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1672 Cards in this Set
- Front
- Back
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A child with Turner's syndrome is noted to have an abnormal kidney on renal US.
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Horseshoe kidney
lower pole fusion behind the inferior mesenteric arteries |
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Pt. with Wegener's granulomatosis develops hematuria and an abnormal urine cytology.
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Transitional cell carcinoma
Pt. is on cyclophosphamide, which produces hemorrhagic cystitis and TCC |
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An Egyptian man has microscopic hematuria and an abnormal urine cytology.
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Squamous cell carcinoma
pt. has Schistosoma hematobium involving the bladder plexus |
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An uncircumcised male has an ulcerative lesion on the undersurface of the glans penis and palpable inguinal adenopathy.
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Squamous cell carcinoma (penis)
Lack of circumcision is greatest risk factor |
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A man who has worked with aniline dyes in teh past, develops microscopic hematuria and an abnormal urine cytology
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Transitional cell carcinoma
Most likely it is bladder, but it could be renal pelvis as well. |
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A 45yo woman with a long-history of headaches develops microscopic hematuria and abnormal urine cytology.
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Transitional cell carcinoma
Analgesic abuse predisposes to TCC |
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A 72 yo man has bilateral painless masses in his testicles.
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Malignant lymphoma
metastatic, not primary not the bilaterality |
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A patient with acute myelogenous leukemia develped acute renal failure after being aggressively treated with multiple chemotherapy agents.
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Uric acid crystals
Example of tumor lysis syndrome |
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Crystal associated with ethylene glycol poisoning
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Calcium oxalate
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Inborn error of metabolism associated with renal stones and hexagonal crystals in teh urine
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Cystine-cystinuria
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Complication associated with sickle cell trait, acute pyelonephritis, analgesic abuse, and DM.
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Renal papillary necrosis
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Depressoin related to a vitamin deficiency
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Niacin deficiency
Correlation with decreased tryptophan conversion into serotonin |
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Vitamin difference between ovo lactovegetarian ad a pure vegan.
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pure vegan lack B12, while ovolacto does not
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Farmer rubs lesion off from teh back of his neck but it gew back.
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Actinic (solar) keratosis
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Inborn error of metabolism associated with pellagra
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Hartnup's disease
loss of neutral amino acids in teh GI and GU tract loss of tryptophan leads to ellagra due to decrease in synthesis of niacin |
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MCC of increased plasma homocysteine in US.
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folate deficiency
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Patient taking dapsone develops cyanosis resistant to O2 therapy
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Pt. has methemoglobinemia doe to oxidation of iron to ferric state
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Diffrence of Beta+ and Beta0 thalassemia
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Beta+ synthesizes some Beta chains, while Beta0 does not synthesize any Beta chains due to a stop codon
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Sequence in hypoxic cell injury
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Hypoxia
decrease oxidative phosphorylation in mitochondria leading to a decrease in ATP 1) Increased anaerobic glycolysis 2) Dysfunction of Na/K ATPase pump 3) Ribosomes detach from RER a) irreversible cell membrane injury: intracellular release of lysosomes damage membrane, endogenous activation of pholpholipases wiht release of toxic lipid products, cytoskeletal alterations b) irreversible nuclear changes: activation of nuclear enzymes by Ca++, nuclear pyknosis an dlysis c) irreversible mitochondrial dysfunction: entry of Ca++ into mitochondria wiht activation of phospholipases causing destruction of inner and outer membrane, Ca++ produces large densities |
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SLE glomerulonephritis
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Antibody excess immune deposits combined with IgG
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A 74 yo man with colon cancer develops generalized anasarca, He has proteinuria >3.5 g/24hr an dfatty casts in his urine. A renal biopsy shows diffuse glomerular disease. Silver stains demonstrate epimembranous spikes adn the presence of subepithelial deposits on EM
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Diffuse membranous GN
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A 10 yo boy living in Salt Lake City, Utah has bilateral sensorineural hearing loss, ocular abnormalities, and glomerulonephritis. Both IF and EM are negative. Foam cells are noted in viseral epithelial cells.
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Alport's syndrome
Sex linked dominant disease |
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A 65 yo man iwht chronic HCV hepatitis has a history of cyanosis of his hands, tip of nose, and ears during cold weather. These findings subside when he comes indoors. He now has palpable purpura in cold-exposed areas
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Cryoglobulinemia
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A 12 yo boy has a history of cellulitis-2 weeks ago. He now presents with periorbital edema, HTN, and smoky colored urine. Urinalysis shows RBC casts with mild proteinuria. Renal biopsy revels a diffuse increase in cellularity along with neutrophilic infiltrate. IF shows granular deposits. Subepithelial deposits are noted on EM
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Acute post-streptococcal GN
Immune reaction secondary to either a group A streptococcus pharyngitis or skin infection. |
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A 62 yo woman with a long history of severe RA and restrictive cardiomyopathy now presents with pitting edema and hypercholesterolemia. Urinalysis shows oval fat bodies and fatty casts. Protein dipstick is 2+, sulfosalicylic acid 2+. Renal biopsy shows hyalinization of the glomerular mesangium. A special stain is ordered
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Systemic amyloidosis
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An 89 yo woman with a history of chronic HCV hepatitis from a blood transfusion now presents with generalized puffiness and mild hypertension. Urinalysis shows oval fat bodies, fatty casts with Maltese crosses, and 4+ protein. A renal biopsy reveals hypercellular glomeruki with an increase in BM thickness and tram-track splitting of the BM. The IF is granular and EM reveals subendotheial deposits. The patient has depressed levels of C3.
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Type I MPGN witht HCV association
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A 24 yo man with a prior hx of a URI is noted to have microscopic hematuria and mild protinuria during a routine PE. He is not hypertensive. A renal biopsy shows a granular IF with predominantly IgA deposition in the mesangium an delectron dense deposits in the same area.
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IgA glmerulonephritis
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A 48 yo woman has proteinuria >3.5 g/24 hour, hypertension, and fatty casts in the urine. A renal biopsy reveals eosinophilic nodular masses in the mesangium of the glomeruli, hyaline arteriolosclerosis of the afferent and efferent arterioles, and increased thickness of the BM of the tubules. IF is negative. EM reveals fusion of the podocytes and increased collagen deposition in the mesangium and BM
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Nodular Glomerulosclerosis in DM
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A 28 yo man with a history of renal disease in his maternal grandfather, has end-stage renal disease requiring dialysis. PE reveals papular red lesions on his skin, peripheral neuropathy, and corneal disease. Previous renal biopsiss exhibited vacuolated visceral epthelial cells which correspond wiht lamellar bodies on EM.
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Fabry's disease
SXR disease with deficiency of alpha-galactocerebrosidase A and accumulation of ceramide trihexoside. |
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A normotensive 10 yo boy, with a previous hx of an URI presents with generalized pitting edema. He has had problems with allergies since early childhood. Urinalysis reveals proteinuria >3.5g/24 hr, fatty casts, and oval fat bodies. His clinical findings improve rapidly with high dose corticosteroids.
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Lipoid nephrosis (minimal change glomerulopathy)
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A 25yo woman presents with HTN. A urinalysis reveals mild proteinuria, hematuria, and RBC casts. A serum ANA exhibits a rim pattern. An anti-dsDNA titer is extremely high
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Type IV SLE glomerulonephritis
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A phlebotomist inadvertently sticks himself with a needle after drawing blood from a patient with AIDs. Which of the following infections is the phlebotomist at most risk for contracting?
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1:300 chance of becoming HIV positive
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A phlebotomist inadvertently sticks himself with a needle after drawing blood from a patient. Which of the following infections is the phlebotomist at most risk for contracting?
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HBV has the greatest viral oad in blood of all viruses
You cannot get syphilis from transfused blood |
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Most common antibody encountered in clinical practice.
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CMV antibodies
Its almost impossible to find someone negative for CMV antibodies |
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Hemorrhagic skin necrosis associated with warfarin therapy.
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Heterozygote carriers for protein C become homozygote when given warfarin in 6-8 hours when the half-life of previously gamma-carboxylated protein C disappears - now the patient is hypercoagulable
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A patient who has chronic hepatitis and has been transfused in the past most likely has antibodies directed against
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HCV is the mcc of transfusion hepatitis
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A 68 yo woman has an anterior mediastinal mass and non-tender, generalized lymphadenopathy, hepatosplenomegaly, normocytic anemia, thrombocytopenia, and hypogammaglobulinemia most likely has
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CLL is a B cell malignancy
neoplastic B cells cannot transform into plasma cells |
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Rationale for beginning heparin and warfarin at teh same time
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The shortest factor VII and protein C and the longest is prothrombin
Previously activated vitamin K-dependent factors have long half-lives |
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A 75yo woman in a nursing home has non-palpable ecchymoses limited to the back of her hands. A CBC is unremarkable. The patient most likely has
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senile purpura
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Most common type of hereditary thrombosis disorder.
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Factor V Leiden
Cannot be degraded by protein C and S |
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Most common infection transmitted by a blood transfusion is due to.
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CMV is present in donor lymphocytes
Radiation of the blood kills the lymphocytes and prevents infection in the recipient bone marrow transplant patients are particularly prone to CMV infections in the lungs |
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Which of the following vitamin toxicities predisposes a patient who is taking warfarin to bleed and have an INR outside the normal range
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Vitamin E toxicity decreases the synthesis of vitamin K dependent factors in the liver.
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A weightlifter develops a sudden onset of abdominal pain along with hypvolemic shock. At surgery, his abdominal cavity is filled up with blood. The cause of the intraabdominal bleed is most likely associated with
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Anabolic steroids cause liver cell adenomas, which have a tendency to bleed.
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A 30yo man with AIDS has pitting edema, HTN, proteinuria >3.5g/24hrs, and fatty casts in the urine. A renal biopsy exhibits glomerular disease
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Focal segmental glomerulosclerosis
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A 29 yo woman presents with generalized pitting edema and hypertension. A renal biopsy reveals diffuse glomerular disease with increased thickness of BM and hypercellularity. Silver stains reveal "tram tracks" splitting of the BM. An EM exhibits "dense deposits" in the glomerular BM. The pt has a persistently low serum C3.
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Type II MPGN or "dense deposit disease"
Patients have C3 nephritic factor - autoantibody against C3 convertase in alternative system that causes it to continually activate C3 causing very low levels |
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A 25 yo man who initially presented to the hospital with hemoptysis, has progressed into renal failure. A renal biopsy shows linear immmunofluorescence.
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Goodpasture's syndrome
Rapid progressive crescentic glomerulonephritis |
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Young man presents with hemoptysis and then develops acute glomerulonephritis
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Goodpasture's syndrome
anti-BM antibodies type II hypersensitivity |
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Hypersensitivity pneumonitis that is primarily seen in textile workers
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byssinosis
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Hypersensitivity pneumonitis that is commonly occurs in farmers who enter a closed room with fermenting corn
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silo filler's disease
nitrogen dioxide |
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Pneumoconiosis who most common lesion is a benign pleural plaque
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asbestosis
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A pregnant woman in her 32nd week of gestation has premature contractions. Which drugs should she be given to protect her baby form developing the respiratory distress syndrome
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Glucocorticoids
Increase surfactant synthesis in the baby |
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A 38 yo woman wiht chronic headaches develops episodic asthmtic attacks. The most likely cause is
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Ingestion of non-steroidal anti-inflammatory agents with release of leukotrienes classic triad asthma
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Farmer and his wife are brought to the ER by their son because they are too weak to walk or drive and their vision is blurry and exam reveals ptosis, facial weakness, nonreactive dilated pupils, dry mucous membrane, and normal DTRs? - diagnosis
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C botulinum food poisoning
Rx. wiht botulism antitoxin Danger of respiratory paralysis - toxin blocks the release of acetylcholine |
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Young woman with intermittent bouts of diarrhea and constipation associated with cramping right and left lower quadrant pain
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Irritable bowel syndrome
Intrinsic motility defect in bowel Flexible sigmoidoscopy is negative |
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Intravenous drug abuser in prision
Type of hepatitis |
HBV
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Country jail with outbreak of hepatitis
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HAV most likely
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Hepatitis associated wiht urticaria, fever, arthralgia, and the nephrotic syndrome
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HBV
Serum sickness type of disease type III immunocomplex mechanism vasculitis associated with polyarteritis nodosa |
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Immunizations given at birth to a baby whose mother is positive for HBsAg.
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Hep B vaccine-active immunization
HBIG - passive immunization |
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In a patient with B12 deficiency who is being treated with pharmacologic doses of folate, which of the following will be corrected
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neurologic deficits remain, hence the importance of making the correct diagnosis
Megaloblastic anemia is corrected |
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In an alcoholic with a macrocytic anemia and hypersegmented neutrophils and a normal neurologic exam, which tests is most indicated
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RBC folate is more sensitive than serum folate
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A 4yr old child has eaten rat poison and is hemorrhaging
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Rat poison is warfarin, which blocks all the vitamin K-dependent factors,
Both PT and PTT are prolonged Rx with IM vitamin K |
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Child living with elderly grandparents develops a GI bleed
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Child ate grandparents warfarin
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A child has eaten raw hamburgers and no has a hemolytic anemia and renal failure
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HUS due to O157:H7 serotype of E. coli
Low platelet count and prolonged bleeding time |
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A woman has menorrhagia, easy bruising and epistaxis
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VWD
Prolonged bleeding time and prolonged PTT |
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A man has a family history of a bleeding disorder which began with his mother's father.
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Hemophilia A
Maternal father transmits the disease to all his daughter's (SXR trait) who are asymptomatic carriers The daughters transmit the gene to 50% of their sons Prolonged PTT |
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A 49 yo woman with fibromyalgia is taking NSAIDs for pain
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Qualitative platelet defect
Prolonged bleeding time |
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Major crossmatch
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Patients serum reacted against donor RBCs
does not guarantee survival of the infused donor RBCs Does not prevent patient antibodies developing against donor RBC antigens Detects the presence of patient antibodies against donor RBC antigens |
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58 yo smoker, painless jaundice wiht clay colored stools, painful varicosities in teh right upper shoulder area, similar lesion in left thigh a few weeks ago
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Migratory thrombophlebitis in a patient with carcinoma of the head of pancreas with obstruction of bile flow
Called Trousseau's sign |
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Patient with diarrhea and episodic flushing of the skin (due to serotonin), nodular liver (mets from carcinoid tumor of terminal illeum), elevated urinary 5-hydroxyindoleacetic acid level (metabolite of serotinin), thick, plaque-like deposits found on the tricuspid and pulmonic valve leaflets (carcinoid heart dz with tricuspid insufficiency and pulmonic stenosis from fibrotic effect of serotinin)
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Carcinoid heart disease
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16 yo died suddenly playing basketball
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Hypertrophic cardiomyopathy
Asymmetric hypertrophy of the interventricular septum with conduction defects Murmur intensity increases (worse) with factors decreasing preload (standing, Valsalva, venodilator) Murmur intensity decreases (better) with factors increasing preload (sustained hand grip, squatting, lying down, Beta blockers) |
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Pulmonary capillary wedge pressure readings (normal <12 mm Hg) except in hypovolemic shock (volume depletion) versus an acute MI involving the left ventricle (increased hydrostatic pressure in left heart and pulmonary vein)
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Hypovolemic shock - 2 (low)
AMI -30 (high) |
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Hypertensive 1 yo child has multiple nodular masses in teh skin; small basophilic staining cells S100 antigen positive, primary lesion in
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Adrenal medulla - neuroblastoma
An APUD tumor |
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2 yo girl with necrotic, bloody, grape-like mass protruding from the vagina; biopsy reveals malignant cells with cross-striations; tumor stains negative for cytokeratin, factor VIII related antigen and carcinoembryonic antigen, and positive for desmin; cancer is most likely derived from?
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Muscle - embryonal rhabdomyosarcoma
MC sarcoma in children. |
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65 yo woman with abdominal distention, primary cancer most likely responsible for induration in pouch of douglas on rectal examination
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Ovarian cancer - induration due to seeding by the cancer.
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75 yo man with point tenderness in the lower vertebral column, elevated serum alkaline phosphatase (osteoblastic metastasis), tests or procedures would be your first step in teh evaluation of this patient
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DRE; think cheap
Bone tenderness implies stage IV disease and DRE should be positive |
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Metastatic adenocarcinoma in left supraclavicular node (Virchow's node) would most likely have its primary origin in:
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Stomach adenocarcinoma
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15 yo girl, sudden onset of RLQ pain, pregnancy test is negative, cystic mass with bone and calcifications in the right ovary:
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Cystic teratoma
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Pediatric cancers into the order of decreasing frequency:
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Acute lymphoblastic leukemia
Primary CNS tumor Burkitt's lymphoma Neuroblastoma |
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Most common ionizing radiation-induced cancer:
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Acute leukemia
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An ulcerated lesion that develops in a keloid secondary to a third degree burn or a ulcer located at teh orifice of a chronically draining sinus that does not respond to medical management is most likely due to:
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Development of squamous cell carcinoma
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Hematuria in a 58 yo smiker would most likely be associated with which of the following groups of cancers:
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Renal adenocarcinoma/transitional cell carcinoma of the bladder
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Most responsible for the increased incidence of basal cell carcinoma in the US
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Sun exposure beginning at an early age
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Exudative lung reaction associated with exposure to moldy hay:
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Farmer's lung - thermophilic actinomycetes
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In a patient who is lying on the right side, a foreign body or aspirated material would most commonly localize to these primary sites in the lung:
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Right middle lobe
Right upper lobe posterior segment |
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In a patient who is lying on their back, aspirated material would most likely localize to this segment of the lung:
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Right lower lobe superior segment
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Lymph node
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B cells in follicles
T cells in parafollicular area Histiocytes in sinuses |
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Patient with an increase in amylase and lipase:
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Patient most likely an alcoholic with acute pancreatitis
Cannot be mumps because of lipase |
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Staghorn calculus:
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Magnesium ammonium phosphate
Urease uropathogen like Proteus Alkaline urine pH |
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Overdose of barbiturates:
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Acute respiratory acidosis
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Eye effecs in Cushings syndrome
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Cataracts from increased glucocorticoids
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Flank mass in a child
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Wilm's tumor
Associated with aniridia and hemihypertrophy in the AD type of Wilms |
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What makes a laboratory test more specific?
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Raise teh upper limit of normal, which increases specificity (fewer FPs) and positive predictive value
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Findings at autopsy of RDS
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Hyaline membranes with massive atelectasis
Atelectasis leads to massive intrapulmonary shunting |
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Baby bleeds after circumcision on 10th day in a mother who is breast feeding her baby.
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No vitamin K in breast milk
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Abetalipoproteinemia
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Absence of apo B leads to low CH levels
Malabsorption Low levels of all lipid fractions Blindness Hemolytic anemia Treated with vitamin E |
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Sudden onset Left Flank Pain, hypotensive, pulsatile mass:
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Ruptured abdominal aortic aneurysm
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Chest palpitations particularly when anxious:
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Mitral valve prolapse
Myxomatous degeneration due to an increase in dermatan sulfate |
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Click murmur relations in mitral valve prolapse:
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Decrease preload causes click and murmur to come closer to S1
Anxiety Standing up Valsalva Increase preload causes click and murmur to come closer to S2 (lying down, clenching fist (increases systemic vascular resistance and decreases cardiac output), squatting (increases systemic vascular resistance)) |
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Aortic stenosis:
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MC valvular lesion associated with:
hemolytic anemia with schistocytes Syncope with exercise Angina with exercise |
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28 yo patient has a family histor of sudden cardiac death at a young age:
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hypertrophic cardiomyopathy
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Chambers or vessels with the highest SaO2 in Tetralogy of Fallot:
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Pulmonary Vein
Left Atrium |
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Chambers or vessels have the lowest SaO2 in a newborn with a machinery murmur (PDA)
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Right atrium
Right ventricle |
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Shunts or groups of shunts cardioprotective in Tetralogy of Fallot:
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PDA (unoxygenated blood goes to PA for oygenation in lungs)
ASD (step up of oxygen in the right heart) |
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Viral myocarditis, develops hypotension, neck vein distention, a drop in blood pressure on inspiration, an dmuffled heart sounds:
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Pericardial effusion from coxsackie myocarditis.
Bx of heart would show a lymphocytic infiltrate with destruction of muscle |
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First step in management ofpericardial effusion:
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Echocardiogram
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Newborn baby girl, swelling of dorsum of hands/feet (lymphedema), cystic mass in neck (dilated lymphatics that stretch skin and produce webbed neck)
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Lymphedema in child with Turner's syndrome
XO Defects in lymphatics |
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22 yo AIDS, raised, red lesions on hard palate:
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Kaposi's sarcoma
Most common site for KS in GI tract, due to fellatio Rx with intralesional alpha-interferon |
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X-ray findings in osteogenic sarcoma
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Mass in metahysis with invasion into surrounding muscle
Upper tibia or lower femur Codman's triangle sunburst appearance of bone made by osteoid Rb suppressor gene relationship |
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X-ray findings in Ewing's sarcoma
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Onion skinning around bone shaft
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Young woman with episodic hematuria after URI and negative ASO titer
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Classic Hx for IgA glomerulonephritis (Berger's)
MC type of GN |
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Retinoic acid Rx for acute progranulocytic leukemia (M3)
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Retinoic acid increases differentiation of leukemic cells
t;15:17 translocation Lots of Auer rods DIC always present |
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First step i work-up of a peripheral blood smear of microcytic anemia
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Order serum ferritin
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Barbiturate inducing acute porphyric attack
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Acute intermittent porphyria
AD disease with absent uroporphyrinogen synthase Belly full of scars |
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Mother with maculopapular rash during pregnancy and neonate with saber shins
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Congenital syphilis
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Hemorrhagic infarct of brain in patient with atrial fibrillation
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Embolic infarct
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Patient with twitching of face with tapping of facial nerve
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Tetany due to decrease inionized calcium
Threshold potential is lowered so muscle/nerve are partially depolarized Chvostek's sign Trousseau's sign is when thmb adducts into palm when taking blood pressure |
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Elderly patient does not develop a hemolytic transfusion reaction when given wrong ABO blood group
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Elderly patients normally lose isohemagglutinins with age, so none may be present to attack ABO antigens in transfused blood
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Screen for autoimmune disease in relatives
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Screen for HLA antigens unique to the autoimmune disease or serum ANA depending on the way the question is worded
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Source of Legionella infections
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Air conditioning cooling towers/condensers,
Showers Vegetable misters in grocery stores Produces interstitial nephritis wiht type IV renal tubular acidosis Destruction of JG apparatus with hyporeninemia and hypoaldosteronism |
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Patient taking penicillin for streptococcal infection develops hemolytic anemia
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Due to autoimmune hemolytic anemia (Type II) against BPO attached to RBC membrane
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Epidural hematoma
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Fracture of temporoparietal bone and rupture of middle meningeal artery
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Malabsorption with blunt villli
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Celiac disease
Order anti-gliaden or endomysial antibodies |
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J-K disease from brain instrument treated with formaldehyde
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Prions are the infective agent
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Bronze diabetes
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hemochromatosis
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40 yo man with dementia and senile plaques in brain
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Down syndrome patient with Alzheimer's
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Easy bruising in hospitalized patient on antibiotics
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Vitamin K deficiency form destruction of colon bacteria by the antibiotic
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Pancreatic tumor associated with peptic ulcers
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ZE syndrome with secretion of gastrin
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Multinucleated giant cell associated with viral infection
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Measles - Warthin-Finkeldy giant cell
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Mechanism of cerebral edema in Pb poisoning
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Increase in delta-aminolevulinic acid in brains is toxic and produces demyelination and increased vessel permeability
Can be prevented by taking heme, which inhibits ALA synthase |
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Alcoholic with bad breath and cavitary lung lesion
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Lung abscess from aspiration of oropharyngeal material
Mixed aerobes and anaerobes |
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Main site for acetaminophen toxicity in liver
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Around terminal hepatic venule (centrilobular)
Least amount of oxygen in this site (zone III) Also the site for fatty change in alcoholic or shock |
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Block left renal vein
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Produces a left-sided varicocele
Left spermatic vein normally empties into the left renal vein - mechanism for varicocele The Right spermatic vein empties into IVC |
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Injury to head with polyuria
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Central diabetes insiidus from transection of pituitary stalk
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Supine and where does foreign body go
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Superior segment of RLL
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Methyl alcohol (Wood's alcohol)
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Increased anion gap metabolic acidosis (converted into formic acid)
Optic neuritis and potential for blindness Rx with IV ehtanol |
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Ethylene glycol (antifreeze)
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Increased anion gap metabolic acidosis (converted into oxalic acid)
Renal failure from calcium oxalate crystals obstructing the lumens Rx with IV ethanol Ethanol is a competitive antagonist with methyl alcohol for alcohol dehydrogenase |
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Isopropyl alcohol (rubbing alcohol) poisoning
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Metabolic end-product in the liver is acetone (no metabolic acidosis unlike other alcohols)
Increases serum osmolal gap difference between calculated and measured serum osmolality >10 Clinical: deep coma with hyporeflexia |
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Mercury poisoning
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MOA-toxic in inorganic (elemental) form: dental amalgams
Used to be used in hat making industry Toxic in organic form: fungicides, contaminated fish Clinical: diarrhea, visible on x-rays, nephrotoxic ATN involving the proximal tubules, cerebral/cerebellar neuron loss, constricted visual fields Rx - dimercaprol |
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Arsenic poisoning
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Sources: pesticides, animal dips, fowler's solution, rx for syphilis in 1930s
Clinical: garlic odor to breath, severe diarrhea, "rice water stools similar to cholera", arsenic melanosis: gray skin wiht dark macules, squamous cell carcinoma of skin an dlungs, nails have transverse bands, concentrates in keratin/hair nails, convulsions/coma MCCOD: nephrotoxic acute tubular necrosis invoving proximal tubules, liver angiosarcoma Rx - dimercaprol |
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Mushroom Poisoning (Amanita)
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MOA: toxin inhibits RNA polymerase
Abdominal pain/vomiting bloody diarrhea Jaundice: extensive fatty change |
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Petroleum product (gasoline, kerosene) disorders
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Euphoria (drunk acting) when inhaled (or ingested)
Addicting Toxic doses: convulsions, tinnitus, non-cardiogenic pulmonary edema |
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Strychnine poisoning
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MOA: CNS stimulant that blocks postsynaptic inhibition
Clinical: tetanic convulsoins, opisthotonus, risus sardonicus, death |
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Poisonous snake envenomations
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Pit vipers: rattlesnake (MC), water moccasins, copperheads:: local swelling/necrosis, hematologic problems (DIC), antivenin is available with a danger of srum sickness
True cobras: coral snake (neurotoxin that blocks acetylcholine release leads to paralysis and death, similar to botulinum poison), coral snake has following color banding (red and yellow will kill a fellow) Harmless king snake red and black is a friend of Jack |
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CD10
|
Common acute lymphoblastic leukemia antigen (CALLA)
|
|
|
Kid staring into space that has broken bones:
|
absence seizures
|
|
|
Testicles in hernia sac
|
Testicles are not translucent
Translucency in the scrotal sac implies a hydrocele |
|
|
Doc worker for 20 years with lung mass:
|
Primary lung canacer secondary to asbestos exposure from asbestos insulation around pipes in ships
|
|
|
Belly full of scars
|
Acute intermittent porphyria due to deficiency of uroporphyrinogen synthase
|
|
|
Flame hemorrhages in teh retina
|
Sign of hypertensive retinopathy
|
|
|
Visual field defect wiht craniopharyngioma
|
Bitemporal hemianopsia (impinges on the optic chiasm)
|
|
|
Stacks of hemoglobin when the blood is deoxygenated
|
HgbS
|
|
|
Patient with normal PT, PTT, bleeds after surgery even after receiving fresh frozen plasma:
|
Probable platelet problem
e.g., Thrombocytopenia, patient on NSAIDs |
|
|
Cavitary lesions in upper lobe:
|
MCC is reactivation TB (not primary)
Histoplasmosis Klebsiella pneumoniae Squamous carcinoma |
|
|
Well-differentiated squamous cell carcinoma of lung or any other tissue
|
Keratin is red
Look for squamous pearls |
|
|
Patient with Marfan's syndrome has diastolic murmur
|
Aortic regurgitation due to stretching of aortic valve ring by the dissection.
|
|
|
Smoking effects on the cardiovascular/CNS system
|
Increases risk for AMI increased risk for recurrent AMI as well
Increases risk for sudden cardiac death Increases risk for peripheral vascular disease Increases risk for strokes Contributing factors: Enhanced atherosclerosis due to chemicals in smoke and nicotine effect on blood pressure and heart rate Atherogenic lipid profile Tissue hypoxia secondary to excess carbon monoxide (CO) Hypercoagulability |
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|
Smoking effects on the respiratory system
|
COPD - 80% of all cases, chronic bronchitis, emphysema
Recurrent infections - pneumonia, URIs Exacerbates bronchial asthma Cancer |
|
|
Smoking effects on the GI system:
|
GERD
Delays the rate of ulcer healing Increased risk for oral, upper and lower GI cancer USMLE scenario - advice to give a smoker iwth history of peptic ulcer disease: stop smoking |
|
|
Effects of smokeless tobacco (snuff, chewing tobacco)
|
Nicotine addiction
Oral leukoplakia/cancer inside the lip, under the tongue or cheek Verrucous squamous cancer Nasal cancer - snuff users Aggrivation of CV disease - nicotine effect |
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|
Smoking effects on bone and menopause
|
Increases the risk for osteoporosis in men and women
Biochemical reaction in women Estradiol (most potent estrogen) is normally metabolized in teh liver into estrone, which is metabolized into methoxyestrone (no hormonal activity) or estriol (strong estrogen activity) Smokers have greater conversion of estrone into the inactive metabolite leading to low estriol levels Low levels of estrogen increase the risk for osteoporosis and premature menopause |
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|
Passive smoking effect on children
|
Pathogenesis of passive smoke effects
75% of total combustion product in a cigarette is exhaled Risk of passive smoke extends to children as well as adults Increases the incidence of SIDS Increases risk for lung cancer - 1-2 times increased cancer risk Exacerbates asthma Increases risk for otitis media Increases risk for recurrent upper and lower respiratory infections |
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Miscellaneous smoking effects
|
Increases risk for developing proteinuria in DM
Directly responsible for 25% of residential fires Vitamin C deficiency |
|
|
Beneficial effects smoking cessation
|
Longevity: smokers who quit before 50 years of age ahve half the risk of dying over the next 15 years than a asmoker has
Lung cancer: in 10 years, there is a 50% reduction in lung cancer when compared to smoker, after 15 years, there is only a 16% risk for lung cancer when compared to a smoker AMI risk approaches that of a nonsmoker after 1 year of abstinence Prengancy: pregnant women who stop smoking in the first trimester reduce the risk of a low birthweight baby to that of a nonsmoker Forced expiratory volume in 1 second is not improved by cessation of smoking rate of decline is similar to that of a non-smoker |
|
|
Drugs and interstitial pulmonary fibrosis
|
Amiodarone
Bleomycin Busulfan Cyclophosphamide Nitrofurantoin Nitrosourea Methysergide Also retroperitoneal fibrosis and Raynaud phenomenon Methotrexate Procarbazine |
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|
Automobile mechanic
|
carbon monoxide
|
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|
Pesticide industry
|
Organophosphates
Arsenic |
|
|
Meat Packing
|
Polyvinyl chloride with risk of hepatic angiosarcoma
|
|
|
Insulation
Demolition Roofing material |
Asbestos: lung cancer, mesothelioma, fibrous pleura plaques (MC overall complication of asbestos), formaldehyde
|
|
|
Dry cleaning
|
Carbon tetrachloride with liver necrosis due to free radicals
|
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|
Rubber/Chemical industry
|
Benzene: aplastic anemia, leukemia
Aniline dyes: bladder cancer |
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|
Battery
Smelter Plumber/Foundry |
lead poisoning,
|
|
|
painter
|
Methylene chloride: converted into carbon monoxide, solvents, lead
|
|
|
Petroleum industry
|
Benzene
Polycyclic hydrocarbons: lung cancer |
|
|
Sewer worker
|
Hydrogen sulfide gas: sulfhemoglobinemia
|
|
|
Liver metabolism of alcohol
|
Alcohol - (alcohol dehydrogenase) - acetaldehyde + NADH - (aldehyde dehydrogenase-blocked by disulfiram)- acetate + NADH - Acetyl CoA
|
|
|
Pharmacologic action of alcohol
|
CNS depressant in descending order
Cerebral cortex Limbic system Cerebellum Lower brain stem Potentiates inhibitory neutotransmitters like gamma-aminobenzoic acid Aldehyde dehydrogenase deficiency: affects 40% of Asians, build up of acetaldehyde and GI upset Alcohol toxicity: 50mg/dL euphoria, gregarious 100mg/dL legally drunk in most states 300-350mg/dL stupor or coma >500 mg/dL death |
|
|
Delirium tremens
|
Following occur 3-5 days after complete withdrawal
Tremulousness Disorientation Visual Hallucinations Agitation RX with IV diazepam and thiamine |
|
|
Diseases where alcohol is the leading cause
|
1) Thiamine deficiency: Vernicke's syndrome, Korsakoff's psychosis, congestive cardiomyopathy
2) Macrocytic anemia: folate deficiency 3) Acquired sideroblastic anemia; microcytic anemia with ringed sideroblasts 4) Mallory Weiss syndrome: tear of the distal esophagus/proximal stomach from retching 5) Boerhaave's syndrome: rupture of the distal esophagus proximal stomach from retching 6) Cirrhosis 7) Esophageal Varices; effect of portal vein hypertension due to alcoholic cirrhosis 8) Fatty change in the liver 9) Hemosiderosis; alcohol increases the reabsorption of iron 10) Acute and chronic pancreatitis 11) Type IV hyperlipidemia: alcohol increases synthesis of VLDL 12) Klebsiella pneumoniae pneumonia |
|
|
Alcohol as a cancer risk
|
Squamous carcinoma (synergistic with smoking):
midesophagus, oropharynx, larynx Adenocarcinoma: Pancreas, liver |
|
|
Alcohol effects on CNS/PNS
|
Wernicke's syndrome/Korsakoff's psychosis
Cerebellar degeneration: Hu and Yo antibodies noted in spinal fluid Dementia DTs Distal peripheral neuropathy Central pontine myelinolysis: demyelination syndrome due to rapid IV Rx of hyponatremia |
|
|
Smoking epidemiology
|
MCC of premature death in the US
MC single preventable cause of cancer Incidence of smoking is increasing in women and decreasing in men Nicotine intake can be monitored by measuring plasma or urine level of continine (only derived from the metabolism of nicotine) Moves into the brain where it attaches to nicotinic cholinergic receptors to produce its gratifying effects/complication of smoking Highly addictive agent Inactivation of the p53 suppressor gene by a point mutation on chromosome 17 is the MC genetic defect in smoking induced cancer |
|
|
Cancers where smoking is the leading cause:
|
Lung cancer: squamous, small cell, and adenocarcinoma to a lesser extent
MCC of death due to cancer in both men and women Oral pharyngeal and laryngeal and mid-esophageal squamous cancer Pancreatic adenocarcinoma Transitional cell carcinoma of bladder Renal Adenocarcinoma |
|
|
Cancers where smoking has been implicated but is not the MC risk factor
|
Cervical cancer
Squamous cancer Carcinogens found in cervical secretions Stomach adenocarcinoma Breast Adenocarcinoma-primarily in women who are slow acetylators of N-acetyltransferase 2 enzymes Prostate adenocarcinoma Colon adenocarcinoma Leukemia-increased risk of both lymphoid and myeloid leukemias Alcohol is a cocarcinogen iwth smoking that further enhances the risk of oropharyngeal, esophageal, laryngeal cancers Smoking + asbestos exposure markedly enhances the incidence of primary lung cancer (but not mesothelioma) |
|
|
Frostbite
|
Localized tissue injury secondary to direct (ice cyrstallization in cells) and indirect damage (vasodilation/thrombosis)
Tissue painless |
|
|
Generalized hypothermia
|
Core body temperature <35C
Whole body exposed to freezing temperatures for a prolonged period of time Uncoupling of oxidative phosphorylation Venous pooling that may progress into circulatory failure and death |
|
|
Electrical injury
|
Ohm's Law
Current (I, amps)=voltage (E)/resistance (R, ohms) Current is most important factor in electrocution AC>DC risk for eletrocution Dry skin has the greatest resistance to current, particularly the hands and feet Wet skin lowers the resistance to current, since voltage is a constant, lowering resistance increases current Current moving from the left arm to the right lieg is most dangerous (involves the heart - Vfib) Blood is an excellent conductor of currend COD: cardiorespiratory arrest with Vfib and respiratory paralysis |
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|
Ionizing radiation
|
Shorter the wavelength the greater penetration
Low penetration include alpha/beta particles High penetrateion include gamma rays Radiation injury direct or indirect injury to DNA Indirect type produces hydroxyl free radicals from hydrolysis of water in the tissue DNA is most susceptible protein Tissue susceptibility to radiation Direct damage related to degree of mitotic activity Peak sensitivity is in G2 and M phase S phase is least sensitive |
|
|
Tissues with a high radiosensitivity
|
Hematopoietic cells
Germinal cells in the testes, ovraries |
|
|
Tissues with low radiosensitivity
|
brain is most resistant to radiation
Bone Mature cartilage Muscle |
|
|
Total body irradiation
|
Hematopoietic system first system affected
Vessels change-thrombosis, then fibrosis Skin changes including erythema, edema, blistering, chronic radiodermatitis Potential for squamous cell carcinoma GI tract with diarrhea |
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|
UV-light (nonionizing radiation)
|
UVA - Woods lamp
UVB - Sunburn, corneal burns form skiing, mutagenic effect on skin (thymine dimers) UVC - germicidal |
|
|
UVB related cancers
|
Basal cell carcinoma is MC skin cancer
Squamous carcinoma Malignant melanoma |
|
|
Laser radiation
|
Intense localized heat that is equivalent to a third degree burn
|
|
|
Microwave radiation
|
Produces a skin burn
Adversely affect pacemaker devices Inconclusive complications, cataracts, cancer, sterility |
|
|
Infrared radiation
|
Burns
Cataracts |
|
|
High altitude injury - general
|
O2 concentration is 21% (normal)
Decreased barometric pressure Hyperventilation is essential at high altitude since is lowers alveolar CO2 (respiratory alkalosis) automatically increases alveolar PAO2 which increases arterial PO2 |
|
|
Acute mountain sickness
|
Occurs within the first 24-36 hours of an ascent above 8000-10000 feet
Headache, lethargy, insomnia, dyspnea Rx with descent, increase fluid intake, and oxygen Prevention by acclimatizing before ascending and using acetazolamide, which is a carbonic anhydrase inhibitor that produces metabolic acidosis (compensation for the expected respiratory alkalosis High altitude pulmonary edema is noncardiogenic |
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Changes after death
|
Rigor mortis is due to decrease in ATP in muscle
|
|
|
Sites of alcohol reabsorption
|
Small intestine 75%
Stomach 25% Partially metabolized by alcohol dehydrogenase |
|
|
Top five causes of death in males and females regardless of age and sex in the US in descending order
|
Heart disease
Cancer Stroke COPD MVA |
|
|
Top three causes of death in children aged 1-14.
|
Accidents - 50%
Falls 25%-30% Burns - 10-15% Cancer Congenital anomalies |
|
|
Top three risk factors leading to increased morbidity/mortality in the United States in descending order
|
Cigarette smoking
Dietary factors and Activity patterns High saturated fat, low fiber diet Lack of exercise Alcohol abuse |
|
|
Gunshot wounds
|
Contact wounds - contain soot and gunpoweder in the wound (fouling)
Intermediate wounds - powder tattooing (stippling of skin around the entrance site) Distant wounds - no powder tattooing Exit wounds are larger and more irregular than entrance wounds |
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|
Motor vehicle accidents
|
MCC accidental death between 1-39 years of age: commonly alcohol-related, particularly in teenagers
Seat belts and air ags have reduced morbidity/mortality |
|
|
Drowning
|
Common COD in children from 1-14 years
Near drowning: survival following asphyxia secondary to submersion Wet drowning: 90% of cases-laryngospasm on contact with water then relaxation/aspiration of water Fresh/salt water drowning: whether fresh or salt water drowning, surfactant is destroyed in lungs leads to atelectasis wiht intrapulmonary shunting which leads to diffuse alveolar damage and initiates spasm in the bronchiles Immediate COD in drowning is cardiac arrhythmia |
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|
First degree burns
|
Painful partial thickness burns
Produce cell necrosis limited to the epidermis Heals without scar |
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|
Second degree burns
|
Painful partial thickness burns
Involve entire epidermis Form blisters within epidermis Heal without scarring unless they are deep |
|
|
Third degree burns
|
Painless full thickness burns
Extensive necrosis of epidermis/adnexa Extensive scarring complicated by keloid formation (propensity for squamous cell carcinoma) Healing comes from residual epithelium at the margins of the burn and from adnexal structures |
|
|
COD from burns
|
Infection due to Pseudomonas aeruginosa followed by Staphylococcus aureus
HOUSE FIRES: smoke inhalation MCCOD; CO an dcyanide poisoning commonly occur |
|
|
Hyperthermia
|
Core body temp >37.2C
|
|
|
Heat cramps
|
afebrile
Common in untrained athletes/laborers who become volume depleted Lose excess amounts of athletes training in hot/humid environment Develop severe olume depletion |
|
|
Exertional type of heat stroke
|
Core body temperatures >41C
People working or running on hot day Knin hot/dry Profound lactic acidosis Rhabdomyolysis common |
|
|
Non-exertional type of heat stroke
|
Elderly/Chronically ill patients
Hot/dry skin without sweating (hypohidrosis) Lactic acidosis/rhabdomyolysis uncommon |
|
|
Malignant hyperthermia
|
AD disease
Defect in calcium release channels in the muscle sarcoplasmic reticulum Massive muscle contractions with extremely high temperatures after induction of anesthesia by halothane and succinylcholine (muscle relaxant) Rx with dantrolene Screen family members with muscle biopsy and caffeine/halothane contraction test on musle |
|
|
Body temperature and redness of skin for a patient walking briskly on a hot day
|
No increase in rectal temperature
Vasodilatation of vessels in skin producing redness |
|
|
Marathon runner on a hot day
|
Increase in rectal temperature (probably heat exhaustion)
Vasodilatationof vessels in skin roducing redness |
|
|
Congenital syphilis
|
Primarily transplacental
Uncommon infection during first 5 months of prenancy Anatomical barriers prevent access to the fetal circulation |
|
|
Early neonatal syphilis (first 2 years)
|
Hepatomegaly MC sign
Osteochrondritis (inflammation of bone) Mucocutaneous lesions Pneumonia alba (lobar pneumonia) Persistent rhinitis |
|
|
Late neonatal syphilis (>2 years)
|
Frontal bossing is MC sign
Sabor shins Rhagades(perioral linear scars) Hutchinson's triad - teeth (notched upper incisors called Hutchinson's teeth and malformed molars called mulberry molars) Interstitial keratitis (blindness) Sensorineural hearing loss Rx: penicillin |
|
|
Congenital VZV
|
Chorioretinitis - potential for blindness
Limb hypoplasia cortical atrophy in the brain Vesicular skin lesions |
|
|
Increased body fat as an age dependent disorder
|
Decreases the number of insulin receptors leading to glucose intolerance
|
|
|
Respiratory system as an age dependent disorder
|
Obstructive type of pattern in pulmonary function tests (senile emphysema)
Decreased elasticity (reduced recoil on expiration) Decreased forced expiratory volume in 1 secend Decreased forced vital capacity Increased total lung capacity Increased residual volume Low normal PaO2 |
|
|
Cardiovascular system as an age dependent disorder.
|
Loss of elasticity in aorta
Decreased cardiac output and heart rate in response to stress At rest, the cardiac output is unchanged |
|
|
Musculoskeletal system as an age dependent disorder
|
Osteoarthritis in weight bearing joints
|
|
|
CNS as an age dependent disorder
|
Cerebral atrophy with mild forgetfulness
Impaired sleep patterns (insomnia, early waking) Parkinsonian-like gait |
|
|
Sensory changes as an age dependent disorder
|
Cataracts
Arcus senilis (ring of cholesterol around the cornea) Prebyopia (inability to focus on near objects Prebycusis (sensorineural hearing loss particularly at high frequency Otosclerosis (fusion of the ear ossicles producing conductinve hearing loss |
|
|
Immune system as an age dependent disorder
|
Decreased T cell function (often anergic to common skin antigens, positive PPD non-reactive or absent)
Loss of isohemagglutinins to blood antigens (may not develop a hemolytic transfusion reaction if blood is mismatched |
|
|
Skin as an age dependent disorder
|
Loss of skin elasticity (increased cross-bridging of collagen
Senile purpura over the dorsum of hte hands an dlower legs where bumping into objects is most likely ot occur Decreased sweating (eccrine glands fibrosed, danger of heat stroke |
|
|
GI tract as an age dependent disorder
|
Decreased gastric acidity
Decreased colonic motility (constipation whch predisposes to diverticulosis) Decreased activity of the hepatic cytochrome P450 system (danger of drug toxicity) |
|
|
Male reproductive system as an age dependent disorder
|
Prostate hyerplasia (increased urine residual volume with subsequent increase in urinary tract infections)
Prostate cancer (only cancer that is age dependent) Decreased testosterone |
|
|
Female reproductive system as an age dependent disorder
|
Breast and vulvar atrophy due to decreased estrogen
Increased gonadotropins |
|
|
Endocrine system as an age dependent disorder
|
Increased glucose intolerance (due to increase in body fat and subsequent reduction in insulin receptor synthesis)
|
|
|
Renal changes as an age dependent disorder
|
Decreased GFR with reduction in the creatinine clearance (risk of drug toxicity due to slow clearance of drugs)
|
|
|
CV age related changes increased incidence in elderly but not inevitable
|
Atherosclerosis wiht incrased incidence of coronary artery disease, peripheral vascular disease, and atherosclerosis with increased incidence of coronary artery disease, peripheral vascular disease, adn strokes
Temporal arteritis Aortic stenosis (MC valvular abnormality in the elderly) Systolic hypertension due to loss of aortic elasticity |
|
|
Musculoskeletal system age related changes increased incidence in elderly but not inevitable
|
Osteoporosis (vertebral column for women and femoral head for men)
Paget's disease of bone |
|
|
Respiratory system age related changes increased incidence in elderly but not inevitable
|
Pneumonia usually Streptococcus pneumoniae (why pneumovax is important in elderly)
|
|
|
CNS age related changes increased incidence in elderly but not inevitable
|
Alzheimer's disease
Parkinson's disease Strokes Subdural hematomas |
|
|
Sensory changes age related changes increased incidence in elderly but not inevitable
|
Macular degeneration
|
|
|
Skin age related changes increased incidence in elderly but not inevitable
|
UVB light-induced cancers
Actinic keratosis |
|
|
Endocrine system age related changes increased incidence in elderly but not inevitable
|
Endocrine system - type II diabetes mellitus
|
|
|
Fetal alcohol syndrome and teratogenic effects in newborns
|
MC teratogen in US 2:1000 live births
Clinical Mental retardation Intrauterine growth retardation Maxillary hypoplasia Microcephaly Atrial septal defects Hypoglycemia at birth |
|
|
Teratogen heroin
|
Small for gestational age
Irritability/hyperactivity High pitched cry with excessive hunger Salivation Sweating Tremors Fist sucking Temperature instability Seizures |
|
|
Teratogen isotretinoin
|
Used in treating cystic acne
Must order a pregnancy test prior to placing a woman on teh drug Patient must be on birth control pills while taking the drug Newborn effects (3 C's) Craniofacial abnormalities (small ears) Micrognathia Cleft palate Cardiac defects CNS malformations (hydrocephalus, microcephaly) |
|
|
Teratogen phenytoin
|
Nail hypoplasia
CNS abnormalities Cleft lip/palate Conginital heart disease |
|
|
Maternal smoking
|
Vasoconstrictive effects of nicotine produce placental ischemia,
Endothelial damage increases the risk for thrombosis in placental vessels Low birth weight babies |
|
|
Maternal SLE
|
SLE patients who have anti-Ro (anti-SSA) IgG antibodies in their serum may have newborns with complete heart block
|
|
|
Teratogen thalidomide
|
Previously used in teh US to control nausea associated with pregnancy - currently used in Rx of leprosy
Limb abnormalities Amelia (absent limbs Phocomelia (seal-like limbs) |
|
|
Teratogen valproate
|
Open neural tube defects
|
|
|
Teratogen warfarin
|
Contraindicated in pregnancy
Should use heparin CNS defects Nasal hypoplasia |
|
|
Congenital infections
|
TORCH syndrome (toxoplasmosis, Other, Rubella, CMV, Herpes
Increase in IgM in cord blood Vertical transmission Transplacental MC type Blood contamination during delivery Cervical infection Breast feeding |
|
|
Congenital CMV
|
MC in-utero viral infection: majority are asymptomatic
Primarily transplacental Clinical Bilateral sensorineural hearing loss MC complication Periventricular calcification hepatosplenomegaly Chorioretinitis Urine culture is gold standard Urine cytology reveals large, basophilic intranuclear inclusions in renal tubular cells Rx ganciclovir, then foscarnet if former doesn't work |
|
|
Congenital Rubella
|
Primarily transplacental Highest incinence iof congenital anomalies in first 8 weeks
Virus interferes with protein synthesis and produces a vasculitis Clinical Sensorineural deafness MC complication Cataracts PDA |
|
|
Congenital toxoplasmosis
|
Primarily transplacental
Contracted by women after exposure to cat litter Pregnant women should avoid cleaning cat litter during pregnancy Contracted also by handing or eating undercooked meat products Greater risk of fetal infection later in pregnancy than earlier Clinical Chorioretinitis MC late complication Calcification in basal ganglia Sabin Feldman dye test (uses live organisms) gold standard, but test is rarely preformed |
|
|
Congenital Herpes type 2
|
Primarily contracted by passing through teh birth canal in women actively shedding the virus
Women actively shedding the HSV-2 virus are delivered by C-section Greater chance of fetal infection with primary rather than recurrent Herpes Clinical Local of systemic disease (encephalitis, skin infections) Rx: acyclovir |
|
|
Teratogen DES
|
Mothers received DES to prevent threatened abortions
DES interferes with the development of mullerian structures in female fetus causing abnormalities in teh tubes, uterus, cervix, upper one-third of vagina Female siblings: vaginal adenosis is the MC abnormality and is the precursor of clear cell adenocarcinoma of the vagina/cervix Cervical incompetence Increased incidence of spontaneous abortions Uterine abnormalities Problems with implantation Fallopian tube abnormalities Fertility problems |
|
|
Maternal DM and the teratogenic effects in newborns
|
Increased irthweight
Hyperinsulinism in teh fetus from poor maternal glycemic control increases muscle mass Hyperinsulinism increases fat deposition Open neural tube defects Cleft lip/palate Respiratory distress syndrome: fetal hyperinsulinism in response to maternal hyperglycemia inhibits fetal surfactant production by thpe II pneumocytes |
|
|
Teratogen cocaine
|
Maternal effects
Hypertension Abruptio placenta Newborn hyperactivity Microcephaly (MC effect) Interruption of blood flow leading to infarction (CNS, bowel, missing digits) |
|
|
Mechanisms of teratogens
|
Teratogens are most detrimental during the embryonic period
First 9 weeks of life (4th-5th wk most sensitive) Open neural defects occur when tube normally closes between the 23rd-28th day Specific effects of some teratogens Some interfere with formation of mitotic spindle Interfere with production of ATP Some interfere with gene production |
|
|
Malformations
|
Disturbance that occurs in the morphogenesis of an organ
Hypospadias faulty closure of urethral folds Epispadias due to a defect in genital tuburcle Club foot Ventricular septal defect |
|
|
Deformations
|
Anatomical defects resulting from mechanical factors (extrinsic forces) that usually occur in the last two trimesters after organs have developed
Oligohydramnios producing facial and limb abnormalities (called Potter's facies) |
|
|
Simple way of calculating the carrier rate of a disease given the prevalence of a genetic disease (Hardy Weinberg equation)
|
Reflects the distribution of a mutant gene in the population, example using prevalence of CF of 1/2500.
Number of couples at risk (1/2500)/(1/4)=(1/625) Carrier rate of CF: square root of 1/625= 1/25 |
|
|
Calculation of the prevalence of a genetic disease given the carrier rate
|
CF with a carrier rate of CF is 1/25
Number of couples at risk is equal to the arrier rate in males x the carrier rate in females, or 1/25 x 1/25 = 1/625 Risk of having a child with CF is 1/4, hence 1/625 x 1/4 = prevalence of 1/2500 |
|
|
Mitochondrial DNA disorders:
|
mtDNA primarily codes for enzymes involved in mitochondrial oxidative phosphorylation reactions
Ova contain mitochondria Affected women transmit symptomatic abnormal allele to all their children Sperm lose their mitochondria during fertilization Affected males do not transmit abnormal allele to any of their children Leber's hereditary optic neuropathy Myoclonic epilepsy Lactic acid with stroke |
|
|
Multifactorial (polygenic) inheritance
|
Multiple small mutations plus the effect of environment
Should be suspected when there is an increased prevalence of disease amone relatives of affected individuals Parents and offspring have 50% of their genes in common Cleft lip/palate Congenital heart disease Coronary artery disease Gout Type II DM Essential hypertension Open neural defects Congenital pyloric stenosis |
|
|
SXD disorders
|
Percentages of children with the abnormal allele are the same as those in SXE disorders
Dominant abnormal allele causes disease in both males and females Affected woman transmits symptomatic disease to 50% of her daughters and 50% of her sons Affected males transmit symptomatic disease to all of their daughters and none of their sons Familial hypophosphatemia Alport syndrome |
|
|
Lesh Nyhan syndrome
|
SXR disease with a deficiency of HGPRT
No inhibition of PRPP in purine metabolism Clinical Hyperuricemia Mental retardation Self mutilation |
|
|
Fragile X syndrome
|
Some geneticists say it is a sex-linked dominant disease, owing to the fact that female carriers may express the disease in future generations
Second MC genetic cause of mental retardation MC Mendelian disorder associated with mental retardation Clinical Mental retardation Macroorchidism at puberty 30% of female carriers are mentally retarded or have impaired learning Due to anticipation and addition of trinucleotide repeats with future generations Abnormal fragile X chromosome DNA analysis for carrier identification (ID CGG trinucleotide repeat is the best test to confirm) |
|
|
SXR disorders
|
Examples in decreasing frequency
Fragile X syndrome G6PD deficiency Duchenne's muscular dystrophy Hemophilia A/B SCID Wiskott-Aldrich syndrome Testicular feminization Color blindness Chronic Granulomatous dz of childhood Bruton's agammaglobulinemia |
|
|
AR diseases
|
NO evidence of penetrance, variable expressivity, late manifestations
Most AR diseases are enzyme deficiencis, inborn errors of metabolism Acute intermittent porphyria and C1 esterase inhibitor deficiency(heriditary angioma) are both autosomal dominant G6PD and Lesch Nyhan are both SXR Examples of those that are not enzyme defiiencies: CF Sickle cell Hemochromatosis Wilson's disease |
|
|
AD disorders
|
Associated with structural defects in proteins and receptors
Late manifestations of disease Exhibit penetrance Variable expressivity Mechanisms of AD disease without a family Hx: MCC is incomplete penetrance New mutation |
|
|
Examples of AD diseases (in decreasing frequency)
|
von Willebrand's disease
Familial hypercholesterolemia Adult polycystic Kidney disease Hypertrophic cardiomyopathy Huntington's disease Neurofibromatosis Congenital spherocytosis Familial polyposis Acute intermittent porphyria Osteogenesis imperfecta Marfan syndrome |
|
|
Mendelian disorders in descending order of frequency
|
Autosomal dominant
Autosomal recessive Sex-linked recessive Sex-linked dominant |
|
|
Trisomy 13 (Patau's syndrome)
|
Cleft lip/palate
Severe mental retardation Polydactylyl cystic kidneys |
|
|
Trisomy 18 (Edward's syndrome)
|
Severe mental retardation
Clenched hands with overlapping 2nd and 5th fingers Rocker bottom feet |
|
|
Risk for furure children with Down's
|
1-2% overall risk for trisomy 21
Maternal age; women >35 5-15% risk for parent with a balanced translocation Karyotype of affected child should always be determined to evaluate risk for siblings to have affected children |
|
|
Down's clinical findings
|
Epicanthal folds iwth upward slanting
Simian palmar crease Poor reflexes/hypotonicity CV Endocardial cushion defects (combined ASD and VSD) Major determining factor for survival in early infancy and childhood Duodenal atresia Hirschsprung's disease Increased incidence of leukemia Alzheimer's disease All males are sterile Females have 50% chance of having a child with Down's |
|
|
Risk of recurrence of genetic disorders
|
Mendelian disorders have the greatest risk of recurrence
|
|
|
Genetics disorders in African Americans
|
Sickle cell trait/disease 8-10% prevalence of sickle cell gene
Alpha/Beta Thalassemia G6PD deficiency Hereditary persistence of HgbF |
|
|
Geneticc disorders in Ashkenazi Jews
|
Factor Xii deficiency
Gaucher's disease Tay Sachs disease |
|
|
Genetic disorder in Northern Europeans
|
CF - MC genetic disease interfering with the patient's avility to reproduce owing to early death or problems iwth fertility
|
|
|
Genetic disorder in Mediterranean peoples
|
G6PD deficiency
Sickle cell trait/disease Beta thalassemia |
|
|
Genetic disorder in SE Asians
|
Alpha thalassemia
|
|
|
MC genetic syndrome associated with advanced maternal age
|
trisomy 21
|
|
|
Down syndrome pathogenesis
|
Trisomy 21
95% of all cases 47 chromosomes Maternal origin for extra chromosome Robertsonian translocation 4% 46 chromosomes in child Mother iwht 45 chromosomes usually mother MC genetic cause of mental retardation IQ 25-50 in 80% |
|
|
Lyon's hypothesis
|
One of the 2 chromosomes in a female is randomly inactivated
Inactivated X chromose becomes a Barr body Male with kleinfelter's syndrome have 1 Barr body Females with Turner's syndrome have no Barr bodies |
|
|
Cystic fibrosis molecular genetics
|
Deletion of 3 nucleotides coding for phenylalanine on chromosome 7
CF transmembrane regulator is defective and is degraded before reaching the cell membrane after it leaves the Golgi apparatus |
|
|
Tay Sachs molecular genetics
|
4 base insertion produces a frameshift mutation
Codes for defective hexosaminidase |
|
|
Sickle cell disease/trait molecular genetics
|
Point mutation involving thymidine replaced by adenine codes for Valine instead of Glutamic acid in 6th position of Beta-globin chain
|
|
|
Beta-thalassemia major molecular genetics
|
Point mutation produces a stop codon leading to termination of DNA transcription of Beta-globin chain
|
|
|
Trinucleotide repeat disorders molecular genetics
|
Progressively worse disease occurs in future generations (anticipation)
constant repetition of 3 nucleotide bases More trinucleotide repeats are added each generation leading to progrossively worse disease and earlier manifestation of the disease Huntington's disease Fragile X syndrome Friedreich's ataxia Myotonic dystrophy |
|
|
Nondisjunction
|
Cause of the maority of chromosome number disorder
Due to unequal separation of chromosomes in first phase of meiosis |
|
|
Mosaicism
|
Nondisjunction of chromosomes in mitotic division in the early embryonic period
Two chromosomally different cell lines are derived from a single fertilized egg Most cases involve sex chromosomes gonadal dysgenesis |
|
|
Translocation
|
One part of a chromosome is transferred to a non-homologous or homologous chromosome
Called a balanced translocation if the translocation fragment is functional |
|
|
Robertsonian translocation in Down syndrome
|
Type of a balanced translocation with a reciprocal translocation between 2 acrocentric chromosomes
Usually chromosomes 21 and 14 Produces 1 long chromosomes (14.21) Mother has the translocation:45 chromosomes with 1 long #14.21, 1 normal #14 and one normal #21 Mother is normal since both translocated fragments are functional |
|
|
Cri-du-chat
|
Deletion of short arm of chromosome 5
Mental retardation Cry like a cat |
|
|
Microdeletion syndromes
|
Loss of small portion from 1 chromosome can only identified with high resolution techniques
Microdeletion on chromosome 15 may result in the Prader-Willi syndrome if from paternal origin Angelman syndrome if form maternal origin |
|
|
Presentation of Prader-Willi syndrome
|
Obesity
Hypogonadism Mental Retardation Genomic imprinting |
|
|
Angelman syndrome
|
Happy puppet
child always happy/laughing but cannot talk Genomic imprinting |
|
|
How is cP450 changed in alcoholics
|
Increased synthesis of GGT
Excellent enzyme marker for alcoholic liver disease |
|
|
How is NADH change in alcoholics
|
Increased production of NADH in its metabolic breakdown causes biochemical reactions involving NADH to move in its direction resulting in:
Lactic Acidosis (pyruvate to lactic acid Fasting hypoglycemia (pyruvate is unavailable for gluconeogenesis Hypertriglyceridemia (1,3 bisphosphoglycerate to dihydroxyacetone phosphate to glycerol 3-phosphate to TG) |
|
|
How do ketoacids change in alcoholics
|
Increased synthesis
Acetyl CoA, the end product of alcohol metabolism is used in the following reactions: acetyl coA + acetyl CoA to acetoacetyl CoA to HMG CoA to acetoacetic acid Increase in NADH converts it into Beta hydroxybutyric acid (B-OHB) |
|
|
How is fatty acid synthesis changed in alcoholics
|
Increased fatty acid synthesis
Due to the increase in acetyl-CoA The initial substrate for the synthesis of FAs |
|
|
What is hyperuricemia in alcoholics
|
Lactic acid/ketoacids compete with uric acid for excretion in the kidneys
|
|
|
What anion gap is found in alcoholics
|
Increased anion gap metabolic acidosis
Lactate + Beta hydroxybutyric acid |
|
|
What is respiratory acidosis due to in smokers
|
Air gets in but cannot get out, so CO2 is retained
|
|
|
Is there hypoxemia in smoking
|
YES
low PaO2 |
|
|
What are CO levels in smokers
|
Increased CO levels
CO is present in cigarette smoke |
|
|
Do smokers have polycythemia
|
Secondary poycythemia
Low PaO2 stimulates erythropoietin release |
|
|
What is neutrophilic leukocytosis in smokers
|
Absolute neutrophilic leukocytosis
Metabolites in smoke mobilize the neutrophil marginating pool in the circulation by decreasing leukocyte adhesion to endothelial cells |
|
|
Describe plasma/serum turbidity
|
Due to an increase in TG; turbidity does not occur with an increase in cholesterol in plasma
TG is carried by lipoproteins - chylomicrons-85% - VLDL-55% TG is falsely increased after eating - due to diet derived chylomicrons Chylomicrons form a supranate in plasma: contain very little protein-less dense than VLDL VLDL forms an infranate-contains more protein than chylomicrons and does not float on the surface of plasma Increased turbidity interferes with measurement of enzymes and serum Na-falsely low enzyme values and sodium (pseudohyponatremia) |
|
|
How does serum albumin concentration relate with serum calcium concentration
|
1) Albumin binds 40% of total calcium in blood - 13% of calcium is bound to other substrates - 47% calcium is free, ionized calcium - metabolically active calcium
2) Low serum albumin decreases calcium bound to albumin-hypocalcemia - no tetany is present, since the ionized levels are normal - PTH is normal |
|
|
What is the significance of ESR in old age
|
Probably indicates a disease process
|
|
|
Drugs inhibiting cytochrome system in the liver
|
Drugs - H2 blockers, proton blockers
Danger of drug toxicity |
|
|
Drugs enhancing the cytochrome system in the liver smooth endoplasmic reticulum (SER):
|
Drugs - alcohol, barbiturates, rifampin, phenytoin
Effect on SER - SER hyperplasia - increased synthesis of GGT - Enzyme is normally located in SER - decrease drug levels owing to increased metabolism of the drug Clinical senario - woman on phenytoin who is also taking birth control pills gets pregnant - phenytoin revved up the SER and increased metabolism of birth control pill |
|
|
Lipids and fasting
|
TG component coming from chylomicrons falsely increases serum TG levels - chylomicrons contain diet derived TG, hence the patient must be fasting to eliminate this variable
Fasting or lack of fasting does not affect cholesterol and HDL concentration - normally CH is <3% of the chylomicron fraction - fasting is unnecessary for an accurate CH or HDL Fasting is necessary for an accurate calculated LDL - LDL=CH-HDL-TG/5, if TG is falsely increased, it will falsely lower the calculated LDL |
|
|
Analytes increased with hemolyzed blood sample secondary to venipuncture
|
LDH1 isoenzyme fraction is primarily increased and is greater than LDH2 isoenzyme fraction (LDH1/LDH2 flip)
False positive diagnosis of acute myocardial infarction - LDH1 isoenzyme is also in cardiac muscle Potassium - pseudohyperkalemia, false increase K is the major intracellular cation ECG will not show a peaked T wave |
|
|
HgbF
|
Left shifts oxygen dissociation curve
Protects newborns with sickle cell disease Most of the RBCs at birth contain HbF - inhibits sickling Less HgbS concentration not high enough for sickling HgbS must be >60% in RBC for spontaneous sickling Dactylitis (bone infarctions of digits) begins in 6-9 mths |
|
|
Lab differences in Newborns
|
High hemoglobin due to increased HgbF
Left shifts oxygen dissociation curve - tissue hypoxia Stimulus for EPO release Increases RBC production with subsequent increase in Hgb concentration |
|
|
Lab differences in Children
|
Increased serum alkaline phosphatase (ALP) - 3-5 times higher than adults - osteoblasts release enzyme when stimulated by vitamin D
Increased serum phosphate - required to drive calcium into bone Slight decrease in hemoglobin concentration when compared to adult levels |
|
|
Main lab differences in adult male and female
|
Iron studies are all lower in women (serum iron and ferritin)
Lower Hgb concentration in women |
|
|
Normal changes in pregnancy
|
1) Greater increase in plasma volume than RBC mass: Decreases Hb and Hct - dilutional effect: increases GFR and creatinine clearance - due to increased plasma volume - decreases serum BUN/creatinine/uric acid - dilutional effect+increased renal clearance
|
|
|
Calculation for sensitivity
|
TP/TP+FN
or A/A+C |
|
|
Calculation for specificity
|
TN/TN+FP
or D/D+B |
|
|
Calculation for negative predictive value
|
TN/TN+FN
or D/D+C |
|
|
Calculation for positive predictive value
|
TP/TP+FP
or A/A+B |
|
|
Calculation for prevalence
|
TP+FN/TP+FN+FP+TN
or A+C/A+B+C+D |
|
|
Describe Prevalence
|
Prevalence = Incidence x Duration of the disease (Incidence is a constant in this relationship)
All people with the disease/All people with and without the disease |
|
|
Effect of decreasing the upper limit of normal of a test reference interval on sensitivity, specificity, PV-, PV+
|
Increases sensitivity and PV-
Decreases specificity and PV+ |
|
|
PV+ in a test with 100% specificity
|
PV+ is always 100%, since the FP rate is zero - this underscores why test with 100% specificity are used to confirm disease
|
|
|
PV- in a test with 100% specificity
|
PV- may be a TN or a FN
It does not exclude disease |
|
|
Use of a test with 100% specificity
|
Confirms disease since there are no FP test results
|
|
|
Use of a test with 100% sensitivity
|
Best used to screen for disease
Excludes disease when the test results returns negative Includes people with disease when the test result returns positive |
|
|
PV- of a test with 100% sensitivity
|
PV- must be 100% since there are no FN test results in a test with 100% sensitivity
this underscores why tests with 100% sensitivity exclude disease when the test result returns negative |
|
|
PV+ of a test with 100% sensitivity
|
Test result is either a TP or FP, therefore, the PV+ is never 100% owing to the chance that it may be a FP, people with the disease are always included
|
|
|
Patient with SLE with Raynaud's phenomenon
|
More common with PSS and CREST syndrome
|
|
|
African American took primaquine and then developed anemia with bite cells
|
G6PD deficiency
|
|
|
Patient with intense occipital headache with blood in CSF
|
Probable subarachnoid bleed in a patient with a ruptured congenital berry aneurysm
|
|
|
Septic arthritis in young adult:
|
Neisseria gonorrhoeae
|
|
|
Child with disease characterized by neutrophils that cannot kill bacteria
|
Could be chronic granulomatous disease of childhood or
Myeloperoxidase deficiency |
|
|
Thrombotic thrombocytic purpura
|
Platelet thrombi (not DIC)
CNS hemorrhage Hemolytic anemia and schistocytes Renal failure Thrombocytopenia (consumed in thrombi) Normal PT and PTT Increased bleeding time |
|
|
CSF analysis in AIDS patient with meningitis showed an encapsulated organism
|
Cryptococcus
(AIDS pt. is put in a crypt (crypto) in a tuxedo (toxo) and goes to heaven to see JC(Jesus Christ) and CMV (See Mary the Virgin) |
|
|
Calculate anion gap
|
AG=serum Na-(serum Cl + serum HCO3)
Increased AG (add acid) due to - lactate, salicylate, Beta-OHB, AcAc, oxalate (ethylene glycol), formate (methyl alcohol), phosphate/sulfate (real failure) Normal AG (lose bicarbonate) due to-diarrhea, renal tubular acidosis (proximal and distal) |
|
|
Organism causing pyelonephritis
|
E.coli
Ascending infection due to vesicoureteral reflux |
|
|
Febrile woman with non-radiating flank pain on right side. What would be present in her urine?
|
WBC casts (pyelonephritis)
|
|
|
Woman with painless nodule lateral to cricoid cartilage
|
Probable papillary cancer of thyroid
|
|
|
MEN I
|
Pituitary tumor
Parathyroid adenoma Pancreatic tumor (usually ZE) Peptic ulcer (due to ZE and hypercalcemia from hyperparathyroidism) |
|
|
MEN IIa
|
Medullary carcinoma thyroid
Hyperparathyroidism Pheochromocytoma |
|
|
MEN IIb
|
Medullary carcinoma
Pheochromocytoma Mucosal neuromas |
|
|
Calcitonin is marker for medulary carcinoma of thyroid
|
calcitonin lowers calcium by inhibiting osteoclasts
|
|
|
Hypercalcemia in a patient with MEN syndrome
|
Hyperparathyroidism with increased PTH
|
|
|
Primary aldosteronism
|
Hypertension
Non-pitting edema Hypernatremia (mild or upper limit of normal) Hypokalemia Metabolic alkalosis |
|
|
Hypoaldosteronism effects
|
(spironolactone, Addison's, destruction of JG apparatus)
Hypovolemia from salt loss Hyperkalemia Normal AG metabolic acidosis |
|
|
Mutation producing neurofibromatosis
|
Inactivation of NF suppressor gene
|
|
|
Hepatic encephalopathy with flapping tremors
|
Relates to false neurotransmitters and increase in ammonia from bacterial degradation of urea in the intestine
|
|
|
Sexually active man with sterile pyuria and no organisms seen on gram stain
|
Probably Chlamydia trachomatis non-specific urethritis
|
|
|
Man with pain in posterior aspect of left testicle
|
Epididymitis
Depending on age of the patient organism could be Neisseria/Chlamydia if <35 or E. coli/Pseudomonas aeruginosa if >35 |
|
|
Young woman with a stroke and irregular left ventricle filling
|
Embolization from atrial myxoma
|
|
|
Lady that just returned form Asia has severe dyspnea within a day of arrival
|
Probable pulmonary embolus from sitting too long
|
|
|
Cystic hygroma in the neck area in a fetus
|
Turners syndrome
Lymphatic defects are common cystic hygroma becomes webbed neck Lymphedema of dorsum of hands and feet |
|
|
Tumor of 4th ventricle
|
Ependymoma - neoplastic ependymal cells
Usually in children |
|
|
Ascites in a patient with a normal liver biopsy
|
Portal vein thrombosis leading to portal hypertension
|
|
|
Elderly woman with 2 days of eye pain and dilated vessels on white of the eye that don't blanch with vasoconstricting drugs:
|
Probable glaucoma
|
|
|
Atrophy of tail of caudate nucleus
|
Huntington's disease
|
|
|
Vitamin D excess
|
Hypercalcemia
Urinary stones |
|
|
Vitamin C excess
|
Calcium oxalate stones
|
|
|
Paget's disease of bone in an elderly woman
|
Early phase of lysis (resembles multiple myeloma except it does not have clear margins)
and then bone deposition with soft mosaic bone (pathologic fractures) Increased serum alkaline phosphatase |
|
|
Man with severe hyponatremia and high urine osmolality
|
Inappropriate ADH syndrome from small cell cancer in the lung
High urine osmolality is due to increased peritubular hydrostatic pressure and loss of sodium in the urine as well as constant concentration of the urine from excess ADH |
|
|
Factitious insulin injection
|
Hypoglycemia
High serum insulin Low C-peptide (suppressed by hypoglycemia) If C-peptide is increased, patient has insulinoma |
|
|
Type I vs Type II DM
|
Type I:
Insulitis due to autoimmune destruction HLA relationship Antibodies against islets and insulin complete insulin deficiency Type II: Amyloid in islets Family History No antibodies Relative insulin deficiency with decreased insulin receptors and postreceptor defects |
|
|
Post-transfusional hepatitis
|
HCV
|
|
|
Pulmonary fibrosis with pulmonary artery hypertension
|
Could be due to drugs (amiodarone, bleomycin, busulfan, methotrexate)
Hamman-Rich lung from alveolitis syndromes |
|
|
AIDS patient with purple lesions on skin
|
Kaposi's sarcoma due to Herpesvirus 8
|
|
|
Case study of child with medullobastoma
|
Malignant cerebellar tumor
|
|
|
Alzheimer's disease
|
Remember Down syndrome relationship and chromosome 21: 40 years old with AD is an adult with Down's syndrome
Senile plaques #1 cause of senile dementia Loss of higher intellectual function |
|
|
Man with extrapyramidal signs
|
Parkinson's disease due to loss of dopamine
|
|
|
Case study of a woman with gonorrhea
|
Probable PID shortly after menses
|
|
|
Anorexic patient has more risk for osteoporosis due to:
|
Loss of estrogen
|
|
|
Left sided heart murmurs and abnormal heart sounds increase in
|
Expiration
|
|
|
Right sided heart murmurs and abnormal heart sounds increase on
|
Inspiration
|
|
|
Aortic stenosis
|
Systolic ejection murmur with radiation into carotids (S4 and increases on expiration)
Diminished pulse MCC is congenital bicuspid aortic valve MCC of microangiopathic hemolytic anemia with schistocytes MC valvular lesion associated with syncope and angina |
|
|
Description of an x-ray of emphysema
|
Increased A-P diameter
Depressed diaphragms Vertically oriented heart |
|
|
Tension pneumothorax
|
Tear in pleura acts like check valve, pleural pressure higher than atmospheric
Lung compressed and not collapsed Mediastinal structures shift to opposite side Diaphragms low Decreased breath sounds Tympany to percussion |
|
|
Spontaneous pneumothorax
|
Subpleural blebs in tall, slender males is a common cause
Pleural pressure same as atmospheric pressure Lung collapse Diaphragm rises Trachea shifts to side of collapse Decreased breath sounds Tympany to percussion |
|
|
Atelectasis (collapse of alveoli)
|
Decreased percussion
High diaphragm Increased tactile fremitus Decreased breath sounds Inspiratory lag Trachea shift to side of atelectasis |
|
|
Chronic alcohol abuse leads to congestive cardiomyopathy and cardiac failure
|
Could be due to thiamine deficiency or direct toxic effect on the heart
|
|
|
Type II pneumocytes are the repair cells of the lung in pneumonia and ARDS:
|
Lamellar bodies (surfactant) are cytoplasmic markers of the cell
|
|
|
Drug addict with fever and pansystolic murmur increasing on inspiration
|
Tricuspid regurgitation due to S. aureus infective endocarditis
|
|
|
Type 2 diabetic with no diet control
|
Hgb A1c is high
|
|
|
Polycystic ovarian syndrome
|
17-ketosteroids (DHEA and androstenedione)
Testerone, and estrone are elevated LH>FSH |
|
|
Benzene:
|
Causes aplastic anemia and acute leukemia
|
|
|
Testicular torsion
|
Testis raised on affected side
Loss of cremasteric reflex |
|
|
Clinical case of ulcerative colitis in young man
|
Bloody diarrhea
|
|
|
Clinical case of an elderly man with prostatic cancer
|
Remember osteoblastic metastasis in lower lumbar vertebra
If the history is only one of urinary retention and problems with getting up at night, it is prostate hyperplasia and not cancer |
|
|
21-Hydroxylase deficiency
|
Salt loser
Increased 17-Ketosteroid Decreased 17-Hydroxycorticoids Increased ACTH Female pseudohermaphroditism |
|
|
11-Hydroxylase deficiency
|
Hypertension - increased mineralocorticoids
Decreased 17-Ketosteroids Increased 17-hydroxycorticoids Increased ACTH Decreased serum cortisol Female pseudohermaphroditism |
|
|
17-Hydroxylase deficiency
|
Hypertension - increased mineralocorticoids
Decreased 17-Ketosteroid Decreased 17-Hydroxycordicoids Increased ACTH Decreased serum cortisol Female hypogonadism Male pseudohermaphroditism |
|
|
Cardiac tamponade occurs
|
3-7 days post AMI
|
|
|
Pregnant patient accidentally swallowed I-131
|
Baby will probably develop hypothyroidism
|
|
|
Duchenne's muscular dystrophy
|
SXR disorder with absence of dystrophin
|
|
|
PGE2 synthesized in the placenta keeps what open during pregnancy
|
Ductus Arteriosus
|
|
|
In a patient with acute nephritis, what lab test should be ordered:
|
ASO titer to R/O poststreptococcal GN
|
|
|
RBC casts
|
nephritic syndrome
|
|
|
WBC casts
|
Acute pyelonephritis and drug induced tubulointerstitial nephritis
|
|
|
Renal tubular casts
|
Acute tubular necrosis
|
|
|
Fatty casts
|
Nephrotic syndrome
|
|
|
Waxy casts
|
Chronic renal failure
|
|
|
Teratomas
|
Germ cell origin
Located in midline - testes/ovaries, anterior mediastinum, pineal |
|
|
Glandular metaplasia of distal esophagus
|
Barrett's esophagus in GERD
|
|
|
Kwashiorkor
|
Has decreased oncotic pressure due to decreased protein intake but adequate number of calories
Defects in cellular immunity Anemia Ascites Fatty liver from decreased apoproteins |
|
|
Marasmus
|
Total calorie deprivation
Broomstick extremities |
|
|
Mycoplasma pneumoniae is the MC organism for
|
Atypical pneumonia in adults
|
|
|
Neutrophils phagocytose what type of crystals in gout
|
Monosodium urate crystals
|
|
|
Pancreas biopsy in cystic fibrosis patient
|
Atrophy is the growth alteration
|
|
|
Epidural hematoma
|
Ruptured middle meningeal artery
|
|
|
Rapidly progressive dementia with neurofibrillary tangles
|
Creutzfeldt Jacob
|
|
|
Defective synthesis of type I collagen in
|
Ehlers-Danlos syndrome
|
|
|
Auer rods
|
Only seen in AML (progranulocytic included)
Not seen in chronic or monocytic leukemia |
|
|
Case of extravascular hemolytic anemia. Hypersensitivity is equivalent to
|
EHA is a type II reaction, so look for another type II reaction:
Goodpastures Graves Myasthenia gravis |
|
|
Primary hyperparathyroidism electrolytes:
|
Hypercalcemia
Hypophosphatemia Normal AG metabolic acidosis |
|
|
Case of hemolytic uremic syndrome
|
Schistocytes
D-dimers (fibrin strands with links between them) Thrombocytopenia - platelets consumed Increased bleeding time Normal PT and PTT - not DIC |
|
|
Common complication of severe hemophilia A
|
Hemarthroses
|
|
|
Klinefelter syndrome
|
47 XXY
Low testosterone High FSH and LH High estrogen |
|
|
Macrocytic anemia with neurologic symptoms
|
Cobalamin deficiency (B12)
|
|
|
Mesothelioma
|
Asbestos exposure (ship-yard, roofer>20 yrs)
NO smoking relationship |
|
|
Temporal arteritis
|
Granulomatous giant cell arteritis
Increased sed rate Jaw pain when chewing Potential blindness |
|
|
Proximal dissecting aortic aneurysm
|
Aortic regurgitation murmur
idening of aortic arch Loss of pulse Potential for tamponade |
|
|
Hypophysectomy
|
Zona fasciculata undergoes atrophy due to loss of ACTH
|
|
|
Case of emphysema and pathology
|
Destruction of elastic tissue support in respiratory unit
Centrilobular involves respiratory bronchioles Panacinar involves respiratory bronchile, alveolar duct, an alveoli Paraseptal involves the alveolar duct and alveoli (common cause of pneumothorax) |
|
|
Down syndrome with vomiting and maternal polyhydramnios
|
Duodena atresia
|
|
|
Down syndrome with constipation at birth
|
Hirschsprung's disease
|
|
|
High risk of colon cancer
|
Multiple polyps
|
|
|
Elevated alpha fetoprotein in pregnant woman
|
Do an amniocentesis to rule out open neural tube defect
|
|
|
Decreased alpha fetoprotein in pregnant women
|
Down syndrome
|
|
|
Complications of prostate hyperplasia
|
Infection
Urinary retention It does not progress to cancer |
|
|
High serum TSH
|
Primary hypothyroidism
|
|
|
Thyromegaly, normal TSH and T4, increased antimicrosomal and thyroglobulin antibodies
|
Early Hashimoto's thyroiditis
|
|
|
Osteogenesis imperfecta
|
Deficiency of type I collagen
Blue sclera - due to visualization of choroidal veins |
|
|
MCC of fatty liver and cirrhosis
|
Alcohol abuse
|
|
|
Case of mass in fallopian tube in a patient with an increase in Beta-hCG
|
Ectopic
|
|
|
Bacterial meningitis
|
Increased opening pressure
High protein Low glucose Increased neutrophils |
|
|
Brain tumor in the third ventricle
|
Colloid cyst or
Choroid plexus papilloma |
|
|
Patient deterioration after CNS trauma
|
Herniation
|
|
|
Kartagener's syndrome
|
Absent dynein arm in cilia
|
|
|
Rinne and Weber test are like if you have cerumen in your ear
|
Rinne lateralizes to affected ear
Webbers has cone conduction>air conduction Signs of conductive hearing loss |
|
|
Injection of 1 liter of saline, start seeing diuresis
|
Due to an increase in Atrial Natiuretic Factor
|
|
|
After head trauma, the urine osmolality is 700 mOsm/Kg
|
Inappropriate ADH syndrome
Not DI (urine Osm would be low) |
|
|
Primary hypoparathyroidism
|
Primary due to previous surgery or autoimmune destruction
|
|
|
1,25 dihydroxycholecalciferol
|
Active form of vitamin D
Requires PTH for its synthesis 1-alpha-hydroxylase |
|
|
Graves disease
|
Type Ii hypersensitivity
IgG antibody against TSH receptor Unique to Graves: Exophthalmos Pretibial myxedema TSH low and T4 high Rx wiht Beta-blockers to inhibit adrenergic effects and propylthiouracil to inhibit enzyme synthesis |
|
|
Differences between primary/secondary hypothyroidism in relation to T4 and TSH
|
Both have low T4
Primary has high TSH Secondary has low TSH |
|
|
Woman who was vomiting
|
Hypokalemia
Metabolic alkalosis |
|
|
Diarrhea
|
Normal AG metabolic acidosis
Normal serum sodium (isotonic loss) Hypokalemia |
|
|
A patient in the hospital accidentally gets infused with saline contaminated wiht E. coli and develops shock, 2 days later there is bleeding from all puncture sites, what will be the findings:
|
DIC with decreased fibrinogen and platelets
Increased D-dimers |
|
|
A 16 yo footbal player suddenly dies during a game, what will be seen on autopsy:
|
Disarrayof the myocardial fibers in interventricular septum
Hypertrophic cardiomyopathy |
|
|
A person develops congestive cardiac failure and decreased GFR. The renal tubule cells show hydropic change. What is the cause of the hydropic change
|
Damage to the Na/K pump
|
|
|
Graph showing collagen formation after an AMI
|
Graph that starts and increases after 10-14 days
|
|
|
An AIDS patient develops diarrhea with an acid-fast organism. What is the most likely cause?
|
Cryptosporidium
|
|
|
A patient with liver cirrhosis and ascites develops spontaneous bacterial peritonitis, what is the most likely organism?
|
E. coli
|
|
|
A patient is being treated for leukemia with anti-cancer drugs. What kind of kidney stones is he likely to develop?
|
Uric acid from urate nephropathy
|
|
|
A person has a crescendo-decrescendo murmur heard in the right second intercostal space that radiates to the carotids, what is the defect?
|
Aortic Stenosis
|
|
|
Which type of hepatitis is not affected by alcohol?
|
HAV
|
|
|
46 XX female is born with male genitalia and a vagina that ends in a blind pouch, has hypertension and hypernatremia
|
Adrenal hyperplasia
Hydroxylase deficiency |
|
|
Baby is born with puffy face, sluggish and diminished deep tendon reflexes?
|
Cretin (hypothyroidism)
|
|
|
A systolic murmur is heard in the mitral area. It increases in intensity by 1 grade after a pause. What murmur is it?
|
Mitral Regurgitation
|
|
|
Girl comes in with corneal rings, hepatic and brain changes
|
Copper in Wilson's disease
|
|
|
Patient comes in with leukemia. Over the past year she has developed a decreased hematocrit with microcytic hypochromic anemia:
|
Anemia of chronic disease
|
|
|
Pregnant woman has polyhydramnios. What does the fetus have?
|
Anencephaly
|
|
|
Tumor with loss of p53 suppressor gene. Loss of regulation at what point?
|
G1 to S phase
|
|
|
Boy with pica for paint has anemia with basophilic stippling. What will be the finding in this patient?
|
Increased free erythrocyte protoporphyrin in Pb poisoning
|
|
|
90 yo lady suddenly dies. On autopsy the cerebral ventricles are enlarged. What is teh most likely cause?
|
Cerebral atrophy
|
|
|
Previously healthy 12 yo girl develops aplastic anemia. Cause?
|
Parvovirus
|
|
|
Different diagrams of wound healing and must identify which one is correct.
|
Basal layer of the epidermis joining with the one on the other side.
|
|
|
Patient with small-medium vessel disease in HBsAg positive. Diagnosis?
|
Polyarteritis nodosa
|
|
|
Graph with increased basophils, neutrophils and monocytes. What is the cause?
|
GM-CSF
|
|
|
Patient has a stab wound to chest and there is lung collapse. What is the pressure inside the pleural cavity?
|
Same as atmospheric pressure
|
|
|
Scenario of a man who has had a stroke and died. Autopsy shows brain with hemorrhage. What is the cause?
|
Stroke involving lenticulostriate branches of the MCA due to hypertension
|
|
|
Man working with rocks develops pulmonary symptoms
|
Silicosis
|
|
|
Tactile fremitus
|
Increased in consolidations and
Decreased in pneumothorax |
|
|
Egophony
|
E sounds like A
Sign of consolidation |
|
|
Percussion
|
Decreased in consolidation, pleural effusion
Tympanitic in pneumothorax |
|
|
Scar tissue in brain
|
Also called gliosis adn due to astrocyte proliferation
|
|
|
Tissue most affected by decreased oxygen:
|
Renal medulla (particularly straight portion of proxomal tubule)
Followed by neurons in the brain |
|
|
Hypertensive brain injury:
|
Intracerebral hemorrhage
|
|
|
Patient with acute pyelonephritis
|
WBC casts
|
|
|
Complications of anorexia nervosa (marathon runner):
|
Secondary amenorrhea due to decreased GnRH
Osteoporosis |
|
|
Patient with bilateral hydronephrosis:
|
Urethral obstruction
|
|
|
Hormone increased in ascites:
|
Aldosterone due to decreased cardiac output and decreased metabolism by liver
|
|
|
Organ secondarily affected in cirrhosis of liver:
|
Spleen enlarged due to portal hypertensoin
|
|
|
Amniotic fluid embolism
|
Causes DIC
|
|
|
Serum haptoglobin:
|
Decreased in intravascular hemolytic anemia
|
|
|
Type of anemia in chronic lymphocytic leukemia:
|
Autoimmune hemolytic anemia
|
|
|
Neonatal respiratory distress syndrome:
|
No surfactant
|
|
|
Findings 30 min after acute myocardial infarction:
|
No changes
|
|
|
Phosphorus increased in what kind of renal failure
|
Chronic
|
|
|
M TB site in reactivation:
|
Upper lobe of lung
High O2 tension |
|
|
Pancoast tumor cause Horner syndrome:
|
Destruction of superior cervical anglion in posterior mediastinum.
|
|
|
Gp 120 attachment of HIV virus to:
|
CD4 molecule
|
|
|
Causes of children getting a disease when parents don't have any evidence of it:
|
Incomplete penetrance in an autosomal dominant disease
|
|
|
Patient with a history of bone marrow transplant and who is on Cyclosporin, has neutropenia and develops esophagitis
|
Picture of intranuclear inclusion -
If a single inclusion or an owl eye, pick CMV, If multinucleated cell with intranuclear inclusions, pick Herpes |
|
|
Enzymes decreased in lead poisoning:
|
Ferrochelatase
ALA dehydrase |
|
|
Patient with a history of hypertension develops an intracranial hemorrhage. What part of the brain is affected
|
Basal ganglia (putamen is the most common area)
|
|
|
Huntington's disease:
|
Caudate atrophy
Dementia Odd movements Autosomal dominant Trinucleotide repeat disorder |
|
|
Firefighter with a history of dyspnea 6 hours following a fire. Histologic section of alveoli with hyaline membranes:
|
ARDS
|
|
|
Most likely organism for septic arthritis.
|
Neisseria
|
|
|
Alcoholic with a history of dpression and hypoglycemic episodes. Low blood glucose and no C-peptide:
|
Patient has been haking insulin
|
|
|
Cause of acute renal failure in a patient in a nursing home who hasn't eaten or drunk anything for a while. Patient is dehydrated, has a history of a stroke 6 months ago, and has increased BUN and creatinine from previous values. He has pyuria byt no hematuria. he has not urinated in 12 hours. After catheterization, 100mL of very dark yellow urine is removed. What is it?
|
Probably prostatic hyperplasia causing urinary retention and infection.
|
|
|
Cause of pneumonia in cystic fibrosis:
|
Pseudomonas aeruginosa
|
|
|
An alcoholic has a Klebsiella infection involving the upper lobe of the right lung, what kind of necrosis is it
|
Liquefactive necrosis
|
|
|
Granular IgG and C3 deposits are found in teh glomerular BM:
|
Type II membranoproliferative GN
|
|
|
What part of the kidney is most involved in diabetes:
|
Glomerulus
|
|
|
Tall, skinny 17 year old basketball player wiht long arms and legs and hyperflexible joints, what is teh boy likely to develop:
|
Marfan's with danger of dissecting aortic aneurysm
|
|
|
A 6 year old boy ingests rat poisoning, along with supportive therapy, what should be given:
|
IM vitamin K injection
|
|
|
Prenatal vitamins:
|
Iron women only have 400mg of iron stores adn lose 500 mg in pregnancy
Folate only 3-4 months supply in liver B12 is not necessary unless a woman is a pure vegan |
|
|
Most cost effective way of preventing hepatic coma in cirrhotics
|
Reduce protein intake
Derease ammonia load to liver where urea cycle is dysfunctional |
|
|
Vitamin deficiency associated with depression:
|
Niacin deficiency due to tryptophan deficiency,
Tryptophan synthesizes serotonin, which is decreased in depression |
|
|
Vitamin deficiency associated with a tea and toast diet in elderly patient with bleeding gums:
|
Vitamin C
|
|
|
Patient being treated for TB develops a microcytic anemia:
|
Sideroblastic anemia form B6 deficiency related to INH Rx.
|
|
|
Vitamin D deficiency in a patient on phenytoin:
|
Increased metabolism by the cytochrome system
|
|
|
Pure vegan is breast feeding baby. Baby develops anemia
|
B12 deficiency
|
|
|
Child with milk allergies develops macrocytic anemia
|
Taking goats milk which is deficient in folic acid
|
|
|
After an earthquake in southern CA many people develop pulmonary symptoms, what is the most likely causal organism:
|
Coccidioides
|
|
|
Cause of anemia in a paatient wiht nodular sclerosing type of lymphoma
|
Anemia of chronic disease
|
|
|
Woman wiht incomplete mole. Genotype?
|
triploid 69 XXY
|
|
|
Patient insensitive to burning of hands
Upper extremity muscle weakness |
Syringomyelia
|
|
|
Fuzzy balls in apical lung cavities in a patient wiht massive hemoptysis
|
Aspergillus
|
|
|
Solitary coin lesion in teh lungs of a patient from Mississippi
|
Histoplasmosis
|
|
|
Patient wiht prosthetic heart valve has schistocytes inperipheral blood:
|
Prosthetic valve is malfunctioning causing hemolytic anemia
|
|
|
MCC of bladder diverticula:
|
Prostatic hyperplasia
|
|
|
Prevent keloid formation:
|
Intralesoinal injection of corticosteroids
|
|
|
Mother and father blind but no family history of blindness, one child already blind, chance other child will be blind:
|
Patients proabably have homomzygous AR disease and parents were asymptomatic carriers
All children will have the disease (100%) |
|
|
MCC of bladder diverticula:
|
Prostatic hyperplasia
|
|
|
Prevent keloid formation:
|
Intralesional injection of Corticosteroids
|
|
|
Mother and fater blind but no family history of blindness, one child already blind, chance other child will be blind
|
Patients probbly have homozygous AR disease and parents were asymptomatic carriers
All children will have the disease (100%) |
|
|
Vitamin deficiency in pheochromocytoma
|
Vitamin C
Catalyzes dopamine to norepinephrine |
|
|
Phases of acute inflammation
|
Begins wiht transient vasoconstriction before vasodilitation from histamine release
|
|
|
Yellow mass extending up inferior vena cava:
|
Renal adenocarcinoma invading renal vein with extension up IVC.
|
|
|
Granuloma in AIDS patient:
|
Would have macrophages but they would not be activated to kill phagocytosed organisms since CD4 T helper cells are gone
|
|
|
Cause of increased serum cortisol and thyroxine in pregnancy
|
Increase in synthesis of their respective binding proteins by estrogen stimulation of liver
TSH and ACTH are both normal Free hormone levels are normal |
|
|
Mother with poyhydramnios and fetus wiht anal atresia:
|
VATER syndrome:
Vertebral defects Anal atresia Tracheoesophageal fistula Radial (absent) and Renal abnormalities |
|
|
Patient wiht deep venous thrombosis only given warfarin (not heparin) experiences further popagation of venous clot:
|
Heterozygote protein C deficiency
Short half life of protein C renders the patient hypercoagulable in 6-8 hrs, since factors V and VIII are increased due to complete absence of protein C in the blood Patient could also have developed hemorrhagic skin necrosis |
|
|
Patient develops oliguria after an intravenous pyelogram:
|
Developed nephrotic acute tubular necrosis
Dangerous to order an IVP in multiple myeloma and diabetes mellitus |
|
|
Rheumatoid factor
|
IgM antibody against IgG
|
|
|
Child whose father has a history of osteogenic sarcoma, develops an eye problem.
|
child probably has retinoblastoma wiht inactivation of Rb suppresor gene on chromosome 13
Osteoginic sarcoma and breast cancer are other cancers associated with this suppressor gene Likely that this was an autosomal dominant inheritance pattern, so one of the Rb suppressor genes was already inactivated at birth If relatives on mother's side are all normal, then the child's eye problem would likely be sporadic inactivation (mutation) of the Rb suppressor gene, where both chromosomes have to be inactivated |
|
|
Weight lifter develops numbness and tingling in the arm while sleeping
|
Thoracic outlet syndrome with compression of subclavian artery and brachial plexus by hypertrophied anterior scalenus muscle.
|
|
|
Male child with chronic infection with a granulomatous reaction
|
Chronic granulomatous disease of childhood
XR inheritance Absent NADH oxidase in neutrophils and monocytes therefore cannot convert molecular oxygen into superoxide free radicals (absent respiratory burst) and cannot kill bacteria, especially Staphylococcus aureus Without superoxide, peroxide cannot be produced by superoxide dismutase Without peroxidase, myeloperoxidase cannot combine peroxide with chloride to produce bleach |
|
|
chromosome 21 codes for Alzheimer precursor protein (APP) part of which is amyloid-Beta protein
|
Toxic to neurons, association with Down syndrome
MCC of Alzheimer's in patient's under 40 |
|
|
Apolipoprotein gene E, allele E4 located on chromosome 19
|
Produces a product that increases the neurotoxicity of teh A-Beta protein in Alzheimer's disease
Cause of familial late-onset type |
|
|
Abnormality on chromosome 14 in Alzheimer's disease
|
Synthesizes a Tau microtubule-associated protein located in neurofibrillary tangles
|
|
|
Hamartoma
|
Overgrowth of tissue normally present in the organ
Bronchial hamartoma: increase in cartilage Peutz jeghers polyp Hyperplastic polyp in the sigmoid colon Angiomyolipoma of kidney: seen in tuberous sclerosis |
|
|
Heterotopic rest (choristoma)
|
Normal tissue in a place it is not normally present
Pancreatic tissue in wall of stomach Gastric mucosa in a Meckel's diverticulum |
|
|
Patient with restrictive lung disease, Raynaud's phenomenon, renal disease
|
Progressive systemic sclerosis (scleroderma)
Esophageal dysmotility is another major problem leading to replacement of smooth muscle by collagen Dysphagia for solids and liquids |
|
|
AAT deficiency:
|
AR disease
AAT is an anti-elastase that destroys elastase (protease) released by neutrophils Children with certain phenotypes develop cirrhosis: PAS/AAT in the hepatocytes (defect in secretion of AAT out of hepatocytes) Young adults with certain phenotypes have complete deficiency of AAT and develop panacinar emphysema (entire respiratory unit destroyed) in lower lobes (absent alpha 1 globin peak on a serum protein electrohoresis) |
|
|
First step in management of tension pneumothorax
|
Positive pressure in pleural cavity push the lungs and mediastinum in opposite direction, hence compromising respiration and venous return to the heart
Insert needle into second intercostal space (anterior chest) to release positive pressure buildup in the pleural cavity |
|
|
Graves disease:
|
IgG antibody directed against the TSH receptor:
Type II hypersensitivity reaction |
|
|
Newborn with tetany and small ears:
|
DiGeorge syndrome
3rd and 4th pharyngeal pouches do not develop (absent thymus and thymic shadow and absent parathyroids) Expect hypocalcemia |
|
|
NSAIDs:
|
Prolongs bleeding time
Inhibiting cyclooxygenase decreases synthesis of TXA2 and platelets cannot aggregate Normal platelet count and prothrombin and partial thromboplastin time |
|
|
Nine month old black child has dactylitis
|
Sickle cell crisis
Sickle cell disease is due to a point mutation (missense mutation) where valine replaces glutamic acid in teh 6th position of the Beta-globin chain |
|
|
Pernicious anemia:
|
Autoimmune destruction of parietal cells
Absent intrinsic factor (B12 deficiency) and acid production Achlorhydria causes increase in serum gastrin levels |
|
|
Hemophilia A
|
SXR
Deficient VIII coagulant VIII complexes with platelet factor 3 IXa and calcium to activate factor X |
|
|
NSAIDs (indomethacin)
|
Decrease PGE2, which normally maintains the mucous barrier in th estomach and proximal duodeum
Predisposes to gastric erosions and peptic ulcer |
|
|
Women with excessive weight loss (marathon runner, aerobics instructor, anorexia nervosa, GI Jane)
|
Decrease secretion of GnRH from hypothalamus leading to decrease in gonadotropins
Secondary amenorrhea Osteoporosis (lack of estrogen) |
|
|
Women in 40's with malignant ascites adn large ovarian mass:
|
Probably a mucinous cystadenocarcinoma
A very large ovarian tumor often associated with pseudomyxoma peritonei, if it was bilateral, then a serous cystadenocarconima would be most likely |
|
|
Posterior acute MI, Right heart enlarges in 1 week, pulmonary capillary wedge pressure is decreased
|
Probable right ventricular infarction with pure right heart failure
Potentially could be a pulmonary embolus producing right heart strain |
|
|
Gross (G) and Microscopic (M) changes in an acute MI
|
0-4 hrs.: no G/M change
4-12 hrs: no G change/M shows coagulation necrosis after 6 hrs 12-24: G shows early pallor/M shows more advanced coagulation necrosis 1-3 days: G definite pallor/M neutrophilic infiltrate coming in from the perimeter of the infarct + advanced coagulation necrosis 3-7d: period of maximal softness/time for ruptures/macrophages move in from the perimeter to remove dead tissue 7-10d: G is the same as 3-7d/M shows collagen deposition |
|
|
Thyromegaly, normal thyroxine and TSH, presence of antimicrosomal and antithyroglobulin antibodies
|
Early stage of Hashimoto's thyroidtis
|
|
|
Patient develops dementia after instrumental involvement in the brain:
|
CJ disease due to prions
|
|
|
Baby wit syndactyly
|
Defect in apoptosis, which normally would have caused regression of those insipidus
|
|
|
Hematopoiesis in last month of fetus
|
Occurs in bone marrow
|
|
|
Baby chokes with every feeding and develops pneumonia
|
TE fistula
Blind proximal esophagus Distal esophagus arises from trachea: stomach distended Mother with polyhydramnios |
|
|
DES
|
Interferes with development of Mullerian structures
|
|
|
Patient with a central line develops hemiparesis
|
Central line is inserted either into the subclavian vein or the internal jugular vein
Clot develops in the central line and embolizes to right atrium and enters systemic circulation through an atrial septal defect. |
|
|
Hyponatremia
|
Could be due to an:
A) excess of free water (inappropriate ADH syndrome) B) reabsorption of proportionately more water than salt (edema states like R heart failure, cirrhosis) C) Loss of proportionately more salt than water (loop/thiazide diuretics, 21-hydroxylase deficiency, Addison's disease with loss of mineralocorticoids RxA: Water restriction RxB:Water and salt restriction + diuretics RxC: Isotonic saline |
|
|
Sex differentiation
|
Y chromosome determines genetic sex
Absence of Y results in differentiation of germinal tissue into ovaries. Wolfian duct structures undergo apoptosis Prensece of Y causes germinal tissue to differentiate into testes. Mullerian inhibitory factor is synthesized leading to apoptosis of mullerian tissue in the male fetus. Fetal testosterone develops, epididymis, seminal vesicles, vas deferens Fetal DHT develops: prostate, external male genitalia: fusion of the labia leads to scrotum, extension of the clitoris leads to penis 5-alpha-reductase: converts testosterone into DHT |
|
|
True hermaphroditism
|
Patient has both male/female gonads: ovary and testis or ovotestis
Majority are 46 XX genotype |
|
|
Pseudohermaphrodite
|
Patient whose phenotype (appearance) is not in agreement wiht genotype (true gonadal sex)
Male pseudohermaphrodite: genotypic male (XY with testes), phenotype appears female (female genitalia), e.g., Testicular feminization Female pseudohermaphrodite: genotypic female (XX with ovaries), phenotypically resembles a male, e.g., virilization in androgenital syndrome |
|
|
5 alpha-reductase deficiency:
|
Male pseudohermaphrodite: not present in females
Absence of DHT effect on male fetus: testes located in inguinal canals, absence of prostate gland: no DHT effect, absence of all mullerian structures: no tubes/uterus/cervix/upper one-third of vagina since mulerian inhibitory factor is present External genitalia female due to ansence of DHT effect: blind vaginal pouch, vagina partly mullerian inorigin and partly of urogenital sinus origin Presence of testosterone effect including ipididymis, seminal vesicles, vas deferens |
|
|
Testicular feminization
|
SXR disease: MCC of male pseudohermaphroditism
Deficiency of androgen receptors:DHT and testosterone are present but cannot function wihtout a receptor No mullerian structures: mullerian inhibitory factor ispresent No male accessory structures: no testosterone effect, absent epididymis/seminal vesicles/vas deference/prostate gland External genitalia remain female: no DHT effect, vagina ends in a blind pouch Testicles are located in inguinal canal or abdominal cavity: surgically removed owing to a risk for seminoma Estrogen unopposed since estrogen receptors are normal: secondary female characteristics are well developed Patient is reared as a female Laboratory findings: normal testosterone/DHT, increased LH: LH does not respond to the negative feedback of testosterone |
|
|
Smoker with flank pain and mass, hematuria
|
Renal adenocarcinoma
Derives from proximal renal tubular epithelium Smoking MCC |
|
|
Family tree with AD inheritance pattern showing disease occurring at an earlier age in affected members:
|
Trinucleotide repeat disorder: diseaase gets worse in future generations due to addition of trinucleotide (e.g., CAG)
Huntington's disease an AD movement disorder associated iwth dementia would occur an earlier age Female carriers of fragile X will develop symptoms of mental retardation. |
|
|
Stillborn of diabetic mother inpoor glycemic control
|
Likely see hyperplasia/hypertrophy of Beta-islet cells in teh pancreas as a fetal response to maternal hyperglycemia
|
|
|
Cirrhosis of liver:
|
Nodules are regenerative nodules composed of hepatocytes with no cord-sinusoid-cord pattern
Antiboties that would be helpful in determining the cause would be antibodies against HCV Antigen that would be useful is HBsAg |
|
|
Newborn has cataracts and vomiting
|
Probably an inborn error of metabolism (e.g., galactosemia or hereditary fructose intolerance)
Order a urine for reducing substances: defects fructose and galactose |
|
|
IV infustion of thiamine (B1) in an alcoholic:
|
Thiamine is a cofactor for pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, and alpha-ketoacid dehydrogenase
All of these reactions produce NADH, which in turn, generates 6 ATP |
|
|
Electrolyte abnormalities in diabetic ketoacidosis:
|
Increased anion gap metabolic acidosis
Increase in AcAc and Bety-OHB, hyponatremia Dilutional effect of water moving out of ICF into ECF by osmosis, hyperkalemia transcellular shift of K+ out of cell as H+ moves into the cell Actually the patient is deficient in K+ due to osmotic diuresis, loss of excessive aount of Na+ and K+ in urine Osmotic diuresis |
|
|
Child with petechia, thrombocytopenia, normal PT and PTT, no schistocytes:
|
Idiopathic thrombocytopenic purpura, type II hypersensitivity
|
|
|
Vegetarian with micrcytic anemia
|
probable iron deficiency, plant iron is ferric and mst be converted into ferrous to be reabsorbed
Very small risk for iron deficiency |
|
|
Woman with facial rash, arthralgia, positive VDRL with negative FTA-ABS
|
SLE
not the biologic false positive syphilis serology due to anti-cardiolipin antibodies |
|
|
Raised red lesions in AIDS patient:
|
Most often due to Kaposi's sarcoma (HSV-8)
could also be bacillary angiomatosis due to Bartonella henselae: silver stains identify organism, also cause of cat scratch disease |
|
|
Animal with AB alleles crossed with animal with AC alleles. What percent of offspring can receive an AA organ?
|
75%
AA - 25% AC - 25% AB - 25% BC - 25% |
|
|
ABG:
pH: 7.22 PaCO2: 69 HCO3-: 27 |
Acute uncompensated respiratory acidosis:
Birbiturate overdose, CNS trauma, ARDS, Paralyzed diaphragm or other muscles of respiration |
|
|
ABG:
pH: 7.26 PaCO2: 26 HCO3-: 11 |
Metabolic acidosis with partial compensation:
Any cause of increased AG metabolic acidosis: lactate, AcAc, Beta-OHB, formate (methyl alcohol poisoning), oxalate (ethylene glycol poisoning), renal failure, salicylate Any cause of normal AG metabolic acidisos: diarrhea, renal tubular acidosis |
|
|
ABG:
pH: 7.33 PaCO2: 68 HCO3-: 34 |
Chronic respiratory acidosis with partial compensation:
Chronic bronchitis Bronchiectasis Lungs in cystic fibrosis |
|
|
ABG:
pH: 7.42 PaCO2: 22 HCO3-: 14 |
Mixed primary respiratory alkalosis and primary metabolic acidosis:
Salicylate intoxication Endotoxic shock |
|
|
ABG:
pH: 7.51 PaCO2: 48 HCO3-: 38 |
Metabolic alkalosis with partial compensation:
Vomiting, Loop/Thiazide diuretic Mineralocorticoid excess (primary aldosteronism) |
|
|
ABG:
pH: 7.56 PaCO2: 24 HCO3-: 21 |
Respiratory alkalosis with partial compensation:
Pulmonary embolus Anxiety Restrictive lung disease |
|
|
Serum Na+: 118
Serum K+: 3.0 Serum Cl-: 88 Serum HCO3-: 22 |
Patient has inappropriate ADH syndrome
Note the dilutional effect on all the analytes, especially the serum Na+ |
|
|
Serum Na+: 130
Serum K+: 3.0 Serum Cl-: 80 Serum HCO3-: 36 |
Patient has metabolic alkalosis due to vomiting or diuretics (thiazides or loops)
|
|
|
Serum Na+: 130
Serum K+: 5.5 Serum Cl-: 88 Serum HCO3-: 10 |
Patient has increased anion gap (32 mEg/L) metabolic acidisos
Hyperkalemia is due to transcellular shift |
|
|
Serum Na+: 128
Serum K+: 5.8 Serum Cl-: 114 Serum HCO3-: 14 |
Patient has Addison's disease or a type IV RTA due to mineralocorticoid deficiency
Note that these patients have a normal AG metabolic acidosis and hyperkalemia |
|
|
Serum Na+: 140
Serum K+: 3.0 Serum Cl-: 114 Serum HCO3-: 14 |
Patient has a normal anion gap metabolic acidosis due to diarrhea or a type I or type II RTA
Note the hypokalemia |
|
|
Serum Na+: 150
Serum K+: 2.0 Serum Cl-: 107 Serum HCO3-: 36 |
Patient has mineralocorticoid excess (primary aldosteronism)
|
|
|
Asian man with nasopharyngeal mass
|
Nasopharyngeal carcinoma
Associated with EBV |
|
|
Myeloperoxidase deficiency
|
Acquired or genetic
Ansent azurophilic granules in neutrophils in peripheral blood Respiratory burst is normal - can generate superoxide FRs Cannot kill bacteria Microbicidal defect No MPO to produce bleach |
|
|
congenital adhesion molecule (Beta2-integrins) defect
|
FAilure of hte umbilical cord to separate in newborns
No adhesion of neutrophils to the endothelial cells No inflammatory cells in the umbilical stump |
|
|
MCV: increased
Hypersegmented neutrophils: present Autoantibodies (against IF and parietal cells): present Achlorhydria: present Serum gastrin levels: increased Risk of stomach adenocarcinoma: increased Plasma homocysteine: increased Urine methylmalonic acid: increased Neurological disease: present Schilling's test: Corrected by adding IF Dx Folate, B12 deficiency or PA |
Pernicious Anemia
|
|
|
MCV: Increased
Hypersegmented neutrophils: Present Autoantibodies (against IF and parietal cells): Absent Achlorhydria: Absent Serum gastrin levels: Normal Risk of stomach adenocarcinoma: None Plasma homocysteine: Increased Urine methylmalonic acid: Increased Neurological disease: Present Schilling's test: Not corrected by IF Dx Folate, B12 deficiency or PA |
B12 deficiency
|
|
|
MCV: Increased
Hypersegmented neutrophils: Present Autoantibodies (against IF and parietal cells): Absent Achlorhydria: Absent Serum gastrin levels: Normal Risk of stomach adenocarcinoma: None Plasma homocysteine: Increased Urine methylmalonic acid: Normal Neurological disease: None Schilling's test: Not used Dx Folate, B12 deficiency or PA |
Folate deficiency
|
|
|
Folate deficiency
|
MCV: Increased
Hypersegmented neutrophils: Present Autoantibodies (against IF and parietal cells): Absent Achlorhydria: Absent Serum gastrin levels: Normal Risk of stomach adenocarcinoma: None Plasma homocysteine: Increased Urine methylmalonic acid: Normal Neurological disease: None Schilling's test: Not used |
|
|
B12 deficiency
|
MCV: Increased
Hypersegmented neutrophils: Present Autoantibodies (against IF and parietal cells): Absent Achlorhydria: Absent Serum gastrin levels: Normal Risk of stomach adenocarcinoma: None Plasma homocysteine: Increased Urine methylmalonic acid: Increased Neurological disease: Present Schilling's test: Not corrected by IF |
|
|
Microcytic anemias
MCV: Low Serum Iron: Low TIBC: High % Sat: Low Serum ferritin: Low RDW: High RBC count: Low RBC FEP: High Hgb electro.: Normal Marrow iron: Absent Miscellaneous: Ferritin best |
Iron deficiency
|
|
|
Microcytic anemias
MCV: Low Serum Iron: Low TIBC: Low % Sat: Low Serum ferritin: High RDW: Normal RBC count: Low RBC FEP: High Hgb electro.: Normal Marrow iron: High Miscellaneous: - |
ACD
|
|
|
Microcytic anemias
MCV: Low Serum Iron: Normal TIBC: Normal % Sat: Normal Serum ferritin: Normal RDW: Normal RBC count: High RBC FEP: Normal Hgb electro.: alpha-thal, normal: Beta-thal, Increased HgbA2 & HgbF Marrow iron: Normal Miscellaneous: Hgb electro gold standard |
Alpha, Beta-Thal minor
|
|
|
Microcytic anemias
MCV: Low Serum Iron: High TIBC: Low % Sat: High Serum ferritin: High RDW: Normal RBC count: Low RBC FEP: High Hgb electro.: Normal Marrow iron: High Miscellaneous: course basophilic stippling, ringed sideroblasts |
Sideroblastic (Pb poison)
|
|
|
RBC mass: Increased
Plasma volume:Increased SaO2: Normal Erythropoietin: Decreased |
Polycythemia rubra vera
|
|
|
RBC mass: Increased
Plasma volume:Normal SaO2: Decreased Erythropoietin: Increased |
Appropriate polycythemia COPD, cyanotic CHD
|
|
|
RBC mass: Increased
Plasma volume: Normal SaO2: Normal Erythropoietin: Increased |
Extopic polycythemia renal disease, HCC
|
|
|
RBC mass: Normal
Plasma volume: Decreased SaO2: Normal Erythropoietin: Normal |
Relative polycythemia: volume depletion
|
|
|
Oxygen saturation findings in congenital heart disease:
RA: 75 RV: 75 Pulm a.: 75 Pulm v.: 95 LV: 95 Aorta: 95 |
Normal SaO2
|
|
|
Oxygen saturation findings in congenital heart disease:
RA: 75 RV: 80 Pulm a.: 80 Pulm v.: 95 LV: 95 Aorta: 95 |
VSD
|
|
|
Oxygen saturation findings in congenital heart disease:
RA: 80 RV: 80 Pulm a.: 80 Pulm v.: 95 LV: 95 Aorta: 95 |
ASD
|
|
|
Oxygen saturation findings in congenital heart disease:
RA: 75 RV: 75 Pulm a.: 80 Pulm v.: 95 LV: 95 Aorta: 95 |
PDA
|
|
|
Oxygen saturation findings in congenital heart disease:
RA: 75 RV: 75 Pulm a.: 75 Pulm v.: 95 LV: 80 Aorta: 80 |
Tetralogy of Fallot
|
|
|
Oxygen saturation findings in congenital heart disease:
RA: 80 RV: 80 Pulm a.: 80 Pulm v.: 95 LV: 80 Aorta: 80 |
Transposition of the Great Vessels
|
|
|
Obstructive lung disease summary of pulmonary function tests
|
TLC: Increased
RV: Increased TV: Decreased VC: Decreased FEV1: Decreased FVC: Decreased FEV1/FVC: Decreased |
|
|
Restrictive lung disease summary of pulmonary function tests:
|
TLC: Decreased
RV: Decreased TV: Decreased VC: Decreased FEV1: Decreased FVC: Decreased FEV1/FVC: Normal to increased |
|
|
Location of Ulcerative Colitis
|
Primarily targets the rectum.
May extend up into left colon in continuous fashion (no skip lesions) or involve entire colon. Does not involve other areas of GI tract |
|
|
Location of Crohn's Disease
|
Terminal ileum involved in 80%
Terminal ileum alone 30% Ileum/colon 50% Colon alone 20% Anal involvement 75% Fissures, fistulas, abscesses Involves areas from mouth to anus |
|
|
Extent of Ulcerative colitis
|
Mucosal and submucosal
|
|
|
Extent of Crohn's disease
|
Transmural
|
|
|
Gross features of UC
|
Inflammatory polyps - pseudopolyps representing areas on inflamed residual mucosa
Friable, red mucosa bleeds easily when touched Ulceration/hemorrhage. no skip areas |
|
|
Gross features of Crohn's disease
|
Fat creeps around the serosa
Tick bowel wall and narrow lumen Skip areas Stricutres, fistulas in areas other than anus Deep linear ulcers, cobblestone pattern, aphthoid ulcers |
|
|
Microscopic features of UC
|
Active disease: mucosal inflammation wiht crypt abscesses (neutrophils)
Dysplasia/cancer may be present Chroinic disease: neutrophils replaced by lymphocytes/plasma cells. Dysplasia/cancer may be present |
|
|
Microscopic features of Crohn's
|
Very diagnostic features:
Noncaseating granulomas (60%), transmural inflammation with subserosal lymphocytic infiltration |
|
|
Complications of UC
|
More common than CD:
Toxic megacolon Hypotonic/distended bowel Sclerosing pericholangitis HLA B27+ ankylosing spondylitis/uveitis Pyoderma gangrenosum Adenocarcinoma (10% greatest risks are pancolitis, early onset of UC, and duration of disease >10 years) |
|
|
Complications of Crohn's
|
More common than than UC:
Fistula formation Obstruction Disease in other areas of GI tract Calcium oxalate renal stones |
|
|
Clinical UC
|
Left sided abdominal cram ping (not obstruction), diarrhea with blood/mucus, rectal bleeding, tenesmus (painful stooling)
|
|
|
Clinical Crohn's
|
RLQ colicky pain
Obstruction in area of terminal ileum iwht diarrhea Bleeding if colon involvement |
|
|
Radiograph UC
|
Lead pipe appearance in chronic disease
|
|
|
Radiograph Crohn's
|
String sign in the terminal ileum from luminal narrowing by inflammation
Fistulas |
|
|
HBsAg: negative
HBeAg: negative Anti-HBc-IgM: positive Anti-HBc-IgG: negative Anti-HBs: negative |
Serologic gap
|
|
|
HBsAg: positive
HBeAg: positive Anti-HBc-IgM: positive Anti-HBc-IgG: negative Anti-HBs: negative |
Acute infection or chronic if >6 months
|
|
|
HBsAg: negative
HBeAg: negative Anti-HBc-IgM: negative Anti-HBc-IgG: positive Anti-HBs: positive |
Recovered from HBV
|
|
|
HBsAg: negative
HBeAg: negative Anti-HBc-IgM: negative Anti-HBc-IgG: negative Anti-HBs: positive |
Immunized
|
|
|
HBsAg: positive
HBeAg: negative Anti-HBc-IgM: negative Anti-HBc-IgG: negative Anti-HBs: negative |
Earliest phase of acute HBV
|
|
|
POsm post H2O deprivation: 292
UOsm post H2O deprivation: 750 UOsm post ADH injection: 760 |
Normal
|
|
|
POsm post H2O deprivation: 319
UOsm post H2O deprivation: 110 UOsm post ADH injection: 550 |
Central diabetes insipidus
|
|
|
POsm post H2O deprivation: 312
UOsm post H2O deprivation: 98 UOsm post ADH injection: 120 |
Nephrogenic diabetes insipidus
|
|
|
POsm post H2O deprivation: 288
UOsm post H2O deprivation: 760 UOsm post ADH injection: 780 |
Psychogenic
|
|
|
Serum T4: Increased
RTU/T4BR: Increased FT4-I: Increased TSH: Suppressed I-131: Increased |
Grave's disease
|
|
|
Serum T4: Increased
RTU/T4BR: Increased FT4-I: Increased TSH: Suppressed I-131: Decreased |
Factitious thyrotoxicosis
|
|
|
Serum T4: Increased
RTU/T4BR: Increased FT4-I: Increased TSH: Suppressed I-131: Decreased |
Thyroidistis (acute, subacute)
|
|
|
Serum T4: Decreased
RTU/T4BR: Decreased FT4-I: Decreased TSH: Increased I-131: Decreased |
Primary hypothyroidism (Hashimoto's)
|
|
|
Serum T4: Decreased
RTU/T4BR: Decreased FT4-I: Decreased TSH: Decreased I-131: Decreased |
Secondary hypothyroidism (hypopituitarism/hypothal)
|
|
|
Serum T4: Increased
RTU/T4BR: Decreased FT4-I: Normal TSH: Normal I-131: Normal |
Increased TBG (increased estrogen)
|
|
|
Serum T4: Decreased
RTU/T4BR: Increased FT4-I: Normal TSH: Normal I-131: Normal |
Decreased TBG ( increased androgens)
|
|
|
Serum cortisol: Increased
Urine for free cortisol: Increased Low dose dexamethasone: Cortisol not suppressed High dose dexamethasone: Cortisol not suppressed Plasma ACTH: Decreased |
Adrenal Cushings
|
|
|
Serum cortisol: Increased
Urine for free cortisol: Increased Low dose dexamethasone: Cortisol not suppressed High dose dexamethasone: Cortisol not suppressed Plasma ACTH: Markedly increased |
Ectopic Cushing's
|
|
|
Serum cortisol: Increased
Urine for free cortisol: Increased Low dose dexamethasone: Cortisol not suppressed High dose dexamethasone: Cortisol suppressed Plasma ACTH: Normal to Increased |
Pituitary Cushing's
|
|
|
Non-caseating granuloma in an African-American with hypertension:
|
Sarcoidosis
|
|
|
Soft, tender lump in the inquinal area of a child:
|
Cryptorchid testis
|
|
|
Kidney of hypertension:
|
Nephrosclerosis - due to hyaline arteriolosclerosis
|
|
|
Woman with a 3cm mass removed from breast. One year later, the lung is involved. Mechanism of spread?
|
Hematogenous
|
|
|
Crateriform lesion on inner side of eye. Site of origin?
|
Basal cell carcinoma - derives from basal cell layer
|
|
|
Parotid mass with and without atypia
|
With atypia is a mucoepidermoid carcinoma
Without atypia is pleomorphic adenoma |
|
|
Patient with AIDS has a space occupying lesion in the brain:
|
Toxoplasmosis
|
|
|
Arteriogram of upper arm with a history of an absent radial pulse:
|
Damage to brachial artery - extension of the axillary artery and divides into the radial and ulnar artery
|
|
|
Hypoglosal nerve in brain stem:
|
Exits in medulla at preolivary sulcus
|
|
|
Cerebellum:
|
Purkinje (rabies inclusions), mossy fibers in lower cerebellum
|
|
|
Spinal spinothalamic tract and medial lemniscus:
|
Both go to thalmus
|
|
|
Types of junctions in lateral region of cells:
|
Zona occludens (tight junctions)
Zona adherens Desmosomes Gap junctions (nexus, passage of materials, dye passes from one cell to the next) |
|
|
Leaky junctions:
|
Present in proximal tubules of the kidneys
|
|
|
Actin:
|
Present in muscle in iris but are not responsible for motility in sperm
|
|
|
Signs of right hemisection:
|
Bilateral loss of pain and temperature sensation within dermatome of involved segments (crossed spinothalamic in ventral commissure)
Ipsilateral flaccid paralysis in affected myotomes (ventral horn) Contralateral loss of pain and temperature sensation one segmant below lesion (lateral spinothalamic tract) Ipsilateral spastic paralysis with pyramidal signs (loss of lateral corticospinal tract) Ipsilateral loss of tactile discrimination/positional sense/vibratory sensation from arm adn leg (loss of posterior columns) |
|
|
Brain stem for localization of CN VII
|
Patient history was paralysis of orbicularis oculi on right side and buccinator and facial muscles on right side
|
|
|
Brain stem for localization of CN VIII
|
History of sensorineural hearing loss
Located at cerebellopontine angle |
|
|
Brain stem for localization of CN VI
|
History of problem with lateral gaze - loss of function of lateral rectus
|
|
|
Solitary nucleus:
|
Receives general visceral afferents from CN IX and X and special visceral afferents from CN VII, IX, and X and projects these to the pons and thalamus
|
|
|
Neuroanatomy of brain slices for locations of structres involved in different disease:
|
Caudate nucleus - absent in Huntington's chorea
Lenticular nucleus - degenerated in patients iwth Wilson's disease and is associated Substantia nigra - see depigmentation in Parkinson's disease |
|
|
Hemiballismus in patient wiht Wilson's disease:
|
Degeneration of the subthalamic nucleus
|
|
|
Tabes dorsalis
|
Dorsal column syndrome - loss of tactile discrimination, loss of joint and vibratory sensation, paresthesia and pain (dorsal root irritation)
Astereognosis Hypo/areflexia (dorsal root deafferentation) Urinary incontinence/constipation/impotence (dorsal root deafferentation) |
|
|
CT of abdomen
|
Kidney is behind the pancreas
|
|
|
CT of thorax:
|
ID structures at tht level of the sternal angle
|
|
|
Muscle that attaches at iliac crest:
|
Gluteus medius, which abducts and rotates the thigh
Distal attachment is greater trochanter of femur |
|
|
Visual field defect wiht craniopharyngioma or acromegaly:
|
Bitemporal hemianopsia - impinges on optic chiasm
|
|
|
Outpouching of floor of diencephalon:
|
Cerebrum
|
|
|
Neurotransmitter of raphe nucleus
|
Serotonin
|
|
|
Location in a cystourethrogram of the urogenital diaphragm:
|
Muscles are deep transverse perineal and sphincter urethra muscle
In male, it is located just distal to prostate In female, probable at beginning of urethra when it exists the bladder |
|
|
Spinal cord site for loss of two point discrimination in left leg:
|
Fasciculus gracilis in dorsal columns covers two point discrimination for the ipsilateral leg (closest to midline)
Fasciculus cuneatus (lateral to cuneatus) covers two point discrimination for the ipsilateral arm |
|
|
Spinal cord site for loss of pain sensation in left leg:
|
Lateral spinothalamic tract on right side of cord (remember the cross-fibers)
|
|
|
Patient with dyscalculia, finger agnosia, left/right confusion.
|
Lesion in visual association cortex (angular gyrus) in left parietal lobe
Called Gerstmann's syndrome |
|
|
Papilledema
|
Swelling of the optic nerve - indicates an increase in intracranial pressure
|
|
|
Omphalocele
|
Midgut loop fails to return to abdominal cavity
Shiny sac visible at base of umbilicus |
|
|
X-ray of duplicated ureter:
|
Congenital anomaly
|
|
|
Horseshoe kidney
|
Lower poles fuse
Kidney trapped behind inferior mesenteric artery |
|
|
Nerve cut producing sensory loss on medial side of leg when taking saphenous vein for CABG procedure:
|
Saphenous nerve, which is a branch of femoral nerve
|
|
|
CT of abdomen:
Structure that splenic vein empties into: |
Empties into portal vein (posterior to neck of pancreas)
PV is composed of splenic vein and superior mesenteric vein (largest vessel) Inferior mesenteric vein ends by joining the splenic vein |
|
|
Ulnar nerve functions:
|
Medial epicondyle injuries
Normally adducts thumb - adductor policis muscle |
|
|
Lightening pains when coughing
|
Due to herniated disc compressing sensory root
|
|
|
EM of plasma cell:
|
Secretes antibodies
Prominent rough ER Eccentric nucleua with cartwheel appearing nuclear chromatin |
|
|
characteristics of postganglionic peripheral nervous system fibers:
|
Short
Near end organ |
|
|
Duodenal ulcer perforation and bleed:
|
Gastroduodenal artery
|
|
|
MRI of knee joint in a patient with a positive posterior drawer sign:
|
ID posterior cruciate ligament
|
|
|
Bicornuate uterus
|
Failure of fusion of paramesonephric duct
|
|
|
CN V:
|
Goes through superior orbital fissure
|
|
|
Melatonin:
|
Produced in the pineal gland
|
|
|
Abdominal incision to avoid interrupting blood supply:
|
midline
|
|
|
Cleft palate:
|
Maxillary prominence fails to fuse iwth medial nasal prominence
|
|
|
Hematopoiesis at 28th week:
|
Bone marrow main site
|
|
|
Schwann cell/oligodendrocyte:
|
Schwann cell makes myelin for PNS oligodendrocyte for CNS
Schwann cels develop form neural crest cells |
|
|
Location of neurohypophysis in teh pituitary:
|
Neurohypophysis is posterior lobe where ADH is stored
|
|
|
Loss of pain and temperature on side of face:
|
CN V lesion
|
|
|
Derivation of adrenal medulla
|
Nural crest origin (S100 antigen positive)
Neuroblasts develop into ganglia Know the layers of the adrenal gland from outside in from the cortex to medulla Glomerulosa (aldosterone) Fasciculata (cortisol) Reticularis (sex hormones) Medulla (catecholamines) |
|
|
Tibial nerve function:
|
Plantar flexion of toes
Injury causes - loss of plantar flexion Foot dorsiflexed an deverted Sensory loss on sole of foot |
|
|
Composition of aortic valve (also pulmonic valve)
|
Lined by endothelium and have abundant fibroelastic tissue plus a dense collagenous core
Avascular MV and TV have a loose connective tissue core composed of dermatan sulfate which is increased in mitral/tricuspid valve prolapse (myxomatous degeneration) |
|
|
Break humerus, wrist drop:
|
Radial nerve injury
|
|
|
Post-radical mastectomy - Winged scapula
|
Indicates injury to the long thoracic nerve; paralysis of the serratus anterior muscle
|
|
|
Patient with nosebleed and rhinorrhea:
|
Fracture of cribriform plate in ethomoid sinus
|
|
|
Medial longitudinal fasciculus demyelination in multiple sclerosis:
|
Bilateral internuclear ophthalmoplegia
|
|
|
parathyroid derivation:
|
Third and fourth pharyngeal ppuches
|
|
|
Aortic arch derivatives:
|
First: Part of maxillary artery
Second: Stapedial and hyoid artery Third: Common carotid artery and proximal portion of the internal carotid artery Fourth: Aortic arch on the left and proximal portion of the right subclavian artery on the right Sixth: Proximal portion of the pulmonary artery on the left and the ductus arteriosus. |
|
|
Nerve that runs along the radial artery:
|
Median nerve
|
|
|
Artery affected in femoral neck fracture:
|
Medial femoral circumflex artery
Damage leads to aseptic necrosis of the femoral head |
|
|
EM of egg:
|
Where does sperm penetrate (zona pellucida)
|
|
|
Type I collagen
|
Bone
Tendon Skin Greatest tensile strength |
|
|
Type III collagen
|
Initial collagen of wound repair
Replaced by type I via collagenase with Zn as a cofactor |
|
|
Type IV collagen
|
Basement membrane
|
|
|
Type X collagen
|
Epiphyseal plate
|
|
|
Wallerian degeneration:
|
Schwann cells begin to proliferate and form a tube that will serve to guide axon sprouts in the regeneration process
Regeneration of the nerve occurs by the outgrowth of multiple axon sprouts from the proximal surviving segment of the axon Sprouts are directed distally down the tube established by the proliferating Schwann cells Sprouts are remyelinated and reestablish continuity with the motor end of the muscle |
|
|
CT liver:
|
Hepatic vein drains into the IVC
|
|
|
Eye closed cannot open and eye deviated down and out.
|
Oculomotor nerve palsy
|
|
|
Eye down and in
|
Trochlear nerve palsy
|
|
|
Blunt inury to the back of the throat:
|
Potential injury to the cervical sympathetic ganglion
Ptosis and meiosis of the right eye |
|
|
Vertical diplopia
|
Cranial nerve IV palsy
|
|
|
Patient with headache and physical findings of mydriasis in the right eye in association with m ild lid lag, and deviation of the eye down and out:
|
An aneurysm compressing cranial nerve III
Headache is the giveaway for aneurysm |
|
|
Patient with a recent history of bacterial meningitis has horizontal diplopia in the left eye, which is worse on gaze to the left
|
Cranial nerve VI palsy
Lateral rectus weakness from VI nerve palsy |
|
|
Patient with bilateral lateral rectus muscle weakness.
|
Increase in intracranial pressure
classic sign Papilledema usualy present |
|
|
Paralysis of upard gaze in an inant
|
Hydrocephalus secondary to stenosis of The aqueduct of Sylvius
This is called Parinaud's syndrome |
|
|
Multiple ocular motor nerve disorders:
|
DM
Common cranial nerve palsies from osmotic damage to nerves |
|
|
Weakness of the quadriceps muscle and an absent knee jerk reflex:
|
Herniated L3-L4
|
|
|
Fall on outstretched arm with pain in the middle and lateral portion of clavicle and upper extremity remains in abduction, extension, and internal rotation
|
Nerve injury is C5-C6
Erb-Duchenne syndrome, or superior brachil plexus injury due to a clavicular fracture (most common fracture in newborns) C8-T1 are inferior brachial plexus injuries or Klumpke's syndrome |
|
|
Patient has paralysis of the oculomotor nerve after a head injury:
|
Uncal herniation with compression of the IIIrd nerve
Ptosis of eye, mydriasis |
|
|
Numbness of the thenar aspect of the hand
|
Median nerve (carpal tunnel)
|
|
|
Wrist bone with greatest incidence of aseptic necrosis:
|
Scaphoid bone
|
|
|
Fetal circulation:
|
Ductus venosus and umbilical vein have the highest oxygen content
|
|
|
EM of small bowel:
|
Look for microvilli on teh surface
|
|
|
Histologic section of seminiferous tubule:
|
Sertoli cell synthesizes sex hormone binding globulin and also synthesizes inhibin, which has a negative feedback with FSH
|
|
|
Bands in skeletal muscle:
|
A band has myosin ATPase: contracts
|
|
|
Respiratory bronchiole:
|
Last airway structure with cilia
Respiratory unit where gas exchange occurs is the respiratory bronchiole, alveolar duct, and alveoli |
|
|
Terminal bronchioles:
|
cilia but no goblet cells
Site of obstruction in asthma, cystic fibrosis and chronic bronchitis Site where turbulent air flow becomes laminar due to parallel branching of the airways |
|
|
Normal EM of a cell:
|
Know all the normal organelles in a cell
Golgi aparatus - posttranslational modification of various compounds RER - protein synthesis SER - site of cytochrome P450 system, synthesis of steroids, site of GGT |
|
|
Voice hoarseness post thyroid surgery
|
Injury to laryngeal nerve
|
|
|
MRI of orbit:
|
location of the superior oblique muscle
|
|
|
MRI of abdomen:
|
Splenic artery is above the pancreas
|
|
|
Chest x-ray:
|
Fluid in the costophrenic sulcus in CHF
|
|
|
X-ray with enargement of the posterior heart:
|
Enlarged LA in a patient with mitral stenosis
Most posteriorly located chamber in the heart See best with transesophageal ultrasound |
|
|
MRI of the carotids with occlusion of the anterior cerebral artery:
|
Would effect the contralateral leg
|
|
|
Schwannoma in jugular foramen:
|
Weakness of palate/loss gag reflex/laryngeal paralysis (X), trapezius/sternocleidomastoid (XI)
Loss taste sensation posterior third of tongue (IX) |
|
|
Weber syndrome
|
Lesion of oculomotor nerve and UMN signs
Usually associated with a midline, midbrain lesion |
|
|
Horner's syndrome
|
Diagram of vertebra and sympathetic trunk
Pick superior cervical sympathetic ganglion |
|
|
Pupil light reflexes with eye diagrams of pupils:
|
One set is an oculomotor nerve lesion with the light in the pupil in a down and out location
|
|
|
Brainstem anterior view:
|
find area of oculomotor nerve
|
|
|
Frontal lobe lesion
|
Affects personality
|
|
|
Inferior quadrantanopia
|
Defect in the superior fibers in teh parietal lobe
|
|
|
Loss of sensation in the bands, history of burns without knowing it:
|
Syringomyelia in cervical cord and involvement of crossed spinothalamics
|
|
|
Cross transection of fasciculus gracilis:
|
Effects vibration and fine touch of lower extremity only
|
|
|
CN III and UMN signs on opposite side:
|
Midline midbrain lesion
|
|
|
Loss of pain and temperature and UMN signs on opposite side:
|
Mid pons lesion
|
|
|
Horner's syndrome with localization of lesion on a diagram:
|
Lateral medullary syndrome with associated cranial nerve palsy in teh medulla and hypothalamus with associated temperature regulation problems
|
|
|
Parkinson's disease:
|
MPTP drug of abuse association - derivative of meperidine
|
|
|
Cross-section of an embryo:
|
Identify neural crest tissue
|
|
|
Blood production prior to birth:
|
YOLK SAC leads to LIVER leads to BONE MARROW
|
|
|
Bochdalek hernia in posterolateral part of diaphragm on left:
|
Present early in life
visceral contents extend into the chest cavity causing severe respiratory distress at birth Parasternal diaphragmatic hernias extend through the foramen of Morgagni beneath the sternum and do not usually develop symptoms until later in life |
|
|
Artery associated wiht foregut, midgut, hindgut:
|
Foregut: celiac
Midgut: superior mesenteric Hindgut: inferior mesenteric |
|
|
Damage to hearing in a rock and rol band player:
|
Injury to cochlea
|
|
|
Small vs. large bowel: Plicae semilumaris
|
Plicae semilumaris go around entire circumference of small bowel and are interrupted in large bowel
|
|
|
Argyll-Robertson pupil:
|
Accommodates when patient follows finger moving towards the nose, but does not react to direct light
Neurosyphilis |
|
|
MRI of liver:
|
Hepatic vein - vessel emptying into the inferior vena cava
|
|
|
Pathogenesis of hypospadias:
|
Faulty closure of urethral folds
|
|
|
Pathogenesis of epispadias:
|
Defect in genital tubercle, associated with exstrophy of bladder
|
|
|
Feces draining from umbilicus in 4 day old:
|
Persistent umbilical (vitelline) sinus
|
|
|
Urine draining from umbilicus in 4 day old:
|
Persistent urachal sinus
|
|
|
Femoral neck fracture:
|
Bleeds into the capsule and may compromise medial femoral circumflex artery leading to avascular necrosis
|
|
|
Embryology of mullerian duct, wolffian duct, urogenital sinus
|
Structures derived from the Mullerian duct include: Fallopian tubes, Uterus, Cervix, upper 1/3 of vagina
In male fetuses, the paired wolffian (mesonephric ducts) form the epididymis, seminal vesicles, and vas deferens, testosterone controls this, DHT develops the external genitalia of the male fetus and the prostate gland In female fetuses, teh wolffian duct normally regresses: Inclusion may persist to form cysts, Structures derived from urogenital sinus include: Vestibule, lower 2/3rds of the vagina |
|
|
Anatomy/histology of ovary:
|
Lined by coelomic epithelium: suface derived ovarian tumors derived from this
Outer cortex contains the follicles Medulla contains mesenchymal tissue and steroid-producing hilar cells - stromal thecosis of the hilar cells leads to hirsutism Ovaries in a postmenopausal woman should not be palpable - enlarged ovary is cancer until proven otherwise |
|
|
Oogonia at birth
|
Arrested in prophase I of meiosis and are called primary oocytes
Arrested cells are diploid and have 46 chromosomes |
|
|
Primary oocyte
|
Primary oocyte completes the first meiotic division within the mature follicle shortly before ovulation -
Secondary oocyte is haploid and contains 23 chromosomes, it enters the second meiotic division but is arrested in metaphase II at the time of ovulation, the secondary oocyte completes meiosis II during fertilization |
|
|
Anatomy/histology of cervix:
|
Endocervix (mucus secreting columnar cells) + exocervix (squamous cells, begins at cervical os)
Squamocolumnar junction (SCJ) is where the two epithelium's meet Endocervical epithelium normally migrates down into the exocervix and replaces the normally squamous epithelium with mucus secreting columnar epithelium columnar cells exposed at teh cervical os undergo squamous metaplasia (called the transformation zone) the TZ is the area where squamous dysplasia and cancer develops |
|
|
Bilateral internuclear ophthalmoplegia:
|
Demylination of medial longitudinal fasciculus, pathognominic of multiple sclerosis
When the patient is asked to look right, the right eye moves and has jerk nystagmus but the left eye is still looking straaight ahead When the patient is asked to look left, the left eye moves and has jerk nystagmus but the right eye is still looking straight ahead |
|
|
Rotator cuff tear:
|
Common cause of shoulder pain
Components of the rotator cuff include the tendon insertions of: supraspinatus, infraspinatus, teres minor, subscapularis muscles S/S of rotator cuff injuries - pain/weakness with active shoulder abduction |
|
|
Shoulder dislocation:
|
Majority are anteriorly dislocated
Often injure the axillary artery/nerve |
|
|
Tennis elbow:
|
Pain occurs in teh area where the extensor muscle tendons insert near the lateral epicondyle
common in: raquette sports, repetitive use of a hammer or screwdriver |
|
|
Golfer's elbow:
|
Pain is located where the flexor muscle tendons insert near the medial epicondyle
|
|
|
Ulnar nerve compression:
|
The ulnar nerve may be entrapped in the following areas: transverse carpal ligament, elbow (funny bone area)
There is pain an dnumbness of the ulnar aspect of the forarm and ring and little finger plus weakness of the intrinsic muscles of the hand |
|
|
Reflex loss in C4-C5 disc:
|
Biceps reflex associated with musculocutaneous nerve C5-C6
|
|
|
Reflex loss in C5-C6 disc:
|
Supinator
|
|
|
Reflex loss in C6-C7 disc:
|
Triceps reflex associated wiht radial nerve C6-C8
|
|
|
DeQuervain's disease
|
Chronic stenosing tenosynovitis of the first dorsal compartment of the wrist
Due to overuse of the hands and wrist The first dorsal compartment contains the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) Extension friction causes thickening of the tendon sheath and stenosis of teh osseofibrous tunnel Pain occurs on the radial aspect of the wrist and is aggravated by moving the thumb - pain in the region of the radial styloid process |
|
|
Ganglion cyst
|
Common cause of a bulge on the dorsum of the wrist when the wrist is flexed
Ganglion cyst is filled with mucinous material Sometimes called the Bible tumor since a bible is often used to smash the cyst. |
|
|
Compartment syndromes:
|
Increase of pressure in a confined space - pressure reduces perfusion, which may lead to permanent inchemic contractures of the muscle in the compartment
S/S of a compartment syndrome: pain, paresthesia, pallor, paralysis, pulselessness Cause of compartment syndrome: Fractures, injuries to arteries/soft tissue, prolonged limb compression Volkmann's ischemic contracture: is a complication of a supracondylar fracture of the humerus, there is injury to the brachial artery and median nerve, brachial artery ischemia leads to increased pressure in teh closed muscle compartments of the forarm with a subsequent decrease in venous and then arterial perfusion: this may lead to permanent ischemic contractures of the muscle |
|
|
Carpal tunnel syndrome:
|
Entrapment syndrome of teh median nerve in teh transverse carpal ligament of the wrist
It may also be entrapped between the bellies of the pronator teres muscle along with the radial artery Causes: RA/pregnancy, overuse of the wrist/hands, amyloidosis, hypothyroidism S/S: pain, numbness, or paresthesia in the thumb, index finger, second finger, and the radial side of the thrd finger, thenar atrophy, pain is reproduced by tapping over the median nerve |
|
|
Claw hand
|
Ulnar nerve palsy
Ulnar nerve functions: adduction of the fingers due to innervation of the palmar and dorsal interosseus muscles, adduction of the thumb (adductor pollicic muscle) |
|
|
Wrist drop
|
Radial nerve palsy
Radial nerve functions: extensor muscles of the wrist and digits Wrist drop refers to a hand that is flexed at the wrist and cannot be extended Injury may be due to: midshaft fractures of the humerus, draping the arm over a park bench (Saturday night palsy) |
|
|
Waiter's tip deformity
|
Brachial plexus lesion involving C5 and C6 upper trunk injury
Clinical findings in Erb-Duchenne's palsy Birth injury of the brachial plexus with damage to externally rotate the arm Inability to supinate the forearm Absent biceps reflex Asymmetric Moro reflex: no movement on the affected side |
|
|
Klumpke's paralysis
|
Birth injury of the brachial plexus with injury to the C7 and C8 and T1 lower trunk injury
Paralysis of the hand Horner's syndrome |
|
|
Axillary nerve injury (C5-C6)
|
Fracture of the surgical neck of the humerus
Dislocation of the shoulder joint Usually anterior dislocation May also injure the axillary artery Patient cannot abduct the arm to the horizontal position or hold the horizontal position when a downward force is applied to the arm - paralysis of deltoid muscle Weakening of lateral rotation of the arm - paralysis of teres minor muscle |
|
|
Arteries, nerves, tendons cut with a deep laceration of the radial side of the wrist:
|
Artery - radial artery
Nerve - median nerve: courses along the radial artery Tendons - palmaris longus, flexor carpi radialis |
|
|
Arteries, nerves, tendons cut with deep laceration of the ulnar side of the wrist
|
Artery - ulnar artery
Nerve - ulnar nerve Tendon - flexor carpi ulnaris |
|
|
Cause of shin splints:
|
Repetitive loading of the anterior compartment muscles of the tibia
Inflammation occurs at teh musculotendinous insertions: these are often called "stress fractures" |
|
|
MC site for a compartment syndrome in the leg:
|
Anterior compartment of the tibia
|
|
|
Mechanism of low back pain:
|
MCC is spasm of the paraspinal muscles
Ligament strains: anterior/posterior longitudinal ligaments Nerve root irritation: intervertebral disc disease with nerve root compression Disease involving vertebral column - metastasis, multiple myeloma, osteoporosis with compression fractures |
|
|
MCC of intervertebral disc disease:
|
Degeneration of fibrocartiage/nucleus pulposus
The ruptured disc material may herniate posteriorly and compress the nerve root and/or spinal cord Pain radiates from the low back to the buttock, down the leg, below the knee S/S of disc herniation - leg pain is aggravated by straight leg raising |
|
|
Herniation of L5-S1 disc:
|
Sensory loss - Lateral and posterior calf, plantar aspect of the foot
Reflex loss - Achilles' reflex (tibial nerve L4-S3) Motor deficit - loss of plantar flexion Loss of foot eversion (weakness of peroneus longus/brevis) |
|
|
Herniation of L4-L5 disc:
|
Sensory loss - dorsum of the foot, webbed space between teh great toe
Reflex loss - none Motor deficit - loss of dorsiflexion of the big (great toe) due to weakness of the extensor hallucis longus |
|
|
Herniation of L3-L4 disc:
|
Sensory loss - medial leg to the maleolus
Reflex loss - knee jerk (femoral nerve L2-L4) Motor deficit - quadriceps weakness due to weakness of knee extension, loss of dorsiflexion of the foot due to weakness of the tibialis anterior |
|
|
Cuada equina syndorome:
|
Bowel or bladder dysfunction
Saddle area anesthesia |
|
|
Spondylolisthesis:
|
Forward subluxation of one vertebral body on another
MCC is spondylosis - defect in the vertebral lamina (pars interarticularis) with separation from the main body of the vertebra |
|
|
Superior gluteal nerve injury:
|
Causes - surgery, Duchenne's muscular dystrophy
Waddling gait - the superior gluteal nerve supplies the gluteus medius and minimus muscles, there is a loss of abduction of the thigh and inability to pull the pelvis down, there is a positive Trendelenburg's sign, raising of the foot on the injured side causes it. |
|
|
Inferior gluteal nerve injury:
|
Patient is unable to walk
Inferior gluteal nerve supplies the gluteus maximus muscle The patient leans backward when the heel strikes the ground |
|
|
MC site of sciatic nerve entrapment:
|
sciatic notch in the buttocks
|
|
|
Peroneal nerve injury:
|
MC site of entrapment is behind the knee - common in people who cross their legs a lot
The patient has a slapping gait Motor deficits - loss of foot eversion due to weakening of the peroneus longus and brevis mucles, loss of foot dorsiflexion due to weakening of the tibialis anterior mucle, loss of toe extension due to weakening of the extensor digitorum longus and hallucis longus muscles combined effect of all the above produces an equinovarus deformity (plantar flexion with foot drop and inversion of the foot), loss of the ankle jerk reflex |
|
|
MC site for lateral femoral nerve entrapment:
|
Inguinal ligament - entrapment of the nerve produces meralgia paresthetica, there is a numbness or burning sensation over the lateral part of the thigh when walking or prolonged standing
It is common in obese patients |
|
|
Obturator nerve injury (L2-L4)
|
Motor deficit - the leg swings out when walking since the obturator nerve supplies muscles that are involved with hip adduction
Sensory loss-medial aspect of the thigh, loss of the knee reflex |
|
|
Tibial nerve injury (L4-S3)
|
Motor deficits - loss of plantar flexion of the foot due to weakening of the gastrocnemius, soleus, and plantaris muscles
Loss of flexion of the toes due to weakening of the flexor digitorum longus and hallucis longus muscles Foot inversion ue to weakening of the tibialis posterior muscle The above motor deficits combine to produce calcaneovalgocavus where there is dorsiflexion and inversion of the foot Loss of the ankle jerk reflex |
|
|
Femoral nerve injury (L2-L4)
|
Femoral nerve injury occur due to injury in the area of the femoral triangle, which is a common site for catheterization punctures
Motor deficits - patient cannot flex the thigh due to weakening of the sartorius and iliacus muscle Patient cannot extend the leg due to weakening of the quadriceps muscle Loss of the knee jerk reflex, term applied to a forward displacement of the thoracic spine, kyphosis Stated another way, kyphosis is an increase in the normal posterior convexity of the thoracic spine, there is a forward displacement of the spine: hump back If severe, kyphosis may lead to chest restriction and respiratory acidosis |
|
|
Kyphosis in adolescents:
|
Forward bending of the spine
MCC is muscular/postural problems commonly seen in tall adolescents Scheuermann's disease - abnormal vertebral end-plates leading to disc herniations into the vertebrae called Schmorl's nodes |
|
|
Scoloiosis:
|
Term applied to lateral curvature of the spine
Idiopathic scoliosis - usually affects adolescent girls between 10-16 years of age Usually a right thoracic curve Forward bending causes a paraspinous prominence on teh right from a hump in the ribs due to a rotational component of the vertebra |
|
|
Test used to eveluate meniscus injuries:
|
McMurray test -
Test for the medial meniscus: patient is supine, knee is acutely flexed, foot is grasped and the leg is externally rotated, knee is slowly extended while the other hand feels the posteromedial margin of the knee joint, a click along the posteromedial margin indicates a medial meniscus tear: femur passes over the tear. Test for a lateral meniscus injury : same procedure as above except the leg is rotated internally and extended, a click is palpated along the posterolateral margin of the joint. |
|
|
Location and function of the anterior cruciate ligament (ACL):
|
ACL attaches the anterior part of the tibia to the lateral condyle of the femur - prevents anterior movement of the tibia in relation to the femur
|
|
|
Location and function of the posterior curciate ligament (PCL):
|
PCL extends form the posterior part of the tibia to the medial condyle of the femur - prevents posterior movement of the tibia in relation to the femur
|
|
|
Tests used to evaluate the cruciate ligaments in the knee:
|
Anterior draw test to evaluate ACL - patient is supine, hip flexed, knee flexed, examiner places hand on the posterior aspect of the tibia, anterior is applied neutral, external, internal direction: positive test is when there is anterior displacement of the tibia
Posterior draw test: Examiner place hand on teh anterior aspect of teh proximal tibia, posterior force is applied in neutral, external, internal direction; positive posterior test is when there is posterior displacement of the tibia |
|
|
Functions of the medial collateral ligament:
|
Supports the medial side of the knee joint
Attahes the medial epicondyle of the femur with the shaft of the tibia Resists valgus and external rotational forces of the proximal tibia in relation to the distal femur |
|
|
Functions of the lateral collateral ligament:
|
Supports the lateral side of the knee joint
Attaches the lateral epicondyle of the femur to the head of the fibula Resist varus forces and rotational forces of the proximal fibula in relation to the distal femur |
|
|
S/S of meniscus injury:
|
Pain
Knee catches, locks, or gives way when walking Swelling popping of the knee |
|
|
Medial meniscus injury
|
Mechanism of injury - MC internal derangement of knee joint
Most commonly part of a valgus injury Structures damaged - Medial meniscus, medial collateral ligament, ACL, Positive McMurray's test - click on posteromedial margin with the knee flexed, externally rotated, and slowly extended |
|
|
Lateral meniscus injury:
|
mechanism of injury - Varus injury
Injury to lateral collateral ligament Positive McMurray's test - click on posterolateral margin with the knee flexed externally rotated, and slowly extended |
|
|
ACL injury:
|
Mechanism of injury - MC ligament injury, torn most commonly in a valgus injury secondary to clipping or skiing
Positive anterior draw sign |
|
|
PCL injury:
|
Mechanism of injury - hyperextension of the knee secondary to an anterior force pushing the tibia in a posterior direction
Positive posterior draw sign |
|
|
Medial collateral ligament injury:
|
torn with valgus injuries
|
|
|
Lateral collateral ligament injury:
|
torn with varus injuries
|
|
|
MCC of an ankle sprain:
|
Sprain of lateral ankle ligaments from inversion of a plantar flexed foot
Common in basketball, volleyball and football |
|
|
MC lateral ligament that is sprained:
|
Anterior talofibular ligament - very important ligament in stabilization of plantar flexion in the foot
|
|
|
MC nerve injured with clavicular fractures:
|
Ulnar nerve
|
|
|
MC nerve injured in proximal humerus fractures:
|
Axillary nerve
|
|
|
MC nerve injured in mid-shaft/distal third of humerus:
|
Radial nerve - Nerve travels in the spiral groove
Wrist drop |
|
|
MCC of pain in the elbow and inability to supinate the forearm in 1-4 year old:
|
Subluxation of the head of the radius - usually due to jerking of the hand by an impatient or abusing parent
|
|
|
MC fracture associated iwth falling on the outstretched hand:
|
Colles fracture of the distal radius
MC fracture of the wrist Radiologically, it produces a "dinner fork" deformity of the proximal radial fragment (displaced upward and backward) Second most common fracture in osteoporosis in women |
|
|
MC carpal bone fracture:
|
Scaphoid - pain in the anatomical snuff box located below the radial styloid process
High incidence of aseptic necrosis |
|
|
MC hip dislocation:
|
Posterior - usually due to a car accident with the flexed knee in an abducted position in forced into the dashboard
Limb is shortened, flexed, adducted, internally rotated at teh hip Danger of damage to sciatic nerve Anterior - limb is shortened, abducted, externally rotated at the hip, neurovascular compromise of the femoral artery, vein, nerve, aseptic necrosis of femoral head |
|
|
MC femoral fracture:
|
Femoral next fracture - it most commonly occurs in the elderly male patient with osteoporosis
Groin or knee pain is present complications - aseptic necrosis of femoral head due to damage to teh medial meforal circumflex artery |
|
|
MC foot bone fractured after a fall from a height:
|
Calcaneous
|
|
|
MC fracture associated with ecchymoses of the mastoid, basilar skull fracture:
|
Petrous portion of the temporal bone
Otorrhea (CSF fluid leading out of the ear) may also occur |
|
|
MC fracture associated with rhinorrhea
|
Orbital fractures
Orbital fractures also produce raccoon eyes (periorbital hemorrhage and opthalmopegia (eye muscle entrampment) |
|
|
Cross-section of spinal cord:
|
Location of pain in right hip
Location for sympathetic preganglionic fibers |
|
|
Shining light in left eye causes pupil to constrict in left but not the right eye. When shining light in right eye, pupil constricts in the left but not the right eye:
|
Right CN III dysfunction
|
|
|
Foreign body in alveolus:
|
Phagocytosed by alveolar macrophage
|
|
|
Site for hemineglect:
|
Right parietal
|
|
|
Patient smells rubber. Mass located in left temporal lobe. Visual field defect:
|
Right upper quadrantanopia
|
|
|
Pineal gland:
|
Site for melatonin formation
|
|
|
Superficial cerebral veins:
|
Drain into superior sagittal sinus
|
|
|
Site odontoblasts develop from:
|
Odontoblasts develop into dentin
Odontoblasts are on inner aspect of the developing tooth Outer portion develops enamel from ameloblasts |
|
|
Hyperlipoproteinemias:
|
Type I and V have chylomicrons associated with them
Type II is increase in LDL Type III is remnant disease (dysbetalipoproteinemia) Increase in VLDL in type IV and type V |
|
|
PCR mechanism:
|
Used DNA polymerase to break down DNA into fragments
|
|
|
Locations of biochemical processes in cell:
|
Cytosol - glycolosis, pentose phosphate shunt, FA synthesis, glycogen synthesis
Mitochondrial matrix - Beta-oxidation of FAs, TCA cycle Inner mitochondrial membrane - oxidative phosphorylation Both cytosol and mitochondria - gluconeogenesis, urea cycle, heme synthesis |
|
|
Neurotransmitter form an essential amino acid:
|
Serotonin coming from tryptophan
|
|
|
Brain energy during starvation:
|
Ketone bodies
Uses glucose during fed and fasting state |
|
|
Gluconeogenic enzymes:
|
Pyruvate carboxylase
Phosphoenolpyruvate carboxykinase Fructose 1,6-bisphosphatase (rate limiting) Glucose 6-phosphatase (deficient in von Gierke's glycogenosis) |
|
|
RBC ribosomes:
|
Lost after RBC leaves bone marrow
Persistence in peripheral blood produces basophilic stippling Course basophilic stippling sign of Pb poisoning (ribonuclease denatured by Pb) |
|
|
Beta-Thalassemia mechanisms:
|
Most often a splicing defect for mild forms
Severe Beta-thal is due to stop codon preventing Beta-chain transcription |
|
|
Man with 2900 calorie diet with 30% of it representing fat, how many grams is fat:
|
Fat has 9 cal/g
2900 x .30 = 870 870/9 = 97 grams |
|
|
Vmax and Km:
|
Glucokinase - high Km (low affinity for glucose) and high Vmax (only reacts with glucose)
Hexokinase - low Km (high affinity for glucose, good for fasting state) and low Vmax (reacts with all hexose sugars) |
|
|
Essential fatty acids (FAs)
|
Linoleic acid - C18:2w6, produces arachidonic acid, not cardioprotective, corn oil/safflower oil
Alpha-linolenic - C18:3w3, Cardioprotective (lower triglycerides, inhibit platelet aggregation, produce anti-inflammatory prostaglandins, less damage to myocardial tissue in infarctions, found in fish oils, canola oil (best oil) |
|
|
I cell disease:
|
Inability to phosphorylate the mannose residues of potential lysosomal enzymes located in Golgi apparatus, hence they cannot be taken up by the lysosomes to degrade complex substrates
|
|
|
Number of glucoses necessary to build palmitic acid a 16 carbon compound:
|
4 glucoses, each glucose rum produces 2 acetyl CoA, the latter containing 2 carbons each
|
|
|
Insulin lack in DKA:
|
Decreased glycolysis, glycogenesis, fatty acid synthesis, storage of fat in adipose
|
|
|
Glycogenesis in the
Well fed state Fasting state Starved state |
Increased
None None |
|
|
Glycogenolysis
Well fed state Fasting state Starved state |
Decreased: none in the liver, some in muscle
Increased: early supply of glucose derived from liver not muscle None: glycogen used up |
|
|
Gluconeogenesis
Well fed state Fasting state Starved state |
None
Increased: primary source of glucose after glycogenolysis Decreased: just enough to supply RBCs |
|
|
Triacylglycerol synthesis in liver/adipose
Well fed state Fasting state Starved state |
Increased
None None |
|
|
Lipolysis
Well fed state Fasting state Starved state |
None
Increased Increased |
|
|
Fate of glycerol
Well fed state Fasting state Starved state |
Synthesize more triacylglycerol in liver
Substrate for gluconeogenesis Substrate for gluconeogenesis |
|
|
Beta-oxidation of fatty acids:
Well fed state Fasting state Starved state |
none
Increased Markedly increased: primary fuel for muscle |
|
|
Muscle catabolism
Well fed state Fasting state Starved state |
None: increased protein synthesis and uptake of amino acids
Increased: supply amino acids for gluconeogenesis Decreased: conserve muscle for important body functions |
|
|
Urea synthesis/excretion
Well fed state Fasting state Starved state |
Remains constant: handles NH4 load from protein degradation in gut by bacteria
Increased: deamination of amino acids used for gluconeogenesis increases urea synthesis Decreased: less muscle breakdown of protein with less amino acids to degrade |
|
|
Ketone body synthesis
Well fed state Fasting state Starved state |
None
Increased Markedly increased: by-product of acetyl CoA from increased Beta-oxidation of fatty acids |
|
|
Muscle use of glucose for fuel:
Well fed state Fasting state Starved state |
Primary fuel
Decreased None: mainly uses fatty acids |
|
|
Muscle use of fatty acids for fuel:
Well fed state Fasting state Starved state |
None
Increased: primary fuel Markedly increased: primary fuel |
|
|
Muscle use of ketones for fuel:
Well fed state Fasting state Starved state |
None
Some: alternative fuel None: allows the brain to use ketones for fuel |
|
|
Brain use of glucose for fuel
Well fed state Fasting state Starved state |
Remains constant
Remains constant Decreased: allows RBCs to primarily use glucose for fuel |
|
|
Brain use of ketones for fuel
Well fed state Fasting state Starved state |
None
None Increased: primry fuel |
|
|
RBC use of glucose for fuel
|
Remains constant
Remains constant Remains constant |
|
|
Type I lipid disorders examples
|
Familial lipoprotein lipase deficiency
Apo CII deficiency Cannot hydrolyze chylomicrons |
|
|
Type II lipid disorders examples:
|
Familial hypercholesterolemia
Absent or defective LDL receptors |
|
|
Type III lipid disorders examples:
|
Familial dysbetalipoproteinemia "remnant disease"
Deficiency of apo E. Chylomicron and LDL remnants are not metabolized in the liver |
|
|
Type IV lipid disorders examples:
|
Familial hypertriglyceridemia
Decreased catabolism or increased synthesis of VLDL |
|
|
Type V lipid disorders examples:
|
Most commonly a familial hyertriglyceridemia with exacerbating factors
Combination of type I and type IV mechanisms |
|
|
Type I lipid disorders: Clinical and Lab
|
Rare childhood disease
Increased chylomicrons and TG with a normal cholesterol and LDL Standing chylomicron test: supranate but no infranate |
|
|
Type II lipid disorders: Clinical and Lab
|
AD disorder with premature CAD, achilles tendon xanthomas are pathognomonic, Rx: statin drugs
Acquired causes: diabetes, hypothyroidism, obstructive jaundice, progesterone in birth control pills Type IIa: increased LDL and cholesterol, normal TG Type IIb: increased LDL, cholesterol, and TG |
|
|
Type III lipid disorders: Clinical and Lab
|
Increased CAD risk
Hyperuricemia Obesity DM Cholesterol and TG equally elevated Increase in chylomicron and IDL remnants Ultracentrifugation followed by electrophoresis identifies remnants |
|
|
Type IV lipid disorders: Clinical and Lab
|
AD disorder, most common hyperlipoproteinemia, TG begins increasing at puberty
Increased incidence of CAD and peripheral vascular disease Rx: fibric acid derivatives, reduce carbohydrate and alcohol intake Acquired causes: alcoholism, diuretics, Beta-Blockers, renal failure Marked increase in TG and slight increase in cholesterol Standing chylomicron test: turbid infranate HDL decreased (inverse relationship with VLDL) |
|
|
Type V lipid disorders: Clinical and Lab
|
Particularly common in alcoholics and DKA
Hyperchylomicronemia syndrome: abdominal pain, pancreatitis, dyspnea (impaired oxygen exchange), hepatosplenomegaly (fatty change), papules on skin Markedly increased TG with normal LDL, standing chylomicron test supranate and infranate |
|
|
Rate limiting reaction in cholesterol synthesis:
|
HMG Co reductase: inhibited by cholesterol and statin drugs (competitive inhibition with mevalonic acid), enzyme converts HMG CoA into mevalonic acid
|
|
|
Rate limiting reaction in fatty acid synthesis:
|
Acetyl CoA carboxylase
Enzyme converts acetyl CoA into malonyl CoA |
|
|
Rate limiting reaction in Beta-oxidation of fatty acids:
|
Carnitine acyltransferase I
Enzyme in outer membrane of mitochondria removes acyl group from fatty acyl CoA and transfers it to carnitine (acylcarnitine) Inner membrane enzyme removes acyl group from acylcarnitine and transfers it back to CoA to produce fatty acyl CoA |
|
|
Rate limiting reacting in glycolysis:
|
Phosphofructokinase I
Enzyme converts fructose 6-phosphate into fructose 1,6-bisphosphate |
|
|
Rate limiting reaction in gluconeogenesis:
|
Fructose 1,6-bisphosphatase
Enzyme converts fructose 1,6-bisphosphate to fructose 6-phosphate |
|
|
Rate limiting reaction in glycogen synthesis:
|
Glycogen synthesis
Enzyme forms alpha-1,4-glycosidic linkages between a glucose unit form UDP-glucose and the non-reducing end of an existing glycogen chain |
|
|
Rate limiting reaction in glycogenolysis
|
Liver phosphorylase
Enzyme cleaves alpha-1,4-linkages (releases glucose 1-phosphate) but stops working four glucose units from the branch point |
|
|
Rate limiting reaction in pentose phosphate pathway:
|
Glucose 6-phosphate dehydrogenase
G6PD converts glucose 6-phosphate to 6-phosphogluconate |
|
|
Rate limiting reaction in lipolysis:
|
Hormone sensitive lipase
Enzyme hydrolyzes triacylglycerol into fatty acids and glycerol |
|
|
Rate limiting reaction in urea cycle:
|
Carbamyl phosphate synthase I
Enzyme converts CO2 + NH4 + 2 ATP into carbamyl phosphate |
|
|
Rate limiting reaction in pyrimidine metabolism
|
Carbamyl phosphate synthase II
Enzyme converts 2 ATP + CO2 + glutamine into carbamoyl phosphate |
|
|
Rate limiting reaction in purine metabolism:
|
Glutamine-PRPP aminotransferase
Enzyme coverts PRPP+ glutamine into 5'-phosphoriboysylamine |
|
|
Rate limiting reaction in heme synthesis:
|
ALA synthase
Enzyme converts succinyl CoA + glycine into delta-aminolevulinic acid |
|
|
Rate limiting reaction in ketone body synthesis:
|
HMG CoA synthase
Converts acetoacetyl CoA into HMG CoA |
|
|
Uncoupling agents:
|
Render the inner mitochondrial membrane permeable and carry protons with them into the mitochondrial matrix (destroys the proton gradient): dinitrophenol, pentachlorophenol (used to treat wood to prevent insect invasion), thermoginin (natural uncoupling agent in brown fat of newborns that helps keep newborn internal temperatures higher)
Rate of chemical reactions increases to produce more NADH and NADPH since it is being siphoned off into the mitochondrial matrix without the synthesis of ATP - potential for hyperthermia Mitochondrial poisons (alcohol, salicylates) also render the inner mitochondrial membrane permeable to protons, but they do not directly take protons with them into the matrix (not true uncoupling agents): Decrease ATP synthesis |
|
|
Patient with pheochromocytoma:
|
Decrease tyrosine (not an essential AA) in the diet, since it is the precursor for the catecholamines
Also decreased ascorbic acid which converts dopamine into norepinephrine |
|
|
Lesch Nyhan:
|
SXR with absent HGPRT
Self-mutilation Hyperuricemia Mental retardation |
|
|
Glucokinase and hexokinase:
|
Glucokinase: only inliver, high Vm and high Km
Hexokinase: In all tissues, inhibited by glucose 6-phosphate, low Vm and low Km |
|
|
Branched chain amino acids and maple syrup urine disease:
|
Only muscle can metabolize branced chain amino acids
Missing dehydrogenase enzyme |
|
|
Locations of glucose 6-phosphatase (gluconeogenic hormone):
|
Liver
Kidney Intestinal epithelium (lesser extent than others) Absent in von Gierke's disease |
|
|
Shuttles and what they carry:
|
Carnitine - even chained fatty acids
Malate and glycerol 3-phosphate - NADH |
|
|
Functions of cholesterol:
|
Vitamin D synthesis in teh skin (7-dehydrocholesterol)
Steroid synthesis Cell membranes Synthesis of bile salts/acids |
|
|
Acetyl CoA uses:
|
FA synthesis
CH synthesis Ketone body synthesis Synthesis of citrate along with oxaloacetic acid Not a substrate for gluconeogenesis |
|
|
Ketone body synthesis:
|
HMG CoA synthase is the rate-limiting enzyme
HMG CoA lyase converts HMG CoA into acetoacetic acid, while in cholesterol synthesis, HMG CoA reductase converts HMG CoA into mevalonic acid 23 ATP produced for fuel |
|
|
Enzyme kinetics:
|
Vmax represents the maximum velocity of an enzyme reaction when all enzyme sites are fully saturated
Km (Michaelis-Menton constant) of an enzyme represents the substrate concentration at which the reaction velocity is one-half of Vmax Km describes the enzymes affinity for substrate Increased Km indicates decreased affinity of the enzyme for substrate Decrease Km indicates increased affinity of the enzyme for substrate |
|
|
Competitive inhibitors:
|
Vmax is not changed since the reaction rate is unchanged whether the competitive inhibitor (ethylene glycol, methyl alcohol) is binding to the active site of the enzyme (alcohol dehydrogenase) or alcohol
Km increases (decrease in the affinity of the enzyme for alcohol), since the enzyme is also actively binding with ethylene glycol/methyl alcohol Infusing alcohol decreases the metabolism of ethylene glycol/methyl alcohol, hence the effect of a competitive inhibitor is reversed by increasing substrate Methotrexate is also a competitive inhibitor |
|
|
Reversible noncompetitive inhibitors:
|
Vmax is decreased, however the Km remains the same
Reversible noncompetitive inhibitors bind reversibly away form the active binding site of the enzyme and form either unreactive enzyme-inhibitor complexes or enzyme-substrate-inhibitor complexes Affinity of the enzyme for substrate is unchanged (Km), since the inhibitor inactivates teh enzyme, which automatically decreases teh effective concentration of active enzyme Increasing substrate concentration does not reverse the effect of teh inhibitor, since the inhibitor is blocking enzyme activity away form teh active binding site Examples of reversible noncompetitive inhibitors include angiotensin converting enzyme inhibitors (substrate in angiotensin I); physostigmine, which is a cholinesterase inhibitor (substrate acetylcholine); and, allopurinol, an xanthine oxidase inhibitor (substrate xanthine) Irreversible inhibitors permanently inactivate enzymes by forming strong covalent bonds: examples include lead, aspirin, and organophosphates, enzyme kinetics are the same as those for reversible noncompetitive inhibitors |
|
|
ATP count using palmitic acid as an example:
|
1) Divide the number of carbons in the FA by 2 to arrive at the number of acetyl CoAs produced: palmitic acid = 16 carbons (8 acetyl CoA)
2) Each acetyl CoA produces 12 ATP when converted to Co2 and H2O in the TCA cycle: 8x12=96 ATP 3) Subtract 1 from teh number of acetyl CoA produced to arrive at teh number of NADH2 and FADH2 produced: 7 NADH + 7 FADH2 4) Each NADH produces 3 ATP: 7x3=21 5) Each FADH2 produces 2 ATP: 7x2=14 6) Total ATP=131 |
|
|
Urea cycle:
|
Method of eliminating ammonia
Locaed in teh hepatocyte Chronic iver disease: low buN, elevated ammonia |
|
|
Epinephrine given and only small branched chains of glycogen found:
|
Debrancher enzyme deficiency
|
|
|
Cholesterol synthesis:
|
First few steps are similar to ketone body synthesis except HMG CoA lyase is used instead of HMG CoA reductase
|
|
|
Apolipoprotein in liver and intestine
|
Liver (100)
Intestine (48) |
|
|
Liver can not use ketones for fuel:
|
liver cannot activate acetoacetate in teh mitochondria, which requires succcinyl CoA: acetoacetate CoA transferase (a thiotransferase enzyme) in order to convert AcAc into acetoacetyl CoA
|
|
|
Pregnant woman is a beer drinker - what supplements does she need?
|
Still needs folate because alcohol increases loss of folate in urine and stool which offset the amount of folate present in beer
|
|
|
Insulin:
|
Key hormone of the fed state
Activates phosphatase (dephosphorylation) |
|
|
Glucagon:
|
key hormone of the fasting state
Activates protein kinase (phosphorylation) |
|
|
mannose 6-phosphate:
|
Involved in transfer of dolichol (lipid) in the RER in the synthesis of O-linked glycosides
Involved in transfer of lysosomes from Golgi apparatus to the lysosomes |
|
|
Major source of NADPH
|
Pentose phosphate shunt
Malate dehydrogenase (malic enzyme) reaction to a lesser extent NADPH supplies reducing equivalents |
|
|
Mutation changes an mino acid sequence which one would have the greatest effect on migration in a serum protein electrophoresis:
|
One with the most negative charges (most acidic) - glutamine
One that would remain closest to the anode (-pole) is the most basic amino acid - arginine |
|
|
Mechanism of ketoacidosis in DKA:
|
Increased Beta-oxidation of fatty acids and production of acetyl CoA, which is used by the liver to synthesize ketone bodies
|
|
|
Promoter location:
|
Upstream location
|
|
|
Energy source for protein synthesis:
|
GTP
|
|
|
Isoenzyme with 2 genes, 4 subunits:
|
LDH isoenzymes;
5 isotypes: LLLL, LLLH, LLHH, LHHH, HHHH |
|
|
Second messengers:
|
Atrial natiuretic peptide: cGMP
Insulin: tyrosine kinase Nicotinic: ion channels |
|
|
Best method of detecting relatedness of a new bacteria:
|
Restriction fragment length poymorphism
|
|
|
Biochemistry of hepatic encephalopathy:
|
Increase in aromatic amino acids phenylalanine, tyrosine, tryptophan (mnemonic-PTT) leads to increased synthesis of false neurotransmitters (GABA, octopamine) in hepatic encephalopathy
Branched chain amino acids inhibit synthesis of false neurotransmitters - reason why they are given for Rx. |
|
|
Energy in cardiac muscle:
|
Beta-oxidation of fatty acids
|
|
|
Lipid facts;
|
Functions of HDL - Reservoir for apolipoproteins in teh blood
Transport of esterified cholesterol to teh liver Transfers cholesterol ester to VLDL in exchange for TG using cholesterol ester transport protein Taken up by scavenger receptors in the liver |
|
|
In patients with diabetic ketoacidosis you would expect:
|
Activation of hormone sensitive lipase in teh adipose, conversion of glycerol 3-phosphate into dihydroxyacetone phosphate
In the fasting state you would expect - loss of inhibiton of carnitine acyltransferase by malonyl-CoA in fed state, you expect - activation of citrate lyase in the cytosol Inactivation of hormone sensitive lipase in adipose, increased production of palmitic acid in teh cytosol |
|
|
Findings in PKU:
|
AR disease with deficiency of phenylalanine hydroxylase
Newborn must be exposed to phenylalanine in teh diet before it is increased Mousy odor Projectile vomiting simulating congenital pyloric stenosis Tyrosine missing, hence it must be supplied in the diet Can diagnose by aminocentesis and finding the abnormal gene Eliminate phenylalanine from diet Pregnant woman with PKU must be on PHY free diet otherwise affected fetus will develop permanent CNS damage in utero owing to exposure of PHY |
|
|
Disorders of galactose metabolism:
|
Galactokinase deficiency: benign AR disease
Positive urine Clinitest (detects all reducing sugars except sucrose, which is not a reducing sugar Galactosemia: AR disease with deficiency of GALT Excess galactose is converted into galactitol (polyol or alcohol sugar), which like sorbitol, is osmotically active Damages lense, nerve tissue, CNS, liver Excess galactose 1-PO4 is toxic: cirrhosis, mental rtardation, renal damage, neonatal hypoglycemia (lack of glucose 6-PO, a substrate for gluconeogenesis Rx is a lactose free diet for teh first two years Pregnant women with galactosemia can synthesize lactose in their breast milk |
|
|
Disorders in fructose metabolism
|
Fructose is an essential nutrient for sperm stored in teh seminal vessicles
Can be synthesized from mannose and sorbitol Fructosuria: AR disease with missing fructokinase, positive urine Clinitest due to fructose Heriditary frutose intolerance: AR disease iwth a deficiency of aldolase B, accumulation of fructose 1-PO4, which is toxic to the liver (cirrhosis), fasting hypophosphatemia (excess fructose traps phosphate in cells), depletion of ATP leads to RBC hemolysis and rhabdomyolysis, increased adenosine monophosphate, which is converted into uric acid leading to gout Must eliminate table sugar from diet |
|
|
Sorbitol
|
Osmotically active solute that is sythesized in those tissue containing aldose reductase, which include - lens, ova, seminal vesicles
Schwann cells, retina, kidneys, aldose reductase converts glucose into sorbitol and sorbitol dehydrogenase converts sorbitol into fructose Hyperglycemic states, like DM, there is an excess of sorbitol produced in the above tissues leading to osmotic damage - cataracts Peripheral neuropathy due to destruction of Schwann cells, microaneurysms in retinal vessels due to destruction of pericytes |
|
|
Homocystinuria:
|
AR disease wiht a deficiency of cystathionine synthase
Both homocysteine and methionine are increased in serum S/S: resemble Marfan syndrome (dislocated lens, arachnodactyly, eunuchoid) Distinctive features of homocystinuria: Increased in plasma homocysteine hevels leads to vessel damage/thrombosis (strokes, AMI) Mental retardation Increased urine homocysteine and increased serum/urine methionine |
|
|
Alkaptonuria
|
AR disease with an absence of homogentisate oxidase
Accumulation of black, homogentisate pigment in joints/cartilage leads to generative joint disease Urine turns balck when oxidized upon exposure to light |
|
|
Hereditary tyrosinosis
|
AR disease with a deficiency of fumarylacetoacetate hydrolase
Increase in serum tyrosine: cabbage-like odor cirrhosis wiht an extremely high incidence of hepatocellular carcinoma Renal disease (aminoaciduris) Death in the first year of life |
|
|
Lysosomal storage diseases:
|
Definition: absene of degrading enzymes in lysosomes: contain hydrolytic enzymes, accumulation of complex substrates in lysosome: sphingolipids, glycosaminoglycans, glycogen (Pompe's disease), most are AR diseases wiht the exception of two diseeases, which are SXR - Fabry's disease, Hunter's disease
Lysosomal enzymes are synthesized in the rough endoplasmic reticulum, enzymes are transported to the Golgi apparatus; they undergo post-translational modification, they are phosphorylated at one or more mannosyl residues to form 'mannose 6-phosphate', which is attached to the side chains; mannose 6-phosphate residues on teh target lysosomal enzymes; small transport vesicles are pinched off the Golgi membrane that contain the receptor bound enzymes; the vesicles fuse and release enzymes into lysosomes located in teh cotosol; receptors return to the Glgi apparatus to repeat the process over again |
|
|
Glycosaminoglycans (GAGs) and their disorders:
|
GAGs complexes of predominantly branched, strongly negatively charged polysaccharide chains with repeating units of amino sugars and acid sugars
Chondroitin sulfate: most abundant GAG; important component in cartilage Heparan sulfate; mainly responsible for the negative charge of the glomerular basement membrane Hyaluronic acid: major component of synovial fluid Dermatan sulfate: ground substance in heart valves that is increased in mitral valve prolapse; increased in pretibial myxedema |
|
|
Sphingolipids and their disorders:
|
Sphingolipids include: sphingomyelin, cerebrosides, gangliosides
Sphingomyelin: involved in teh synthesis of cell membranes in nerve tissue Sphingosine is the backbone of sphingomyelin, sphingosine is used to produce ceramides Tay Sachs disease: AR wit a deficiency of hexosaminidase; a 4 nucleotide insertion leads to a frameshift muttion and an abnormal hexosaminidase; lysosomal accumulation of GM2 ganglioside; common in Ashkenazi Jews; normal at birth, severe mental retardation by six months; blindness wiht a chrry red spot int eh macula; no hepatosplenomegally; EM exhibits whorled configuration s in lysosomes that look exactly the same as lamellar bodies with surfactant in type II pneumocytes Neiman-Pick: AR disease with a deficiency of sphingomyelinase; lysosomal accumulations of sphingolyelin; bubbly appearance in macrophages/neurons; mental retardation; hepatosplenomegaly; EM exhibits zebra bodies in lysosomes Gaucher disease: AR disease with deficeincy of glucocerebrosidase; lysosomal accumulation of glucocerebroside (fibrillary appearance (crumbles up newspaper) in macrophages; adult type associated with massive hepatosplenomegaly and an increase in serum total acid phosphatase derived from macrophages |
|
|
Metachromatic Leukodystrophy
|
AR disease with a deficiency of arylsulfatase A and a lysosomal accumulation of sulfatide: results in the synthesis of abnormal arylsulfatase activity decreased/absent
|
|
|
Krabbe disease:
|
AR disease wiht a deficiency of galactosylceramidase an a lysosomal accumulation of galactocerebroside; results in the synthesis of an abnormal myelin; progressive psychomotor retardation; multinucleated globoid cells in CNS
|
|
|
Hurler's disease:
|
AR disease with a deficiency of alpha-1-iduronidase; lysosomal accumulation of dermatan/heparan sulfate; sever mental retardation; course facial features; corneal clouding; coronary artery disease (lipid accumulates in coronary vessels, vacuoles in peripheral blood leukocytes
|
|
|
Hunter's disease:
|
SXR disease with a deficiency of L-iduronosulfate sulfatase; lysosomal accumulation of dermatan/ heparan sulfate, milder disease than Hurler's
|
|
|
Glycogen synthesis (glycogenesis):
|
Glycogen synthetase (insulin enhanced, rate limiting enzyme) - glycogen: branched chain polysaccharide of D-glucose residues iwth alpha-1-4 linkages
Glycogen synthetase produces alpha-1,4 linkages between the glucose residues by adding linkages to an already existing glycogen primer glucosyl 4:6 transferase makes branches by transferring 5-8 glucosyl residues form teh non-reducing end of the linear glycogen chain to another residue on the chain and attracting it to the chain by an alpha-1,6 linkage - glycogen synthetase then adds glucose residues to the new non-reducing ends on teh branches and to the old non-reducing ends Liver glycogen maintains blood glucose during the fasting state until its stores are depleted - gluconeogenesis is the most important factor maintaining glucose in the fasting state Muscle glycogen is used only by muscle |
|
|
Glycogenolysis:
|
Occurs in the fasting state: glucagon/epinephrine activate adenylate cyclase
Activated glycogen phosphorylase A (rate limiting enzyme, muscle and liver phosphorylases) cleaves alpha 1-4 bonds up to 4 glucose residues of a branch point Glucosyl (4:4) transferase (debrancher enzyme) removes 3 of the outer glucose residues that are left on the branch and transfers them to the non-reducing end of another chain where glycogen phosphorylase A cleaves off more glucose 1-phosphates Amylo-alpha-1,6 glucosidase (debrancher enzyme): cleaves off the remaining 1 glucose on teh chain leaving behind a free glucose: ratio of glucose 1-PO4 to free glucose is -10/1 Small amounts of glycogen are degraded in lysosomes by alpha 1,4 glucosidase (acid maltase, which is deficient in Pompe's disease) |
|
|
Von Gierke's glycogenosis:
|
AR disease wit a deficiency of glucose 6 phosphatase, a gluconeogenic enzyme that is primarily located in the liver and kidneys
Glucose is decreased in the fasting state (fasting hypglycemia) and glucose 6-phosphate accumulates leading to an increased synthesis of normal glycogen primarily in the liver and kidneys (hepatorenomegaly) Glycogen excess in renal tubules interferes with lactic acid and uric acid excretion; increased anion gap metabolic acidosis and increased incidence of gout Stimulation tests for gluconeogenesis using glucagon, fructose, galactose cannot increase blood glucose owing to the missing glucose 6-phosphatase |
|
|
Pompe's glycogenosis:
|
AR disease with a deficiency of the lysosomal enzyme slpha-1,4 glucosidase (acid maltase)-only glycogenosis that is a lysosomal storage disease
Accumulation of normal glycogen in lysosomes in multiple organs Restrictive cardiomyopathy form glycogen deposition in the heart is the MC COD |
|
|
McArdles disease (glycogenosis):
|
AR disease iwth a deficiency of muscle phosphorylase
Muscle glycogen cannot be degraded leading to reduced amounts of glucose for muscle energy Early fatigue with exercise (no ATP) leading to muscle cramps - rhapdomyolysis - myoglobinuria Absence of lactic acid in bloof after exercise Normal blood glucose: muscle does not contribute to blood glucose Enzyme assay of muscle confirms diagnosis-compatible with life |
|
|
Debrancher and brancher deficiencies:
|
Debrancher/brancher deficiencies are all associated with an accumulation of abnormal glycogen
Glucosyl 4:6 transferase (brancher) deficiency - no branches on glycogen Glucosyl (4:4) transferase debrancher deficiency: increase in alpha-limit dextrins (small branched oligosaccharides) adn decrease in free glucose; epinephrine challenge leads to an increase in alpha-limit dextrins and a decrease in free glucose Amylo-alpha-1,6 glucosidase debrancher deficiency - decreased amounts of free glucose, since the remaining glucose cannot be cleaved off |
|
|
Glycogenoses with fasting hypoglycemia;
|
Von Gierke's
Deficiency of liver debrancher enzymes Deficiency of liver phosphorylase |
|
|
Sequence of collagen synthesis
|
Initial synthesis in fibroblast
Formation of polypeptide pro-alpha1 and pro-alpha2 chains Hydroxylation of proline and lysine by vitamin C: site for cross-linking outside the fibroblast Glycosylation of lysine residues iwth glucose and galactose Assembly of 3pro-alpha chains- inter andintra chain disulfide bonds at C terminal extensions Formation of triple helix Procollagen molecules translocated to Golgi apparatus for packaging and secretion Extracellular synthesis of collagen Procollagen molecule secreted into extracellular space Procollagen peptidases cleave N-terminal and C-terminal propeptides to release triple helix Collagen molecules form fibrils, cross-linking of collagen fibrils to increase tensile strength: lysyl oxidase (copper is a cofactor) is a cross-linking enxyme |
|
|
IV infusion of thiamine (B1) in an alcoholic
|
Thiamine is a cofactor for pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, and alpha-ketoacid dehydrogenase
All these reactions produce NADH, which generated 6 ATPs |
|
|
silent mutation
|
Altered codon specifies the same amino acid without altering the henotypic effect (UUG) to (CUG) - both lysine
|
|
|
Missense mutation:
|
Altered codon specifies a different amino acid leading to variable phenotypic effects UUG (lysine) to UCG (serine)
Sickle cell disease/trait; valine replaces glutamate in the 6th position of the Beta-globin chain |
|
|
Nonsense mutation:
|
Altered codon is a stop codon (UAA, UAG, UGA) causing premature termination during protein synthesis
Beta-thalassemia major: a point mutation roduces a stop codon leading to termination of DNA transcription of Beta-globin chain |
|
|
Frameshift mutation
|
Caused by insertion or deletion of any number of nucleotides not divisible by 3
Shifts teh reading frame during translation of mRNA leading to a randomly incorrect amino acid sequence and production of a truncated protein due to introduction of a premature stop codon Tay Sachs: 4 base insertion produces a frameshift mutation; codes for a defective hexosaminidase Cystic fibrosis: 3 base deletion wiht loss of phenylalanine on chromosome 7: this is NOT a frameshift mutation since it is a multiple of 3 Transcribes a defective CF transmembrane regulator that disintegrates before it goes to the cell membrane |
|
|
Glycine:
|
Smallest amino acid, inhibitory neurotransmitter in spinal cord (blocked by toxin in tetanus), synthesis of heme and collagen an dbile salts and acids
|
|
|
Alanine:
|
Alanine ycle during fating major substrate for gluconeogenesis (transaminated into pyruvate)
|
|
|
Valine
|
Essential AA
Branched-chain amino acid Not degraded in liver Utilized by muscle Increased in maple syrup urine disease |
|
|
Leucine
|
Essential AA
Branched-chain amino acid Not degraded in liver Ketogenic Utilized by muscle Increased in maple syrup urine disease |
|
|
Isoleucine
|
Essential AA
Branched-chain amino acid Not degraded in liver Utilized by muscle Increased in maple syrup urine disease |
|
|
Methionine
|
Essential AA
Polypeptide chain initiation Methyl donor (as S-adenosyl methionine) |
|
|
Proline:
|
Helix breaker
Only amino acid wiht side chain attached to alpha-amino group Hydroxylation in collagen aided by ascorbic acid binding site for cross bridges in collagen |
|
|
Phenylalanine:
|
Essential AA
Increased in phenylketonuria (PKU) Aromatic side chains: increased in hepatic coma |
|
|
Tryptophan
|
Essential AA
Serotonin, niacin, melatonin percursor Aromatic side chains: increased in hepatic coma |
|
|
Cysteine:
|
Forms disulfide bonds
Component of glutathione, an important antioxidant in RBCs (deficient in G6PD) |
|
|
Serine:
|
single-carbon donor: converted into glycine when caron removed
Phosphyryated by kinases |
|
|
Threonine:
|
Essential AA
Phosphorylated by kinases |
|
|
Tyrosine
|
Precursor of catecholamines, melanin, thyroid hormones
Phosphorylated by kinases: important in second messengers Aromatic side chains: increase in hepatic coma Must be suplied in diet in phenylketonuria (PKU) |
|
|
Asparagine:
|
Insufficiently synthesized by neoplastic cells
Asparaginase used for treatment of leukemia |
|
|
Glutamine:
|
Most abundant amino ai
Major carrier of ammonia Nitrogen donor in synthesis of purines and pyrimidines NH3 detoxification in brain and liver Amino group carrier from skeletal muscle to other tissues in fasting state Fuel for kidney, gut, and cells in immune system in fasting state |
|
|
Lysine:
|
Essential AA
Basic AA Postiive charge at pH 7 Ketogenic Abundant in histones Hydroxylation in collagen aided by ascorbic acid Binding site for cross-bridges in collagen |
|
|
Arginine:
|
Essential AA
Basic AA Positive charge at pH7 Essential for growth in children: stimulates GH and insulin Abundant in histones |
|
|
Histidine
|
Essential AA
Basic AA Postive charge at pH 7 Effective physiologic buffer Residue in hemoglobin coordinated to heme Fe++ Essential for growth in children Zero charge at pH 7.4 |
|
|
Aspartate:
|
Acidic AA
Strong negative charge at pH 7: important for binding properties of albumin Forms oxaloacetate (substrate for gluconeogenesis) by transamination |
|
|
Glutamate:
|
Acidic AA
Strong negative charge at pH 7: imortant for binding properties of albumin Forms alpha-ketoglutarate by transamination |
|
|
Genetic basis of mild Beta-thalassemia:
|
Primarily a splicing defect, severe Beta-thalassemia is a stop codon (nonsense mutation)
|
|
|
Effect of decreased LDL receptors on HMG CoA reductase:
|
Normally, increased uptake of cholesterol in a cell decreases synthesis of LDL receptors and reduces gene transcroption of HMG CoA reductase resulting in less de novo cholesterol synthesis in the cell
Decrease in LDL receptors decreases the uptake of cholesterol in the cell, therefore, less cholesterol causes increased transcription of HMG CoA reductase, hence an increase in cholesterol synthesis in the cell |
|
|
Diphtheria toxin:
|
Inhibits protein synthesis by ADP ribosylation of elongation factor 2
Antitoxin an derythromycin are the Rx of choice Prevent with diphtheria toxoid immunization |
|
|
Pseudomonas aeruginosa toxin:
|
Exotoxin A inhibits protein synthesis using the same mechanism as diphtheria toxin
|
|
|
Neisseria gonorrhoea:
|
Gram negative diplococcus
Endotoxin is lipooligosaccharide (NOT lipopolysaccharide like N. meningitidis) Oxidase positive - contain cytochrome c Chocolate agar - modified Thayer-Martin pili- Attach to mucosal surfaces Resists phagocytosis by neutrophils Antigenic change responsible for repeated infections IgA protease-hydrolyzes secretory IgA to make it easier to stick to vagina and urethra Capsule - protects against phagocytosis Sugar fermentatin - glucose (N. meningitidis is maltose and glucose) Plasmid mediated penicillinase producing strains Discharge in first week after sexual contact Rx- ceftriaxone or spectinomycin if allergic to penicillin |
|
|
Francisella tularensis:
|
G- rod
Can survive in macrophages for prolonged periods Antiphagocytic capsule Vector-ticks using a wild rabbit reservoir MC transmission- cleaning animal hides (rabbits) Requires csteine for growth Rx-streptomycin |
|
|
Camphylobacter jejuni:
|
Comma/S shaped G- rods
Ingestion of contaminated poultry, milk, or water Decreased gastric acidity increases chance of infection Grows at 42 decrees C MCC bacterial gastroenteritis in US Some strains have enterotoxin similar to cholera Bloody stools resembling ulcerative colitis Association with Guillain-Barre syndrome- antibody against organism cross-react with neurons Rx: erythromycin |
|
|
MCC of otitis media/sinusitis in children:
|
Streptococcus pneumoniae
|
|
|
MCC of otitis externa
|
Pseudomonas aeruginosa
Rx with topical polymyxin B + neomycin + hydrocortisone Also cause of malignant otitis external in diabetics |
|
|
Hemophius influenzae
|
G- coccobacillus
Requires factor X (hemin, blood) and V (NAD) for growth |
|
|
Macrophages:
|
Multilobulated nucleus and have granules
Previous monocytes Microglial call macrophages of CNS and reservoir of HIV in CNS |
|
|
NK cells:
|
Type II hypersensitivity reactions
Graft vs. Host reactions Kill tumor cells Called large granular lymphocytes with antigenically stimulated |
|
|
Clue cell:
|
Gardnerella vaginalis adherent to squamous cells
Bacterial vaginosis Rx wit metronidazole |
|
|
Sporotrichosis
|
Prick fo thorn from rose
Prick from lobster spine- packed in sphagnum moss which has organism |
|
|
Patient sticks himself with a knife an ddevelops trismus:
|
Tetanus
|
|
|
Rx of Pneumocystis carinii pneumonia in HIV
|
Trimethoprim-sulfamethoxazole
|
|
|
Picture of budding yeast with narrow based bud:
|
Cryptococcus neoformans
Rx with amphotericin |
|
|
Rx of choice for Chlamydia trachomatis:
|
Doxycycline: competitively block binding of tRNA to the 30S ribosomal subunit involved in protein synthesis
|
|
|
Chocolate agar:
|
Contains blood which supports growth of bacteria
|
|
|
Child with meningitis and picture of gram negative diplococcus:
|
Neisseria meningitidis
Capsule prevents phagocytosis Endotoxin (lipopolysaccharide) produces shock IgA protease degrades secretory IgA to allow adherence of organism to mucosa in posterior nasopharynx Prevention-use vaccine, give rifampin to close contacts Rx with penicillin G |
|
|
Normal microflora of skin:
|
MC is coagulase negative staphylococcus
Less commonly-Staphylococcus aureus Corynebacteria Propionibacter (important in acne) Clostridium perfringens (20% of healthy people) Candida Malassezia |
|
|
Picture of Aspergillus:
|
look for narrow angled septate hyphae and fruiting body
|
|
|
Coccidioidomycosis
|
Think SW
Arthrospores in dust Spherules with endospores in tissue |
|
|
Recurrent vesicles around mouth and vermillion boarder of lips:
|
Herpes simplex I
Latent in sensory ganglia |
|
|
Elderly man with painful vesicles in any dermatome:
|
Herpes zoster (shingles)
Latent in cranial sensory ganglia |
|
|
Complementation in defective (mutant) virus:
|
Replication of another virus provides missing function required by the mutant virus
|
|
|
Initial defense against Salmonella in blood:
|
Endotoxins released by bacteria activate the alternative complement system
|
|
|
Self-induced abortion:
|
Cervical swab and put into anaerobic medium for Clostridium perfringens
|
|
|
Spirochetes in synomvial fluid:
|
Lyme's disease due to Borrelia burgdorferi
|
|
|
Infertile woman wiht scarred fallopian tubes:
|
Chlamydia trachomatis MCC
|
|
|
J-K disease from brain instrument treates with formaldehyde:
|
Prions is transmissible agent
|
|
|
Coxsackie:
|
MCC of myocarditis (dilated cardiomyopathy with lymphocytes in biopsy) and pericarditis
|
|
|
Wound infection:
|
G+ cocci= S. aureus
|
|
|
Middle aged woman wiht meningitis:
|
Streptococcus pneumoniae- G+ diplococcus
|
|
|
Patient with pneumonia has elevated ASO titer:
|
Group A streptococcus
|
|
|
Gram positive rod resistant to heat:
|
Bacillus anthrax
|
|
|
MOA of Streptococcus agalactiae (Group B streptococcus):
|
Inhibits phagocytosis
|
|
|
Cause of an immunodeficiency with a high IgM:
|
Defect in isotype switching
|
|
|
Cyclosporine necessary in identical twin transplant - Why?
|
There is still some difference in MHC sites from crossover of chromosomes during meiosis.
|
|
|
Major drift with influenza:
|
Major changes in the reassortment of genome pieces indicating a need for a new vaccine; only protects against influenza A; egg based vaccine; killed virus vaccine
|
|
|
Receptor for HIV:
|
CD4 molecule on helper t cells (also macrophages, dendritic cells)
|
|
|
CD common to both B and T cells
|
CD45 is present in all leukocytes
|
|
|
CD10:
|
Common acute lymphoblastic leukemia antigen (CALLA)
|
|
|
Complement fixation reactions:
|
Hemolysis of test system RBCs is a negative test, while lack of hemolysis is a positive test
|
|
|
Hanta virus:
|
Carried in rodents (deer mice)
ARDS Hemorrhage Renal failure Viral RNA in lung tissue- PCR test is best overall test |
|
|
Staphylococcus aureus:
|
Protein A attaches to Fc receptor of macrophages, hence blocking opsonization of bacteria
|
|
|
Proteus mirabilis:
|
Moves wiht flagella; urease producer
|
|
|
Mycoplasma pneumoniae:
|
Requires sterols
|
|
|
Latex agglutination reactions:
|
Antibody to capsular antigens in attached to the beads
|
|
|
Locations of cells in lymph node:
|
B (follicles), T (paracortex), histiocytes (sinuses)
|
|
|
Cells that attack protozoans:
|
CD4 T cells
|
|
|
What gives bacteria that shape:
|
Peptidoglycan layer in teh cell wall
|
|
|
Tumbling motility, gram positive rods:
|
Listeria monocytogenes
Invades mononuclear cell Beta-hemolysis in blood agar Transplacental infectin in fetus or occurs in renal transplant patients Mainly contracted from eating unpasturized cheese- goat's milk cheese |
|
|
Gray membrane that bleeds when removed:
|
Diphtheria
|
|
|
Dengue:
|
Transmitted by mosquito
Aedes aegypti Same mosquito as in yellow fever "Breakbone fever" Hemorrhageic fever |
|
|
Infection associated wiht premature rupture of the membrane:
|
Group B streptococcus (S. agalactiae)
CAMP test |
|
|
IL-1 functionon B lymphocytes
|
Activates B cells
|
|
|
Location for Staphylococcus aureus carriers:
|
Anterior nares
|
|
|
Rhinovirus:
|
Common cold occurs more often in fall and winter
Too many types to produce an effective vaccine Person to person droplet infection and contamination of hands Acid-labile-does not cause gastroenteritis because of this |
|
|
Virus responsible for a cold in spring and summer:
|
Adenovirus
|
|
|
Lactobacillus in vagina:
|
Responsible for the acid pH
|
|
|
Influenza vaccine:
|
Killed
Egg-based |
|
|
Hib vaccine:
|
Antibody against capsular polysaccharide
|
|
|
In addition to the normal childhood immunizations, what additional immunization are recommended in sickle cell disease and cystic fitrosis:
|
Pneumococcus and influenza Pneumovax is given after 2 years of age
|
|
|
Which live vacine can be given to a patient iwth AIDS:
|
MMR
MMR is given only because the natural infection for measles is worse that the one that potentially could happen with the attenuated virus |
|
|
Live vaccines:
|
Cannot give to immunocompromised patients: (organ transplant patient)
MMR: (only one that you can give to AIDS patients) Varicella OPV BCG, Smallpox Yellow fever |
|
|
Polysaccharide vaccines:
|
Pneumococcus
Hib-meningococcal vaccine is another example |
|
|
Killed virus vaccines:
|
Influenza
Rabies SALK vaccine |
|
|
Immunizations that are contraindicated in patients wiht anaphylactic reactions against eggs:
|
MMR
Influenza Yellow fever |
|
|
Immunizations that are contraindicated in patients with anaphylactic reactions against neoycin:
|
MMR
Varicella (neomycin is a preservative) |
|
|
Verrucoid lesion in lower extremity in a patient returning form South America
|
South American blastomycosis
Yeast with a ships wheel appearance North American blastomycosis has broad based buds |
|
|
Newborn baby in HIV positive mother:
|
Newborn has anti-gp 120 in the serum (IgG antibody)
Prevent HIV in newborn by giving mother AZT |
|
|
Most common cause of diarrhea in children:
|
Rotavirus
|
|
|
E. coli
|
Attaches to the urogenital epithelium
Hence its #1 status for urinary tract infections |
|
|
Bruton's agammaglobulinemia
|
SXR
Dfect in pre-B to B cells no germinal folicles in nodes or plasma cells Prone to respiratory infections Rx with IV gamma globulin |
|
|
SCID:
|
Combined B and T cell deficiency
First immunodeficiency treated wiht gene therapy- replacement of adenosine deaminase No germinal follicles or plasma cells, No T cells in parafollicular area Accumulaition of dATP, which inhibits ribonucleotide reductase with subsequent decrease in deoxynucleoside triphosphate precursors for DNA which reduces the formation of B and T cell precursors BM transplant helpful |
|
|
Wiskot Aldrich:
|
SXR
Triad Sinopulmonary infections, eczema, thrombocytopenia B/T cell deficiency- decreased IgM: poor antigenic response to bacterial polysaccharide Normal IgG; increased IgA and IgE Defects in CMI develop late Increased incidence of leukemia/lymphoma Rx-BM transplant |
|
|
Common variable immune deficiency (CVID)
|
No inheritance pattern
Intrinsic defect in B cell maturation into antibody-producing plasma cells Presents between 15-35 years of age Recurrent sinopulmonary infections- decreased Ig production Giardiasis, malabsorption due to celiac sprue All Igs decreased Rx- IV gamma-globulin |
|
|
Selective IgA deficiency:
|
MC hereditary immunodeficiency
Intrinsic defect in B cell differentiation into committed B cells synthesizing IgA and/or possible T cell defect that prevents B cells from synthesizing IgA clinical Recurrent sinopulmionary infections- lack of secretory IgA Giardiasis Autoimmune disease Allergies Develop anti-IgA antibodies with exposure to blood products- danger of anaphylactic reaction when exposed to blood products with IgA Serum an dsecretory IgA levels decreased |
|
|
Sex-liinked lymphoproliferative syndrome:
|
SXR
B cell deficiency- EBV-related disease Hypogammaglobulinemia Malignant lymphoproliferative diseorders |
|
|
DiGeorge syndrome (thymic hypoplasia):
|
Pure T cell deficiency- no inheritance pattern
Failure of the 3rd (inferior parathyroids/thymus) 4th (superior parathyroids) pharyngeal pouches to develop Clinical- Aabnormal facies Hpoparathyroidism with hypocalcemia and tetany Absent thymic shadow, truncus arteriosus (cyanotic congenital heart disease) Chronic candidiasis PCP graft vs. host reaction (must irradiate blood to destroy donor immunocompetent lymphocytes) Rx- thymic grafts Bone marrow transplants |
|
|
Ataxia telangiectasia:
|
AR disease,
B/T immunodeficiency- develops in 2-5 year olds Clinical- Cerebellar ataxia Telangiectasias in eyes/skin, sinopulmonary infections Chromosome instability syndrome Increased susceptibility for chromosomal mutations DNA enzyme repair defects (increased risk for lymphomas/leukemias) Thymic hypoplasia Low IgA/IgE Increased serum alpha-fetoprotein |
|
|
Part of a vaccine that is antigenic:
|
Polysaccharide capsule
|
|
|
Person working with animal hides develops lung disease:
|
Bacillus anthrax- woolsoter's disease
|
|
|
Cryptococcus:
|
Evades host destruction via its polysaccharide capsule
|
|
|
Child with anemia and diarrhea:
|
Hookworm (Necator) produces iron deficiency
Rx-albendazole |
|
|
Lymphocutaneous nodues in a rose gardener:
|
Sporotrichosis
Rx: itraconazole Old Rx was treat with potassium iodide |
|
|
Elderly male smoker with non-productive cough, bacteria fails to grow on ordinary media (must be supplemted with iron and cysteine), need Dieterle silver stain ti identify:
|
Legionella
Fluoroquinolones or erythromycin + rifampin |
|
|
Macrophage activation:
|
Gamma-interferon secreted from helper T cell
|
|
|
AIDS:
|
Most common acquired immunodeficiency
|
|
|
Hyperacute rejection of a transplant:
|
ABO incompatibility or patient had anti-HLA antibodies against an HLA antigen in the graft
Type II hypersensitivity reaction |
|
|
HLA A, B, C code for class I antigens:
|
CD8 cytotoxic T cells recognize these antigens
|
|
|
HLA D loci code for class II antigens:
|
CD4 helper T cells
Macrohages recognize |
|
|
Graft vs host reaction:
|
NK cell mediated
Common in bone marrow and liver transplants Clinical- Rash Jaundice (necrosis of bile ducts) Diarrhea Danger in T cell deficient patients |
|
|
Receptor for EBV:
|
CD21 on B cells
Polyclonal stimulator causing increased synthesis of immunoglobulins- reason for hypergammaglobulinemia in AIDS Increased cell dividions increases risk for t;8:14 and development of burkitt's lymphoma |
|
|
CD type for histiocytes:
|
CD1
Positive in patients wiht histiocytosis X- Hand-Schuller-Christian Letterer-Siwe Eosinophilic granuloma |
|
|
Destroy C. difficile in bedpan:
|
autoclave
|
|
|
M. tuberculosis:
|
Mycolic acid in cell wall is responsivle for acid-fastness
|
|
|
Blastomycosis
|
Spores associated with beaver dams and inland water ways
Broad-based bud Verrucoid skin lesion resembles squamous cancer |
|
|
Impetigo:
|
Most commonly caused by group A streptococcus
|
|
|
CD3
|
Antigen recognition site for T cells
|
|
|
Antigen that binds to CD4 on T cells in HIV
|
gp120
|
|
|
Risk for HIV if accidental needle stick form an HIV positive patient
|
1/330, Rx with triple therapy for 6 months an get ELISA test at repeated intervals
|
|
|
Fever in malaria:
|
Coincides with rupture of RBCs
|
|
|
Hematologic abnormality associated wiht Rx of malaria
|
Treat with primaquine and develop acute intravascular hemolysis in G6PD deficiency
|
|
|
Pathogen community acquired infection rather than a nosocomial infection:
|
Mycoplasma pneumoniae
|
|
|
Single most important infectious cause of death in the world:
|
Tuberculosis
|
|
|
Asthma, massive hemoptysis and external otitis
|
Aspergillus fumigatus
Narrow angle, septate, corona |
|
|
Cavitary lesion on a chest x-ray
|
Primary squamous carcinoma of hte lung
Histoplasmosis Lung abcess Reactivation TB is cavitary |
|
|
Mycoacterium Tuberculosis and sarcoidosis are BOTH associated with:
|
Granulomatous hepatitis, the former the MC infectious cause and the latter the MC non-infectious cause
|
|
|
Greenish discoloration of the sputum in a febrile 4 year old child wiht cystic fibrosis is MOST LIKELY due to
|
Pseudomonas aeruginosa- pyocyanin
|
|
|
Pathogens that are branched with a standard Gram stain:
|
Nocardia asteroides-
Partially acid-fast Strict aerobe Actinomyces Strice anaerobe Sulfur granules Draining sinus tracts in jaw, thorax, or abdomen |
|
|
65 year old cave explorer for Indian artifacts in the Sonoran desert of Arizona presents with fever, flu-like symptoms, a non-productive cough and painful red nodules on the anterior aspect of his lower left leg (erythema nodosum). A solitary coin lesion with an egg shel-like cavity is noted in the upper portion of his left lower lobe on a chest x-ray:
|
Coccidioidomycosis
|
|
|
An asymptomatic, afebrile 48 year old Black man, who has lived all of his life in Ohio, is noted to have multiple calcifications throughout both lung fields and in the spleen:
|
Histoplasmosis
|
|
|
Scotchromogen associated with ainless cervical adenopathy in children:
|
Mycobacterium scrofulaceum
|
|
|
MCC of disseminated TB in AIDS
|
Mycobacterium avium-intracellulare
|
|
|
MCC of a swimming pool granuloma
|
Mycobacterium marinum
|
|
|
MCC of intestinal tuberculosis in the US
|
Mycobacterium tuberculosis- swallow infectd sputum and organisms taken up by macrophages in Peyer's patches
|
|
|
Photochromogen that produces pulmonary tuberculosis:
|
Mycobacterium kansasii
|
|
|
Rapidly growing TB associated wiht infection in immunocompromised hosts and in prosthetic devises:
|
Mycobacterium fortuitum
|
|
|
Pathogen that commonly produces lung abscesses, common secondary invader in the lung in patients with rubeola or influenza, produces tension pneumatocyst leading to tension pneumothorax in cystic fibrosis patients:
|
Staphylococcus aureus
|
|
|
Pathogen that is contracted when the newborn passes through the birth canal. It produces a pneumonia characterized to abrupt onset of tachypnea, wheezing, hyperaeration, eosinophilia and a conspicuous lack of fever. It is often associated with a conjunctivitis:
|
Chlamydia trachomatis
|
|
|
Systemic pathogen that is often associated with the presence of indwelling venous/arterial catheters and immunodeficiency states. It produces a pneumonia characterized by diffuse nodular infiltrates adn evidence of vessel invasion:
|
Candida albicans
|
|
|
Childhood pathogen that may produce a pneumonia associated with Warthin-Finkeldey multinucleated giant cells:
|
Rubeola
|
|
|
Water loving pathogen that is most commonly seen in men over 40 years old who are smokers. It produces a confluent bronchopneumonia, with fever, non-productive cough, hemoptysis and other systemic signs and symptoms. It commonly produces hyponatremia related to development of interstitial nephritis leading to hyporeninemic hypoalosteronism. The pathogen is best visualized with direct IF or a silver stain:
|
Legionella pneumophila
|
|
|
Respiratory pathogen with a signifcant mortality in those over 55 years of age and who have underlying renal, cardiac or lung problems. It produces a severe, exudative pneumonia iwht a propensity for secondary bacterial invasion. There is an asssociation with Reye's syndrome in children that take aspirin:
|
Influenza
|
|
|
Respiratory pathogen is transmitted without a vector, unlike other pathogens into its family group. It is primarily transmitted by inhalation by individuals who have an association with the birthing process in sheep, cows and goats or in those who work in teh milk industry: It is particularly common in workers who shovel feces in sheep:
|
Coxiella burnetii
|
|
|
Respiratory pathogen that is transmitted by direct hand to hand transfer of infected material and by respiratory droplet infection. It's main reservoir is school children. Development of a vaccine is highly unlikely:
|
Rhinovirus
|
|
|
Respiratory pathogen transmitted by droplet infection. It accounts for approximately 10% of community acquired atypical pneumonias and a smaller percentage of cases of bronchitis. Cold agglutinins are not associated with this pathogen. There may be an association with coronary artery disease. It responds well to doxycycline, like other members of its family:
|
Chlamydia pneumoniae (TWAR)
|
|
|
Strict anaerobe that can produce an empema that drains through a sinus tract out to the skin surface. yellow fleks of material in the drainage fluid should be Gram stained to demonstrate its characteristic morphology:
|
Actinomyces israelii
|
|
|
Pathogen that is commonly contracted in military stations and in crowded situations. It produces an interstitial pneumonia and is often associated with erythema multiforme and bullous myringitis. It responds well to erythromycin:
|
Mycoplasma pneumoniae
|
|
|
Respiratory pathogen that is an example of a zoonosis. It is associated with an interstitial pneumonia. Its incidence has declined by putting tetracycline in animal feed:
|
Chlamydia psittaci
|
|
|
Predominantly a respiratory pathogen, this strict aerobe is most commonly seen in patients with defects in cellular immunity, particularly in the setting of heart trensplantation. It produces microabscesses in teh lungs, often with granuloma formation. A characteristic feature, aside from its unusual Gram stain morphology, is that it is martially acid fast:
|
Nocardia asteroides
|
|
|
MCC of death in patients iwth cystic fibrosis
|
Pseudomonas Aeruginosa
|
|
|
MCC of pneumonia and bronchiolitis in infants:
|
RSV
|
|
|
MCC of croup with inspiratory stridor. A lateral neck x-ray revelas a 'steeple sign"
|
Parainfluenza
Tracheal obstruction |
|
|
MCC of inspiratory stridor in a child whose lateral neck x-ray reveals the "thumbprint" sign. Its incidence has decreased owing to the use of a vaccine:
|
Hemophilus influenzae
|
|
|
MCC of bronchopneumonia an dlobar pneumonia in the general population:
|
Streptococcus pneumoniae
|
|
|
An executive in an office in NYC has a window air conditioner that is a favorite roost for pigeons. She and her secretary both develop lung disease:
|
Cryptococcus neoformans
|
|
|
An HIV positive patient wiht fever, night sweats, cough, dyspnea wiht exertion, a CD4 T helper count of 350 cells, and cavitary apical lung disease:
|
Mycobacterium tuberculosis
Note that MAI only comes when the helper T cell count is <100 |
|
|
MC fungal infection in an HIV positive patient:
|
Candidiasis
|
|
|
MCC of recurent pneumonia in a patient wiht AIDS:
|
Streptococcus pneumoniae
|
|
|
Inspiratory stridor is commonly associated with:
|
Parainfluenza virus infection (croup)
Acute epiglottitis |
|
|
Chlamydia trachomatis and the respiratory syncytial virus are BOTH commonly associated with:
|
Interstitial type of pneumonia
|
|
|
Klebsiella pneumoniae
|
Upper lobe cavitation
Thick mucous and fat gram negative rods Association with an alcoholic |
|
|
In a 30 year old man who lives in TN, you would expect a calcified solitary coin lesion in the lung to represent:
|
An old granuloma (histoplasmosis)
|
|
|
A bridge painter in Brooklyn, NY develops a pulmonary infiltrate. Which of the following pathogens are on your differential list:
|
Histoplasma capsulata (starlings)
Cryptococcus neoformans (pigeons) |
|
|
26 year old male, who presented with a sudden onset of 103 degrees F, dyspnea, cough productive or rusty-colored sputum, and pleuritic chest pain in the right upper lung. A chest x-ray reveals a right upper lobe consolidation. A gram stain of sputum is pending
|
Streptococcus pneumoniae pneumonia
Rx with penicillin G. |
|
|
Systemic fungus wiht broad-based buds presents with a skin disorder simulating squamous carcionoma as well as lung disease:
|
Blastomyces dermatitidis
|
|
|
Systemic fungus that most simulates primary and reactivatoin TB and has yeast forms phagocytosed by alveolar macrophages:
|
Histoplasma capsulatum
|
|
|
Pulmonary pathogens that are vessel invaders adn have the capacity to produce pulmonary infarctions:
|
Candida albicans
Pseudomonas aeruginosa Aspergillus fumigatus Mucor species |
|
|
Ptients who are being treated for tuberculosis may develop sideroblastic anemia
|
complication of isoniazid
Produces pridoxine deficiency B6 is necessary in heme synthesis in the mitochondria of RCs Leads to a sideroblastic anemia |
|
|
Streptococcus pneumoniae:
|
MCC of-
meningitis in patients >18 years old Spontaneous peritonitis in children with ascites Otitis media Sinusitis |
|
|
28 year old man with AIDS who presents with chronic, recurrent, profuse, nonbloody, watery diarrhea. An Entero-Test (string test) reveals oocyts that are partially acid-fast positive:
|
Cryptosporidium parvum
|
|
|
Afebrile 22 year old man and several other members of his family developed severe vimiting without diarrhea ~ 1-6 hours after eating potato salad at a picnic. They all recovered uneventfully 12-24 hours later:
|
S. aureus with preformed toxin
|
|
|
Systemic fungus wiht broad-based buds presents with a skin disorder simulating squamous carcionoma as well as lung disease:
|
Blastomyces dermatitidis
|
|
|
Systemic fungus that most simulates primary and reactivatoin TB and has yeast forms phagocytosed by alveolar macrophages:
|
Histoplasma capsulatum
|
|
|
Pulmonary pathogens that are vessel invaders adn have the capacity to produce pulmonary infarctions:
|
Candida albicans
Pseudomonas aeruginosa Aspergillus fumigatus Mucor species |
|
|
Ptients who are being treated for tuberculosis may develop sideroblastic anemia
|
complication of isoniazid
Produces pridoxine deficiency B6 is necessary in heme synthesis in the mitochondria of RCs Leads to a sideroblastic anemia |
|
|
Streptococcus pneumoniae:
|
MCC of-
meningitis in patients >18 years old Spontaneous peritonitis in children with ascites Otitis media Sinusitis |
|
|
On a trip to the Far East, a man develops a high fever associated wiht bradycardia, absolute neutropenia, and splenomegaly. A blood culture is positive for a gram negative organism:
|
Salmonella typhi
|
|
|
28 year old man presents with diarrhea with mucus and blood. A stool for fecal leukocytes reveals blood and neutrophils. Pseudomembranes are noted in a colonoscopy:
|
Could be-
Shigella sonnei Campylobacter jejuni |
|
|
Patient wiht AIDS develops diarrhea with steatorrhea. A biopsy reveals macrophages with foamy cytoplasm
|
Mycobacterium avium-intracellulare with Whipples-like syndrome
|
|
|
Odynophagia in a HIV positive 28 year old man with white plaque-like material on his tongue and buccal mucosa that scrapes off and leaves a bloody base:
|
Candida albicans
|
|
|
Elevated serum amylase associated with meningoencephalitis:
|
Paramyxovirus infection (mumps)
|
|
|
Gastrointestinal lymphomas arising form mucosa associated lymphoid tissue (MALT) in the stomach:
|
Helicobacter pylori
|
|
|
MC invasive enterocolitis that commonly simulates ulcerative colitis and pseudomembranous colitis:
|
Campylobacter jejuni
|
|
|
MCC of diarrhea in children during the winter months that has an ELISA test for aid in its diagnosis
|
Rotavirus
|
|
|
Common cause of diarrhea in AIDS and MCC of biliary tract disease adn pancreatitis in AIDS:
|
CMV
|
|
|
MCC of gastroenteritis in adults:
|
Norwalk virus
|
|
|
MCC of a secretory diarrhea when outside the US:
|
Enterotoxigenic E. coli
|
|
|
MCC of a microangiopathic anemia, thombocytopenia, and renal failure in children:
|
Enterohemorrhagic E. coli-
Serotype O157:H7 |
|
|
Elderly patient develops diarrhea a week after being treated for pneumonia while in hospital. A flexible sigmoidoscopy reveals a gray-yellow exudate in the rectosigmoid:
|
C. difficile
Rx wiht metronidazole |
|
|
Common causes of dysentery and hemolytic urmic syndrome in children
|
Shigella sonnei and Enterohemorrhagic E. coli
|
|
|
MCC of non-typhoid enteric fever and cause of osteomyelitis in patients with sickle cell disease
|
Salmonella paratyphi
|
|
|
Transmitted by a human carrier and produces a disease associated wiht fever, sepsis, vasculitis, diarrhea, hepatosplenomegaly, and gallbladder disease. It is NOT the most common cause of osteomyelitis in children with sickle cell disease:
|
Salmonella typhi
|
|
|
MC organism contaminating blood transfusions and may be associated with triggering ankylosing spondylitis:
|
Yersinia enterocolitica
|
|
|
Produces obstruction of the terminal ileum:
|
Mycobacterium tuberculosis
Swallowed organism from a primary in the lungs. |
|
|
Invasive helminth that is often disseminated in AIDS patients with a common cause of autoinfection and superinfection:
|
Strongyloides stercoralis
|
|
|
Type (s) of hepatitis with no proootective antibodies:
|
Hepatitis C and D
|
|
|
Types of hepatitis wiht no chronic state:
|
Hepatitis A and E
|
|
|
MC type of hepatitis found in day care centers:
|
A
|
|
|
MC type of hepatitis leading to hepatocellular carcinoma
|
B and C
|
|
|
MC hepatitis associated wiht polyarteritis nodosa
|
HBV
|
|
|
MC hepatitis in traveler's to places outside the US
|
A
|
|
|
MC hepatitis in jails and corrective institutions
|
A
|
|
|
MC sexually transmitted types of hepatitis
|
A, B, C
|
|
|
MC cause of posttransfusion hepatitis and chronic hepatitis
|
C
|
|
|
MC type of hepatitis prevented by immunization
|
Hep B and D
Also prevents hepatocellular carcinoma from HBV cirrhosis |
|
|
MC type of hepatitis transmitted parenterally
|
B, C, D
|
|
|
MC type of hepatitis wiht protective antibodies
|
A, B, and E
|
|
|
Most common hepatitis producing fulminant hepatitis in a patient with a pre-existing hepatitis
|
Hepatitis D: requires HBsAg to infect hepatocyte
|
|
|
Most common hepatitis transmitted by the fecal-oral route
|
A and E
|
|
|
MC type of hepatitis in homosexuals:
|
A; unprotected anal intercourse
|
|
|
MC type of hepatitis that may lead to chronic hepatitis
|
B, C, D
|
|
|
MC type of hepatitis associated with cryoglobulins and membranoproliferative glomerulonephritis
|
C
|
|
|
MC type of hepatitis transmitted by accidental needle stick
|
B
|
|
|
MCC of spontaneous bacterial peritonitis in adults with cirrhosis and ascites:
|
E. coli
Streptococcus pneumoniae is MC in ascites associated wiht nephrotic syndrome in children |
|
|
Pathogen asociated with inguinal lymph nodes containing granulomatous microabscesses and localized lymphedema and rectal strictures as a complication
|
Lymphogranuloma venereum- only STD without ulcers
|
|
|
32 year old woman complains of a vaginal discharge that has a 'fishy odor'. It is particularly nticable during coitus. the discharge has a pH of 5. Examination of the discharge shows bacteria adhering to epithelial cells:
|
Gardnerella vaginalis- clue cells
Not an STD only Rx the patient wiht metronidazole |
|
|
35 year old diabetic presents iwth vaginal discharge that is thick and has the appearance of cottage cheese
|
Candida albicans
Rx with fluconazole |
|
|
32 year old female presents with intense vulvar pruritus. She has a purulent malodorous frothy green vaginal discharge. the discharge can be wiped from the wall of the vagina nd leaves patchy vaginal erythema (strawberry vagina. The pH of the discharge is 5.6
|
Trichomonas vaginalis
Rx both partners with metronidazole |
|
|
MCC of neonatal meningitis. Causes chorioamnionitis due to an ascending infection from the vagina and cervix. Risk of infection of neonate is greater when there is premature rupture of hte membranes prior to delivery:
|
Group B streptococci (Streptococcus agalactiae)
|
|
|
23 year old woman on the third day of menses presents with fever, severe lower abdominal pain and adnexal tenderness with movement of the cervix. History reveals sexual intercourse 3-4 days prior to menses:
|
Neisseria gonorrhea- the short incubation period is most consistent with GC rather than Chlamydia
She has PID and should be treated wiht ceftriaxone and doxycycline, the later to cover possible Chlamydia trachomatis as a coinfection |
|
|
34 year old patient has had an IUD in place fo 9 months as a method of birth control and now complains of vaginal discharge. At the request of the patient, the IUD is removed. Yellow flecks of material are attached to the IUD which on Gram stain reveal a filamentous gram positive bacteria:
|
Actinomyces
|
|
|
46 year old woman presents with dysuria, increased frequency, and a mucopurulent vaginal discharge. Vaginal smears of the exudate and examination of the urinary sediment are negative for organisms but show many leukocytes. Her last sexual exposure was 10 days ago:
|
Chlamydia trachomatis
|
|
|
33 year old female from Equador has recently been diagnosed with chronic endometritis. A microscopic examination of the endometrial tissue reveals poorly formed granulomas and an infiltrate of plasma cells:
|
Mycobacterium tuberculosis
|
|
|
32 year old woman has a painful ulcer on the left labia majora and ipsilateral painful inguinal lymph nodes. A gram stain from the base of the ulcer reveals gram negative rods in a 'school of fish' orientation
|
Hemophilus ducreyi
|
|
|
25 year old woman has a painless ulcer on the left labia majora and ipsilateral painful inguinal lymphadenopathy
|
Treponema pallidum- primary syphilis
|
|
|
23 year old woman develops fever, painful lymphadenopathy, and painful vesicles on her external genitalia that later ulcerate. A Tzank prep from teh base of one of the ulcers is positive:
|
Herpesvirus type 2- note how primary infection is systemic
|
|
|
Patient from New Guinea presents with a painful, serpiginous type of raised sore on the labia majora. There is not lymphadenopathy. A biopsy is taken and reveals macrophages with intracellular organisms:
|
Calymmatobacterium granulomatis: the patient has granuloma inguinale and the intracellular bodies are called donovan bodies
|
|
|
23 year old sexually active woman is noted to have fern-like lesions around the labia and perianal area. Her RPR is negative:
|
HPV- the patient has condloma acuminata, or veneral warts
|
|
|
30 year old ornithology graduate student presents with altered mental status, stupor, and headache. There is no nucal rigidity. He has been studying marsh birds over the last month in a mosquito-infested swamp area in the Midwest. A gram stain and culture of the CSF is negative:
|
Patient has an arborvirus type of encephalitis
|
|
|
18 year old Navy recruit presnts wiht fever, headache, and a positive Kernig's test. He is the 10th case in the past week that has occurred at the base:
|
The patient has meningitis, most lilely Neisseria meningitidis based on teh crowded conditions
|
|
|
32 year old man renal transplant patient who is immunosuppressed has a positive India ink preparation:
|
Cryptococcal meningitis
|
|
|
Bilateral ophthalmia neonatorum during the first week:
|
N. gonorrhoeae,
Transmitted on teh way through teh cervix |
|
|
Corneal transplant, brain instrumentation:
|
Can transmit the pions of Creutzfeldt-Jakob disease
|
|
|
Diabetic ketoacidosis
|
Mucormycosis in frontal lobes
Ketoacidosis accelerates the growth of the fungus |
|
|
MCC of meningitis after 18 years old:
|
Streptococcus pneumoniae
|
|
|
Rubeola:
|
Cause of subacute sclerosing panencephalitis- slow virus disease
|
|
|
Papovavirus infection:
|
Viral agent of progressive multifocal leukodystrophy, a slow virus disease
|
|
|
Bubbles and holes spongiform change in the brain
|
Describes CJ disease
Prions |
|
|
Gamma Interferon
|
Produced by CH4 T helper cells an dNK cells
Functions- Activates macrohages to kill microbial pathogens Antiviral activity Induces class I and II antigens Increases production of IL-2 and IL-12 by CD4-T helper cells |
|
|
IL-1
|
Produced by macrophages
Fever inflammation Acute phase reactant synthesis of proteins in liver Osteoclast activator Stimulates B cell production and antibody production |
|
|
IL-2
|
Produced by CD4 T helper cells
Primarily a T cell growth factor Promotes B cell/NK cell proliferation |
|
|
IL-3
|
Produced by T cells and thymic epithelial ells
Stimulates pluripotential stem cell marrow Increases hematopoiesis |
|
|
IL-4
|
Produced by activated T cells
Mainly promotes growth of B cells Switch of IgM synthesis in B cells to IgE synthesis in type I hypersensitivity reactions |
|
|
IL-5
|
Produced by T cells and mast cells
Promotes growth of eosinophils Promotes IgE synthesis |
|
|
IL-6
|
Produced by T cells, macrophages, endothelial cells, fibroblasts, epithelial cells, primarily stimulates synthesis of acute phase reactants in the liver in acute inflammation
|
|
|
IL-12
|
Produced by macrophages
Promotes growth of CD8 T cells Promotes differentiation of CD4 T helper cells into Th1 and Th2 classes Promotes production of gamma-interferon Enhances NK activity |
|
|
Granulocyte colony stimulating factors (G-CSF)
|
Produced by fibroblasts
Stimulates neutrophil development in the bone marrow |
|
|
Granylocyte/macrophage colony stimulating factor (GM-CSF)
|
Produced by macrophages and T cells
Stimulates neutrophil and monocyte development in the bone marrow |
|
|
B cells:
|
10-20% of total lymphocyte count
Markers: intracytoplasmic mu heavy chains: pre-B cell Surface mu and delta heavy chains: mature B cell and antigen recognition site Function: antibody synthesis Surface receptors: IgG Fc receptors; CD21 for EBV Testing: B cell count: flow cytometry; immunoglobulin concentration: order of decreasing concentration IgG, IgA, IgM, IgD, and IgE; detect isohemagglutinins; mitogen stimulation pokeweed |
|
|
T cells:
|
60-70% of total lymphocyte count
Markers: monoclonal antibody marker studies for cluster designation (CD) types; immature T cells have nuclear enzyme terminal deoxynucleotidly transferase (tdT) no their surface Functions: type IV hypersensitivity; cytokines regulate B cells; defense against intracellular pathogens (TB, protozoa) Testing: mitogen assays: functioning T cells are specifically activated by phytohemagglutinin and concanavalin A; skin tests to evaluate cellular immunity Candida is the main antigen used Absence of an immune indicates anergy of a lack of cellular immunigy (AIDS) |
|
|
AIDS epidemiology:
|
gp 120 viral envelope protein of virus attaches to CD4 molecule of T helper cells and other cells; monocytes/macrophages/dentritic cells/microglial cells (CNS macrophage); astrocytes
P24 core protein surrounds viral genomic RNA; only increased during initial infection and when the patient develops AIDS; 2 separate peaks CD4 T helper cell is lysed by the virus; usually direct HIV cytotoxicity Reverse transcriptase converts genomic RNA into proviral double stranded DNA; integrated into host cell's DNA with virally encoded integrase enzyme After transcription, HIV messenger RNA is translated into various proteins: env encodes gp120.gp41; pol encodes reverse transcriptase/integrase; gag encodes p24 antigen Viral core consists of genomic RNA surrounded by an inner membrane composed of p24 core antigen: assembled near the host cell's plasma membrane Budding of the progeny virion through the host cell membrane is where the viral core acquires the external envelope to become a mature HIV virion |
|
|
Mode of HIV transmission in the US in descending order:
|
Receptive anal intercourse between men
Vaginal intercourse male to female: infected semen has more surface area to infect Female to male: less surface area in teh male urethra to infect |
|
|
Positive enzyme immunoabsorbent assay (EIA) test for HIV in a newborn
|
Due to transplacental transmission of the IgG antibody form teh infected mother
Document HIV infection in newborn by detection of HIV RNA by PCR (best test) and p24 antigen capture assay |
|
|
AIDS testing with enzyme immunoabsorbent assay (EIA):
|
Initial screening test
Detects anti-gp120 antibody Sensitivity 99,5-99.8% Poor specificity due to low prevalence of HIV posivity in the general population |
|
|
AIDS testing with western blot:
|
Confirmatory test for indeterminate or positive IEA
Positive western plot: presene of p24 and gp41 antibodies and either gp120 ro gp160 antibodies; combined positive predictive value of a positive EIA/Western blot is 99.5% |
|
|
AIDS tests for monitoring immune status:
|
CD4 T helper cell count:
HIV RNA by PCR- best overall test to monitor viral burden |
|
|
Non-AIDS defining infections:
|
Oral thrush
Oral hairy leukoplakia (EBV glossitis) Shingles (zoster) Molluscum contagiosum (pox virus) |
|
|
Diagnosis of AIDS:
|
HIV positive plus
CD4 T helper count <200 specific malignancies specific infections |
|
|
AIDS miscellaneous infections:
|
Bacillary angiomatosis:
due to Bartonella henselae: identify with silver stains Simulates Kaposi's sarcoma Recurrent bacterial pneumonia: Streptococcus pneumoniae, infections encountered with CD4 T heoper count 100-200, MCCOD in AIDS Infections encountered with CD4 T helper count <100; disseminated MAI: usually <75; Candida esophagitis; CMV retinitis/esophagitis; Toxoplasma encephalitis; Cryptosporidiosis (diarrhea, cryptococcal meningitis) |
|
|
Testing of complement system:
|
Classical pathway: low C4 or C2 if activated
Alternative pathway: low factor B if activated Integrity of both pathways: low C3 if either system is activated Activation increases the concentration of split fragments: C3a, C5a, C3b Functional assessment of the complement system: total hemolytic complement assay (CH50) |
|
|
Major Histocompatibility Complex (MHC)
|
Mature RBCs lack class I antigen
Individuals inherit 1 HLA haplotype form each parent in codominant fashion: both haplotypes are expressed |
|
|
Transplantation success requirements:
|
ABO blood group compatibility- most important test
Absence of preformed anti-HLA cytotoxic antibodies in teh recipient's serum Close matches for HLA-A, B, and D loci between recipient and donor |
|
|
Lymphocyte crossmatch:
|
Screens for recipient anti-HLA antibodies against donor lymphocytes
|
|
|
Lymphocyte microcytotoxicity test:
|
identifies HLA-A and B derived class I antigen profiles in recipient and donor lymphocutes using known test sera
|
|
|
Mixed lymphocyte reaction
|
Used for Class II antigen (D loci) matching
Functional lymphocytes from teh recipient and previously irradiated (killed) donor lymphocytes are mixed together with tritiated thymidine to detect the degree of compatibility between their D loci: increased radioactivity indicates incompatibility Recipient's lymphocytes are irradiated (killed) and functional donor lymphocytes are reacted against the host's HLA-D loci to check for a graft versus host reaction (GVH) |
|
|
Transplant donors:
|
Siblings are best source- chance of a sibling having another sibling with a 0, 1, or 2 haplotype match is 25%, 50%, and 25% respectively
Parents are automatically a 1 haplotype match |
|
|
Graft types:
|
Autograft: transfer of tissue for self to self; best survival
Syngeneic graft- graft between identical twins Allograft-graft: between unrelated individuals Xenograft: transplant of tissue from one species to another |
|
|
Corneal transplants:
|
Best overall allograft survival rate
|
|
|
HLA haplotypes and disease:
|
Familial predisposition to disease: weak penetrance, disease not invariable, usually requires exposure to an environmental factor
HLA-A3 hemochromatosis HLA-B8/DR3: celiac disease HLA-B27: ankylosing spondylitis HLA-DR2: multiple sclerosis HLA-DR3/DR4: type I insulin-dependent diabetes mellitus HLA-DR4: rheumatoid arthritis |
|
|
Examples of type I hypersensitivity reactions
|
Atopy- familial predisposition (multifactorial inheritance) to evelop an allergic reaction (eczema, hives, seasonal conunctivitis, seasonal rhinitis, asthma, hypersensitivity to bee/wasp/hornet stings
Rx: anaphylactic reactions sc administration of aqueous epinephrine 1:1000 dilution |
|
|
Examples of type II hypersensitivity reactions
|
Involves antibody reactions iwth or without complement
Examples: Goodpastures, warm autoimmune hemolytic anemias and cytopenias, Rh/ABO hemolytic disease of newborn, cells/helminths coated by specific IgG/IgE antibodies are destroyed by cells with low affinity IgG/IgE Fc receptors, myasthenia gravis: anti-acetylcholine receptor antibodies Graves disease: IgG thyroid-stimulating Ig directed against TSH receptor |
|
|
Examples of type III immunocomplex (IC) hypersensitivity reaction:
|
Circulating ICs (antigen + IgG/IgM) deposit in target tissue and activate the complement system; chemotactic agents recruit neutrophils/macrophages that damage the tissue
Pathogensis of localized IC reactions (Arthus reactions)- first antigen exposure results in antibody production; second exposure to antigen deposited in tissue leads antigen-antibody ICs complement system activation; neutrophil/macrophage damate of tissue (serum sickness: Rx of rattlesnake envenomations with use of horse serum antitoxins SLE glomerulonephritis (GN): anti-DNA + DNA ICs Post-streptococcal GN: antibacterial antigen antibodies + bacterial antigen ICs Henoch-Schonlein-Purpura: antiIgA antibodies against IgA Polyarteritis nodosa: HBsAg + anti-HBs ICs Rheumatoid arthritis: IgM antibodies against IgG (rheumatoid factor) clinical example fo an Arthus reaction- Farmer's lung: antigen is thermophilic actinomycetes |
|
|
Examples of type IV immunocomplex (IC) hypersensitivity reaction:
|
T cell mediated
Antibody-independent cellular immune reactions involving CD4 helper cells (DRH reactions) and CD8 cytotoxic T cells Types of DRH reactions: contact dermatitis, poison ivy, nickle Skin tests: tuberculin sensitivity, patch test in contact dermatitis, granulomas, pathogenesis of cytotoxic T cell reactions Cytotoxic T cells normally interact wiht class I antigens on nucleated cells; alteration of class I antigens on target cells activates cytotoxic T cells to release perforins that destroy the cell Examples: neoplastic/virally infected cell, foreign antigen in a transplant cell |
|
|
Parasitology terms
|
Definitive host: host that harbors teh adult, or sexual stage of the parasite
Intermediate host: host that harbors the larval, or asexual stage of the parasite Protozoa- amebae, ciliates, flagellates, sporozoa, Helminths- nematodes: roundworms Cestodes: tapeworms Trematodes: flukes |
|
|
Entameba histolytica (amebiasis)
|
Erythrophagocytosis
Bloody dysentery Liver abscess Rx: metronidazole |
|
|
Naegleria fowleri (primary amebic meningoencephalitis)
|
Swimmin in fresh water lakes
Meningoencephalitis Rx: amphotericin B |
|
|
Acanthamoeba (keratitis)
|
Soft lens wearers tha keep them in overnight or do not clean in proper solutions
Rx: propamidine |
|
|
Cryptosporidium parvum (sporozoan):
|
Acid-fast oocysts
MC pathogen in AIDS diarrhea contaminates reservoirs leading to wide-spread diarrhea Positive Entero-Test Rx- paromomycin |
|
|
Toxoplasma gondii (sporozoan)
|
MCC of space occupying lesion of brain in AIDS
Pregnant woman avoid cats and eating undercooked meat Rx- pyrimethamine |
|
|
Babesia species (sporozoan)
|
Carried in Ixodes dammini (same tick as borrelia burgdorferi)
Intererythrocytic parasite with hemolytic anemia Rx- clindamycin + quinine |
|
|
Types of plasmodia species (sporozoans)
|
P. vivax: MC
P. falciparum: most deadly P. malariae P. ovale Female Anopheles mosquito is the vector for malaria Sexual cycle (schizogony) develops in the mosquito Asexual cycle (sporogony) develops in humans Reinfection of hepatocytes my merozoites as in P. vivax and P. ovale infestations is responsible for relapses |
|
|
Who is resistant to plasmodia species?
|
Patients with sickle cell trait/disease
Glucose-6-phosphate dehydrogenase deficiency Beta-thalassemia are resistant to P. falciparum infection: mustiple reasons including Short life-span of RBCs Increased fragility of RBCs Increased levels of HgF: parasites cannot feed on this type of Hgb Most blacks are Duffy blood group (Fy) antigen negative, which renders them resistant to P. vivax infections- the organism requires the antigen as a receptor before it parasitizes the RBC |
|
|
Pathogenesis of anemia in malaria
|
Relates to both intravascular and extravascular hemolysis of RBCs, the later by removal of infected cells by splenic macrohages
Clinical picture for the "benign" forms of malaria includes Periodic paroxysms of shaking chills: correlates wiht intravascular rupture of RBC High fever with a specific pattern in all type except P. falciparum Quotidian (P. falciparum): daily spikes (paroxysms) of fever the persist for a few days and occasionally (no specific pattern) break every couple of days Tertian (P. vivax and ovale): paroxysms of fever every 48 hours (alternate days) Quartan (P. malariae): paroxysms of fever every 72 hours Splenomegally is a consistent feature in all malarias: spleen may spontaneously rupture |
|
|
P. malariae
|
Infestations may lead to membranous glomerulonephritis
|
|
|
P. falciparum
|
multi-infestation of RBCs by ring forms is common
Only type that only has ring forms and gametocytes in the PB: Massive intravascula hemolysis results in hemoglobinuria: Hgb turns black color in the presence o an acid pH, hence the term blackwater fever Chloroquine MC prophylasis Safe during pregnancy Kills blood schizonts and is gametocidal to all malaria except falciparum, resistant strains of P. falciparum, use mefloquine |
|
|
Treatment for plasmodia species
|
P. vivax/ovale: Chloroquine + primaquine (schizonticide in liver and gametocidal to falciparum)
P. falciparum: IV quinidine gluconate for people who cannot take drugs orally or quinine sulfate + doxycycline if they can take drugs orally |
|
|
Balantidium coli (sporozoan)
|
Large cysts
Colonic ulcers with bloody diarrhea Rx: tetracycline |
|
|
Giardia Lamblia (flagellate):
|
MC protozoal cause of chronic diarrhea/malabsorption in US
Day care centers Mountain springs Positive Entero-Test Rx: metronidazole |
|
|
Trichomonas vaginalis (flagellate)
|
STD
Rx both partners Tumbling motility Rx: metronidazole |
|
|
Hemoflagellates:
|
Human infections:
Leishmanial forms are within macrophages Leshmaniasis: only the intracellula (leishmanial) forms are present in humans African trypanosomiasis: only the extracellular (trypanosomal) forms are present in humans American trypanosomiasis or Chagas disease: both leshmanial (causes tissue destruction) an trypanosomal forms are present in humans |
|
|
African trypanosomiasis (sleeping sickness)
|
Caused by Trypanosoma brucei gambiense or Trypanosoma brucei rhodesiense
Bite of an infected txetxe fly Clinical: encephalitis, increased IgM, somnolence: release of sleep mediators by the organisms Trypanosomes are capable of antigen variations Rx: suramin for early infection (non-CNS disease_ and melarsoprol later stages (CNS infection) |
|
|
American trypanosomiasis (Chagas disease)
|
Caused by Trypanosoma cruzi
Bite of the reduviid bug Clinical: major cause ofprogressive heart failure leading to death Acquired achalasia/Hirschsprung's disease Rx: nifurtimox |
|
|
Leishmaniasis:
|
Visceral leishmaniasis: Leishmania donovani complex
cutaneous leshmaniasis: leshmania tropica complex Leishmania introduced by the bite of an infected sandfly (phlebotomus) Visceral Leishmaniasis or Kala-Azar Massive hepatosplenomegaly and anemia Rx: antimony stibogluconate Cutaneous Leishmaniasis: involves skin alone: ulcers (problem in the Gulf War) Rx: antimony stibogluconate |
|
|
Nematodes:
|
Those wiht larval phases in the lungs leading to pneumonitis/hemoptysis
Ascaris Lumbricoides Necator americanus Strongyloides stercoralis Strongyloides stercoralis has the only free living larval form that can survive in nature |
|
|
Enterobius vermicularis (pinworm nematode):
|
Anal pruritus
Apendicitis Urethritis in girls No eosinophilia: not invasive Embryonated Egg rx: albendazole |
|
|
Trichuris trichiuria (whipworm, nematode)
|
Diarrhea
Rectal prolapse Eosinophilia Rx: albendazole |
|
|
Ascaris lumbricoides (nematode)
|
Larval phase in lungs: cough, pneumonitis, eosinophilia
Adults cause intestinal obstruction: no eosinophilia (not invasive) Rx: albendazole or mebendazole |
|
|
Ancyclostoma duodenale and Necator americanus (hookworm, nematodes)
|
Larval phase in lungs
Mouth parts attach to tips of villi Iron deficiency anemia Larva infect soil and can penetrate feet Eosinophilia Rx: albendazole |
|
|
Strongyloides stercoralis (nematode)
|
Larval phase in lungs
Rhabditiform larvae (not eggs) pass in stool Infective filariform larvae in soil can penetrate feet Autoinfection and superinfection (especially in AIDS) Eosinophilia Positive Entero-Test Rx: ivermectin or albendazole |
|
|
Trachinella spiralis (trichinosis, nematode):
|
Contracted in may by the eating of raw or poorly cooked pork containing the encysted larvae of the organism (pig intermediate host)
Larvae have a propensity for skeletal muscle: often become calcified Pronounced eosinophilia Muscle pain Orbital edema Rx: corticosteroid and albendazole |
|
|
Toxocara canis or cati (visceral larva migrans, nematodes)
|
Toxocara canis and Toxocara cati are the etiologic agents in visceral larva migrans
Man (usually children) is an abnormal host and only larva develop: intermediate host Visceral larve migrans: hepatosplenomegaly, pronounced eosinophilia Rx: diethylcarbamazine |
|
|
Ancyclostoma spp. (cutaneous larva migrans or creeping eruptions, nematodes):
|
Caused by dog and cat hookworms
Usually contracted by children playing on sandy beach or sandy playgrounds where dogs and/or cats urinate Larvae penetrate the skin and produce serpiginous tunnels in the skin which causes intense pruritis and scratching Rx: ethyl chloride spray and ivermectin |
|
|
Anisakis simplex (nematode)
|
Contracted by eating raw fish dishes such as sushi and sashimi, as well as pickled herring
Larvae penetrate gastric and intestinal mucosa and produce cramping abdominal pain, epigastric distress, vomiting and diarrhea within a few hours after being ingested Rx: physical removal of the organisms by endoscopic forceps |
|
|
Wucheria bancrofti, Brugia malayi (filariasis, nematodes)
|
Microfilaria of Wucheria bancrofti or Brugia malayi are the ausative agents
Transmitted by the bite of infected mosquitos: Anopheles, Aedes, Culex Microfilana characteristically circulate in teh bloodstream at night and enter into the lymphatics: mature and produce an inflammatory reaction resulting in lymphedema (elephantiasis) of the legs, scrotum find microfilaria in the blood at night: sheathed and lack nuclei in the tail Rx: ivermectin |
|
|
Onchocerca volvulus (river blindness, nematode):
|
Microfilaria of transmitted to man via the bite of an infected blackfly (Simulian)
Larvae migrate across the eye and produce blindness Adult worms lodge in teh lymphatics: produce subcutaneous nodules Microfilaria do not enter the bloodstream: no periodicity (night or day time rhythm) Find microfilaria in a skin biipsy that are unsheathed and do not have nuclei extending to the tail Rx: ivermectin and remove the dodules |
|
|
Dirofilaria immitis (heart worm disease, nematode)
|
Dog heart worm that usually lives in the right ventricle of the dog
Microfilaria transmitted to man through teh bite of a mosquito Larvae enter the right heart and emboize to the lung: small pulmonary infarct presenting as a coin lesion Rx: no effective drugs |
|
|
Hymenolipis nana and diminutus (cestode)
|
MC tape worm infectin in US
Rx: praziquantel |
|
|
Diphyllobrothrium latum (fish tapeworm, cestode)
|
Larvae in lake trout
Cause of B12 deficiency Rx: praziquantel |
|
|
Taenia saginata
|
Beef tapeworm, cestode:
INgest larvae in undercooked beef Man is difinitive host Rx: praziquantel |
|
|
Taenia solium
|
Can contract by eating larvae in undercooked pork (intermediate host): man definitive host
Can contract by eating eggs from an infected human and only larva develops in patient (intermediate host) Called cysticercosis CNS lesions iwht seizures Rx: praziquantel |
|
|
Echinococcus granulosis or multiocularis (hydatid disease, cestode)
|
Sheep with larvae (intermediate host) eaten by dog (develop adults who lay eggs, definitive host); man ingests the egg (evelops larvae which penetrate the liver, intermediate host)
Anaphylactic reaction if cyst fluid enters peritoneum Greek or Basque sheepherders Rx: percutaneous drainage+ albendazole |
|
|
Trematode disorders:
|
Trematodes, or flukes, are flat, unsegmented worms with a complex developmental cycle
In schistosomal disease, the cycle is as follows: Egg (human) Ciliated miracida larvae infect snails; produce fork tailed cercaria larvae; penetrate skin of human; produce disease In non-Schistosomal disease, the cycle is as follows: Egg: ciliated miracidia larvae; infect snails; produce fork tailed cercaria larvae; infect a 2nd intermediate host Aquatic vegetation (Fasciolopsis buski, Fasciolo hepatica Fish (Clonorchis sinensis) Crabs (Paragonimus westermani); form infective metacercaria; man ingests the 2 intermediate host: disease Note that snails are always involved in teh life cycle of both schistosomal and non-schistosomal disease |
|
|
Schistosoma mansoni, japonicum and hematobium (schistosomiasis or bilharziasis, trematodes:
|
Infection acquired by the penetration of the ciliated miracidia larvae from infected snails into teh skin which then enter the lymphatics and distribute into subcutaneous tissue and the mesenteric veins
S. mansoni favors the intra hepatic portal veins: penetration of the skin by the larvae produces pruritus (swimers itch); larvae develop into adult worms that travel against the circulation and deposit eggs to which teh host develops an nflammatory response marked by concentric fibrosis (pipe stem cirrhosis) in the vessel wall S. hematobium favors development in the urinary venous plexus where the eggs incite an inflammatory reaction (hematuria common) and squamous metaplasia of the bladder epithelium, which predisposes to squamous carcinoma of the bladder Rx: praziquantel |
|
|
Clonorchis siensis (chinese liver fluke)
|
Ingest larvae in fish (usually fish paste)
Larvae ascend bile ducts into liver and gallbladder and become adults in teh bile ducts Causes jaundice and cholangiocarcinoma Rx: praziquantel |
|
|
Scorpions
|
Poisonous species capable of causing fatality lives in Southwestern deserts (Centruroides gertschi)
Neurotoxin Bite site shows no initial reaction; increased sensation ; no sensation in the area of the bite; whole extremity becomes numb; increased BO; ascending motor paralysis; death Rx: no specific treatment for poisonous species |
|
|
Mites:
|
Chiggers
Pruritic dermatitis best treated with topical antipruritic agents (crotamiton and calamine lotion) Human itch mite (Sarcoptes scabies); tissue injury by adult females boring into the stratum corneum; burrows are visible as dark lines between teh fingers, at teh wrists, on teh nipples, or on the scrotum; females lay eggs at teh end of the tunnel: responsible for intensely pruritic lesion Adulst: disease is limited to the webs between the fingers, intertriginous areas, and spares the soles, palms, face and head Infants: no burrows, and the palms, soles, face, adn head ARE involved Rx: permethrin cream |
|
|
Head, body, and pubic lice (crabs)
|
Pediculus hemanis capitis is the head louse
Lays its nits or eggs on hair shafts Rx: permethrin followed by lindane if the initial Rx is unsuccessful Pediculus humanis corporis is the body louse: lives on the surface of the skin and reeds in the clothing Use malathion powder on the clothing of infected patients, not on the patient Phthirus pubis is teh pubic louse (crabs): lives in teh pubic hairs: looks like a crab Rx: permethrin |
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Fire ant bites:
|
Sharp painful bite
wheal/flare reaction: type I hypersensitivity reaction Reaction followed by vesiculation/skin necrosis Bites commmonly occur in people who crawl under houses |
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Patient wiht fever, cough, diarrhea/vomiting, organism requires special medium for culture:
|
Most likely transmitted by aerosolization from environmental source
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Viruses:
|
All have protein and nucleic acid
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Patients serum is reacted against antigen, sensitized RBCs, and complement. RBCs do not hemolyze:
|
Complement fixation test
Lack of hemolysis indicates patient has antibodies against the antigen Presence of heolysis indicates no antibodies |
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|
Interpretation of minimal inhibitory concentration:
|
Lowest concentration that drug inhibits growth, determine minimal bactericidal concentration: must culture the tubes to see which one has no growth of the organism
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Bloody diarrhea after returning from Mexico. Neutrophils in stool:
|
Amebiasis
Rx with metronidazole |
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|
TB reactivates in apex:
|
Highest O2
TB is strict aerobe |
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Allopurinol
|
Inhibits xanthine oxidase
|
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Isoniazid
|
Causes pyridoxine deiciency leading to peripheral neuropathy and sideroblastic anemia
MOA- INH is nicotinic acid derivative that inhibits synthesis of mycolic acid in mycobacteria cell wall |
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Succinylcholine
|
Depolarizing agent used as muscle relaxant during surgery
Binds to nicotinic receptors in skeletal muscle causing persistent depolarization at motor end-plate Hydrolyzed plasma cholinesterase Initial fasciculations followed by muscle paralysis Duration of action only 5-10 minuts Effects not reversed by cholinesterase inhibitors- no pharmacologic antidote to overdose Some patients have atypical cholinesterase adn cannot metabolize the drug |
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Preganglionic neurotransmitter acetylcholine:
|
Activates muscarinic and nicotinic receptors
Muscarinic effects: pupilary miosis (contracts iris sphincter, used after cataract surgery); accommodation of lens for near vision (contacts ciliary muscles), bronchoconstrictor; slow heart rate (SA node effect); increase PR interval (AV node effect); stimulate GI secretions; increases GI motility (enteric nervous system stimulation); micturation (stimulate detrusor muscle, which relaxes internal sphincter of bladder) |
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Nitric oxide:
|
Potent vasodilator synthesized in endothelial cells
Activates cyclic GMP, which inactivates myosin light chain kinase in smooth muscle cells leading to vasodilation ACh can lead to its synthesis when injected into vessels |
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Woman in third trimester has premature contractions:
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Use terbutaline, a selective Beta2-adrenergic receptor agonist that inhibits uterine contractions
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Effect of aspirin on kidney:
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Decrease PGE2 synthesis (vasodilator) leading to unopposed AT II effect
Renal papillary necrosis |
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Methotrexate
|
Blocks dihydrofolate reductase- macrocytic anemia due to folate deficiency
S phase inhibitor Leucovorin rescue interstitial fibrosis in lungs |
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Peripheral neuropathy and cancer drug:
|
Vincristine
|
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MOA of sucralfate:
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Viscous polymer of sucrose octasulfate + aluminum hydroxide that adheres to ulcer crater
Stimulates PGE2 in mucous cells-responsible for mucus barrier |
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|
Effect of mixing statin drugs with niacin:
|
Rhabdomyolysis- each drug by itself can produce rhabdomyolysis
|
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MOA of amphotericin B:
|
Binds ergosterol in fungal cell membrane, which increases its permeability
Nystatin has same mechanism |
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MOA of clotrimazole:
|
Inhibits ergosterol synthesis
Other azole compounds have similar action |
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MOA of flucytosine:
|
Inhibits nucleic acid synthesis
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MOA of griseofulvin
|
Inhibits microtubule function and mitosis
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Propylthiouracil:
|
Drug of choice for decreasing synthesis of thyroid hormone in Graves disease
Agranulocytosis Only drug that can be used in pregnancy |
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|
Fastest way to increase heart beat in shock:
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Order of drugs with decreaseing effectiveness:
Isoproterenol Dobutamine Dopamine Dopamine in low doses is best for renal vasodilatation |
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Dapsone
|
Sulfone that inhibits synthesis of folic acid by M. leprea
May precipitate hemolytic anemia in G6PD deficiency May produce methemoglobinemia Nephrotic syndrome Peripheral neuropathy |
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Prolongation of QRS on ECG
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Quinidine
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Anticonvulsant/antiepileptic drug with effect on epiphysieal plate:
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Phenytoin via its revving up of the cytochrome system in teh liver adn causing vitamin D deficiency- increased metabolism of 25 hydroxylated vitamin D
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MOA of onansetron
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Selective serotonin 5-HT3 receptor antagonist
Useful in blocking chemoreceptor trigger zone in teh area postrema, hence preventing vomiting |
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Opioid overdose:
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Respiratory depression:
Respiratory acidosis Miotic pupils |
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First Rx of alcoholic in ER
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IV thiamine to prevent acute Vernicke's encephalopathy
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Heparin:
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MCC of thrombocytopenia in hospital
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Acute Rx for couarin overdose when bleeding is life-threatning:
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FFP best choice
Use IM vitamin K for les serious bleeds |
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Nitrofurantoin:
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Concentrated in urine
Urinary tract antiseptic |
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Cyclophosphamide
|
Hemorrhagic cystitis
Transitional cell carcionoma Activated (not metabolized) in the liver |
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Doxorubicin and prednisone:
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Metabolized in liver
|
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Gout after cancer therapy:
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Prevent by giving allopurinol (xanthine oxidae inhibitor)
Danger of urate nephropathy |
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Muscle fasciculation s after neuromuscular block:
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Initial effect of succinylchoine
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MOA of levodopa:
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Blocks peripheral dopa decarboxylase
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Bronchial asthma
|
Albuterol medihaler most often used for mild to moderate asthma
Corticosteroid medihaler used for severe asthma |
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Rx of paroxysmal supraventricular tachycardia:
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Adenosine, including its association with WPW syndrome
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MOA of clonidine
|
Activates alpha2-adrenergic and imidazole receptors in the central nervous system which reduces sympathetic outflow from the vasomotor center in the medulla
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Captopril
|
Bradykinin side-effect include cough and angioedema- ACE normally degrades bradykinin
Cough not seen with losartan |
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Hydralazine
|
Better tolerated in fast acetylators
Cause of drug-induced SLE Can be used in hypertension in pregnancy |
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Patient wiht HTN, hypernatremia and hypokalemia:
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Losartan, an ATII receptor antagonist, is the best drug
Corrects HTN and electrolyte problems (blocks release of aldosterone, hence sodium is lost in the urine and potassium retained) |
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Rx of pulmonary edema:
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Loop diuretic is very useful- decreases preload
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Rx of opioid overdose
|
Naloxone, which is a competitive opioid receptor antagonist
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Urinary retention in prostate hyperplasia:
|
Use selective alpha1-blockers
Relax smooth muscle in bladder neck and prostate Examples: prazosin, terazosin |
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MOA of saw palmetto:
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Anti-androgen effect
Blocks androgen uptake and availability without altering serum levels Causes shrinking of transitional zone of prostate around the urethra |
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Narcolepsy:
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Rx with amphetamines
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Premature labor and must deliver baby
|
Give glucocorticoids to increase surfactant synthesis
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Drug used to eliminate calcium in patient wiht hypercalcemia:
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Loop diuretic
|
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Drug used to remove calcium from urine in a calcium stone former:
|
Hydrochlorothiazide
|
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Patient with respiratory alkalosis and then metabolic acidosis
|
Salicylate intoxication
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S-phase drug used in treatment of acute lymphoblastic leukemia:
|
Methotrexate
|
|
|
Analog of hypoxanthine requiring HGPRTase for bioactivation
|
6-mercaptopurine
Allopurinol could cause toxicity, since the drug is a purine |
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|
Drug that competes with dUMP for thymidylate synthase:
|
5-fluorouracil
|
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|
Drug used in Rx of Wilm's tumor
|
Actinomycin D (dactinomycin)
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Antimetabolite that together with an antibiotic is used in Rx of acute myelogenous leukemia:
|
Cytarabine + Daunomycin (Anthracycline antibiotic)
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|
Nephron site responsible for ACE inhibitors causing increase in serum creatinine:
|
Block in AT II (works as vasoconstrictor of efferent arteriole in glomerulus) by ACE inhibitor removes important control for maintaining intrarenal blood flow causing potential for renal failure (particularly with bilateral renal artery stenosis)
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Nephron site of action of thiazides:
|
Na/Cl pump in cortical thick ascending limb
|
|
|
Vitamin given in Rx of TB:
|
Pyrodoxine (B6) used up when using isoniazide
Risk of peripheral neoropathy and sideroblastic anemia |
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|
Drugs that are generally safe in pregnancy:
|
Safe
Methyldoopa Hydralazine Low doses of propylthiouracil Cephalosporins Penicillin NOT SAFE Methotrexate ACE inhibitor Retinoic acid Sulfur containing drugs |
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|
Why is gentamicin ineffective in Legionella infections:
|
Aminoglycosides affect the 30S ribosomal subunit
Resistance to any drugs that are protein synthesis inhibitors may be due to: Inactivation of the drug by bacterial enzymes Decreased uptake of drugs via points in bacterial membranes Decreased binding of drug to 30S ribosomal subunits |
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|
Classic ECG changes for cardiovascular drugs
|
Prolonged QS with: quinidine, amiodarone
Prolonged QT interval with: sotalol, amiodarone Prolonged PR interval with: digitalis, Beta-blockers, calcium channel blockers Giant U wave wit quinidine ST depression with digitalis (hockey stick configuration), quinidine Short QT intervals with digitalis Flat T wave with quinidine Bradycardia with quinidine |
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|
Know mechanisms for resistance to various classes of antibiotics:
|
Note the ones above for 30S protein synthesis inhibitors:
Tetracyclines Aminoglycosides Spectinomycin |
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|
Patient with Salmonella and G6PD deficiency:
|
Avoid TMP/SMX (sulfur drug)
|
|
|
MOA of disulfiram reaction with metronidazole:
|
Inhibits aldehyde dehydrogenase
|
|
|
MOA of norfloxacin:
|
Inhibits DNA gyrase
|
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|
MOA of erythromycin:
|
INhibits 50S ribosomal subunit in bacterial protein synthesis
Also other macrolides Chloramphenicol Clindamycin |
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|
Chloramphenicol:
|
Aplastic anemia in adults - idiosyncratic, not dose dependent as it is in newborns (gray baby syndrome)
|
|
|
Child eats honey and gets weak:
|
Botulism
Intestinal colonization of organism with toxin production - toxin blocks the release of ACh |
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|
Antihypertensives increasing blood lipids:
|
Beta-blockers
Thiazides |
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|
MOA of trimethoprin
|
Blocks dihydrofolate reductase
|
|
|
Muscle relaxant for electroconvulsive Rx:
|
Succinylcholine
|
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|
Rx of prostate cancer:
|
Leuprolide- GnRH agonist blocks FSH and LH and lowers testosterone and DHT
Flutamide: competes with testosterone for androgen receptor Finasteride: Blocks 5alpha-reductase, decreases DHT, increases testosterone (good for preventing impotency and hair growth), mainly used in prostate hyperplasia Ketoconazole: reduce testosterone synthesis more often used in hyperplasia |
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|
Young woman with vaginal cytology containing malignant cells:
|
DES exposure wiht clear cell adenocarcinoma
|
|
|
CMV infection:
|
Ganciclovir first, then foscarnet if it does not work
|
|
|
Most common side-effect of immunosuppressant drugs:
|
Infection
Squamous cancer of skin MC cancer |
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|
Rx of absence seizures:
|
Ethosuximide
|
|
|
EEG in patient wiht absence seizures:
|
Shows 3 sec spike and wave discharge
Increased with hyperventilation |
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|
Drug abuser with flu-like syndrome, fever, mydriasis:
|
Methadone + naloxone
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|
|
Rx of ADHD
|
Methylphenidate
|
|
|
Rx of depression:
|
Tricyclic antidepressant: clomipramine blocks neuronal reuptake of NOR (+2) and serotinin (+3)
|
|
|
Phenytoin interaction with theophylline:
|
Phenytoin revs up cytochrome system and increases etabolism of theophylline
|
|
|
Effect of chronic use of a hypnotic drug to induce sleep
|
Psychologic dependence
|
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|
Patient with Wegener's granulomatosis has hemorrhagic cystitis:
|
Cyclophosphamide effect
|
|
|
Patient with HTN has SLE-like syndrome
|
Hydralazine
|
|
|
VAsoconstrictors that increase IP3:
|
Drugs activating alpha-1-adrenergic receptors
|
|
|
Know mechanisms of action at receptors (adrenergic, cholinergic, hypothalamic releasing factors, histamine, VIP)
|
cAMP, IP3/diacyclglycerol
|
|
|
Iron poisoning in child
|
Biggest concern is hemorrhagic gastritis and liver necrosis
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|
Ring finger with blue discoloration on undersurface and Hx of drug abuse and frequent sexual activity:
|
IV heroin abuser using finger as site of injection that is selling sex for drugs.
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|
|
Gold salts:
|
Used in Rx of rheumatoid arthritis
Oral drug called auranofin Parenteral form called gold sodium thiomalate Takes 3-6 months before effects are noticed Complications: potentially fatal dermatitis/stomatitis common, bone marrow depressoin, flushing, hypotension, tachycardia, renal disease |
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|
Hydroxychloroquine:
|
Used in Rx of rheumatoid arthrisis
Complications: retinal degeneration, dermatitis, bone marrow depression |
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|
Penicillamine
|
Used in Rx of rheumatoid arthritis
Complications: aplastic anemia, renal damage (membranous glomerulonephritis) |
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|
Penicillin MOA
|
Beta-lactam antibiotic cell wall synthesis inhibitor
Binds to receptors in bacterial cytoplasmic membrane Inhibits transpeptidase enymes that cross-link peptidoglycan chains in bacterial cell wall Activates autolytic enzymes in bacterial cell wall |
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|
Chloramphenicol MOA
|
Inhibits bacterial protein synthesis
Binds to 50S ribosomal subunits, hence indirectly inhibiting transpeptidation by peptidyltransferase |
|
|
Mesna:
|
Mercaptoethanesulfonate
Reduces incidence o hemorrhagic cyxtitis associated with cyclophosphamide by reducing formation fo acrolein |
|
|
Ribavirin MOA
|
Inhibits guanosine triphosphate formation, which prevents capping of viral mRNA
Blocks RNA-dependent RNA polymerases Used in Rx o RSV infections |
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|
Ondansetron MOA
|
5-HT3 receptor blocker: central antemetic
|
|
|
Iron poisoning in child
|
Biggest concern is hemorrhagic gastritis and liver necrosis
|
|
|
Ring finger with blue discoloration on undersurface and Hx of drug abuse and frequent sexual activity:
|
IV heroin abuser using finger as site of injection that is selling sex for drugs.
|
|
|
Gold salts:
|
Used in Rx of rheumatoid arthritis
Oral drug called auranofin Parenteral form called gold sodium thiomalate Takes 3-6 months before effects are noticed Complications: potentially fatal dermatitis/stomatitis common, bone marrow depressoin, flushing, hypotension, tachycardia, renal disease |
|
|
Hydroxychloroquine:
|
Used in Rx of rheumatoid arthrisis
Complications: retinal degeneration, dermatitis, bone marrow depression |
|
|
Penicillamine
|
Used in Rx of rheumatoid arthritis
Complications: aplastic anemia, renal damage (membranous glomerulonephritis) |
|
|
Penicillin MOA
|
Beta-lactam antibiotic cell wall synthesis inhibitor
Binds to receptors in bacterial cytoplasmic membrane Inhibits transpeptidase enymes that cross-link peptidoglycan chains in bacterial cell wall Activates autolytic enzymes in bacterial cell wall |
|
|
Chloramphenicol MOA
|
Inhibits bacterial protein synthesis
Binds to 50S ribosomal subunits, hence indirectly inhibiting transpeptidation by peptidyltransferase |
|
|
Mesna:
|
Mercaptoethanesulfonate
Reduces incidence o hemorrhagic cyxtitis associated with cyclophosphamide by reducing formation fo acrolein |
|
|
Ribavirin MOA
|
Inhibits guanosine triphosphate formation, which prevents capping of viral mRNA
Blocks RNA-dependent RNA polymerases Used in Rx o RSV infections |
|
|
Ondansetron MOA
|
5-HT3 receptor blocker: central antemetic
|
|
|
Doxorubicin
|
Antibiotic
MOA: intercalate base pair; interact with topiosomerase II; generate free radicals; block synthesis of DNA/RNA and cause DNA strand scission Side effects: dose-dependent congestive cardiomyopathy via free radical damage; marrow suppression; dexrazoxane, a FR scavenger, may protect against cardiotoxicity |
|
|
MAO inhibitor used in treating a patient wiht resting tremor:
|
Selegiline
Blocks MOA type B, which normally metabolizes dopamine, so brain levels increase Hepatic metabolism produces amphetamine |
|
|
Dantrolene MOA
|
Blocks calcium release from sarcoplasmic reticulum os skeletal muscle
DOA in Rx of malignant hyperthermia Used in Rx of muscle spasm in cerebral palsy |
|
|
Digitalis:
|
Blocks Na/K ATPase pump in cardiac muscle: 3Na into muscle an d2K out of muscle
|
|
|
Antihypertensive wiht Coombs positive hemolytic anemia:
|
methyldopa
Alters Rh antigens on surface of RBC, so IgG autoantibodies react against it Type II hypersensitivity |
|
|
Fluoroquinolone MOA
|
Blocks bacterial DNA synthesis by inhibiting topoisomerase Ii (DNA gyrase) and topoisomerase IV
DNA gyrase important in relaxation of supercoiled DNA involved in normal transcription adn duplication Type IV topoisomerase important in separation of replicated chromosomal DNA during cell division |
|
|
Benzodiazepines
|
Retrograde amnesia
|
|
|
Propylthiouracil MOA
|
Reduces iodination of tyrosine
Reduces coupling of MIT and DIT to form T3 and T4 Inhibits peripheral conversion of T4 to T3 by inhibiting the outer ring 5'-deiodinase Side effects- Rash, agranulocytosis |
|
|
Drug lowering HDL
|
Probucol
May cause torsade de pointes Variation of QRS configuration Type of polymorphic ventricular tachycardia May prolong QT interval |
|
|
Drugs causing torsade de pointes:
|
Drugs that slow ventricular repolarization and prolong QT interval
Quinidine Sotalol Phenothiazine Cisapride |
|
|
MOA inhibitor asociations
|
Inhibit MAO bype A (metabolizes NOR, serotonin, tyramine) and B (metabolizes dopamine)
Hypertensive reactions if taking foods with tyramine- (by broduct of tyrosine metabolism; bananas, fermented products like cheee, beer, wine) Sympathomimetic reaction in that it causes the release of stored catecholamines leading to hypertension Administered with fluoxetine (SSRI) produces serotonin syndrome: hyperthermia, myoclonus |
|
|
Stage fright/test anxiety
|
Give propranolol
|
|
|
H1 antagonists for:
|
Hay fever
|
|
|
Beta-2 agonists:
|
Activate adenylate cyclase to increase cAMP
|
|
|
Bronchial asthma
|
Zileuton: inhibits 5-lipoxygenase
Safirlukast and montelukast block leukotriene receptors |
|
|
MOA of methadone
|
Rx of opioid abuse
Saturates CNS opiate receptors |
|
|
Receptor involved in tardive dyskinesia
|
D2
|
|
|
Phencyclidine toxicity
|
Angel dust, reacts iwht opioid-like sigma receptors and subtypes of glutamate receptors
Dissociative anesthesia: loss of sensation in lower limbs, agitation/violent behavior: cannot hold patient down |
|
|
Acyclovir MOA
|
Guanosine analog that is activated to form acyclovir triphosphate a conpetitive substrate for DNA polymerase: subsequent chain termination following incorporation into viral DNA
Clinical uses: varicella/zoster virus, mucocutaneous/genital herpes |
|
|
Girl on rifampin becomes pregnant while on birth control pills:
|
Rifampin revs up the liver cytochrome system (like alcohol, barbiturates, phenytoin) and caused increased metabolism of birth control pills
|
|
|
Antagonist of alpha1-blocker
|
Alpha1-agonist like pseudoephedrine
|
|
|
Complications of thiazides
|
Hyponatremia
Hypokalemia Metaabolic alkalosis Hyperuricemia Hyperglycemia Hypercalcemia: thiazides are used in the Rx of calcium stone formers owing to increased reabsorption of calcium out of the urine |
|
|
ACE inhibitor effect on plasma renin activity
|
Increases due to decrease in ATII and aldosterone
|
|
|
Drugs affecting tubulin in mitotic phase:
|
Vinca alkaloids
Paclitaxel |
|
|
Rx of benzodiazepam overdose
|
Flumazenil
|
|
|
Use of aqueous epinephrine in shock
|
1:1000 dilution subcutaneously
|
|
|
Dantrolene
|
Used in teh treatment of malignant hyperthermia post halothane exposure
|
|
|
Treatment of acetaminophen overdose:
|
Acetylcysteine to replace used up GSH: neutralizes acetaminophen free radicals formed in teh liver cytochrome system
|
|
|
MOA of loop diuretic:
|
Blocks Na+, K+, 2Cl- cotransport pump in the thick ascending limb in the renal medulla
Also blocks calcium reabsorption: used in teh Rx of hypercalcemia |
|
|
Cyanide poisoning treatment:
|
Amyl nitrite is first administered to produce methemoglobin, which combines wiht cyanide to form thiocyanate, which is ecreted
|
|
|
Thrush:
|
May be a complication of a corticosteroid inhaler
|
|
|
Isotretinoin
|
Always order a prebnancy test in females
Put patients on BCP |
|
|
MOA of propylthiouracil:
|
Blocks iodination of the tyrosine residues of thyroglobulin
Also blocks coupling of DIT and MIT Only drug that can be used in pregnancy (low doses) but may produce goiter in the newborn and nail defects |
|
|
P450 system in the liver
|
Makes drugs water soluble
|
|
|
Angioedema and renal failure
|
ACE inhibitor relationship
|
|
|
MOA of retinoic acid
|
Behaves like a steroid in that it binds to receptors in the nucleus with subsequent transcription of genes
Proteins produced by this ation are important in growth, differentiation, reproduction, and embryonic development Also used in treatment of acute progranulocytic leukemia, where it increases the maturation of the blasts |
|
|
Allopurinol action in purine synthesis
|
Blocks xanthine oxidase: schematic of purine metabolism was provided and had to identify the reactions hypoxanthine to xanthine and xanthine to uric acid
Mercaptopurine degradation is inhibited as well |
|
|
Most common antibiotic used to prevent endocarditis in patients wiht valvular disease:
|
Amoxicillin is the drug of choice
All valvular diseases except asymptomatic MVP and all congenital heart disease except asymptomatic ASD |
|
|
Yellow coloration of the skin that can by mistaken for jaundice - what drug?
|
Quinacrine
Chlorpromazine and arsenic produce a blue-gray color to the skin |
|
|
Diffuse erythema followed by separation of the skin (salded skin syndrome or toxic epidermal necrolysis) - drug?
|
Barbiturates
Sulfonamides Phenytoin NSAIDs |
|
|
Hair loss in a woman
|
Oral contraceptives: predictable side effect
Estrogen causes hair to be at same stage of development May also occur after delivery |
|
|
Erythematous, hyperpigmented plaque-like lesion that recurs at teh same site every time:
|
Fixed drug eruption:
Phenolphthalein NSAIDs Tetracycline Bactrim Barbiturates |
|
|
Group of drugs has the highest association with urticarial and maculopapula lesions:
|
Amoxicillin
TMP.SMX Ampicillin/penicillin Rashes are teh MC adverse reaction to drugs, wiht maculopapular rashes leading teh list Most drug reactions involving skin are not type I hypersensitivity histamine-related, however those involving penicillin are usually type I hypersensitivity |
|
|
Elderly woman on thiazides is most at risk for developing
|
Gout
|
|
|
Tardive dyskinesia, malignant syndrome (sweating, hyperpyrexia, autonomic instability)
|
Neuroleptics
|
|
|
Antipsychotic drug requiring visual examination
|
Thioridazine: also produces heart conduction defects
|
|
|
Nephrogenic diabetes insipidus
|
Lithium for bipolar disturbances
|
|
|
Drug contraindicated with MAO inhibitor
|
Epinephrine
|
|
|
Use of phentolamine
|
Non-selective alpha-blocker that lowers blood pressure during surgery for a pheochromocytoma
|
|
|
MOA of AZT
|
Inhibits reverse transcriptase
Produces a macrocytic anemia unrelated to folate/B12 Initial drug regimen used in Rx of HIV: 2 nucleoside analogs (AZT, lamivudine) and 1 protease inhibitor (indinavir) |
|
|
Tests to monitor Rx of HIV
|
HIV RNA by polymerase chain reaction
Monitors viral burden during Best Test: CD4 T helper count; immune status; prophylaxis marker |
|
|
MOA of nucleoside drugs
|
Block reverse transcriptase
|
|
|
MOA of protease inhibitor:
|
Suppress HIV replication by blocing protein processing later in teh HIV cycle
|
|
|
MOA of nonnucleoside reverse transcriptase inhibitors:
|
Non-competitively inhibits reverse transcriptase (nevirapine)
|
|
|
Side-effects of didanosine
|
Pancreatitis
Hepatitis Peripheral neuropathy |
|
|
Side-effects of lamivudine (3TC)
|
Rash
Peripheral neuropathy Bone marrow toxicity |
|
|
Side-effect of non-nucleoside reverse transcriptase inhibitors
|
Rash
|
|
|
Side effects of indinavir:
|
Protease inhibitor associated with renal stones
|
|
|
CD4 helper T cell count for prophylaxis against PCP
|
<200 cells
Rx with TMP/SMX |
|
|
CD4 helper T cell count for prophylaxis against toxoplasmosis:
|
<100
Rx with TMP/SMX |
|
|
CD4 helper T cell count for prophylaxis against MAI
|
<50 - 100 cells
Rx with clarithromycin |
|
|
Rx of Pb poisoning
|
BAL and EDTA
|
|
|
Drugs involved in folate metabolism
|
Phenytoin blocks intestinal conjugase: polyglutamate to monoglutamate
BCP and alcohol block uptake of monoglutamate in the jejunum Methotrexate/TMP/SMX block dihydrofolate reductase |
|
|
Cromylyn sodium
|
Stabilizes mast cell membrane preventing release of preformed mediators and release of prostaglandins/leukotrienes after the release reaction
|
|
|
Methotrexate
|
Blocks dihydrofolate reductase and the onversion of dihydrofolate to tetrahydrofolate
|
|
|
Cyclooxygenase:
|
Aspirin inhibits irreversibly
NSAIDs reversible |
|
|
Thromboxane A2
|
Synthesized in platelet
Vasoconstrictor INcreases platelet aggregation Bronchoconstrictor |
|
|
MOA of proton blockers
|
Blocks H, K, ATPase proton pump in parietal cell: not a receptor mediated event
Useful in the treatment of ZE syndrome, GERD, and H. pylori infections |
|
|
MOA of H2 blockers
|
Blocks H2 receptor, which normally activates adenylate cyclase producing cAMP which stimulates protein kinase
|
|
|
MOA of acetylcholine:
|
Activates cholinergic receptor causing the release of calcium, which stimulates protein kinase
|
|
|
MOA of misoprostol
|
Blocks the prostaglandin receptor, which normally inhibits adenylate cyclase and cAMP production
|
|
|
7-fold membrane spanning protein - drug?
|
Propranolol, a non-seleceive Beta blocker
|
|
|
Phase 3 clinical trials:
|
Double blind
|
|
|
Ticlopidine
|
MOA: inhibits ADP-induced expression of platelet glycoprotien receptors, which reduces fibrinogen binding and platelet aggregation
Substitute for aspirin in preventing strokes, CAD if the patient is allergic to aspirin Causes neutropenia Prolongs the bleeding time |
|
|
Drug induced SLE
|
Procainamide
Hydralazine |
|
|
Overdose of succinylcholine:
|
Use acetylcholine blockers
|
|
|
ACE inhibitors:
|
Increase in renin and ATI, but decrease in ATII and aldosterone
Aldosterone eventually increases, hence the addition of spironolactone to keep aldosterone suppressed; increases longevity in CHF |
|
|
Arsenic poisoning
|
Rx with dimercaprol
|
|
|
Chloroquine was used in the treatment of malaria dna malaria recurred-why?
|
Exoerythrocytic/hepatic stage
P. vivax P. ovale Drug kills active disease but does not eradicate hepatic stage |
|
|
Primaquine in treatment of malaria
|
Not good in teh active stage but does kill the hepatic stage of P. vivax and ovale
|
|
|
Dantrolene:
|
Reduces the release of calcium from the sarcoplasmic reticulum of skeletal muscle
Antispasmodic drug Also used in treating malignant hyperthermia |
|
|
Methanol:
|
Increased anion gap metabolic acidosis due to conversion of methanol into formic acid
Optic nerve degeneration and blindness Treat with alcohol infusion to block metabolism of methanol by alcohol dehydrogenaes |
|
|
Botulism toxin
|
Blocks the release of acetylcholine: diagram may be given of neurotransmitter synthesis and must locate the block
Used to treat LES spasm in achalasia |
|
|
Ribavirin
|
Used in severe RSV infections in children
|
|
|
Rx of asthma with albuterol:
|
B2-selective agonist: bronchodilator
Albuterol may cause hypokalemia: drives K into cells by activating the ATPase pump |
|
|
Acetylcholine breakdown:
|
Occurs in the synapse into choline and acetate by acetylcholinesterase in the cleft
Products are recycled and not excreted |
|
|
Ketoconazole
|
Inhibits the metabolism of nonsedating antihistamines like Seldane leading to cardiac arrhythmias
|
|
|
Codeine
|
Metabolized into morphine is small amounts owing to significant first pass metabolism of morphine in the liver
|
|
|
Delirium tremens:
|
Rx with benzodiazepines
|
|
|
Lovastatin
|
Inhibits HMG CoA reductase
|
|
|
Patent ductus arteriosus:
|
Keep open with PGE2
Close with indomethacin |
|
|
Cephalosporins + aminoglycosides
|
Synergistic effect of enhancing nephrotoxicity
|
|
|
Erythromycin
|
Interacts with the 50S subunit of bacterial ribosomes leading to inhibition of protein synthesis
Inhibits the formation of initiation complex and interferes with translocation reactions Resistance develops secondary to plasmid-mediated formation of enzymes that methylate the receptor that erythromycin binds with Coliforms produce a transmissible plasmid that produces an esterase that hydrolyzes the lactone ring of erythromycin |
|
|
Chloramphenicol
|
Gray baby syndrome: dose related aplastic anemia
|
|
|
TMP
|
Inhibits dihydrofolate reductase
Plasmid-mediated resistance TMP/SMX has synergetic effect from the sequential blockade of folate synthesis since SMX blocks dihydropterate synthase, which is an exzyme that converts paraaminobenzoic acid into dihydrofolate |
|
|
Metronidazole
|
Produces a disulfiram-like reaction
|
|
|
Fluconazole:
|
Treatment of esophageal candidiasis in AIDS
|
|
|
Cholinomimetic used in treating open angle glaucoma
|
Pilocarpine
Physostigmine |
|
|
Dobutamine:
|
Inotropic (increase contractility) vasodilator (decreases afterload) that activates alpha and Beta1>Beta2 activity without much chronotropic effect
Used in the treatment of shock (cardiogenic) associated with hypotension and hypotension associated with renal failure or CHF |
|
|
Dopamine
|
Stimulates Cardiac Beta1 receptors, peripheral alpha-receptors, and dopaminergic receptors in vessels in the renal and splanchnic bed
At low doses, it is primarily a vasodilator that increases renal and splanchnic blood flow At high doses, it increases cardiac contractility (inotropic) and cardiac output via its activation of cardiac Beta1 receptors |
|
|
Benzodiazepines
|
Via its own receptors in the thalmus, limbic structures, and cerebral cortex which are part of the GABA receptor-chloride ion channel macromolecular complex, benzodiazepines facilitate the inhibitory action of GABA via increased conductance in the chloride ion channel
Flumazenil blocks this effect by blocking the receptor for benzodiazepines and is the treatment of choice for benzodiazepam overdose |
|
|
An elderly woman on thiazides is most at risk for developing?
|
DM
|
|
|
A child who ingests 30 adult aspirins will most likely develop
|
An increased anion gap metabolic acidosis
Children, unlike adults, do not commonly develop a mixed metabolic acidosis and respiratory alkalosis Rx is to perform gastric lavage and add activated charcoal and to produce an alkaline urine for increased excretion of the acid |
|
|
Open angle glaucoma is best treated with
|
Beta1 and Beta2 blockers
Timolol is a favored agent Pilocarpine may also be used Open angle glaucoma is the MC type of glaucoma: produces gradulal loss of peripheral vision (tunnel vision) and optic atrophy |
|
|
Trazodone
|
Second generation anti-depressant
inhibition of serotonin reuptake Sedation May cause priapism |
|
|
Thioridazine
|
Retinitis pigmentosum may be a complication
|
|
|
Tamoxifen
|
Weak estrogen that acts as an antagonist in breast tissue (estrogen competes with tamoxifen for binding to the receptor) and partial agonist in uterus (can produce endometrial hyperplasia)
Also protects against osteoporosis and can be used in women who have ERA positive tumors Can be used in treating progestin-resistant endometrial cancer Complications: Flushing (menopausal symptoms), vaginal bleeding, potential for endometrial hyperplasia/cancer |
|
|
Acetaminophen
|
Analgesic and antipyretic but not an anti-inflammatory agent
Inhibits prostaglandin synthesis in the CNS Very weak cyclooxygenase inhibitor MC drug causing acute fulminant hepatitis Converted into free radicals in the liver Glutathione inactivates the FRs Acetylcysteine treatment replaces GSH |
|
|
Digitalis toxicity
|
Treat with digifab
|
|
|
Cephalosporins
|
First generation: drug of choice for surgical prophylaxis in many cases
Second generation: Rx of sinusitis (cefuroxime); Rx of mixed anaerobic infections Third generation: Rx of meningitis; Rx of GC and Lyme's disease (ceftriaxone) |
|
|
Clozapine:
|
Blocks D4 (dopamine) and 5-HT3 receptors moreso than D2
|
|
|
Fever in a patient on a loop diuretic:
|
Do not use any type of NSAID since it blocks renal synthesis of prostaglandin, which vasodilates the afferent arteriole
Use acetaminophen to lower fever, since it does not interfere with protaglandin synthesis Loop diuretics lead to volume depletion, hence angiotensin II will be elevated (vasoconstricts efferent arteriole); loss of prostaglandin effect predisposes the patient to renal failure |
|
|
Red man syndrome
|
IV vancomycin
|
|
|
Drug for bacterial carrier states (S. aureus, N. meningitidis, H. influenzae)
|
Rifampin
|
|
|
Single dose drug for GC and Chlamydia
|
Azithromycin
|
|
|
Rx of malignant hypertension
|
Nitroprusside
|
|
|
Antihypertensive and antiarrhythmic drug that lowers blood pressure and increases heart rate:
|
CCB
nifedipine |
|
|
Estrogen:
|
Lipid effects: lowers LDL/VLDL
Prevents osteoporosis: inhibits osteoclast activating factor (IL-1) secreted by osteoblasts Thrombogenic: natural estrogens are less thrombogenic than synthetic estrogens; increase synthesis of coagulation factor; decrease ATIII; Increases liver synthesis of transcortin and thyroid binding globulin: increases total cortisol/thyroxine levels without an increase in free hormone Increases liver synthesis of sex hormone (testosterone or androgen) binding globulin: lowers free testosterone Cancer risk: endometrial, breast, intrahepatic cholestasis, cholelithiasis |
|
|
Acetaminophen
|
Analgesic and antipyretic but not an anit-inflammatory agent
Inhibits prostaglandin synthesis in the CNS Very weak cyclooxygenase inhibitor MC drug causing acute fulminant hepatitis Converted into free radicals in the liver- glutathione inactivates the FRs, acetylcysteine treatment replaces GSH |
|
|
Digitalis toxicity:
|
Treat with digoxin antibodies (FAB fragments)
|
|
|
Oral contraceptives:
|
Pill effects: Inhibits LH surge, which prevents ovulation
Increase malar eminence pigmentation: "pregnancy mask" Ethinyl estradiol (synthetic estrogen) increases liver synthesis of many proteins 19-norestrosterone (progestational agent) effects: Water retention/weight gain, reduction in estrogen receptor synthesis (atrophy of endometrial glands), increase LDL, decrease HDL Complications: thrombogenic, stimulate trypptophan metabolism; lowers serotonin - depression, increases liver synthesis of angiotensinogen: MCC of HTN in young women, intrahepatic cholestasis, hepatic adenoma: tendency to rupture, increasegallstone formation Cancer risks: cervical, breast controversial, hepatocellular carcinoma Protective pill effects: fibrocystic change in teh breast, endometrial cancer, ovarian cancer: less ovulation reduces risk for cancer: pelvic inlammatory disease: Neisseria gonorrhoeae not Chlamydia trachomatis; uterine leiomyomas, endometriosis, acne, rheumatoid arthritis, hirsutism |
|
|
Iron toxicity:
|
Clinical setting: accidental overdose of ferrous sulfate in children
S/S of iron toxicity: hemorrhagic gastritis, hepatic necrosis wiht liver failure, shock/metabolic acidosis, x-rays reveal undigested radiopaque pills in GI tract Rx- iron binding agents, oral phosphate or bicarbonate salts (precipitate unabsorbed iron), parenteral deferoxamine |
|
|
Organophhosphate poisoning:
|
MOA: irreversible block of acetylcholine esterase (noncompetitive inhibitor), accumulation of acetylcholine at synapses/myoneural junctions
Source: pesticides, Initial autonomic system overactivity: excessive lacrimation/salivation, fecal incontinence, constricted pupils Nicotinic effects later in toxicity: muscle weakness and paralysis, muscle fasciculations, low serum and RBC cholinesterase (pseudocholinesterase) Rx: atroopine Rx of choice, pralidoxime (2-PRAM) also may be used |
|
|
Rx of HTN
|
Weight reduction is the most important factor in lowering BP
|
|
|
Carbonic anhydrase inhibitors:
|
MOA: blocks the proximal reclamation of bicarbonate
Bicarbonate binds iwth Na ions and is excreted in teh urine (diuretic effect) Produces a normal AG metabolic acidosis form bicarbonate lost in the urine Clinical uses: Chronic management of glaucoma: reduces the rate of aqueous humor formation and reduces intraocular pressure Alkalinizes the urine: good Rx for drug toxicities 9salicylate intoxication) Rx of acute mountain sickness: produces metabolic acidosis, which is the compensation for respiratory alkalosis |
|
|
Clinical uses of thiazides
|
Initial drug used in Rx of HTN in elderly patients: also reduces the incidence of strokes and fatal AMIs in tehis age group
Initial drug used in Rx of systolic HTN in the elderly One of the initial drugs used in Rx of HTN in African Americans Rx of choice in treatment of nephrogenic diabetes insipidus: volume depletion from increased proximal reabsorption of NA and water reduces degree of polyuria Rx of hypercalciuria in calcium stone formers Rx of proximal RTA: increases reclamation of bicarbonate |
|
|
Clinical uses of loop diuretics:
|
Initial drug used in Rx of HTN in chronic renal failure
Rx of choice for hypercalcemia after a diuresis is started with isotonic saline CHF with acute pulmonary edema Rx of halide poisonings: fluoride, bromide Acute renal failure: flush out tubular cells obstructing the lumen and can change an oliguric to polyuric renal failure |
|
|
MOA of spironolactone:
|
Blocks the aldosterone-enhanced Na/K pump in the late distal convoluted tubule and collecting duct: K sparing effect, danger of hyperkalcemia
Blocks the proton/K pump in the collecting tubules: danger of normal AG metabolic acidosis Blocks androgen receptors: Rx of hirsutism, produces gynecomastia in men |
|
|
MOA of triamterene/amiloride:
|
They are not aldosterone inhibitors, they block Na reabsorption and the secretion of K in the aldosterone -enhanced Na/K pump: K sparing effect
|
|
|
MOA of non-selective Beta blockers
|
Block Beta receptors in teh heart: reduce sympathetic stimulation, reduce BP, decreased contractility of the heart, decrease heart rate, reduce secretion of renin in kidneys
Block Beta recetors in teh smooth muxcle and liver: blocks catecholamine-induced glycogenolysis |
|
|
MOA of selective Beta1 blockers
|
Cardioselective beta blockers
Primarily target Beta 1 receptors in the heart Less bronchoconstriciton than nonselective blockers |
|
|
Side effects of Beta blockers
|
Conduction disturbances: AV block, block adrenergic signs/sx ofinsulin/oral sulfonylurea-induced hypoglycemia in diabetes mellitus- does not block sweating
Incude bronchospasm in those with asthma- less bronchoconstriction with selective types Depression Lipid effects (mainly in non-selective) Increase TG decrease HDL Rebound angina Hypertension if abruptly withdrawn- up regulation of Beta adrenergic receptors occurs when they are blocked |
|
|
Clinical uses of Beta-blockers:
|
Hypertension
Angina Congestive heart failure and acute myocardial infarction- increases survival Cardiac arrhythmias Essential tremor- benign condition with trembling of hands Prevention of migraine headaches Graves' disease- blocks adrenergic signs and symptoms Pheochromocytoma Hypertrophic subaortic stenosis |
|
|
MOA of alpha-adrenergic blockers:
|
In lowering BP, they block post-synaptic alpha-adrenergic receptors
Vasodilate arterioles/venules Reduce vascular resistance Relax smooth muscle in urinary bladder and prostate: useful in Rx of BPH Unlike Beta-adrenergic blockers, they lower TG and CH, and increase HDL Nonselective types block alpha1 and alpha2 adrenergic blockers- produce too much compensatory tuypes of effects (tachycardia |
|
|
Side-effects of alpha-adrenergic blockers
|
Dizziness due to orthostatic hypotension
Prazosin may produce a positive serum ANA |
|
|
Alpha-Adrenergic blockers phenoxybenzamine and phentolamine:
|
Produces a chemical sympathectomy
Rx of hypertensive episodes wiht pheochromocytoma until surgical removal of tumor Phentolamine- Rx of hypertensive episodes due to pheochromocytoma during surgery Rx of skin necrosis and ischemia in accidental inections of epinephrine or other vasoconstricotrs |
|
|
MOA of clonidine:
|
Centrally acting adrenergic drugs: examples include clonidine, methyldopa
Stimulate alpha2 adrenergic receptors and imidazoline receptors in the CNS Reduces efferent peripheral sympathetic outflow Reduction in blood pressure due to reduction in cardiac output: decreased heart rate and vasodilation of resistance vessels Increase renal blood flow MOA of methyldopa: same as for clonidine, converted by central nonadrenergic neurons into methylnorepinephrine, it's active metabolite Side-effects for methyldopa: Coombs positive hemolytic anemia, Drug induced SLE, drug induced hepatitis: may be fulminant |
|
|
MOA of calcium channel blockers:
|
Examples: Verapamil, diltazem, nimodipine, nicardipine
block L-type calcium channels in smooth muscle and cardiac muscle Peripheral arteriole vasodilator: no venular dilatation Decrease cardiac contractility and heart rate: negative inotropic and chronotropic effece, respectively coronary artery vasodilatation |
|
|
MOA of hydralazine, minoxidil, nitroprusside
|
Arteriolar vasodilator: hydralazine and minoxidil
Arteriolar/venular dilatator: nitroprusside No effect on reducing left ventricular muscle mass Side effects: drug induced SLE with a positive serum ANA: hydralazine, minoxidil: hypertrichosis Nitroprusside: thiocyanate toxicity |
|
|
Initial drugs used in Rx of hypertension (HTN) in African-Americans:
|
diuretics
Calcium channel blockers: addded if the desired goal is not established ACE inhibitors or AT II-receptor blockers |
|
|
Initial drug used in Rx of HTN in DM:
|
Ace inhibitors are the Rx of choice: HTN control is the single most important factor in preventing a loss of renal function in DM
|
|
|
Initial drug used in Rx of HTN in CHF:
|
ACE inhibitors are the Rx of choice
|
|
|
Drugs used in Rx of HTN in pregnancy
|
Methyldopa hydralazine- alternative drug choice
|
|
|
Drug used in Rx of HTN in a patient with urinary retention form prostate hyperplasia:
|
Alpha-Adrenergic blocker
|
|
|
drugs used in Rx of HTN in asthmatics:
|
CCB
|
|
|
Initial drug used in Rx of HTN in a patient iwth osteoporosis:
|
Thiazides- increased calcium reabsorption in the kidneys
|
|
|
ACE inhibitor
|
Decreases preload-inhibit aldosterone
Decreases afterload-inhibit AT II |
|
|
Hydralazine, minoxidill:
|
Decrease afterload alone- vasodilators
|
|
|
Nitroprusside:
|
Decreases preload: venodilator
Decreases afterload: vasodilator Rx of choice in treatment of malignant hypertension and lowering blood pressure in a dissecting aortic aneurysm |
|
|
Thiazides:
|
Decreases preload alone: reduces volume by losing salt and water
|
|
|
CCB
|
Decreases afterload alone: vasodilator
|
|
|
Probucol:
|
An antioxidant that is used in treating recurrent xanthelasmas
May produce torsade de pointes (polymorphic ventricular tachycardia), lowers HDL levels |
|
|
Nicotinic acid and fibric acid derivatives:
|
Capillary lipoprotein lipase
Hence increasing the hydrolysis of VLDL in the circulation |
|
|
HMG CoA reductase inhibitors and fibric acid derivatives
|
Should not be used together since they both may be associated wiht rhabdomyolysis and the potential for polyuric acute renal failure
|
|
|
HMG CoA reductase inhibitors, nicotinic acid, and fibric acid derivatives:
|
Associated with drug-induced hepatitis wiht elevation of the transaminases
|
|
|
HMG CoA reductase inhibitors and bile acid resins:
|
Upregulate LDL receptors synthesis on hepatocytes, hence lowering scrum CH and LDL
|
|
|
HMG CoA reductase in hibitors and nicotinic acid
|
Inhibit enzymes in tehir mechanisms of action of lowering lipids
|
|
|
Flushing associated wiht nicotinic acid:
|
Controlled pretreatment wiht aspirin
|
|
|
Fibric acid derivatives:
|
Greatest overall effect of all lipid lowering agents in raising HDL levels
|
|
|
HMG CoA reductase inhibitor and fibric acid derivatives:
|
Increase the chance for warfarin toxicity
|
|
|
Bile acid resins:
|
Lower warfarin levels, hence causing undercoagulation of patients on warfarin
|
|
|
Bile acid derivatives:
|
Cause a malassimilation of drugs that are commony used in teh treatment of heart disease
|
|
|
Nicotinic acid:
|
Drug of choice for familial combined hypercholesterolemia and in owering Lp (a)
|
|
|
HMG CoA reductase inhibitors:
|
Drugs of choice for lowering LDL
|
|
|
Nicotinic acid and fibric acid derivatives:
|
Significant effect in lowering triglyceride levels
|
|
|
Estrogen
|
lowers LDL levels
INcrease bone density |
|
|
Fibric acid derivatives:
|
Associated with the inappopriate ADH syndrome
|
|
|
Types of drugs of abuse (DOA):
|
Sedatives: barbiturates, alcohol,
Stimulants: cocaine Hallucinogens:lysergic acid diethylamide |
|
|
MC Drugs of abuse in adolescents
|
Marijuana
Alcohol |
|
|
CNS effects of long-term drug abuse:
|
Damage to neurotransmitter receptor sites
|
|
|
Drug screening
|
Urine best screening medium for DOA
Blood also used in drug assays |
|
|
Sympathomimetic drug of abuse syndrome:
|
Examples: amphetamines, cocaine
S/S: tachycardia/sweating, mydriasis (pupil dilation), hypertension, hyperthermia |
|
|
Anticholinergic drug of abuse syndrome:
|
Examples: antidepressant, antihistamines, antiparkinson-type medications, atropine, muscle relaxants
S/S: mydriasis, fever, dry skin |
|
|
Opiate/sedative drug uf abuse syndrome
|
Heroin, benzodiazepines, barbiturates
S/S: respiratory depression leading to respiratory acidosis, miotic pupils (pinpoint), hypotension |
|
|
Psychedelic/hallucinogenic drug of abuse syndrome
|
PCP
LSD |
|
|
Antidotes used in unconscious patients:
|
Dextrose: R/O possible hypoglycemia from insulin overdose
Naloxone: possible opiate overdose IV thiamine: glucose may precipitate Wernicke's encephalopathy in alchoholics wiht thiamine deficiency |
|
|
IV drug abuse MC
|
Localized infection in skin abscess due to Staphylococcus aureus
HBV MC systemic infection HIV Infective endocarditis: MC tricuspid and aortic valve S. aureus MCC Tetanus: complication of "skin popping" |
|
|
Heroin:
|
Derived form poppy plant
Usually "cut" wiht some agene: granulomatous reactions occuring in skin/lungs form the cutting agents Non-cardiogenic pumnary edema: frotheing form teh mouth is common Focal segmental glomerulosclerosis: Hypertension + Nephrotic syndrome Rx: naloxone, a morphine derivative wiht a high affinity for opioid binding sites of the mu receptor type |
|
|
Meperidine:
|
MC DOA in health professionals
1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) By-product of attempted synthesis of meperidine Produces irreversible parkinson's: cytotoxic to neurons in nigrostriatal dopaminergic pathways |
|
|
Methadone
|
Legal synthetic opioid taken orally: mainly used to detoxify opiate abusers
Long acting drug Saturates CNS opiate receptors Prevents suddne euphric action associated with heroin Causes physical dependence/tolerance |
|
|
Benzodiazepine toxicity:
|
MOA: enhance the frequency of opening up of GABAa receptor-chloride ion channels leading to increases chloride ion conductance
GABA is an inhibitory neurotransmitter Drug of choice for alcohol withdrawal syndrome Rx of toxicity: flumazenil, an antagonist of benzodiazepine and does not block barbiturates or other depressants |
|
|
Barbiturate toxicity
|
MOA: enhance the duration of opening of the GABAa receptor chloride ion channels leading to increases chloride ion conductance
Depress neuronal activity in reticular activating system: inhibits the inhibitory effects of GABA and glycine (an amino acid inhibitory neurotransmitter) Bulae over pressure points: erythema mutiforme Alkalinizing the urine increases its excretion and lowers blood concentrations |
|
|
Cocaine
|
MCCOD from DOA in US
Blocks uptake of neurotransmitters dopamine/NOR by presynaptic axon Predisposes to: sudden death, acute MI, stroke, pulmonary edema, ventricular arrhythmias, myocarditis S/S: hypertension, sinus tachycardia, psychosis, sezure acitvity, mydriasis |
|
|
Amphetamines:
|
MOA: release catecholamines form presynaptic terminals
Examples: amphetamines: Dextroamphetamine Rx obesity, methylphenidate Rx ADHD and narcolepsy methamphetamine Ice is street form of the drug Hallucinations: drug that most simulates schizophrenia |
|
|
Marijuana:
|
MC illegal DOA used in USMOA: contains the psychoactive stimulatn THC which binds to receptors in substantia nigra, globus pallidus, hippocampus, cerebellum
Derives from leaves adn flowering tops of hemp plants Cannabis sativa) Hashish is extractd resin of mariuana that has 5-10 times the potency of the parent compound High lipid solubility: THC is present in urine for more than a week clinical uses: cancer: decreases NV in cancer patients, Lower intraocular pressure in glaucoma Analgesia S/S of marijuana use: reddening of conjunctiva, euphoria, delayed reaction time: engineer driving a train involved in a crash with an oncoming train was found to have THC metabolites in his urine |
|
|
LSD (lysergic acid diethylamide)
|
MOA: ergot alkaloid that binds to D2 dopamine receptors in the brain
Also blocks 5-HT2 serotonin receptor in peripheral tissue Predisposes to chromosomal breakage leading to congenital defects S/S: LSD toxicity: hallucinations, flashbacks, |
|
|
PCP
|
Angel dust
MOA reacts with opioid-like sigma receptors and subtypes of glutamate receptors (antagonists) Initially introduced as a dissociative anesthetic: separates bodily functions from the mind without a loss of consciousness S/S of PCP toxicity: aggitation/violent behavior; coma with eyes open; impervious to pain |
|
|
Use of Beta-blocker in Rx of Graves disease:
|
Thyroid hormones normally upregulate synthesis of Beta-receptors that interact with catecholamines and produce many of the symptoms of thyrotoxicosis
Giving Beta-blockers, blocks teh Beta-receptors, hence blocking the adrenergic symptoms of thyrotoxicosis |
|
|
Electrolyte changes when giving insulin:
|
Drives glucose into the cell along with potassium and phosphate
|
|
|
Rx of carcinoid syndrome
|
Ocreotide (somatostatin analogue)
Also used in Rx of acromegaly and ViPomas |
|
|
Patient went into congestive heart failure. What drug could have potentiated this?
|
Verapamil
Potent negative tnotropic effect |
|
|
Patient with asthma not responding to albuterol:
|
Rx with corticosteroid medihaler
|
|
|
Patient with pneumonia due to a gram positive diplococcus (Strep pheumoniae)
|
Rx with Penicillin G, which blocks cell wall synthesis
|
|
|
Yohimbe
|
Vasodilator used to Rx impotence
|
|
|
Gingo biloba
|
Improves memory
|
|
|
Ginseng
|
Stress-protective
|
|
|
Saw Palmetto
|
Rx prostate hyperplasia
|
|
|
Echinacea
|
Wound healing
Immunostimulant |
|
|
Kava
|
Sedative
|
|
|
Melatonin
|
Sleep
Rx of jet-lag |
|
|
St. Johns Wort:
|
Rx of depression
|
|
|
Jojoba
|
Cosmetic hair growth
|
|
|
Soy
|
Phytoestrogen
|
|
|
Green tea
|
Antioxidant, decrease cancer
|
|
|
Valerian
|
Sleep
|
|
|
Functions of medullary thick ascending limb`
|
Generation of free water via the active Na+/K+/Cl- co-transport pump
This pump is the most sensitive part of the nephron for damage due to tissue hypoxia Blocked by loop diuretics Pump also reabsorbs calcium (not PTH-enhanced) |
|
|
Functions of cortical thick ascending limb
|
Na+/Cl- pump in early distal tubule-
Na+ and Ca++ (PTH enhanced reabsorption) cations share the same channel for reabsorption Blocked by thiazides |
|
|
Functions of the macula densa
|
Interacts with the uxtaglomerular (JG) apparatus on teh afferent arteriole
Increased Na+ in the urine inhibits renin release and vice versa |
|
|
Functions of aldosterone-enhanced ATPase Na+/K+ exchange pump in distal collecting tubule and collecting ducts:
|
Na+ is reabsorbed in exchange for K+
Effect of increased distal delivery of Na+ from more proximal acting diuretics (loop diuretic or thiazide diuretic) There is an augmented Na+/K+ exchange, which may lead to hypokalemia and increased reabsorption of bicarbonate (metabolic alkalosis) |
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|
Functions of aldosterone enhanced H+/K+ ATPase pump and H+ ATPase pumps in the alpha-intercalated cells in the collecting ducts
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Primary sites for the excretion of excess H+ ions
Dysfunction of the H+/K+ ATPase pump is the primary cause for type I distal RTA |
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Normal dilution of urine
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UOsm in thelate distal collecting tubule/collecting duct is normally ~150 mOsm/kg
Primarily contains free water and a smaller amount of obligated water that must accompany solute When POsm is low, ADH is inhibited: absence of ADH causes teh loss of free water in the urine Positive free water clearance: CH2O=V-COsm, where CH2O=free water clearance V=volume of urine in mL/min COsm=obligated water To calculate COsm: COsm=UOsm x V/POsm A positive CH2O indicated dilution (free water is lost in the urine) Example: urine volume 10mL POsm 250 mOsm UOsm 150 mOsm: COsm = 150 x 10/250 = 6mL CH2O = 10-6 = 4mL |
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Normal concentration of urine:
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Increase in POsm is a stiulus for ADH release
ADH renders the late distal and collecting ducts permeable to free water (not Na+, cannot reabsorb obligated wwater) Urine is concentrated Negative CH2O (free water is reabsorbed back into the blood) Urine volume 10mL POsm 300 mOsm/kg UOsm 900 mOsm/kg COsm=900 x 10/300 = 30mL CH2O = 10-30 = -20mL Ability to concentrate urine is the first abnormality in renal failure |
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Central and nephrogenic DI
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Both have low UOsm an dincreased POsm
Central DI shows> 50% increase in UOsm with administration of vasopressin Nephrogenic DI shows <50% increase in UOsm with vasopressin |
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Respiration changes with increasing altitude:
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Respiratory alkalosis
Hypoxemia due to decreased atmospheric pressure not a decrease in % oxygen in air Increase in 2,3-BPG right shifts the ODC |
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Effect of VIP (vasointestinal peptide) and enkephalins on GI tract
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VIP relaxes smooth muscle, increases intestinal secretion, increases pancreatic secretion
Enkephalins (opiates) contract smooth muscle, decrease intestinal secretion |
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Inhibin:
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Synthesized in Sertoli cells in seminiferous tubules
Negative feedback wiht FSH Increased if seminiferous tubules are destroyed Normal if Leydig cells are destroyed, since testosterone has a negative feedback with LH |
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Hormone increading/decreasing gastric secretions
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Gastrin
Hormones inhibiting acid secretion: secretin and gastric inhibitory peptide |
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Placental anatomy/physiology:
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Maternal surface has slightly bulging areas called cotyledons which are covered by a layer of decidua basalis
Fetal surface is entirely covered by the chorionic arteries (venous blood returning form teh fetal heart) adn 1 umbilical vein (carries oxygenated blood from the placenta) Chorionic villus/umbilical cord, chorionic villi project in the intervillous space, which contains maternal blood from which oxygen is extracted: spiral arteries from the uterus empty into the space chorionic villi are lined by trophoblastic tissue: outside layer is composed of syncytiotrophoblast: synthesizes hCG and human placental lactogen (growth hormone of pregancy) and inside layer is composed of cytotrophoblast: clear cells, the interior of the chorionic villus has fetal blood vessels, which coalesce to form the chorionic vessels that converge with the umbilical cord The umbilical cord contains 2 umbilical arteries (contains deoxygenated blood exiting the fetal heart and returning to the placenta) and 1 umbilical vein (contains oxygenated blood) |
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Effect of increased total peripheral resistance on vascular function curve
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Same as teh venous return curve, which depicts the relationship between venous return and right arterial pressure
Increasing TPR (vasoconstriction) decreases venous return to heart, decrease right atrial pressure and decrease ardiac output This causes a counterclockwise rotation of the curve: venous return increases, right atrial pressure increases, and cardiac output increases |
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hCG:
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Has luteinizing hormone activity
Keeps corus uteum of pregnancy synthsizing progesterone until 8-10 weeks and then placenta takes over the function |
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Stimulation of histamine H2 receptors:
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Increases secretion of acid by parietal cells
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GI peptide injected into cerebrospinal fluid that increases appetite for carbohydrate:
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Somatostatin: this normally is made in hypothalamus where is functions to inhibit growth hormone, hence inhibiting GH causes hypoglycemia and the body would crave more carbohydrate to increase glucose levels
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Atrial naturiuretic peptide:
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mediated by guanylate cyclase, increased if left or right atrium is volume overloaded
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Central diabetes insipidus:
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Injecting vasopressin causes an increase in urine concentration (POsm) and decrease in urine volume
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Location of angiotensin converting enzyme:
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Pulmonary capillaries
Increased in sarcoidosis Non-competitive inhibition by ACE inhibitors |
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Vitamin D type in kidneys:
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1,25(OH)2D3
Kidney has 1alpha-hydroxylase in proximal tubules (PTH stimulates synthesis) Renal disease MCC of hypovitaminosis D |
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Effect of thyroid hormone excess on bone:
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Osteoporosis: increases bone turnover resulting in loss of bone mass
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Central diabetes insipidus
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Injecting vasopressin causes an increase in urine concentration (POsm) and decrease in urine volume
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Primary site for temperature regulation:
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Anterior hypothalamus
Fever is due to release of pyrogens stimulating IL-1 release from macrophages IL-1 increases synthesis of PGE2 in the anterior hypothalamus PGE2 raises the hypothalamic set-point (normal core temperature viewed as too low), nhence anterior hypothalamic reactions of heat generation prevail Heat generating mechanisms if core temperature is below set-point include: Increasing the release of thyroid hormones (increases metabolic rate) Vasoconstriction of skin vessels (sympathetic stimulation of hormones slpha-receptors in smooth muscles) Sympathetic stimulation of Beta-receptors in brown fat (increases metabolic rate and heat production) Shivering (most effective system, center located in polsterior hypothalamus, leads to activation of alpha and gamma motoneurons innervating skeletal muscle) Heat dissipating mechanisms (coordinated in posterior hypothalamus) if core temperature is above set-point include: reducing sympathetic tone (vasodilation) of skin vessels leading to shunting of blood through venous plexus in teh ski Increased sympathetic activity of cholinergic fibers innervating sweat glands leading to sweating |
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Cause of decrease in jugular venous pulse on inspiration:
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Decrease in lung compliance (sarcoidosis)
Decreased volume of air in the alveoli leads to less copression of vessels in the interstitial tissue, hence they fill up better and drain blood off easier |
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Iron reabsorption:
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Meat has heme iron, which is ferrous and easy to reabsorb in the small intestine (primarily the duodenum):
Once absorbed into enterocytes, heme is enzymatically degraded to release iron, Most of the iron is diverted to storage as ferritin in the enterocyte (called apoferritin) While a small amount is delivered to plasma transferrin, the circulating binding protien of iron Plants have non-heme iron, which is in the ferric state non-heme iron furst binds to mucin in teh stomach (renders it insoluble) The mucin-non-heme complex then binds to proteins on the mucosal surface of the duodenum for transport into the cotosol where it is enzymatically degraded to release iron A cytosolic protein called mobilferrin transfers the iron to the mucosal ferritin stores or to transferrin in the plasma When body stores of iron are replete, mucosal cells are shed with their stored mucosal ferritin in order to prevent iron overload and tranferrin synthesis in the liver is decreased When body stores are depleted, most of the iron is directed towards transferrin in the plasma and transferrin synthesis in the liver is increased |
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Renal reabsorption curve:
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Glucose is most often asked aobut
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Destory hypothalamus, what hormone increaes:
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Prolactin- no dopamine to inhibit
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Effect of carotid message:
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Slows heart rate
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Major site of water reabsorption in the GI tract
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In descending order:
Jejunum Ileum colon |
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Most effective nephron site for acid excretion
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Proximal tubule of the kidney
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Nephron site for ADH effect
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collecting duct
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Nephron site for greatest generation of free water/most susceptible to ischemia:
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Thick ascending limbin the medulla
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constriction of the efferent arteriole:
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Increases the GFR and decreases renal plasma flow
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filtration fraction in the glomerulus:
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FF=GFR/RPF
constrict afferent arteriole, no change in FF (decrease GFR/decrease RPF) constrict efferent arteriole increases FF Increase plasma protein concentration, hence increasing oncotic pressure, decreases the FF Decreasing plasma proeitn concentration, hence decreasing oncotic pressure, increases the FF constricting the ureter, decreases PBS, hence decreasing GFR and the FF without affecting RPF |
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Negative charege of GBM
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heparan sulfate
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Carotid massage
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Decreases heart rate and increases vasodilation (carotid sinus baroreceptor innervated by the IX and Xth nerve
Impulses generated in this receptor inhibit tonic discharge of vasoconstrictor nerves and excite vagal innervation of the heart producing vasodilation, venodilation, drop in blood pressure and heart rate, and a decrease in cardiac output |
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3% Hypertonic saline and effect on POsm and ADH levels:
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3% hypertonic saline increases POsm
Increased POsm stimulates the release of ADH (increases) Atrial natriuretic peptide is also stimulated and normally does inhibit ADH release, however, hypertonicity overrides ANP |
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Patient walking briskly on a hot day:
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No increase in rectal temperature, vasodilation of vessels in skin
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Marathon runner on a hot day:
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Increase in rectal temperature
Vasodilation of vessels in skin |
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Vagus nerve functions in teh stomach
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Increases gastric acid secretion and gastric motility: vagotomy decreases acid secretion and motility
The vagus nerve represents the parasympathetic innervation of the stomach and duodenam |
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Sympathetic nervous system in teh stoach/duodenum:
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Inhibits secretion and motility
Sympathetic fibers are located in teh celiac plexus form T5-T9 |
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Motilin:
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Hormone modulating GI muscle activity
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0.9% normal saine with KCl
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The crystalloid solution used to replase gastric loses
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Creatinine clearance (CCr)
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Creatinine clearance formula: CCr=UV/P
V=24 hour urine (mL/min) Creatinine is not a perfect clearance substance Causes of a decreased CCr: increasing age, inadequate 24hr urine collection(decreased urine volume in the numerator), renal failure Causes of an increased CCr: Normal pregnancy (increase in plasma volume increases GFR and CCr), early diabetic nephropathy |
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FENa+ (fractional excretion of sodium)
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Useful in the workup of oliguria: FENa+=(UNa+ x PCr)/(Pna+ x UCr) x 100
Values<1 indicate intact tubular function Values >1 (usually >2) indicate tubular dysfunction |
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Myocardial physiology:
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Cardiac hypertrophy increases wall stress, sinus tachycardia reduces filling of the coronary arteries
Increasing heart rate raises myocardial oxygen consumption: cardiac muscle uses Beta-oxidation of fatty acids for energy Venoconstriction: increases preload alone Restrict salt and water intake: decreases preload alone Increase cardiac contractility: no change in preload/afterload |
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Normal gas physiology at the tissue level:
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CO2 derived from tissue enters teh RBC adn combines with H2O via carbonic anhydrase to form H2CO3
H2CO3 dissociates into H+ and HCO3 teh latter leaving the RBC in exchange for Cl- anions H+ combines with oxygenated Hgb-O2 which releases O2 O2 leaves the RBC, dissolves in plasma an dincreases capillary PO2 |
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Normal gas physiology at the pulmonary level:
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Alveolar O2 diffuses into the plasma of the pulmonary capillary owing to a greater partial pressure of alveolar O2
O2 enters the RBC and combines with ferrous ions on deoxyhemoglobin to form oxyHgb and H+ HCO3 enters the RBC from the plasma and combines with H+ to form H2CO3 Cl- anions leave the RBC to counterbalance the entry of HCO3- H2CO3 dissociates into CO2 and H2O: CO2 leaves the RBC and dissolves in the plasma to increase the PCO2, which enters the alveoli for excretion |
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Important anatomical considerations for urine control:
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Urogenital diaphragm: muscles of the urogenital diaphragm are the deep transverse perineal and sphincter urethra muscle
Location of the UG diaphragm on a cystourethrogram is just distal to the prostate in a male Location of the urogenital diaphragm on a cystourethrogram in a female is the beginning of urethra where it exists the bladder Functions of the detrusor muscle: relaxed: storage of urine in the bladder, contracted: emptying of bladder Functions of the sympathetic in bladder control: relaxes the detrusor muscle: aids in urine storage in teh bladder, contracts internal sphincter: increases urine storage functions of the parasympathetic system: contracts the detrusor muscle: empties teh bladder, relaxes the internal sphincter muscle by blocking sympathetic inhibition: allows emptying of the bladder |
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Thyroid hormone
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Diffuses into cytosol
Binds to receptors in teh nucleus: DNA binding domain has zinc fingers, other hormones wiht similar binding: steroids, retinoic acid, vitamin D |
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Angiotensinogen
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Synthesized in liver
Increased synthesis form estrogen |
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Major vehicle for crrying CO2 in blood
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Bicarbonate (70%)
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Residual volume
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volume of air left over after maximal expiration
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Total lung capacity
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Amount of air in a fully expanded lung, measured wiht a nitrogen or helium dilution method
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Functional residual capacity
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Total amount of air in the lungs at the end of a normal expiration (end of TV)
Obtained by a helium dilution technique or body plethysmography |
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Forced vital capacity
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Total amount of air expelled after a maximal inspiration: the RV is what is left over at the end of maximal expiration: normal FVC is 5L
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Forced Expiratory volume in 1 second
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How much air a person can expel from the lungs in 1 second after a maximal inspiration
Normal FEV1 is 4L |
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Ratio of FEV1/FVC
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Normally 0.80: 4/5L
Peak expiratory flow meter: outpatient method of evaluating forced vital capacity (FVC), commonly used by asthmatics to evaluate their airways |
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Method for measuring RV
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Subtract teh expiratory reserve volume (ERV) from the functional residual capacity (FRC)
ERV is the amount of air forcibly expelled at teh end of a normal expiration (end of the TV) FRC=ERV+RV |
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Diffusion capacity (DLco)
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DLco is the method of measuring the ability of a gas to diffuse through the alveolar/capillary interface: utilizes CO
DLco is primarily dependent on the following parameters: CO reaching the alveoli (decreased due to V/Q mismatches: atelectasis, COPD), CO crossing the alveolar/capillary interface (decreased due to pulmonary fibrosis or fluids in the interface) |
