Week 1 Random Flashcards
Bloom’s Taxonomy
Components of Diagnosis
Explanation
Prognostication
Therapy
H & P
HISTORY
Chief Complain History of present illness Past medical history Surgical history Family history Social history Sexual history Review of systems Allergies Medications
PHYSICAL
Physical exam Labs Imaging and other ancillary tests Assessment/Differential Diagnosis
AP & CP and subcategories
AP
Surgical Pathology, Cytology, Hematopathology, Autopsy
CP
Clinical Chemistry, Microbiology, Blood Bank/Transfusion/ Molecular and Genetic Pathology, Hematopathology
Why order tests
Routine
Preoperative
Monitoring
Diagnostic
Lab categories
Chemistry
Urinalysis
Microbiology
Hematology
Serology (antigen interaction)
Reference Range vs. Optimal Range
Reference range – “normal” that encompasses 95% of population; specific to the equipment
Optimal (health) range – therapeutic target associated with optimal health set by us
Analytic Variability vs. Intraindividual variability
Analytic Variability – variability due to equipment
Intraindividual variability – natural biological fluctuations
General Chemistry (lab) / CMP
Aka Chem20, Profile1, Chem7 Comprehensive Metabolic Panel (CMP)
Liver, kideny, electrolytes, lipids, and glucose test
Liver function
- Synthesis and secretion of proteins Storage of energy (glycogen)
2 Metabolizes many drugs and toxins
- Transformation and Clearance (e.g. conjugation of bilirubin)
- Aids digestion (biliary system)
AST/ALT elevation
Hepatic injury or necrosis:
- viral hepatitis
- fatty liver
- toxins (including medications)
- strenuous exercise
What is the cause for uncojugated and conjugated bilirubin elevation?
Unconjugated: ELEVATED
- hemolysis
- kernicterus (destuction of baby’s blood)
- Crigler-Najjar syndrome (deficiency of conjugating enzyme)
- Gilbert’s disease (reduced activity of glucuronyltransferase)
Conjugated: ELEVATED
(due to obstruction)
- hepatitis,
- dubin-johnson syndrom (obstruction in secretion of conjugated form into bile)
- biliary obsturction (bile cannot flow into intestine)
Hemoglobim breakdown
Hemoglobim
heam
biliverdin
bilirubin (uncoj)
bilirubin (conj)
urobilinogen
stercobiliongen
Albumin function
- Main agent of intravascular osmotic pressure
- Serves in the transport of bilirubin, hormones, and metals, vitamins, and drugs
* making 150-250mg/kg/day
Albumin increas and decrease
INCREASE:
- Dehydration Decrease:
DECREASE (synthesis):
- End-stage liver disease
- intestinal malabsorption syndromes
- protein malnutrition e.g.
DECREASE (loss):
- nephrotic syndrome
Globulin function composition and test for the level
COMPOSITION
Serum proteins including carrier proteins
Enzymes
Complement
TEST
immunoglobulins serum electrophoresis
Kideny function
Filters 200L & removes 2L
Produces Erythropoeitin
Produces Renin
Produces Vit D
Kidney tests
- Blood Urea Nitrogen (BUN) – measures breakdown of proteins
- Creatinine – breakdown product of creatine in muscles
- Urinalysis (physical, chemical e.g. glucose, bilirubin, protein, leukocyte, pH, specific gravity, and microscopic examination)
Blood in urine symptom
Urinary Bladder Cancer
Heart tests
- Lipid Panel (possible blockage - artheroschlerosis)
- Beta Natriuretic Protein (released when heart stretches)
- Troponins (damage to muscle)
Brain tests
Lumbar puncture: protein, glucose, cell differential, culture, blood
Lungs tests
Arterial Blood Gas (ABG) pH, O2, CO2
Endocrine tests
Hemoglobin
A1c
TSH
FSH
LH
PTH
Testosterone
Estrogen *
Osler’s Rule
Correlate all abnormalities into a single plausible explanation
Differential diagnosis
A systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible. Systematically obtain information then use process of elimination
Progressive disclosure
interaction design technique often used in human computer interaction to help maintain the focus of a user’s attention by reducing clutter, confusion, and cognitive workload. This improves usability by presenting only the minimum data required for the task at hand.
RCT
Randomized Control Trial
Prodivdes fair conclusion and blinding
Removes bias
Coincidence vs. Concoted incidence
Coincidence – unlikely event occurring by chance
Bayes’ Theorem
Allows calculation of a probability if something is correct or incorrect based on the evidence
Research questions should be…
Types of research questions…
Qualities:
Specific, answerable, novel, and relevant
Types:
descriptive, evaluative, and explanatory
Evidence Based Medicine practice requirement:
AAAAA
Asses the patient (clinicla problem)
Ask the clinical question (PICO)
Acquire the evidence (search for evidence)
Appraise the evidence (usability and closeness to truth)
Apply
Types of studies
Case series and case reports (based on chart notes)
Case control studies (base on chart notes with control notes)
Cohort studies (follow the group)
Randomized Control Studies
Declaration of Helsinki
The placebo can be only used when no alternative drugs are availible.
Patient consent.
Bradford-Hill Criteria for Causation
- Strength of association
- Consistency of different studies
- Specificity of association with particular disease
- Temoral relationship (exposure precedes disease)
- Biological gradient (dose-response relationship)
- Plausability (biological plausilibity)
- Coherence (consistent with what is known)
- Experiment reversibility
- Existence of analogous evidence
Types of imaging
X-Ray Fluoroscopy (X-Ray real time)
CT scan (forms sections)
MRI (joints, neural tissue, dense breast tissue no good for blood or bone)
Ultrasound (sonar, water)
Mammography (good for dense breast tissue, not good for masses of blood, better for soft tissue)
Sievert values
1 Sv 5.5% chance of cancer
10,000 mSv radiation sickness
50 mSv lowest dose for cancer
15 mSv C.T. Scan of abdomen and pelvis
2 mSv head C.T. Scan
2 mSv natural radiation/year
- 10 mSv cheast X-ray
- 01 mSv dental X-ray
Standard position for Chest X-ray
PA
Number of X-Rays required to visualize 3D
2
X-Ray depends on
Atomic number, density, and thickness
Types of X-Ray anodes
Usually – tungsten
Mammography – rhodium
Types of contrast media
High Osmolar HOCM
Low Osmolar LOCM
Iso Osmolar IOCM
Air-Liquid interfaces
Help to determine the position
Relationship between penetration, contrast, and voltage
Up penetration -> lower contrast
Up penetration -> higher voltage
Body penetration reduces dose Object
Penetration reduces contrast
Window setting
Allow adjustment and focus on a specific tissue
Contrasts medium
Barium (Ba) CT – safe unless there is a perforation
Gadolinium (Ga) MRI – changes the relaxation time; dangerous to kidney function if reduced; may cause nephrogenic systemic fibrosis (NSF)
Senescent
No division
Prescription abbreviations ac ; bid ; gtt ; od/s ; po ; pc ; prn ; q4h ; qd ; tid ; IV ; IM
ac - antre cibum - before meals
bid - bis in die - twice a day
gtt - gutta - drops
od - oculus dexter - right eye
os - oculus sinister po -
per os - by mouth
pc - post cibum - after meals
prn - Pro re nata - as needed
q3h - quaque 3 hora - every 3 hours
qd - quaque die - every day
tid - ter in die - 3 times a day IV (intravenously)
Prescription components
SUPERSCRIPTION
1) Name of practitioner including address
2) Patients name, address, age, weight, and date
INSCIRPTION
3) Drug name, strength, quantity, ect.
SUBSCRIPTION
4) Directions
5) Refil times
6) Label
7) Specify if brand and not generic is desired
8) Signature of practitioner
Categories of drugs
Over-the-Counter
Legend Drugs (prescription)
Controlled Substances (Principal or secondary site of action is the Central Nervous System generally)
Classification of controlled substances
Schedule I: no currently accepted medical use and may lead to serious dependence
Schedule II: accepted medical use; may lead to severe dependence; may not be refilled; must be filled within 14 days (nv); do note fill before/dispense until; handwrited only; separate sheet
Schedule III: Moderate to low physical dependence and possible high psychological dependence; 6 refill
Schedule IV: Low dependence; 6 refill
Schedule V: Limited dependence liability
Requirements for prescribing controlled substances
DEA number
Registered with specific state
Visible proof of registration
Legitimate medical purpose
Cannot self-prescribe Schedule II-IV
Bio-equivalents Therapeutic Equivalents
Bio-equivalents – the same chemical property of a generic drug
Therapeutic Equivalents – the same effect of the drug
FDA Recall drugs classes
Class I – Severe health consequence
Class II – cause temporary or medically reversible adverse health
Class III – is not likely to cause adverse health
FDA Category Use in Pregnancy
Category A – fail to demonstrate a risk to the fetus
Category B
Category C – Drugs should be given only if the potential benefit justifies the potential risk to the fetus
Category D – There is positive evidence of human fetal risk
Category X – the risk of the use of the drug in pregnant women clearly outweighs any possible benefit
Human mitochondrial genome
16.5 kb mtDNA encodes
13 proteins 22 tRNAs, and 2 rRNAs
4P’s
Predictive
Preventative
Personalized
Participatory
SSLPs
simple sequence length polymorphisms (SSLPs): tandem repeat sequences that display length variations.
1) minisatellites, also known as variable number tandem repeats (VNTRs)
2) microsatellites or simple tandem repeats (STRs)
Pol α Pol β Pol γ Pol δ Pol ε
Pol α - Primase activity; Initiates DNA synthesis; No Proof
Pol β - DNA Repair; No Proof
Pol γ - Replicates mitochondrial DNA; Proof
Pol δ - Elongates Okazaki fragments; Proof
Pol ε - Leading strand synthesis & DNA Repair; Proof
Herpes 1 vs 2
Herpes simplex 1 is a DNA virus that causes cold sores.
Herpes simplex 2 causes most genital herpes infections.
Levels of Maternal Serum Alpha-Fetoprotein
HIGH:
Dating error, Neural Tube defects, Twins, Abdominal Wall defect, Fetal demise, Low Birth Weight
LOW:
Fetal demise, Dating error, Lack of pregnancy, Molar Pregnancy, Trisomy
When and why are Heel stick blood draws done
Newborns before discharge and at 10-14 days, to test for
Metabolic Disorders(phenylketonuria)
Endocrine Disorders(Hypothroidism)
Hematological Disorders (Sickle Cell) Cystic fibrosis
Breast Quadrants
UIQ, UOQ, LIQ, LOQ
Lipid Panel
Cholesterol
Triglycerides
HDL
Cholest/HDL Ratio
LDL
Quadruple aim
Triple Aim (Better patient experience, better patient outcome, lower cost)
+ physician experience
Mutations causes
Endogenous
- attack by reactive oxygen species
- replication errors
Exogenous
- UV and ionizing radiation including x-rays and gamma rays, plant toxins
- Man-made mutagenic chemicals that act as DNA intercalating agents, cancer chemotherapy and radiotherapy
- Viruses
Functions of blood
Gases-O2,
CO2 Nutrients,
electrolytes,
waste Hormones,
cell signals (cytokines)
Immune response
Inflammatory response
Clotting
Acid buffering
Complete Blood Count test results
- RBC (quantity of blood) (count/uL) expressed in 10^6
- Hgb (concentration of hemoglobin) – Hemoglobin (spectronomny) in g/dL; O2 carrying capacity
- Hct (concentration of blood) – Hematocrit % of blood cells (HCT = RBC (cells/L) x MCV (L/cell))
- MCV (size of blood) – Mean corpuscular volume (fL) measured by counter plotted on historgram
- RDW – Red cell distribution width (standard deviation)
- Plt (count/uL)
- WBC =white blood cells=leukocytes=white cells count/mL
- WBC (count/uL)
RBC (erythorcyte) Hormone that simulates? How many cells are made per day? Lifespan of RBCs?
EPO
2-3 trillion
120 days
H/H
Hematocrit / Hemoglobin
Types of blood cells
Blood stem cells
Myeloid stem cell RBC (early Reticulocyte) Platelest
Myeloblast -> all WBCs except Lymphocyte Neutrophilic stab=band cell (early Neutrophil)
Lymphoid stem cell -> Lymphoblast B, T Lymphocyte and NK
Neutrophil = “polys” = “segs”
Effects on RBCs sizes
Lack B12 = large
Lack Iron = small
Risk of occurence vs. reoccurence
occurence = Depends on population frequencies of the disorder and the rate of spontaneous mutations
recurrence = the probability that a genetic disorder that has occurred in a family will recur in another member in the same or in future generations
Ka vs. Kd
Association constant = [P·L]/([P][L]) (affinity) Dissociation constant = ([P][L])/[P·L]
Michaelis Menten Equation
v = Vmax·[S]/(KM + [S])
where
Vmax = [E]tot·k3
and
KM = (k2 + k3)/k1
Lineweaver Burk Plot
The enzyme with the highest “specificity” or “preference” for catalyzing a reaction is the enzyme with the highest specificty
v = Vmax·[S]/(Km + [S]) 1/v
Km/(Vmax[S]) + 1/Vmax y
1/Vmax x = 1/Km slopeKm/Vmax
Enzyme types: Oxidoreductases Transferases Hydrolases Lyases Isomerases Ligases
Oxidoreductases – e- transfer
Transferases – group transfer
Hydrolases – hydrolysis reaction
Lyases – addition of groups to double bonds or formation of double bonds by removal of groups
Isomerases - transfer of groups within molecules
Ligases - formation of C-C, C-S, C-O, and C-N bonds by condensation coupled with ATP
Enzyme Specificity
Vmax/KM
Irreversible Inhibitors
Competitive Inhibition
Non-Competitive Inhibition
Uncompetitive Inhibition
Irreversible Inhibitors – Vmax DOWN; Km unaffected (Removing the concentration of the enzyme)
Competitive Inhibition – Km UP; Vmax unaffected (Always can out compete the enzyme)
Non-Competitive Inhibition – Vmax DOWN; Km unaffected (alternative reactions)
Uncompetitive Inhibition – Vmax DOWN; Km DOWN (Even enzyme is saturated, rate will be slower; Km substrate binds more readily)
Anemia diagnosis
MCV and RDW
Repair systems and causes for activations
BaseER – X-Ray, radicals, alkylating agents, spontaneous reaction
NucleotideER - UV; polycyclic aromatic hydrocarbons
RecR/NHEJ - IR, UV-light; X-rays; anti-tumor agents
MismatchR - replication errors
Radiolucent
allow radiation to pass more freely
Positive contrast vs. Negative contrast examples
Barium (high density) vs. Air (low density)
Object penetration reduces what? Body penetration reduces what?
Object penetration reduces the contrast Body penetration reduces the dose
Brest mammography CC (craniocaudal) MLO (mediolateral oblique)
squeezed top-bottom squeezed left-right
Genome composition
1/2 Transposons (SINES, LINES, and retrovir like)
1/3 Genes (1.5% exons, introns)
1/4 Repeats, other?
Site specific recombination types:
- DNA only
- Retrovilar-like retrotransposons
- Nonretroviral retrotransposons
DNA only
- short inverted repeats
- cut and paste
Retroviral-like retrotransposons
- Long terminal repeats
- Reverse transcriptase and integrase
Nonretroviral retrotransposons
- Poly A at 3’ end of an RNA intermediate
- Reverse transcriptase and endonuclease
PICO
P: Patient or population (age, sex, race)
I: Intervention (exposure, diagnostic test, therapy)
C: Comparison group (nothing, placebo, another intervention)
O: Outcome of interest (clinical effect or intervention)
Four basic gene elements
Promoter, coding, intervening, structural (untranscribed and 3’ and 5’ UTR)
Radioucent material from most to least
Air, Fat, Water/tissues, Spongy, Bone, Compact Bone
Antibiotics acting on Topoisomerase
EUKYAROTES
Irinotecan
Act on: Human topoisomerase I
Uses: Colon, ovarian, small cell lung cancers
Etoposide
Act on: Human topoisomerase II (prevents ligation)
Testicular cancer
Doxorubicin
Act on: Human topoisomerase II (intercalating agent; stabilize topo II on DNA)
A variety of cancers
BACTERIA
Ciprofloxacin
Act on: Bacterial DNA gyrase (topoII)
Use: Gm(-) infections, COPD
Jaundice
A medical condition with yellowing of the skin or whites of the eyes
Kernicterus
Hyperbilirubinemia during the neonatal period describes the history of nearly all individuals who suffer from kernicterus. It is thought that the blood–brain barrier is not fully functional in neonates and therefore bilirubin is able to cross the barrier.
Gilbert’s disease
The cause of this hyperbilirubinemia is the reduced activity of the enzyme glucuronyltransferase, which conjugates bilirubin and a few other lipophilic molecules.
Kwashiorkor
Is a form of severe protein–energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty infiltrates. Sufficient calorie intake, but with insufficient protein consumption, distinguishes it from marasmus. Kwashiorkor cases occur in areas of famine or poor food supply.
Nephrotic syndrome
It is characterized by an increase in permeability of the capillary walls of the glomerulus leading to the presence of high levels of protein passing from the blood into the urine low levels of protein in the blood.
Atherosclerosis
Artery wall thickens as a result of invasion and accumulation of white blood cells and remnants of dead cells, including cholesterol and triglycerides, eventually calcium and other crystallized materials, within the outer-most and oldest plaque.
Nephrogenic systemic fibrosis (NSF)
Renal failure due to exposure to gadolinium
Heart hypertrophy
Increase in volume of the heart
Hemothorax
Is a type of pleural effusion in which blood accumulates in the pleural cavity.
Appendicitis
is an inflammation of the appendix; left untreated will burst and spill infections materials into the abdominal cavity
Fibroid
are non-cancerous growth that develop in or just outside a woman’s uterus. Uterine fibroid develop from normal uterus muscle cells that start growing abnormally. As the cells grow, they form a benign tumor.
Pelvic inflammatory disease
is an infection of female reproductive organs; PID is one of the most serious complications of a sexually transmitted disease
Peritonitis
is an inflammation of the peritoneum the tissue that lines the inner wall of the abdomen; left untreated can result in sepsis; severe abdominal pain worsened by any movement
Ovarian torsion
refers to the rotation of the ovary to such a degree as to occlude the ovarian artery and/or vein
Endometriosis
Happens when tissue normally found inside the uterus grows in other parts of the body; it may attach to the ovaries, fallopian tubes, the exterior of the uterus, the bowel, or other internal parts.
Small bowel obstruction
occurs when small or large intestine is partly or completely blocked
Ectopic pregnancy
a pregnancy in which the fetus develops outside the uterus, typically in a Fallopian tube
Gastroenteritis
or stomach flu is an inflammation of the stomach and intestines, typically resulting from bacterial toxins or viral infection and causing vomiting and diarrhea
Constipated
infrequent bowel movement and difficulty during defecation
Ovarian cyst
are fluid-filled sacs or pockets within or on the surface of an ovary; a large cysts can cause
Electrolytes
odium, Potassium, Chloride, Phosphorus, Calcium, Carbon dioxide, and Magnesium
AST
ALT
aspartate transaminase–alanine transaminase ratio
OR
aspartate aminotransferase–alanine aminotransferase ratio
LFT
Liver profile
Medical Research
Evidence Based Medicine
Characteristics
- Delcaration of Helsinki
- Bradford-Hill criteria for causation
- Data collection and outcomes
- Sample size, power, and cuasation
Defining characteristics of studies
Primary outcomes must be well defined
Secondary outcomes are common
Sample size determined based on the primary outcome
Composite outcomes can be useful
Sample SD
Population SD
What properties can be changed in beam?
Volatge
Anode
Under and Over Penetration
Breast Density and Composition Mammogram
Breast Mammogram
MRI characterstics
0.5-3 Tesla
Small radio frequencies
MRI constrast media are considered safer than CT media
Evidence: Case Series and Case Reports
Retrospective observational studies
Determine commonalities in medical history or other associations among those affected
Evidence: Case Control Studies
Retrospective observational studies of a particular diagnosis or exposure
Can establish correlations but cannot prove causation
Evidence: Cohort Studies
Used when a RCT would be unreasonable or unethical.
Compare two groups of subjects over time, one having a particular condition or receiving a particular treatment, the other not
Evidence: Randomized Controlled Studies
Randomly assigns subjects into treatment group or a control group to compare efficacy of a treatment, diagnosis, drug
Over the counter Drugs characteristics
Deemed safe without professional guidance
Quality standards during manufacturing
Safety and effectiveness monitored by FDA
Legend / Prescirption drugs characteristics
Require physician to be dispenced
Considered unsafe unless supervides by a licensed practitioner
Must be labeled “Federal law prohibits dispensing without prescription”
Controlled Substances characteristics
Addictive potential for trafficing
Primary or secondary stie on CNS
Drug Enforcement Agency responsible for identifying and regulating drugs in this class
Can be OTC, legend, or unabailable
Who is responisble for standards for drug purity in the US?
Non-profit organizations like USP or U.S. Pharmacopoeia
e.g. of DNA and RNA viurs
Herpes (DNA) and HIV-1 (RNA)
Purifying Selection
Negative Selection
Synteny
Stretches of conserved gene order on chromosomes
e.g. globin genes clusters
Acyclovir
High fiedility proofreading mechanisms
Inherited Syndromes with DNA Repair defect
MSH2, 3, 6, MLH1, PMS2 (colon cancer) = mismatch repair
Xeroderma pigmentosum (XP) (skin cancer) = nucleotide excision repair
Ataxia–telangiectasia (AT) (leukemia) = ATM protein kinease
BRCA2 (breast cancer) = homologous recombination
Fanconi anemia (leukemia) = DNA interstand cross-link repair
Transposons
DNA only
short inverted repeats
cut and paste
Retroviral-like retrotransposons
Long terminal repeats
Reverse transcriptase and integrase
Nonretroviral retrotransposons
Poly A at 3’ end of an RNA intermediate
Reverse transcriptase and endonuclease
Role of RBCs, WBCs, and platelates
RBC: O2/CO2 transport, acid buffer
WBCs: immune response, inflammation
Platelets: clotting
Why there might be a little variability between RBCs?
Young RBCs (reticulocytes) are slightly larger.
