursor
-can also causes neutrophil and macrophage chemotaxis and neutrophil degranulation
pt presents with diabetes insipidus, hypothyroidism, and tremor… what medication did the pt take and why do you have to make sure they arent pregnant while on the med
lithium
-its a teratogen and causes ebstiens anomaly (think thi-tri)
what are myxomatous changes
pathologic weakening of connective tissue
what disease is associated with myxomatous degeneration with pooling of proteoglycans in the media layer of arteries
marfans disease
- associated with aortic aneurysms and dissections
- AD mutation in fibrillin (extracellular matrix protein)
mneumonic for twins and number of amnions/chorions
SCAB
4 days/morula: Separate chorion and amnion
8 days/balstocyst: shared Chorion
12 days/implanted blastocyst: shared Amnion
13+ days/formed embryonic disc: shared Body
cardiolipin-cholesterol-lecithin antigen is used for what
screening test for treponema pallidum
-then look for the actual treponemal antigens
small bacterial bowel overgrowth results in a decrease in what vs an increase in what
deficiency of vitamins A, B12, D, E, and iron
increase in folic acid and vitamin K
bartonella henslae
cat scratch disease
-axillary lymphadenopathy
bacilliary angiomatosis
- red dots all over
- ONLY in immunocompromised pts
can use a silver stain for dx and you can use macrolides for both if needed but doxycycline is preferred in BA
where can beta 1 receptors be found
heart and kidney (juxtaglomerular part)
acute febrile illness with headache, retro-orbital pain, joint and muscle pain
dengue fever
-transmitted via aedes aegypti
what drugs have disulfirma like reactions
Sorry Pals, Cant Go Mingle
1st generation Sulfonylureas, Procarbazine, certain Cephalosporins, Griseofulvin, and Metronidazole
greatest risk with a cavernous hemangioma
hemorrhage
main inflammatory cytokines
IL-1, IL-6, TNF-alpha —> leads to endothelial damage, capillary leakage, hemorrhagic necrosis
fever and fatigue with new onset cardiac murmur
infective endocarditis
triad involved in scleroderma and what are the types
- autoimmunity
- noninflammatory vasculopathy
- collagen deposition with fibrosis… FIBROUS REPLACEMENT
Diffuse
- widespread and rapid progression
- anti-scl-70 antibody (anti-DNA topoisomerase-I antibody) and anti-RNA polymerase III
Limited
- CREST syndrome
- limited skin involvement to face and fingers
dysuria and gross hematuria, erythematous bladder
-not necessarily painful
schistosomaiasis
- due to infected snails residing in freshwater
- in asia, africa, and south america
gross hematuria, acute flank pain, passage of tissue fragments in urine
-in a pt with sickle cell disease/trait, diabetes mellitus, analgesic nephropathy, or severe obstructive pyelonephritis
renal papillary necrosis
who is at an increased risk of vibrio vulnificus
those with liver disease and iron overload
-presents with septic shock, bullous lesions, hemorrhagic bullae, and necrotizing fascitis
hyponatremia + lung mass
SIADH (paraneoplastic syndrome)
pirfenidone
antifibrotic agent that blocks TGF-beta to slow progression of pulmonary fibrosis
pts presents with recurrent pulmonary infections (S aureus and pseudomonas), pancreatic insufficiency, infertility, nasal polyps, and clubbing of nails
cystic fibrosis
-for long term you can give pancreatic lipase
-newborns are more likely to have meconium ileus
what supplies blood to the different parts of the ureter
proximal: renal artery
middle: mix of different arteries like gonadal and common iliac
distal: superior vesicle artery
buzzword: erythrocyte p antigen
parvovirus B19
elevated urine methylmalonic acid and propionic acid
methylmalonic acidemia due to a deficiency of methylmalonyl-CoA mutase
- newborn will present with tachypnea, vomiting, lethargy
- hyperammonia, kototic hypoglycemia, metabolic acidosis
*note if you only have increased levels of propionyl-CoA then its a propionyl-CoA carboxylase deficiency
pt comes in with purulent sputum, recurrent infections, hemoptysis, and digital clubbing… what is this and whats associated with it
- associations: obstruction, smoking, cystic fibrosis, kartagners, allergic bronchopulmonary aspergillosis
- pathology: chronic necrotizing infection of bronchi or obstruction —> permanently dilated airways
what make crohns pts more susceptible to gallstones
- increased bile acid wasting
- crohns causes inflammation of the terminal ileum which is where bile is supposed to be taken back up and you cant do this so you let more of it out into the feces
- this causes the cholesterol/bile acid ratio to increase and the extra cholesterol leads to an increased likelihood of gallstones
how to histologically differentiate between crohns and uc
crohns –> noncaseating granulomas, patchy inflammation throughout the GI tract, multinucleated giant cells, paneth cell metaplasia
uc –> crypt abscesses (neutrophil collections with glandular lumen) and crypt atrophy
how to tell the difference between fever and heat stroke and whats the difference in management
FEVER
- cytokine activation during inflammatory infection
- febrile seizure (benign and self limiting)
- manage with acetaminophen/ibuprofen for comfort and antibiotic therapy if needed —-> supportive care only
HEAT STROKE
- inability of body to dissipate heat
- CNS dysfunction, end-organ damage, acute respiratory distress syndrome, rhabdomyolysis
- manage with rapid external cooling, rehydration and electrolyte correction
persistent RUQ pain, murphy sign (inspiratory arrest), fever, leukocytosis
calculous cholecystitis –> due to gallstone impaction in cystic duct resulting in inflammation and gallbladder thickening
-gallbaldder outflow obstruction
-mucosal disruption by lysolecithins, bile salt irritation of luminal epithelium, prostaglandin release with transmural inflammation, gallbladder hypomotility, increased intraluminal pressure causing ischemia, and bacterial invasion
finger abduction and thumb adduction
ulnar nerve
thumb oppostion
median nerve
dropped p wave… where is the problem
p wave in the SA node (in the right atrial wall)
how does the GLUT4 receptor work
carrier-mediated transport // facilitated diffusion (moves from high concentration to low concentration)
-stereoselective with preference for D-glucose
intracranial hypertension (papilledema), dry skin, hepatosplenomegaly
what nutrient problem is this
vitamin A overdose
what diabetes medication causes weight loss vs weight gain
loss: metformin and GLP-1 analogs and SGLT2 inhibitors
gain: sulfonylureas and meglitinides and glitazones
type of epithelia cells in the ovary vs uterus vs fallopian tube
ovary –> simple cuboidal
uterus and fallopian tubes –> simple columnar
how does squatting help in a pt with tetralogy of fallot (pathologically caused by deviation of the infundibular septum)during a tet spell
increasing systemic vascular resistance
what defect can cause an indirect inguinal hernia as well as fluid collection around the testes (communicating hydrocele)
failure of obliteration of the processus vaginalis
-this leaves a persistent connection between the scrotum and peritoneal cavity through the inguinal canal
- if the opening is small then fluid can leak through leading to a communicating hydrocele
- if the opening is large then bowel or peritoneal organs can herniate through LATERALLY to the inferior epigastric vessels causing an indirect inguinal hernia (covered in spermatic cord tissue)
what is the classic treatment for lung abscesses
clindamycin
migratory (superficial) thrombophlebitis
aka. Trousseau sign (superficial venous thromboses)
- seen in hypercoagulability usually due to a visceral cancer (of pancreas, colon, or lung)
most susceptible part of the heart to form a thrombus
left atrial appendage
what do you see on histology in a pt who had an amniotic fluid embolism
- clinically you will see the mother go into respiratory/cardiac distress then suffer from DIC
- histologically you will see pulmonary artery branch with swirls of fetal squamous cells
what do you see in wolff-parkinson white syndrome
- LOOK FOR THE FREAKING DELTA WAVE
- atrioventricular reentrant tachycardia
what happens to the nonstenotic kidney in renal artery stenosis of just one kidney
it gets exposed to very high pressures due to all the renin released by the other kidney
-so it undergoes hyaline arteriolosclerosis (onion-skinning)
whatre the common paraneoplastic syndromes associated with Renal Cell Carcinoma
hypercalcemia and erythrocytosis
insulin-dependent glucose transporters
GLUT4 –> adipose tissue and striated muscle
note: exercise can also increase GLUT4 expression
insulin-independent transporters (BRICK LIPS)
GLUT1 –> RBCs, brain, cornea, placenta
GLUT2 (bidirectional) –> beta islet cells, liver, kidney, kidney, GI tract
GLUT3 –> brain and placenta
GLUT5 –> fructose
SGLT1/2 (Na-glucose cotransporters) –> kidney and small intestine
Brain RBCs Intestine Cornea Kidney Liver Islet beta cells Placenta Spermatocytes
what can cause increased uric acid production
cytotoxic chemotherapeutic agents (tumor lysis syndrome)
mechanism of action of aminoglycosides and whatre the adverse effects
irreversible inhibition of initiation complex through binding of the 30S subunit
- can also cause misreading of mRNA and block translocation
- requires O2 for uptake (only for anaerobes)
- adverse effects: nephro- and oto- toxic
- mechanism of resistance: bacterial transferase enzymes inactivate the drug by acetylation, phosphorylation, or adenylation
valsalva (strain phase), abrupt standing, and nitroglycerin administration all cause what
decreased preload, decreased left ventricular blood volume
-increase in hypertrophic cardiomyopathy murmur intensity
sustained handgrip, squatting, and passive leg raise all cause what
increase in afterload and preload
boerhaave syndrome vs mallory weiss syndrome
both are due to violent retching and both are tears of the esophagus
boerhaave: transmural involving all layers so you get air in the mediastinum, usually in the distal esophagus… pt will present with crepitus and crunching sound
mallory-weiss: longitudinal usually in gastroesophageal junction confined to submucosa and mucosa…. pt will present with hematemesis
what movement is the piriformis muscle involved in
external hip rotation and if damaged it can compress the greater sciatic nerve
-both are in the greater sciatic foramen
antral predominant gastritis
H pylori
- increases risk of peptic ulcer disease and MALT lymphoma
- normal/decrease in gastrin and gastric acid secretion
different volume of distributions and what that means
Low (3-5L)
- intravascular
- large/charged molecules; plasma protein bound
Medium (14-16L)
- ECF
- small hydrophilic molecules
High (41L)
- All tissues including fat
- small lipophilic molecules, especially if bound to tissue protein
horizontal transection of the rectus abdominis muscle must be done carefully as to not cut what
inferior epigastric arteries as they enter the muscle at the level of the arcuate line
most common cause of portal hypertension
cirrhosis
-variceal hemorrhaging is due to left gastric vein shunting
meperidine
opioid agonist
dystrophic calcification on aortic valve… what is the first step in this occurring?
cell necrosis (in the setting of normal calcium levels) -you will see psammoma bodies
-if they have high calcium levels then its some sort of metastasis
toxins of bordetella pertussis
tracheal cytotoxin –> destroys ciliated epithelial cells
pertussis toxin –> AB toxin enters cells and activates adenylate cyclase, leading to alterations leading to alterations in cellular signaling that inhibits phagocyte activity
Bcl-2
antiapoptotic molecule (inhibits apoptosis) -follicular and diffuse large B cell lymphoma
phenytoin adverse effects
all the adverse effects
- p450 inducer
- hirsutism
- enlarged gums
- nystagmus
- yellow/brown skin
- teratogen
- osteopenia
- inhibits folate absorption
- neuropathy
sevelamer mechanism of action
nonabsorbable anion-exchange resin
-decreased intestinal absorption of phosphorus
vitiligo
absence of melanocytes in the skin/epidermis
potency of inhaled anesthetics
minimal alveolar concentration
asbestosis can cause two types of cancer and which is more likely
- bronchial epithelium (most common)
2. malignant mesothelioma
how is melanin formed
tyrosine oxidation
what does angiotensin II stimulate
aldosterone and endothelin 1
ischemic necrosis of the pituitary vs acute hemorrhage
ischemic necrosis = sheehan syndrome due to hypoperfusion of the enlarged pituitary gland
acute hemorrhage = pituitary apoplexy usually presents with headache and bilateral hemianopsia and opthalmoplegia… usually occurs due to preexisting pituitary adenoma
where the blood in the body the LEAST oxygenated
coronary sinus (even less O2 than in the pulmonary artery)
MDD with atypical features… what are these features and which drugs are most likely to work
mood reactivity –> mood improves in response to a positive event
leaden paralysis –> pts arms and legs feel heavy
rejection sensitivity –> overly sensitive to light criticism
-MAOIs are useful cause these are more likely to cause treatment resistant MDD
what is a key feature in PRIMARY herpes simplex virus
gingivostomatitis… the pain this causes usually results in dehydration (most common reason for hospitalization)
subluxation
malalignment
hepatocytes with finely granular, homogenous, pale pink cytoplasm (eosinophilic with ground-glass hepatocytes)
hep b infection
how do citrate levels affect kidney stone formation
citrate excreted by the urine usually binds calcium oxalate and takes it out of the body (into the urine) with it so youre less likely to form stones when you have a high urinary concentration of citrate
what is the problem in diabetic gastroparesis
dysfunction of gastric enteric neurons
what do the pili of neisseria meningitis bind to
colonization of nasopharyngeal epithelium
if the question stem tells you that a heart murmur gets worse during inspiration… what do you do
pick the answer where something is wrong with the right side of the heart
-blood goes back to the heart on inspiration
what are the mRNA stop codons
UGA –> U Go Away
UAA –> U Are Away
UAG –> U Are Gone
speed of conduction down an axon depends on 2 constants… what are they
length (space) constant –> measure of how far along the axon an electrical impulse can travel without needing to be regenerated by ion channels
time constant –> measure of the time it takes for the membrane potential to respond to a change in membrane permeability
note: velocity = length/time
what is the most common cause of community acquired pneumonia in HIV and non-HIV pts?
strep pneumo
-you will see lobar consolidation
what to think when you have a salt wasting/vomiting baby
21-hydroxylase deficiency
decrease in cortisol and no aldosterone is being made so you have a baby with a lot of sex hormones
-low bp and increased K+
how can you decrease renal plasma flow but increase filtration fraction
constrict the efferent arteriole
top 3 risk factors for coronary heart disease
- noncoronary atherosclerotic disease
- diabetes mellitus
- chronic kidney disease
pelvic fracture and now the pt cant pee… what do you think of
posterior urethra
what is required to make lactate in anaerobic metabolism
NADH is used
in glycolysis NAD+ is used so these two cycles kinda work together
first line treatment for psoriasis
topical corticosteroids
and
vitamin D analogs –> inhibit T cell and keratinocyte proliferation and stimulate keratinocyte differentiation
compare and contrast bipolar 1 vs 2
1 –> manic episode only (depressive episodes common but not required for diagnosis)
2 –> hypomanic + depressive episode
what artery can compress CN3
PCA (posterior communicating artery)
how to adapt to urea cycle disorders
limit protein intake b/c the urea cycle is essentially from amino acid catabolism
what shape are the crystals in pseudogout
rhomboid
owl eye should only make you think of 2 things….
- hodgkin lymphoma – reed sternberg cells
2. CMV (HHV-5)
where and how is the most common way for the liver to have tumors
tumors from the colon are most likely to spread to the liver via the portal system
what are the first three steps in collagen synthesis and where do they occur
- synthesis
- hydroxylation
- glycosylation
Note –> these all occur in the RER
tyrosinase deficiency
albinism
succinylcholine
- strong ACh receptor agonist
- depolarizing neuromuscular blocking drug
- Reversal of blockade
- —phase 1 block: prolonged depolarization
- —phase 2 block: repolarized but blocked
- adverse effects –> hypercalcemia, hyperkalemia, and malignant hyperthermia, bradycardia
what are the nondepolarizing neuromuscular blocking drugs
atracurium, cistracurium, pancuronium, rocuronium, vecuronium
-competitive ACh antagonists
-you can reverse this block with neostigmine + atropine OR glycopyrrolate
cytotoxic vs vasogenic edema
cytotoxic –> intracellular edema, impaired function of ATP-dependent Na/K+ pump on neuronal cell membranes
vasogenic –> extracellular edema, increased vascular permeability due to effects of pro-inflammatory cytokines
what gene is abnormal in hereditary pulmonary hypertension
BMPR2
-causes smooth muscle cell proliferation
if a pt gets a high-volume blood transfusion…. why should you keep an eye on their calcium levels
citrate anticoagulants can chelate plasma calcium leading to hypocalcemia causing peripheral neuromuscular excitability (parasthesia, muscle spasm)
-most common with very rapid transfusion rates or at low transfusion rates but in a pt with hepatic insufficiency b/c citrate is metabolized by the liver
tremor when carrying out simple daily activities
essential tremor –> inherited AD and you can give pts beta blockers (propranolol)
large, unilateral adenexal mass, thickened endometrium
- yellow firm ovarian mass
- small cuboidal cells in sheets with gland-like structures containing acidophilic material
- microfollicular pattern with pink, eosinophilic center
Granulosa cell tumor
- increase estrogen and inhibin
- call-exner bodies // coffee bean nuclei
- yellow theca cells with lipid
what do transaminase levels do
if they are increased then you know the disease process has something to do with the liver
what are ceruloplasmin levels in wilson disease
low ceruloplasmin and you will also see high urinary copper levels as well
placenta accreta vs increta vs percreta
accreta –> attaches to myometrium without penetrating it, most common
increta –> placenta penetrates into myometrium
percreta –> placenta penetrates/perforates through myometrium and into uterine serosa invading the entire uterine wall
all three of these can cause postpartum bleeding
how are monoclonal antibodies removed from the system when given
-note that they can only be given IV/SubQ/IM due to their large molecular size
removed via….
1. target mediated clearance –> receptor mediated endocytosis upon binding to their targets, removing them from circulation
- nonspecific clearance –> constituitively taken up by reticuloendothelial macrophages (via binding to Fc receptors) and vascular endothelial cells (via pinocytosis)
* note the removal is NOT hepatic or renal
if you see a pt with eisenmenger syndrome how can you tell what is causing it
ASD/VSD cause total body cyanosis
PDA causes lower extremity cyanosis first
where do direct inguinal hernias go and how do older men usually acquire these
go through external (superficial) inguinal ring only
- covered by external spermatic fascia
- occurs in older men due to an acquired weakness in the transversalis fascia
MSH2, MSH6, MLH1, and PMS2 should lead to what…
lynch syndrome // hereditary nonpolyposis colon cancer (AD)
- colorectal cancer
- endometrial cancer
- ovarian cancer
lumbosacral plexopathy
- occurs during fetal descent as a result of direct compression of the lumbosacral trunk
- pts present with foot drop and numbness of the lateral aspect of the leg and dorsum of the foot
defective transportation of cystine, ornithine, lysine, and arginine across the intestinal lumen and kidneys
Cystinuria (AR)
- impaired absorption of these amino acids
- pts have recurrent nephrolithiasis
- urinalysis may show pathognomonic hexagonal cystine crystals
what does reverse transcriptase-PCR detect
quantifies levels of messenger RNA
if a pt is given nitroprusside then develops lethargy and confusion (possible methemoglobinemia) then what should you think
cyanide poisoning
-give pt sodium thiosulfate (the sulfur donor converts cyanide to thiocyanate, which is excreted in the urine)
buzzqord… pt ingests apricot seeds (amygdalin)
cyanide poisoning
-give pt hydroxocobalamin, nitrates, and sodium thiosulfate
what parts of the lung are affected in each type of lung transplant rejection
hyperacute –> fibrinoid necrosis with hemorrhage and ischemia (white graft rejection)
acute –> perivascular mononuclear infiltrates in small blood vessels of the lung and it can expand to the alveolar walls as well
chronic –> scarring/fibrosis of small airways leading to bronchiolitis obliterans
desmolase
cholesterol side chain cleavage enzyme
-cholesterol to pregnenolone
what is reverse T3
when T4 goes into tissues it usually gets converted into T3 and reverse T3
- reverse T3 is an inactive metabolite
- T3 is stronger and goes to work
most common type of pericarditis
MOST COMMON: fibrinous pericarditis
hemorrhagic pericarditis: seen in malignancy, coagulopathy, TB, and post cardiac surgery
purulent pericarditis: seen in active bacterial infection
newborn with tachypnea, sneezing, and diarrhea… what do you give them
methadone cause they likely have neonatal abstinence syndrome
blasts cells in the peripheral blood of a younger boy
ALL
- these blast cells usually make T-lymphocytes
- pts usually present with mediastinal mass
- TdT+ –> DNA polymerase
- t(12;21) –> better prognosis
- may spread to CNS and testes
where does parvovirus replicate?
in erythrocytes
leukocytoclastic vasculitis
cutaneous small vessel vasculitis
- only affects skin and typically arises due to drug or pathogen exposure
- usually see palpable purpura on lower extremities
- histology: perivascular inflammation of small blood vessels with fibrinoid necrosis and predominance of neutrophils and fragmented neutrophilic nuclei
- penicillins, cephalosporins, sulfonamides, phenytoin, and allopurinol are known to cause this
what causes decreased lung elasticity in emphysema
destruction of interalveolar walls
pt with B12 deficiency and macrocytic anemia and stomach problems
AUTOIMMUNE GASTRITIS
-cells attack H+/K+ ATPase and intrinsic factor
where does osteomyelitis occur in the bone
metaphysis
where do giant cell tumors occur in bone
epiphysis of long bones
where does ewing sarcoma of the bone occur
diaphysis of long bones especially in the femur
how to treat diabetic ketoacidosis
saline and insulin (both IV)
- increase bicarb
- decrease potassium
cytochrome p450 monooxygenase
enzyme system present in hepatic microsomes and endoplasmic reticula of varied other tissues
-metabolizes steroids, alcohols, toxins, and other foreign toxins
how to treat pneumocystis jirovecii
TMP-SMX (given for both prophylaxis and treatment)
-sulfa allergies then give–> pentamidine
tertiary vs quaternary amines
tertiary CAN cross the blood brain barrier (physostigmine, galantamine, donepazil, rivastigmine)
quaternary CANNOT cross the blood brain barrier (neostigmine, edrophonium, and pyrostigmine)
if a pt has an angiomyolipoma what should you immediately think of
tuberous sclerosis
drug that causes mouth ulcers
methotrexate (also causes myelosuppresion, hepatotoxicity, pulmonary fibrosis, nephrotoxicity, folate deficiency)
what to think of when a baby presents with poor weight gain and greasy/bulky stool
abetalipoproteinemia (AR)
- mutation in gene for microsomal transfer protein (MTP)
- deficiency in ApoB-48, ApoB-100
- chylomicrons, VLDL, LDL are absent
- affected infants present with severe fat malabsorption, steatorrhea, failure to thrive
- later manifestations include retinitis pigmentosa, spinocerebellar degeneration due to vitamin E deficiency, progressive ataxia, acanthocytosis
- intestinal biopsy shows lipid-laden enterocytes
Treatment –> restriction of long-chain fatty acids, large doses of oral vitamin E
how to histologically tell the difference between aspergillus and mucor/rhizopus
A –> acute septate branching
M/R –> wide angle non-septate branching
how does the huntingtin gene cause decreased transcription of certain genes
the mutated protein blocks histone acetyltransferase
why would an alcoholic become hypoglycemic
ethanol blocks the TCA cycle by increasing the NADH/NAD+ ratio
-this inhibits gluconeogenesis
how do nitrates work cellularly
increasing cGMP causing venodilation
pneumonic for reye syndrome
SHINE Steatosis of liver hepatocytes Hypoglycemia/Heptaomegaly Infection (VZV, influenza) Not awake (coma) Encephalopathy
pt presents with acute renal failure, altered mental status, and oxylate crystals on renal biopsy
ethylene glycol poisoning
-pt develops acute tubular necrosis with vacuolar degeneration and ballooning of proximal tubular cells
what do finasteride, flutamide, ketoconazole, and spironolactone have in common
all have antiandrogenic effects
epidural vs subdural
epidural –> b/w skull and dura mater
subdural –> b/w dura and arachnoid mater
3 major medications to use for MRSA
- Vancomycin –> blocks glycopeptide polymerization by binding D-Ala-D-Ala
- Daptomycin –> depolarizes cellular membrane by creating transmembrane channels
- Linezolid –> inhibits bacterial protein synthesis by binding to 50S subunit
what is the equation for filtration fraction
RPF/GFR
dystrophin
deleted in duchennes
- dystrophin helps anchor muscle fibers primarily in skeletal and cardiac muscles
- connects actin to transmembrane proteins (a- and B-dystroglycan which are both connected to the ECM)
what type of cancer does a pt have who only presents with low blood count and low hemoglobin as well as low reticulocytes
thymoma (2 different paraneoplastic syndromes)
- pure red cell aplasia
- good syndrome –> hypogammaglobulinemia
what acid base disturbance is associated with DKA
increased anion gap metabolic acidosis
treatment for bacterial vaginosis
this is the fishy one
-treat with metronidazole or clindamycin
LM, EM, and IF for acute poststrep glomerulonephritis
LM –> glomeruli enlarged and hypercellular
IF –> starry sky, granular appearance (lumpy bumpy), due to IgG, IgM, and C3 deposition along the GBM and mesangium
EM –> subepithelial humps
capitation vs global payment
capitation –> fixed predetermined fee to cover all medical expenses required by a pt…. payment structure underlying HMO
global payment –> insurur pays a provider a single payment to cover everything associated with an incident of care, usually done for elective surgeries
dexamethasone
steroid that can treat inflammation and decrease cytokines
-can be used in pts with pneumococcal meningitis before antibiotic therapy is initiated to decrease risk of adverse outcomes and death
where are the juxtaglomerular cells primarily located
afferent arteriole
-they are modified smooth muscle cells with renin containing zymogen granules
facial nerve root problem is what
increased sensitivity to sound (right as it exits the brainstem)
engorged pulmonary capillaries with intraalveolar pink acellular material more prominent at the lung bases
pulmonary edema
- pts with left sided heart failure get this
- chronic alcoholism can cause dilated cardiomyopathy and pulmonary edema
saw tooth rete ridges in skin
lichen planus Ps -pruritic -purple/pink -polygonal papules -plaques *note: chronic lesions often show wickham striae (white/lacy markings)
topiramate
block sodium channels and increase GABA
-anticonvulsant that is also used for migraine prophylaxis
list the long acting benzos
diazepam, chlordiazepoxide, and flurazepam
hypertensive pt with stroke in brain…. what type of imaging do you get to confirm
Charcot-Bouchard microaneurysm
- get a CT scan (cant be seen on angiography)
- associated with hypertension and seen in the lenticulostriate areas of the brain
- intracerebral hemorrhage
- progressive neurologic deficits followed by headache
complications of adult type coarctation of the aorta
these pts commonly die of hypertension-associated complications
- left ventricular heart failure
- ruptured dissecting aortic aneurysm
- intracranial hemorrhage
how to tell the difference between the gross morphology of hypertensive vs hypertrophic cardiomyopathy
hypertensive –> uniform thickness of LV
hypertrophic –> localized thickness of the interventricular septum
first line medication for pt with MDD but wants a favorable sexual side effect profile
bupropion
- inhibits NE and DA reuptake
- also used for smoking cessation
- stimulant side effects, headache, and decreases seizure threshold in bulemic pts
acrochordons
skin tags (flesh colored)
pigmented neurons in the posterior rostral pons at the lateral floor of the 4th ventricle
locus ceruleus
-main site of norepinephrine synthesis
MI + new systolic murmur
papillary muscle rupture/displacement causing mitral regurg but this goes away with revascularization
why do pts with hypothyroidism have increased levels of LDL and triglycerides
decreased LDL receptor expression
