UWorld part 2 Flashcards
what does the middle meningeal artery branch off of
Maxillary artery
What does the maxillary artery branch off of
External carotid artery.
What is tachyphylaxis
Rapidly declining effect after a few days of use
alpha adrenergic agonists have tachyphlaxis, resulting in..
rebound rhinorrhea (which is nasal congestion w/o cough, sneezing, or post nasal drip. Rhinorrhea may or may not be present)
Nitroglycerine and tachyphylaxis
Dimished release of NO from target cells. ergo why you need drug free intervals of 8-10 hours.
How is fibromyalgia dx?
Dx made in pt with chronic pain and fatigue for >3 months in absence of physical or laboratory findings suggestive of an inflammatory etiology
tx of fibromyalgia
gradual incremental aerobic exercise
TCA
SNRI
Ankylosing spondylitis
Chronic inflammatory disease of the axial skeleton characterized by progressive pain and stiffness of the spine, sacroiliitis, and positive HLA-B27 serology
Dermatomyositis
autoimmune condition causing bilateral proximal muscle weakness assoc with violaceous eruption on the eyelids and knuckles and elevated creatine kinase levels
Polymalgia rheumatica is what
frequently assoc with what
Inflammatory disorder that affects patients >=50 yo and causes bilateral pain and morning stiffness in the shoulders and hips, weight loss, fever, malaise, and an elevated ESR
Freq assoc with giant cell (temporal) arteritis
Lichen planus
What might be on the plaque surface
5 Ps -Polygonal -Planar -Pruritic -Purplish -Plaques on the wrists, hands, trunk, and legs
Finely reticulated scale termed Wickham’s striae may be present on the plaque surface.
Dermatitis herpetiformis presents how?
Strong association?
erythematous pruritic papules, vesicles, and bullae ahtat appear bilaterally and symetrically on the extensor surfaces.
Strongly assoc with celiac disease
why is dietary fructose rapidly metabolized compared to other sugars (glucose/galactose/mannose)
Dietary fructose is phosphorylated in the liver to F1P and is rapidly metabolized b/c it bypasses PFK-1, the major RLS of glycolysis.
Bone specific alk phos reflects ___ activity
osteoblastic activity.
what markers for osteoclastic activity and which is most reliable?
Urinary deoxypyridinoline (most reliable)
tartrate resistant acid phosphatase
Urinary hydroxyproline
How is bone specific ALK phos differentiated from liver alk phos
Bone specific is easily denatured by heat (bone=boil)
how to treat post operative urinary retention w/ incomplete bladder emptying?
Muscarinic agonist (bethanechol)
or
Alpha1 blocking drug
Enfuvirtide mechanism
binds to heptad repeat 1 (HR1) of gp41, preventing from undergoing conformational changes necessary for the viral membrane to fuse w/ the target cellular membrane. as a result HIV genome denied entry into uninfected CD4+ t cells
why does left ventricular ruptured free wall cause death
profound hypotension from cardiact tamponade, restriction of ventricular filling during diastole.
cardiac tamponade triad
- elevated jugular venous pressure
- profound hypotension
- muffled heart sounds
First step in dx malabsorption
Sudan III stain of stool identifying fecal fat >7 g/day
schistocytes are dx of
traumatic mechanism, either Microangiopathic hemolytic anemia
or
Mechanical damage
HUS vs. DIC
in HUS, Coag system is not activated so coag tests are normal (pt and ptt)
causes of microangiopathic hemolytic anemia
- HUS
- TTP
- DIC
- Malignant hypertension
- Metastatic carcinoma
pathophys of HUS
endothelial cell injury, isolated activation of platelets and formation of microthrombi.
TTP vs. HUS
TTP in adults w/ predominant neurological symptoms
HUS in children with predominant renal involvement
What characteristics common to both TTP and HUS
Fever
Thrombocytopenia
Microangiopathic hemolytic anemia
Tx for TTP or HUS
Emergent plasmapheresis
Dx for dubin johnsons yndrome
conjugated hyperbilirubinemia w/ direct bilirubin fraciton of at least 50% and an otherwise normal liver function profile must be present
Confirm w/ elevated urinary coproporphyrin I
histo feature of dubin johnson
normal but a dense pigment composed of epinephrine metabolites w/in the lysosomes can be seen
how does streptokinase work
forms complex with plasminogen, cleaving it to form plasmin. Plasmin cleaves fibrin, thereby dissolving thrombi
Streptokinase-plasminogen complex also destroys fibrinogen and clotting factors V and VII
SE to streptokinase
hemorrhage
hypersenstivity (b/c protein synth by beta hemolytic streptococci)
organism most commonly assoc with cryoglobulinemia is
hepatitis C virus
what organisms assoc with hemadsorption (hemagglutinins or glycoproteins w high affinity for RBCs expressed on the host cell)
Influenza
Parainfluenza
flucytosine use
mechanism
used in combo with amphotericin B for cryptococcal meningitis in AIDS patients
Nucleotide analog that competitively inhibits RNA synthesis in fungal cells
caspofungin mechanism
use
Blocks synth of glucan component of the fungal cell wall
active against candida and aspergillus.
griseofulvin mech
use
interacts w/ fungal cell microtubules, inhibiting mitosis
accumulates in keratin containing tissues and treats dermatophyte infections (microsporum, epidermophyton, trichophyton)
cyclosporine mech
and use
immunosuppressant in transplant patients to prevent rejection by decreasing IL2 production (thus inhibit T cell prolif)
Polyenes examples
mech
Amphotericin B and nystatin
Binds ergosterol molecules in fungal cell membranes and creates pores causing cell lysis. (especially leakage of K+)
most common locations for colon cancer
rectosigmoid is most common
ascending colon is 2nd most common
left sided vs. right sided colon tumors presentation
left sided tend to be smaller and cause obstruction
right sided cause bleeding, so iron deficiency anemia
what differentiates the different presentations of m leprae
lepromin skin test (m leprae antigens injected intradermally) differentiate between tuberculoid and lepromatous
deficiencies of C3 predispose to
encapsulated organism recurrent infections
deficiencies of C5-9 predisposes to
recurrentinfxn of neisseria meningitidis or n gonorrhoeae
leukocyte adheison deficiency is caused by what?
presents as
defect in D18, common component in many integrins, responsible for leukocyte adherence and transmigration through endothelial walls
presents with
- Delayed separation fo the umbilical cord
- Recurrent cutaneous infection w/o pus formation
- poor wound healing
inherited defect involving interferon gamma results in
disseminated mycobacterial disease in infancey or early childhood. need lifelong treatment w antimycobacterial agents.
xla predisposes to
recurrent lower respiratory tract and giardia lamblia infection
use dependence of class I antiarrhythmics
1C>1A>1B
platelet derived growth factor receptor mutations play a role in
chronic myelomonocytic leukemia
tartrate resistant acid phosphatase stains positively in.
this condition presents with
hairy cell leukemia. the neoplasti cells are B lymphocyte precursors and are CD20+.
presentation
- splenomegaly
- fatigue
- pancytopenia
Terminal deoxynucleotidyl tranfserase (TdT) is responsible for what?
is positive in what?
Adding nucleotides to the VDJ regions of the antibody gene for antibody diversity.
marker of immature lymphocytes both B and T.
Neoplastic cells in acute lymphoblastic leukemia (ALL) are TdT positive.
auer rods found in myeloblasts in AML stain positive for what
peroxidase.
auer rods indicate myeloid differentiation
prognosis of colorectal adenocarcinoma is directly related to what and not to what
related to stage of the tumor
NOT TO THE GRADE
what are the 3 clinical phenotypes of 21-hydroxylase deficiency
classic salt wasting
classic non salt wasting
non classic, delayed
treatment of congenital adrenal hyperplasia
administer low dose exogenous corticosteroids to suppress ACTH secretion. thus decrease androgen production.
medullary carcinoma of the thyroid gland is characterized by
extracelluar deposits of amyloid formed by calcitonin secreted from neoplastic parafollicular C cells
P450 Inhibitors
SICKFACES.COM
Sodium valproate Isoniazid Cimetidine Ketoconazole Fluconazole Alcohol binge/acute Chloramphenicol Erythromycin Sulfonamides Ciprofloxacin Omeprazole Metronidazole
Grapefruit juice
P450 inducers
CRAP GPS induce me to madness
Carbamazepines Rifampin Alcohol chronic Phenytoin Griseofulvin Phenobarbital Sulfonylureas
what artery runs w/ the radial nerve
deep brachial artery
dermatomyositis presentation
- proximal muscle weakness
- violaceous discoloration of the upper eyelids (heliotrope rash)
- Raised violaceous scaling eruption on the knuckles (Gottron’s sign)
- CPK levels elevated
How does PTH act on osteoclasts to cause bone resorption?
binds to osteoblasts, stimulating them to release RANK-ligand and monocyte colony stimulating factor (M-CSF).
These two factors stimulate osteoclastic precursors to differentiate into bone-resorbing, mature osteoclasts
Also decreases release of Osteoprotegerin (OPG) a decoy receptor for RANK-ligand. this allows more interaction between RANK-ligand and the osteoclasts.
Where in the body is oxygen extraction the highest
myocardium. resting is 75%-80%, up to 90%.
in heart ischemia, how quickly do you lose contractility
how long before irreversible dmg
w/in 60 seconds. Although total ATP may still be normal, it is rapidly depleted from areas of the cell w/ high metabolic demand (cytosol surrounding the contraction fibers and electrolyte transport pumps)
reversible if less than 30 minutes. Keep in mind it won’t come back right away is it is stunned
heterophile antibody negative mononucleosis like syndrome dx is
cytomegalovirus infection
aseptic meningitis and herpangina (fever, posterior pharyngeal gray vesicles/ulcers) in children
Coxsackie A
PML from JC virus presentation
hemiparesis
visual field defects
cognitive impairment
What are the two major risk factors for developing ARDS, adult respiratory distress syndrome
what does it cause?
Sepsis and Shock are the two major risk factors for ARDS.
Presents with:
Non-cardiogenic pulmonary interstitial
intra-alveolar edema,
inflammation,
alveolar hyaline membranes
first line antiplatelet drugs
aspirin or clopidogrel
ticlodipine SE
neutropenia presenting as fever and mouth ulcers
where is low frequency sound heard best
at the apex of the cochlea near the helicotrema
where is high frequency heard best
at the base of the cochlea near the oval and round windows
acanthosis is what
and is assoc with what
increase in thickness of the stratum spinosum (b/w the granular cell layer and the basal layer of the epidermis)
Associated with psoriasis
Spongiosum is what
assoc with what
intercellular epidermal edema that histologically appears as an increase in the width of spaces b/w cells.
associated with spongiotic dermatitis,
acantholysis is what
assoc with what
loss of cohesion b’/w keratinocytes in the epidermidis or in adnexal structures.
assoc with spongiotic dermatitis.
Dyskeratosis is what
assoc with what
abnormal premature keratinization of individual keratinocytes. may be strongly eosinophilic and have small basophilic nuclear remnants.
found in diseases like scc
urticaria/hives is characterized by
superficial dermal edema and lymphatic channel dilation.
no epidermal changes are present
what has a high specificity for rheumatoid arthritis
antibodies to citrullinated peptides/proteins
what is citrullination
tissue inflammation causes arginine residues in proteins like vimentin to be enzym converted into citrulline. this changes protein shape and can serve as antigen.. Exaggerated response to this is seen specifically in Rheumatoid Arthritis.
what CD is found on all NK cells and binds to the constant region of IgG
CD16
what CD inhibits complement C9 binding
CD55 and CD59
What CD is endotoxin receptor found on macrophages
CD14
carcinoid syndrom
BFDR Bronchospasm and wheezing Flushing Diarrhea Right sided heart lesion (valvular lesion and HEart murmurs)
if patient is on cyp450 3a4 inhibitor, what statin can u give them
pravastatin
ataxia telangiectasia is caused by what (mech)
presentation
defect in ATM gene leading to DNA double strand breaks and cell cycle arrest
(the As!!) cerebellar defects (Ataxia),
spider Angiomas (telangiectasia),
IgA deficiency (repeated sinopulmonary infections)
increase in AFP
catalase positive organisms that become problematic in CGD
Staph aureus
Burkholderia cepacia
Serratia maracescens
Nocardia
Aspergillus
AFP marker
useful marker in cirrhotic pt at increased risk for hepatocellular carcinoma. regularly monitoring in this pt population is recommended.
CEA marker assoc with what
used for what
assoc with colorectal cancer
used for staging/planning. NOT screening
CA125 marker assoc w/
used for
assoc w/ ovarian cancer. also other malignancies and other benign.
not effective screening. monitoring temporal changes may be of benefit
PSA use
establish extent of prostate cancer and evaluate response to cancer treatment. controversial to screen.
Acid phosphatase marker assoc with
undergoing active osteoclast initiated bone resorption
LAD coronary supplies
anterior 2/3 of the interventricular septum
the anterior wall of the left ventricle
part of the anterior papillary muscle
left circumflex coronary artery supplies
lateral and posterior superior walls of the left ventricle via obtuse marginal branches
acute marginal branches arise from the right coronary areteyr to supply
wall of the rigth ventricle
what is carbamazepine used for
mech?
generalized tonic clonic seizures
simple and complex partial seizures
mood stabilizer in bipolar
trigeminal neuralgia
Mech: blocks voltage gated Na channels in cortical neurons, stabilizing in an inactivated state.
SE of carbamazepine
Bone marrow suppression
Hepatotoxic
ADH secretion (so SIADH)
ethosuximide mechanism
blocks T-type Ca2+ channels and decreases calcium current in thalamic neurons
detection of elevated amounts of ____ helps dx creutzfeldt jakob disease
14-3-3 protein
how to treat neonatal opioid withdrawal
tincture of opium
most common cause of meconium ileus
CF
Most common cause of death for CF patients
Pneumoniae
what is identified in about 50% of systemic b cell lymphomas and almost all primary CNS lymphomas occuring int he setting of HIV infection?
Epstein Barr Virus
in patients with Hypertrophic cardiomyopathy, how does dynamic left ventircular outflow tract obstruction occur
due to abnormal systolic anterior motion of the anterior leaflet of the mitral valve toward a hypertrophied interventricular septum
what drugs can increase serum uric acid levels
Niacin
Hydrochlorothiazide
Cyclosporine
Pyrazinamide
SE of niacin
increased uric acid
facial flushing/warmth (prevent w/ aspirin)
Hepatotoxicity at high dose
Worsening hyperglycemia in diabetic patients.
SE of statins
hepatitis
myopathy
myalgias
SE of fibrates
hepatotoxicity
myopathy (increased when in combo with statins)
Increase risk of cholesterol gall stones
SE of bile acid binding resins
GI upset
Impaired nutrient absorption and drugs
Hypertriglyceridemia
SE of ezetimibe
mechanism of ezetimibe
Elevations in liver enzymes
Myopathy
Mech: selectively inhibits intestinal absorption of cholesterol
Isoniazid MOA
inhibits mycolic acid synthesis
Rifampin MOA
inhibits bacterial DNA dependent RNA polymerase
Ethambutol MOA
Inhibits mycobacterial cell wall synthesis but with no effect on creation of mycolic acid. Unclear mechanism how.
Streptomycin MOA
Aminoglycoside antibiotic, inhibits bacterial 30S ribosomal subunit, halting protein synthesis.
Uses for streptomycin
Mycobacterium tuberculae
Plague (Yersina pestis)
Tularemia (Francisella tularensis)
prophylaxis for MAC (mycobacterium avium complex)
Azithromycin
what happens to amniotic fluid total protein and albumin concentrations from early gestation to term
Decrease by 50%
What happens to sphingomyelin over the course of pregnancy
unchanged. (it is phosphotidylcholine aka lecithin that increases in the mid 3rd trimester)
acute drug intoxication of
depressed mental status/miosis/respiratory depression
heroin
acute drug intoxication of
choreiform movements/tooth decay/tachycardia/violent behavior and psychosis
methamphetamine
acute drug intoxication of
chest pain/seizures/mydriasis
cocaine
acute drug intoxication of
violent behavior/hallucinations/nystagmus (horizontal or vertical)
PCP/phencyclidine
MOA of PCP
NMDA receptor antagonist –>excess release of excitatory NT
differences b/w PCP and methamphetamine
Meth is longer, lasting up to 20 hours
Nystagmus (vert or horiz) only seen in PCP
cytoplasmic inclusions in oligodendrocytes
Describes
Progressive multifocal leukoencephalopathy
Microglial nodules and multinucleated giant cells are characteristic of
Viral infections of CNS, (Found in HIV assoc encephalopathy for example)
how does prion disease appear?
Affected gray matter undergoes spongiform change: vacuoles form within cytoplasm of neurons and neutrophils. Later grow bigger and form cysts, involving larger areas of the brain tissue.
No inflammatory changes.
major adaptive immune mechanism that prevents reinfection w/ the influenza virus is
anti-hemagglutinin antibodies
what hereditary syndromes are assoc with pheochromocytoma
MEN2A and MEN2B and Von Hippel Lindau disease
Rule of 10s for what condition and what are the rules
Pheochromocytoma 10% part of hereditary syndromes 10% bilateral 10% extradrenal 10% malignant
femoral neck fractures associated with what vessel injury
medial circumflex (which supplies the majority of the blood suppply to the femoral head and neck)
ergonovine test
most sensitive provocative diagnostic test for coronary vasospasm
moa of ergonovine
ergot alkaloid that constricts vascular smooth muscle by stimulating both alpha adrenergic and serotonergic receptors. low doses induce coronary spasm, chest pain, and ST segment elevation
phentolamine moa
alpha1 alpha2 adrenergic antagonist, therefore vasodilating drug
tx for prinzmetal’s angina (variant angina)
nitrates
calcium channel blockers
stabilizing force for secondary structure of proteins
hydrogen bonds
Stabilizing force for tertiary structure of proteins
Ionic bonds
Hydrophobic interactions
Hydrogen bonds
Disulfide bonds
why is there increased incidence of cholelithiasis in women who are pregnant or using oral contraceptives
Estrogen induced increased cholesterol synthesis by upregulating hepatic HMG-CoA reductase activity
Progesterone reduces bile acid secretion and slows gallbladder emptying
meniere’s disease presentation
triad of
- tinnitus
- vertigo
- hearing loss
Mechanism of meniere’s disease
increased vol of endolymph from defective resorption. This causes damage to both the vestibular and cochlear components of the inner ear.
what is meniere’s similar to?
how is it different?
tinnitus/vertigo/hearing loss similar to mass lesions at the cerebellopontine angle (acoustic neuromas, schwannomas of CN VIII)
but the acoustic schwannoma would be progressive and constant not episodic w/ exacerbations and remissions as seen with meniere’s disease
treatment of lung abcesses
Need to cover both anaerobic and aerobic bacteria. so give Clindamycin, the drug of choice for lung abcesses.
what is most common in ALL, B cell or T cell derived. how can you differentiate?
B cell responsible for 70-80%
T cell has symptoms of mediastinal compression (esophageal or superior vena caval syndrome or respiratory symptoms)
B cell has fever, malaise, bleeding, bone pain, hepatosplenomegaly
where does the coronary sinus empty?
right atrium
what can cause coronary sinus dilation
pulmonary hypertension or any factor causing dilatation of the right atrium
pulmonary pressure of
RA RV PA LA LV Aorta
RA:0/8 RV:4/25 PA:9/25 LA:2/12 LV:9/130 Aorta:70/130
RPF is what
RPF=RBF(1-hematocrit)
dx of schizophrenia
2 of 5
- delusions
- hallucinations
- disorganized speech
- grossly disorganized behavior
- negative symptoms
greater than 6 months, including PRODROMAL AND RESIDUAL PERIODS with at least 1 month of active symptoms
canagliflozin mechanism
SGLT2 inhibitors, leading to significant glucose urinary loss (normally 90% of filtered glucose reabsorbed in proximal tubule)
canagliflozin contraindication
moderate to severe renal impairment
what drugs do u need to test thyroid function before taking
amiodarone
lithium
what drugs do you need to test liver function and heart failure before taking
thiazolidinediones
screening tests for treponema pallidum
confirmatory tests
screening with RPR or VDRL
Confirmatory with FTA-ABS
isospora belli causes what
chronic watery profuse diarrhea in immunocompromised patients, especially AIDS
how does trypanosoma cruzi cause achalasia/megacolon/megaureter/megaesophagus
releases neurotoxin that destroys the myenteric plexus and causes intramural parasympathetic denervation of smooth muscle.
what bacteria produce IgA proteases
N gonorrhea
N meningitidis
Strep pneumoniae
Haemophilus influenzae
peptidoglycan precursor molecules consist of
disaccharide of
N-acetylmuramic acid (MurNAc)
N-acetylglucosamine (GlcNAc)
what do sulfonamide antibiotics compete with for incorporation into folic acid?
PABA (paraaminobenzoic acid)
b12 vs. b6 deficiency, how are they different and why?. what does this result in?
b12 is respon for conversion of methylmalonyl CoA to succinyl CoA. thus elevation of methylmalonyl CoA seen only in b12 def
also the incorportaion of nonphys fatty acids into neuronal lipids results in the neurologic dysfunction.
where do most nonsecretory adenomas arise from?
gonadotrophs. presents with mass effects and hypogonadism.
do not produce intact FSH or LH, instead overproduce alpha subunits.
grow slowly
most common cell type in normal pituitay
somatotrophs (secreting Growth Hormone) 50%
Most common pituitary denoma
prolactinoma
hemophilia vs. platelet disorders
platelet disorders have petechial lesions, hemophilia DOES NOT.
mild hemophilia is about what of normal
5% of pro-coagulant normal
hemophilia vs. von willebrand disease
hemophilia has spontaneous hemarthroses but von willebrand disease does not
platelet disorders cause
prolongation of bleeding time
petechiae
von willebrand disease causes
prolongation of bleeding time increased PTT (b/c protects circulating factor VIII from degradation)
desmopressin treats what
mild to moderate hemophilia A
where does hydroxylation of proline and lysine residues in collagen occur
rough ER
most common complication if SAH is survived. how does it present?
how is it seen?
how is it prevented?
secondary arterial vasospasm
new onset confusion and or focal neurological deficit 4-12 days after initial insult.
may not show on CT, but transcranial color doppler may see it.
prevent w/ nimodipine, a selective CCB
most deadly complication of SAH
how does it present
how is it seen
rebleeding, not the most common overall (that is secondary arterial vasospasm). it is the most deadly though.
presents as sudden development of new severe headache, nasuea, vomiting, change in level of consciousness
Seen by CT
what is contained in the superior colliculi
conjugate vertical gaze center
horner syndrome is assoc with what
spinal cord lesion above T1
which occurs with…
Pancoast tumor
Brown sequard syndrome
Late stage syringomyelia
what are the nuclei of vagus nerve and what do they do
I. Nucleus solitarius: conveys visceral sensory information (taste/baroreceptors/gut distension)
II. Nucleus Ambiguous: Conveys visceral motor innervation (Pharynx/Larynx/Upper esophagus)
III. Dorsal motor nucleus: Autonomic fibers (Heart/Lungs/Upper GI)
thalamic syndrome characterized by
characterized by
total sensory loss on the contralateral side of the body.
no motor deficits
proprioceptoin profoundly affected
lesion of internal capsule would cause
motor deficit
ischemic events in pons frequently assoc w/
- coma
- bilateral paralysis
- decerebrate rigidity
- pinpoint pupils
- death
dmg to caudate nucelus assoc w/
transient hemiparesis
frontal lobe symptoms (inattentiveness, abulia, forgetfulness)
agitation/psychosis/choreoathetosis/dyskinesia
lacunar infarctions are the result of what
what are the risk factors?
result of small vessel lipohyalinosis and atherosclerosis involving the penetrating vessels supplying the deep brain structures.
uncontrolled hypertension and diabetes mellitus are risk factors for this condition
causes of congenital hydrocephalus
impaired csf outflow due to congen abnormalities like
- Type II arnold-Chiari malformations
- Hereditary aqueductal stenosis
- prenatal infections (toxoplasmosis)
presentation of congenital hydrocephalus
irritability
poor feeding
muscle hypertonicity and hyperreflexia (dmg from stretching of periventricular pyramidal tracts)
presentation of acute hepatitis B infection
I. Prodrome
-serum sickness like: malaise, fever, rash, pruritis, lymphadenopathy, joint pain
II. Anorexia, nausea, jaundice, RUQ pain. elevated ALT AST, bilirubin and alkphos increase
best way to prevent tetanus
maternal immunization w/ tetanus toxoid, this transfers protective IgG across placenta to the neonate.
what change in blood pressure is seen in old people?
what is it caused by?
isolated systolic hypertension (ISH)
age related decrease in compliance/increased stiffness of the aorta and its proximal major branches
erythrocytes and leukocytes in stool indicate
Enteroinvasive E coli
Campylobacter jejuni
Salmonella
Shigella
Erythrocytes w/o leukocytes in stool indicates
Enterohemorrhagic E coli O157:H7 (toxin mediated enterocyte death and intestinal hemorrhage w/o mucosal invasion)
leukocytes w/ monocytic predominance is typical for
typhoid fever caused by salmonella typhi
leukocytes w/ neutrophilic predominance is typical of
invading bacterial that cause dysentery or inflammatory diarrhea
- Shigella
- Salmonella
- Campylobacter jejuni
- EIEC
Watery diarrhea w/ no erythrocytes or leukocytes indicate
Vibrio cholerae
Enterotoxigenic E coli
thiamine is a necessary cofactor for
pyruvate dehydrogenase
alpha-ketoglutarate dehydrogenase
transketolase
growth pattern of strawberry type capillary hemangiomas
initially grow in proportion with patient, eventually regressing and completely by 7 yrs of age
what happens in cystic fibrosis mechanistically most common?
3 bp deletion removing phenylalanine at amino acid 508. causes impaired posttranslational processing (improper folding and glycosylation) detected by ER. as result it is targeted for proteasomal degradation, preventing it from ever reaching the cell surface
se of lithium involving kidney
antagonize vasopressin on principal cells w/in the collecting duct system.
dysplastic vs. carcinoma is what
reversibility of changes. once the dysplastic cells have breached the basement membrane as seen in invasive carcinoma, the process is no longer considered reversible.
High grade dysplasia=carcinoma in situ
microsopic findings in reye syndrome
electron microscopic findings
micro: microvesicular steatosis (presence of small fat vacuoles in the cytoplasm of hepatocytes). No necrosis or inflammation in the liver.
EM: Swelling, deceased number of mitochondria, glycogen depletion
although u avoid giving aspirin to children under 16, what is an exception
aspirin is a mainstay of kawasaki
characteristic light microscopy findings for viral hepatitis
apoptosis of hepatocytes
acinar necrosis
periportal mononuclear inflammatory inflammation
characteristic finding in right sided heart failure patients
centrilobular congestion
primary biliary cirrhosis displays what
bile duct destruction
periductal granulomatous inflammation,
bile duct proliferation.
presentation of reye’ syndrome
hepatic dysfunction
encephalopathy (hepatic dysfunction and toxic effect of hyperammonemia on the CNS leading to cerebral edema)
how does schilling test work
oral radiolabeled cobalamin and intramuscular unlabeled cobalamin. if URINE EXCRETION higher than 5% then normal. if lower, then repeat with intrinsic factor. If still low then pernicious anemia is ruled out and suggests malabsorption syndrome: pancreatic insufficiency/bacterial overgrowth/short gut syndrome
three phases of dopamine action depending on dose
low: Dopamine D1 receptors (vasodilation and increased blood flow to mesenteric and renal)
Medium: beta1 (increased cardiac contractility)
High: alpha1 (vasoconstriction)
what is normal in ARDS
pulmonary capillary wedge pressure is normal (elevated would suggest cardiogenic hemodynamic cause of pulmonary edema)
most common brain tumor and presentation
metastasis (lung, breast, kidney, skin/melanoma). multiple well circumscribed masses at the junction of gray and white matter.
most common adult primary brain tumor, and second, and third
glioblastoma multiforme
meningioma
acoustic neuroma
neurovasc pairing:
axilla/lateral thorax
surgical neck of humerus
midshaft of humerus
distal humerus/cubital fossa
popliteal fossa
Posterior to medial malleolus
long thoracic/lateral thoracic
Axillary/Posterior circumflex
Radial/Deep Brachial
Median/Brachial
Tibial/Popliteal
Tibial/Posterior tibial
McCune-Albright syndrome
precocious puberty
cafe au lait spots
fibrous dysplasia of bone
Albright heredtiary osteodystrophy (aka type 1A psseudohypoparathyroidism)
pth resist at renal tubules leading to
decreased serum calcium, increased phosphate
Increase PTH release
C3a does what
stimulates mast cell histamine release, causing increased vascular permeability and vasodilation
what is critical for formation and maintenance of granulomas
Interferon-gamma
IL-12
TNF-alpha
prader willi cause and presentation
maternal imprinting (normal and silent) but Paternal gene is deleted/mutated
hyperphagia, obesity, intellectual disability, hypogonadism, hypotonia.
Angelman cause and presentation
Gene from dad is silent and normal. MAternal gene is deleted/mutated
inappropriate laughter, seizures, ataxia, severe intellectual disability.
for prader willi and angelman syndromes, how else can it present other than normal silent and then deleted/mutated allele?
25% of prader willi and 5% of angelman have uniparental disomy.
most common cause of lung abcess
peptostreptococcus
prevotella
bacteroides
fusobacterium
risk factors for lung abcess
alcoholism drug abuse seizure disorders stroke dementia
(conditions increasing aspiration risk)
surface ectoderm gives rise to
skin and appendages
nasal and oral epithelium
anal epithelium to the dentate line
lens and cornea
neuroectoderm gives rise to
all neurons of the CNS neurohypophysis retina pineal gland preganglionic autonomic fibers astrocytes ependymal cells choroid plexus
mesoderm gives rise to
muscles bones blood genital tissues dermis most organ systems NO EPITHELIAL SURFACES
endoderm gives rise to
thyroid tissues
epithelial linings of the
- GI tract
- Lung
- Urethra
- Bladder
- Outer and middle ear
Liver
Pancreas
Lungs
notochord gives rise to
nucleus pulposus
how does methyl capping work
5’ end of all mRNA capped with a 7-methylguanosine residue by a unique 5’ to 5’ linkage which occurs in 2 stages.
- addition of guanine triphopshate to teh 5’ end of the mRNA catalyzed by guanlyltransferase
- Methylation of the guanosine cap catalyzed by guanine-7-methyltransferase.
noninflammatory diarrhea causes
ETEC
EAEC
V cholerae
C perfringens
inflammatory diarrhea causes
Shigella EHEC EIEC C. difficile C. jejuni
presentation of elevated somatostatin
mechanism?
abd pain gallbladder stones constipation hyperglycemia steatorrhea
(b/c inhibition of…
- insulin
- glucagon
- gastrin
- secretin
- cck
- gastrointestinal motility)
presentation of VIPoma
intractable diarrhea
hypokalemia
achlorhydria
(hypotensive due to dehydration and vasodilatory)
zinc deficiency presentation
erythematous skin lesions around body orifices that are predominantly vesicular and pustular w/o a central clearing
- hypogonadism
- azoospermia
- hair loss
- impaired taste
- night blindness
- impaired wound healing.
presentation of glucagonoma
diabetes mellitus
necrolytic migratory erythema (elevated painful and pruritic rash affecting face, groin, extremities. over time coalesce to form large lesions w/ central clearing of bronze colored induration)
normocytic normochromic anemia resembling anemia of chronic disease
who wouldnt you give an ACEI to?
patients dependent on efferent arteriole constriction to maintain renal perfusion (eg: renal artery stenosis). this can lead to acute renal failure
heroin and pamidronate can cause
focal segmental glomerulosclerosis
gold therapy can cause
membranous nephropathy
aminoglycosides, radiocontrast media, cisplatin, amphotericin B , and foscarnet can cause
drug induced tubular necrosis (direct toxic or ischemic effects)
Sulfonamides, methotrexate, intravenous acyclovir, triamterene can cause
drug induced tubular obstruction (intratubular precipitation of tissue degradation products, drugs, or drug metabolites)
Methicillin (most common), cephalopsorin, acetazolamide, allopurinol, sulfonamides, NSAIDs, can cause
acute allergic interstitial nephritis
lithium and cyclosporine can cause
chronic interstitial nephritis
most common and second most common causes of cystitis and acute pyelonephritis
E. coli is most common 80%
Staph saprophyticus is 2nd
major clinical manifestations of factor V leiden
DVT
Cerebral vein thrombosis
Recurrent pregnancy loss
cord factor does what
mycobacterium can cause disease by
- inactivate neutrophils
- damage mitochondria
- induce release of TNF
dx of dubin johnson is made how
conjugated chronic hyperbilirubinemia with a direct bilirubin fraction of at least 50% and an otherwise normal liver function profile.
treatment of digitalis toxicity
oral activated charcoal
manage serum potassium by insulin/kayexalate/hemodialysis (not calcium gluconate)
Digoxin specific antibody fragments
how does PTH work?
acts on osteoblasts to stimulate secretion of monocyte colon stimulation factor and RANKligand. thus stimulating osteoclastic precursor to become mature osteoclasts.
immune complex vasculitis assoc with IgA and C3 deposition
Henoch Schonlein purpura
Henoch schonlein purpura presentation
purpuric rash
colicky abd pain
poly arthralgia
wegeners/granulomatosis w/ polyangiitis presentation
nasal mucosal ulcerations (saddal nose if severe)
glomerulonephritis (oliguria)
serum cytoplasmic stainining antineutrophil cytoplasmic antibodies (C-ANCA)
Takayasu arteritis presentation
weak upper extremity pulses, large vessel vasculitis involving aorta and proximal branches.
lesions are similar to giant cell arteritis
Giant cell arteritis presentation
headache and blurred vision
N-MYC overexpression seen in
Neuroblastoma
Small cell carcinoma of the lung
most common primary CNS tumors in adults
Glial origin
Meningiomas
Pituitary adenomas
GFAP found in
Astrocytomas (glioblastoma multiforme)
Oligodendrogliomas
Ependymomas
Peripheral neural sheath tumors
how are meningiomas Dx?
also where are they from
from cells of arachnoid villi. Benign.
Dx by imaging, do NOT stain for GFAP or synaptophysin
where is synaptophysin found
presynaptic vesicles of:
- Neurons
- Neuroectodermal
- Neuroendocrine
although liver is resistant to infarcts due to dual blood supply, when can it?
Transplanted liver undergoing hepatic artery thrombosis.
can develop biliary tree infarction and organ failure b/c the collateral blood supply is severed during transplantation.
how quickly does irrev dmg in neurons occur during complete ischemia
5 minutes
withdrawal of opiods
dilated pupil piloerection hyperactive bowel sounds lacrimation* yawning*
withdrawal of alcohol and benzodiazepines
seizures* (main diff from opioids withdrawal)
tachycardia
palpitations
mechanism of griseofulvin
use for griseofulvin
binding of microtubular proteins
dermatophytes only
SE of amphotericin B
Nephrotoxicity
Hypokalemia
Hypomagnesemia
treat paroxysmal supraventricular tachycardia
Increase vagal tone by
- Carotid sinus massage
- Valsava maneuvar
if this fails then IV adenosine
how does intestinal phase decrease gastric acid secretion
ileum and colon release peptide YY, binds to receptors on the endocrine, histamine-containing cells described as enterochromaffin like. This counteracts the cephalic and gastrin phases of acid secretion
untreated sleep apnea leads to
pulmonary HTN
Right sided heart failure
how does homocysteine get to cysteine?
I. Serine/B6/Cystahtionine synthetase
II.B6/Cystathionase
how does homocysteine get to methionine
N-5-methyl-tetrahydrofolate and B6
how can Down syndrome occur?
- Trisomy 21 (95%) by meiotic nondisjunction
- Unbalanced Robertsonian translocation (2-3%) 46 chr but extra arm of chr21 attached to another chromosome
- Mosaicism.
findings for obstructive lesion in a mainstem bronchus preventing ventilation of an entire lung leading to lung collapse
Unilateral pulmonary opacification
Deviation of the mediastinum toward the opacified lung
muddy brown cast
acute tubular necrosis
where does hypoxia affect most in renal
why?
Proximal Tubules
Ascending limb of Henle’s loop
b/c located in outer medulla of the kidney, area w/ low blood supply.
AND
active (ATP consuming) transport of ions
symptoms of temporal arteritis
- headache
- craniofacial pain syndromes
- polymalgia rheumatica
- Sudden vision loss
polymalgia rheumatica is assoc with what?
presents how?
assoc w/ temporal arteritis/giant cell vasculitis
neck, torso, shoulder, pelvic girdle pain and morning stiffness
fatigue fever wt loss also.
cAMP signaling
FLAT ChAMP
FSH LH ACTH TSH CRH hCG ADH (V2) MSH PTH Calcitonin GHRH Glucagon
cGMP signaling
ANP
NO (EDRF)
IP3 signaling
GOAT HAG
GnRH Oxytocin ADH (V1) TRH Histamine (H1) Angiotensin-II Gastrin
Steroid receptor
VETTT CAP
Vitamin D Estrogen Testosterone T3/T4 Cortisol Aldosterone Progesterone
Intrinsic tyrosine kinase
Insulin IGF-1 FGF PDGF EGF
MAP kinase pathway
Think growth factors
Receptor assoc tyrosine kinase
Prolactin
Immunomodulators (cytokines IL-2, IL-6, IL-8, IFN)
GH
JAK/STAT pathway
think Acidophiles and Cytokines
PIG
encapsulated bacteria
which are the most common
SHiNE SKiS
Streptococcus pneumoniae Haemophilus influenzae Neisseria meningitidis E. coli Salmonella Klebssiella Group B Strep
most common are
Strep pneumoniae
Haemophilus influenzae
osteomyelitis in child w/ sickle cell disease, most common cause, then the next
Salmonella is the most common cause
Staph aureus
E. coli
what can potency of inhaled anesthetic depend on?
what doesnt it?
can depend on
- body temperature
- decreases w/ increasing pt age
does not depend on:
type of surgery/duration of anesthesia/sex/height/wt
C3b function
opsonization
C3a, C4a, C5a function
anaphylaxis
C5a function
recruits and activates
neutrophil
monocytes
eosinophils
basophils
when do u give acute gout patients glucocorticoids
elderly w/renal dysfunction, because they can’t take colchicine or NSAIDs
Klinefelter
cause
47 xxy
primary hypogonadism (elevated FSH and LH, low testosterone) long lower extremities
small firm testes
azoospermia
due to progressive destruction and hyalinization of the seminiferous tubules
kallman
cause
low LH, FSH, low testosterone, decreased sperm
due to failed migration of GnRH cells and fomration of olfactor bulb
anosmia is also seen
Drug induced lupus vs. SLE differentiate
DILE rarely has anti dsDNA seen in SLE.
drugs that induce DILE
which are highest risk?
Sulfonamides Hydralazine Isoniazid Procainamide Phenytoin Minocycline Quinine
highest risk seen in
procainamide
hydralazine
portocaval anastomoses
esophageal varices
hemorrhoids
caput medusae
[portal circulation/systemic circulation]
Left gastric vein/Esophageal vein
Superior rectal vein/Middle and inferior rectal veins
Paraumbilical veins/Superficial and inferior epigastric veins
main complications from varicose veins
Most common?
painful thromboses stasis dermatitis skin ulcerations poor wound healing superficial infections
Venous stasis ulcers over the medial malleolus are the most common
pilocytic astrocytoma vs. medulloblastoma
pilocytic astrocytoma has a cystic and solid component
medulloblastomas are always solid
what is milrinone
phosphodiesterase inhibitor that increases cardiac contractility and decreases both preload and afterload
what is the metyrapone stimulation test
blocks cortisol synthesis by inhibiting 11betahydroxylase (which converts 11 deoxycortisol to cortisol)
this should increase ACTH, serum 11-deoxycortisol, urinary 17-hydroxycorticosteroids (11-deoxycortisol is metabolized in liver to 17-hydroxycorticosteroids). failure to rise indicates HPA failure
most common lung cancer in general population. Also in women. also in nonsmokers.
Adenocarcinoma.
specific symptoms to graves disease
infiltrative dermopathy (pretibial myxedema) and exophthalmos
caused by autoimmune response against thyrotropin receptor that results in the accumulation of glycosaminoglycans w/in the affected tissues.
