Question
Main Division
Id
Sub Division
Notes
654
Anatomy
Cardiovascular System
4/15 Left ventricle forms apex of the heart.
1623
Anatomy
Cardiovascular System
Dysphagia can be from compression of the esophagus by a
dilated and posteriorly displaced left atrium in patients with
rheumatic heart disease and mitral stenonsis/regurg.
x2
4th aortic arch:
- left -> aortic arch
- right -> proximal right subclavian artery
1751
Anatomy
Cardiovascular System
6th aortix arch:
- Proximal pulmonary arteries
- One left -> ductus arteriosus
PDA is from an embryonic derivative of the 6th aortic arch.
1805
Anatomy
Cardiovascular System
4/15 Varicocele occures when the aorta and superior
mesenteric artery comress the left renal vein
The increased pressure in the left renal vein causes retrograde
bloow flow to the testes and dilation of the pampiniform plexus
Left renal vein becomes the left spermatic (gonadal) vein
1805
Anatomy
Cardiovascular System
Compression of the left renal vein between the superir
mesenteric artery and the aorta = "nut cracker effect" can
cause hematuria and flank pain.
Pressure can also be elevated in the left gonadal vein, leading
to Varicocele (varicies of the testicular pampiniform plexus)
4/15 Skull fractures at the pterion risk lacerating the middle
meningeal artery, a branch of the Maxillary artery CN V2.
1813
Anatomy
Cardiovascular System
Pterion = where the frontal, parietal, temporal, and sphenoid
bones meet
1883
Anatomy
Cardiovascular System
4/15 *Right border of the heart Right atrium
The right middle lung lobe can obscure the xray silhouette of
the right heart border.
1884
Anatomy
Cardiovascular System
4/15 The IVC is formed by the union of the right and left
common illiac veins at L4-L5
1884
Anatomy
Cardiovascular System
The IVC is formed by the union of the right and left common
iliac veins at the level of L4-L5. The renal arteries and veins lie
at the level of L1. The IVC returns venous blood to the heart
from the lower extremities, portal system, and abdominal and
pelvic viscera.
1943
Anatomy
Cardiovascular System
4/15 *Right sided face and arm swelling R. brachiocephalic
vein obstruction Presents similar to SVC syndrome but onlyl
onone side of the body
x2
Right sided brachiocephalic vein obstruction = right sided face
and arm swelling and engorgement of subcutaneous beins on
the same side of the neck.
1943
1967
1967
Anatomy
Anatomy
Anatomy
Cardiovascular System
Cardiovascular System
Cardiovascular System
Brachiocephalic vein draings the ipsilateral jugular and
subclavian veins. The bilateral brachiocephalic veins combine
to form the SVC. BRachiocephalic vein obstruction causes
symptoms similar to those seen in SVC syndrome but only on
one side of the body.
4/14 The great saphenous vein is located superfically in the leg
and is the longest vein in the body. Surgeons acess the great
saphenous vein in the medial leg. It drains the femoral vein
within the region of the femoral triangle a few cm inferolateral
to the pubic tubercle.
x2
Great saphenous vein is a superficial vein of the leg that
originates on the medial side of the foot, course anterior to the
medial malleolus, and then travels up the medial aspect of the
leg and thigh.
It drains into the femoral vein within the rgion of the femoral
triangle a few cm inferolateral to the pubic tubercle.
2130
Anatomy
Cardiovascular System
4/15 MC site of injury from blunt aortic trauma (motor vehical
accident) is the aortic isthmus (right after artic arch). Aortic
isthmus is tethered by the ligamentum arteriosum to the
pulmonary trunk and is releativley fixed and immobile compare
to the adjacent descening aorta.
7646
Anatomy
Cardiovascular System
4/15 *Left ventircular leads in biventricular pacemakes course
through the Coronary sinus
Which resides in the atrioventricular groove on the posterior
aspect of the heart
8294
Anatomy
Cardiovascular System
Early systolic murmur best heard over the left lower sternal
border that is accentuatedby inspiration = tricuspid regurg
8333
Anatomy
Cardiovascular System
4/15 The decending thoracic aorta lies posterior to the
esophagus
The left atrium lies anterior to the esophagus
8610
Anatomy
Cardiovascular System
Chest Xray in Left Ventricular failure with pulmonary edema
shows: Cardiomeagly (greater than half of the thorax), pleural
effusions, Kerley B lines, increased vascular shadowing
(alveolar edema)
11730
Anatomy
Cardiovascular System
4/15 SA node is located at the junction of the right atrium and
SVC
4/15 *Cannulation of the femoral vein should occur
approximatley 1cm below the inguinal ligament and just medial
to the femoral artery pulsation
11763
Anatomy
Cardiovascular System
*Order of vessels in femoral triangle (lateral to medial/out to in)
femoral nerve > femoral artery > femoral vein > deep inguinal
nodes.
11763
Anatomy
Cardiovascular System
NAV = femoral nerve, then artery, then vein
11764
11832
Anatomy
Anatomy
Cardiovascular System
Cardiovascular System
4/15 *Where is the optimal site for obtaining vascular acess in
the lower extremity during cardiac catheterization? Common
femoral artery below the inguinal ligament Cannulation above
the inguinal ligament can significantly increase the risk of
retroperitoneal hemorrhage. MCC of unexpected mortality after
cardiac cath. Bleeding in the retro peritoneal space cannot be
controlled with manual compression
4/15 Thromboembolic complications of atherosclerosis in the
internal carotid artery are the most common cause of Central
Retinal Artery Occlusion
Internal carotid > opthalmic > retinal artery
11842
Anatomy
Cardiovascular System
A. fib is associated with increased risk of systemic
thromboembolism (ex. dysarthria, left hemiparesis, left lower
face weakness)
The left atrial appendage is the MCC of the thrombus
formation.
11956
1747
Anatomy
Anatomy
Cardiovascular System
Endocrine, Diabetes &
Metabolism
Locted interatrial septum near the opening of the coronary
sinus = AV node
*b/w tricuspid valve and the IVC opening = Site of
radiofrequency ablation for atrial flutter
*The lower border of the fossa ovalis = foramen ovale (fetal
opening betweel right and left atria)
*Upper part of the crista terminalis (anterior right atrium) near
the SVC opening = SA node
The cricothyroid is the only muscle innervated by the external
branch superior laryngeal nerve. It is at risk of injury during
throidectomy due to its close proximity to the superior thyroid
vein and artery.
The rest of the laryngeal muscles are innervated by the
reccurent laryngeal nerves
Imperforate hymen
8390
11908
303
Anatomy
Anatomy
Anatomy
Female Reproductive
System & Breast
Female Reproductive
System & Breast
Gastrointestinal & Nutrition
incomplete degeneration of the central portion of the fibrous
tissue band connecting the wall of the vagina.
Primary amenorrhea, normal secondary sex characteristics,
cyclic abdominal or pelvic pain (due to accumulation of
menstrual blood in vagina and uterus -hematocolpos), vaginal
bulge or mass palpated anterior to the rectum.
4/16 Bilater ligation of the internal iliac artery can decrease
uterine blood flow and postpartum hemmorhage that is
unresponsive to meds. (Uterus has collateral bloof flow from
the ovarian arteries to mainatain the uterus)
SMA syndrome occurs when transverse portion of the
duodenum is entrapped b/w SMA and aorta causing symptoms
of partial small bowel obstruction.
Causes: diminished mesenteric fat, prononced lordosis,
surgical correction of scoliosis
x2
11753
Anatomy
MVA, hypotention, tachycardia, left shoulder pain, nausea,
Gastrointestinal & Nutrition hiccups = Splenic laceration
Aortic rupture is not associated with persistent left shoulder
pain or hiccups.
4/15 The short gastric vein drain blood from the gastric fundus
into the = Splenic vein
11795
Anatomy
Gastrointestinal & Nutrition
Inflammation of the pancreas can cause a blood clot in the
=splenic vein (the splenic vein runs along the posterior surface
of the pancreas). This can increase pressure in the short
gastric veins and lead to gastric varicies ONLY in the fundus of
the stomach.
Anastamosis of SMA and IMA:
11839
Anatomy
Gastrointestinal & Nutrition Marginal artery of Drummond (marginal artery)
and inconsistently present arc of Riolan (mesenteric
meandering artery)
Above dentate line = internal hemorrhoids = drains into
superior rectal veins (--> to inferior mesenteric veins)
Artery: superior rectal artery (branch of IMA)
11840
Anatomy
Gastrointestinal & Nutrition
Below dentate line = external hermorrhoids
Veins: drains into inferior rectal vein (internal pudendal vein ->
internal iliac vein)
Artery: inferior rectal artery (branch of internal pudendal a.)
Rx for BPH =
alpha-adrenergic blockers - which relax the smooth muscle in
the bladder neck or
1737
Anatomy
Male Reproductive System 5-alpha reductase inhibtors -which reduce hormonal influence
on the prostate by preventing the conversion of testosterone to
dihydrotestostrone
The prostate is located between the pubic symphysis and the
anal canal in inferior sections on CT scan
2021
11658
Anatomy
Anatomy
Male Reproductive System Testes drain into para-aortic lymph nodes
Testicular torsion
- due to twisting of the testis aroun the spermatic cord
(containing the gonadal artery)
- resulting in compression of pampiniform plexus
- "left testi is higher than the right"
Male Reproductive System - Pain after intense workeout
- absent cremasteric reflex (elevation of testis while pinching
the skin in upper thigh)
Gonadal artery arises from the abdominal aorta
Prostatectomy or injury to prostate plexus can cause erectile
dysfunction. Cavernous nerves arise from the prostatic plexus,
pass under pubic arch innervate corpora cavernosa of penis
and urethra.
11800
Anatomy
Male Reproductive System Pudendal nerve injury = fecal incontinence or external urethral
sphincter paralysis
Pelvic splachnic n = detrusor overactivity (urge incontinence)
Loss of cremasteric reflex is MC seen with testicular torsion or
L1-L2 spinal injury.
Atrophy of:
Subthalamic nucleus = hemiballism (involuntary large
amplitude, flinging movements, proximal limbs) = lacunar
stroke (HTN, diabetes)
635
Anatomy
Nervous System
Caudate nucleus = chorea (involuntary, low amplitude, distal
limbs) = Huntingtons
lentiform nucleus (golbus pallidus/putamen) = Wilsons disease
= liver, psych, neuro triad.
4/15
Sensory loss over lateral leg and dorsum of foot = Common
peroneal nerve
Sensory loss over the sole of the foot = Tibial nerve
Ankle dorsiflexion = deep peroneal nerve
1149
Anatomy
Nervous System
Impaired foot eversion = Superficial peroneal nerve
Impaired foot inversion = Tibial nerve and Deep peroneal nerve
Injury to the lateral neck of the fibula = Common peroneal nerve
Proximal fibular fracture = Common peroneal nerve
Pineal gland tumor - MCC of germinoma, present with
obstructive hydrocephalus and perinaud syndrome
1261
Anatomy
Nervous System
Damage to the thalamas - contralateral hemisensory loss,
behvioural changes, language deficits.
Dorsal midbrain (parinaud syndrome) - paralysis of upward
gaze, ptosis, pupillary abnormalities
Obstructive hydrocephalus - papilledema, headache, vomiting
1639
Anatomy
Nervous System
Superior gluteal nerve injury = hip drop
abducts the thigh
Pelvis sags toward the UNAFFECTED (contralateral) side
when the patient stands on the affected leg (positive
trendelenburg sign)
When walking pt will lean toward the affected (ipsilateral) side
to compensate for the hip drop (gluteus medius lurch)
Cause: pelvic trauma, butt injection, damage during hip surgery
Flexion of thigh at hip and extention of leg at knee = femoral
(knee buckling, loss of patellar reflex)
1693
Anatomy
Nervous System
4/15 Saddle anesthesia and loss of anocutaneous reflex =
Cauda equina syndrome (damage to S2-S4)
1743
Anatomy
Nervous System
4/16 Sensory loss of the thumb = Ulnar nerve
Sensory loss of the palm = Median nerve.
1802
Anatomy
Nervous System
Adduction of the thigh = Obturator nerve
1846
Anatomy
Nervous System
4/16 *Wernickie's and Borcha's area are supplied by = Middle
Cerebral artery
2020
Anatomy
Nervous System
Ventromedial hypothalamic nuclei - mediates satiety
(destruction leads to hyperphagia)
2127
Anatomy
Nervous System
Posterior cerebral artery (branches off basilar artery) supplies
CN III and IV and other structed in the midbrain. It alsop
supples the thalamus, medial temporal lobe, splenium of the
corpus callosum, occipital lobe.
Presents with contralateral homonymous hemianopia with
macular sparing.
The neural structure most frequent affected in pt with Wernicke
encephalopathy is the mammilary body (part of the Papez
circuit).
2129
Anatomy
Nervous System
Alcholic pt need to be given IV thiamine before dextrose
administration because giving dextrose without thiamine can
precipitate wernicke's encephalopathy.
Homless alcoholic pt has substantial difficulty with short-term
memory, nystagmus, opthalmoplegia, ataxia.
Cranial nerves:
8522
Anatomy
Nervous System
Cribiform plate - CN I
Optical canal - CN II
Superior orbital fissure - CN III, IV, V1 (Occipital), VI,
opthalmic vein
Foramen rotundum - CN V2 (maxillary)
Foruman ovale - CN V3 (mandibular)
Foramen spinosum - Middle meningial artery & vein
Internal acoustic meatus - CN VII, VIII
Jugular foramen - CN IX, X, XI
Hypoglossal canal - CN XII
Foramen magnum - spinal roots of CN XI, brain stem, vertebral
arteries
Lesion in jugular foramen = Vernet syndrome
8594
Anatomy
Nervous System
Meyer's loop in temporal lobe = Contralateral superior
quadrantanopia
8859
Anatomy
Nervous System
Vertigo can be due to vestibular dysfunction (inner ear)
Removal of the appendix can damage the iliohypogastric nerve
and cause decreased sensation and/or burning at the
suprapubic region.
11769
Anatomy
Nervous System
Iliohypogastric nerve provides sensation to the suprapubic and
gluteal regions and motor function to the anterolateral
abdominal wall muscles.
11850
Anatomy
Pregnancy, Childbirth &
Puerperium
4/15 * Horizontal transection of the rectus abdominis muscle
(during a cesarean section for a large-for-gestational-age baby)
must be done carefully not to damage The inferior epigastric
arteries (enter the muscle at the level of the arcuate line). The
inferior epigastric arteries below the arcuate line are suceptible
to injury (hematoma) due to lack of supporting posterior rectus
sheath.
1535
Anatomy
Pulmonary & Critical Care
4/15 The phrenic nerve carries pain fibers from the
diaphragmatic and mediastinal pleura causing pain in the base
of the neck and over the shoulder (C3-C5).
1695
Anatomy
Pulmonary & Critical Care
4/14 Stab wounds immediatley above the clavicle and lateral to
the manubrium will injure what structures? = Lung apices and
pleura extend above the calvicle and first rib. This stab wound
would puncture the pleura and cause penumothorax.
8703
Anatomy
Pulmonary & Critical Care
4/15 Internal laryngeal nerve mediates the afferent limb of the
cough reflex. Food can become lodged in the piriform recess
and may cause damage to the nerve impairing cough reflex.
1680
Anatomy
Renal, Urinary Systems &
Electrolytes
Proximal 1/3 of the ureter recieves its blood supply from
brances of the renal artery
1700
Anatomy
Renal, Urinary Systems &
Electrolytes
Left kidney lies immediately below the tip of the 12th rib
1700
Anatomy
Renal, Urinary Systems &
Electrolytes
Fracture of the posterior 12th rib can injure the kidneys
10962
Anatomy
Renal, Urinary Systems &
Electrolytes
Urinary incontinence when coughing = Stress incontinence =
urethral sphincter dysfunction
11708
Anatomy
Renal, Urinary Systems &
Electrolytes
aponeurosis = external oblique, internal oblique, and
trasversus abdomini muscle
Injections in the superomedial quadrant of the buttock can
cause:
1640
Anatomy
Rheumatology/Orthopedics
& Sports
Trendelenburg gait (gluteus medius gait)
- Injury to the contralateral superior gluteal nerver
Injection in the superomedial, inferomedial, inferolateral regions
of the buttoks risk injury = Sciatic nerve
Safest site = Superolateral quadrant of the buttocks (although
anterolateral gluteal region is preffered)
1682
Anatomy
Rheumatology/Orthopedics
Bones of writst: Some Lovers Try Positions They Can't Handle
& Sports
1733
8671
11679
11683
Anatomy
Rotator Cuff:
Supraspinatus = Abduction
Rheumatology/Orthopedics
Infraspinatus = External rotation
& Sports
Teres minor = Adduction and external rotation
Subscapularis = Adduction and internal rotation
Anatomy
4/15 Thigh abduction = Superior gluteal n.
Rheumatology/Orthopedics
Thigh extention = Inferior gluteal nerve.
& Sports
Loss of patellar reflex = Femoral n.
Anatomy
Latissimus dorsi is innervated by thoracodorsal nerve.
Rheumatology/Orthopedics
Function = extention adduction and internal rotation of the
& Sports
humerus
Anatomy
Rx for carpel tunnel syndrome: a longitudinal incision through
Rheumatology/Orthopedics the transverse carpal ligament relieves the pressure on the
& Sports
nerve
Glans of penis - drain into deep inguinal lymph nodes
Scrotum - drain into superficial inguinal lymph node
Testes - drain into paraortic lymph nodes
Prostate - drains into the internal iliac lymph nodes
11830
11629
Anatomy
Behavioral
science
Rheumatology/Orthopedics
& Sports
Lower extremity superfical lympahtic system is divided into
medial and lateral tracks.
Medial - up superficial inguinal and bypasses politeal node
lateral lesions - cause lymphadenopathy in both politeal and
inguinal lymph nodes.
Gastrointestinal & Nutrition
Physicians should routinely ask their patients about the use of
herbal preparations and nutritional supplements and advise
them on the quality, saftey, and efficacy of these products.
"Explain that weight loss supplements are poorly regulated and
have potential risks"
8456
Behavioral
science
General Principles
An arrangment in which a payor (individual, employer, govt
neitity) pays a fixed predetermined fee to cover all medical
services required by a patient = Capitation
11847
Behavioral
science
General Principles
Preventable adverse event: injury to a patient due to failure to
follow evidence-based best practice guidelines.
11532
Behavioral
science
Miscellaneous
(Multisystem)
Sleep deprivation in physicians often cause cognitive
impairment, resulting in medical errors.
11535
Behavioral
science
Miscellaneous
(Multisystem)
Avoiding the use of unsafe abreviations and trailing zeros (ie.
2.0) in medication orders can help reduce the incidence of
medication errors.
11537
Behavioral
science
Miscellaneous
(Multisystem)
Elderly Pt is experiencing anticholinergic side effects due to
the combine anticholinergic effects of amitriptyline and
diphenhydramine.
Impaired memory, confusion, hallucination, dry mouth, burry
vision, impaired sweating, tachycardia, increased risk of falls.
11549
Behavioral
science
Miscellaneous
(Multisystem)
Closed loop communication - when team member repeat back
the information recieved to ensure that the correct info was
convey. This reduces the risk of errors in medical settings.
11550
1458
Behavioral
science
Behavioral
science
Miscellaneous
(Multisystem)
Nervous System
A discharge checklist detailing medication changes and
follow-up appointments can significantly facilitate a patients
transition from the hospital and improve adherence to
outpatient treatment. Individuals who experience a smooth
transition from the inpatient to the outpatient setting are at
lower risk for early rehospitalization.
Narcolepsy
- chronic sleep disorder
- excessive day time sleepiness
- cataplexy
- REM sleep-related phenomena (hypnagogic/hyponopompic
hallucinations and sleep paralysis)
Pt falls asleep in the afternoon while watching TV/reading, feels
refreshed after a brief nap, sometimes hears a voice call his
name prior to falling asleep.
1834
2122
Behavioral
science
Behavioral
science
Nervous System
Serotonin release neurons are primarily found in the Raphe
Nuclei of the brain stem.
Nervous System
Delirium is a reversible, acute-onset confusional state
chracterized by fluctuating level of consciousness with deficits
in attention, memory, and executive function. In contrast,
dementia is of gradual onset is irreversible and does not
involve fluctuations in cousciousness.
Dopamine 2 agonst in the nigrostrial pathway can result in
Acute dystonic reaction (spasmodic torticollis). Other
extrapyrimidal symtoms (akanthisia, parkinsonism)
8323
Behavioral
science
Nervous System
Medication with M1 receptor antagonist properties
(benztropine) or antihistamine diphenhydramine help
re-establish the dopaminergic-cholinergic balance and
effectivley treat acute dystonia.
Drug induced parkinsonism is caused by dopamine (D2)
receptor blockers in the nigrostratal pathway.
261
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Rx: centerally acting antimuscarinic agent (ex. trihexyphenidyl,
benzotropine)
Levdopa shouldnt be used because is can precipitate
psychosis.
573
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Atypical depression
- mood reactivity
- laden paralysis (heavy arms and legs)
- rejection sensitivity
- reversed vegetative signs = increased sleep, hyperphagia
Rx. CBT, SSRI are 1st line
For treatment resistant = MAO inhibitors (Phenelzine,
tranylcypromine, selegiline)
574
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
MCC of death in pt with Tricyclic antidepressant (TCA) toxicity
is arrhythmias caused by inhibition of fast sodium channel
conduction.
TCAs inhibit the reuptake of norepi and serotonin
870
1287
1347
Behavioral
science
Behavioral
science
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Chronic ethanol use causes downregulation of GABA receptors
Psychiatric/Behavioral &
Substance Abuse
Methadone:
full mu opioid receptor agonist
has a long half life with sustained effects after chronic dosing
supresses craving and withdrawl symptoms for >24h
Good bioavailability (can take it orally)
S/E: prolong QT, respiratory depression, overdose
Psychiatric/Behavioral &
Substance Abuse
Persistent depressive disorder (dysthymia)
- Chronic depressed mood > 2 years
- no symptom free period for >2 months
Pt has no suicidal thoughs or problems with concentration or
changes in appeitie or sleep. Pt has little energy, hopeless.
1353
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Heroin (opioid) withdrawl symptoms:
- Nausea, vomitting, abdominal cramps, muscle aches
- dilated pupils
- yawning
- piloerection
- lacrimation
- hyperactive bowel sounds
Seizures, tachycardia, palpatations = seen in alcohol or benzo
withdrawl
2047
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Schizoaffective disorder:
- major depressive or manic episode concurrent with
symptoms of chizophrenia
- history of delusions or hallucinations for >2 weeks in the
ABSENCE of mood episode (major depressive or manic
episodes)
Frontal lobe = executive function and personality
7752
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Left Frontal Lobe defect:
- apathy
- depression
Right Frontal Lobe defect:
- disinhibited behaviour
8943
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Addressing opioid use disorder:
- Validate the patients concern about the pain control
- Engage in a non judgmental collabrative discussion of HOW
he is using the medication
- and explore resons for his escalating use.
10458
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
"Let me explain why antibiotics are not the best choise and
offer options to relieve your symptoms"
10465
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Hallucination in the absent of other psychiatric symptoms in a
child after the death of a loved one can be a part of normal
grief.
Children under the age of 6 so not understand the finality of
death.
11607
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Antidepressant monotherapy should be avidided in patients
with bipolar disorder due to the risk of precipitating mania.
11622
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Major depressive disorder requires a depressed mood to be
present most of the day almost everyday for > 2 weeks.
Rx. for treatment resistant schizophrenia = Clozapine
Clozapine is also given for schizophrenia associated with
suicide.
11743
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
11756
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Side effects:
- Agranulocytosis (Must monitor absolute neutrophil count)
- Seizures
- Myocarditis
- Metabolic syndrome
Rx Panic disorder
1st line for long term = SSRI
Rx Acute in emerg = Benzodiazepine
Fluoxetine (SSRI) is the DOC for Bulemia nervosa
11807
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Bupropion (norepi/dopamine reuptake inhibitor) contradicted in
bulimia nervosa/anorexia due to elevated risk of seizures
Olanzaipine - atypical antipsychotic associated with weight gain
At age 2 a child should have a vocab of 50-200 words and be
able to use 2 word phases.
11810
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
Language (isolated language disordeR) is the most commonly
delayed milestone at 10-15% at age 2. This child should have a
hearing examination, speech and langage examination.
11824
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
4/14 *Depersonalization/derealization disorder = Feelings of
detachment from or being an outside observer of one's self
(depersonalization), experiencing surroundings as unreal
(derealization)
11846
Behavioral
science
Psychiatric/Behavioral &
Substance Abuse
1st line for PTSD = CBT and SSRIs
784
Behavioral
science
Patient privacy: When pt is incapacitated or is not present,
Social Sciences
basic information can be shared if in the physicians
(Ethics/Legal/Professional)
professional judgment doing so is in the patients best interest.
784
Behavioral
science
Social Sciences
(Ethics/Legal/Professional)
Under HIPAA, physicians may disclose patient information to
friends and family members only when the patient gives
explicit permission or does not object when given a reasonable
oppertunity.
Inform the woman that the patient is stable, but that she will
have to wait until he can give permission to share any details.
Behavioral
science
All surrogate medical decisions, including next-of-kin decisions
Social Sciences
(wife/children), must be based on the best estimation of what
(Ethics/Legal/Professional)
the patient would of wanted.
1129
Behavioral
science
Exceptions to patient confidentiality:
- Suspected child or elder abuse (laws for spousal abuse vary
by state)
Social Sciences
- knife or gunshot wounds
(Ethics/Legal/Professional)
- Diagnosing a reportable communicable disease
- Threats to harm self or others and reasonable ability to carry
out the threat in the near future.
7487
Behavioral
science
In non emergency settings trained language interpreter should
Social Sciences
be used to ensure optimal medical care; this applied to deaf
(Ethics/Legal/Professional)
patients using ASL (American sign language)
7767
Behavioral
science
It is ethically problematic for physicians to accept expensive
Social Sciences
gifts as they may influence or appear to nfluence physician
(Ethics/Legal/Professional) behavior. These gifts should be declined after expressing
appeciation for the gesture.
Behavioral
science
Romantic and sexual relationships with current patients are
always unethical. Relationships with former non-psychiatric
Social Sciences
patients may be acceptable on a case by case basis provided
(Ethics/Legal/Professional)
the physician-patient relationship is terminated well
beforehand.
10508
Behavioral
science
First step in medical error should be root cause analysis
(identify what, how, why a preventable adverse outcome has
Social Sciences
occured.) the first step involves collecting data mainly though
(Ethics/Legal/Professional)
interviewing multiple individuals involved in the steps leading to
the outcome.
10533
Behavioral
science
Social Sciences
Mother refuses treatment of meningitis to her child - Obtain a
(Ethics/Legal/Professional) court injunction to mandate continued treatment.
1128
10464
Health maintenance organization (HMO) is an insurance plan
with low monthly premiums, low copayments and deductibles,
and low total cost for the patient.
11668
1047
Behavioral
science
Biochemistry
Social Sciences
(Ethics/Legal/Professional) HMOs reduce utilization by confining parients to a limited panel
of providers, requiring referra from a primary car provider to
specialist consultations and denying payment for services that
so not meet established guidlines.
Cardiovascular System
Vitamin B1 (Thiamine):
Dry berberi is characterized by symmetrical peripheral
neuropathy
Wet beriberi includes the addition of high output congestive
heart failure.
Vitamin B2 (riboflavin) - cheilosis, stomatitis, glossitis, anemia,
seborrheic dermatitis
Vitamin B6 (pyridoxine) - cheilosis, glossitis, dermatitis, and
affective symptoms
847
Biochemistry
Endocrine, Diabetes &
Metabolism
Glut-4 is the only insulin dependent transporter. Glut-4 is found
in muscle cells and adipocytes.
NAD+ is required to convert glyceraldehyde-3-phosphate to
1-3bisphosphoglycerate in glycolysis.
1019
Biochemistry
Endocrine, Diabetes &
Metabolism
Under anaerobic conditions, NADH transferes electrons to
pyruvate to form lactate and regenerate NAD+.
Pt 8 y/o with excercise intolerance has absent lactate
dehydrogenase activity. Strenuous exercise leads to inhibiton
of glycolysis in skeletal muscle due to intracellular depletion
of? NAD+
1022
Biochemistry
Endocrine, Diabetes &
Metabolism
What cofactor is needed to convert ocaloacetate to PPP?
Which step in the TCA is this co factor synthezied in.
1022
Biochemistry
Endocrine, Diabetes &
Metabolism
GTP formed in the TCA step succinyl-CoA --> Succinate is
subsequently used to convert oxaloacetate (TCA) to -->
phosphenolpyruvate.
Endocrine, Diabetes &
Metabolism
NADPH formed in the HMP shunt or (pentose phosphate
pathway) is used in:
1) Cholesterol and fatty acid synthesis
2) gultathione antioxidant mechanism.
1066
Biochemistry
Galacitiol accumulates in lens of patients with galactosemia
and causes osmotic damage leading to cataracts formation.
1074
Biochemistry
Endocrine, Diabetes &
Metabolism
Galactitol is formed from increased circulating galactose (seen
in galactosemias)
Galactokinase deficiency - cataracts, asympotomatic (aldolase
reductase)
Classic galactosemia - cataracts WITH hepatocellular
manifestations
1119
Biochemistry
Endocrine, Diabetes &
Metabolism
HMP occurs in the cytosol, transketolase is an enzyme in
HMP shunt.
1383
Biochemistry
Endocrine, Diabetes &
Metabolism
Look up signal transduction in physio
x2
Transmembrane domains help anchor the protein to the
phospholipid bilayer of the cell membrane.
1383
Biochemistry
Endocrine, Diabetes &
Metabolism
1473
Biochemistry
Endocrine, Diabetes &
Metabolism
Integral membrane proteins contain trandmembrane domains
composed of alpha helix with hydrphobic amino acid resides
(ie. alanine, valine, leucine, isoleucine, phenylalanine,
tryptophan, methionine, proline, glycine).
Mitochondrial dna codes for trna, rrna and proteins. Each
mitochondria has 1-10 copies.
1886
2016
2016
2102
11950
Biochemistry
Biochemistry
Biochemistry
Biochemistry
Biochemistry
Endocrine, Diabetes &
Metabolism
Endocrine, Diabetes &
Metabolism
Endocrine, Diabetes &
Metabolism
Endocrine, Diabetes &
Metabolism
Endocrine, Diabetes &
Metabolism
x2
Primary carnitine deficiency
- myopathy (elevated CK, weakness)
- cardiomyopathy (S3 gallop)
- hypoketotic hypoglycemia
- decreased muscle carnitine content
- defect in the protein responsible for carnitine transport across
the plasma membrane
- Without carnitine, FA can't be beta oxidized to acetyl coA in
the mitochondria --> cardiac/skeletal m. can't generate ATP and
- liver is unable to synthesize keton bodies (acetoacetate)
when glucose levels are low
Well-developed smooth ER is found in all steroid-producing
cells (eg. adrenals, gonads, liver)
The smooth ER contains enzyme for steroid and phospholipid
biosynthesis (while the RER does not)
All steroid producing cells have a well developed smooth ER
(cells in the adrenals, gonad, liver)
Smooth ER contains enzymes for steroid and phospholipid
biosynthesis
Elderly patients with dementia or hemiparesis may have
dysphagia. Dysphagia is a risk factor for aspiration pneumonia.
Intracellular receptors located in the cytoplasm or nucleus can
act directly as transcription factors. They typically bind
lipid-soluble hormones because the ligand has to diffuse
across the cell membrane to read the receptor. Once bound to
their ligan these receptors bind directly to target DNA
sequences via zinc fingers to regulate gene expression.
Ex. Steroid (estrogen, aldosterone, cortisole), thyroid hormone,
fat soluble vitamin receptors.
In prokaryotes: DNA I, II, III have 3' to 5' exonuclease activity.
1434
Biochemistry
General Principles
1029
Biochemistry
Hematology & Oncology
HOWEVER DNA polymerase I is the only one to also have 5'
to 3' exonuclease activity. This activity functions to remove the
RNA primer created by RNA primase and repair damaged DNA
sequences.
RBCs bypass the ATP
In sickle cell anemia sickling (Aggregation of sickle cells) is
promoted by oxygen unloading (low oxygen levels), increased
acidity, or low blood volume (dehydration)
1241
1337
Biochemistry
Biochemistry
Hematology & Oncology
Hematology & Oncology
Organs in which blood moves slowly (spleen, liver) are
predisposed to lower oxygen levels or acidity. Organs with high
metabolic demands (brain, muscle, placenta) promote sickling
by extracting more oxygen from the blood (oxygen unloading)
Photosensitivty presents as vesicles and blister formation on
sun exposed areas, as well as edema puritis, pain, erythema.
Porphyria cutanea tarda = Uroporphyriogen decarboxylase
1413
Biochemistry
Hematology & Oncology
Myoglobin is oxygen storing protein in skeletal and cardiac
muscle. (myoglobin is only found in the bloodstream after
muscle injury)
1413
Biochemistry
Hematology & Oncology
Myoglobin has a much higher affinity for oxygen than
hemoglobin.
Heme oxygenase degrades heme into biliverdin, CO, ferric iron.
1456
Biochemistry
Hematology & Oncology
1487
Biochemistry
Hematology & Oncology
Biliverdin is green in color but becomes yellow when is is
reduced to bilrubin by biliverdin reductase.
UAA, UGA, UAG stop codons
Cysteine become an essential amino acid in patients with
homocystinuria.
1332
Biochemistry
Miscellaneous
(Multisystem)
Methionine is an aa that can be degraded into succinyl-CoA
and SAM which are used to make homocysteine ->
cystathionine -> cysteine
Homocystinuria - cystathionie synthase defect
Cysteine becomes essential in pts with homocystinuria
1332
Biochemistry
Miscellaneous
(Multisystem)
Homocysteine build up causes elevated methionine in
homocystinuria. Homocystein is prothrombotic and can cause
acute coronary syndrome (increase troponins), atherosclerosis.
Sx: hypercoagulability and thromboemobolic occlusion, ectopia
lentitis (ocular lens displacment) and intellectual disability.
1048
Biochemistry
Nervous System
Vitamin A overuse can result in intracranial hypertension
(Causing papilledema due to increased ICP), skin changes,
hepatosplenomegaly
1) Branch chain a-ketoacide dehydrogenase - defect in Maple
Syrup Urine Disease
2) pyruvate dehydrogenase
3) a-ketoglutarate dehydrogenase
1336
Biochemistry
Nervous System
Require 5 Cofactors(TLCFN)
i) Thiamine pyrophospate (B1)
ii) Lipoate
iii) Coenzyme A
iv) FAD
v) NAD
5
Ornithine transport into mitochondria is essential for urea
formation. Ornithine is combined with cabamoyl phosphate in
the mitochondria to form citulline (2nd step or urea cycle)
1372
Biochemistry
Nervous System
Urea cycle defects cause neurological damage due to
accumulation of ammonia.
Protein restriction improves this condition.
1998
Biochemistry
Nervous System
Organophosphate posioning?
1249
Biochemistry
Pulmonary & Critical Care
Desmosine cross-links is responsible for the rubbery/elastic
property of elastin. lysyl oxidase + copper co factor oxidatively
deaminates some of the lysine residues of tropoelastin,
facilitating the formation of desmosine cross links.
Ehlers-Danlos, and Menkes disease have problems with the
cross-linking step in collagen synthesis.
1989
Biochemistry
Renal, Urinary Systems &
Electrolytes
Metabolize cermide trihexoside
1989
Biochemistry
Renal, Urinary Systems &
Electrolytes
4/16 *deficiency a-galactosidase A = Fabry disease
*Episodic peripheral neuropathy, angiokeratomas, hypohidrosis
(decreased sweating) = Fabry's disease (a-galactosidase A)
*Accumulation of ceramide trihexoside = Fabry's disease
*Late complications in Fabry's disease = renal failure,
cardiovascular disease (LVH)
2017
Biochemistry
Renal, Urinary Systems &
Electrolytes
Primase is a DNA-dependent RNA polymerase that
incorporates short RNA primers into replicating DNA
11939
Biochemistry
Renal, Urinary Systems &
Electrolytes
Arginine derivitives = Creatinine, urea, nitric oxide
361
Biochemistry
Rheumatology/Orthopedics snRNPs (small rbonucleoproteins) are found in spliceosomes.
& Sports
spliceosomes remove introns from pre-mrna
1503
Biochemistry
Alkaptonuria presents with blue-black spots on the sclera,
Rheumatology/Orthopedics urine that turns black on standing, and sometimes debilitating
& Sports
arthralgia/arthirtis (because homogentisic acid is toxic to
cartilage.
8802
Biochemistry
Rheumatology/Orthopedics
neeeds anki cards
& Sports
8802
Biochemistry
Anti-ccp (citrullinated peptides) are highly specific for
Rheumatology/Orthopedics
rheumatoid arthiritis (prolonged morning stiffness that
& Sports
improves with use)
Effect modification is when an external variable postivley or
negatively impact the observed effect of a risk on a disease.
Wil show a signidicant difference in the risk between the groups
1173
1187
1232
Biostatistics
Biostatistics &
Epidemiology
Biostatistics
Biostatistics &
Epidemiology
Biostatistics
Biostatistics &
Epidemiology
Confounding bias occurs when exposure disease relationships
is muddied by the effect of a confounding variable.
Confounders are extreneous factors that correlate with both the
exposure and the disease.
Rising prevalence (# people with the disease at a specific time)
with a stable incidence (# of new cases) in a stable population
(little migration) can be attributed to factors that prolong the
duration of a disease (ie. improved qulaity of care - aka
decreases number of deaths)
PPV increases with prevelence
PPV = True positive/True postive + false positive
Realitice risk is an incidence measure. Can not be used in
people who already have the disease. Relative risk is
calculated in a cohort study where people are followed over
time.
1277
Biostatistics
Biostatistics &
Epidemiology
Prevelance odds ratio is calculated in a cross-sectional study
to compare the prevalence of a disease in different populations
Odds ratio compares the exposure of people with the disease
to those with exposure and no disease. Used in case-control
study,
Sensitivity = TP/TP + FN
1229
Biostatistics
Cardiovascular System
True positive = (Sensitivity) * (# of pt actually with the disease)
False negative = (1 - sensitivity) * (# of pt actually with the
disease)
1301
1013
8422
Biostatistics
Cardiovascular System
Double blinding is used to reduced Observer Bias.
Biostatistics
Endocrine, Diabetes &
Metabolism
Smoking cessation is by far the most effective preventitive
intervention in almost all patients. This is especially true in
diabetics
Biostatistics
Endocrine, Diabetes &
Metabolism
Crossover study - subjects are randomly assigned to a
sequence of 2 or more treatments given consecutivley. A
washout (no treatment) period is often added between
treatment intervals to limit the confounding efects of prior
treatment.
Ie. In a 4 week study group A spends first 2 weeks on new
medication and last 2 weeks on the placebo. Group B spends
first 2 weeks on a placebo and last 2 weeks on the new
medication
1270
1270
35
Biostatistics
Biostatistics
Embryology
Nervous System
Step 2 Valsalva, coughing, leaning forward increase
intracranial pressure
Nervous System
The incidence of a disease is the number of new cases of a
disease per year divided by the total population at risk.
(Remember to subtract the number of people who already have
the disease from the denominator)
Cardiovascular System
Transposition of great arteries is incompatible with life unless
there is another coexisting connection such as a PDA, septal
defect, or patent foramen ovale to allow mixing of O2
pulmonary circulation blood with the systemic circulation.
"Aorta lying anterior, inferior, and to the right of the pulmonary
artery"
202
Embryology
Cardiovascular System
4/18 = What causes Paradoxical embolization (Venous clot into
the arterial circulation causing a stroke) = Patent foramen
Ovale.
Incomplete fusion of atrial septum primum and secundum =
Patent foramen ovale
Tetralogy of fallot occurs due to anterior and cephalad
deviation of the infundibular spetum during devopment
1705
1705
1750
Embryology
Embryology
Embryology
Cardiovascular System
TofF:
1) Overrding aorta
2) VSD
3) Right ventricular hypertrophy (boot shaped heart)
4) Right ventricular outflow tract obstruction
Cardiovascular System
What is the mechanism that causes TofF?
Anterior and cephalad deviation of the infundibular septum
during embryological development - resulting in a malaligned
ventricular septal defect (VSD) with an overriding aorta.
Cardiovascular System
4/18
1st aortic arch (trigeminal n)= regresses completey, but does
give rise to a portion of the maxillary artery.
2nd aortic arch (facial n)= stapedial artery (regresses)
3rd aortic arch (glossopharyngeal n) = Common and proximal
internal carotid arteries.
4th aortic arch (superior laryngeal branch of vagus n) = part of
the true aortic arch and subclavian arteries
6th aortic arch (reccurent laryngeal branch of the vagus n) =
pulmonary arteries and the ductus arteriosus
x2 Third aortic arch forms the common and proximal internal
carotid arteries (palpated in the neck)
1750
Embryology
Cardiovascular System
Associated with the glossopharyngeal nerve and
Third pharyngeal arch: parts of the hyoid bone, stylopharngeus
muscle.
1960
Embryology
Dermatology
MCC metastatic tumors to the brain = lung cancer, renal
cancer, melanoma
Melanocytes are derived from neural crest cells
1740
550
Embryology
Embryology
Ear, Nose & Throat (ENT)
Endocrine, Diabetes &
Metabolism
Cleft lip = failure of fusion of the maxillary prominence and
intermaxillary segment.
Premature infants born at <32 weeks gestation are at
significant risk of surfactant deficiency. Coritcosteroids (ie.
Betamethasone, dexamethason) have the greatest effect on
increasing surfactant produciton by accelerating maturation of
type II pneumocytes.
They are adminsted to patients at risk for preterm labor (ie.
preterm premature rupture of membranes) to decrease the risk
of respiratory distress syndrome and mortality.
763
Embryology
Endocrine, Diabetes &
Metabolism
Lingual thyroid
The thyroid gland is formed from evagination of the pharyngeal
epithelium and descends to the lower neck.
Due to failure of migration the thyroid can reside anywhere
alone the thryoglossal duct's usual path, including tongue
(lingual thyroid).
13 y/o pt difficulty breathing, hoarsness, dysphagia began 6
months ago. 70th percentile for height and weight, large red
lingual mass.
771
Embryology
Endocrine, Diabetes &
Metabolism
1) Pheochromocytoma
2) Medullary thyroid cancer (malignancy of parafollicular C
cells)
3a) Parathyroid hyperplasia (MEN 2A)
3b) Mucosal neuromas and marfanoid habitus (MEN 2B)
The thyroid parafollicular C cells and chromaffin cells of the
adrenal medulla are derived from neural crest tissue.
Adrenal coretx is derived from mesoderm.
1809
1831
Embryology
Embryology
Female Reproductive
System & Breast
Female Reproductive
System & Breast
Shortened maginal canal with a rudimentary uterus & fully
developed secondary sex characteristics?
Mullerian aplasia (Mayer-Rokitansky-Kuster-Hauser
syndrome) 46,XX
4/16
*Incomplete lateral fusion of the upper segments of
paramesonephric duct = Bicornuate uterus (indentation in the
center of the fundus)
*Complete lack of fusion of the paramesonephric duct =
Uterine didelphys (double uterus cervix)
*Failed involution of the paramesonephric duct =longitudinal
uterine septum
*How to differentiate between a bicornuate uterus and a
septate uterus = on MRI a longitudinal uterine septum normal
outer uterine contour.
Gastric exctopic tissue is the most common cause of
symptomatic Meckel diverticulum. Gastric acid production
leads to ulceration of adjacent tissue and lower GI bleeded.
321
Embryology
Gastrointestinal & Nutrition
Meckel's
- painless melena
- incomplete obliteration of the ompahlomesenteric duct
Omphalmesenteric (vitelline) duct normally obliterated during
which week of embryonic development?
322
Embryology
Gastrointestinal & Nutrition 7th week
Failure of obliteration involving the omphalomesenteric duct =
Meckel diverticula and vitelline duct cyst (enterocyts)
330
Embryology
Hirschsprung disease is a result of abnormal migration of
neural crest cells during embryogenesis. These cells are the
precursors of ganglion cells of intestinal wall plexi
Gastrointestinal & Nutrition
(Submucosal Meissner and myenteric Auerbach plexus). Since
neural crest cells migrate caudally, the rectum is always
affected in Hirschsprung disease.
Pancreatic divisum: failure of the pancreatic ductal systems of
the ventral and dorsal pancreatic primordia to fuse during
embryogenesis.
437
Embryology
Ventral pancreatic duct gives rise to:
- Uncinate process
Gastrointestinal & Nutrition
- Inferior/posterior portion of the pancreatic head
- Main pancreatic duct (duct of Wirsung)
Dorsal pancreatic duct:
- body, tail and most of the head
438
Embryology
Annular pancreas (pancreatic tissue encricles the duodenum)
- results from abnormal migration of the ventral pancreatic bud
Gastrointestinal & Nutrition - Can compress the duodenal lumen (causing obstruction) or
result in obstructed pancreatic drainage (Acute or chronic
pancreatitis)
Supplied mainly by an artery of the foregut (Celiac) but not a
forgut organ = Spleen
2022
Embryology
Gastrointestinal & Nutrition
Venous return from the spleen courses through the splenic
vein to return to the portal circulation rather than the systemic
circulation.
x2 Uncomplicated umbilical hernia
11803
11962
419
Embryology
Embryology
Embryology
- Incomplete closure of the umbilical ring.
- Defect at linea alba covered by skin (umbilical stump is at the
center of protrusion)
Gastrointestinal & Nutrition - Reducible bulge at umbilicus, notably with increased
abdominal pressure (ie. crying, passing bowel movements)
- Associated conditions: Down syndrome, hypothyroidism,
Beckwith-Wiedeman syndrome
- Resolves spontaneously in the first few years of life.
Tracheoesophageal fistular with esophageal atresia from failure
of the primitive foregut to appropriatley divide into eparate
trachea and esophagus. Infants present shortly after birth with
Gastrointestinal & Nutrition
excessive secretions and chocking/cyanosis during feeds.
Diagnosis can be confirmed by x-ray after the inability to pass
a nasogastric tube into the stomach.
Male Reproductive System
4/15 Communicating hydroceles and indirect inguinal hernias
are cause by incomplete obliteration of the process vaginalis.
Direct inguinal hernias do NOT pass through the inguinal canal
46 XY with functioning Leydig cells but total absence of Sertoli
cells.
Leydig > LH > testosterone > necessary for development of
male internal genitalia.
1449
Embryology
Male Reproductive System
Seminefirous tubules > Sertoli > Mullerian inhibiting factor
(MIF) > involution of parmesonephric ducts (prevents
development of female internal genitalia)
= Male and female internal genitalia and male external genitalia.
The absence of a Y chromosome causes the default female
pattern of gonadal development.
4/14
1870
Embryology
Male Reproductive System
*Faulty positioning of the genital tubercle in the 5th week of
gestation = Epispadias
*Incomplete fusion of the urogenital folds = Hypospadias
496
Embryology
Nervous System
Embryology
Pregnancy, Childbirth &
Puerperium
Failure of neuropore closure by 4 weeks gestation leads to
neural tube defects.
Blastocyst implants 6 days after fertilization.
1772
B-hcg is detected in the serum after 8 days
B-hcg is detected in the urine after 14 days
Dipalmitoyl Phosphatidylcholine (aka lecithin)
800
Embryology
Pulmonary & Critical Care
- Lecithin increases sharply after 30 weeks gestation
- Phosphatidylglycerol production increases at 36 weeks
gestation
- Sphingomyelin should remain constant
A Lecithin:Sphingomyelin ratio > 2.0 indicated adequate
surfactant production to avoid neonatal hyaline membrane
disease.
1833
Embryology
Pulmonary & Critical Care
The most highly oxygenated blood in the fetus is carried by the
umbilical vein, which empties directly into the IVC via the
ductus venosus.
652
Embryology
Renal, Urinary Systems &
Electrolytes
Urine discharge from the umbilicus of infanct = patent urachus
(remnant of the allantois sac)
652
Embryology
Renal, Urinary Systems &
Electrolytes
Straw coloured urine discharged from the umbilicus = patent
urachus
837
Embryology
Renal, Urinary Systems &
Electrolytes
MCC of fetal hydronephrosis = inadequate recanalization of the
uretropelvic junction (b/w kidney and ureter)
Ureters are fully canalized before the metanephros begins to
produce urine (8-10th week of gestation)
1736
Embryology
Renal, Urinary Systems &
Electrolytes
Uteric bud - gives rise to the collecting system of the kidney,
including the collecting tubules and ducts, major and minor
calyces, renal pelvis and the ureters
Metanephric mesoderm (blastema) - gives rise to glomeruli,
bowman's space, proximal tubules, loops of henle, distal
convoluted tubules.
Respiratory failure hours after birth is the MCC of death in new
borns with Potter syndrome
1752
Embryology
Renal, Urinary Systems &
Electrolytes
swallowed amniotic fluid contributes to the development and
maturatio of the fetal lungs. Fetus with potter's syndrome have
lung hypoplasia.
bilaterally enlarged, cystic fetal kidney and oligohydraminos =
ARPKD
1915
Embryology
Renal, Urinary Systems &
Electrolytes
ARPKD - PKHD1 gene mutation codes for fibryocystin (present
in kidney + liver)
Oligohydraminos = decrease amnitic fluid = potter sequence =
flattened facies, limb deformaties, pulmonary hypoplasia.
756
Embryology
4/14 *Third pharyngeal pouch = Thymus and Inferior
parathyroid gland
Rheumatology/Orthopedics *Second pharyngeal pouch = Palatine tonsil
& Sports
*Fourth pharyngeal pouch = Superior parathyroid gland and
ultimobrachial body
Myasthenia gravis is associated with a mediastinal mass
(thymoma, thymic hyperplasia).
756
1684
Embryology
Embryology
Rheumatology/Orthopedics
& Sports
The thymus and inferior parathyroid glands arise from the 3rd
pharyngeal pouch.
Pharyngeal pouch
1) epithelium of middle ear and auditory tube
2) epithelium of palantine tonsil crypts
3) thymus, inferior parathyroid
4) Superior parathyroid glands, ultimobranchial body
4/16 Sacral agenesis causing lower extremity paralysis and
Rheumatology/Orthopedics urinary incontinence = Caudal regression syndrome is
& Sports
condition characterized by. Associated with poorly controlled
maternal diabetes.
4/18 Bicuspid aortic valve is the most common congenital
cardiac malformation in Turner syndrome
8292
Genetics
Cardiovascular System
A non stenotic bicuspid aortic valve can manifest as an early
systolic, high-frequency click over the right 2nd
intercostalspace.
883
1725
Genetics
Genetics
Dermatology
Xeroderma pigementosum
- autosomal recssive
- decrease ability to repair DNA following damage by UV light
- DNA excision repair defect
- High incidence of all forms of cutaneous malignancy
Dermatology
4/16 Androgenic alopecia (male patterned baldness)
demonstartes polygenic inheritence with vairable expressivity
=Other polygenic conditions: Epilepsy, Glaucoma, HTN,
Ischemic heart disease, Schizophrenia, DM type 2
Intellectual disability, gait or posture abnormality, eczema,
musty body ordor in a toddler = PKU
1789
Genetics
Dermatology
PKU is autsomal recessive (1/4 chance sibling of a child with
disease will also have the disease)
1412
Genetics
General Principles
Deletion or insertion of a number of bases that is not divisible
by 3 results in frameshift mutations. Frameshift mutations alter
the reading frame of the gentic code resulting in the formation
of nonfunctional proteins.
Cystic fibrosis is a result of a frameshift mutation.
Telomerase is a reverse transcriptase (RNA-dependent DNA
polymerase) that lengthens telomeres by adding TTAGGG
repeats to the 3' end of chromosomes.
1438
Genetics
General Principles
Stem cells have long telomeres due to high telomerase
activity, allowing them to proliferate indefinitely in a controlled
manner.
Viruses with segmented gneomes (ie. Orthomyxovirus,
rotaviruses, influenza) are capable of gentic shifts through
reassortment.
1469
Genetics
General Principles
Reassortment (Genetic shift) involved exchanged of entire
genomic segments, a far more dramatic process than the point
mutations responsible for genetic drift.
Recombination and Reassortment (only segmented virus) will
cause some progeny to contain the new genetic material.
1469
1790
2029
Genetics
Genetics
Genetics
General Principles
x2
Segmented viruses are capable of genetic shift through
reassortment:
- Reovirus (colorado tick fever, Rotavirus)
- Orthomyxovirus (Influenza)
- Arenavirus (LCMV)
- Bunyavirus (Hantavirus, sandfly/rift valley, california
encephalitis, crimean-congo)
General Principles
An unaffected individual (with unaffected parents) who has a
sibling affected by an autosomal recessive condition has a 2/3
chance of being a carrier for that condition.
General Principles
Releasing factors recognize stop codons (UAA, UAG, UGA)
and terminate protein synthesis. They facilitate release of the
polypeptide chain from the ribosome and dissolution of the
ribosome-mRNA complex.
2030
1486
Genetics
Genetics
General Principles
Hematology & Oncology
TATA box is a promoter region that binds transcription factors
and RNA polym II during initiation of transcription. It is located
approx. 25 bases upstream from the beginning of the coding
region.
4/19 Heterochromatin has a low level of transcriptional activity
(inactive). Composed of heavily methylated DNA and
deacetylated histones. Typically collects at the periphery of the
nucleus.
Euchromatin is loosely arranged and exhibits a high level of
transcription activity (transcriptionally active).
Sicke cell anemia is autosomal recessive. You must inherit 2
mutant genes for Hbs (one from each parents).
2040
Genetics
Hematology & Oncology
In order for a child of two healthy parents to get sickle cell,
BOTH parents must carry the sickle cell trait.
Beta thalassemia has a mutation in the kozak sequence.
2086
Genetics
Hematology & Oncology
Kozac sequence helps start translation in eukaryotes by
helping the mRNA the AUG start codon.
Kozak consensus sequence is analogous to the shine-Dalgaro
sequence in E.coli
Beta thalaseemia result in hypochromic, microcytic anemia
due to decreased beta globin chain synthesis.
2087
Genetics
Hematology & Oncology
Unpaired alpha chains percipitate within red cells and cause
membrane damage leading to ineffective erythropoesis and
extravascular hemolysis.
4/15 Telomerase synthesizes telomeric DNA sequences that
can replace the lost chromosomal ends of telomeres
11912
Genetics
Hematology & Oncology
Cancer cells typically contain increased telomerase activity to
allow for continued proliferation
1461
Genetics
Infectious Diseases
Recombination - gene exchange that occurs through crossing
over of 2 dsDNA molecules.
Reassortment - mixing of genome segments in segmented
viruses that infect the same host cell.
Transformation - uptake of naked DNA by a prokaryotic or
eukaryotic cell. In virology also describes incorportation of
viral DNA into a host cell chromosome. Typically causes no
genomic change in progeny virions.
Interference - when one virus inhibits replication or release of a
2nd virus that
11907
Genetics
Infectious Diseases
Reassortment describes the mixing of genomic segments in
segmented viruses (ie influenza) that infect the same host cell.
Genetics
Klinefelter 47XXy
- tall stature
- firm testes/cryptorchidism
Male Reproductive System - azoospermia (infertility)
- gynecomastia
- mild intellectual disability (severity increases with each
additional X chormosome)
343
807
Genetics
Reccurent pneumo, digital clubbing, azoospermia, bilateral
absence of the vas deferens = Cystic fibrosis
CFTR gene = impaired ion transport, abnormal development of
Wolffian structures resulting in vasal agenesis & defect sperm
transport.
Male Reproductive System Dx: elevated sweat Cl levels, measure nasal transepithelial
potential dif
Infertility due to absent vas deferens bilaterally (azoospermia)
= Cystic fibrosis
Infertility due to immotile spermatozoa = Primary ciliary
dyskinesia/Kartageners
Achondroplasia is caused by a mutation that results in the
activation of fibroblast growth factor receptor 3 (FGFR3)
701
Genetics
Miscellaneous
(Multisystem)
Achondroplasia is autosomal dominant in 15% of cases and a
sporadic mutation (due to advanced paternal age) in 85% of
cases
A heterozygous parent (diseased) of an autosomal dominant
disease has 50% chance of passing on the mutation to their
offspring)
1822
Genetics
Miscellaneous
(Multisystem)
Trisomy 13 Patau Syndrome:
- secondary to meiotic nondisjunction in mothers of advanced
maternal age
- Key physical findings reflect defective prechordal mesoderm
fusion resulting in midline defects (eg. holoprosencephaly,
microphthalmia, cleft lip/palate, omphalocele)
- Cutis aplasia
- Polydactyly
- Cardiac defects
- Renal defects
- umbilical hernia (omphalocele)
- cleft lip/palate
- Microphthalmia
- microcephaly/holoprosencephaly
- Rocker bottom feet
1823
Genetics
Miscellaneous
(Multisystem)
Trisomy 18 Edwards:
- meiotic non disjunction
- Micrognathia
- prominent occiput
- significant hypertonia
- low set ears
- heart defects (VSD, PDA)
- Rocker bottom feet
- Clenched hands with overlapping fingers
- Renal defects (horseshoe kidney)
- Limted hip abduction
- Die in utero or by 2 weeks
344
Genetics
Nervous System
Fragile X syndrome = Macroorchidism, large jaw and ears
590
Genetics
Nervous System
Early onset alzheimers is seen in Down syndrome.
Maternally inherited, which of the following is the most likely
explanation for variability in clinical presentation b/w the pt and
his sister? Heteroplasmy
596
Genetics
Nervous System
Heteroplasmy is responsible for the clinical variability of
mitochondrial diseases.
Mitochondrial encephlomyopathy with lactic acidosis and
stroke like episodes (MEALS)
1808
955
Genetics
Genetics
Nervous System
Pregnancy, Childbirth &
Puerperium
Fragile X syndrome
- X-linked FMR1 gene loss of function mutation
- Neurobehvaoural problems
- Prominent forehead
- large ears
- long narrow face
- prominent chin
- macroorchidism (large testes)
- hyperlaxity of joints in the hand
- developmental delay (speech and motor)
Fetal placental Aromatase deficiency
- high androgen, low estrogen in a female fetus
- Maternal virilization (hirsutism) commonly occurs during
pregnancy due to transfer of excess androgens into maternal
circulation
- normal internal genitalia and ambigous or male-type external
genitalia (cliormegaly, female pseudohermaphrodism)
Aromatase converts androgens into estrogens in the ovaries,
testes, placenta and other peripharal tissues.
4/19
Primary oocyte arrest in Prophase of meiosis I until ovulation
1688
Genetics
Pregnancy, Childbirth &
Puerperium
Secondary oocyte arrested in metaphase II until fertilization
occurs at which point its completes its division
Meiosis I is arrested in Prophase I for years until Ovulation
Meiosis II is arrested in metaphase II until fertilization
Meitotic nondisjunction Down syndrome (increased maternal
age) = Trisomy chromosome 21 (47, XX, +21)
1825
Genetics
Pregnancy, Childbirth &
Puerperium
Unbalanced Robersonian translocation Down syndrome (less
common) = 46, XX t(14,21) translocation between 2
acrocentric nonhomologous chromosomes
Balanced robertsonian translocation
( increase rate of miscarriage) = have 0 copies of chromosome
21
Chorionic villil in clusters = Complete mole
Central heterogenous mass with multiple cystic areas,
swisscheese or snow storm pattern =
fetal tissue with normal placental villi intermixed with hydropic
villi = Partial mole
1830
Genetics
Pregnancy, Childbirth &
Puerperium
Complete mole commonly results from the fertilization of an
ovum that has no maternal chromosomes by 1 spem 23X (90%
of cases) = 46XX
Less commonly 2 sperm fertilize 1 empty ovum and create
46XY
Pulmonary & Critical Care
Mutation in the CFTR gene product causes defective
post-translational folding and glycosylation. Resulting in
degradation of the CFTR integral membrane protein before it
reaches the cell surface.
Genetics
Pulmonary & Critical Care
The probability that a child of parents from 2 populations with
different mutant allele carrier frequencies will inherit an
autosomal recessive disease (Cystic fibrosis) is 25% or 1/4
multiplied by the carrier frequency of the mothers populations
and fathers population
1407
Genetics
Congenital hypothyroidism is usually asymptomatic at birth.
Rheumatology/Orthopedics After maternal T4 wanes, infants develop constipation,
& Sports
lethargy, hypotonia, macroglossia, umbilical hernia, large
anterior frontanelle.
1935
Genetics
Variable clinical expressions in affected family members can
Rheumatology/Orthopedics
occure due to heteroplasmy, which is the coexistence of
& Sports
distinct versions of mitochondrial genomes in an individual cell.
8711
Histology
Cardiovascular System
805
1791
Genetics
Scar tissue = Type 1 collagen
Granulaton tissue = Type 3
1015
Histology
Female Reproductive
System & Breast
4/16 Clue cells = Gardnerella vaginallis
Pernicious anemia is an autoimmune disorder cause by
antibody mediated destruction of parietal cells in the gastric
body and fundus.
124
Histology
Gastrointestinal & Nutrition
Histologically: loss of parietal cells with marked lymphocytic
and plasma cell infiltration.
Parietcal cells are oxynitic (pale pink), round, plate-like cells
found predominatly in the upper glandular layer that secrete
gastric acid and instrinsic factor (IF).
367
Histology
Large hepatocytes filled with finely granular, homogenous, pale
Gastrointestinal & Nutrition pink cytoplasm (eosinophilic inclusions) = Accumulation of
hepatitis B surface antigen within infected hepatocytes.
Stratified squamous epithelium is found in the oropharynx,
laryngopharynx, anterior epiglottis, upper hald of the posterior
epiglottis and vocal folds (true vocal cords).
483
Histology
Infectious Diseases
HPV can cause warty growth (papillomas) on the true vocal
cords, producing hoarseness and possible stridor (upper
airway obstruction) because they are lined with stratfied
squamous epithelium.
True vocal cords = stratified squamous epithelium
483
Histology
Infectious Diseases
1536
Histology
Nervous System
The blood brain barrier is formed by tight junctions
1936
Histology
Nervous System
Kinesin is a microtuble associated motor protein.
Carries vessicles and organelles away from the cell body
toward the nerve terminal
HPV like stratified squamous epithelium = anus, cervix, true
vocal cords. lips
Ectopic pregnancy
Sample would reveal decidualized endometrium only.
This is constent with dilated colied edeometrial glands,
vascularized edmatous stroma.
334
Histology
Pregnancy, Childbirth &
Puerperium
These changed normally occur in the luteal phase of menstrual
cycle under the influence of progesterone as the endometrium
prepares for implantation
Straight short endometrial glands and compact stroma =
proliferative phase of menstrual cycle
Proteinases:
- Elastase
- Cathepsin G
- Matrix matelloproteinases
484
Histology
Pulmonary & Critical Care
Antiproteinase:
- alpha1-antitrypsin
- alpha2-Macroglobulin
- TIMPs
Elastase is contained in macrophages and neutrophils.
488
Histology
Pulmonary & Critical Care
Club cells (Formley Clara cells) are non cilliated, secretory
parts of the terminal respiratory epithelium. They help detoxify
inhaled substances by cytochrom P450 mechanism.
8
Histology
Renal, Urinary Systems &
Electrolytes
APSGN on IF shows granular depositis of IgG, IgM and C3 in
the mesangium, basement membranes = starry sky
appearance
27
Histology
Renal, Urinary Systems &
Electrolytes
subepithelial humps in APSGN represent immune complexes
composed of igG, igM, and C3
Histology
Actin filaments (thin) bind to structural proteins at the Z-line.
Rheumatology/Orthopedics The unbound actin project into the middle of the sarcomere
& Sports
where they interact with thick myosin filaments during muscle
contraction.
1734
556
Immunology
Allergy & Immunology
Type 1 hypersensitivty (Bee sting) mediated by:
- antibody class switching to IgE on intial exposure
- subsequent expsure: degranulation of mast cells and
basophils with release of histamine and heparin
743
Immunology
Allergy & Immunology
Reactice arthritis (reiters syndrome) can cause Sacroliitis
Why does Hib (heamophilus influenzae serotype b) vaccine
contain both the sapsular polysaccharide for Hib as well as the
conjugated tetanus toxoid?
965
Immunology
Allergy & Immunology
The polysaccahride capsule provokes an antibody-mediated (B
cell) immune response, however polysaccahride vaccines are
ineffective in children <2 due to their immature humoral
immunity.
Immunogenicity is increased as a result of T cell dependent
stimulation of B lymphocytes and the production of memory B
lymphocytes.
Calcineurin is an essential protein in the activation of IL-2
which promoted the growth and differentiation of T-cells.
1155
Immunology
Allergy & Immunology
Immunosuppressants such as cyclosporine and tacrolimus
work by inhibiting calcineurin activation.
4/15 Tryptase = is relatively specific to mast cells and can be
used as a marker for mast cell activation.
2068
Immunology
Allergy & Immunology
Anaphylaxis results from widespread mast call and basophil
degranulation and results in =histamine and tryptase release
4/15 * high affinity IgE receptors is found on the surface of
mast cells and basophils
2069
Immunology
Allergy & Immunology
*Cross-linking of multiple membrane bounded IgE antibodies
by a multivalent antigen results in =aggregation of the igE
receptors causing degranulation of mast cells and basophils
Which acts in the most ismilar manner to IgG antibodies to
facilitate phagocytosis? Complement C3b
11677
Immunology
Allergy & Immunology
Opsonins:
- IgG
- C3b
- mannose-binding lectin
- C-reactive protein
pneumococcal polysaccharide vaccine (Pneumovax):
- protects against wider range of serotypes.
- but antibody levels decline over approx 5 yrs.
- not immunogenic in children age <2 due to their relatively
immature humoral antibody response
11872
Immunology
Allergy & Immunology
pneumococcal conjugate vaccine (Prevnar):
- contains a nontoxic diptheria protein conjugated to the
polysaccharide that boosts the immune response through
T-cell recruitment.
- strongly immunogenic in infancy, elderly,
immunocompromised
Patchy necrosis with granulation tissue = Ischemia
568
Immunology
Cardiovascular System
Acute graft rejection occurs weeks after transplant and is cell
mediated (den intersitia lymphocytic infilterates)
Acute graft rejection = 1-4 weeks post transplant
568
Immunology
Cardiovascular System
Histology: dense infiltrate of mononuclear cells usually
composed primarily of T-lymphocytes.
Acute graft rejection ir mediated by host T-lymphocyte
sensitization against graft (foreign) MHC antigens.
1613
Immunology
Dermatology
Graft-vs-host disease (GVHD)
- Donor/Graft Tcells become sensitized against host MHC
antigens
2079
Immunology
Dermatology
4/16 which cells are directly involved in delayed HSR (type IV)
= CD4+ helper T cells and macrophages (and CD4+ then
recruits CD8+)
373
Immunology
Gastrointestinal & Nutrition
in children <6 y/o >80% of HAV infection are anicteric (no
jaundice)
Anti-hep A IgG postive = prior infection with HAV
373
Immunology
Hepatitis A virus infection is most commonly silent or
subclinical ("anicteric") in young children but can also present
as an acute self-limited illness characterized by jaundice,
malasise, fatigue, anorexia, nauseam, vomiting, RUQ pain or
Gastrointestinal & Nutrition an aversion to smoking.
An asymptomatic patients with IgG antibodies against hep A
(HAV) who has never been vaccinated likely has prior infection
with HAV.
561
745
Immunology
Immunology
SCID
- Adenosine demainase deficiency or X-linked
- Chronic diarrhea & failure to thrive
Gastrointestinal & Nutrition
- Treatment is presently being researched using retroviral
vectors to infect pt stem cells with the gene coding for
adenosine deaminase.
Gastrointestinal & Nutrition
Group of malignant epithelial cells in the sigmoid colon that
have decreased their surface expressin of MHC class I
antigen. Which of the following immune effector cell types is
most likely to kill the transformed epithelial cells? Natural killer
cells.
NK cells recognize and kill cells with decreased MHC class I
antigen cell surface expression, such as virus-infected cells
and tumor cells. They are large lymphocytes that contain
perforins and granzymes in cytoplasmic granu
Children with IgA deficiency, X-linked agammaglobulinemia,
and Common vaiable immune deficiency have a predisposition
to developing chronic Giardiasis.
1596
Immunology
Gastrointestinal & Nutrition
Giardia presents with watery diarrhea, nausea, abdominal
cramps, malabsorption, foul-smelling stool.
Dx Giarida: Stool microscopy for ova and parasites
1597
Immunology
IL-10 reduces production of pro-inflammatory TH1 cytokines
Gastrointestinal & Nutrition (IL-2 and IFN-gamma), reduces MHCII expression, inhibits
activated dendritic cells and macrophages.
IL-10 has protective effect in Chron's disease
1597
Immunology
IL-10 is an antinflammatory cytokine that has protective effects
in Chron's disease:
- through inhibiton of TH1 cytokines
Gastrointestinal & Nutrition
- reduction of MHC-II expression,
- and suppression of activated macrophages and dendritic
cells)
8384
Immunology
Gastrointestinal & Nutrition
IFN-gamma (a Th1 cytokine) is a key factor in eliminating
Mycobacterium TB
Hematology & Oncology
Wiskott-Aldrich syndrome:
- Eczema, recurrent infections, thrombocytopenia
- WAS gene mutation
- X-linked recessive
- T cells unable to recognize actin cytoskeleton
- Increase risk of autoimmune disease and malignancy
- Incr IgE, IgA
- Fewer and smaller platlets
537
540
Immunology
Immunology
Hematology & Oncology
The classical complement cascade begins with binding of C1
complemnt to either two molecules of igG or 2 molecules of
IgM. Because igM circulate in pentameric form it is a much
better activator of the complement system.
The C1 molecule binds to the Fc region of the heavy
immunoglobulin chain in the region near the hinge point.
559
953
Immunology
Immunology
Hematology & Oncology
Immature T-lymphocytes express both the CD4 and CD8 cell
surface antigens in additon to a complete TCR or a pro-TCR.
These lymphocytes exist in the thymic cortex where they
undergo positive selection and in the thymic medulla where
they undergo negative selection.
Hematology & Oncology
The chemokine receptor CCR5 acts as a coreceptor tht
enables the HIV virus to enter cells. Deletion of both of the
genes that code for this receptor results in resistance to HIV
infection. Deletion of one allele leads to delayed manifestations
of the disease in infected individuals.
Isotype switching occurs in the germinal centers of lymph
nodes and required interaction of the CD40 receptor on B-cells
with the CD40 ligand (CD154) expressed by activated T-cells.
1614
Immunology
Hematology & Oncology
IgG is the main serum immunoglobulin of the secondary
responds.
Isotype switching occurs through genetic rearrangment of the
heavy chain constant regions. This is modulated by T-cell
cytokines such as IL-2, IL-4, IL-5, IL-6, IFN-Y
1683
Immunology
Hematology & Oncology
Anti-rh immune globulin consists of IgG anti-D antibodies that
opsonize Rh+ fetal erythrocytes, promoting clearance by
maternal reticulenodthelial macrophages and preventing
maternal Rh sensitization. It is routinely administered to
Rh-negative women at 28 week gestation and immediatley post
partum.
IgG crosses the placenta.
8261
Immunology
Hematology & Oncology
Maternal blood types A and B do not cause erythroblastosis
fetalis and hemolytic disease of the newborn because Anti-A
and Anti-B are of the IgM type and cannot cross the placenta.
Type O mothers antibodies are mainly IgG and can cross the
placenta and cause fetal hemolysis.
8480
Immunology
Hematology & Oncology
1) Margination
2) Rolling: Sialyl lewis X or PSGL-1 binds to L selectin on
neutrophils or E-selectin/P-selectin on endothelial cells.
3) Activation
4) Tight adhesion: Neutrophils bind CD 18 beta 2 integrin
(Mac-1 and LFA-1) to intercellular adhesion molecule-1
(ICAM-1)
5) Transmigration: Platlet endothelial cell adhesion molecule 1
(PECAM-1)
Natural killer cells kill target cells by inducing apoptosis.
8532
Immunology
Hematology & Oncology
Paracortex is not well developed in pt with Digeorge Syndrome.
Candida oppertunistic in immunocompromised.
pseudohyphae-producing yeast with ability to form germ tubes.
112
Immunology
Infectious Diseases
T lymphocytes (Th cells) are important for prevention of
superficial candida infection (oral/esophagus candida,
cutaneous, vulvovaginitis candida).
Neutrophils prevent hematogenous spread of candida.
Disseminated candida (candidemia, endocarditis). More
common in neutropenic pt. (chemo)
377
Immunology
Infectious Diseases
Table
*Immunized against hep B = anti-HBs antibody
*Recover from hep B infection = anti-HBs, anti-HBc antibodies
*Active infection = HBsAg
Vertical transmission of hep B from pregnant females to unborn
child can occur in women with active hep B infection.
378
560
Immunology
Immunology
Infectious Diseases
Infectious Diseases
**The presence of HBeAg (a marker of viral replication and
increased infectivity) in the mother greatly increases the risk of
vertical transmission of the virus. Because of this concern the
newborns of all mothers with active hep B are passively
immunized at birth with hep B immune globulin (HBIG) followed
by active immunization with recombinant HBV vaccine.
IgA protease is produced by:
- Neisseria meningitidis
- Neiseria gonorrhoeae
- Strep pneumoniae
- Heamophilus influenzae
IgA protease - splits the IgA molecule at the hinge region (into
Fab and Fc fragments) which makes it less effective and
facilitates bacterial adherence to mucosa.
587
Immunology
Nervous System
Step2 : Diastolic blood pressure over 110 is a hypertensive
emergency and one sided paralysis = Lacunar infarct
(lenticulostriatl artery)
Ataxia telgenectasia = cerebellar ataxia, Iga defciency, spider
angiomas
673
Immunology
Nervous System
Ataxia telangiectasia
- Cerebellar atrophy leads to ataxia
- have severe imunodeficiency with repeated sinopulmonary
infections
- increased risk of cancer because of inefficient DNA repair
- hypersensitive to ionizing radiation (defect in DNA repair
genes)
- oculocutaenous telangiectasias
739
Immunology
Nervous System
Inability to form Membrane attack complex (MAC) = C5b-C9
deficiency = Recurrent Neisseria meninhitidis infections
Defective immunoglobulin isotype switching = Hyper-IgM
syndrome
541
Immunology
Pulmonary & Critical Care
557
Immunology
Pulmonary & Critical Care
Chronis granulomatous disease has increased susceptibility to
CATALASE positive + organisms.
571
Immunology
Pulmonary & Critical Care
Chronic granulomatous disease = NADPH oxidase deficiency
Cause: genetic absence of the CD40 ligand on T-lymphocytes
or from a genetic deficiency in the enzyme responsible for the
DNA modification that takes place during isotype switching
MHC class I
- Structure: Heavy chain and B2-microglobulin
- Viruses, tumor ptoteins, antigens are processed in the
cytoplasm
- Causes apoptosis of presenting cell
746
762
Immunology
Immunology
Pulmonary & Critical Care
Pulmonary & Critical Care
MHC class II
- Structure: Alpha and beta polypeptide chains
- Bacterial; antigens are phagocytosed and digested by
lysosomes within which antigen binds to MHC II
- causes activation of TH cells which stimulate the homoral
and cell mediated immune process
IL-12 stimulate the differentiation of naive T-helper cells into
the Th1 subpopulation. Pt with IL-12 receptor deficiency suffer
from sever mycobacterial infections due to the inability to
mount a strong cell-mediated granulomatous immune
response. They are treated with IFN-Y
Influenza vaccine:
1) inactivated (killed) by injection
2) live attenuated by nasal spray
What happens when you get the flu after you recieved the
inactivated influenza vaccine?
1466
Immunology
Pulmonary & Critical Care
Inactivated influenza vaccine functions by neutralizing
antibodies against hemagglutin antigen.
These antibodies inhibit binding of hemagglutinin to sialylated
receptors on the host cell membrane. This prevents the live
virus from entering cells via endocytosis.
Eosinophil proliferation and activation during a parastic
infection is stimulated by IL-5 produced by Th2 and mast cells.
750
Immunology
Renal, Urinary Systems &
Electrolytes
This is an example of antibody-dependent cell mediated
cytotoxicity
Eosinophils are seen in late phase type 1 hypersensitivity rxns
and chronic allergic rxns
758
Immunology
Renal, Urinary Systems &
Electrolytes
HSP - IgA immune complex mediated vasculitis, generally
follows upper resp or other minor infection
Diagnosis is confirmed by skin biopsy showing igA deposition
in bloow vessels
IL-2's anti cancer effect on metastatic melanoma and renal cell
carcinoma = increased activity of Tcells and natural killer cells
8530
Immunology
Renal, Urinary Systems &
Electrolytes
8530
Immunology
Renal, Urinary Systems &
Electrolytes
CD4 helper t cells -> produce IL-2 -> stimulated growth of
CD4+ and CD8+ and activates natural killer cells and
monocytes.
Il2 destroys Tumor cells by enhancing natural killer cell activity.
741
Immunology
Acute serum sickness
- Type III HSR (deposition of antibody-antigen complexes)
- Components: Neutrophils
- fever, pruritic skin rash, arthralgias 7-14 days after exposure
Rheumatology/Orthopedics
- Histology: small vessel vasculitis with fibrinoid necrosis and
& Sports
intense neutrophil infiltration
- Deposition of IgG or IgM complemnt fixing antibodies results
in localized complement consumptin and hypocomplementemia
(decreased serum C3 and C4)
HLA Class I proteins (HLA B27):
*are expressed by all nucleated cells and present endogenous
antigens to CD8 cytotoxic T cells.
*- ankylosing spondylitis, reactive arthritis, psoriatic arthritis,
IBD arthritis
752
Immunology
Rheumatology/Orthopedics
**HLA Class II proteins (DR, DP, DQ):
& Sports
* are expressed by antigen-presenting cells (eg. macrophages,
dendritic cells) and present predominatly foreign antigens to
CD4+ helper T cells.
*- Rheumatoid arthritis, type 1 DM, celiac disease
Fusion of the sacroiliac joints
Protein M:
- major virulence factor for Step pyogenes.
- Inhibits phagocytosis and compliment activation.
- cytotoxic for neutrophils in blood
- mediator of bacterial attachments
- antigenic and target of type specific humoral immunity.
723
Microbiology
Allergy & Immunology
Hyaluronate/Hyaluronic acid
- present in the capsule (external to the cell wall)
- antiphagocytic activity
- help staph aureus tunnel through connective tissue
- Allows spread of strep in subcutaneous tissue
- causes exothalmos in Graves
6 y/o, immigrant, fever, neck swellinh, palatal paralysis, gray
pharyngeal exudate, difficulty breathing = Coryne diptheriae
(AB toxin specific for neural and cardiac tissue)
1388
1389
Microbiology
Microbiology
Allergy & Immunology
Allergy & Immunology
Rx Coryne diptheriae:
1) Diptheria antitoxin = passive immunization - transfer of
pre-existing neutralizing antibodies
(inactivates all circulating toxin but doesnt work against toxins
that have alread reached cardiac or neural cells)
2) penicillin or erythromycin
3) DPT vaccine
Non-pathogenic corynebacterium can cause severe
pseudomembranous pharyngitis after acquring the Tox gene
via lysogenization by a temperate bacteriophage. (Phage
conversion premitting exotoxin production)
8565
Microbiology
Allergy & Immunology
Scarlett Fever (Group A strep)
- fever, pharyngitis (gray-white tonsillar exudates)
- scarlet spots of blotches (boiled lobster appearance)
- sand-paper-like rash
- circumoral pallow (pale around mouth)
- strawberry tongue
- Can predispose to: Acute Rheumatic fever and
glomerulonephritis
Mumps predisposes to Orchitis
Always assume coagulase-negative staph infection is
methicillin-resistant and treat with vancomycin, especially in
nosocomial infection.
645
Microbiology
Cardiovascular System
If susceptibility results indicate methicillin-susceptible isolate
vancomycin can be switched to naficiliin or oxacillin.
Pt mitral valve replacement 1 month ago, develops nosocomial
endocarditis with coagulase-negative staph (Staph epidermidis)
= Vancomycin
679
Microbiology
Cardiovascular System
4/18 MCC of septic arthiritis in patients with prosthetic joints =
Staph epidermidis
MCC of endocarditis in pt with prosethetic valve = Staph
epidermidis
Which Staph species are coagulase negative? = Staph
epidermisis, Staph haemolyticus, Staph saprophyticus
Novobiocin sensitive = Staph epidermidis
Entrococcal (group D strep) Endocarditis:
733
1003
Microbiology
Microbiology
Cardiovascular System
Cardiovascular System
- Infective endocarditis after a genitourinary (cystoscopy)
procedures.
- UTI
- wound infections
- gamma hemolytic (no hemolysis on agar)
- Catalase ngative
- PYR positive
- Can grow in hypertonic (6.5%) saline and bile
4/14 *Dextrans facillitate strep adherence to fibrin = Strep
(Fibrin and platlets are deposties at sites of enothelial trauma
providing a site for bacterial adherence and colonization during
bacteremia
*Gram positive bug capable of producing extracellular
polysaccharides using sucrose as a substrate = Viridans
streptococci (dental procedures - produce dextran)
Viridans streptococci (dental procedure)
1003
Microbiology
Cardiovascular System
Produce extracellular polysaccharides (dextrans) using
sucrose as a substrate. Dextrans facilitate step adherence to
fibrin. Fibrin and platletes are deposited at sites of enodthelial
trauma.
In pt with pre-existing valvular lesions (ex. MVP) Step virdirans
can adhere to fibrin-platelet aggregates and establish infection
that leads to endocarditis.
Grey pharyngeal exudate in unvaccinated/immigrant = Coryne
diptheriae.
Diptheria toxin inhibits protein synthesis by inhibiting
ADP-ribosylation of EF-2 leading to cell death and necrosis.
1092
Microbiology
Cardiovascular System
A/B exotoxin - B allows penetration of A into the cell to inhibit
ribosome function
immunization (DTP) vaccine induce production of circulating
IgG against the exotoxin B subunit.
Coryne diptheria toxin = AB exotoxin that inhibits protein
synthesis by ADP-ribosylation of EF-2
1094
Microbiology
Cardiovascular System
Toxin acts locally causing respiratory cell necrosis with
formation of fibrinous, coagulative exudates.
Grayish pahyrnfeal exudate,
8282
680
Microbiology
Microbiology
Cardiovascular System
Most important steps for prevention of central venous catheter
infections (via Staph aureus) are:
- Proper hand hygene
- Full barrier precautions during insertion (mask, gloves)
- Chlorhexidine skin disinfection
- Avoidance of the femoral insertion site
- Removal of the catheter when it is no longer needed
Dermatology
Syaphylococcal scalded skin syndrome:
exfoliatin exotoxin
positive nikolsky sign
Neutropenia <500 incresases susceptibility to gram -ve
organisms
973
Microbiology
Dermatology
Psuedomonas aeruginosa bactermia is assocaited with
exthyma gangrenosum (skin patched with ulcerations and
necrosis. (looks like DIC but normal platley, Pt, PTT)
Exotoxin A = protein synthesis inhibitor
elastase = degrades elastin - important for blood vessel
destruction
phospholipase C = degrades cellular membranes
pyocyanin = generates reactive oxygen species
1553
Microbiology
Dermatology
postherpetic neuralgia (localized dematomal pain that persistis
for several months following zoster eruption) is the most
common neurological complication of VZV.
unvaccinated child with fever and rash that starts on the face
and spreads to the trunk = Measles
1669
Microbiology
Dermatology
Rubeola (measles)
paramyxo
Rubella (german measles)
togavirus
postauricular lymphadenopathy
rash spreads faster does not darken
Bartonella neselae causes
1) cat scratch disease
2) bacillary angiomatosis
3) culture-negative endocarditis
1898
Microbiology
Dermatology
Cat scratch disease characterized by tender regional
lymphadenopathy (often just a single lymph node) proximal to
the lesion/scratch.
Axillary lymphadenopathy is extremley common in
Burn patient, gram -ve, oxidase +, non lactose fermenting =
psuedomonas
8858
Microbiology
Dermatology
Rx: only few penicillins (ticarcillin, piperacillin) and
cephalosporins (ceftazidime, cefepime) have activity against it
8342
Microbiology
Ear, Nose & Throat (ENT)
Malignant otitis externa (MOE) severe ear infection seen in
elderly diabetic pt = Pseudomonas aeruginosa
- nonlactose-fermenting
- oxidase-positive
- motile gram-negative rod
- Pneumonia (in cystic fibrosis and ventilated pt)
- Life threatening infection in neutropenic and burn pt
- Otitis externa (particularily malignant)
- Hot tub folliculitis
- Ecthyma gangrenosum
- produces procyanin (blue-green) pigment
- Emits grapelike fruit odor
- Produces endotoxin (fever, shock)
Friable cervix with easy bleeding = gonococcal cervicitis
(neisseria gonorrhoeae and chlamydia trachomatis)
1008
Microbiology
Female Reproductive
System & Breast
classically asymptomatic, detected by nucleic acid
amplification testing
Can cause PID leading to infertility
1027
Microbiology
Female Reproductive
System & Breast
Advanced maternal age = 35
Abdominal pain, bloody vaginal discharge, orthostatic
hypertension, positive pregnancy test/beta-hcg = ectopic
pregnancy/ruptured ectopic pregnancy
1932
Microbiology
Female Reproductive
System & Breast
#1 risk factor for ectopic pregnancy is tubular scarring
Infection with neisseria gonerrhea and chlamydia causes pelvic
inflammatory disease leading to tubular scarring
11802
Microbiology
Female Reproductive
System & Breast
4/16 yellow green frothy discharge with vaginal inflammation =
Trichomonas vaginalis, motile trichomonads on saline
microscope
Thick cottage cheese like discharge with vaginal inflammation
= Candida albicans, psudohyphae, normal pH
Thin, off white discharge with a fishy ordor = Gardnerella
(bacterial vaginosis), clue cells, positive whiff test amine odor
with KOH
x2
Clostrdium difficile colitis following use of clindamycin
1397
1592
Microbiology
Microbiology
Gastrointestinal & Nutrition
General Principles
Pathogenesis: Inactivate Rho-regulatory proteins involved in
signal transduction and actin cytoskeletal structure
maintenance -> toxins cause distruption of intracellular tight
junctions leading to cell rounding and increase intestinal fluid
secretion (watery diarrhea)
CMV doesnt usually affect immuncompotent patients. If CMV
is seen in a immuncompotent individual it is probably
Mononucleosis-like syndrome (negative monospot test)
Found in south asia and cause splenomegaly:
1595
Microbiology
General Principles
Malaria is classically associated with anemia and
thombocytopenia.
Viceral leshmaniasis (kala-azar) manifests as progressive
splenic enlargment and weight loss over months.
109
Microbiology
Hematology & Oncology
Inoculation of Candida albicans into serum at 37C (98.6F) for 3
hours leads to the formation of true hyphae from the yeast.
These growing hyphae are called germ tubes.
Candida is the most common cause of opportunistic mycosis.
MC organism injured during blunt abdomina trauma = Spleen
732
Microbiology
Hematology & Oncology
Splenic red pulp is for:
destroying old and abnormal RBC
emergency store of blood cells and platlets
Clearance of circulating bacteria that get lodged in the splenic
cords. Macrophages present them to b/Tcells in the white pulp.
Encapsulated bugs are resistant to regular phagocytosis but
not splenic opsonizing antibody
asplenic prophylactic vaccination for: s. pneumo, h. influ, n.
meni
Mycoplasma pneumoniae can lead to complement mediated
intravascular hemolytic anemia
957
Microbiology
Hematology & Oncology
because m. pneumoniae and erythrocytes have smiliar antigen
(I-antigen) in their cell membranes. The antibodies causing this
destruction are IgM cold agglutins.
Anemia with elevated lactate dehydrogenase (or positive
coombs test or elevated reticulocyte count) = hemolytic anemia
Mycoplasma is causative agent in walking pneumonia and
many tracheobronchitis.
In adults (esp teachers) Parvovirus presents with acute,
symmetric arthalgia/arthritis involving hands, wrist, knees, and
feet with or without rash.
1374
Microbiology
Hematology & Oncology
Fetal parvovirus can lead to:
- interruption of erythropoiesis -> profound anemia
- CHF
- pleural effusions
- pericardial effusions
- ascites
Fetal hydrops = pleural effurion with secondary pulmonary
hypoplasia, ascites
EBV envelope glycoprotein gp350 binds to CD21 (present on
the surface of B cells)
1375
1496
Microbiology
Microbiology
Hematology & Oncology
Hematology & Oncology
CD4 with HIV gp120
CD21 with EBV gp350
Erythrocyte P antigen (globoside) with parvovirus B19
Parvovirus B19 causes aplastic crisis in pt with sickle cell
anemia.
Noneveloped single-stranded DNA = Parvovirus
Latent EBV infection is present in up to 90% of normal
indivduals with reactivation common in immunosuppressed pt.
1724
Microbiology
Hematology & Oncology
Aids pt have increased risk for EBV associated lymphomas:
Burkitts lymphoma, AIDS related primary central nervous
system lymphoma
Genetic variations created during hep c (HCV replication result
in marked variety in the antigenic structure of HCV envelope
proteins.
44
Microbiology
Infectious Diseases
The production of host antibodies lags behind that of new
mutant HCV strains, preventing infected individuals from
mounting an effective immune response.
In a population universally vaccinated with recombinant HBsAg
which disease would dissapear?
45
46
105
Microbiology
Microbiology
Microbiology
Infectious Diseases
Hepatitis D (aka delta agent, hepatitis delta virus)
- only capable of causing infection when encapsulated with
HBsAg
Infectious Diseases
Mother with positive HBsAg and HBeAg have a high risk of
transmitting hepatitis B (HBV) during delivery. Infected
neonates experience high levels of HBV replication,
demonstrate mildly elevated liver enzymes, and are at high
risk for chronic infection.
Infectious Diseases
47 y/o pt with CML, headache, scant nasal discharge,
paranasal sinus tenderness, left-sided orbital swelling,
cellulitis, mild proptosis and ptosis of left eye, biopsy of sinus
shows septate hyphae = Aspergillus fumigastus
Oral thrush: white patches on the pral mucosa
(pseudomembranous candidiasis) that can be easily scapred
off revealing an erythromatous mucosal surface underneath.
111
Microbiology
Infectious Diseases
Oral thrus is a localized Candida albicans infection -->sexual
practices reveal underlying cause
Oral thrush is associated with wearing dentures, DM,
imunosuppression. Unexplained oral thrush in a healthy pt
suggests possible HIV.
Hep C is genitcally unstable because it lacks proofreading 3' ->
5' exonuclease activity in its RNA polym.
388
Microbiology
Infectious Diseases
Hep C envelope glycoprotein sequence also contain a
hypervariable region prone to frequent genetic mutation.
MCC of lung abscesses is anaerobic bacteria from the
gingivodental sulcus
532
Microbiology
Infectious Diseases
Lung abscess is a common complication of aspiration
pneumonia (Occurs in alcoholics).
Homless alcoholic pt, green foul smelling sputum, a cavitary
lesion in the middle lobe of the right lung with air-fluid levels.
What is the cause?
Aspiration of oropharyngeal contents
678
Microbiology
Infectious Diseases
Novabiocin - NO StRESs
Staph Saprophiticus Resistant
Staph Epidermidis Sensitive
Impetigo: painful non itchy pustules blistering (perioral)
eruption that eventually leads to formation of a golden yellow
crust (honey crusted) usually seen in children newborns =
Staph aureus (MCC) or Group A beta hemolytic strep
725
Microbiology
Infectious Diseases
Post infectious complications of Group A Strep (s. pyogenes):
Acute rhematic fever: strep pharyngitis
APSGN: Strep skin infection (impetigo) or strep pharyngitis
APSGN: presents with dark colo coloured urine, facial
puffiness/edema
963
Microbiology
Infectious Diseases
Gram neg meningitis in baby = h influenza? Listeria?
968
Microbiology
Infectious Diseases
Neonatal tetanus from unhygienic deliveries or cord care can
be prevented by vaccination of women who are pregnant or
may become pregnant. Immunized mother provides passive
immunity via transplacental igG, protecting infants until they
recieve active immunization around 2 months of age.
971
Microbiology
Infectious Diseases
Black eschar:
- Bacillus anthrax
- Mucor & rhizpus
Pulmonary anthrax = wool sorters disease (MCC Goat hair) p.
121
972
Microbiology
Infectious Diseases
Myalgia, fever, malaise, hemorrhagic mediastinitis, bloody
pleural effusion, shock, death = Bacillus anthracis
Produces an antiphagocytic capsule that is required for
pathogenicity. Capsule is unique in that it contains D-glutamate
instead of polysaccharide. Cultures form nonhemolyzing
adherent colonies that form long chains "serpentine" or
"medusa head"
Intracellular polyphosphate granules = Coryne dipth
977
Microbiology
Infectious Diseases
Vibrio cholerae
- comma shaped
- oxidase +
- gram - bacillus
- watery diarrhea after ingesting contaminated food or water
- grows on highly alkaline selective media
thiosulfate-citrate-bile salts-sucrose (TCBS) agar
- Extremley acid sensitive
- infectious dose is usually very high
Pt with Achlorhydia (antacid use, omeprazole, gastritis) require
a much lower infectious dose.
24 y/o f with right knee and left elbow and wrist severe pain
and swelling, joint aspiration shows opaque exudate with high
neutrophil content and intracellular organisms =
1007
Microbiology
Infectious Diseases
Neisseria gonorrhoeae disseminated gonococcal infection (DGI)
- typically presents as triad polyarthralgias, skin lesions,
tenosynovitis, or purulent arthritis without skin lesions
- DGI is one of the MCC of septic arthritis in sexually active
young adults
Infection with Neisseria gonorrhoeae does not result in lasting
immunity due to the bacterias ability to modify their outer
membrane proteins by the process of antigenic variation.
Antibodies formed during one infection will oly be specific for
that single antigenic epitope.
1026
Microbiology
Infectious Diseases
Gonorrhea remains widley susceptible to 3rd gen
cephalosporins. Chlamydia is a frequent co infection so
treatment should inculde azithromycin or doxycycline.
Reccurnt Neisseria also in compliment def
1099
Microbiology
Infectious Diseases
4/15 Travelers diarrhea = E. Coli (ETEC) heal liable cholera-like
4 y/o boy watery diarrhea became bloody (dysentery), fever,
abdominal cramps = bacterial enteritis
1135
Microbiology
Infectious Diseases
Shigella:
- non lactose fermenting
- gram - on MacConkey agar
- ferment glucose without gas production
- do not generate hydrogen sulfide
- grow on triple sugar iron agar
- cannot replicate at refrigeration temparature
- Pathogenic mechanism = Muscosal invasion (spreads
through host-cell actin polymerization)
H2S production (black color):
1) Salmonella
2) Proteus
Pt with sickle cell, pain over right thigh, fever = Salmonella
Osteomyelitis
Salmonella:
-Nonlactose dermenting, oxidase-negative, motile organisms
-endotoxin, vi capsule (causes resistance to opsonization)
1137
Microbiology
Infectious Diseases
1309
Microbiology
Infectious Diseases
Oxidase + Gram -:
1) Campylobacter
2) Vibrio
3) H. pylori
4) Salmonella
5) Proteus
6) Shigella
7) Yersinia
Isoniazid inhibits synthesis of mycolic acid (only works on TB).
Without mycolic acid the mycobacteria lose their acid-fastness
and become unable to synthesize new cells walls or multiply.
How can an enveloped RNA animal virus aquire the ability to
infect human epithelial cells?
1411
Microbiology
Infectious Diseases
Mutation in the viral encoded surfce glycproteins that mediates
virion attachment to target host cell plasmalemma receptors.
Postexposure prophylaxis of rabies immune globulin and
vaccination is not effective after the onset of symptoms.
1465
Microbiology
Infectious Diseases
Rabies vaccine consists of various rhabdovirus strains grown
in tissue cell culture and inativated by beta-propiolactone
(Inactivated vaccine)
Live attenuated vaccines: shingles, varicella, yellow fever
Inactivated toxoid vaccine: Tetanus-(reduced) diphtheria
vaccine
1495
Microbiology
Infectious Diseases
Parvovirus (B19, 5th disease, erythema infectiosum) is highly
tropic for erythrocyte precursor cells and replicated
predominantly in the bone marrow.
Pravo B19 replicated in erythrocyte precursors in the bone
marrow.
A UTI characterized by dysuria and hematuria is most likely
hemorrhagic cystitis
1498
Microbiology
Infectious Diseases
MCC of acute hemorrhagic cystitis in children (paticularily
males) = Adenovirus
Parvovirus B19 = aplastic crisis in pt with chronic hemolytic
disorders, hydrops fetalis,
Herpes simplex virus (HSV): Tzanck smear/PCR,
multinucleated giant cells
1499
Microbiology
Infectious Diseases
Primary HSV-1 results in herpetic gingivostomatitis. Prodromal
symptoms (fever, malaise, chills) behins approx 1 week after
contact with infected person. Painful vesicles appear on lips,
gingiva, palate, tongue, oropharynx. Pain of gingivostomatitis
causes dehydration MCC for hospitalization.
HSV1 latent trigeminal, HSV2 latent in sacral ganglia.
Reactivation of HSV1 = herpes labialis mild unilat lips
1550
Microbiology
Infectious Diseases
Recurrence of genital herpes (HSV-2) can be reduced through
daily treatment with oral valacyclovir, acyclovir, famciclovir.
Viral brochiolitis is a lower respiatory tract infection that
usually occurs before the age of 2 is MCC by respiratory
syncytial virus (RSV)
1668
Microbiology
Infectious Diseases
Viral bronchiolitis presents with: lowe grade fever, cough,
rhinorrhea, congestion, tachypnea, increased work of
breathing, diffuse wheezes and crackles.
"Becomes glycosylated before being proteolytically cleaved
into 2 small proteins in the ER and Golgi"
1672
Microbiology
Infectious Diseases
In HIV replication cycle, polyprotein precursors are encoded by
the structural genes (gag, pol, env). Only the env gene
polyprotein product is glycosylated to gp160 and proteolytically
cleaved withing the ER and golgi to form the envelope
glycoproteins gp120 and gp41.
1949
Microbiology
Infectious Diseases
Rx for gonorrhea = Ceftriazone (3rd gen cephalsporin) &
azithromycin (macrolide)
11377
Microbiology
Infectious Diseases
4/16 *Aedes aegypti mosquitoe transmits which viruses? =
Dengue fever and Chikungunya
*Acute febrile illiness with headache, retro-orbital pain and
joint/muscle pain = Dengue fever
*Febrile illness with flu like symptoms, prominent
polyarthralgias, and diffuse macular rash = *Chikungunya fever
11524
Microbiology
Infectious Diseases
Babesiosis --> Ixodes tick
Infectious Diseases
4/16 *Intraerythrocytic pleomorphic rings (maltese cross) =
Babesiosis on Giemsa stain
*lxodes tick as a vector = Babesiosis (Babesia microti), Lyme
disease (Borrelia burgdorferi), human granulocytic
anaplasmosis
11540
Microbiology
Cat bite:
- Pasturella
- Bartonella henselae (lymphangitis in IC host)
11547
11633
Microbiology
Microbiology
Infectious Diseases
Infectious Diseases
Dog bite:
- Pasteurella
- Strep
- Staph
Broad based budding yeast = bastomycosis
Dimorphic fungi endemic to SW US = Coccidioides
Positive india ink (capsule) = Cryptococcus
Pseudohyphae with blastoconidia = Candida
Right-angle branching hyphae = Mucormycosis (Mucorales or
Rhizopus)
Spherules with endospores = Coccidioides
Small Oval yeast within macrophages = Histoplasma
Presence of a central vascular catheter and recepit of
parenteral nutrition are risk factors for Candidemia.
11765
Microbiology
Infectious Diseases
Bacterial veginosis:
- grayish white fishy smelling discharge
- Clue cells (epithelial cells covered with gram-variable rods)
- No inflammation
- Positive whiff test (amine odor with KOH)
- Rx (only if symptomatic) Metronidazole or clindamycin
11766
Microbiology
Infectious Diseases
4/16 *indole-positive gram negative rods = Ecoli
*Gram negative fast lactose fermenters (MacConkey agar) =
Klebsiella, Ecoli, Enterobacter
*Gram negative, non lactore fermenting, oxidase positive =
Pseudomonas aeruginosa
11812
Microbiology
Infectious Diseases
d) pseudomonas
e) staph/actino
116
Microbiology
Nervous System
Cyryptococcal meningitis diagnosed by india ink staining of
cerbrospinal fluid.
Strep pneumoniae (lancet shaped) the the MCC of bacterial
meningitis in adults of all ages
735
Microbiology
Nervous System
Neisseria meningitis (Bean-shaped) 2nd MCC of meningitis in
patients <60 years of age. Tends to occur in places people live
in close quarters (dorms)
Listeria meningitis: immunosupressed pt and elderly. 3rd MCC
in neonates (after group B strep and E.coli)
Neisseria meningitis 2nd MCC of bacterial meningitis in adults
737
Microbiology
Nervous System
Route: Pharynx -> blood -> choroid plexus -> meninges
Waterhouse-fredrichsen is a complication of Neisseria
meningitidis that may involve adrenal gland destruction, DIC,
and shock.
738
Microbiology
Nervous System
Signs and symptoms of septic shock: spiking fever, chills
arthralgia, myalgias, purpuric cutaneous lesions, and
hypotention that may progress to shock and death.
1005
1038
Microbiology
Microbiology
Nervous System
Nervous System
Meningococci ( Neisseria meningitidis)are commonly isolate
from the oropharynx and nasopharynx of asymptomatic
carriers.
Congenital toxoplasmosis: Aquired in utero
1) Hydrocephalus - macrocephaly and enlargment of the
ventricles due to CNS inflammation
2) intracranial calcifications
3) Chrorioretinitis - inflammation of the choroid and retina that
can leave cotton-like white/yellow scars on the the retina
visible on funduscopy
Ecoli virulence factors:
- Neonatal meningitis Ecoli = Capsule polysaccharide
- Bacteremia & septic shock = LPS
1140
Microbiology
Nervous System
- Gastroenteritis (bloody) = Verotoxin (shiga-like)
- Gastroenteritis (watery) = Heat stable/heat-liable enterotoxin
- UTI = P. fimbriae
1391
Microbiology
Nervous System
Listeria monocytogenes
- narrow zone of beta hemolysis
- tumbling motility at 22 degrees
- Cultured at temperatures as low as 4 C
- requires intact cell-mediated immunity to be eliminated from
body
- Neonates under 3 months are esp vulnerable because their
cell mediated immunity is not fully developed
Studies reveal normal nerve conduction velocity but decreased
compound muscle action potential (CMAP) =
1399
1402
Microbiology
Microbiology
Nervous System
Nervous System
Clostridium botulism (home canned food):
- Prevents release of Ach from PREsynaptic nerve terminals at
NMJ --> preventing muscle contraction
Clostridium tetani travels within mortor neuron by retrograde
transport into the spinal cord where it causes inhibiton of
inhibitory interneurons and unregulated firing of primary motor
neurons.
Route: Wound -> motor neuron axons -> spinal cord
1552
Microbiology
Nervous System
Varicela IgG antibodies suggest primary infection with VZV
(chickenpox)
Campylobacter --> Gullian barre
1601
Microbiology
Nervous System
GBS is a demyelinating syndrome of the peripheral nerves
characterized by ascending muscle paralysis.
Neisseria meningitis
- upper respiratory infection, meningitis, meningococcemia
- Immunity is provided by antibodies against their
polysaccharide capsules
1853
Microbiology
Nervous System
18 y/o 2 day fever, headache, nausea, vomitting, myalgia,
nuchal rigidity, purpuric rash, CSF with high protein, low
glucose = Meningococcal meningitis Neisseria meningitidis
West Nile Virus (flavivirus +ssRNA)
- female mosquitos (Culex)
- Neuro invasive disease can present as encephalitis,
meningitis, flaccid paralysis
1906
Microbiology
Nervous System
68 y/o lower extremity weakeness, Texas in the summer,
confused, morbilliform rash on trunk and arms, coarse hand
tremor, flaccid paralysis of bilateral lower extremities, Viral
RNA?
Viral meningitis:
- Enterovirus (MCC of aseptic meningitis)
- Arbo virus, HSV2
- WBC <500
- lymphocytic predominance
- Glucose levels are normal or slightly reduced
- Protein < 150
- No organisms on CSF gram stain
1966
Microbiology
Nervous System
Bacterial meningitis
- Neonate: Group B strep agalactiae
- Adults: Strep pneumo, Neisseria
- WBC count >1000
- Neutrophillic predominance
- Glucose levels <45
- Protein often >250
Botulism initially presents as a descending paralysis that first
manifest with cranial nerve abnormalities (diplopia, dysphagia,
dysphonia [3Ds])
1997
Microbiology
Nervous System
Muscarinic antagonits - inhibit postsynaptic action of Ach
Botulism - blocks presynaptic exocytosis of Ach
organophosphates - prevent Ach degredation in synaptic cleft
2083
Microbiology
Nervous System
4/19 2nd MCC of multiple ring enhancing lesions in an HIV pt
positive for EBV = Primary central nervous system lymphoma
(diffuse large cell non hodgkin lymphoma of B-cell origin)
biofilms - synthesis of an extracellular polysaccharide matrix
8533
Microbiology
Nervous System
Staph epidermidis - gram positive coagulase negative staph
produces biofilms
MCC of eye problem in congenital CMV is chorioretinitis. Also
seen in toxoplasmosis.
11551
Microbiology
Ophthalmology
Congenital cataracts = in utero rubella
Inclusion conjunctivitis = Chlamydia trachomatis in a new born
1464
Microbiology
Pregnancy, Childbirth &
Puerperium
Congenital rubella triad
- congenital cataracts (white pupils)
- sensory-neural deafness
- PDA
Measles, mumps, rubella are LIVE attenuated vaccines.
Hep A, and rabies are killed vaccines.
1575
Microbiology
Pregnancy, Childbirth &
Puerperium
Maternal rubella infection produces:
- low grade fever
- maculopapular rash with cephalocaudal progression
- posterior auricular suboccipital lymphadenopathy
- polyarthritis and polyarthralgia sequelae
Congenital rubella:
- sensorineural deafnress
- cataracts
- cardiac malformations (PDA)
108
Microbiology
Pulmonary & Critical Care
Aspergillus fumigatus
- Septate hyphae that branch at 45 degrees (V shaped)
- Develops in old lung cavities (from TB, emphysema,
sarcoidosis)
- Aspergillus colonizes the cavity by forming a "fungus ball"
- Findings: radioopaque structre that shifts when the patients
changes position
- asympotmatic or hemoptysis
- Oppertunistic in immunosupressed and neutropenic pt
(invasive pulmonary aspergillosis)
- Also cause lung HSR in allergic bronchopulmonary
aspergillosis in asthma pt
Budding yeast with thick capsule = Cryptococcus neoformans
114
117
Microbiology
Microbiology
Pulmonary & Critical Care
Pulmonary & Critical Care
Can sause symptomatic disease most commonly
menigoencephalitis. (typically seen in pt with HIV, sarcoidosis
or leukemia, and those on high dose corticosteroid therapy)
Cryptococcus neoformans:
- Capsule appears as a clear unstained zone with india ink
- Stains red with mucicarmine
4/16 *Pulmonary blastomycosis is characterized by =
granuloma formation in immunocompetent pt.
121
Microbiology
Pulmonary & Critical Care
*Blastomycosis extrapulmonary dissimenation to skin and
bones occur in =immunoCOMPROMISED individuals
Histoplasma capsulatum
- Present in birn and bat droppings (cave exploration)
- Mississipi, ohio river (Central US)
- Ovoid cells with macrophages
266
Microbiology
Pulmonary & Critical Care
269
Microbiology
Pulmonary & Critical Care
i) Multinucleated spherules = Coccidiodies
ii) Ovoid cells with macrophages = Histoplasma
iii) Budding yeast with a thick capsule = Cryptococcus
iv) Pseudohyphae and blastoconidia = Candida
v) Septate hyphae with dichotomous branching = Aspergillus
Spherules packed with endospores = Coccidioides immitis
Pt with fever, cough, consolidation on CXR = pneumonia
Community aquired pneumonia (CAP)
- Strep pneumoniae (MCC)
- H. influ
- Morexella
- Klebsiella
- Staph aureus
730
Microbiology
Pulmonary & Critical Care
Atypical pneumonia
- Mycoplasma pneumonia
- Chlamydophila pneumonia
- Legionella
Strep pneumoniae:
- partial alpha hemolysis
- bile soluble
- optochin sensitive
4/19
very high fever in a smoker, radiographic evidence pneumonia,
with GI symptoms (watery diarrhea) = Legionella Community
aquired pneumonia
960
Microbiology
Pulmonary & Critical Care
Unique lipopolysaccharide chains on the outer membrane
inhibit gram staining = Legionella
Dx Legionella = antigen in urine
Sputum gram stain shows many neutrophils but no bacteria,
and hyponatremia = Legionnaire's disease
Community hospotal with nosocomial pneumonia, silver stain,
slow growth on charcoal yeast extract (supplemented with
L-cysteine and iron) =
961
962
Microbiology
Microbiology
Pulmonary & Critical Care
Pulmonary & Critical Care
Legionella pneumonia
- exposure to contaminated water (recent travel cruise/hotel,
hospital/nursing home stay)
- sputum gram stain show many neutrophils but few or no
organisms
- Culture on BCYE
Cherry red epiglottia + lard harsh sound with every inspiration
= H. influenza
H. influenza vaccine Polyribisylribitol phosphaste
964
Microbiology
Pulmonary & Critical Care
Haemophilus influenzae:
- requires factor X (hematin) and factor V (NAD+) to grow
- Pathogenicity depends on presence of an antiphagocytic
polysaccharide capsule
- Type B strain is most invasive and virulent and has a cpasule
consisting of linear polymer of polyribitol phosphate
- Unencapsulated H influ is part of norma flora and causes
primary local infections
3 y/o fever, malaise, swollen right knee, recent otitis media,
unvaccinated, gram - = H influ
5 y/o boy with dysphagia, drooling, fever, stridor, cherry-red
epiglottis, progressive airway obstruction.
967
Microbiology
Pulmonary & Critical Care
Acute Epiglottis: H.influenzae tybe b
Though Hib vaccine has dropped the incidence, it can still
cause disease in unimmunized pt as well as fully immunized pt
in some cases.
999
Microbiology
Pulmonary & Critical Care
Prenatal screening for Group B strep at 35-37 weeks gestation
to identify if they require INTRAPARTUM antibiotics (penicillin
or ampicillin) prophylaxis
Failure to decolorize with hydrochloric acid and alcohol after
straining carbolfuchsin = Acid fast stain (Mycobacterim or
Nocardia)
1215
Microbiology
Pulmonary & Critical Care
a) Mycolic acid - Mycobacteria cell wall
b) N-acetylmuramic acid - form peptidoglycan layer in both
Gram + and gram c) Teichoic - link to peptidoglycan cell wall of gram-positive
d) LPS - outer envelope of Gram e) Ergosterol - fungal cell membrane
Naked, single stranded, positive (SS+) Rna virus =
Picornavirus (rhinovirus)
1373
Microbiology
Pulmonary & Critical Care
Purified RNA molecule that induces viral protein synthesis and
viral genome replication in a host cell = SS+ RNA (able to act
directly as mRNA using the host's intracellular machinery for
translation) ex. picornavirus
1377
1441
Microbiology
Microbiology
Pulmonary & Critical Care
Ether dissolves enveloped (lipid bilayer that makes the outer
envelope) viruses.
Pulmonary & Critical Care
CGD increase suseptibilteriaity to catalase + organisms: CATs
Need PLACESS to Belch their Hairballs
- Nocardia
- Pseudomonas
- Listeria
- Aspergillus
- Candida
- Ecoli
- Staph
- Serratia
- B cepacia
- H pylori
Oral thrush, intersitial pneumonia, severe lymphoenia in the
first year of life = Mother-to child vertical transmission of HIV-1.
1463
Microbiology
Pulmonary & Critical Care
Antiretroviral therapy during pregnancy reduces the risk of
perinatal transmisison of HIV from 35% to 1-2% and is
recommended for all pregnant women with HIV.
Herpes viruses - double standed eveloped DNA virus (EBV,
CMV)
1576
Microbiology
Pulmonary & Critical Care
CMV penumonitis MCC of CMV following lung transplant. Show
enlarged cells with intranuclear and intracytoplasmic inclusions
(viral particles); often with surrounding halo (owl's eye
inclusion)
Abrupt onset fever, headache, myalgia, malaise, ill household
school aged children = Influenza
1666
Microbiology
Pulmonary & Critical Care
Pt (especially ELDERLY > 65 yrs ) with recent influenza
infection are vulnerable to Secondary bacterial pneumonia
(reccurent fever, dyspnea, productive cough, pulmonary
consolidations) because of virally-induced damage to the
mucociliary clearance mechanism of respiratory epithelium.
MCC for 2ndary bacterial pneumo:
1) Strep pneumo
2) Staph aureus
3) H. influenzae
1667
Microbiology
Pulmonary & Critical Care
Paramyxovirus viral laryngotracheitis (croup)
Walking pneumonia (low grade fever, malaise, chronic dry
nagging cough) = Mycoplasma
1679
Microbiology
Pulmonary & Critical Care
Chest Xray suggest a sever penumonia even though the
patient appears relativley well.
Mycoplasma pneumonia requires cholesterol to grow because
their cell membrane is compose of a single cholestrol rich
phospholipid bilayer.
1767
Microbiology
Pulmonary & Critical Care
4/14 *Community acquired pneumonia is pt with CD count <
200 = pneumocystis jiroveci
*Community aquired pneumonia in immunocompetent pt =
Strep pneumoniae
Legionellosis
1) Pontiac fever (acute, flue like, self limited disease)
2) Legionnaires disease (high fever, bradycardia, neurological
symptoms, watery diarrhea)
8257
Microbiology
Pulmonary & Critical Care
Legionella:
- falculatatively intracellular
- gram stain shows many neutrophils but no organisms
- HYPONATREMIA
56 pt fever, headache, mild confusion, cough, watery diarrhea,
cruise to hawaii, lower lobe crackles, bilateral intersital
infilterates, smoker = Legionella pneumonia
Klebsiella pneumonia:
- encapsulated, lactose fermening, gram negative bacillus
- Thick, mucoid, blood-tinged (currant jelly suptum) and lung
tissue necrosis with early abcess formation
- Thick capsule is seen as a clear zone on gram stain and
causes characteristic mucoid growth
9989
Microbiology
Pulmonary & Critical Care
65 y/o alcoholic fever, chills, chest pain, crackles, right upper
lob infiltrate, gram negative bacillu, pink-colored mucoid
colonies on macconkey agar.
Mucoid:
- Klebsiella
- Pseudomonas
Pulmonary actinomycosis develops most commonly following
aspiration and can be confused with lung abscess, malignancy,
or TB.
10993
Microbiology
Pulmonary & Critical Care
Microscropic findings: filamentous, branching, gram + bacteria,
sulfur granules.
55 y/o malaise, cough, yellow sputum streaks of blood, poorn
dentition with dental caries, gingivitis, enlarged submanibular
lymph nodes, extensive right upper lung consolidative process
= Actinomycosis
Fever, headache, patchy lung nodules, 1.2cm ring enhancing
focal lesion with surrounding edema in the right frontal lobe
11638
Microbiology
Pulmonary & Critical Care
Nocardia:
- gram + rod (beaded or branching)
- partially acid-fast
- aerobic
- immunocompromised or elderly
- Cavitary pneumonia -> similar to TB
- CNS involvment -> brain abcess
- Cutaenous involvment
- Rx: TMP-SMX, surgical drainage of abscess
Schistosomiasis - Freshwater, snails, Africa
8541
Microbiology
Renal, Urinary Systems &
Electrolytes
S. haematobium: Urnicary schistosomiasis
S. mansoni: intestinal schistosomiasis
S. japonicum: hepatic schistosomiasis -> Periportal "pipstem"
fibrosis (pathognomonic)
Most impt mediatior of sepsis (Septic shock) and cachexia =
TNF-a an acute phase cytokine produced by activated
macrophages.
1799
31
39
Pathology
Pathology
Pathology
Allergy & Immunology
Cytokines responsible for inducing the systemic inflammatory
response
- IL-1
- IL-6
- TNF-alpha
Cardiovascular System
Berry aneyrysms are particularly prone to rupture when
associated with coarctation of the aorta, because HTN in
branches of the aortic arch proximal to the coarct. Resulting in
subarachnoid hemorrhage.
Cardiovascular System
4/18 Slow growth rate of an atherosclerotic occlusion allows for
the development of collateral circulation around the point of
occlusion.
Table
41
72
Pathology
Pathology
Cardiovascular System
Cardiovascular System
Prominent granulation tissue and neovascularization are found
in the infarct zone during the secodn week after MI.
Infective endocarditis:
Janeway lesions - nontender, mcular, erthematous lesions
typically located on the palms and soles.
They are a result of septic microembolization from valvular
vegetations and are composed of bacter, neutrophils
(microabscesses), necrotic material, subcutaenous
hemorrhage.
4/18 Endocardial thickening and fibrosis of tricuspid and
pulmonary valves are characteristic of carcinoid heart disease.
Dx 5-HIAA in urine.
74
Pathology
Cardiovascular System
Seritonin stimulated fibroblast growth and fibrogenesis. Only
affects right heart because vasoactive producted are
inactivated distally by pulmonary vascular enothelial
monoamine oxidase.
Fibrinous pericarditis develops in about 10-20% of pts 2-4 days
following a transmural MI. Inflammatory raction to cardiac
muscle necrosis so it is localized to the region of the
pericardium overlying the necrotic myocardial segment.
89
Pathology
Cardiovascular System
Sharp pleuritic chest pain = pericardial involvment
Exacerbation with swallowing = posterior percardium
involvment
Radiation into the neck = inferior pericardium involvment
(adjacent to the phrenic nerve supplying the diaphragm)
Prolonged QT with sensory neural deafness = Jervell and
Lange- Nielsen syndrome
91
Pathology
Cardiovascular System
QT prolongation predisposes to syncopal episodes and
possible sudden cardiac death due to torasdes de pointes.
Acute onset, mid-chest pleuritic pain that decreases on sitting
up and leaning forward is characteristic of acute pericaditis.
97
Pathology
Cardiovascular System
Fibrinous or serofibrinous pericaditis is the most common form.
Percardial friction rub = Acute pericarditis
Pericardial knock = Constrictive (Chronic) pericarditis which
requires month or years to develop.
176
Pathology
Cardiovascular System
4/18 Vacuoles and phospholipid-containing amorphous
densities within the mitochondria signify irreversible cell injury
because it implys a permenant inability to generate further ATP
via oxidative phosphorylation.
Mitochondrial swelling = indicated reversible cell injury
176
Pathology
Cardiovascular System
Mitochondrial vacuolization generally signifies irreversible
injury. It implies a permenant inability to generate further ATP
via ETC.
6/18 *Caseous necrosis occurs most commonly with =
tuberculous infection . Also seen in fungal infections (ie.
Histoplasma, cryptococcus, coccidioides)
178
Pathology
Cardiovascular System
184
Pathology
Cardiovascular System
Orthopnea (supine dyspnea relieved by sitting up) is quite a
specific sign of left sided heart failure
188
Pathology
Cardiovascular System
Hamartin gene mutation - Tuberous sclerosis
Frataxin mutation - Friedrichs ataxia
x2
Nonbacterial thrombotic endocarditis (NBTE) chracterized by
deposition of sterile platelet thrombi on cardiac valves.
231
Pathology
Cardiovascular System
NBTE is commony associated with advanced malignancy and
can also occur with chronic inflammatory disorders (ie. SLE)
and sepsis.
Lipofuscin is the product of lipid peroxidation, accumulating in
aging cells (esp. in pt with malnutrition and cachexia)
300
Pathology
Cardiovascular System
448
Pathology
Cardiovascular System
449
Pathology
Cardiovascular System
Yellow-brown, finely granular perinuclear pigment is the
product of free radical injury and lipid peroxidation. Seen in the
heart and liver of aging cachectic, malnourished patients.
endarterectomy: surgical removal of part of the inner lining of
an artery.
4/16 * Homogenous acellular thickening of arteriolar walls =
Hyaline arteriosclerosis associated with lower levels of HTN
*Onion like concentric thickenking of arteriolar walls =
Hyperplastic arteriolosclerosis in renal arteroles can result
from perpetuate malignant HTN (persistent diastolic pressure
>130)
4/14 *hypersensitivity to components of tobacco smoke =
Thromboangitis obliterans (Berger's disease)
451
Pathology
Cardiovascular System
*Segmental thrombosing vasculitis that extends into contguous
veins, and nerves, encasing them in fibrous tissue =
Thromboangitis obliterans (berger's disease)
Lymphangiosarcoma can occure approx 10 yrs following
radical mastectomy for breast cancer.
470
Pathology
Cardiovascular System
Persistent lymphedema (with chronic dilatation of the lymphatic
channels) predisposes partients to the development of
lymphangiosarcoma.
Lymphangiosarcoma: a rare malignant neoplasm of the
endothelial lining of lymphatic channels.
470
Pathology
Cardiovascular System
Liver hemangiosarcoma is a rare malignant vascular
endothelial cell neoplasm associated with such carcinogens:
- Arsenic (exposure to pesticides)
- Thorotrast (a former radioactive contrast medium)
- Polyvinyl chloride (a plastic widely used in industry)
471
Pathology
Cardiovascular System
4/18 Tumor cells express CD31 = PECAM1 Endothelial cell
marker (hepatic angiosarcoma)
Exposure to arsenic, thorotrast or polyvinyl chloride causes
what kind of cancer = hepatic angiosarcoma
729
Pathology
Cardiovascular System
4/19 Staph aureus causes right sided endocarditits in IV drug
users
729
Pathology
Cardiovascular System
Right sided endocarditis in Iv drug user = Stap aureus
crecendo-decrescendo systolic murmur peaking in midsystole
(between S1/S2) characteristic of aortic pulmonic stenosis.
939
Pathology
Cardiovascular System
MCC of aortic stenosis in elderly pt = degenerative
calcification of the aortic valve.
1040
Pathology
Cardiovascular System
4/18 Presentation of serosal inflammation in SLE = Pleuritis or
pericarditis (MCC cardio manifestation in SLE)
Organ suceptibility to infarction (from greatest to least) = CNS,
myocardium, kidney, spleen, liver.
1875
Pathology
Cardiovascular System
Infarct in an otherwise normal liver are rare because it has a
dual blood supply: the portal vein and hepatic artery.
In experiments transient myocardial ischemia causes
myocardial cells to increase in size. This effect is due in part
to? Intracellular Ca2+ accumulation
1882
Pathology
Cardiovascular System
Ion pump failure due to ATP deficiency during cardiac ischemia
causes intracellular accumulation of Na+ and Ca+. The
increased intracellular solute concentration draws free water
into the cell causing the cellular and mitochondrial swelling
observed on histology.
Glomus tumor (glomangioma) OR a subungual melanoma =
Bluish neoplasm occuring underneath the nail bed.
467
Pathology
Dermatology
936
Pathology
Dermatology
Glomangioma is a tumor of modified smooth muscle cells of a
glomus body. Function of the glomus body = shunt blood away
from the skin surface in cold temperatures in order to prevent
heat loss and to direct blood flow to the skin surface in hot
enviorments to facilitate the dissipation of heat.
Acanthosis nigricans
a) Multinucleated cells with intranuclear inclusions = VZV
shingles
b) Acantholysis and intercellular IgG deposits = Pemphigus
vulgaris
1042
Pathology
Dermatology
c) Eosinophillic cytoplasmic inclusions = Molluscum
contagiosum --> Pox virus
d) Microabscesses at the tips of dermal papillae = Dermatitis
herpetiformis
Invasive creast carcinoma typically presents as an irregularly
shaped adherent breast mass, MCC in upper outer quadrant.
1056
Pathology
Dermatology
Malignant infilteration of the suspensory ligaments of the
breast causes dimpling of the overlying skin
4/18 Acute eczematous dermatitis is characterized by
spongiosis on histology. HSR type IV
1115
Pathology
Dermatology
Accumulation of edema fluid in the intercellular spaces of the
epidermis. With chronic exposure lesions become less
edematous with thickening of the stratum spinosum and
stratum corneum
Layers of the skin =
1937
Pathology
Dermatology
Axillary lymph node dissection is a risk factor for the
development of chronic lymphedema involving the ipsilateral
arm.
Chronic lymphedema predisposes to the development of
angiosarcoma (Stewart-Treves syndrome).
Compound nevus: raised papules with uniform brown to tan
pigmentation. Has dermal and epidermal involvment.
11502
Pathology
Dermatology
Junctional nevi: Flat, black- to brown- pigmented macules with
darker coloration in the center than the periphery and
preserved skin markings.
Intradermal nevi: Skin to tan colored, dome shaped, sometimes
pedeunculated. Lose tyrosine activity and produce little to no
pigment.
221
Pathology
Endocrine, Diabetes &
Metabolism
Craniopharyngioma - Rathkes pouch remnant, solid, cystic,
calcified.
927
Pathology
Endocrine, Diabetes &
Metabolism
No change in ACTH/cortisol after high dose dexamethason=
Ectopic ACTH secretion (ie. small cell lung cancer)
MCC of death in diabetic patients = Coronary heart disease.
1011
Pathology
Endocrine, Diabetes &
Metabolism
1839
Pathology
Endocrine, Diabetes &
Metabolism
Annorexia - decreased leptin levels -> inhibits pulsatile GnRH
-> causing decreased LH and FSH secretion -> low circulating
estrogen -> amenorrhea, bone loss
Pt with noncoronary atherosclerotic disease, DM, Chronic
kidney disease are at the same risk of cardiovascular events
(Eg. MI, stroke) as pt with known coronary heart disease.
8531
Pathology
Endocrine, Diabetes &
Metabolism
fulfonylureas increase insulin release by closing the k+
channels on the beta cells of the pancrease causing an
increase in intracellular calcium which causes exocytosis of
insulin granules. Pt will have elevated insulin and c-peptide
with sulfonylureas, insulinomas
1992
Pathology
Female Reproductive
System & Breast
4/14 *HIV coinfections allow HPV infection to persist and
enhances expression of HPV oncogenes = increaseding risk
for cervical dysplasia/cancer
57
Pathology
Gastrointestinal & Nutrition
Aflatoxin can cause a g to c mutation in p53 and cause
hepatocellular carcinoma
59
Pathology
Gastrointestinal & Nutrition Metastasis to the liver is more common/likely then liver cancer
Pt has cholPain after eating fatty meals = gallbladder hypo
motility (biliary stasis )
71
Pathology
Gastrointestinal & Nutrition
CCK stimulation test? Shows slow and incomplete gallbladder
emptying
Porcelain gallbladder - firm, palpable gallbladder and extensive
calcification throughout the gallbladder wall.
87
Pathology
Gastrointestinal & Nutrition
associated with increased risk for adenocarcinoma of the
gallbladder.
88
Pathology
Gastrointestinal & Nutrition Pneumobilia (air in the biliary tract) = gallstone ileus
Tropheryma whippelii (whipple disease) - small itnestine,
joints, centeral nervous system
131
Pathology
Presents a: middle aged white male presenting with
Gastrointestinal & Nutrition malabsorption (fat in stool) with diarrhea and weight loss.
Proliferate in the marcophages only - enalrged foamy
macrophages packed with rod shaped bacilli and
PAS+positive, diastase-resistant granules.
132
Pathology
Gastrointestinal & Nutrition
Tropheryma whippelil - is PAS positive magenta because of the
glycoproteins present in the cell wall
NOD2 mutation in Chron disease
135
Pathology
Gastrointestinal & Nutrition
NOD2 activates --> NF-kB (proinflammatory transcription
factor) --> increases cytokine production
distal duodenal ulcer = h pylori
Ulcer found beyond duodenal bulb = Zollinger Ellison Syndrome
305
Pathology
Gastrointestinal & Nutrition
362
Pathology
Gilbert syndrome = pt with no apparent liver disease who have
Gastrointestinal & Nutrition mild unconjugated hyperbilirubinemia (Increased total bilirubin,
normal direct)
400
Pathology
Gastrointestinal & Nutrition
flattening of diaphragm = hyperinflation of lungs usually due to
emphysema
404
Pathology
Gastrointestinal & Nutrition
Enterocutaneous fistulas (bowel contents drains into the
surface of the skin) can be seen in Crohn's disease.
406
Pathology
Gastrointestinal & Nutrition
The most common location affected in chron's disease is the
terminal ileum.
Secretin inhibits the secretion of gastrin from g cells BUT
administering secretin in ZES increases gastrin from the tumor
(gastrinoma)
Abdominal pain, bloody diarrhea, signs of shock (hypotension,
tachycardia) in the setting of untreated ulcerative colitis = toxic
megacolon
410
Pathology
Gastrointestinal & Nutrition Toxic megacolon can also be associated with Clostridium
difficile
Do a plain abdominal x-ray because barium contrast and
colonoscopy are contradicted because of risk of perforation.
429
Pathology
Colon cancer at a young age with no polyps and family history
of colon cancer = hereditary nonpolyposis colon cancer
Gastrointestinal & Nutrition (HNPCC) or Lynch syndrome
MSH2, MLH1 mutation = DNA mismatch repair.
1143
Pathology
Gastrointestinal & Nutrition Shigella - m cells at the base of micro villi in peyers patch
1423
Pathology
Gastrointestinal & Nutrition
Increase alkaline phosphate and gamma glutamyl
transpeptidase = biliary injury
1783
Pathology
Gastrointestinal & Nutrition
Chrons disease is associated with Perianal fistulas (skin tags,
fissures)
1806
Pathology
Vit E deficiency presents with neuromuscular disease (skeletal
Gastrointestinal & Nutrition myopathy, spinocerebellar ataxia, polyneuropathy) and
hemolytic anemia.
Low-grade fever, dark colored urine, anorexia/nausea, right
upper quadrant pain = acute viral hepatitis
1863
Pathology
Gastrointestinal & Nutrition
Hepatocytes necrosis and apoptosis with mononuclear
infiltrates. Hepatic necrosis is characterized by cellular
swelling and cytoplasmic emptying (ballooning degeneration)
Chronic non-atrophic gastritis in the antrum of the stomach =
h. Pylori
1918
Pathology
Gastrointestinal & Nutrition
Chronic infection in the body of the stomach has an increased
risk for gastric adenocarcinoma And MALT lymphoma
1927
Pathology
Councilman body (apoptotic or acidophillic bodies) - when
Gastrointestinal & Nutrition hepatocytes undergo apoptosis they form round acidophillic
bodies
9920
Pathology
Gastrointestinal & Nutrition
Curvilinear areas of lucency that parallel the bowel wall lumen
on x-ray= necrotizing enterocolitis
Hand hygiene is the single most important measure to reduce
the risk of transmission of hospital-aquired infections.
11514
Pathology
General Principles
Isolation is for airbone infections
294
Pathology
Hematology & Oncology
Iron overload (hemosiderosis) is a common and serious
complication of chronic hemolytic anemia and frequent blood
transfusions. Hemosiderin accumulation (Kupffer cells
containing coarse, yellowish-brown cytoplasmic granules) is
the cardinal histologic finding. Chelation therapy is indicated to
reduce parenchymal iron deposition.
Pt with beta thalassemia who received numberous blood
transfusions has hemosiderin accumulation.
4/14
615
Pathology
Hematology & Oncology
*MCC childhood brain tumor = Pilocytic astrocytomas
*Most common location of pilocytic astrocytomas = cerebellum
*Medulloblastomas are located exclusively in = The cerebellum
(most commonly in the vermis)
*Childhood brain tumor that presents with hydrocephalus =
Ependymomas (arise from the lining of the ventricle and can
obstruct CSF flow)
Alcoholic develop macrocytic anemia (MCV >100) due to folic
acid def (within months) or Vitamin B12 def (within years)
1580
Pathology
Hematology & Oncology
The underlying biochemical feature of megaloblastosis is a
defect in DNA synthesis. Folate deficiency impairs synthesis
of puring an pyrimidine bases.
"diminished thimidine synthesis"
EBV virus is seen in ~50% of systemic B-cell lymphomas and
almost all primary CNS lymphomas in pt with HIV.
1630
Pathology
Hematology & Oncology
Brukitt lymphoma (high mitotic index) in an HIV pt is
associated with EBV
1755
Pathology
Hematology & Oncology
Burkitt's lymphoma [t(8;14)]
- c-myc oncogene --> functions as a transcription activation
4/19
1758
Pathology
Hematology & Oncology
Bcl-2 inhibits apoptosis and promoted survival of tumor cells
Bcl-2 = follicular lymphoma
t(14;18) = follicular lymphoma
Mutations of genes responsible for DNA mismatch repair lead
to = hereditary nonpolyposis colon cancer (lynch syndrome)
and other visceral malignancies
Proto-oncogenes:
ABL - CML, ALL
kRAS - lung, colon, pancreatic
hRAS - renal cell, bladder
BRAF - melanoma
HER1 - squamous lung
HER2 - breast, ovarian
SIS - astrocytoma, osteosarcoma
TGFA - astrocytoma, hepatocellular
1760
Pathology
Hematology & Oncology
Tumor supressors:
APC/beta-catenin- Pancreatic, colon, stomach, familial
adenomatous polyposis
BRCA1, 2 - breast, ovarian
DCC - colon
NF1 - neuroblastoma, sarcoma, nf1
RB - retinoblastoma, osteosarcoma
TP53 - p53
VHL - renal cell, von hippel lindau
WT1 - wilms
RBCs that appear blue and slightly larger on Write-Giemsa
stain = Reticulocytes
1796
Pathology
Hematology & Oncology
Reticulocytes lack a cell nucleus but retain basophilic, reticular
(mesh-like) network of residual ribsosomal RNA
Blasts cells in periphery = Leukemia
MCC of leukemia in a child = ALL
1798
Pathology
Hematology & Oncology
The neoplastic cells of ALL arise from lymphocytic precursors
of either Pre-B (70% of cases) or pre-T (15% of cases) cells.
T cell ALL often presents as a mediastinal mass that can
cause respiratory symptoms, dysphagia, SVC syndrome.
The major clinical manifestations of factor V Leiden include
deep vein thrombosis (DVT), cerebral vein thrombosis, and
recurrent pregnancy loss.
1879
Pathology
Hematology & Oncology
1-9% of caucasians worldwide are heterozygote carriers of
factor V Leiden, which is modified to resist activated Protein C.
The resulting hypercoagulable state predisposes to deep vein
thromboses, which are the source of the most pulmonary
emboli.
1921
Pathology
Hematology & Oncology
Small cell (Oat cell) lung cancer with cushing syndrome is the
result of a paraneoplastic syndrome causing ectopic production
of ACTH.
1963
Pathology
Hematology & Oncology
aml
11750
Pathology
Hematology & Oncology
Lymphocyte with cytoplasmic projections = Hairy cell
Intraerythrocytic ring forms = Malaria
Myeloid cells with azurophillic rod like granules = Auer rods
AML
Heterophile antibodies = EBV (mono)
Ringed sideroblasts = Myelodysplastic syndrome
Mitochondrial iron accumulation surrounding the RBC nucleus
= Ringed sideroblasts
4/16 *Testosterone =negativley inhibits the hypothalamus
(GnRH) and the pituitary (FSH, LH). Inhibin B only negativley
inhibits FSH.
580
Pathology
Male Reproductive System In cryptochidism if the undescended testes are not surgically
moved to the scrotal sac the seminiferous tubles become
atrophic and hyalinized over time resulting in low sperm count.
Sertoli cells that secrete inhibin are located in the seminiferous
tubules.
In patients with bilateral angiomyolipomas the incidence of
tuberous sclerosis is 80-90%
6
Pathology
Miscellaneous
(Multisystem)
Renal angiomyolipoma is a benign tumor composed of blood
vessels, smooth muscle, and fat.
Tuberoys sclerosis - brain hamartomas (with consequent
seizures and MR), ash leaf skin patches, bilateral renal
angiomyolipoma, facial angiofibroma, cardiac rhabdomyomas
285
Pathology
Miscellaneous
(Multisystem)
Squamous to columnar metaplasia in the esophagus (Barett's
esophagus) is a complication of long standing GERD. This
increases the risk of esophageal adenocarcinoma.
Columnar to squamous metaplasia can also occur in the
trachea of chronic smokers.
4
Pathology
Nervous System
intracranial berry aneurysm pf the circle of willis (subarachnoid
hemorrhage) are often seen in ADPKD
Lacunar infacts most comnly due to hypertensive
arteriosclerosis
22
Pathology
Nervous System
Involved in deep brain structures (basal ganglia, Pons) and
subcortical white matter ( internal capsule, corona radiata)
You can't see ischemia/infarcts on first day on CT**
Anti smooth muscle antibodies = autoimmune hepatitis
397
Pathology
Nervous System
Wilson disease - excess hepatic copper accumulation,
damaged hepatocytes leake free copper that deposits into
othet tissues (basal ganglia -neuro symptoms, cornea
-kayser-flecher rings)
Why do you have increased transaminases in wilson disease?
VHL:
468
Pathology
Nervous System
1)
2)
3)
4)
hemangioblastoma or retina or cerebellum
pheocromocytma
renal cell carcinoma
congenital cysts/neoplasms in kidney, liver, and pancreas
The changes seen in the neuronal body after the axon is
severed are called axonal reaction. This process reflects an
increased protein synthesis that facilitates axon repair.
494
Pathology
Nervous System
Enlarged, rounded cells with peripherally located nuclei and
dispersed finely granular nissal substances are seen.
Wallerian degeneration occurs in the segment of axon that has
lost connection with cell body. It represents the degeneration of
axon and myelin distal to a point of injury.
Arnold-Chiari malformations are congenital abnormalities. They
are cause by impaired development of the posterior fossa.
504
Pathology
Nervous System
Chiari type 1 - is relatively benign and may manifest in
adulthood
Chiari type II - severe and evident in newborn
506
593
Pathology
Pathology
Nervous System
Nervous System
Subdural hematoma
- Crescent shaped
- Rupture of the cortical bridging beins
- recognize CT scan
Alzheimers - decrease in acetycholine levels in basal nucleus
of meynert (which participates in memory and cognition) and
hippocampus (formation of new memories)
Huntingtons - Atrophy of the nucleus caudatus. NMDA
receptors are depleted in the striatum of these pt.
613
Pathology
Nervous System
4/14
*Glioblastoma arises from = astrocytes and is typically located
with the cerbral hemisphere
*What is a buttfly glioma? Glioblastoma that crosses the
corpus callosum (midline)
Loss of neurons in the caudate nucleus and putamen =
Huntingtons
632
Pathology
Nervous System
636
Pathology
Nervous System
Huntingtons
- atrophy caudate nucleus
- moderate atrophy putamen and frontal lobes
- Decrease GABA, Ach, Supstance P in striatum (in caudate
and putamen)
- NMDA (N-methyl-D-aspartate) receptors bind glutamate and
cause neuronal death
- Autosomal dominant
- Incr CAG chromosome 4
hypertrophic cardiomyopathy is the MCC of death in Friedreich
ataxia
Severe vitamin E deficency closely mimicks Friedreich ataxia.
Both have ataxia, dysarthria, and loss of postion and vibration
sensation.
671
Pathology
Nervous System
Vitamin E defeciency is most notable in the nervous system it
causes degeneration of spincerebella tracts, dorsal column of
spinal cord and peripheral nerves.
Vitamin E deficiency is rare but can be seen in pt iwth fat
malabsorption, abetalipprotinemia, and low birth weight infants
672
Pathology
Nervous System
Friedreich ataxia - characterized by cerebella ataxia
(degeneration of spinocerebella tracts) and loss of
position/vibration sensation (Dorsal column/dorsal root ganglia
degeneration), hyphoscoliosis, hypertrophic cardiomyopathy,
peas canvas (high plantar arch)
Tertiary neurosyphillis:
Argyll Robertson pupils - manifests with a ligh-near
dissociation and are caused by damage to midbrain tectum.
906
Pathology
Nervous System
**ARP - Accomodation reflex present, pupillary reflex present
Tabes dorsalis - affects the dorsal columns and dorsal roots of
spinal cord, results in loss of position and vibrtation sense and
severe lacinating pains. Peripheral reflexes may also be absent
Rapid response to acyclovir indicates a viral infection most
likely caused by herpes simplex
908
Pathology
Nervous System
Viral meningitis CSF has lymphocyte pleocytosis, normal
glucose, elevated protein
911
Pathology
Nervous System
multiple vaculoes seen n grey matter of the brain = spongiform
encephalopathy (crutzfeldt jakob disease)
Gullian-barre syndrome is strongly associated with
Campylobacter jejuni
1058
Pathology
Nervous System
Demyelination is accompanied by an endoneural inflammatory
infilitrate consisiting of lymphocytes and macrophoages.
Endomysial infammatory infiltrations is seen on polymyositis
1060
1151
Pathology
Pathology
Nervous System
Nervous System
Diabetic mononeuropathy often involves cranial nerve III
(oculormotor nerve). It is causes by ischemia. - ptosis, down
and out gaze, and normal light and accomodation reflex
Oligodrendroglioma - fried egg
Glioblastoma - psuedo-palisading
Medulloblastoma - homer-wright roseetes small blue cells
Pilocytic astrocytomas - hair like projection
Schwannoma - palisading nucleo, Verocay bodies
Meningioma - psomma body - whorled pattern of cellular growth
Cystic tumor in the cerebellum of a child is most likely pilocytic
astrocytoma
1153
Pathology
Nervous System
comprised of spindle cells with hair like glial processes that
are assocated with microcysts. These cells are mixed with
Rsenthal fibers and granular eosinophilic bodies.
In HIV patients with a solid mass ring enhancing lesions
if CD count is less than 200 = check for toxoplasmosis
1260
Pathology
Nervous System
If EBV is present in CSF = Primary CNS lymphoma
Diffuse large B-cell lymphoma is the most common subtype.
High grade tumor with poor prognosis
1263
Pathology
Nervous System
Opsoclonus myoclonus is a parneoplastic syndrome
associated with neuroblastoma. -spontaneous bursts of
non-rhythmic conjugate eye movements
MCC of extrcranial neoplasm in children
1264
Pathology
Nervous System
Causes of Carpel tunnel: Pegnancy (Fluid accumulation),
hypothroidism (glycosaminglycan buildup), DM (connecive
tissue thickening), rheumatoid arthiritis (Tendon inflammation)
Symptoms worse at night
1304
8295
Pathology
Pathology
Nervous System
Nervous System
Schwannoma = S-100
Attention and concentration can be tested by
Counting down from 100 by intervals of 3 or 7,
reciting months of the year in reverse order,
or spelling "world" backwards
Dx for dementia required impairment across several cognitive
domains during MMSE as well as functional impairment in daily
living activitives
11631
11632
Pathology
Pathology
Nervous System
Nervous System
Vision loss that spontanousely recovers (both seen in females):
young age = multiple sclerosis
older = Giant cell tempral arteritis
Cerebellar vermis modulates axial/truncal posture coordination
via connections with the medical descending motor systems
Patients may develop vertigo and nystagmus
8325
Pathology
Pregnancy, Childbirth &
Puerperium
Congential torticollis
- typically notes by 2-4 weeks of age
- child prefers to hold head tilted to one side
- MCC = malposition of the head in utero or birth trauma
- most cases resolve with conservative therapy and stretching
excersises
IFN-Y - forms phagolysosomes, causes nitric oxide synthase
release, and makes granulomas and caseous necrosis.
IL-12 - stimulate natural kills cells to destroy target cells. Also
causes T hellper cells to secrete IFN-Y
302
Pathology
Pulmonary & Critical Care
Neutrophils and macrophages release lysosomal enzymes to
causes tissue damage and abcess formation
Spiking Fever, productive cough, round density air fluid levels
in the lung = Pulmonary abscess
485
Pathology
Pulmonary & Critical Care
Pancreatitis is a major risk factor for ARDS as it results in the
release of a large amount of inflammatory cytokines and
pancreatic enzymes, which leads to activation of neutrophils in
the alveolar tissues. During the initial phase, intersitial and
intraalveolar eddema, inflammation and fibrin depositions
cause the alveoli to become lines with waxy hyaline
membranes.
4/16 *Pancreatitis is a major risk factor for = ARDS
486
Pathology
Pulmonary & Critical Care
*Increased pulmonary capillary premeability and leaky
alveolocapillary membrane = ARDS, decreased lung
complicance, increased work of breathing, worse V/Q
mismatch, normal PCWP (6-12mmHg)
elevated PCWP = Cardiogenic pulmonary edema (ie.
decompensated LV failure)
564
Pathology
Pulmonary & Critical Care
62, cough, dyspnea, pale tan-colored fluid, columnar
mucin-secreting cells that line the alveolar spaces without
invading the stroma or vessels.
Adenocarcinoma in situ (bronchialveolar carcinoma)
650
666
Pathology
Pathology
Pulmonary & Critical Care
Small cell carcinoma of the lung is a neuroendocrine tumor
therefore stains:
- neural cell adhesion molecule (NCAM, aka CD56)
- neuron-specific enolase
- chromogranin
- synaptophysin
- sometimes neurofilaments
Pulmonary & Critical Care
Idopathic pulmonary fibrosis
- Interstitial fibrosis with cystic air spaces
- Dense fibrosis, fibroblast proliferation, cyst formation
- predominatly in the subpleural and paraseptal spaces
- "usual interstial pneumonia (UIP)"
- Persistent non productive cough, exertional dyspnea
- Restrictive PFTs -> FEV1/FVC ration > 80%, decr FVC, TLC
25 y/o dyspnea, fatigue, pain and bluish discoloration of fingers
and toes on cold exposure (raynounds phenomenon),
tightening of the skin over fingers, accentuated S2 over upper
left sternal border, mild hepatomegaly, bilateral lower extremity
pitting edema =
825
Pathology
Pulmonary & Critical Care
Pulmonary arterial hypertention [PAH] which in turn has
caused cor pulmonale and R. CHF
Sclerodactyly & raynound phenomenon = CREST syndrome
Pulmonary HTN is a common complication of systemic
sclerosis
975
Pathology
Pulmonary & Critical Care
Tricuspid endocarditis in iv drug users (#1 Staph aureus, #2 P.
aeruginosa). These patients can develop multiple spetic emboli
in lungs. Pulmonary infarcts are almost always hemorrhagic
due to the dual blood supply to the lungs (pulmonary and
bronichal arteries).
1221
Pathology
Pulmonary & Critical Care
Ghon complex occurs in a primary TB infection.
10
Pathology
Renal, Urinary Systems &
Electrolytes
young adult with painless hematuria within 5-7 days of an
upper respiratory tract infection = Iga nephropath (berger
disease)
13
Pathology
Renal, Urinary Systems &
Electrolytes
C-ANCA associated RPGN is also called pauci immune GN
due to the absence or sarcity of ig and C3 deposits. Pt
presents with renal failure, pulmonary symptoms (cough,
dyspnea, hemoptysis) , and upper resp tract syptoms
(epistaxis, mucosal ulceration, chronic sinusitus).
25
Pathology
Renal, Urinary Systems &
Electrolytes
Corticosteroids are very helpful in minimal change disease
382
Pathology
Renal, Urinary Systems &
Electrolytes
Spike and dome = membranous nephropathy
Albumin loss with minimal loss of the more bulky proteins
(such as IgG and macroglobulin) defines selective proteinuria.
383
Pathology
Renal, Urinary Systems &
Electrolytes
385
Pathology
Renal, Urinary Systems &
Electrolytes
Nephrotic syndrome has selective loss of albumin.
Pathology
Renal, Urinary Systems &
Electrolytes
4/16 homogenous deposition of eosinophilic hyaline material in
the intima and media of small arteries and arterioles = hyaline
arteriosclerosis (DM or poorly controlled HTN)
455
Minimal change disease is an exmaple of a highly selective
proteinuria: mostly low molecular weight proteins, such as
albumin and transferrin are excreted.
Signs of embolism (blue tow, livedo reticularis (vissible veiney
thighs) with normal peripheral pulses) following an invasive
vascular procedure (eg. angiogrpahy, angioplasty, aortic
surgery) is = Atheroemoblic disease.
810
Pathology
Renal, Urinary Systems &
Electrolytes
Atheroembolic disease needle-shaped cholesterol containing
debris get dislodged from larger arteries (the aorta during
cardiac cath) and lodges into smaller vessels. may involve:
kidneys (MCC), GI, CNS & skin.
Straining on urnination in an elderly male suggests bladder
outflow obstruction (BOO), a condition usually due to prostate
enlargment.
MCC of BOO is BPH
811
Pathology
Renal, Urinary Systems &
Electrolytes
BPH leads to intermittent bladder outlet obstruction - pt
experiences a sensation of incomplete bladder empting =
urinary rentions
Overflow incontinence is the next clinical stage
Urinary rentention results in increased pressure in the urinary
tract and resultant reflux nephropathy
Hexagonal crystals in kidney stones = Cystinuria
814
Pathology
Renal, Urinary Systems &
Electrolytes
Positive cyanide-nitropursside test = Cysteine in urine
Cystinuria results from defective dibasic amino acid transport
in intestinal and proximal renal tubular cells
Risk factors for nephrolithiasis (kidney stones)
816
Pathology
Renal, Urinary Systems &
Electrolytes
832
Pathology
Renal, Urinary Systems &
Electrolytes
4/16 Unilateral kidney atrophy (one bigger than the other) =
Renal artery stenosis (can present with postprandial pain and
weight loss due to intestinal ischemia)
834
Pathology
Renal, Urinary Systems &
Electrolytes
Abrupt onsent of gross hematuria in an otherwise healthy
patient with a family history of sickle cell disease suggests =
renal papillary necrosis (RPN)
835
Pathology
Renal, Urinary Systems &
Electrolytes
Drug induced intersital nephritis - presents with fever, rash,
oliguria 1-3 weeks after initiation of treatment a beta-lactam
antibiotic (ampicillin, NSAIDs, sulfonamides, rifampin, diuretics
884
Pathology
Renal, Urinary Systems &
Electrolytes
Diabetic nephropathy - kimmelstein Wilson nodules
Pathology
Renal, Urinary Systems &
Electrolytes
4/16 * Complication of the recovery phase in ATN =
Hypokalemia (due to vigorous diuresis but because the RT
cannot yet fully function electrolyte balance is altered. High
volume hypotonic urine)
886
Hypercalciuria - Primary hyperparathyroidism
Hyperoxaluria - Chron disease
Hypocitraturia - Distal renal tubular acidosis
Hyperuricosuria - Gout
888
Pathology
Renal, Urinary Systems &
Electrolytes
WBC casts are pathognomonic for acute pyelonephritis
Elderly pt with
1054
Pathology
Renal, Urinary Systems &
Electrolytes
1.
2.
3.
4.
easy fatigability (due to anemia)
constipation (due to hypercalcemia)
bone pain
renal failure
Multiple myeloma
Pt with chronic kidney disease may develop Renal
osteodystrophy from secondary hyperparathroidism.
1663
Pathology
Renal, Urinary Systems &
Electrolytes
In CKD failure of the glomerular and tubular function causes
hyperphosphatemia (from decreased phosphate filteraton) and
hypocalcemia (from decreased
1,25-dihydroxycholecalciferol/vit D) which results in increased
PTH --> increased bone reabsorption.
4/16 Impetigo is a superficial skininfection characterized by
honey-colored crust =Strep and staph are usually responsible
1850
Pathology
Renal, Urinary Systems &
Electrolytes
What symptomes do you see in HSP? abdominal pain, joint
pain, lower extremity palbable purpura
Pt with HSP also have increased risk of intussusception
Renal - IgA Berger and HSP both cause mesangial proliferation
and crescent formation
1862
Pathology
Renal, Urinary Systems &
Electrolytes
Clear cells in clear cell renal carcinoma are cells with high
glycogen or lipid content.
1913
Pathology
Renal, Urinary Systems &
Electrolytes
Waxy casts in urine = advanced renal disease/chronic renal
failure
1916
Pathology
Renal, Urinary Systems &
Electrolytes
4/16 Vesicoureteral refluc can be a complication of
prostatectomy or bladder surgery. Predisoposes to
pyelonephritis and hydroureteronephrosis.
Accidental ligation of the ureter causes obstructive uropathy
with Hydronephrosis and flank pain (due to distention of the
ureter and renal pevlis
7623
Pathology
Renal, Urinary Systems &
Electrolytes
Transitional cell carcinoma of the bladder typically presents as
gross hematuria is an elderly man.
11806
Pathology
Renal, Urinary Systems &
Electrolytes
Smoking history, painless hematuria, policy thesis (elevated
hematocrit), left sided renal mass + renal cell carcinoma
239
Pathology
Rheumatology/Orthopedics
Antistreptolysin O titers = rhuematic fever
& Sports
Transmural inflamation with fibrinoid necrosis = Polyarteritis
nodosa. PAN is commonly associated with hepatitis B.
457
Pathology
"Transmural inflammation of mid sized arteries with areas of
homogenous eosinophillic arterial wall necrosis. Areas of
Rheumatology/Orthopedics
internal elastic lamina disruption."
& Sports
Vasculity associated with antibiotic use: Microscopic
polyangitis (type III HSR)
Vasculitis linked to asthma: Churg-strauss
Pathology
Presence of primary unmineralized spongiosa in the medullary
cannals = Osteopetrosis
Rheumatology/Orthopedics Excessive unmineralized osteoid = Vitamin D
& Sports
Superiosteal resorption wiht cystic degeneration =
hyperparathyroidism
Trabecular thinning with fewer interconnections = Osteoporosis
634
Pathology
Dystonia: neurological movement disorder characterized by
sustained, involuntary muscle contractions, which force certain
parts of the body into abnormal sometimes painful, movements
or postures.
Rheumatology/Orthopedics MCC = spasmodic toricollis (cervical dystonia)
& Sports
Blepharospasm = 2nd MCC involuntary, forcible closure of the
eyelids. Initally presents as uncontrollable blinking.
Writer's cramp = dystonia of hand
Myoclonus: sudden brief sometimes severe (shock-like)
muscle contraction. Ex. hiccup
721
Pathology
Rheumatology/Orthopedics
Osteomyelitis?
& Sports
1266
Pathology
Duchenne muscle dystrophy chracterized by calf
Rheumatology/Orthopedics
pseudohypertrophy (Muscle fibers of the distal extremities are
& Sports
later replaced by fat and connective tissue)
629
Synovial fluid analysis showing rhomboid-shaped calcium
pyrophosphate crystals is diagnostic of pseudogout.
Postivieley birefringent under polarized light. The knee joint is
involved in >50% of cases.
1451
Pathology
Rheumatology/Orthopedics
Caclium hydroxyapatite - Calcific tendonitis, MC in rotator cuffs
& Sports
Monosodium urate - Gout, needle shaped and negatively
birefringent
Calcium pyrophosphate - pseudigout
Calcium oxalate - found in renal calculi
Allopurinol used to prevent attacks of acute gouty arthritis
1835
1874
8710
375
42
Pathology
Pathology
Pathology
Rheumatology/Orthopedics
& Sports
Rheumatology/Orthopedics
& Sports
High synovial fluid lekocyte count >100,000 and absent crystal
strongly suggest bacterial joint infection
Septic arthritis is very often due to gonococcus in young
adults. Acute monoarticular arthritis requires antibiotics
treatment to prevent joint destruction, osteomyelitis and
sepsis.
Excessive matrix metalloproteinase activity and myofibroblasts
accumulation during would healing can result in contracture in
the wound margins.
Contractures produce deformities of the wound and
surrounding tissues, most often on the palms, soles, anterior
thorax, or at serious burn sites.
Rheumatology/Orthopedics
4/16 Pain when hip is extended = Psoas major (psoas abcess)
& Sports
Pathophysiology Allergy & Immunology
x2 Hep B virus does not have a cytotoxic effect itself however
the presence of vial HBsAg and HBcAg on the cell surface
stimulate the host's cytotoxic CD8+ T lymphocytes to destroy
infected hepatocytes.
Pathophysiology Cardiovascular System
Time after total ischemia:
60 seconds: Loss of cardiomyocyte contractillity.
Less than 30 mins: reversible contractile dysfunction
More than 30 min: irreversible ischemis injury
4/18 Transthyretin = protein tetamer produced in the liver acts
as a carrier of thyroxine and retinol. Mutation in transthyretin
gene causes Transthyretin-related-senile-amyloidosis cause
amyloid in the myocardium (infiltrative or restrictive
caridomyopathy)
93
Pathophysiology Cardiovascular System
Reduced LV complicance (inc stiffness) indicates = diastolic
dysfunction
Impt causes of Diastolic heart failure = HTN, obesity,
infiltrative disorder (transthyrtin, sarcoidosis)
96
Pathophysiology Cardiovascular System
hypotention, elevated JVD with clear lungs, tachycardia,
pulsus paradoxus (loss of palpable pluse during inspiration) =
Cardiac tamponade
186
Pathophysiology Cardiovascular System
heart cant relax and fill up
In young females b/w the ages of 20 and 40, primary
pulmonary HTN may be responsible for cor pulmonale.
196
Pathophysiology Cardiovascular System
RVH is a feature of cor pulmonale
Cor pulmonale - Right sided heart failure due to pulmonary HTN
196
Pathophysiology Cardiovascular System
RVH is a feature of cor pulmonale a condition cause by
primary pulmonary hypterntion. PPH is seen In young females
20-40
198
233
Pathophysiology Cardiovascular System
Pathophysiology Cardiovascular System
4/18 Hypoxia induced vasoconstriction and emphysematous
obliteration of the vasculature is the pathophysiology of
pulmonary HTN due to = COPD
The best indicator of mitral stenosis severity is the length of
time between S2 (specifically the A2 component, caused by
aortic valve closure) and the opening snap (OS). A shorter
interval indicated a more sever stenosis.
MS presents with a diastolic rumbling murmur with presystolic
accentuation due to left atrial contaction.
x2 (graph)
235
Pathophysiology Cardiovascular System
Mitral stenosis classic fidnings: loud S1, early diastolic
opening snap after S2, and a low pitched diastolic rumble.
The opening snap is caused by the sudden opening of the
mitral valve leaflets when the left ventricular pressure falls
below the left atrial pressure at the beginning of diastole.
296
Pathophysiology Cardiovascular System
4/18 *Hallmark of cell injury/death/necrosis = dystrophic
calcification in the setting of normal calcium levels
*Metastatic calcification occurs in normal tissue in the setting
of hypercalcemia
*Age related cacific aortic stenosis is preceded by = cell
necrosis.
446
Pathophysiology Cardiovascular System
In pathogensis of atherosclerotic plaques: release of
platelet-derived growth factor (PDGF) released by locally
adherent platlets.
530
Pathophysiology Cardiovascular System
x2
PAH follows a 2 hit hypothesis. An abnormal BMPR2 gene is
1st insult and predisposes to excessive endothelial and smooth
muscle cell proliferation. 2nd insult is thought to activate the
disease process resulting in vascular remodeling, elevated
pulmonary vascular resistance and progressive pulmonary
HTN.
Hypoxic vasoconstriction - of the pulomary arteries and
obliteration of the vascular bed are seen in COPD, OSA,
interstital lung disease.
843
Pathophysiology Cardiovascular System
CHF
- Cardiac output is decreased
- Decreased perfusion to the viscera/organs due to decreased
cardiac output
- Decreased lung compliance and Oxygen diffusion. Incr
pressure in pulmonary circulation results in transudation of
fluid into the lng interstitium and air spaces.
- Increased arterial resistance (Afterload) (due to RAAS
pathway and incr sympathetic output) exacerbate HF by
making it more difficult for the failing heart to pump blood to the
tissues.
945
Pathophysiology Cardiovascular System
Abnormally prominent, upsloping left atrial "v wave" during
cardiac catheterization is a major hemodynamic finding =
Mitral regurgitation
2096
Pathophysiology Cardiovascular System
4/16 Young imigrant with bilateral knee swelling as a child most
likey has what valvular problem? = Mitral regurg (rheumatic
heart diseasE)
2099
Pathophysiology Cardiovascular System
Pulsus paradoxus: decrease in systolic bp of >10 mmHg with
inspiration. MCC cardiac tamponade, also severe asthma,
COPD, constrictive pericarditis.
Inspiration causes inc venous return to the right heart. In
conditions where expansion is impaired (cardiac tamponade)
the inc in r.ventricular volume leads to bowing of IV septum
toward left ventricle. Leads to decrease in LV ESV/SV w/ dec
in systolic pressure on inspiration
Kortokoff sound: sound listen for during bp
Exacerbation of Asthma or COPD are the MCC of pulsus
paradoxus in absence of significant pericardial disease.
2100
Pathophysiology Cardiovascular System
Rx. Beta-adrenergic agonist: Gs protein -> activated adenylyl
cyclase --> inc intracellular cAMP -> bronchial smooth muscle
relaxation.
S4 heart sound is a low frewuency sound heard at the end of
diastole just before S1 (Lub-DuBB-BB).
2107
Pathophysiology Cardiovascular System
S4 is due to decreased left ventricular compliance and is often
associated with restrictve cardiomyopathy, left ventricular
hypertrophy, hypertrophic cardiomyopathy.
VSD = low-pitched golosystolic murmur that accentuates
during maneurvers that increase afterload (Handgrip).
2117
Pathophysiology Cardiovascular System
Small VSD are often asymptomatic and detected incidentally
during routine cardiac auscultation.
2124
Pathophysiology Cardiovascular System
4/15 MCC of coronary sinus dilation = elevated right sided
heart pressure secondary to pulmonary hypertention (Also
occurs in patients with anomalous venous drainage into
coronary sinus, perisistent left SVC and Total anomalous
pulmonary venous return)
11636
Pathophysiology Cardiovascular System
highest burden of atherosclerosis is in the lower abdominal
aorta and coronary arteries.
308
Pathophysiology Ear, Nose & Throat (ENT)
Menieres diease is related to incresed volume and pressure of
endoluphm in the vestibular apparatus -tinnitus, vertigo,
sensorineural hearing loss
308
Pathophysiology Ear, Nose & Throat (ENT)
Meniere disease - disorder of the inner ear characterized by
increased voume and pressure of the endolymph
(endolymphatic hydrops) due to defective resorption of
endolymph.
Meniere triad: tinnitus, vertigo, sensorineural hearing loss.
11628
213
218
Pathophysiology Ear, Nose & Throat (ENT)
Pathophysiology
Pathophysiology
Endocrine, Diabetes &
Metabolism
Endocrine, Diabetes &
Metabolism
Cholesteatomas: collection of squamous cell debris that form a
round pearly mass behind the tympanic membrane in the
middle ear. Can cause conductive hearing loss due to erosion
into auditory ossicles.
prolactinoma - increase prolactin inhibits GnRH leading to
decreased LH leading to decreased testosterone
bitemporal hemianopsia (compress optic chiasm)
hypogonadism/erectile dysfunction/decreased libido
Prolactinoma has similar symptoms to menopause because
(increase prolatin decrease GnRH decrease estrogen ->
osteoperosis, vaginal dryness)
pt with SIADH have clinically normal body fluid volume and low
plasma osmolality (euvolemix hyponatremia)
226
Pathophysiology
Endocrine, Diabetes &
Metabolism
ft of volume overload (peripheral edema, elevated JVD) are not
seen in SIADH due to excretion of sodium in urine
(natresis)/hyponatremia
Primary hyperaldosteronism due to aldosterone adenoma
(Conn syndrome) - hypertention, hypokalemia alkalosis
(muscle weakness and paresthesias)
454
Pathophysiology
Endocrine, Diabetes &
Metabolism
elevated plasma aldosterone, low plasma renin, aldosterone
remains elevated following oral saline load
P.318 FA also put objective on pictures of adrenal layers
Klinefleter syndrome - progressive destructio and hyalinization
of the seminiferous tubles cause the testes to be small and firm
582
Pathophysiology
Endocrine, Diabetes &
Metabolism
inhibin levels are secreased as a result of sertoli cell damage,
leydig dysfunction results in reduced testosterone levels.
Increased FSH/LH due to no feedback inhibition.
gynecomastia, smal but firm testes, azoospermia
somatostatin is secreted by the hypothalamus and inhibits GH
from the anterior pituitary.
601
Endocrine, Diabetes &
Pathophysiology
Metabolism
Somatostatin in also decreted from pancreas delta cells and
dereases the secretion of secretin, cck, glucagon, insulin,
gastrin.
Somatostatinoma - pancreas tumor or delta cells with hyper or
hypoglycemia, steatorrhea, and gallbladder stones (due to
inhibition of cck by somatostatin)
608
Pathophysiology
Endocrine, Diabetes &
Metabolism
Metyrapone stimulation test inhibits 11-deoxycortisol from
becoming corisole. decrease cortisol increases ACTH
(inhibition of negative feedback)
11B- hydroxylase deficiency: HTN and hypokalemia
611
Pathophysiology
Endocrine, Diabetes &
Metabolism
17a-hydroxylase deficiency: HTN and hypokalemia
(mineralocorticoid excess)
21-hydroxylase deficiency: hypothention and hyperkalemia
(mineralocorticoid deficiency)
623
Pathophysiology
Endocrine, Diabetes &
Metabolism
graves pretibial myxedema = lower leg skin thikening and
induration
637
Pathophysiology
Endocrine, Diabetes &
Metabolism
graves disease treatment propthyouracil/methamizole cause
agranulocytosis (increase vuneribility to infection) discontinue
drugs and WBC count w/ differential to confirm diagnosis
698
Pathophysiology
Endocrine, Diabetes &
Metabolism
Sex steroids (estrogen) initally increase linear growth of
epiphyseal cartilage but also encourages closure of the
epiphyseal growth plate. Therefore, pt with percocious puberty
will initally appear very tall but will ultimatley have have short
stature.
Somatomedin c (IGF-1) causes the differentiation and
proliferation of chondrocytes in the epiphyseal growth plate
causing linear growth but does not accelerate epiphyseal
closure.
764
765
Endocrine, Diabetes &
Pathophysiology
Metabolism
Pathophysiology
Endocrine, Diabetes &
Metabolism
Serum TSH level is the most sensitive screening test for
diagnosing primary hypothyroidism. In hypothyroidism the TSH
rise occurs well before low thyroid hormon level is seen.
myoedema - focal mounding of muscles following percussion
(lump appears when hit with reflex hammer). Seen in
hypothyroidism secondary to slow reabsorption of calcium by
the sarcoplasmic reticulum.
Hypothyroid myopathy presents with myalgia, proximal muscle
weakness, cramping, and increase serum creatinine kinase.
767
Pathophysiology
Endocrine, Diabetes &
Metabolism
Potassium iodide is used to treat radioactive iodide exposure
772
Pathophysiology
Endocrine, Diabetes &
Metabolism
Estrogen (OCP/pregnancy) increase TBG -> increase total T4
and normal free T4
849
Pathophysiology
Endocrine, Diabetes &
Metabolism
p 97, 309 glucagon
921
Pathophysiology
Endocrine, Diabetes &
Metabolism
Type 1 DM diagnostic test = fasting glucose > 126, random
glucose >200 or elevated heemoglobin A1c >6.5%
Endocrine, Diabetes &
Metabolism
uncrontrolled Maternal gestational diabetes - leads to high
levels of glucose in the mother that can cross the placenta
leading to high levels of glucose in the fetus which stimulates
fetal insulin. Chronic stimulation of fetal beta cells leads to beta
cell hyperplasia and hyperinsulinism.
922
Pathophysiology
elevated insulin levels cause increased fat deposition and
enhanced fetal growth resulting in macrosomia (big head).
Endocrine, Diabetes &
Metabolism
925
Pathophysiology
928
Endocrine, Diabetes &
Pathophysiology
Metabolism
Functional hypothalamic amenorrhea - secondary amenorrhea
due to low body weight/frequent strenuous exercise.
Decreased leptin lelvels inhibit pulsatile GnRH release from the
hypothalmus -> causing decreased pituitary LH/FSH -> low
estrogen -> amenorrhea
causes of cushings effects on adrenals:
exogenous glucocorticoid - bilateral adrenal atrophy
929
Pathophysiology
Endocrine, Diabetes &
Metabolism
low plasma renin in primary hyperaldosteronism
930
Pathophysiology
Endocrine, Diabetes &
Metabolism
Remeber serum cortisol is indirectly proportional to serum
ACTH
933
Endocrine, Diabetes &
Pathophysiology
Metabolism
981
Pathophysiology
1163
Endocrine, Diabetes &
Pathophysiology
Metabolism
Endocrine, Diabetes &
Metabolism
in Pheochromocytoma Pt symptoms are often episodic
(hypertention that resolves before giving any medication) due
to the fluctuations in catcholamine synthesis by the tumor.
Vitamin D deficiency leads to decreased serum Calcium and
phosphate and increased PTH
hyperplasia of zona faciculata and reticularis from prolongd
ACTH stimulation is seen in Cushing syndrome
Zona golmerulosa is primarily regulated by angiotensin II.
1326
Pathophysiology
Endocrine, Diabetes &
Metabolism
Phosphorylation of serine and theronine residues of insulin
receptor and insult rreceptor substratesby serine kinase leads
to insulin resistence.
this Phosphorylation can be induced by TNF-a, catecholamine,
glucocorticoids, glucagon.
1327
Endocrine, Diabetes &
Pathophysiology
Metabolism
Excess visceral fat (surrounding internal organs) is seen in
insulin resistance (type 2 DM)
Measured by waist circumference or waist-to-hip ratio
acanthosis nigricans is a sign of insulin resistence (DM type 2)
1328
Endocrine, Diabetes &
Pathophysiology
Metabolism
578
Female Reproductive
Pathophysiology
System & Breast
2095
Pathophysiology
Female Reproductive
System & Breast
insulin resistence - increased lipolysis -> releases free fatty
acids.
Protective factors for epithelial ovarian cancer (CA-125)
- Oral contraceptives
- multiparity, breastfeeding
- tubal ligation, salpingo-oophroectomy
4/19 Rx for PCOS = weight loss (reverse insulin resisteance
and restore normal ovulatory function), OCP (to minimize
endometrial proliferation, reduce androgenic symptoms and
prevent unwanted pregnancy), Clomiphene (selective estrogen
receptor modulator prevents negative feedback inhibition on
hypothalamus and pituitary)
Medications that induce ovulation = clomiphene, letrozole
Acute cholecystitis imaging for dx
80
#1) Ultrasound shows: gallbladder wall thickening,
pericholecystic fluid, postive sonographic murphy sign -> signs
Pathophysiology Gastrointestinal & Nutrition of gallbladder inflammation
if inconclusive:
#2) Cholescintigraphy (radio nucleide biliary scan): gallbladder
will not be visualize due to obstruction of cystic duct
Systemic mastocytosis - mast cell proliferation in the bone
marrow, skin, other organs.
306
Pathophysiology Gastrointestinal & Nutrition
Mast cell proliferation if associated with KIT (CD 117) mutation
a receptor tyrosine kinase.
Causes excessive histamine release - syncope, flushing,
hypotention, puritis, urticaria.
323
Pathophysiology Gastrointestinal & Nutrition Sudan III stain - > fat in the stool -> malabsorption
363
Pathophysiology Gastrointestinal & Nutrition
Crigler Najer - has neurological defects due to kericetrus (
bilirubin deposits in the brain)
Acute hepatitis B infection can cause a serum-like sickness
syndrome with joint pain, lymphadenopathy, and a pruritic
urticarial rash. Other features may include RUQ pain,
hepatomegaly, and elevated AST/ALT.
365
Pathophysiology Gastrointestinal & Nutrition
Early marker of acute infection: hepatitis B surface antigen
(HBsAg) which may be detectable prior to symptoms or
changes in transaminase levels.
412
Why do people with Chron disease affecting the terminal ileum
get gallstones? Because bile salts are reabsorbed(for re-use)
Pathophysiology Gastrointestinal & Nutrition
in the ileum. Decreased bile salts leads to cholestrol
percipitation in the bile = gallstone
1662
Pathophysiology Gastrointestinal & Nutrition
1907
Pathophysiology Gastrointestinal & Nutrition D xylose tests brush border enzyme defects
Mallory-Weiss tear leads to metabolic alkalosis due to
repetitive forceful vomiting.
Enteric bacteria can produce vitamins (ex. Vitamin K, Folate)
inhibit proliferation of surrounding pathogenic bacteria and
digest unabsorbed dietary sugars and convers them to fatty
acids.
11860
Pathophysiology Gastrointestinal & Nutrition
Gastric bypass surgery can call small intestinal bacterial
overgrowth (SIBO) due to excessive bacteria proliferation in
the blind ended gastroduodenal segment. SIBO results in
deficiency of most vitamins (B12, A, D, E) and iron, but
increases production of folic acid and vit k
Factor VII has the shortest half life of the coagulation factors
1291
Pathophysiology Hematology & Oncology
Failure to correct PT with Vitamin K supplementaion indicates
liver disease.
1855
1940
Pathophysiology Hematology & Oncology
Sickle cell anemia
- Dactylitis (painful swilling of the hands and feet)
- hemolysis causes:
- increased indirect bilirubin
- increase lactate dehydrogenase
- decreased level of haptoglobin
Pathophysiology Hematology & Oncology
Beta Thalassemia minor:
- Asymptomatic adult of mediterranean decent
- increased hemoglobin A2 (in some) and hemoglobin F
- Caused by a mutation that result in defective transcription,
processing, and translatin of Beta-globin mRNA.
vWF binds platelet glycoproteins to subendothelial collagen on
injured blood vessels walls.
2098
Pathophysiology Hematology & Oncology
vWF also acts as a protective carrier protein for circulating
factor VIII.
Liver mass with increased AFP = hepatocellular carcinoma
822
1141
1390
Pathophysiology Infectious Diseases
Pathophysiology Infectious Diseases
Pathophysiology Infectious Diseases
HBV has a strong association with development of
hepatocellular carcinoma usually after HBV-induced cirrhosis.
Intergration of viral DNA into the cellular genome of the host is
considered a trigger of neoplastic changes.
HBsAg = synthesized during acute stage of infection.
Dissapears as anti-HBsAg is formed and infection beings to
resolve.
HBeAg = indicates high level of infectivity
HBcAg = recent or acute infection
4/16 *Gram negative sepsis is cause by the release of LPS
from bacterial cells during division or by bacteriolysis. LPS is
NOT activley secreted by bacteria. Lipid A is the toxic
component of LPS. It causes activation of macrophages
leasing to wide spread release of IL-1 and TNF-alpha which
causes the s/s of septic shock: fever, hypotention, diarrhea,
oliguria, vascular compromise and DIC.
ADP ribsolylation inactivates EF-2 inhibiting host cell protein
synthesis
Coryne diptheriae & Pseudomonus aeruginosa
Methadone is used to help ween a pt with withdrawl symptoms
off of heronie. Naloxone is used to treat heronie overdose.
1255
Pathophysiology Nervous System
Naloxone is a pure opioid recepter antagonist. Used for acut
opioid intoxication or overdose and for diagnosing opioid
dependence.
Untreated hydrocephals leads to spasticity due to stretching of
the periventricular pyrimidal tracts, developmental delays,
seizures.
1854
Pathophysiology Nervous System
Congenital Hydrocephalus: structural malformation that causes
impaired CSF draning
macrocephaly, poor feeding, muscle hypertonicity,
hyperreflexia, enlarged ventricles.
Hydrocephalus ex-vacuole: Normal CSF expansion following
cerebral volume loss rather than abnormal CSF accumulation.
335
Pathophysiology
Pregnancy, Childbirth &
Puerperium
Choriocarcinoma is a malignant form of gestrational
trophoblastic disease composed of anaplastic cytotrophoblasts
and syncytiotrophoblasts without villi. It often presents as
dyspnea/hemoptysis due to pulmonary metastasis from
hematogenous spread.
28 y/o f SOB, hemoptysis, vaginal bleeding, had a baby 9
weeks ago, uterus enlarged, incr B-hCG, multile bilateral lung
nodules = Choriocarcinoma
Atopic (extrinisic allergic) asthma only has two treatments that
releave bronchospasms.
661
Pathophysiology Pulmonary & Critical Care
Leukotriene D4 receptor antagonists - Zafirlukast, montelukast
(long term releif)
Inhaled antimuscarinin agent that blocks M3 receptors in the
smooth muscle and submucosal gland - Ipatropium (Short term
relief)
1919
Pathophysiology Pulmonary & Critical Care
EMphysema is a obstructive lunge disease with
- decreased FEV1/FVC ratio <70%
- increased TLC (hyperinflation)
- decreased diffusing capacity for carbon monoxide (due to
destruction of aveoli and ajoining capillary beds)
/\F508 mutation = cystic fibrosis transmembrane condductance
regulator (CFTR) protein
1939
Pathophysiology Pulmonary & Critical Care
817
Pathophysiology
831
Pathophysiology
**Pt with CF produce eccrine sweat with higher than normal
concentrations of sodium and chloride. Exposure to high
temperature or exercise can lead to hyponatremia due to
excessive sodium loss through sweat; therefore, salt
supplementation.
Renal, Urinary Systems &
Electrolytes
Increased citrate and high fluid intake help prevent renal stone
formation.
Renal, Urinary Systems &
Electrolytes
Anatomical or functional vesicouretral reflux (retrograde flow of
urine to the ureters carrying pathogens present in the bladder
to the kidney) is almost always necessary for the development
of acute pyelonephritis (UTI following sexual intercourse)
1050
Pathophysiology
Renal, Urinary Systems &
Electrolytes
Tumor lysis syndrome is a result of chemotherapy treatment
for tumors with high cell turnover. Lysis of tumor cells cause
the release of pottasium, phophorus, and uric acid (metabolite
of tumor nucleic acid).
pH is lowest/most acidic in the distal tubules and collecting
ducts, therefore are the most probable sites to form/ become
obstructed by crystals
1050
1841
Renal, Urinary Systems &
Pathophysiology
Electrolytes
Pathophysiology
Renal, Urinary Systems &
Electrolytes
Uric acid is soluble at physiological pH, but can percipitate in
the normally acidic enviorment of the distal tubules and the
collecting duct.
Angiotensin II preferentially constricts the efferent arteriole,
therefore maintaining GFR.
ACE-inhibitors cause efferent arteriolar dilation causing GFR
reduction.
Stress incontinence -loss of urethral support & intraabdominal
pressure exceeds urethral sphincter pressure >> leaking with
coughing, sneezing, laughing, lifting
11038
Pathophysiology
Renal, Urinary Systems &
Electrolytes
Urge incontinence - Detrusor overactivity >> Sudden,
overwhelming or frequent need to empty bladder
Overflow incontinence - impaired detrusor contactility, bladder
outlet obstruction >> Constant involuntary dribbling of urine +
incomplete emptying
11040
11516
Pathophysiology
Pathophysiology
Renal, Urinary Systems &
Electrolytes
Renal, Urinary Systems &
Electrolytes
OVerflow incontinence = impaired detrusor contractility ot
bladder outlet obstruction
uncontrolled voiding w/o any sensation of a full bladder,
difficulty starting and maintaing urine stream
Keeping in a catheter for longer thannecessary is the most
significan risk factor for UTI from indwelling catheter
Bone turnover is regulated by ratio of OPG to RANK-L. Bone
tunover increases with OPG is low and RANK-L is high.
640
Pathophysiology
Osteoprotegerin (OPG) blocks binding of RANK-L to RANK and
Rheumatology/Orthopedics
reduced formation of osteoclasts --> decr bone resorption and
& Sports
incr bone density
Low estrogen (menopause) cause osteoporosis by decreasing
OPG, incr RANK-L, and incr RANK in osteoclast precursors.
748
4/14
Rheumatology/Orthopedics
Pathophysiology
*Increased expression of MHC class I antigens on sacrolemma
& Sports
= Polymyositis
4/14 *Lower back pain, improves with excercise but not with
rest in a individual less than 40 = Ankylosing spondylitis
753
*Characterized by stiffness and fusion of the axial joints =
Rheumatology/Orthopedics anylosking spondylitis
Pathophysiology
& Sports
*Respiratory complications in ankylosing sponylitis = limited
chest wall expansion due to involvment of the thoracic spine
and enthesopathies of the costovertebral and costosternal
junctions leading to hypoventilation
982
In primary osteoporosis (decreased bone strength from low
bone mass):
Rheumatology/Orthopedics - calcium is normal
Pathophysiology
& Sports
- phosphorus is normal
- PTH is normal
- have incr susceptibility to fragility fracture
11646
Polymyositis (Anti-Histidyl-tRNA synthetase, anti-Jo-1,
anti-SRP, anti-Mi2, ANA)
- Chronic muscle weakness
Rheumatology/Orthopedics - Difficulty walking up stairs
Pathophysiology
& Sports
- Difficulty combing hair
- Symmetric proximal muscle weakness
- Biopsy: endomysial mononuclear infiltrate and patchy muscle
fiber necrosis
174
Pharmacology
Allergy & Immunology
Lorantidine (2nd generation anti histamine with fewed
sideeffects) should be given to elderly pt.
Spontaneous episodes of rest and nightime angina associated
with transient ST elevation on ECG = Vasospastic or variant
(Prinzmetal) angina
38
Pharmacology
Cardiovascular System
Dihydroergotamine is an ergot alkaloid commonly used to treat
acute migrane headache can trigger Prinzmetal angina.
Possible triggers: cigarette smoking, cocaine/amphetamines,
dihydroergotamine/triptans
Nitrates increase levels of cGMP causing vascular smooth
muscle relaxation.
136
Pharmacology
Cardiovascular System
Increased cGMP lead to decreased activity of myosin
light-chain kinase and myosin light chain dephophorylation.
x2
Dynamic left ventricular outflow tract obstruction that occurs in
Hypertrophic cardiomyopathy worsens with decreased LV
volume, which can be cause by reduction in cardiac preload
and or afterload.
141
Pharmacology
Cardiovascular System
Therefore, medication that decrease venous retun or systemic
vascular resistance (dihydropyridine calcium channel blockers,
nitroglycerin) should be generally avoided.
Avoid in HOCM:
- vasodilators (dihydropyr ca blockers, nitroglycerin, ACE
inhibits)
- diuretics
142
143
148
Pharmacology
Pharmacology
Pharmacology
Cardiovascular System
4/16 Patient taking daily maintenance nitrates need to have a
nitrate free period every day to avoid = tolerance to the drug
Cardiovascular System
Nitrates and phosphodiesterase (PDE) inhibitors (used for
erectile dysfunction and HTN) are contradicted because both
increase intracellular cGMP which causes vascular smooth
muscle relaxation causing a severe decrease in BP.
Cardiovascular System
Digoxin is a positive inotropic agent that directly inhibits
Na-K-ATPase pump --> leading to decrease in Na efflux and
increase intracellular Na --> this inhibits activity of
Na-Ca-exchanger --> causing decreased in Ca efflux
Not in FA
149
Pharmacology
Cardiovascular System
Milrinone, inamirone - Phosphodiesterase-3 inhibitors that
increase cAMP which promotes intracellular calcium influx and
increase cardiac contractility.
Increase cAMP in vascular smooth muscle cells also causes
systemic vasodilation, which limits the use of milrinone and
inamrinon in severly hypotensive patients.
Alpha 1 blocks (Doxazosin, Prazosin, Terazosin) are useful for
treatments of BPH and hypertention.
150
Pharmacology
Cardiovascular System
Pt with CAD, heart failure with HTN = cardioselective Beta
blockers
Hydrochlorothiazide = 1st line for treatment of essential
hypertention in general population
150
Pharmacology
Cardiovascular System
Alpha-1-blockers: Doxazosin, Prazosin, and Terazosin are
useful for the treatment of both BPH and hypertention
Side effects include: orthostatic HTN, vertigo
4/14 *Digoxin is used in heart failure due to its positive
inotropic effect
155
Pharmacology
Cardiovascular System
*Digoxin can be used for ventricular rate control in afib. Why?
decreases AV nodal conduction by increasing parasympathetic
vagal tone.
Life threatening ventricular arrhythmias are the most serious
complication of digoxin toxicity.
156
Pharmacology
Cardiovascular System
Other s/s:
- non specific gi (anorexia, nausea, vomiting)
- neurological (fatigure, confusion, weakness)
- changes in color vision
Niacin causes flushing, warmth and itching primarily mediated
by prostaglandins (PGD2, PGE2)
Pretreat with aspirin.
160
Pharmacology
Cardiovascular System
Niacin:
- incr HDL
- decr LDL
- decr triglycerides
Most statins are metabolized by cytochrom P450 3A4 (except
pravastatin)
Erythromycin (macrolides) increase incidence of statin-induced
myopathy and rhabdomyolysis. Acute renal failure is possible
sequela of rhadbomyolysis.
161
Pharmacology
Cardiovascular System
CYP450 inhibitors:
Cimetidine
Ciprofloxacin
Erythromycin
Azole
Grapefruit juice
Isoniazid
Ritonavir (protease inhibitor)
Absolute contradictions to OCP use:
577
643
Pharmacology
Pharmacology
Cardiovascular System
Cardiovascular System
1) prior hx of thromembolic event or stroke
2) Hx of an estrogen-dependent tumor
3) Women over age 35 yr who smoke heavily
4) Hypertriglyceridemia
5) Decompensated or active liver disease (would impair steroid
metabolism)
6) Pregnancy
The mechanism of vancomycin resistance is organisms such
as VRE is a subsitiution of D-lactate in the place of D-alanine
during the process of peptidoglycan cell wall synthesis. This
prevents the binding of vancomycin to its usual
D-alanyl-D-alanine binding site in the cell wall.
ARBs work by blocking angiotensin II type 1 receptors ->
inhibit the effect of angiotensin II
691
Pharmacology
Cardiovascular System
-
incr renin
incr angiotensin 1
incr angiotensin II
decr aldosterone
no change bradykinin
K+ sparing diuretics = Amiloride, triamterene, spironolactone,
eplerenone.
697
Pharmacology
Cardiovascular System
Spironolactone and eplerenone: competitive aldosterone
receptor antagonists at the cortical collecting tube
Triamterene and amiloride: block Na+ channels in the cortical
collecting tubule
They can cause hyperkalemia (can lead to arrhythmias)
A widened QRS interval or ventricular arrhythmias are
indication for Sodium bicarbonate (NaHCO3) therapy.
708
Pharmacology
Cardiovascular System
711
Pharmacology
Cardiovascular System
Tricyclic antidepressant (TCA) overdose:
- delirium, seizures
- sinus tachy, hypotention
- prolonged PR/QRS/QT intervals
- arrhythmias (vtach, fib)
- dry mouth, blurred vision, dilated pupil
- Urinary tention, flushing, hyperthermia
statins increase LDL receptor density in hepatocytes.
pt with HTN, hypercholestrolemia, sudden onset neurological
deficits (right are weakness, difficulty speaking) that fully
resolved within minutes = Transient ischemic attach (TIA)
713
Pharmacology
Cardiovascular System
Low-dose aspirin is commonly used to prevent ischemic stroke
in pt with TIA.
GI mucosal injury and bleeding/hemorrhage are the most
common side effects of aspirin.
Serious side affects of statins (HMG-CoA reductase inhibitors)
are myopathy and hepatitis.
780
Pharmacology
Cardiovascular System
Check LFTs (hepatic transaminases) before initating therapy
with statins.
Statins decrease LDL
4/18 Signs of intracranial hemmorhage = Decreased level of
consiousness, asymmetric pupils irregular breathing.
Most common adverse affect of fibrinolytic therapy (Ateplace)
= is hemorrhage.
823
Pharmacology
Cardiovascular System
MOA Ateplase = Binds fibin in the clot and converts entrapped
plasminogen to plasmic. PLasmin hydrolyzes key bonds in the
fibirn matrix causing clot lysis and restore coronary blood flow.
Fibrinolytic therapy can be used in an MI when PCI
(precutaneous coronary intervention)
823
Pharmacology
Cardiovascular System
Ateplase binds fibrin in the thrombus and converts entrapped
plsaminogen to plasmin. Plasmin hydrolyzes key bonds in the
fibrin matrix causing clot lysis and restoration of coronary
artery blood flow.
Adenosine is a rapidly acting antiarrhythmic used to quickly
convert people out of PSVT (drug of choice).
898
Pharmacology
Cardiovascular System
It is also reapidly cleared and has a half-life of only less than
10 seconds. It commonly causes chest burning
(bronchospasm), flushing and high grade block as adverse
reactions (remember, this is the drug used for chemical stress
tests!)
Lidocaine is specific for ischemic myocardial tissue and the
DOC for Post-MI arhythmias.
900
Pharmacology
Cardiovascular System
Currently, amiodarone has replaced the lidocaine in the
mangment of ventricular tachycardia.
948
Pharmacology
Cardiovascular System
dry, nonproductive, persisten cough is secondary to ACE
inhibitor use due to accumulation of bradykinin, substance P or
prostaglandins.
Norepinephrine extravasation (blanching of a vein at the IV site
of infusion with induration and pallor, cold, hard, pale)
1164
Pharmacology
Cardiovascular System
Tissue necrosis is best prevented by local injection of an
alpha1 blocking drug (phentolamine)
1194
Pharmacology
Cardiovascular System
Treatment for pregnancy induced Venous thromembolism
(VTE) = low molecular weight heparing (ie. enoxaparin) esp
during early stages of pregnancy.
Herpain does not cross the placenta.
Warfarin crosses the placenta.
Selective arteriolar vasodilators = hydralazine, minoxidil
1252
Pharmacology
Cardiovascular System
- Lower bp by decreases systemic vascular resistance =
baroreceptors cause reflex sympathetic activation = increase
HR, CO, contractillity (tachycardia)
- stimulates RAAS pathway = sodium/fluid retention (peripheral
edema)
- enhance blood flow to peripheral tissues (symptomatic relief
in raynaud phenomenon)
given in combo with sympatholytics and diuretics to counteract
the compensatory effects.
x2
Selective direct relaxation of the smooth muscle of arteroles
but does not affect the veins = Hydralazine (p 298), minoxidil
(p. 603)
1252
Pharmacology
Cardiovascular System
Lower bp but trigger reflex sympathetic activity and stimulate
RAAS. This results in tachycardia and edema/sodium and fluid
retention.
To counteract these effects Hydralazine and minoxidil are
given in combination with sympatholytics and diuretics.
1252
Pharmacology
Cardiovascular System
x2
Orthostatic hypotention = systolic > 20mmhg or diastolic
>10mm Hg on standing or in supine position.
1342
Pharmacology
Cardiovascular System
Causes of Orthostatic hypotention: a1-adrenergic antagonists,
diuretics, volume depletion, autonomic dysfunction
Rx Beta blocker overdose = glucagon
1444
Pharmacology
Cardiovascular System
Glucagon > G protein coupled receptors on cardiac myocytes
> actiave adenylate cyclase > rasie cAMP > calcium release
from intracellular stores & incr SA node firing
4/18 Drug induced lupus: hydralazine and procainamide,
isoniazid, minocycline, Quinidine
1505
Pharmacology
Cardiovascular System
Procainamide is metabolized via hepatic acetylation. Individua
who are slow acetylators aare at greater risk for Drug induced
SLE.
Antibodies in SLE = anti-histone and ANA
4/18
1507
Pharmacology
Cardiovascular System
1776
Pharmacology
Cardiovascular System
Dofteilide = Class III antiarrhythmis potassium channel
blocker. Inhibits outward potassium current during phase 4 of
Ventricular action potential - prolongs repolarization, AP
duration and QT interval.
Combining non-dihydropyridine ca2+ cahnnel blockers and
Beta blockers can have additive negative chronotropic effects
causing severe bradicardia and hypotention.
1776
Pharmacology
Cardiovascular System
x2
Combined use of nondihydropyridine calcium channel blockers
(verapamil, diltiazem) and Beta adrenergic blockers (Atenolol)
can have additive negative chronotropic effects uielding sever
bradycardia and hypotention.
x2
1776
2005
2006
Pharmacology
Pharmacology
Pharmacology
Cardiovascular System
Verapamin, diltiazem (non dihydropyridine calcium channel
blockers) are contradicted with Beta blockers (atenolol)
because they have additive negative chronotropic (HR) effects
causing sever bradycardia and hypotention.
Cardiovascular System
4/18 Potassium spairing diuretics work on the = Collecting duct
(amiloride Na blocker, spironolactone aldosterone receptor
antagoinist)
Cardiovascular System
Betta blockers prolong the PR interval = The longer the PR
interval the longer it takes for an electrical stimulus to travel
from the SA node to the ventricles via the AV node, bundle of
his and fascicular branches.
7640
Pharmacology
Cardiovascular System
Torsade de pointes caused by:
- Antriarrhythmics (sotalol, quinidine)
- antipsychotics (haloperidol)
- antibiotics (macrolide, fluoroquinolones)
8291
Pharmacology
Cardiovascular System
Maintenance dose = Cp x Cl / F
8869
Pharmacology
Cardiovascular System
Class 1c antiarrhythmics prolong QRS duration: Flecainide,
propefenone
Cardiovascular System
Nitrates (IV nitroglycerin):
- primarily venodilators
- increase pheripheral venous capactiance,
- thereby reducing cardiac preload and LVEDV
- Modest arterial dilation
- decrease SVR
- decrease afterload
Cardiovascular System
4/16 Dobutamine = Beta adrenergic agonist B1 > B2 > a1
works on Gs protein increases cAMP increasing myocardial
contractility
11836
11925
1641
Pharmacology
Pharmacology
Pharmacology
Dermatology
Acyclovir, ganciclovir, famciclovir are all nucleoside analogues
that require both herpes viral and cellular kinases for
conversion to their active nucleoside triphosphate form.
Cidofovir is a nucleoside monophosphate (ie a nucleoTIDE)
that requires only cellular kinases for activation.
x2
549
Pharmacology
Endocrine, Diabetes &
Metabolism
584
Pharmacology
Endocrine, Diabetes &
Metabolism
High-dose corticosteroids (prednisone) can cause neutrophillia
(neutrophil demargination) and corticosteroid-induced
psychosis (confusion, hallucinations).
Anastozole and exemestane are Aromatase inhibitors
IV insulin = short acting and regular
600
Pharmacology
Endocrine, Diabetes &
Metabolism
604
Pharmacology
Endocrine, Diabetes &
Metabolism
SGLT2 - blocks glucose absorption in PCT
658
Pharmacology
Endocrine, Diabetes &
Metabolism
Finesteride is a 5-alpha reductase inhibitor used for BPH
1213
Pharmacology
Endocrine, Diabetes &
Metabolism
Propanolol decreases the rate of peripheral conversion of T4 to
T3.
1324
Pharmacology
Endocrine, Diabetes &
Metabolism
pg 97
11527
Pharmacology
Endocrine, Diabetes &
Metabolism
insulin taken at meals = short acting
11565
Pharmacology
Endocrine, Diabetes &
Metabolism
SULFONUREA
aspart peaks at 1-2 h
Regular peaks at 2-4h
Combined hormonal contraceptives:
- Supress GnRH & pituitary gonadotropin (decr FSH, LH)
secretion inhibiting ovulation
- Pill, transdermal patch, vaginal ring, progestin
implant/injection
879
Pharmacology
Female Reproductive
System & Breast
Locally acting progestins:
- Progestin-only pill, Levonorgestrel IUD
- Thickens cervical mucus, impairing sperm penetration
Copper IUD:
- Creates chronic cytotoxic inflammatory response in uterus by
releasing copper ions, impairing sperm migration
1447
165
309
Pharmacology
Female Reproductive
System & Breast
Pharmacology
4/16 Cholestryamine (bile acid binding resin) Increase
cholesterol synthesis. Work by binding bile acid in the GI tract
which decreases the amount of bile returned to the liver thus
increasing hepatic synthesis of new bile acids - a processes
Gastrointestinal & Nutrition
that uses up cholesterol stores in the liver. Decreased hepatic
cholestrol activated HMG-CoAreductase resulting in increased
cholestrol synthesis. Combination therapy of statins and
cholestryamine causes a synergistic reduction in LDL.
Pharmacology
4/15 *Rx used to control symptoms in carcinoid syndrome =
Gastrointestinal & Nutrition Ocreotide (somatostatin annalog) Surgical excision is the most
definitive treatment.
MEtronidazole can cause disulfram-like effects
14 y/o reccurent sinopulmonary infections (esp. Staph aureus,
Pseudomonas aeruginosa), chronic diarrhea, brother died from
severe resp infection = Cystic fibrosis.
808
Pharmacology
Gastrointestinal & Nutrition
Cystic fibrosis causes steatorrhea and failure to thrive due to
malabsorption secondary to pancreatic insufficiency --> which
cna be corrected by pancreatic enzyme supplementaion.
Bioavailability of a drug referes to the fraction of the
adminstered drug that reaches the systemic circulation in a
chemically unchanged form.
1709
Pharmacology
Gastrointestinal & Nutrition
Bioavaibility by a non-intravenous route is always less than 1.
F = (AUC oral x dose IV) / (AUC IV x dose oral)
AUC = area under the curve.
"Area under the oral curve divided by the area under the IV
curve)
Amoxicillin plus clarithromycin to eradicate and prevent
disease recurrence in duodenal ulcers cause by H. pylori
1778
Pharmacology
Gastrointestinal & Nutrition
immigrant, epigastric pain worse at night, relieved by food
ingestion.
Rx for chronic hepatitis C = interferon alpha and ribavirin
8455
Pharmacology
Gastrointestinal & Nutrition
Ribavirin MOA: inhibits the synthesis of guanine nucleotides by
competitivley inhibiting inosine monophosphate dehydrogenase
(Depleting GTP)
Hydrophilic bile acids (urodeoxycholic acid) decrease biliary
cholestrol secretion and increase biliary bile acid
concentration, improving cholestrol solubility.
11739
Pharmacology
Gastrointestinal & Nutrition
Bile acid suplement therapy to dissolve cholestrol gallstones is
an option in patients refusing cholecystetomy or high surgical
risk.
Following IV administration a highly lipophilic drug will be
rapidly distributed to organs with high blood flow (ie. brain,
liver, kidney, lungs).
852
Pharmacology
General Principles
The drug is then slowly redistributed to tissues with relatively
lower blood flow (skeletal muscle, fat, bone).
This accounts for the short duration of action of many
commonly used anesthetics --> propofol
1707
Pharmacology
General Principles
4/16
*Efficacy = Intrinsic ability of a drug to elicit an effect. Measure
the maximum ceiling of activity of a drug with respect to a
particular pharmacodynamic end point. (ie. loop diuretics
cause greater diuresis than any thiazide irrespective of dose.
*Potency = The dose of a drug that is required to produce a
given effect. Potency is mainly affected by the affinity of the
drug for its receptor and the amount of drug that is able to
reach target tissues.
Flushed skin an mydriasis (dilated pupils) result from
muscarinic receptod blockage
1869
Pharmacology
General Principles
Medication with antimuscarinic effects:
1) Atropine
2) TCA (ie. amyitriptyline)
3) H1 receptor antagnosts (ie. diphenhydramine)
4) neuroleptics
5) antiparkinsonian drugs
Drugs that should be used with caution in geriatric patients
(elderly)
11567
359
Pharmacology
Pharmacology
General Principles
Hematology & Oncology
Anticholinergic First generation antihistamine
(diphenhydramine)
alpha blockers
tricyclic antidepressants
sulfonylureas
sedating pain medication
Chloramphenicol can cause
1) dose-related (reversible) anemia, leykopenia,
thrombocytopenia
2) dose-independent (irreversible) aplastic anemia
Chloramphenicol suppresses bacterial protein synthesis by
binding to the ribosomal 50S subunit and inhibiting peptidyl
transderase enzyme.
COX-1 acetylation inhibits generation of thromboxane A2 in
platlets
714
Pharmacology
Hematology & Oncology
COX-2 acetylation blocks prostaglanding production in
inflammatory cells (ie, activated lymphocytes, neutrophils). No
significant effect on platlet function.
Irreversible inhibition of COX-1/COX-2via acetylation: Aspirin
(acetylsalicylic acid)
Reversible inhibition of COX-1/COX-2: diclofenac, ibuprofen,
indomethacin
Heparin MOA = binds to antithrombin III (AT III) via a
pentasaccharide sequence > AT III binds to factor Xa > stops
factor Xa from convertin prothrombin to thrombin
1784
Pharmacology
Hematology & Oncology
Unfractionated herparin has more molecules so it binds to
factor Xa and thrombin
LMWH (enoxaparin) has fewer molecules and acts only on
factor Xa
Both unfractionated heparin and LMWH can bind to
antithrombin to increase its activity against Factor Xa.
2132
Pharmacology
Hematology & Oncology
Only unfractioned heparin is able to bind to both antithrombin
and thrombin to allow antithrombin to inactivate thrombin.
8542
Pharmacology
Hematology & Oncology
4/19 What treatments can you give for tumor lysis syndrome?
what is the difference? = - Risk of TLS can be reduced by
aggressive fluid hydration - Allopurinol inhibits uric acid
formation during tumor lysis - Rasburicase degrades uric acid
to allantoin
Rasburicase = recombinant of urate oxidase that catalyzes the
conversion of uric acid to allantoin (more soluble) which helps
treat hyperuricemia in Tumor lysis syndrome
Bone pain, fatigue, kidney disease, hypercalcemia - Multiple
myeloma
11584
Pharmacology
Hematology & Oncology
neoplastic B lymphocytes mature into plasma cells that
typically synthesize large amounts of Ig or Ig fragments. As a
result of this increased protein production, plasma cells are
particularly susceptible to the effects of proteasome inhibitors
(ie. bortezomib, a boronic acid containing dipeptide)
Proteasome induce apoptosis of the malignant plasma cells.
Amphotericin B (Rx for mucormycosis) binds ergosterol and
alters cell membrane premability.
S/E: Renal toxicity resulting in SEVERE hypokalemia and
hypomagnesemia
274
Pharmacology
Infectious Diseases
Monitor:
1) Creatinine phosphokinase - incr in Daptomycin
(Rhabdomyolysis)
2) TSH - Amiodarone (rx. arrhythmias), Lithium (bp)
3) hypoCalcium - Foscarnet, bisphosphonates
4) K+, Mg - Amphotericin B
Streptomycin is an older aminoglycoside therefore it has
widespread bacterial resistance. Its Use limited to TB, plague,
tularemia
1310
1488
Pharmacology
Pharmacology
Infectious Diseases
Infectious Diseases
Aminoglycoside MOR:
- mutations of the genes that encode ribosomal proteins leads
to modification in the ribosomal binding sites of the drugs.
- aminoglycoside modifying enzymes (transferases)
- mutated porins
4/14
*Antibiotic associated with tinnitus, hearing loss and
nephrotoxicity = Aminoglycoside
*Inhibit genetic code reading and protein synthesis by binding
to the prokaryotic 30S ribosomal subunit = Aminoglycosides
Treating Urethritis in a young male with dysuria and
mucopurulent urethral discharge
1895
Pharmacology
Infectious Diseases
Neisseria gonorrhoeae (gonoccocal urethritis) = Ceftriaxone
Chlamydia trachomatis (non gonnococal urethritis) =
Doxycycline or azithromycin (macrolide)
Rx Primary syphillis Trepnema pallidum = Penicillin (all
spirochetes are gram - with peptidoglycan cell wall)
1952
Pharmacology
Infectious Diseases
Penicillins covalently bind to and inhibit transpeptidase
(enzyme that catalyzes the final cross linking step in
peptidoglycan cell wall formation: the joining of the amino acid
in the 3rd position of the peptidoglycan molecule to the terminal
D-ala-Dala of another peptidoglycan molecule)
Vancomycin directly binds D-ala-Dala and acts at an earlier
stage then penicil
1959
Pharmacology
Infectious Diseases
beta lactamase
In pts with MRSA who are allergic to vancomycin Rx =
Daptomycin
8288
8288
11709
Pharmacology
Pharmacology
Pharmacology
Infectious Diseases
DNA winding-unwinding = Fluroquinolones
Folic acid metabolism = TMP-SMX
Blocks glycopeptide polymerization = Vancomycin (1st line
MRSA)
Ribsome assembly = Linezolid - thrombocytopenia, optic
neuritis, incre risk serotonin syndrome (esp with SSRI)
Infectious Diseases
Daptomycin:
- works against gram + (inclusing MRSA)
- Disrupts bacterial membrane by creating transmembrane
channels that cause intracellular ion leakage. Causes
depolarization of cell memb and inhibits DNA, RNA, protein
synthesis
- Inactivated by pulmonary surfactant (therefore ineffective in
treating pneumonia)
- S/E: Increased creatning phosphkinase (CPK), increased
incidence of myopathy. Therefore monitor CPK levels and
muscle pain/weakness regularly
Infectious Diseases
4/16 Mechanism of resistences:
MOR Mutated penicillin binding protein = penicllin
MOR Mutated porin protein = Penicillin, Aminoglycosides
MOR mutated peptidoglycan cell wall = Vancomycin
MOR impaired influx/increased efflux = Vancomycin,
Quinolones, tetracycline
MOR mutated ribosomal subunit protein = Aminoglycoside
MOR mutated RNA polym = Rifamycin
MOR Mutated DNA gyrase = Quinolones
MOR Methylation of ribosomes = Aminoglycosides
Selgeline is used to delay the progression of parkinsons
disease
inhibitor MAO, type B
259
Pharmacology
Nervous System
can prevent MPTP (parkinson like) inudced damage of
dopamine neurons
Levodopa/carbidopa is only used after combinations of
selegiline, anticholinergics, amantadine no longer provide
control of symptoms
352
Pharmacology
Nervous System
Avoid 1st generation H1-histamine receptor antagonists
(diphenhydramine, chlorpheniramine) which cause sedation
when using other medications that cause CNS depression (ie.
benzodiazepines).
354
Pharmacology
Nervous System
DOC for Trigeminal neuralgia (tic douloreux) = carbamazepine
355
Pharmacology
Nervous System
Seizures with no loss of consiousness:
Focal - Simple (one side) Rx. Cabamazepine
Generalized - Myoclonic (brief jerking movments of both upper
extremities with preservation of consiousness, usually within
first hours of waking up and provoked by sleep deprivation) Rx.
Valproic acid
Carbamzepine is a narrow-spectrum anticonvulsant used for
focal onset seizures. Should be avoided in generalized
epilepsy syndromes as they may aggrevate seizures.
Lamotrigine can be used to treat partial and generalized
seizurres and works by blocking voltage gated sodium
channels.
356
Pharmacology
Nervous System
Steven-Johnson syndrome and toxic epidermal necrolysis are
rare, life-threatening adverse effects characterized by flu-like
symptoms followed by widespread mucocutaneous epidermal
necrosis.
4/19 Onset of action of inhaled anesthetics depends on = its
solubility in the blood (blood/gas partition coefficient)
659
Pharmacology
Nervous System
Characteristics of drugs with high blood gas partition
coefficients = more blood soluble, slower equillibration with
brain, longer/slower onset times, require a larger amount to
saturate blood
Almost all volatile anesthetics increase cerebral blood flow ->
results in increased ICP.
854
Pharmacology
Nervous System
Other side effects of inhaled anesthetics: myocardial
depression, hypotention, respiratory depression, decreased
renal function.
Febrile seizure in a child is managed with Acetaminophen or
ibuprofen for comfort.
866
Pharmacology
Nervous System
Heat stroke in a child is managed by rapid external cooline.
Decreased levels of prostaglandin E2 reduce the
thermoregulatory set point in the hypothalmus - lowering body
temp.
1308
Pharmacology
Nervous System
1320
Pharmacology
Nervous System
1321
Pharmacology
Nervous System
Isoniazid (rx. TB) is chemically similar to pyridoxine (Vitamin
B6)
Jimson weed poisioning aka Gardeners mydriasis Similar to
atropine posioning
1322
Pharmacology
Nervous System
4/14 *Atropine is contraindicated in = glaucoma (atropine
causes mydriasis resulting in narrowing of the anterior
chamber angle and diminished outflow of aqueous humor
therfore may percipitate acute closed angle glaucoma)
*Why is Atropine used to treat bradycardia? = it decreases
vagal influence on the SA and AV nodes
1323
Pharmacology
Nervous System
4/15 Why should you use Pralidoxime over Atropine in
organophosphate posioning? = Organophosphates stimulate
both muscarining and nicotinic receptors
Atropine reverses muscarinic effects but has not effect on
nicotinic effects such a muscle paralysis
Pralidoxime is the only medication that reverses both by
restoring cholinesterase from its bond with these substances
4/16 Cholinergic agonists
1362
Pharmacology
Nervous System
*cholinergic agonist used to stimulate peristalisis in
postoperative ileus = Bethanechol
*cholinergic agonist used to treat non-obstructive urinary
retention (Atonic bladder) = Bathanechol
*cholinergic agonist used to lower intraocular pressure in
glaucoma = Carbachol and pilocarpine. Choilinergic addociated
miosis causes the iris to move further from the cornea. This
widens the anterior chamber angle and allows for better outflow
of aqueous humor.
Barbituates increase duartion of chlorid channel opening
Benzos increase the frequency of chloride channel opening
1443
Pharmacology
Nervous System
Benzos are more short-acting than barbituates
Benzos have both anxiolytic and sedative efffects
Atropine over dose - physostigmine
treatment for Myasthenia gravis - neostygmine
Testing for myasthenia gravis - edrophonium
1564
Pharmacology
Nervous System
Edronphonium - short acting highly potent version of
neostigmine. Administer to patient and see if it improves their
symptoms.
1777
Pharmacology
Nervous System
Barbituates, Phenytoin, Carbamazepine, Rifampin, Griseofluvin
increase CYP450 --> increased warfarin metabolism and
reducing its anticoagulat activity.
1946
Pharmacology
Nervous System
DOC for essential tremor = B-adrenergic antagonist propranolol
Baclofen - an GABA-B receptor effective monotherapy for
treatment of spasticity secondary to both brain and spinal cord
disease (including MS) Tizanidine is also effective and
commonly used.
11458
Pharmacology
Nervous System
172
Pharmacology
MCC of morbitiy/mortality in theophylline intoxication is:
Poisoning & Environmental
1) Seizures
Exposure
2) Tachyarrhythmias (does not usually cause QT prolongation)
1448
Pharmacology
Poisoning & Environmental
Exposure
Rat poison rx = fresh frozen plasma
(Warfarin like toxicity)
507
Pharmacology
Pregnancy, Childbirth &
Puerperium
Valproic acid causes neural tube defects sich as meningocele
1775
Pharmacology
Pregnancy, Childbirth &
Puerperium
First line for lyme disease = doxycycline
222
Pharmacology
Psychiatric/Behavioral &
Substance Abuse
Pt can have amenorrhea from drug induced hyperprolactinemia
from Risperidone (D1, D2 receptor inhibitor for schizophrenia)
4/14
*Akanthisia = Subjective restlessness with inability to sit still
following antipsychotic use
*Acute dystonia = sudden-onest of sustained muscle
contractions following antipsychotic use
*Neuroleptic malignant syndrome = Fever, rigidity, mental
status changes, autonomic instabiliy following antipsychotic use
*Tardive dyskinesia = involuntary momvements (lip smacking,
chreoathetoid movements) after chronic use of antipsychotic
510
Pharmacology
Psychiatric/Behavioral &
Substance Abuse
706
Pharmacology
Psychiatric/Behavioral &
Substance Abuse
Buproprion is the first-line treatment for major depressive
disorder that does not cause sexual dysfunction.
Pharmacology
Psychiatric/Behavioral &
Substance Abuse
Benzos act through positive allosteric modulation of GABAa
receptor complex, resulting in increased frequency of chlorid
ion channel opening -->facillitating the inhibitory action of
GABA in CNS.
937
TCA (amitryptyline) toxicity can mimic anticholinergic (ie
Atropin toxicity) symptoms.
1868
Pharmacology
Psychiatric/Behavioral &
Substance Abuse
Anticholinergic toxicity:
- Fever (hot as a hare)
- mucosal/acillary dryness (dry as a bone)
- cutaneous flushing (red as a beet)
- mydriasis, cycloplegia (blind as a bat)
- delirium (mad as a hatter)
Cocaine and TCAs inhibits presynaptic reuptake of
monoamines (norepi, dopamine, seotonin).
2001
8327
Pharmacology
Pharmacology
Psychiatric/Behavioral &
Substance Abuse
Psychiatric/Behavioral &
Substance Abuse
Effects of cocaine:
- sympathetic stimulation (HTN, tachycardia, mydriasis)
- CNS activation (incr arousal, agitation, seizures).
- potent vasoconstrictor (causes coronary artery vasospasm &
incr platlet aggregation = causes MI)
- intranasal use causes mucosal atrophy and nasal septal
perforation due to ischemia from vasoconstriction
Linezolid used to treat gram + infections, specifically
vancomycin-resistant enterococcus and methicillin-resistant
staph aureus.
Linezolid has MAOI activity and therefore can precipitate
serotonin syndrome when used concomitantly with an SSRI
(eg. paroxetine)
Ipatropium - anticholinergic agent and derivative of atropine.
170
Pharmacology
Pulmonary & Critical Care
Blocks the action of Ach at muscarinic receptors, preventing
bronchoconstriction and reducing the parasympathetic
stimulation of tracheobronchial submucosal glands in the lung
903
Pharmacology
Pulmonary & Critical Care
4/14 *Bosentan = endothelin-receptor antagonist
Table
1312
Pharmacology
Pulmonary & Critical Care
Mycobacterium avium complex (MAC) is a common acid fast
opportunistic pathogen that causes disseminated disease in
HIV pt. Pt with CD4+ counts <50 cells/uL should be
adminstered prophylactic azithromycin to prevent MAC
infection.
Alcoholics are more likley to develop pulmonary infection and
abcesses involving conbinations of anerobic oral flora
(Bacteroides, Prevotella, Fusobacterium, peptostrep) and
aerobic.
1446
Pharmacology
Pulmonary & Critical Care
Clindamycin covers most of these organisms and in thus the
antibiotic of choice for treating lung abscess.
While Kelbseilla also causes aspiration pneumo in alcoholics
treatment (ciprofloaxcin, cefazolin) have poor coverage of
anaerobic organisms.
Air fluid levels in the lung = lung acess
275
Pharmacology
Renal, Urinary Systems &
Electrolytes
4/16
682
Pharmacology
Renal, Urinary Systems &
Electrolytes
Acute angle-closure glaucoma and
683
Pharmacology
Renal, Urinary Systems &
Electrolytes
Loops lose calcium
Pharmacology
Renal, Urinary Systems &
Electrolytes
688
Diuretic often used to manage cerbral edema and increased
intracranial pressure = Mannitol
Severe toxicity of osmotic diuretics = pulmonary edema
692
692
1148
1211
Pharmacology
Pharmacology
Pharmacology
Pharmacology
Renal, Urinary Systems &
Electrolytes
Renal, Urinary Systems &
Electrolytes
Renal, Urinary Systems &
Electrolytes
Renal, Urinary Systems &
Electrolytes
Beta blockers inhibit renin release by blockig beta-1-receptors
located on the juxtaglomerular cells.
ACE is a kiniase that normally degrades bradykinin - Causes
coughing in pt on ACE inhibiors
Beta blockers inhibit renin
ACE inhibitors, ARBs, and k+ sparking diuretics can cause
hyperkalemia
Because ace and arbs decrease aldosterone and aldosterone
causes potasium excretion
Bethanechol is a muscarinic cholinergic agonist that often
improves bladder emptying in pts with post surgery urinary
retention my contracting the detrusor muscle
1211
Pharmacology
Renal, Urinary Systems &
Electrolytes
Difficulty voiding/ incomplete emptying = decreased
contractual it's of fetty sir muscle
1642
Pharmacology
Renal, Urinary Systems &
Electrolytes
Acyclovir can cause crystalline neropathy without adeuate
hydration.
1643
Pharmacology
Renal, Urinary Systems &
Electrolytes
HIV pt with CMV-induced retinitis treated with foscarnet can
result in symptomatic hypocalcemia and hypomagnesemia
(decrease Ca+ Mg)
Foscarnet is an analog of a pyrophosphate that can chelate
calcium and promote nephrotoxic renal magnesium wasting
Urge incontinence or overactive bladder syndrome
is caused by uninhibited bladder contractions (detrusor
instability)
8249
Pharmacology
Renal, Urinary Systems &
Electrolytes
Rx: Antimuscarinic (M3 inhibitor) causes relaxation of detrusor
muscle - can cause confusion and functional decline in the
elderly
Bladder (M3 receptor, Gq)
Stimulation = detrusor contraction (urinary excretion)
Inhibition = detrusor relaxation (urinary retention)
11945
Pharmacology
Renal, Urinary Systems &
Electrolytes
4/14 *Erythropoesis-stimulating agents (ESAs, EPO,
darbepoetin alpha) = can substantially improve anemia
symptoms avoiding blood transfusions in Chronic kidney
disease and dialysis pts.
*Erythropoesis-stimulating agents are associated with an
increased risk for = hypertention and thromboembolic events.
Estrogen - Raloxifene: comeptitive inhibitor estrogen, partial
agonist to decr bone loss and improve BMD. 2nd line
699
Pharmacology
Rheumatology/Orthopedics
& Sports
Urinary Hydroxyproline - breakdown of protein collagen.
Marker of osteoclast activity in osteoperosis
PTH - Teriparatide: stimulates maturation of preosteoblast into
bone forming osteoblasts
TNF - Denosumab: moncolonal antib to the receptor activator
of NFkB ligand (RANKL) = required for osteoclast function
Which of the following is structurally similar to the medication
used to treat Osteoporosis?
699
Pharmacology
Rheumatology/Orthopedics
Pyrophosphate - similar structure to Bisphosphonates.
& Sports
Disrupt osteoclast function by attach to hydroxapatite binding
sites on bony surface.
Etanercept is a fusion protein with domains derived from Fc
portion of IgG and TNF receptor 2. Functions as a decoy
receptor for TNF-a.
Infliximab, adalimumab = other TNF-a inhibitors/ant TNF
monoclonal ab
720
Pharmacology
Rheumatology/Orthopedics TNF-a causes effective sequesteration of mycobacteria with
& Sports
granulomas.
TNF-a inhibitors:
- impair cell mediated immunity
- Promote reactivation of latent TB and can incr risk for
disseminated disease
- also incr susceptibility to fungi and atypical mycobacteria
720
Pharmacology
All patients beginning treatment with TNF-a inhibitors should be
Rheumatology/Orthopedics evaluated for latent tuberculosis with TB skin test.
& Sports
(ex. Rhematoid athritis pt considering etanercept)
Colchicine works primarily by inhibiting microtublar
polymerization. Binds to tublin protein that help form
microtubles, preventing their aggregation.
858
Pharmacology
Rheumatology/Orthopedics
& Sports
Colchicine also reduces formation of leukotriene B4.
Colchicine is contradicted in elderly patients or those with
sever renal dysfunction.
861
1773
Pharmacology
The preferred treatment to prevent recurrent attacks (long term
Rheumatology/Orthopedics nanagment) for Acute gouty arthritis is xanthine oxidase
& Sports
inhibitors (eg. allopurinol, febuxostat) which decrease uric acid
production.
Pharmacology
Osteoperosis is a commone cause of pathologic verterbral
Rheumatology/Orthopedics fractures. Chronic systemic use of glucocorticoids
& Sports
(prednisone) promotes opsteoporosis and increases the risk of
pathological fracture.
facial palsy 3 months ago, hiking trip to New Hampshire, left
knee joint swelling with no surrounding erythema = Lyme
disease, Borrelia burgdorferi, Ixodes tick
1897
Pharmacology
Rheumatology/Orthopedics Rx. doxycycline or peniccillin-type antibiotics
& Sports
Early: flu-like symptoms and erythema chronicum migrans.
Second stage: AV block and facial palsy
Late stage: chronic asymmetric large joint arthritis and
encephalopathy.
Incr risk factors for osteoporotic fractures:
- Long term acid suppression with proton pump inhibitors
(Omeprazole). Insouble calcium (ca carbonate) requires an
acidic enviorm for proper absorption
10930
Pharmacology
Rheumatology/Orthopedics
& Sports
- Non modifiable = age, female sex, white/hispanic/asian,
personal/fam hx of fractures
- Potentially modifiable = decr physical activity, low body
weight, poor calcium/vit D intake, excessive alcohol/tobaco
use, premature menopause, glucocorticoid use
205
Physiology
Cardiovascular System
In tetralogy of fallot squatting during a tet spell increases
sytemic vascular resistance and decreases right to left
shunting, thereby increasing pulmonary blood flow and
improving oxygention status.
Cortisol has no direct vasoactive properties, it augments the
vasoconstrictive effects of catecholamines and angiotensin II.
Cortisol also increases glucose release by the liver in
response to glucagon.
551
Physiology
Cardiovascular System
Permissivness: when one hormone allows another to exert its
maximal effect
Additive: combined effect of 2 drugs equals the sum of their
individual effects.
Tachyphylaxis: Rapidly developing tolerance
x2
551
Physiology
Cardiovascular System
Permissiveness: when one hormone allows abother to exert its
maximal effect.
(ex. Cortisol + norepi)
Fluid overload (IV fluids/normal saline infusion, renal failure,
congestive heart failure) causes an increase in ventricular
filling on the LV volume-pressure loop (increased ventricular
preload)
1511
Physiology
Cardiovascular System
Nitroglycerin - dilates venous arteries thats
Hypertensive emergency = nitropursside
Hypertensive urgency = labetolo, metropolol
1511
Physiology
Cardiovascular System
Normal saline infusion increases preload (LVEDV)
(or any state of fluid overload - renal failure, CHF)
1512
Physiology
Cardiovascular System
IV fluids increase the intravascular and LVEDV. The increase
in preload stretches the myocardium and increases the
end-diastolic sarcomere length, leading to an increase in
stroke volume and cardiac output by the Frank-Starling
mechanism.
1513
Physiology
Cardiovascular System
Park At Venture Avenue
Menemonic for speed of conduction in the heart.
Arteriovenous sunt = high output cardiac fialure
1518
Physiology
Cardiovascular System
decr TPR
incr CO
incr (wide) pulse pressure
incr venous return
S3 is caused by a sudden limitation of vntricular movement
during rapid passive ventricular filling.
1557
Physiology
Cardiovascular System
S3 can be a normal finding in healthy children and young
adults. S3 in age 40 = suggests ventricular enlargment.
S3 seen in: chronic severe mitral regurg, chronic aortic regurg,
and heart failure associated with dilated or ischemic
cardiomyopathy
PCWP = Left atrial pressure
1591
Physiology
Cardiovascular System
In mitral stenosis PCWP > Left ventricular end diastolic
pressure (LVEDP)
Carotid sinus hypersensistivity triggered by pressure on the
carotid sinus by a tight shirt collar.
1609
Physiology
Cardiovascular System
Afferent limb = arises from baroreceptors in cartid sinus >
travels to vagal nucleus and medullary centers via
glossopharyngeal nerve (CN IX)
Efferent limb = parasympathetic impulses via the vagus nerve
(CN X)
1625
1652
Physiology
Physiology
Cardiovascular System
increase Slope = decrease TPR
Cardiovascular System
4/18 Nitroprusside is a short acting balanced venous and
arterial vasodilator that decreases both preload and afterload.
Since these changes are balanced stroke volume is
maintained.
x2 (LV graph)
1652
Physiology
Cardiovascular System
Nitropursside is a short acting vaso/nevodilator that decreases
both preload and afterload.
Preload horizontal length of LV graph
Afterload vertical height of LV graph
Bounding femoral pulses and carotid pulsations that are
accompanied by head bobbing = Aortic regurgitation
1661
2009
Physiology
Physiology
Cardiovascular System
Cardiovascular System
Aortic stenosis - Small pulse amplitude (pulsus parvus) with
delayed peak and slower upstroke of the arterial pulse (pulsus
tardus) due to diminished stroke volume and prolonged ejection
time.
Coronary sinus drains the (deoxygenated) blood from the
coronay arteries. Since the heart will be using the maximum
amount of oxygen the coronary sinus will have the least
amount of oxygen in it. While the pulmonary artery also has a
very low oxygen concentration, there is some oxygen left in the
blood when resturning from systemic vasculature.
2055
8293
Physiology
Physiology
Cardiovascular System
Cardiovascular System
4/18 ECG Absent P waves = Afib
Prolonged QRS interval = Conduction problem due to
fascicular or bunddle branch block.
Prolonged AT = torasades de pointe
Orthostatic hypotention is seen in pregnant women after 20+
weeks dur to compression of the IVC by the gravid uterus in
the supine position.
This reduces venous return and cardiac output which can
result in hypotention and syncope.
8563
Physiology
Cardiovascular System
Nitric oxide is synthesized from arginine by nitric oxide
synthase.
Vasodilation - mediated by Ach, bradykinin, serotonin,
substance P and shear forces. These stimuli activate specific
membrane receptors present on endothelial cells leading to an
incr in cytosolic calcium levels. Activation of enothelial nitric
oxide synthase (eNOS) synthesizes NO from arginine,
NADPH, O2.
NO activated guanylyl cyclase and incr cGMP > activated
protein kinase G > reduction in Ca > relaxatio
Famililal hypocalciuric hypercalcemia - benign autosomal
dosorfer cause by defective calcium-sensing receptors in the
parathyroid gland and kidney.
992
Physiology
Endocrine, Diabetes &
Metabolism
Calcium-sensing receptors are Gq receptors. calcium binds to
Gq and activates phospholipase C which increases IP3/Ca2+
which inhibits PTH secretion.
p437 Costanza
1325
1615
Physiology
Physiology
Endocrine, Diabetes &
Metabolism
Endocrine, Diabetes &
Metabolism
Excersize incr Glut4 transporters on skeletal mucles so
glucose in the blood goes into the muscle and causes a
decrease in blood glucose. This decrease in blood glucose
inhibits insulin release from pancreas and lipolysis,
gluconeogenesis, glycogenolysis occure to maintain bloodgluc
level.
In a pt w/ DM1 excersize causes blood glucose to drop but
insulin is not injected not from the pancreas so its not inhibited.
Insulin inhibits lipolysis, gluconeogen so hypoglycemic
TSH (anterior pituitary) and THRH (hypothalamus) is inhibited
by negative feedback by (high levels) of T3
rT3 (reverse T3) is an inactive form that is made entirely by T4
in the peripheral tissues.
Progesterone is the primayr hormone responsible for stimlation
the endomertriu so that is is suitable for implantation.
Progesterone withdrawl causes endometrial cells to undergo
apoptosis causing menses.
299
Physiology
Female Reproductive
System & Breast
1317
Physiology
Female Reproductive
System & Breast
What hormone is increased the most right after ovulation?
Progesterone (due to LH surge)
1560
Physiology
Female Reproductive
System & Breast
Androgens are converted to estradiol in ovarian granulosa cells
and adipose tissue.
Activation of trypsinogen to trypsin is achieved by
enteropeptidase (or enterokinase), an enzyme produced in the
duodenum.
1251
Physiology
Gastrointestinal & Nutrition Trypsin is essential for protein digestion and absorption in two
ways:
1) degrades complez peptides to dipeptides and amino acids
2) it activates other proteases such as carboxypeptidase,
elastase, chymotrypsin.
1358
Physiology
Gastrointestinal & Nutrition Active transport requires ATP
Parietal cells release hydrogen ions into the gastric lumen by
means of H/K ATPase, which requires hydrolysis of ATP and is
therefore an ACTIVE transport mechanism.
1358
Physiology
Gastrointestinal & Nutrition
Omeprazole is a proton pump inhibitor that supresses the
activity of the gastric parietal cells H/K ATPase leading to an
increase in the pH of the gastric lumen.
1971
1062
Physiology
Physiology
Gastrointestinal & Nutrition
Hematology & Oncology
Secretin (from duodenal s cells) increases bicarbonate
secretion from pancreas.
Unvaccinated newborn includes babies that have no recieved a
Vitamin K injetion at birth. This increases the chance of
hemmorrhage and increased intracranial pressure.
Vitamin K is required for caroxylation of cotting factors.
1082
8351
Fibrinolytics (tPA) can cause a (benign) arrhythmia from
reperfusion injury when given after an MI
Physiology
Hematology & Oncology
Physiology
psychogenic impotence has a rapid onset ("one night I couldnt
have an erection") compared to other causes of erectile
Male Reproductive System
dysfunction (SSRIs, beta blocker, prostatectomy, vascular or
neurolgical impairment.
Morphine is an opioid agonist that selectivley binds to mu
opioid receptors.
Mu receptors are G-protein linked whose actions are mediated
through varioud 2nd messenger pathways.
776
Physiology
Nervous System
1) Activation of K+ channels to increase potassium efflux. Incr
K+ efflux leads to hyperpolarization of the postsynaptic
neruons and blocks pain transmission.
2) inhibit adenyly cyclase > inhibit ca2+ conductance > inhibit
neurotransmitter release
1356
Physiology
Nervous System
4/15 Lesions of the macula cause = central scotomas
pCO2 is a potent vasodilator of cerebral vasculature.
1493
Physiology
Nervous System
A drop in pCO2 due to hyperventilation causes
vasoconstriction increasing vascular resistance and reducing
cerebral blood flow.
Lowering pCO2 is one of the measures employed to reduce
ICP in mechanically ventilated patients with cerebral edema.
1657
Physiology
Nervous System
Progressively weakening diaphragmatic contraction during max
voluntary ventilation with intact phrenic nerve stimulation
indicate neuromuscular junction pathology (ie. myasthenia
gravis) and or abnormally rapid diaphragmatic muscle fatigue
(ie. Restrictive lun or chest wall disease)
Suprachiasmatic nuclei in hypothalamus - cicardian rhythym +
pineal gland function
8573
Physiology
Nervous System
supraoptioc nuclei in hypothalamus - secretion of ADH and
oxytocin
A drug that binds to and activated GABA-A receptors (or
enhances their activity) will increase the conductance of
chloride ions, leading to increased passive transport of chloride
into the cell interior
11755
Physiology
Nervous System
By approaching or reaching the equilibrium potential for
chloride (-75 mV) the cell becomes hyperpolarized and is
temporarily made refractory to firing an action potential.
Normal resting membrane = -70 mV
Sodium = +60 mV (in)
Potassium = -90 mV (out)
Calcium = +125 mV (in)
When PaCO2 and HCO3- are outside normal range, a normal
PH suggests a mixed acidosis/alkalosis disorder compensatory responses do not correct the pH comepletely.
1544
Physiology
Poisoning & Environmental
Exposure
Asprin in toxication triad = fever, tinnitus, tachypnea.
Asprin toxicity usually presents with a mixed respiratory
alkalosis and anion gap metabolic acidosis.
Residual volume is the lung volume that remains after maximal
expiration
1521
Physiology
Pulmonary & Critical Care
1541
Physiology
Pulmonary & Critical Care
V/Q is higher at the apex and lower at the base.
Blood flow is higher at the base and slightly lower at the Apex.
Pulmonary & Critical Care
4/14 *Why is the pO2 in the left atrium/ventricles lower than
that in the pulmonary capillaries? = due to mixing of
oxygenated blood from the pulmonary veins with deoxygenated
blood arising from the bronchial arteria and thebesian veins.
1542
Physiology
**The RV is increased in COPD. This increase is illustrated on
the above graph by a larger-than-normal lung volume at the
end of maximal exhalation.
Normal A-a gradient = 5-15 mm Hg
4 major causes of hypoxemia (low PaO2):
1) Alveolar hypoventilation - only one with a normal A-a gradient
1582
Physiology
Pulmonary & Critical Care
2) Diffusion impairment: incr A-a gradient (alveoli can't be
transported into the blood).
3) V/Q mismatch:
4) Right-to-left shunt
Physiology
Renal, Urinary Systems &
Electrolytes
NSAIS with loop diuretics can result in a decreased diuretic
response
684
Physiology
Renal, Urinary Systems &
Electrolytes
4/16 loops douretics also stimulate renal prostaglandin release.
Loops diuretics also increase renal bloow flow leading to
increased GFR and enhanced drug delivery. Use of NSAIDs
with loop diuretics can result in decreased diuretic response.
1043
Physiology
Renal, Urinary Systems &
Electrolytes
Thick ascending loop of henle is impremable to water.
1161
Physiology
Renal, Urinary Systems &
Electrolytes
ADH acts on the medullary segment of the collecting duct to
increase urea and water reabsorption, allowing for the
production of maximally concentrated urine.
1607
Physiology
Renal, Urinary Systems &
Electrolytes
Highest osmolarity occurs at the bottom of the loop of henle
Physiology
Renal, Urinary Systems &
Electrolytes
684
1982
FF = GFR/RPF
RPF = RBF * (1 - Hematocrit)
2014
Physiology
Renal, Urinary Systems &
Electrolytes
DKA has low pH, low bicarb, and low PaCO2
2014
Physiology
Renal, Urinary Systems &
Electrolytes
4/16 DKA elevated anion gap metabolic acidosis = low pH, low
HCO3-, low PaCO2 Serum bicarb is used to buff the excess
ketoacids in the blood so bicarb levels are low
628
638
Physiology
Physiology
Rheumatology/Orthopedics
& Sports
African american women have higher density and lower risk of
fractures than other women.
Bone mass in adulthood is determined by peak bone mass and
rate of bone loss.
Rheumatology/Orthopedics TRAP stain for osteoclasts (tartrate-resistant acid
& Sports
phosphatase)
Bone-specific alkaline phosphatase reflects osteoBLAST
activity
638
Physiology
Rheumatology/Orthopedics
& Sports
TRAP, urinary hydroxyproline, and urinary deoxypyridinoline
reflect osteoCLAST activity
(urinary deoxypyridinoline is the most reliable)
4/14 *Increases absorption of calcium and decreases
absorption of phosphorus from the kidney = PTH
641
824
987
2061
2062
Physiology
Physiology
Physiology
Physiology
Physiology
Rheumatology/Orthopedics *How does PTH indirectly act on osteoclasts? = Osteoblasts
& Sports
have PTH receptors (not osteoclasts). PTH causes osteoblast
to increase production of RANK-L and M-CSF. These two
factors stimulate precursors of osteoclasts to differentiate into
bone-reabsorbing, mature osteoclasts.
T-Tubules are invaginations of the sacrolemma that extend into
each muscle fiber. They transmit depolarization signals to the
Rheumatology/Orthopedics
sarcoplasmic reticulum and trigger the release of calcium. The
& Sports
uniform distribution of T-tubules ensures coordinated
contraction of all myofibrils
Rheumatology/Orthopedics
& Sports
Haphazaedly oriented segments of lamellar bone with
prominent cement lines = Paget disease of the bone
Excessive RANKL signaling and NF=kB activation. This leads
to increased osteoCLAST differentiation and activity.
4/16 Reduced motor end plate potential = Myasthenia gravis
Autoantibodies against postsynaptic nicotinic Ach receptors =
Myasthenia gravis (results in blockage of the recetors active
Rheumatology/Orthopedics
site, receptor internalization and degradation and damage to
& Sports
the motor endplate due to complement fixiation-leads to
decreased number of function Ach receptors at NMJ -because
threshhold is not reached the muscle cells do not depolarize)
4/16 *Cholinesterase inhibitors (pyridostigmine, neostigmine)
used to treat Myasthenia gravis can cause abdominal
cramping, nausea, sweating nd diarrhea from excessive
cholinergic stimulation of the gut (have muscarinic Ach
Rheumatology/Orthopedics receptors). Scopolamine can be used to treat without affecting
& Sports
the nicotinic Ach receptors on the skeletal muscle/NMJ.
*Cholinesterase function is =to degrade synaptic Ach
(pralidoxime for organophosphate reversal regenerates active
cholinesterase)