The Big Set

Front 1

Often precedes squamous cell carcinoma

Back 1

Actinic keratosis

Sun exposure causes pre-malignant lesions (SCC)
*Dysplasia ~ malignancy risk

Red or brown papules
Cutaneous horns (macroscopic)

Front 2

1 adrenocortical deficiency

Back 2

Addison's disease

Front 3

Polyostotic fibrous dysplasia
Precocious puberty
Cafe-au-lait spots
Short stature
Young girls

Back 3

Albright's syndrome

Front 4

Disease in which albuminocytologic dissociation is observed

Back 4

Guillian-Barre

Front 5

Albuminocytologic dissociation

Back 5

CSF protein increase, but only modest increase in cell count

Front 6

Hereditary nephritis
Nerve deafness

Back 6

Alport's syndrome

Front 7

Anti-basement membrane antibodies

Back 7

Goodpasture's syndrome

Front 8

Anti-centromere antibodies

Back 8

CREST

C --> C: Centromere --> CREST

Front 9

Anti-ds DNA

Back 9

SLE (type 3 hypersensitivity)

Front 10

Anti-epithelial cell antibodies

Back 10

Pemphigus vulgaris

Front 11

Antigliadin antibodies

Back 11

Celiac disease

Front 12

Anti-histone antibodies

Back 12

Drug-induced SLE

Front 13

Anti-IgG antibodies

Back 13

Rheumatoid factor

Rheumatoid arthritis

Front 14

Antimitochondrial antibodies

Back 14

Primary biliary cirrhosis

Front 15

Anti-neutrophil antibodies

Back 15

Vasculitis

p-ANCA, c-ANCA

Front 16

Anti-platelet antibodies

Back 16

Idiopathic thrombocytopenic purpura

Front 17

Arachnodactyly

Back 17

Marfan's syndrome

Front 18

Argyll Robertson pupil

Back 18

Neurosyphilus

Front 19

Arnold-Chiari malformation

Back 19

Cerebellar tonsillar herniation

Front 20

Aschoff bodies

Back 20

Rheumatic fever

Aschoff = Webby area that contains anitschow cells (nuclei look like a football stitch)

Front 21

Atrophy of the mammillary bodies

Back 21

Wernicke's encephalopathy

Front 22

Auer rods

Back 22

Acute myelogenous leukemia (especially the promyelocytic type-M3)

Front 23

Autosplenectomy

Back 23

Sickle cell anemia

Front 24

Babinski's sign

Back 24

UMN lesion

Front 25

Baker's cyst in popliteal fossa

Back 25

Rheumatoid arthritis

Front 26

Bamboo spine on X-ray

Back 26

Ankylosing spondylitis

Front 27

Bartter's syndrome

Back 27

Hyperreninemia

Front 28

Basophilic stippling of RBCs

Back 28

Lead poisoning

Front 29

Becker's muscular dystrophy

Back 29

Defective dystrophin

Less severe than Duchenne's

Front 30

Bell's palsy

Back 30

LMN CN VII palsy

Front 31

Bence Jones proteins

Back 31

Multiple myeloma (kappa or lambda Ig light chains in urine--+lytic bone lesions)

Waldenstrom's macroglobulinemia (IgM)

Front 32

Berger's disease

Back 32

IgA nephropathy

Front 33

Bernard Soulier disease

Back 33

Defect in platelet adhesion (GP1a)

Front 34

Bilateral hilar adenopathy, uveitis

Back 34

Sarcoidosis

Front 35

Birbeck granules on EM

Back 35

Histiocytosis X (eosinophilic granuloma)

Front 36

Bloody tap on LP

Back 36

Subarachnoid hemorrhage

Front 37

Blue bloater

Back 37

Chronic bronchitis

Front 38

Blue-domed cysts

Back 38

Fibrocystic change of the breast

(Subtype)

Front 39

Blue sclera

Back 39

Osteogenesis imperfecta

Also multiple fractures
Hearing loss (middle ear bones break)
Dental imperfections (lack of dentin)

Front 40

Boot shaped heart on Xray

Back 40

Right ventricular hypertrophy

Often as part of
Tetralogy of Fallot

Front 41

Bouchard's nodes

Back 41

PIP swelling as part of osteoarthritis

Secondary to osteophyte formation

Front 42

Boutonniere deformity

Back 42

Rheumatoid arthritis

Flexion of PIP
Hyperextension of DIP

Front 43

Branching rods in oral infection

Back 43

Actinomyces Israelii

Front 44

Bruton's disease

Back 44

X-linked agammaglobulinemia

Front 45

Budd-Chiari syndrome

Back 45

Post-hepatic venous thrombosis

Front 46

Buerger's disease

Back 46

Burger vs. "le Buerger" (petite?)

SMALL AND MEDIUM VESSELS

a.k.a. Thromboangitis obliterans

Causes vascular thromboses:
*Claudication and severe pain
*Superficial nodular phlebitis
*Raynaud's
*GANGRENE

Seen in HEAVY SMOKERS
*Tx = Stop smoking

Front 47

Burkitt's lymphoma

Back 47

8-->14 translocation

Associated w/EBV

Starry sky (macros in lymphocytes) appearance on histology

Front 48

Burton's lines

Back 48

Lead poisoning

Lead sulfide deposition at the interface of teeth and gums

Front 49

Cafe au lait spots on skin

Back 49

Neurofibromatosis

(also Albright's syndrome)

Front 50

Caisson disease

Back 50

Caisson --> Poisson --> FISH


a.k.a. "The bends," Decompression dz

Gas emboli

Front 51

Calf pseudohypertrophy

Back 51

Duchenne's muscular dystrophy

Front 52

Call-Exner bodies

Back 52

Granulosa-theca cell tumor of the ovary

Granulosa and theca surround an "egg" that isn't there--eosinophils instead

Front 53

Cardiomegaly w/apical atrophy

Back 53

Chagas disease

Front 54

Cerebriform nuclei

Back 54

Cutaneous T cell lymphoma
a.k.a. Mycosis fungiodes

Itchy skin patch --> Raised plaque --> Mushroom tumor

(The other form of cutaneous TCL is Sezary syndrome)

Front 55

Chagas disease

Back 55

Trypanosome infection

Cardiomegaly
Megacolon
Megaesophagus

Front 56

Chancre

Back 56

Primary syphilus

Not painful

Front 57

Chancroid

Back 57

Haemophilus ducreyi

PAIN differentiates from syphilus chancre

Front 58

Charcot's triad

Back 58

There are 2!
JR Fudge sundaes are a SIN

Multiple sclerosis: SIN
*Scanning speech
*Intention tremor
*Nystagmus

Cholangitis: JR Fudge
*Jaundice
*RUQ pain
*Fever

Front 59

Charcot-Leyden crystals

Back 59

Product of eosinophil breakdown (membrane component)

Seen as part of Bronchial asthma along w/Curschmann's spirals (whorled mucus plugs)

Front 60

Curschmann's spirals

Back 60

Whorled mucus plugs

Seen as part of Bronchial Asthma along w/Charcot-Leyden crystals

Front 61

Chediak-Higashi disease

Back 61

Phagocyte deficiency

Front 62

Cherry-red spot on macula

Back 62

Lysosomal storage diseases:
*Tay Sachs (Hexosaminidase A)
*Neimann-Pick disease (sphingomyelinase)

Central retinal artery occlusion

Front 63

Cheyne-Stokes respirations

Back 63

Central apnea (irregular breathing)

Causes: CHF, Increased ICP

Front 64

Chocolate cysts

Back 64

Feature of endometriosis

Frequently involves both ovaries

Front 65

Chronic atrophic gastritis

Back 65

Predisposition to gastric carcinoma

Front 66

Chvostek's sign

Back 66

Facial muscle spasm upon tapping

Sign of hypocalcemia
(Low Ca2+ tetany)

Front 67

Clear cell adenocarcinoma of the vagina

Back 67

DES exposure in utro

Front 68

Clue cells

Back 68

Gardnerella vaginitis

Front 69

Codman's triangle on X-ray

Back 69

Osteosarcoma

Front 70

Cold agglutinins

Back 70

IgM

Mycoplasma pneumoniae
Mononucleosis

Front 71

Cold intolerance

Back 71

Hypothyroidism

Front 72

Condyloma lata

Back 72

2 Syphilis

Whitish confluence of smaller (red) skin rashes

Often on the palms and soles

Front 73

Continuous machinery murmur

Back 73

Patent ductus arteriosus

Front 74

Cori's disease

Back 74

Debranching enzyme deficiency

Front 75

Cotton-wool spots

Back 75

Chronic hypertension

Puffy white patches on retina

Front 76

Cough, conjunctivitis, coryza
+
Fever

Back 76

Coryza = Head cold

Measles

Front 77

Councilman bodies

Back 77

Hepatitis

Toxic OR viral

Front 78

Cowdry A bodies

Back 78

Herpes virus

Front 79

Crescents in Bowman's capsule

Back 79

Rapidly progressive crescentic glomerulonephritis

Front 80

Crigler-Najjar syndrome

Back 80

Congenital unconjugated hyperbilirubinemia

Type 1: Greatly REDUCED UDP-glucuronyl transferase
Greatly reduced UDP-glucuronyl transferase
*Tx: PHENOBARBITOL (increases liver enzyme synthesis)

Type 2: ABSENT UDP-glucuronyl transferase
*Jaundice
*Kernicterus (bilirubin in brain)
*Tx: Phototherapy, plasmapheresis

Front 81

Curling's ulcer

Back 81

Acute gastric ulcer associated w/severe burns

Front 82

Currant-jelly sputum

Back 82

Klebsiella

Front 83

Cushing's ulcer

Back 83

Acute gastric ulcer associated w/CNS injury

Front 84

D-dimers

Back 84

DIC

Front 85

Depigmentation of neurons in substantia nigra

Back 85

Parkinson's disease

Rigidity, resting tremor, bradykinesia

Front 86

Dermatitis, dementia, diarrhea

Back 86

Pellagra

Vitamin B3 (niacin) deficiency

Front 87

Diabetes insipidus
+
Exopthalmos
+
Lesions of skull

Back 87

Hand-Schuller-Christian disease

"Chronic progressive histiocytosis"

A multifocal, unisystem langerhans cell histiocytosis seen mostly in children
*Bone invasion
*50% involve pituitary --> DI

Front 88

Dog or cat bite

Back 88

Pasteurella multocida

Front 89

Donovan bodies

Back 89

Granuloma inguinale (bacterial infection)

Front 90

Dressler's syndrome

Back 90

Post-MI fibrinous pericarditis

Weeks-months later

Front 91

Duchenne's muscular dystrophy

Back 91

Deleted dystrophin gene

X-linked recessive

Front 92

Eburnation

Back 92

Osteoarthritis

Polished, ivory-like appearance of bone

Front 93

Edward's syndrome

Back 93

Trisomy 18

Low-set ears
Heart problems
Rocker bottom feet

Front 94

Eisenmenger's complex

Back 94

Change in pathological shunt flow direction during late cyanosis
*When R heart P > L heart

L--> R changes to R --> L

Front 95

Elastic skin

Back 95

Ehlers-Danlos syndrome

Front 96

Erb-Duchenne palsy

Back 96

Superior trunk (C5-C6) injury

"Waiter's tip"

Front 97

Erythema chonicum migrans

Back 97

Lyme disease

Front 98

Fanconi's syndrome

Back 98

Proximal tubular reabsorption defect

Front 99

Fat
Female
Forty
Fertile

Back 99

Acute cholecystitis

Front 100

Fatty liver

Back 100

Alcoholism

(+ Obesity)

Front 101

Ferruginous bodies

Back 101

Asbestosis

Front 102

Gardner's syndrome

Back 102

Form of FAP

Colon polyps
+
Osteomas (usually skull), soft tissue tumors

Front 103

Gaucher's disease

Back 103

Glucocerebrosidase Deficiency

Front 104

Ghon focus

Back 104

TB

Front 105

Glanzmann's thrombasthenia

Back 105

Defect in platelet aggregation (2b-3a)

Front 106

Goodpasture's syndrome

Back 106

Autoantibodies against basement membrane proteins of:
1. Alveoli
2. Glomerulus

Front 107

Gower's maneuver

Back 107

Seen w/Duchenne's

Use of patient's arms to help legs pick self off from the floor

Front 108

Guillian-Barre syndrome

Back 108

Idiopathic polyneuritis

Distal --> Proximal

Front 109

Hair-on-end/Crew cut skull appearance on X-ray

Back 109

Extramedullary hematopoiesis

Seen w/sickle cell, B-thalassemia

Front 110

Hand-Schuller-Christian disease

Back 110

Chronic progressive histiocytosis

Diabetes insipidus
+
Exopthalmos
+
Lesions of skull

Front 111

HbF

Back 111

Thalassemia major

Front 112

HbS

Back 112

Sickle cell anemia

Front 113

hCG elevated

Back 113

Choriocarcinoma, hydatiform mole

Pregnancy

Front 114

Heberden's nodes

Back 114

Osteoarthritis

DIP swelling 2 to osteophytes

Front 115

Heinz bodies

Back 115

G6PD deficiency

Front 116

Henoch-Schonlein Purpura

Back 116

#1 childhood vasculitis

A hypersensitivity vasculitis

Associated w/URIs

Causes

1. Hemorrhagic urticaria that appear and age together

2. Joints (arthritis)

3. GI (Intestinal hemorrhage)
*Abdominal pain and melena

Henoch = NOCH knees (joints)
Schonlein = Stomach
Purpura = Purpura

Front 117

Heterophil antibodies

Back 117

Infectious mononucleosis (EBV)

Front 118

High-output cardiac failure

Back 118

Dilated cardiomyopathy

Seen w/Wet Beriberi (B1 deficiency)

Front 119

HLA-B27

Back 119

PAIR:

Psoriasis

Ankylosing spondylitis

IBD

Reiter's syndrome (See, Pee, Climb a tree/Bend the knee)

Front 120

HLA-B8

Back 120

Skinny people......I wish they 8 more

Graves disease

Celiac sprue

Front 121

HLA-DR2

Back 121

1 representative from each hypersensitivity type:

Hay fever
Goodpasture
SLE
Multiple sclerosis

Front 122

HLA-DR3

Back 122

Diabetes mellitus type 1

Front 123

HLA-DR4

Back 123

Diabetes mellitus type 1

Rheumatoid arthritis
*4 walls in a "rheum"

Front 124

HLA-DR5

Back 124

5 = TIRED

Pernicious anemia (B12 def)
Hashimoto's thyroiditis

Front 125

HLA-DR7

Back 125

Steroid-responsive nephrotic syndrome

7 year olds...

Front 126

SLE antibodies

Back 126

ANA

Anti-phospholipid: May cause false + for syphilus

Very specific:

Anti-dsDNA: Poor prognosis

Anti-Smith (rna binding prot): no prognostic info

Drug induced:
Anti-histone (drug induced)

Front 127

Scleroderma antibodies

Back 127

Anti-centromere = CREST

Anti-Scl-70/topoisomerase = Diffuse

Front 128

Primary biliary cirrhosis antibody

Back 128

Anti-mitochondrial

Front 129

Pemphigus vulgaris antibody

Back 129

Anti-epithelial cell (desmosomes)

Front 130

Hashimoto's thyroiditis antibodies

Back 130

Hashes moto (microsome) and thyroiditis (thyroglobulin)

Anti-microsomal

Anti-thyroglobulin

Front 131

Polymyositis, Dermatomyositis antibodies

Back 131

Anti-Jo-1

Front 132

Sjogren's syndrome antibodies

Back 132

Anti-SS-A (anti-Ro)

Anti-SS-B (anti-La)
*More specific than SSA

Front 133

Anti-U1 RNP antibody

Back 133

Mixed connective tissue diseases

SLE, Scleroderma

Front 134

Autoimmune hepatitis antibody

Back 134

Anti-smooth muscle

Front 135

Type 1 diabetes mellitus antibody

Back 135

Anti-glutamate decarboxylase

Front 136

Wegener's granulomatosis antibody

Back 136

c-ANCA

Binds proteinase 3 in neutrophil cytoplasm

Front 137

p-ANCA

Back 137

Binds myeloperoxidase, which aggregates around neutrophil nucleus

Front 138

Homer Wright rosettes

Back 138

Neuroblastoma

Front 139

Honeycomb lung on X-ray

Back 139

Interstitial fibrosis

Front 140

Horner's syndrome

Back 140

Ptosis
Anhydrosis
Miosis

SC lesion above T1

Front 141

Howell-Jolly bodies

Back 141

Splenectomy or non-functional spleen

Front 142

Huntington's disease

Back 142

Caudate degeneration
Decreased GABA, Ach

Autosomal dominant
Chromosome 4

Front 143

Hyperphagia + hypersexuality + hyperorality + hyperdocility

Back 143

Kluver-Bucy syndrome (amygdala)

Front 144

Hyperpigmentation of skin

Back 144

Addison's (1 adrenal insufficiency)

Front 145

Hypersegmented neutrophils

Back 145

Megaloblastic/macrocytic anemia

Front 146

Hypertension + Hypokalemia

Back 146

Conn's syndrome (aldosterone secreting adenoma)

A form of primary aldosteronism

HTN
Hypokalemia
Alkalosis

Front 147

Hypochromic microcytosis

Back 147

Iron deficiency anemia
or
Lead poisoning

Front 148

Increased alpha-fetoprotein in amniotic fluid/maternal serum

Back 148

Neural tube defects
(Anencephaly, spina bifida)

Front 149

Increased uric acid levels

Back 149

GoLLuM

Gout
Lesch-Nyhan (HGPRT deficiency)
Loop and thiazide diuretics
Myeloproliferative disorders

Front 150

Intussusception: Cause

Back 150

Adenovirus

Causes hyperplasia of Peyer's patches

Front 151

Janeway lesions

Back 151

Endocarditis

Found on palms, soles

Front 152

Jarisch-Herxheimer reaction

Back 152

Syphilis

Overaggressive treatment of an asymptomatic patient

Symptoms are due to rapid bacterial lysis and toxin release

Front 153

Job's syndrome

Back 153

Abnormalities w/neutrophil chemotaxis

Front 154

Kaposi's sarcoma

Back 154

AIDS in MSM

Front 155

Kartagener's syndrome

Back 155

Dynein defect (microtubules of cilia are missing dynein arms)

Situs inversus, infertility, etc.

Front 156

Kayser-Fleischer rings

Back 156

Wilson's disease

Front 157

Keratin pearls

Back 157

Squamous cell carcinoma

Front 158

Kimmelsteil-Wilson nodules

Back 158

Diabetic nephropathy

Front 159

Koilocytes

Back 159

HPV

Front 160

Koplik spots

Back 160

Measles

Front 161

Krukenberg tumor

Back 161

Gastric adenocarcinoma that metastasizes to ovary

Front 162

Kussmaul Hyperpnea

Back 162

Diabetic ketoacidosis

Front 163

Kussmaul Hyperpnea

Back 163

Diabetic ketoacidosis

Front 164

Lens dislocation

Aortic dissection

Joint hyperflexibility

Back 164

Marfan's syndrome

Front 165

Fibrillin deficit

Back 165

Marfan's syndrome

Front 166

Lesch-Nyhan syndrome

Back 166

HGPRT deficiency

"He's got purine trouble"

Front 167

Lewy bodies

Back 167

Parkinson's disease
Frontotemporal dementia (Pick's disease)

Alpha synuclein

Front 168

Libman-Sacks disease

Back 168

Endocarditis associated w/SLE

"LSE w/SLE"

Verrucous (wart-like) lesions on both sides of mitral valve

Front 169

Lines of Zahn

Back 169

Arterial thrombus

Front 170

Lisch nodules

Back 170

Neurofibromatosis
Von Recklinghausen's diease
*17 letters = chromosome 17

Lisch = Hyperpigmented areas on iris

Front 171

Low serum ceruloplasmin

Back 171

Wilson's disease

Front 172

Lucid interval

Back 172

Epidural hematoma

Front 173

Lumpy bumpy appearance of glomeruli on immunofluorescence

Back 173

Post-streptococcal glomerulonephritis

Front 174

Lytic bone lesions on X-ray

Back 174

Multiple myeloma

Met from lung

Front 175

Mallory bodies

Back 175

Alcoholic liver disease

Eosinophilic

Front 176

Mallory-Weiss syndrome

Back 176

Esophagogastric lacerations

PAINFUL (esophageal varices are not)

Front 177

McArdle's disease

Back 177

Muscle phosphorylase deficiency

Front 178

McBurney's sign

Back 178

Appendicitis

Deep tenderness at McBurney's point (RLQ)

Front 179

MLF Syndrome

Back 179

Multiple sclerosis

Front 180

Monoclonal antibody spike

Back 180

1. Multiple myeloma: IgG or IgA
*Called the "M protein"

2. Waldenstrom's macroglobulinemia: IgA

3. MGUS (Monoclonal gammopathy of undetermined significance)

Front 181

Myxedema

Back 181

Hypothyroidism

Front 182

Necrotizing vasculitis (lungs)
+
Necrotizing glomerulonephritis

Back 182

Goodpasture's syndrome

Wegener's

Front 183

Needle shaped, negatively birefringent (yellow) crystals

Back 183

Gout

Front 184

Negri bodies

Back 184

Rabies

Front 185

Nephritis
+
Cataracts
+
Hearing loss

Back 185

Alport's syndrome

Front 186

Neurofibrillary tangles

Back 186

Alzheimer's disease

Front 187

Neimann-Pick disease

Back 187

Sphingomyelinase deficiency

Front 188

No lactation postpartum

Back 188

Sheehan's syndrome (pituitary infarction)

Front 189

Nutmeg liver

Back 189

CHF

Front 190

Occupational exposure to asbestos

Back 190

Maligant mesothelioma

Front 191

Orphan Annie nuclei

Back 191

Papillary carcinoma of the thyroid

Lots of Orphans in the PAPulation

Front 192

Osler's nodes

Back 192

Endocarditis

Front 193

Owl's eye

Back 193

CMV

Front 194

Painless jaundice

Back 194

Pancreatic cancer (head)

Front 195

Pancoast's tumor

Back 195

Bronchogenic apical tumor

*May cause Horner's sydrome

Front 196

Pannus

Back 196

Rheumatoid arthritis

Front 197

Parkinson's disease

Back 197

Nigrostriatal dopamine depletion

Failure to excite the excitatory
+
Failure to inhibit the inhibitory

Lewy bodies (Alpha synuclein)

Depigmentation of the substantia nigra

TRAP:
Tremor at Rest
Rigidity (cogwheel)
Akinesia (impaired movement)
Postural instability

Front 198

Periosteal elevation on X-ray

Back 198

Pyogenic osteomyelitis

Front 199

Peutz-Jegher's syndrome

Back 199

Benign polyposis

Front 200

Peyronnie's disease

Back 200

Penile fibrosis

Bent penis

Front 201

Philadelphia chromosome

Back 201

CML (sometimes AML)

Front 202

Pick bodies

Back 202

Pick's disease (Frontotemporal dementia)

Front 203

Pink puffer

Back 203

Emphysema

Centroacinar = smoking
Panacinar = Alpha 1 def

Front 204

Centroacinar emphysema

Back 204

Smoking

Front 205

Panacinar emphysema

Back 205

Alpha-1-antitrypsin deficiency

Front 206

Pick's disease

Back 206

Progressive dementia

Pathology similar to PD
Progression similar to AD

Front 207

Plummer-Vinson syndrome

Back 207

Plumber wearing a WIG:

Webs (Esophageal--dysphagia)
Iron deficiency anemia
Glossitis

Front 208

Podagra

Back 208

Gout at the MP joint of big toe

Front 209

Hallux

Back 209

Big toe

Front 210

Podocyte fusion

Back 210

Minimal change disease/Lipoid nephrosis

Front 211

Polyneuropathy
Cardiac pathology
Edema

Back 211

Dry beriberi

(B1 deficiency)

Front 212

Polyneuropathy preceded by GI or respiratory infection

Back 212

Guillain-Barre

Front 213

Pompe's disease

Back 213

Lysosomal glucosidase deficiency

Associated w/cardiomegaly

*TV: Girl had progressive muscle weakness, tons of glycogen in muscle

Front 214

Port-wine stain

Back 214

Hemangioma

(seen w/Sturge-Weber)

Front 215

Positive anterior drawer sign

Back 215

ACL injury

Front 216

Pott's disease

Back 216

Vertebral TB

Considered a form of osteomyelitis

Front 217

Pseudopalisade tumor cell arrangement

Back 217

GBM

Front 218

Pseudorosettes

Back 218

Ewing's sarcoma

Neuroectodermal origin

Front 219

Ptosis, miosis, anhidrosis

Back 219

Horner's syndrome

Often Pancoast's tumor

Front 220

Rash on palms and soles

Back 220

2 syphilis

Rocky mountain spotted fever

Front 221

Raynaud's syndrome

Back 221

Recurrent vasospasm in extremities

Front 222

RBC casts in urine

Back 222

Acute glomerulonephritis

Front 223

Recurrent pulmonary Pseudomonas and S. aureus infections

Back 223

Cystic fibrosis

Front 224

Red urine in the morning

Back 224

Paroxysmal nocturnal hemoglobinuria

Complement disorder

Front 225

Reed-Sternberg cells

Back 225

Hodgkin's lymphoma

Front 226

Reid index

Back 226

Increased w/chronic bronchitis

Mucus:Total thickness ratio

Front 227

Reinke crystals

Back 227

Leydig cell tumor

(Testosterone)

Front 228

Reiter's syndrome

Back 228

Can't see, pee, climb a tree/bend the knee

Conjunctivitis
Urethritis
Arthritis

HLA-B27 (MHC1) association
More common in males

Happens after you've "REITED" an STD (chlamydia)

Happens after you haven't been EITing (GI infection)

Front 229

Renal cell carcinoma
+
Cavernous hemangiomas
+
Adenomas

Back 229

Von hippel landau (chromosome 3)

Front 230

Renal EPITHELIAL casts in urine

Back 230

Acute toxic/viral nephrosis

Front 231

Rhomboid crystals
Positively birefringent

Back 231

Pseudogout
Affects older people (>50)
M=F

Calcium pyrophosphate
Usually affects the knee

NO TREATMENT

Front 232

Rib notching

Back 232

Coarctation of the aorta

Caused by enlarged intercostal collaterals

Front 233

Roth spots

Back 233

Endocarditis

Retinal hemorrhages w/pale or white centers

Front 234

Rotor's syndrome

Back 234

Congenital conjugated hyperbilirubinemia

Less severe than Dubin-Johnson
No black liver

Front 235

Rouleaux formation

Back 235

Multiple myeloma

Stacked RBCs

Front 236

S3

Back 236

Increased volume within the ventricle

Left to right shunt
Mitral regurgitation
LV failure

Front 237

S4

Back 237

Atria contracting forcefully to overcome stiff ventricle

Aortic stenosis
Hypertrophic subaortic stenosis

Long-standing HTN
Fibrosis (post MI)

Front 238

Schiller-Duval bodies

Back 238

Yolk sac tumor

Front 239

Senile plaques

Back 239

Alzheimer's disease

B-amyloid

Front 240

Sezary syndrome

Back 240

Form of cutaneous T cell lymphoma

T cells have pathological quantities of mucopolysaccharides

(The other form is Mycosis fungiodes)

Front 241

Sheehan's syndrome

Back 241

Postpartum pituitary infarction/necrosis

Front 242

Shwartzman reaction

Back 242

Neisseria meningitidis

1st exposure: Inflammation, thrombosis (can be cleared)

2nd exposure: Necrosis

Front 243

Signet-ring cells

Back 243

Gastric carcinoma

Front 244

Simian crease

Back 244

Down syndrome

Front 245

Sipple's syndrome

Back 245

Men Type 2a

Medullary Thyroid CA + Hyperparathyroidism

Men 2B = Medullary thyroid CA + Pheochromocytoma

Front 246

Sjogren's syndrome

Back 246

Dry eyes
Dry mouth
Arthritis

Front 247

Skip lesions

Back 247

Crohns

Front 248

Slapped cheeks

Back 248

Erythema infectiosum (5th's disease)

B19 Parvo

Front 249

Slapped cheeks

Back 249

Erythema infectiosum (5th's disease)

B19 Parvo

Front 250

Smudge cell

Back 250

CLL

Front 251

"Soap bubble" on X-ray

Back 251

Giant cell tumor of bone

Front 252

Spike and dome on EM

Back 252

Membranous glomerulonephritis

Front 253

Spitz nevus

Back 253

Benign juvenile melanoma

Front 254

Splinter hemorrhages in fingernails

Back 254

Endocarditis

Front 255

Starry-sky pattern

Back 255

Burkitt's lymphoma (EBV)
8-->14 translocation

Front 256

Strawberry tongue

Back 256

Scarlet fever

Front 257

Streaky ovaries

Back 257

Turner's syndrome

Front 258

String sign on X-ray

Back 258

Crohn's disease

Front 259

Subepithelial humps on EM

Back 259

Post-streptococcal glomerulonephritis

Front 260

Sub-occipital lymphadenopathy

Back 260

Rubella

Front 261

Sulfur granules

Back 261

Actinomyces israelii

Front 262

Swollen gums, bruising, poor wound healing, anemia

Back 262

Scurvy

Vitamin C necessary for hydroxylation of proline and lysine in collagen synthesis

Front 263

Systolic ejection murmur

Back 263

Aortic stenosis

Front 264

8-->14 translocation

Back 264

Burkitt's lymphoma

c-myc

Front 265

9-->22 translocation

Back 265

Philadelphia chromosome

CML

Bcr-abl fusion

Front 266

14 --> 18 translocation

Back 266

Follicular lymphoma

Bcl-2 activation

Front 267

Tabes dorsalis

Back 267

3 Syphilis

Front 268

Tendon xanthomas

Back 268

Familial hypercholesterolemia

Front 269

Thumb sign on lateral x-ray

Back 269

Acute epiglottitis

H. Influenzae

Front 270

Thyroidization of the kidney

Back 270

Chronic bacterial pyelonephritis

Front 271

Tophi

Back 271

Gout

Front 272

Tram-track appearance on LM

Back 272

Membranoproliferative glomerulonephritis

Appearance: 2 glomerular basement membranes in parallel

Front 273

Trousseau's sign

Back 273

Carpal spasm w/arm cuff

Visceral cancer
Pancreatic adenocarcinoma
Hypocalcemia

Front 274

Virchow's node

Back 274

Left supraclavicular node enlargement

Metastatic carcinoma of the stomach

Front 275

Virchow's triad

Back 275

Pulmonary embolism

1. Blood stasis
2. Endothelial damage
3. Hypercoagulation

Front 276

Von Recklinghausen's disease

Back 276

Neurofibromatosis type 1

Front 277

Von Recklinghausen's disease of bone

Back 277

Osteitis fibrosa cystica

"Brown tumor"

Front 278

Wallenberg's syndrome

Back 278

PICA thrombosis

Front 279

Waterhouse-Friderichsen syndrome

Back 279

Meningococcemia --> Adrenal hemorrhage

Front 280

Waxy casts

Back 280

Chronic end-stage renal disease

Front 281

WBC casts in urine

Back 281

Acute pyelonephritis

Front 282

WBCs in urine

Back 282

Acute cystitis

Front 283

Wermer's syndrome

Back 283

MEN type 1

Pituitary
Parathyroid
Pancreas

Front 284

Whipple's disease

Back 284

Malabsorption syndrome

Caused by tropheryma whippelii

Front 285

Wilson's disease

Back 285

a.k.a. hepatolenticular degeneration

Front 286

Wire loop lesions on LM

Back 286

Loop --> Loopus

Lupus nephropathy

Front 287

Worst headache of my life

Back 287

Berry aneurysm

Associated w/adult PCKD

Front 288

Xanthochromia

Back 288

Yellow CSF--processed RBCs

Subarachnoid hemorrhage

Front 289

Xerostomia
+
Arthritis
+
Keratoconjunctivitis sicca

Back 289

Sjogren's

Front 290

Zenker's diverticulum

Back 290

Upper GI diverticulum

Halitosis

Front 291

Zollinger-Ellison syndrome

Back 291

Gastrin secreting tumor associate w/ulcers

Front 292

Most common bacteremia/pneumonia

Back 292

S. aureus

Front 293

Most common bacteria associated w/cancer

Back 293

H. Pylori

Front 294

Most common bacteria in GI

Back 294

#1 Bacteriodes

#2 E. coli

Front 295

Most common brain tumors (adults)

Back 295

Mets
Astrocytoma (including GBM)
Meningioma
Schwannoma

Front 296

Most common brain tumor (kids)

Back 296

Medulloblastoma (cerebellum)

Front 297

Most common supratentorial brain tumor (kids)

Back 297

Craniopharyngioma

Front 298

Most common breast cancer

Back 298

Infiltrating ductal carcinoma

US: 1 in 9 women will develop breast cancer

Front 299

Most common breast mass

Back 299

Fibrocystic change

In post-menopausal women, carcinoma is the most common mass

Front 300

Most common breast tumor (benign)

Back 300

Fibroadenoma

Front 301

Most common bug in debilitated, hospitalized pneumonia patients

Back 301

Klebsiella

Front 302

Most common primary cardiac tumor (adults)

Back 302

Myxoma--ball and valve

4:1 left atrium

Ball and valve structure --> Blocking and syncopal episodes

Front 303

Most common primary cardiac tumor (kids)

Back 303

Rhabdomyoma

Biggest association: Tuberous sclerosis (Ash, Green, CardiacRhab, Astrocytoma, Renal Angiomyolipoma)

Front 304

Most common cardiac tumor (adults)

Back 304

Mets

Front 305

Most common cardiomyopathy

Back 305

Dilated

Front 306

Most common chromosomal disorder

Back 306

Down syndrome

Associations:
*ALL
*Alzheimer's disease
*Endocardial cushion defects

Front 307

Most common chronic arrythmia

Back 307

Atrial fibrillation

HIGH risk of emboli

Front 308

Most common congenital cardiac anomaly

Back 308

VSD

Front 309

Most common constrictive pericarditis

Back 309

TB

Front 310

Most common coronary artery involved in thrombosis

Back 310

LAD > RCA > LCA

Front 311

Most common early cyanosis

Back 311

Tetralogy of Fallot
Transposition of great vessels
Truncus arteriosus

Front 312

Most common late cyanosis

Back 312

VSD, ASD, PDA

Front 313

Patent ductus arteriosus

Back 313

Close w/indomethacin

Keep open w/misoprostol (PGE1)

Front 314

Most common demyelinating disease

Back 314

MS

Front 315

Most common dietary deficit

Back 315

Iron

Front 316

Most common epiglottitis

Back 316

H. influenzae type B

Front 317

Most common esophageal cancer

Back 317

Squamous cell carcinoma

Front 318

Most common gene involved in cancer

Back 318

p53

Front 319

Most common group affected by cystic fibrosis

Back 319

Caucasians

Front 320

Cystic fibrosis complications

Back 320

Fat soluble vitamin deficiencies

Mucous plugs --> Lung infections

Cholesterol gallstones

Front 321

Gynecologic malignancy

Back 321

Endometrial carcinoma

Front 322

Most common heart murmur

Back 322

Mitral valve prolapse

Front 323

Most common heart valve in bacterial endocarditis

Back 323

Mitral

Front 324

Most common heart valve in bacterial endocarditis--IV drug abuser

Back 324

Tricuspid

Front 325

Most common heart valve affected by rheumatic fever

Back 325

#1 Mitral valve
#2 Aorta

Front 326

Most common helminth infection (US)

Back 326

#1 Enterobius vermicularis
*Pinworm

#2 Ascaris lumbricoides
*Roundworm

Front 327

Most common hereditary bleeding disorder

Back 327

Von Willebrand's

Front 328

Most common kidney stones

Back 328

#1 Calcium --radiopaque

#2 Ammonium -- radiopaque
*Urea --> Ammonia
*Urease positive organisms such as Proteus, staphylococcus

Front 329

Most common liver disease

Back 329

Alcoholic

Front 330

Most common location of brain tumors (adults)

Back 330

Supratentorial

Front 331

Most common location of brain tumors (kids)

Back 331

Infratentorial

Front 332

Most common lysosomal storage disease

Back 332

Gaucher's

Glucocerebrosidase deficiency

Front 333

Most common male cancer

Back 333

Prostatic carcinoma

Front 334

Most common malignancy associated w/noninfectious fever

Back 334

Hodgkin's disease

Front 335

Most common malignant skin tumor

Back 335

Basal cell carcinoma (rarely mets)

Front 336

Most common mets to brain

Back 336

~50% of brain tumors are mets

Lots of Bad Stuff Kills Glia

Lung Breast Skin (melanoma) Kidney GI

Front 337

Most common mets to liver

Back 337

Liver metastases > Primaries

Cancer Sometimes Penetrates Benign Liver:

Colon > Stomach > Pancreas > Breast > Lung


or

Please Get Back to CoLorado

Pancreatic GI Breast Colon Lung

Front 338

Most common neoplasm (kids)

Back 338

#1 ALL
#2 Cerebellar medulloblastoma

Front 339

Most common motor neuron disease

Back 339

ALS

Front 340

Most common nephrotic syndrome

Back 340

Membranous glomerulonephritis

Front 341

Most common obstruction of male urinary tract

Back 341

BPH

Front 342

Most common opportunistic infection in AIDS

Back 342

Pneumocystis carinii pneumonia

Front 343

Most common opportunistic infection in AIDS

Back 343

Pneumocystis carinii pneumonia

Front 344

Most common organ receiving mets

Back 344

Adrenal glands (rich blood supply)

Front 345

Most common organ sending mets

Back 345

#1 Lung
#2 Breast and stomach (tied)

Front 346

Most common ovarian tumor (benign)

Back 346

Serous cystadenoma

Front 347

Most common ovarian tumor (malignant)

Back 347

Serous cystadenocarcinoma

Front 348

Most common pancreatic tumor

Back 348

Adenocarcinoma @ head of pancreas

Front 349

Most common patient w/ALL

Back 349

Child

Front 350

Most common patient w/CLL

Back 350

Adult >60

Front 351

Most common patient w/AML

Back 351

Adult > 60

Front 352

Most common patient w/CML

Back 352

Adult 35-50

Front 353

Most common patient w/Hodgkin's

Back 353

Young male

Except nodular sclerosis type-female

Front 354

Most common patient w/minimal change disease

Back 354

Young child

Front 355

Most common patient w/Reiter's

Back 355

Male

Front 356

Most common pituitary tumor

Back 356

#1 Prolactinoma
#2 Somatotropic "adicophilic" adenoma

Front 357

Most common preventable cancer

Back 357

Lung cancer

Front 358

Most common primary bone tumor (adults)

Back 358

Multiple myeloma

Front 359

Most common primary hyper PTH

Back 359

#1 Adenomas
#2 Hyperplasia
#3 Carcinoma

*Adrenal adenoma will cause insufficiency (AI), while a parathyroid adenoma will cause a plethora (hyper PTH)

Front 360

Most common primary liver tumor

Back 360

Hepatoma

Front 361

Most common renal tumor

Back 361

Renal cell carcinoma

Associations:

*Von Hippel-Landau

*Acquired polycystic kidney disease

*Paraneoplastic syndromes (distant neoplasm secretes erythropoietin, renin, PTH or ACTH)

Front 362

Most common secondary hyper parathyroidism

Back 362

Hypocalcemia of chronic renal failure

Front 363

Most common sexually transmitted disease

Back 363

Chlamydia

Front 364

Most common site of diverticula

Back 364

Sigmoid colon

Front 365

Most common site of metastasis

Back 365

#1 Regional lymph nodes

#2 Liver

Front 366

Most common sites of atherosclerosis

Back 366

The first stops from the heart (aorta, coronary arteries)

Knee and neck

#1 Abdominal aorta

#2 Coronary arteries

#3 Popliteal arteries

#4 Carotid arteries

Front 367

Most common skin cancer

Back 367

Basal cell carcinoma

Front 368

Most common stomach cancer

Back 368

Adenocarcinoma

Front 369

Most common testicular tumor

Back 369

Seminoma

Front 370

Most common thyroid cancer

Back 370

Papillary carcinoma

PAPillary has the biggest POP

Front 371

Most common tracheoesophageal fistula

Back 371

Lower esophagus joins trachea/upper esophagus --> blind pouch

Front 372

Most common tumor in men

Back 372

Prostate carcionoma

Front 373

Most common tumor in women

Back 373

Leiomyoma (estrogen dependent)

Front 374

Most common tumor of infancy

Back 374

Hemangioma

Front 375

Most common tumor of the adrenal medulla (adults)

Back 375

Pheochomocytoma (benign)

Chromaffin cells (neural crest) release NE/E, DA
Associated with MEN II, III

Treatment: Phenoxybenzamine (irreversible alpha 1 and 2 blocker)

10% bilateral
10% malignant
10% extra-adrenal
10% calcify
10% kids
10% familial

Symptoms = Spells of the 5 Ps:

Pain (headache)
Pallor
Palpitations
Perspiration
Pressure (BP)

Front 376

Most common tumor of the adrenal medulla (children)

Back 376

Neuroblastoma (malignant)

Tumors along the sympathetic chain

HVA found in urine

N-Myc gene

Front 377

Most common type of Hodgkins

Back 377

Nodular sclerosis

(vs. Mixed celularity, lymphocytic predominance, lymphocytic depletion)

Front 378

Most common type of pituitary adenoma

Back 378

Prolactinoma

Front 379

Most common vasculitis

Back 379

Temporal arteritis

Risk of ipsilateral blindness due to thrombosis of opthalmic artery

Front 380

Most common viral encephalitis

Back 380

HSV

Front 381

Vitamin deficiency

Back 381

Folic acid

Body stores only a 3-4 month supply

Pregnant women at high risk

Front 382

Most frequent cause of Addison's disease

Back 382

AI (Adrenal insufficiency) is AI (autoimmune)

#1 Autoimmune
#2 Infection

Front 383

Most frequent cause of aneurysm, dissecting

Back 383

Hypertension

Front 384

Most frequent cause of aortic aneurysm, ascending

Back 384

Tertiary syphilis

Front 385

Most frequent cause of bacterial meningitis (adults)

Back 385

Streptococcus pneumoniae

Front 386

Most frequent cause of bacterial meningitis (elderly)

Back 386

Streptococcus pneumoniae

Front 387

Most frequent cause of bacterial meningitis (kids)

Back 387

Streptococcus pneumoniae

Neisseria meningitidis

Front 388

Most frequent cause of bacterial meningitis (newborns)

Back 388

Groub B streptococcus

Front 389

Most frequent cause of bacterial meningitis (newborns)

Back 389

Groub B streptococcus

Front 390

Most frequent cancers associated with AIDS

Back 390

Kaposi's sarcoma

Malignant lymphoma (non-Hodgkins)
*True of all immunodeficiency states

Front 391

Most frequent cause of congenital adrenal hyperplasia

Back 391

21-hydroxylase deficiency

Front 392

Most frequent cause of cretinism

Back 392

Iodine deficit (hypothyroidism)

Front 393

Most frequent cause of Cushing's syndrome

Back 393

#1 Corticosteroid therapy

#2 ACTH secretion by pituitary

Front 394

Most frequent cause of death in CML

Back 394

Blast crisis

Front 395

Most frequent cause of death in CML

Back 395

Blast crisis

Front 396

Most frequent cause of death in SLE

Back 396

Lupus nephropathy

Front 397

Most frequent cause of dementia

Back 397

#1 Alzheimer's
#2 Multi-infarct dementia

Front 398

Most frequent cause of DIC

Back 398

#1 Gram-negative sepsis

#2 Obstetric complications

#3 Cancer

#4 Burn trauma

Front 399

Most frequent cause of ejection click

Back 399

Aortic/pulmonic stenosis

Front 400

Most frequent cause of food poisoning

Back 400

Staph aureus

Front 401

Most frequent cause of glomerulonephritis

Back 401

IgA nephropathy (Berger's disease)

Front 402

Most frequent cause of epidural hematoma

Back 402

Rupture of middle meningeal artery

Front 403

Most frequent cause of subdural hematoma

Back 403

Bridging veins (due to trauma)

Front 404

Most frequent cause of hemochromatosis

Back 404

Multiple blood transfusions

Increased risk of CHF, hepatocellular carcinoma

Front 405

Most frequent cause of hepatic cirrhosis

Back 405

Alcohol

Front 406

Most frequent cause of hepatocellular carcinoma

Back 406

Cirrhotic liver

Often associated w/Hep B, C

Front 407

Most frequent cause of holosystolic murmur

Back 407

#1 VSD

#2 Tricuspid regurgitation

#3 Mitral regurgitation

Front 408

Most frequent cause of secondary hypertension

Back 408

Renal disease

Front 409

Most frequent cause of hypoparathyroidism

Back 409

Thyroidectomy

Front 410

Most frequent cause of hypopituitarism

Back 410

Adenoma

Front 411

Most frequent cause of infection in blood transfusions

Back 411

Hepatitis C

Front 412

Most frequent cause of infection in burn victims

Back 412

Pseudomonas

Front 413

Most frequent cause of leukemia (adults)

Back 413

AML

Front 414

Most frequent cause of machine-like murmur

Back 414

Persistent ductus arteriosus

Front 415

Most frequent cause of mental retardation

Back 415

#1 Down syndrome

#2 Fragile X

Front 416

Most frequent cause of MI

Back 416

Atherosclerosis

Front 417

Most frequent cause of mitral valve stenosis

Back 417

Rheumatic heart disease

Front 418

Most frequent cause of myocarditis

Back 418

Coxsackie B

Front 419

Most frequent cause of nephrotic syndrome (adults)

Back 419

Membranous glomerulonephritis

Front 420

Most frequent cause of nephrotic syndrome (kids)

Back 420

Minimal change disease

Assoiated w/infections and vaccinations

Treat w/corticosteroids

Front 421

Most frequent cause of opening snap

Back 421

Mitral stenosis

Front 422

Most frequent cause of osteomyelitis

Back 422

S. Aureus

> Streptococcus, Neisseria

Front 423

Most frequent cause of osteomyelitis in patient w/sickle cell disease

Back 423

Salmonella

Front 424

Most frequent cause of osteomyelitis with IV drug abusers and diabetics

Back 424

Pseudomonas

Front 425

Most frequent cause of acute pancreatitis

Back 425

Alcohol and Gallstones

Front 426

Most frequent cause of chronic pancreatitis in adults

Back 426

Alcohol

Front 427

Most frequent cause of chonic pancreatitis in children

Back 427

Cystic fibrosis

Front 428

Most frequent cause of peau d'orange

Back 428

Carcinoma of the breast

Front 429

Most frequent cause of PID

Back 429

Neisseria gonorrhoeae

Associated w/monoarticular arthritis

Front 430

Most frequent cause of hospital acquired pneumonia

Back 430

Klebsiella

Front 431

Most frequent cause of pneumonia in cystic fibrosis

Back 431

Pseudomonas aeruginosa

Front 432

Most frequent cause of pneumonia in burn infection

Back 432

Pseudomonas aeruginosa

Front 433

Most frequent cause of preventable blindness

Back 433

Chlamydia

Front 434

Most frequent cause of primary amenorrhea

Back 434

Turner's syndrome

Front 435

Most frequent cause of primary hyperaldosteronism

Back 435

Adenoma of adrenal cortex

Front 436

Most frequent cause of pulmonary hypertension

Back 436

COPD

Front 437

Most frequent cause of right heart failure due to a pulmonary cause

Back 437

Cor pulmonale

Front 438

Most frequent cause of sheehan's syndrome

Back 438

Postpartum pituitary infarction due to hemorrhage

Front 439

Most frequent cause of SIADH

Back 439

Small cell carcinoma of the lung

Front 440

Most frequent cause of UTI

Back 440

E. coli (50-80%)

Front 441

Most frequent cause of UTI in young women

Back 441

E. coli
and
Staphylococcus saprophyticus

Front 442

Sensitivity

Back 442

Sensitivity =

True positives
-------------
True positives + False negatives

Front 443

Specificity

Back 443

Specificity =

True negatives
------------------
True negatives + False positives

Front 444

Positive predictive value

Back 444

PPV =

True positives
----------------
True positives + False positives

Front 445

Negative predictive value

Back 445

NPV =

True negatives
-------------------
True negatives + False negatives

Front 446

Relative risk

Back 446

Relative risk (applies in prospective studies)

Exposed w/disease
---------------------
Total exposed

/

Unexposed w/disease
------------------------
Total unexposed

Front 447

Attributable risk

Back 447

Exposed w/disease
---------------------
Total exposed

-

Unexposed w/disease
------------------------
Total unexposed

Front 448

Hardy Weinberg equilibrium

Back 448

p^2 + 2pq + q^2 = 1

p+q = 1

Front 449

Henderson-Hasselbach equilibrium

Back 449

pH =
pKa + log [HCO3-]/0.03 PCO2

[H+] =
24 PCO2
-----------
[HCO3-]

Front 450

Volume of distribution

Back 450

Vd =

Amount of drug in the body
--------------------------------
Plasma drug concentration

Front 451

Clearance

Back 451

Cl =

Rate of elimination of the drug
-----------------------------------
Plasma drug concentration

Front 452

Half-life

Back 452

t 1/2 =

0.7 x Vd
---------
Clearance

Front 453

Loading dose

Back 453

LD =

Cp x Vd/F

Front 454

Maintenance dose

Back 454

MD =

Cp x CL/F

Front 455

Cardiac output

Back 455

CO = HR x SV

CO =

Rate of O2 consumption
-----------------------------
Arterial O2 - Venous O2

Front 456

Mean arterial pressure

Back 456

MAP = CO x TPR

MAP = 1/3 systolic + 2/3 diastolic

Front 457

Stroke volume

Back 457

SV =

End disatolic volume
-
End systolic volume

Front 458

Ejection fraction

Back 458

EF =

End diastolic volume
--------------------- x 100%
End systolic volume

Normally >55%

Front 459

Resistance

Back 459

R =

Driving pressure
-------------------
Flow


R =

8 x viscosity x length
------------------------
Pi x r^4

Front 460

Net filtration pressure

Back 460

Pnet =

net Hydrostatic P - net Osmotic P


Net ~ Capillary P - Interstitial P

Front 461

Glomerular filtration rate

Back 461

Inulin: GFR = UV / P

GFR = K[(Pgc-Pbs) - (Tgc-Tbs)]

U = Urine concentration
V = Urine flow rate
P = Plasma concentration

Front 462

Effective renal plasma flow

Back 462

PAH: ERPF = UV/P

Front 463

Renal blood flow

Back 463

RBF = RPF / 1-Hct

Front 464

Filtration fraction

Back 464

FF = GFR/RBF

Front 465

Free water clearance

Back 465

H2O clearance =

Urine volume - Osmole clearance

Front 466

Physiologic dead space

Back 466

Vd =

Vt x (PaCO2 - PeCO2)
--------------------------
PaCO2

PaCo2 = Arterial
PeCo2 = Expired CO2

Front 467

Vitamin A: Alternative name

Back 467

Retinol

Front 468

Vitamin B1: Alternative name

Back 468

Thiamine

Front 469

Vitamin B2: Alternative name

Back 469

Riboflavin

Front 470

Vitamin B3: Alternative name

Back 470

Niacin

Front 471

Vitamin B5: Alternative name

Back 471

Pantothenate

Front 472

Vitamin B6: Alternative name

Back 472

Pyridoxine

Front 473

Vitamin B12: Alternative name

Back 473

Cobalamin

Front 474

Night blindness

Dry skin

Back 474

Vitamin A deficiency

Front 475

Flu-like symptoms (arthralgia, fatigue, headache, sore throat)

Alopecia and other skin changes

Back 475

Vitamin A excess

Front 476

Vitamin A: Source

Back 476

Leafy vegetables

Front 477

Vitamin A: Function

Back 477

Constituent of visual pigments (retinal)

Front 478

Vitamin B1: Function

Back 478

COFACTOR

HMP shunt: Transketolase cofactor

As TPP (thiamine pyrophosphate), a cofactor for:
1. Branched chain AA dehydrogenase

2. Oxidative decarboxylation of Pyruvate and Alpha-ketoglutarate

Front 479

Vitamin B1: Deficiency

Back 479

BeriBeri (Ber1Ber1) and Wernike-Korsakoff syndrome
*Alcoholism
*Malnutrition

Dry beriberi:
Symmetrical muscle wasting
Polyneuritis

Wet beriberi:
High output cardiac failure
Edema

Front 480

High output cardiac failure

Edema

Back 480

Wet beriberi

Front 481

Vitamin B2: Function

Back 481

Oxidation, reduction yielding 2 ATP:
*FADH2 (oxidation, reduction)
*FMN

Front 482

Cheilosis (inflammation of the lips)

Corneal vascularization

Back 482

Vitamin B2 Deficiency

Front 483

Vitamin B3: Function

Back 483

Oxidation, reduction yielding 3 ATP:
*NAD
*NADP

Front 484

Niacin synthesis

Back 484

Made from tryptophan

REQUIRES vitamin B6

Front 485

Diarrhea

Dermatitis

Dementia

Back 485

The 3D's of pellagra

Vitamin D deficiency

Front 486

Causes of B3 deficiency

Back 486

INHer Car

INH (decreases vitamin B6)

Hartnup disease (tryptophan absorption)

Carcinoid syndrome (uses tryptophan to make serotonin)

Front 487

Dermatitis, Alopecia

Enteritis

Adrenal insufficiency

Back 487

Vitamin B5

No pantene? No hair (also true of vitamin A deficiency)

Front 488

Vitamin B5 function

Back 488

1. Pantothen-A-te is in Co-A
*CoA used for ACYL transfers

2. Component of fatty acid synthase

Front 489

Vitamin B6 function

Back 489

Pyridoxine--At the DOX, the NICE guy got THuGeD (THGD)

1. Required for NIACIN synthesis from tryptophan

2. Becomes pyridoxal phosphate (cofactor):
*Transamination (AST, ALT)
*Heme synthesis
*Glycogen phosphorylase
*Decarboxylations

Front 490

Hyperirritability
Convulsions
Peripheral neuropathy

Back 490

Vitamin B6 deficiency

Causes:
*INH
*Oral contraceptives

Front 491

Vitamin B12 function

Back 491

1. Cofactor for HOMOCYSTEINE METHYLTRANSFERASE
*Converts homocysteine --> Methionine
*Folate also takes part in this rxn

2. Cofactor for METHYLMALONYL-COA MUTASE
*Converts methylmalonyl-CoA --> Succinyl-CoA

Front 492

Macrocytic, megaloblastic anemia

Neurological symptoms

Back 492

B12 deficiency

Spinal cord demyelination:
*Changes in dorsal columns
*Changes in spinothalamic tract
*May be due to decreased methionine (unable to build myelin proteins) or excess methylmalonic acid (toxicity)

Primarily stored in liver (several years worth)

Causes:
*Malabsorption
*Lack of intrinsic factor
*Absence of terminal ileum (Crohn's)

Front 493

Most common VITAMIN deficiency in the US

Back 493

Folic acid

Front 494

Macrocytic, megaloblastic anemia

Back 494

Folic acid deficiency

No neurologic symptoms

Front 495

Folic acid source

Back 495

Leafy greens

FOLate from FOLiage
B12 from BUFFALO

Front 496

Folic acid supply

Back 496

Months

Front 497

Folic acid: Function

Back 497

As THF:

1. Participates in the conversion of HOMOCYSTEINE to METHIONINE

2. DNA, RNA synthesis (nitrogenous bases)

Front 498

Dermatitis

Enteritis

Back 498

Biotin deficiency

Causes:
1. Raw egg consumption: Avidin in egg whites AVIDly binds biotin

2. Antibiotics

Front 499

Biotin: Function

Back 499

PAM in the PM when making eggs

Carboxylations

P = Pyruvate --> Oxaloacetate
AM = Acetyl-CoA --> Malonyl-CoA
PM = Propional-CoA --> Methylmalonyl CoA

Front 500

Swollen gums

Bruising, anemia, poor wound healing

Back 500

Vitamin C deficiency (scurvy)

CDE:
Collagen --> Hydroxylation of proline and lysine

Dopamine-B-hydroxylase (converts DA to NE)

Electrons on iron (keeps it reduced for good absorption)

Front 501

Vitamin C function

Back 501

Collagen --> Hydroxylation of proline and lysine

Dopamine-B-hydroxylase (converts DA to NE)

Electrons on iron (keeps it reduced for good absorption)

Front 502

Vitamin D function

Back 502

D2 = Ergocalciferol (milk)
D3 = Cholecalciferol (sun)
*Get D3 standing next to a tree

Liver: D2/D3 --> 25-OHD (storage)
Kidney: 25-OHD --> 1,25-OHD (active)

Front 503

Hypocalcemic tetany: Nutritional cause

Back 503

Vitamin D deficiency

Front 504

Loss of appetite
Stupor

Back 504

Excess Vitamin D

Seen in sarcoidosis (converts vitamin D to active form)

Front 505

Vitamin E function

Back 505

Antioxidant

Front 506

Fragile erythrocytes

Neurodysfunction

Back 506

Vitamin E

"E is for erythrocytes"

Front 507

Vitamin K function

Back 507

Synthesized by INTESTINAL FLORA

K for Koagulation
K for Karboxylation

Catalyzed Gamma carboxylation of Glutamic acid residues on clotting factors 2, 7, 9, 10 + proteins C and S

Front 508

Increased PT: Nutritional cause

Back 508

Vitamin K deficiency

Causes:
*Neonate = Sterile intestines
*Adult antibiotic use

Front 509

Hair loss (axillary, facial pubic)

Hypogonadism

Delayed wound healing

Back 509

Zinc deficiency

Bone marrow transcription factor

Testosterone transcription factor

Alcohol dehydrogenase transcription factor

Front 510

Ethanol metabolism

Back 510

Ethanol --> Acetaldehyde --> Acetate

1. Alcohol dehydrogenase
*Fomepizole: Methanol, ethylene glycol antidote
*ZERO order kinetics (not concentration dependent)

2. Acetaldehyde dehydrogenase
*Disulfram

Both reactions produce NADH
NAD is the LIMITING REAGENT

Front 511

What alcohol processing enzyme has zero order kinetics?

Back 511

Alcohol dehydrogenase

Front 512

What is the limiting reagent in alcohol processing?

Back 512

NAD+

Front 513

Kwashiorkor

Back 513

Results from protein-deficient MEALS:
*Malnutrition
*Edema
*Anemia
*Liver (fatty)
*Swollen belly

Front 514

Marasmus

Back 514

Energy malnutrition

Tissue and muscle wasting
Loss of subcutaneous fat
Variable edema

Front 515

Ethanol hypoglycemia and fatty liver

Back 515

High NADH/NAD ratio causes:

1. Pyruvate to be shunted to lactate (inhibits gluconeogenesis)

2. OAA to be shunted to malate (inhibits gluconeogenesis)

3. Liver: Glycolysis intermediates to be shunted to FA synthesis (fatty liver)

GLUCONEOGENESIS INHIBITED

Front 516

Nucleosome

Back 516

2 each of H2, H3, H4, H5

Wrapped twice by DNA

Front 517

Heterochromatin

Back 517

Transcriptionally inactive

Condensed

Front 518

Euchromatin

Back 518

Transcriptionally active

Not as condensed

Front 519

Purines

Back 519

PURe As Gold --> A, G

Front 520

Pyrimidines

Back 520

CUT the PY --> C, U, T

1 ring
Uracil = RNA
Thymine = DNA

Front 521

High level of G-C bonds

Back 521

Higher melting point

G-C associations have 3 hydrogen bonds

Front 522

Which nucleotide has a ketone?

Back 522

Guanine

"GOLD key"

Front 523

Which nucleotide has a methyl?

Back 523

Thymine

"THYmine has a meTHYl"

Front 524

Amino acids necessary for purine synthesis

Back 524

Pure ppl make you GAG:

Glycine --> Icing
Aspartate --> Sparring/fighting
Glutamine --> Gluttony

Front 525

Antibiotics, antivirals and anti-fungals to avoid in pregnancy

Back 525

SAFE Moms Take Really Good Care

Sulfonamides --> Kernicterus
*Yellow like sulfer

Aminoglycosides --> Ototoxicity, teratogen

Fluoroquinolones --> Cartilage

Erythromycin (acute cholestatic hepatitis in mom) + clarithromycin (embryotoxic)

Metronidiazole--mutagenesis
*M&M

Tetracyclines--discolored teeth, inhibition of bone growth

Ribavirin -- teratogenic
*RSV, HCV

Griseofulvin--teratogenic
*Antifungal
*Also carcinogenic

Chloramphenicol--"chrome" (gray) baby
*Low URP-uridyl transferase in premies

Front 526

Oocyte development

Back 526

Primary oocytes are in PROPHASE 1

Secondary oocytes are in METAPHASE II

Primary oocytes become secondary oocytes @ovulation (leave prOphase to Ovulate)

Secondary oocytes become Ova w/sperm entry (leave METaphase when they MEET a sperm)

No tetrads formed until after ovulation

Front 527

I band

Back 527

Actin-only portion of the sarcomere

Shortens w/contraction

Front 528

H band

Back 528

Myosin only portion of the sarcomere

Shortens w/contraction

Front 529

A band

Back 529

Entire length of the myosin filament

Does NOT shorten w/contraction

Front 530

Sarcomere: Myosin measurements

Back 530

"My-son? HA!"

H band: Myosin only

A band: Entire myosin length (constant)
*A ~ ALL of the myosin

Front 531

Premature heart beats are stronger/weaker than on-time ones

Back 531

Weaker

Less time for filling --> decreased preload

Less time for Ca2+ in sarcoplasmic reticulum to get to RELEASE SITE

Front 532

Prevalence

Back 532

Prevalence =

Total cases in population at a given time
---------------------------------
Total population at risk

Front 533

Incidence

Back 533

Incidence =

New cases in population over a given period
-----------------------------------
Total population at risk for a new case

Front 534

Systematic error

Back 534

Reduced accuracy/validity

Front 535

Random error

Back 535

Reduced reliability/precision

Front 536

Selection bias

Back 536

Non-random assignment to a study group

Front 537

Recall bias

Back 537

Altered recall

Ex. Knowledge of presence of a disorder alters what is remembered

Front 538

Sampling bias

Back 538

Subjects are not representative to the general pop

Front 539

Late-look bias

Back 539

Information gathered at an inappropriately late time

Front 540

Procedure bias

Back 540

Subjects in different groups are not treated the same

Front 541

Positive/negative skew

Back 541

Wherever the tail is going

Positive = Positive tail
Mean > Median > Mode

Negative = Negative tail
Mean < Median < Mode

Front 542

Standard error of the mean

Back 542

Used to calculate CI

Standard deviation
-----------------------
(n)^1/2

Front 543

CI

Back 543

Mean +/- 1.96 (SE)

SE =
Standard deviation
-----------------------
(n)^1/2

Front 544

Reportable diseases

Back 544

Hep, Hep, Hep, Hooray, the SSSMMART CHICK is GONe

Hep A
Hep B
Hep C
HIV

Salmonella
Shigella
Syphilis
Measles
Mumps
AIDs
Rubella
TB

Chickenpox
Gonorrhea

Hep C and HIV might be exceptions in some states

Front 545

Leading causes of death 65+

Back 545

Heart disease
Cancer
Stroke
COPD
Pneumonia
Influenza

Front 546

Leading causes of death 25-64

Back 546

CHISSeling away at life

Cancer
Heart disease
Injuries
Suicide
Stroke

*#1 and #2 are reversed for the 65+ crowd

*Oldest group to feature injuries and suicide

Front 547

Leading causes of death 15-24

Back 547

I finished HS and went to a College House (I HS CH)

Injuries
Homicide
Suicide
Cancer
Heart disease

Injuries, homicide, suicide precede the top 2 for adults 25-64
Cancer
Heart disease

Front 548

Leading causes of death 1-14

Back 548

I have an ICCHH

Injuries
Cancer
Congenital anomalies
Homicide
Heart disease

Front 549

Leading causes of death in infancy

Back 549

CLoSe your mouth, MR
(CLS MR)

Congenital anomalies
Low birth weight/short gestation
SIDS
Maternal complications
RDS

Front 550

Therapeutic privilege

Back 550

Witholding info when disclosure would severely harm the patient or undermine decision-making capacity

Front 551

Usually required unless

Back 551

Usually required unless:

1. Married or otherwise emancipated

2. Emergency situation

3. Treating STDs, providing counsel or contraception

4. Medical care during pregnancy

5. Management of drug addiction

Front 552

APGAR score

Back 552

Evaluated at 1 minute and 5 minutes
*Each category: 0-2 points

Appearance
*Blue --> Pink trunk --> All pink

Pulse
*None --> <100 /> >100/min

Grimace
*None --> Grimace --> Grimace + cough

Activity
*Limp--> Some --> Active

Respiration
*None--> Irregular --> Regular

Front 553

Complications of low birth weight

Back 553

<2500 g

TIRNIP

Tiny tots

Infections

RDS

Necrotizing entercolitis
*No bacterial colonization ~ mucosal necrosis, esp in colon
*Possible perforation

Intraventricular hemorrhage

Persistent fetal circulation

Front 554

Motor milestone: Birth

Back 554

Rooting reflex

Front 555

Milestones: 3 mo

Back 555

3 things

Motor:
*Holds head up
*Moro reflex desappears

Social:
*Social smile

Front 556

Milestones: 4-5 mo

Back 556

Propping (and rolling)
People

Motor:
*Rolls front to back
*Sits when propped

Social:
*Recognizes peopl

Front 557

Milestones: 7-9 mo

Back 557

Seven - 4 S's

Sit
Scoots (or crawls)
Stranger anxiety
Spins around to see you (orients)

Motor:
*Sits alone
*Crawls

Social:
*Stranger anxiety
*Orients to voice

Front 558

Milestones: 12-15 mo

Back 558

12-14 mo: Babinski disappears

15 mo: Can walk, but doesn't want to YOU to (walk away)
*Walks
*Separation anxiety
*A few words

Front 559

Milestones: 3 years

Back 559

Lots of 3's

Motor:
*Stacks 9 blocks --> 3x3 years
*Rides tricycle --> 3 wheels
*Copies line or circle drawing

Social:
*Toilet training --> "Pee at 3"
*Core gender identity (2-3 yr)
*900 words
*Complete sentences

Front 560

Milestones: 4 years

Back 560

1. Can draw and play hopscotch
2. Can play w/others (even imaginary ones)
3. Can get ready for school (grooming)

Motor:
*Simple drawings (stick figure)
*Hops on 1 foot

Social:
*Parallel play (2-4)
*Cooperative play
*Imaginary friends
*Grooms, brushes teeth

Front 561

Milestones: 6-11 years

Back 561

Reading

Understands death
Conscience

Same-sex friends
Identification w/same-sex parent

Front 562

Milestones: Adolescence

Back 562

Boys ~ 13
Girls ~ 11

Abstract reasoning
Formation of personality

Front 563

Tanner stages

Back 563

1= Childhood

2= Pubic hair begins to develop
*Men: Testes
*Women: Breast tissue elevation

3 = Pubic hair darkens, curls
*Men: Penile length

4 =
Men: Penile width, glans development
Women: Raised areolae

5 = Adult
*Areolae no longer raised

Front 564

BMI

Back 564

Weight in kg
---------------
Height in m^2

< 18.5 = Underweight
> 30 = Obese

Front 565

Sleep stages

Back 565

BATS Drink Blood

Awake: High freq, low amp
BETA: Alert
ALPHA: Eyes closed

Sleep:
THETA waves: 5%

SLEEP spindles + K complex: 45%

DELTA: 25%
*Low freq, high amp

BETA: 25%
*Sawtooth waves
*Variable pulse, BP
*Occurs every 90 min
*Ach based -- REMACH 9000

Front 566

Xeroderma pigmentosum

Back 566

Defect in nucleotide excision repair system

Unable to repair thymidine dimers created by UV light

Front 567

HNPCC: Mutation type

Back 567

DNA mismatch repair system

Enzymes can tell old vs. new based on what has been methylated (old ones)

Front 568

Death cap mushroom poison

Back 568

Alpha-amantin

Inhibits RNA polymerase II (mrna)

Front 569

Prokaryotic vs. Eukaryotic ribosome

Back 569

PrOkaryotes: 30 + 50 = 70

Eukaryotes: 40 + 60 = 80
*Even

Front 570

Energetics of mRNA synthesis

Back 570

ATP = tRNA ACTIVATION (loading)
*2 phosphate bonds (AMP)

GTP = GRIPING (ribosome) and GOING
*1 GTP to bind A site
*1 GTP to translocate

= 4 Phosphate bonds per AA

Front 571

Rb and P53 prevent ___ to ___ transition

Back 571

G1 to S

Because after DNA replicates, division is imminent

Rb (13q mutation): Retinoblastoma
Osteosarcoma

p53 (17p mutation):
Most human cancers
Li-Fraumeni syndrome
*Sarcoma before 45 + cancer under 45 (or sarcoma) in a first degree relative

Front 572

I cell disease

Back 572

Often fatal in childhood

In GOLGI, failure of addition of mannose-6-phosphate to lysosome proteins

Lysosomal proteins secreted outside cell...

Coarse facial features
Clouded cornea
Restricted joint movement (inflammation)

Front 573

Drugs that act on microtubules

Back 573

Mebendazole/thiabendazole (antihelminthic)

Paclitaxel (Taxol) --> Inhibits tubule breakdown

Griseofulvin (anti-fungal) --> Fungal cell wall

Vincristine/Vinblastine --> Inhibits microtubule formation

Colchicine (anti-gout) inhibits WBC taxis

Front 574

Kartagener's syndrome defect

Back 574

Dynein arm

Infertility
Bronchiectasis
Recurrent sinusitis
Situs invertus

Front 575

Actin and myosin

Back 575

MAC'kin the MUSCLE

Microvilli
Adherens junctions
Cytokinesis

Muscle contraction

Front 576

Intermediate filaments

Back 576

DC VeGaN
*Progressively squishier

Desmin --> Muscle
Cytokeratin --> Epithelial cells

Vinmentin --> Connective tissue
GFAP --> Neuroglia
Neurofilaments --> Neurons

Front 577

Collagen

Back 577

Be So Totally Cool, Read Baby Books

Collagen I (90%): Bone, skin, tendon

Collagen II: Cartilage

Collagen III: Reticulin--Blood vessels
*Also, baby ~ uterus, fetal tissue

Collagen IV: Basement membrane or basal lamina
*Glomerulus, lung, lens

Front 578

Collagen synthesis

Back 578

Pre-procollagen = Singles
Procollagen = Unmodified triple
Tropocollagen = Trimmed triple
Collagen = Cross-linked triple

RER:
1. Alpha chains synthesized
2. Hydroxylation: Proline, lysine
*VITAMIN C
3. Glycosylation: Lysines
4. Triple helix formation
5. Secretion

Outside cell:

6. Cleavage of terminal regions
7. Cross-linking: Lysine, hydroxylysine
*Lysyl oxidase

Front 579

Ehlers Danlos

Back 579

Faulty collagen synthesis (no X-linking)

Type III usually affected
*Blood vessel instability (bleeder)
*Berry aneurysms
*Stretchy skin
*Hyperextensible joints

Front 580

Malate-aspartate shuttle

Back 580

Heart and liver

32 ATP

Front 581

Glycerol-3-phosphate shuttle

Back 581

Muscle

30 ATP

Front 582

What transfers methyl units?

Back 582

S-adenosyl-methionine (SAM)

ATP + Methionine --> SAM

Front 583

NADPH: Functions

Back 583

Anabolic processes

P-450 activation

Respiratory burst (NADPH oxidase)

Front 584

Hexokinase vs. Glucokinase

Back 584

Both catalyze:
Glucose --> Glucose-6-P

Hexokinase: Ubiquitous
*High affinity
*Low capacity
*G6P feedback inhibition

gLucokinase: Liver and B cells of pancreas
*Phosphorylates glucose after a meal to SEQUESTER it in the liver
*Low affinity --> NO FEEDBACK
*High capacity
*Induced by insulin

Front 585

What regulates hexokinase?

Back 585

(-) Glucose 6P

Glucose --> Glucose 6-P

Front 586

What regulates phosphofructokinase-1?

Back 586

(+) Fructose 2,6 BP (PFK-2--fed state)
(-) ATP, Citrate

Fructose-6P --> Fructose 1,6 BP

Front 587

What regulates pyruvate kinase?

Back 587

(+) Fructose 1,6 BP
(-) ATP, alanine

PEP --> Pyruvate

Front 588

What regulates pyruvate dehydrogenase?

Back 588

(-) ATP, Acetyl CoA, NADH

Pyruvate --> Acetyl CoA

Front 589

Glycolytic enzyme deficiency

Back 589

Hemolytic anemia from Na/K pump stalling in RBC

Pyruvate kinase

Front 590

Pyruvate dehydrogenase complex

Back 590

B1, B2, B3, B5
+
Lipoic acid

Front 591

Arsenic

Back 591

Vomiting
Rice water stools
Garlic breath

Front 592

Pyruvate dehydrogenase deficiency

Back 592

Lysine + Leucine (only purely ketogenic AAs)

Front 593

TCA cycle

Back 593

Citrate Is Kreb's Starting Substrate for Making Oxaloacetate

Per cycle (2x for glucose)
3 NADH, 1 FADH, 1 GTP
2 CO2

Isocitrate --> CO2, NADH
Alpha keto --> CO2, NADH
Succinyl CoA --> GTP, CoA
Succinate --> FADH2
Malate --> NADH

Front 594

Gluconeogenesis enzymes

Back 594

PPFG: Pathway Produces Fresh Glucose

Pyruvate carboxylase
*Pyruvate --> OAA
*Happens w/backup of TCA cycle (high levels of Acetyl-CoA)
*Requires ATP -- no GNG w/o E to spare
*Requires BIOTIN

PEP carboxykinase
*OAA --> PEP
*REQUIRES GTP (2nd check of energy to spare)

Fructose 1,6 bisphosphatase
*Fructose 1,6 BP --> Fructose 6P

Glucose 6 phosphatase
*Glucose 6P --> Glucose

Front 595

G6PD

Back 595

More prevalent among blacks
X-linked recessive

Heinz bodies: Hb precipitates within RBCs

Bite cells: Phagocytes remove Heinz bodies from RBCs

Cell does a poor job of keeping glutathione reduced

Oxidative damage to RBCs --> Hemolytic anemia

Common causes:
*Fava beans
*TB drugs
*Sulfonamides, primaquine

Front 596

Fructose intolerance

Back 596

AR deficiency of ALDOLASE B

Buildup of fructose-1-phosphate
*Steals/incapacitates tons of phosphate: as a result, inhibition of glucose pathways (glycogenolysis, gluconeogenesis)

Symptoms:
*Vomiting
*Hypoglycemia
*Cirrhosis, jaundice

Treatment: Avoid fructose and SUCROSE (fructose + glucose)

Front 597

Essential fructosuria

Back 597

Defect in FRUCTOKINASE
1st enzyme in fructose pathway

Fructose does NOT enter cells --> only seen in blood in urine

Benign, asymptomatic condition

Front 598

Galactosemia

Back 598

AR absence of GALACTOSE-1-P URIDYLTRANSFERASE

Pathway backup --> Toxic substances including galactitol (toxic)

Hepatosplenomegaly
CATARACTS (Gonna "lack" seeing much")
MENTAL RETARDATION

Treatment: Exclude galactose + lactose (glucose + galactose) from diet

Front 599

Galactokinase deficiency

Back 599

Causes galactosemia, galactosuria

Galactitol accumulation --> Toxicity, but not as severe as Galactosemia

Front 600

Acidic amino acids

Back 600

The "tates"

Aspartate
Glutamate

Front 601

Basic amino acids

Back 601

Histidine
Lysine
Arginine

HISTIDINE LYS (ARG)! It's not positive/basic in the body

That's why LYSINE and ARGININE are the dominant AAs in histones (+ charge to attract - DNA).

Front 602

Gluconeogenic AND Ketogenic essential amino acids

Back 602

PITT (everybody likes him)

They all end in "ine"

Phenylalanine
Isoleucine
Tyrosine
Threonine

Front 603

Gluconeogenic essential amino acids

Back 603

The most wasteful in terms of E: HAM-V

Or: HAm for growing kids
*Histidine, arginine needed during periods of growth

Histidine
Arginine
Methionine
Valine

Front 604

Urea cycle

Back 604

Excretes excess nitrogen

Ordinarily, Careless Crappers Are Also Frivolous About Urination

Ornithine + Carbamoyl phosphate (i)
*Acted on by Ornithine transcarbamoylase
*Happens in mitochondrion (all other steps = cytoplasm)

Citrulline + Aspartate (i)
*Acted on by arginossucinate synthetase

Arginosuccinate
*Acted on by arginosuccinate synthetase

Fumarate (o) + Arginine
*Acted on by arginase

Urea (o)
*Made from arginine + H2O (via arginase)

Front 605

Derivatives of phenylalanine

Back 605

Pound The Darn Donut No Earlier Than Mid-morning

Pound = Phenylalanine
The = Tyrosine --> THYROXIN
Darn = Dopa --> MELANIN
Donut = Dopamine
No = NE
Earlier = Epinephrine
Than = THYROXINE
Mid-morning = MELANININ

Front 606

Phenylketonuria

Back 606

Incidence: 1/10,000
*Screened for at birth

Problem w/Phe --> Tyrosine either:
1. Phe hydroxylase defect
2. THB defect (reduces Phe using Phe hydroxylase as catalyst)

Results:
*Tyrosine becomes essential
*Phe buildup --> Phenylketones in urine

Findings:
*Musty body odor --> AROMATIC defect
*Retardation, eczema --> Phe buildup
*Growth retardation --> Thyroxine
*Fair skin --> Melanin

Front 607

Alkaptonuria

Back 607

A.k.a. Ochonosis

Dark urine --> Like peeing "KAPTAN" (morgan)

The captain was a TYRant (tyrosine)

Congenital deficiency of HOMOGENTISIC ACID OXIDASE

Used to degrade TYROSINE

Buildup of alkapton bodies:
*Urinary excretion (urine turns black)
*Joint deposition (dark CT, +/- arthralgia)

Considered a benign disease

Front 608

Albinism

Back 608

Congenital deficiency of either:
1. Tyrosinase (AR): Tyr --> Melanin
2. Defective tyrosine transporters

Possible mechanism: Poor neural crest migration

Increased risk of skin cancer
Variable inheritance (locus heterogeneity)

Front 609

Homocystinuria

Back 609

Homocysteine has 2 breakdown pathways:
1. Cystathionine synthase
*Homocysteine --> Cystathionine --> Cysteine
*Requires B6

2. Homocysteine methyltransferase
*Homocysteine --> Methionine
*Requires B12/folate

**3 forms of disease:**

1. Deficient cystathionine synthase
*Decrease dietary MET, increase CYS
*Increase dietary B12/folate

2. Inefficient cystathionine synthase (doesn't bind B6 well)
*Increase dietary B6

3. Deficient homocysteine
methyltransferase

Result:
*Excess homocysteine
*Cysteine becomes essential
*MENTAL RETARDATION
*Bone problems: Tall stature, osteoporosis, kyphosis
*Vessel problems (stroke, MI)
*Lens subluxation (down and in)

Front 610

Cystinuria

Back 610

Common 1/7000

Inherited defect of RENAL TUBULAR ABSORPTION in PCT

+ AA Transporter (NH3+): Histidine, lysine, arginine, ornithine, CYSTINE
*Excess cystine in urine

Complications: Cystine kidney STONES
*Treat w/acetazolamide to alkalinize urine, prevent precipitation

Cystine = 2 cysteines connected by disulfide bond

Front 611

Stones and pH

Back 611

If it has a C in it, precipitates in ACIDIC urine

Ca2+
Uric acid
Cysteine

Front 612

Maple syrup urine disease

Back 612

Decreased alpha-KETOACID DEHYDROGENASE

Blocked degradation of branched amino acids
*I Love Vermont maple syrup: Isoleu, LEU (most buildup), Val
*Urine smells like maple syrup

Complications:
*Mental retardation
*CNS defects
*Death

Front 613

Maple syrup urine disease

Back 613

Decreased alpha-KETOACID DEHYDROGENASE

Blocked degradation of branched amino acids
*I Love Vermont maple syrup: Isoleu, LEU (most buildup), Val
*Urine smells like maple syrup

Complications:
*Mental retardation
*CNS defects
*Death

Front 614

Lesch-Nyhan

Back 614

X-linked recessive
HGPRT: "He's got purine recovery trouble"

Absence of HGPRT--> purine salvage
*Hypoxanthine --> IMP
*Guanine --> GMP

Result: Excess uric acid production

Results:
Mental: Retardation, self-mutilation, aggression (Lesch I lay a hand on you), choreoathetosis

Urinary: Hyperuricemia, gout

Front 615

Adenosine deaminase deficiency

Back 615

Adenosine --> Inosine
*Related to purine breakdown pathway
*Backup ~ excess ATP, dATP

Excess ATP, dATP causes feedback inhibition of RIBONUCLEOTIDE REDUCTASE
*Less new nucleotides made for DNA syn

*Rapidly multiplying tissues like marrow are affected --> Decreased LYMPHOCYTE COUNT (SCID--B and T cells)

Front 616

Insulin

Back 616

DEphosphorylates glycogen synthatse

Required for skeletal MUSCLE and ADIPOSE uptake of glucose

Synthesized in pancreatic BETA cells (buh-bye, glucose) from pro-insulin
*By product = C-PEPTIDE

Effects:
1. Glucose transport
2. Glycogen/TG/Protein synthesis
3. Na RETENTION (kidneys)
*Concurrent cellular UPTAKE of K+ (to match increased extracellular Na_)

Front 617

GLUT 1 Transporter

Back 617

RBCs
Brain

Not responsive to insulin

Front 618

GLUT 2 Transporter

Back 618

Bidirectional
Things which sample (islet), reabsorb (kidney), absorb (GI) or produce (liver) glucose

B islet cells
Liver
Kidney
GI enterocytes (blood side)

Not Insulin responsive

Front 619

GLUT 4 Transporter

Back 619

Muscle
Adipose

INSULIN RESPONSIVE

Front 620

Things which don't need insulin for glucose intake

Back 620

BRICK Layer

Brain
RBCs
Intestine
Cornea
Kidney

Liver

Front 621

Von Geirke's Disease

Back 621

Type 1 glycogen storage disease

Problem with
GLUCOSE 6 PHOSPHATASE

1. No gluconeogenesis

2. G1P from glycogen phosphorylase gets stuck at G6P

3.Glucose from limit dextran metabolism (debranching enz) and lysosomal acid maltase pathway can be trapped if phosphorylated by Glucokinase

Poor delivery to tissues:
*Severe hypoglycemia
*Increased blood lactate

Backup of glycogen in liver: hepatomegaly

Front 622

Pompe's Disease

Back 622

Deficiency of LYSOSOMAL ACID MALTASE (1,4 glucosidase)
*POMPOUS: the VIP/fast track enzyme

Trashes the PUMP
*Heart and other muscle --> Cardiomegaly, weakness
*Liver damage

Front 623

Cori's disease

Back 623

Deficiency of DEBRANCHING enzyme

Like mild Von Geirke:

Mild hypoglycemia
*But NORMAL blood lactate
*But gluconeogenesis intact

Some glycogen buildup, hepatomegal

Front 624

McArdle's disease

Back 624

Deficiency of GLYCOGEN PHOSPHORYLASE in skeletal MUSCLE

Increased glycogen in muscle
Strenuous exercise: Cramps, myoglobinuria

Front 625

Lysosomal storage disease: Tay sachs

Back 625

*AR deficiency of HeXosaminidase A (Tay SaX)

GM2 ganglioside -> GM3 -> glucocerebroside

Neural degeneration
CHERRIES AND ONIONS:
*Cherry red spot
*Onion skin lysosomes

Front 626

Lysosomal storage disease: Fabry's

Back 626

F = Female chromosome transmission
A = Alpha galactosidase
B = Blood vessels (CV, renal)
R = RASH (angiokeratoma)
Y = 3 lines (Ceramide TRIhexoside)

X-RECESSIVE deficiency of ALPHA-GALACTOSIDASE A

Ceramide trihexoside --> Glucocerebroside

Vascular issues leading to:
*Cardiovascular, renal disease
*Peripheral neuropathy
*ANGIOKERATOMA (unique)

Front 627

Gaucher's

Back 627

AR deficiency of B-GLUCOCEREBROSIDASE

Gluco cerebroside --> Ceramide

OUCHER'S disease:
*Aseptic necrosis of femur, bone crises
*Macrophages = Crumpled tissue paper

Front 628

Neimann-Pick

Back 628

AR deficiency of SPHINGOMYELINASE
*"Noman picks his nose w/his sphinger"

Spingomyelin --> Ceramide

A lot like Tay-Sachs:
*Neurodegeneration
*CHERRY red spot
*FOAM cells

Cherries + Onions (T-S) vs.
CHERRIES + WHIPPED CREAM (which would you PICK?)

Front 629

Metachromic leukodystrophy

Back 629

AR deficiency of Arylsulfatase A
*Sounds like ARICEPT

Sulfatides/Cerebroside sulfate --> Galactocerebroside

DEMENTIA
Peripheral neuropathy (DEMYELINATION) --> Ataxia

Front 630

Krabbe's

Back 630

AR deficiency of Galactocerebrosidase

Galactocerebroside --> Ceramide

"A slow Krabbe w/little eyes"

Peripheral neuropathy
DEVELOPMENTAL DELAY
OPTIC ATROPHY
GLOBOID CELLS (like eyes)

Front 631

Lysosomal storage dieases: Mucopolysaccharidoses (2)

Back 631

Both cause buildup of heparan sulfate, dermatan sulfate

Hurler's syndrome: AR
*Alpha-L-iduronase
*Gargoyle on a ledge (trying to get fresh air) that can't see (clouding)...hopefully won't HURL him/herself off
*Gargoyle face
*Airway obstruction
*Corneal clouding
*Developmental delay

Hunter's syndrome: XR
*Iduronate sulfatase
*Mild Hunter's but NO CORNEAL CLOUDING
*Good HUNTERS need to see clearly
*AGGRESSIVE BEHAVIOR

*Lesch-Nyhan and Hunter's are XR diseases of developmental delay and aggression

Front 632

What brings Acetyl-CoA out of the mitochondrion for FA synthesis?

Back 632

Citrate shuttle

SYtrate = Synthesis

Front 633

What brings Acyl-CoA (long chain Fatty acids) into the mitochondrion for continued FA breakdown?

Back 633

Carnitine shuttle

CARnitine = CARnage of fatty acids

Carnitine deficiency = Inability to utilize LCFAs + toxic accumulation

Front 634

Ketone bodies

Back 634

ACETOACETATE
B-HYDROXYBUTYRATE

Made from HMG-CoA in liver
Acetyl-CoA -> Acetoacetyl-CoA -> HMG-CoA

Production stimulated by shut-down of TCA cycle (depletion of **OAA**)
1. Starvation
2. Diabetic ketoacidosis
3. Alcohol-related NADH (shunts OAA to malate)

Breath smells fruity (acetone)

Front 635

Urine test for ketones does not detect...

Back 635

B-hydroxybutyrate

Front 636

Rate limiting step of cholesterol synthesi

Back 636

HMG-CoA reductase

Inhibited by statins

Front 637

HDL

Back 637

Mediates cholesterol transport from periphery to liver

Acts as a repository for Apo C-II and Apo E
*Gives ApoE and C-II to chylomicrons and VLDL
*Takes C-II from IDL
*Takes ApoE from LDL

Secreted from both liver AND intestine

Front 638

B-100

Back 638

Lipoproteins originating from liver
(chylomicrons have B-48 for secretion)

Aids in VLDL secretion
Binds LDL receptor (even better w/ApoE)

VLDL
IDL
LDL

Front 639

C-II

Back 639

COFACTOR for LPL

TG delivery:

Chylomicrons
VLDL

Front 640

Signs of high cholesterol

Back 640

AAX

Caused by excess LDL

Atherosclerosis

Arcus cornae --> White or gray opaque ring in the corneal margin

Xanthomas --> Yellowish cholesterol deposits
*Cholesterol-laden histiocytes
*Can deposit in tendons

Front 641

Signs of high triglycerides

Back 641

LEPtin

Lipema retinalis (>2000)
*Excess chylomicrons
*Veins and arteries of the retina appear milky

ERUPTIVE xanthomas (>2000)
*Excess chylomicrons

Pancreatitis (>1000)
*Excess VLDL or Chylomicrons

Front 642

Hyperchylomicronemia

Back 642

Excess chylomicrons

C-II/LPL reaction not working well:
*LPL deficiency
*Altered C-II

HYPER-TRIGLYCERIDE symptoms
*Lipemia retinalis, Eruptive xanthoma, Pancreatitis

Cholesterol also elevated

Front 643

Hypercholesterolemia

(Type 2a familial dyslipidemia)

Back 643

Excess LDL

Decreased LDL receptors

Elevated cholesterol
*Arcus senilis/corneae
*Atherosclerosis
*Xanthomas

Front 644

Hypertriglyceridemia

(Type 4 familial dyslipidemia

Back 644

Excess VLDL due to liver overproduction

Elevated TG's
*Pancreatitis

Front 645

Heme synthesis

Back 645

Succinyl-CoA + Glycine --> ALA
*ALA synthase
*Requires B6

ALA --> Porphobilinogen
*ALA dehydratase
*Inhibited by LEAD

Porphobilinogen ->-> Pre-uroporphyrinogen
*Porphobilinogen deaminase
*ACUTE INTERMITTENT PORPHYRIA

Uroporphyrinogen III --> Co-pro-porphyrinogen
*Uroporphyrinogen decarboxylase
*PORPHYRIA CUTANEA TARDA

Protoporphyrin + Fe2+ --> Heme
*Ferrochelatase
*Inhibited by LEAD

Front 646

Lead poisoning

Back 646

1. Inhibits ALA DEHYDRATASE
*ALA ->-> Porphobilinogen
*ALA buildup

2. Inhibits FERROCHELATASE *Protoporphyrin + Fe2+ --> Heme
*CO-PRO-PORPHYRIN buildup

Front 647

Precipitated by drugs

Painful abdomen

Polyneuropathy

Pink urine

Psychological disturbances

Back 647

Acute intermittent porphyria

Front 648

Imprinting

Back 648

Differences in phenotype exist depending on which parent the gene cam from

AngelMan --> Maternal deletion
Prader-Willi --> Paternal deletion

Front 649

Adult PKD

Back 649

90% are due to AD mutation of APKD1 (chromosome 16--legal adult?)
*Juvenile form is recessive

A = ANEURYSMS (berry)
P = Prolapse (mitral valve)
K = Kidney failure (pain, hematuria, HTN)
D = Dominant inheritance
1 = Liver disease (also polycystic)

ALWAYS BILATERAL

Large cysts --> Massive enlargement of kidneys

Front 650

FAP

Back 650

FAP = Familial ADENOMATOUS POLYPOSIS

APC gene --> ADENOMATOUS POLYPOSIS of the colon

5 letters in polyp --> Chromosome 5q
*Learn the 'APCs' when you're 5

Defect in MISMATCH REPAIR gene
*Dominant phenotype (assume 100% 2nd hit)

COLON becomes covered in polyps AFTER puberty --> Progression to CRC unless resected
*Rectum always involved

Gardner's syndrome: FAP +
1. Osseous and soft tissue tumors
2. Retinal hyperplasia

Turcot's Syndrome: FAP + Glioblastoma

Front 651

Familial hypercholesterolemia: Genetics

Back 651

AD mutation in LDL receptor
(absent, defective)

Heterozygote (1/500): Cholesterol over 300

Homozygote: Cholesterol over 700
*Tendon xanthomas (Achilles)
*MI may develop before age 20

Front 652

Huntingtons

Back 652

AD mutation of chromosome 4
*Hunting 4 food

Triplet repeat disorder (CAG)
*Anticipation

Caudate atrophy
Decreased GABA and Ach --> GAch it's bad

Manifests between 20 and 50
*Depression
*Progressive dementia
*Choreiform movements

Front 653

Marfan

Back 653

AD fibrillin gene mutation

Ocular: Subluxation of lenses

Skeletal abnormalities
*Tall w/long extremities
*Pectus excavatum
*Hyperextensive joints
*Arachnodactyly

Cardiovascular:
*CYSTIC MEDIAL NECROSIS of aorta --> Dissecting aneurysm
*Floppy mitral valve
*Aortic regurgitation as a late complication

Front 654

Neurofibromatosis 1

Back 654

a.k.a. Von Recklinghausen's disease
*Long name: LONG arm of chromosome 17(q)
*17 letters in Von R

AD mutation

"Scalding coffee"
*KyphoSCOLIOSIS
*Cafe au lait spots

Tumors: PALON
*Pheos
*All tumors (inc. skin fibromas)
*Lisch nodules (pigmented iris hamartomas)
*Optic gliomas
*Neural tumors

Front 655

Neurofibromatosis 2

Back 655

AD mutation of chromosome 22q

2 senses:
*Hearing: Bilateral acoustic neuroma (schwannoma)
*Eyes: Juvenile cataracts

Front 656

Tuberous sclerosis

Back 656

AD mutation w/incomplete penetrance, variable penetration

White to green while in the CAR:
*Facial angiofibroma
*Ash leaf spots (depigmented skin)
*Shagreen patch (orange peel skin)
*Other skin lesions (facial adenoma sebaceum)

*Cardiac rhabdomyoma
*Astrocytoma
*Renal angiomyolipomas

Front 657

VHL

Back 657

AD mutation of chromosome 3 (3 parts to name)
HEMANGIO, HALF

Hemangioblastomas (retina, brain--cerebellum, medulla)

Half develop bilateral renal cell carcinomas

Front 658

Cystic fibrosis

Back 658

AR defect in CFTR gene
*Most common lethal genetic disease of Caucasians

Chromosome 7 deletion of Phe 508
*508 area code when I was 7

CFTR is a 2 way Cl- channel
*Secretes Cl- in lungs, GI
*Absorbs Cl- from sweat
*Cl- sweat test is diagnostic

Thick mucus that plugs:

*LUNGS --> Pseudomonas, S. aureus, chronic bronchitis, bronchiectasis, meconium ileus

*PANCREAS --> Insufficiency (malabsorption, steatorrhea), fat soluble vitamin deficiencies

*LIVER

Infertility in males: Bilateral agenesis of vas deferens

Treatment: N-acetylCYSTeine to loosen mucous plugs (also an antidote for aspirin OD)

Front 659

X-linked recessive diseases

Back 659

Be Wise, Fools GOLD Heeds False Hope

Bruton's agammaglobulinemia
*BTK gene; no B lymphocytes

Wiskott-Aldrich syndrome
*Low IgM, high IgA

Fragile X
*FMR1 gene; MR, anticipation

G6PD
*Poor glutathione function

Ocular albinism
*Eye lacks melanin pigment

Lesch-Nyhan syndrome
*Collagen 3

Duchennes
*Dystrophin gene deletion

Hemophilia A and B
*Hemophilia A = Factor 8
*Hemophilia B = Factor 9

Fabry's disease
*Alpha-galactosidase A def --> Ceramide trihexoside

Hunter's syndrome
*Iduronate sulfatase def --> Heparan, dermatan

Front 660

Duchenne's

Back 660

*XR
*Frame-shift mutation causing deletion of dystrophin

Accelerated muscle breakdown
*Onset before 5 years of age

1st = Pelvic girdle muscles
*Gower's maneuver (using upper extremities to stand)

Later: Superior muscles, cardiomyopathy

Pseudohypertrophy of calf muscle
*Fibrofatty replacement

Diagnosis:
**CPK**
**MUSCLE BIOPSY**

Front 661

Becker's

Back 661

XR

Mutated dystrophin gene

Less severe than Duchenne's

Front 662

Fragile X

Back 662

XR defect

Aberrant METHYLATION, expression of FMR1
*Chromosome becomes fragile
*Triplet repeat: CGG
*Expansion in females

2nd most common cause of genetic mental retardation (DS = #1)

FragileX = eXtra-large testes, jaw, ears

Association w/autism

Front 663

Trinucleotide repeat diseases

Back 663

Try HUNTING for MY fried EXX

Huntingtons
Myotonic dystrophy
Friedrich's ataxia
Fragile X

+/- Anticipation

Front 664

Downs Syndrome

Back 664

Downs ~ Drinking age (21)

1/700 (Most common chromosomal disorder)

Increases w/maternal age
*95% Nondisjunction
*4% Robertsonian translocation
*1% Mosaicism

Decreased alpha fetoprotein
Decreased Beta-HCG
Nuchal translucency

Life expectancy: 45-50 years

ASSOCIATIONS:
*ALL, AML
*Alzheimer's disease > age 35
*Duodenal atresia (double bubble)
*Hirschprung's diease

Mental retardation (most common cause)

Head:
*Flat facial profile
*Epicanthal folds

Congenital heart defects: ASD
*Endocardial cushion defects

Hands: Simian crease
Feet: Gap between 1st two toes

Front 665

Edward's Syndrome

Back 665

Edwards ~ Election age (18)

1/8000

Increased risk w/maternal age

No prenatal screening

Life expectancy < 1 year
Severe MR

Low set ears + small jaw

Heart defects

Rocker bottom feet

Front 666

Patau's syndrome

Back 666

Patau ~ Puberty age (13)

1/15,000

Increased risk w/maternal age

No prenatal screening

Life expectancy < 1 year
Severe MR

Holoprosencephaly
Small eyes and cleft palate
Polydactyly
Heart defects
Rocker bottom feet

Front 667

Cri-du-chat

Back 667

Deletion of short (p) arm of chromosome 5

Severe MR --> Cat-like cry
Microcephaly --> Cat-size head
Epicanthal folds --> Cat-like eyes

Cardiac abnormalities

Front 668

22q11

Back 668

CATCH 22

Cleft palate
Abnormal facies
Thymic aplasia --> T-cell deficiency
Cardiac defects
Hypocalcemia (Parathyroid)

DiGeorge: THC --> Thymic, parathyroid (hypocalcemia), cardiac defects

Velocardiofacial: CAC--> Cleft palate, abnormal facies, cardiac

Front 669

Surface ectoderm derivatives

Back 669

Adenohypophysis (anterior pituitary)

Everything exposed to air:
*Epidermis
*Lens of eye
*Epithelial linings of eye, ear, nose

Front 670

Surface ectoderm derivatives

Back 670

Adenohypophysis (anterior pituitary)

Everything exposed to air:
*Epidermis
*Lens of eye
*Epithelial linings of eye, ear, nose

Front 671

Neuroectoderm

Back 671

Neurohypophysis (posterior pituitary)

CNS neurons
Oligodendrocytes
Astrocytes
Ependymal cells
Pineal gland

Front 672

Neural crest derivatives

Back 672

ABCCDE
LMOP

ANS + Schwann cells
Bones of the skull
Parafollicular C cells (thyroid)
DRG
Enterochromaffin + Chromaffin cells

Laryngeal cartilage
Melanocytes
Odontoblasts
Pia (and arachnoid)

Front 673

Endoderm derivatives

Back 673

Gut tube epithelium and derivatives

Lungs
Liver
Pancreas
Thymus
Thyroid (Follicular cells)
Parathyroid

Front 674

Mesoderm

Back 674

ABCD SLUM

Adrenal cortex
Bone, blood
Cardiovascular, CT
Dura mater

Spleen
Lymphatics
Urogenital structures
Muscle

Front 675

Most common mesodermal defects

Back 675

VACTERL

Vertebral defect
Anal atresia
Cardiac defects
Tracheo-Esophageal fistula
Renal defects
Limb defects

Front 676

Tobacco during pregnancy

Back 676

Pre-term labor
Placental problems
ADHD

Front 677

Alcohol during pregnancy

Back 677

#1 cause of congenital malformations in US

May involve migration errors

HHeLL =
*Head and heart
*Limb and lung

Head = Retardation, Microcephaly, Facial abnormalities

Heart = Fistulas
Lung = Fistulas
Limb = Dislocation

Front 678

Twinning

Back 678

Each fetus will always have its own amniotic sac

Front 679

Fetal component of placenta

Back 679

Chorionic villi

Outer layer = Syncytiotrophoblast
*Secretes hCG

Inner layer = Cytotrophoblast

Front 680

Bulbus cordis

Back 680

Smooth parts of left and right ventricle

Front 681

Primitive ventricle, primitive atrium

Back 681

Trabeculated parts of left and right ventricle/atrium, respectively

Front 682

Right horn of sinus venosus

Back 682

Smooth parts of right atrium (and left atrium)

Front 683

Fetal erythropoiesis

Back 683

BSLY --> BeaSLY

Bone marrow: 28+
Spleen: 9-28
Liver: 6-30
Yolk sac: 3-8

Front 684

Foramen ovale closure

Back 684

1st breath: Resistance of pulmonary vasculature DECREASES --> Increased flow through lungs and into LA --> Increased LA pressure

Foramen ovale closes

Front 685

Umbilical vein becomes

Back 685

Ligamentum teres hepatis

Hepatis --> Goes to liver region
*Umbilicus to portal vein + ductus venosus

Contained in falciform ligamen

Front 686

Ductus venosus becomes

Back 686

Ligamentum venosum

Starts where umbilical vein sends a branch to liver

Ends at IVC

Front 687

Ductus arteriosus becomes

Back 687

Ligamentum arteriosum

Front 688

Umbilical arteries become

Back 688

Medial umbilical ligaments

From Internal iliacs to umbilicus

Front 689

Urachus becomes

Back 689

Median umbilical ligamen

Front 690

1st aortic arch: Derivatives

Back 690

1st arch is MAXIMAL

Maxillary artery

Front 691

2nd aortic arch: Derivatives

Back 691

STAPEDIUS IS SECOND

Stapedial artery
Hyoid artery

Front 692

3rd aortic arch: Derivatives

Back 692

C is the 3RD letter of the alphabet

COMMON CAROTID (and part of internal carotids)

Front 693

4th aortic arch: Derivatives

Back 693

Blood gets to the 4 limbs

Left = Aortic arch

Right = Proximal subclavian artery

Front 694

6th aortic arch: Derivative

Back 694

Proximal pulmonary arteries

Left: includes ductus arteriosus

Front 695

Branchial apparatus: Germ layer origins

Back 695

a.k.a Pharyngeal apparatus

Clefts --> Ectoderm

Arches --> Mesoderm + Neural crest

Pouches --> Endoderm

Front 696

Branchial cleft derivatives

Back 696

Cleft 1: External auditory meatus

He had to EAt Meat so he CLEFT

Clefts 2-4 --> Obliterated

Front 697

Branchial arch 1 derivatives

Back 697

TTT MAD MOUTH

Innervated by CN V-2 and V-3

Muscles (TTT MAD):
Tensor tympani
Tensor veli palatini
anterior Tongue (Two-thirds)

Mylohyoid
Anterior belly of Digastric

Mouth =Mastication (Masseter, pterygoids, temporalis)

Mouth =Meckel's cartilage

Malleus (+incus)
Mandible
SphenoMANDIBULAR ligament

Front 698

Branchial arch 2 derivative

Back 698

SSSecond arch
CN SSSeven

The SS Faces the PD

Innervated by CN SSSeven

SS = Reichert's cartilage + mirror muscles
*Stapes
*Stylohyoid ligament AND attachments (Styloid process + hyoid: lesser horn)

Stapedius muscle
Stylohyoid muscle

*FACE = Facial expression muscles

PD = Posterior belly of digastric

Front 699

Branchial arch 3 derivatives

Back 699

3x3 =9 --> Innervated by CN 9

3rd arch = 3 things to remember:

Cartilage --> Greater horn of hyoid
*Great enough to have its own arch

Tongue: Posterior 1/3 (with arch 4)

Muscle: Stylopharyngeus

Front 700

Branchial Arch 4

Back 700

Superior laryngeal branch of CN X

TLC Please --> Take care of cricothyroid!

Tongue--posterior 1/3 (w/arch 3)
Levator veli palatini
Constrictors (pharyngeal)

Cricothyroid

Front 701

Branchial Arch 6

Back 701

In the end, an I for an I

Inferior laryngeal branch of CN X

Intrinsic muscles of larynx EXCEPT cricothyroid

Front 702

Branchial arch innervation

Back 702

The only CNs with both SENSORY and MOTOR components

1 --> CN V-2, V-3
2 --> CN VII
3 --> CN IX
4 --> CN X (S. laryngeal branch)
6 --> CN X (I. laryngeal branch)

Front 703

Ear origins

Back 703

Malleus/incus + tensor tympani
*Part of ARCH 1: TTT Mad Mouth
*CN V-3

External auditory meatus: Cleft 1

Tympanic membrane: 1st branchial membrane
Stapes + Stapedius
*Part of ARCH 2: SS Faces PD
*CN VII

Front 704

Tongue origins

Back 704

Anterior 2/3:
*Part of ARCH 1: TTT Mad Mouth
*CN V-3 --> Sensation

ANTERIOR 2/3 TASTE IS CN VII

Posterior 1/3
*Part of TLC-P: Arch 4 (AND 3)
*CN 9 (most), CN X (posterior)

Motor innervation: CN XII

Muscle origin: Occipital myotomes

Front 705

Branchial pouch 1

Back 705

Endoderm lined structures of the ear

MAC (n' cheese) ET MEC's:

Mastoid air cells
Eustachian tube
Middle ear cavity

Front 706

Branchial pouch 2

Back 706

Epithelial lining of palatine tonsil

Front 707

Branchial pouches 3 + 4

Back 707

3rd pouch:
*THree ~ THymus
*INFERIOR parathyroids

4th pouch:
*Superior parathyroids
*Since it only gets 1 thing, it gets the SUPERIOR parathyroids

DiGeorge: Malformation of 3rd and 4th pouches
*THC: Thymic aplasia, hypocalcemia (no parathyroids), cardiac defects

Front 708

Cleft lip

Back 708

Failure of PRIMARY palate

Failure of fusion of nasal processes: maxillary and medial

Front 709

Cleft palate

Back 709

Failure of SECONDARY palate

Failure of ANY of the following to fuse:
*Nasal septum
*Palatine processes (lateral, medial)

Front 710

Pancreas structure

Back 710

2 embryologic buds:
*VW: Ventral --> Head, Wirsung
*Dorsal --> Everything else, Santorini

Wirsung is the main duct
Santorini is accessory duct
*Santa's little helper

Annular pancreas: Ventral pancreatic head can accidentally encircle duodenum

Front 711

Diaphragm origins

Back 711

Several Parts Build Diaphragm

Septum transversum
Pleuroperitoneal folds
Body wall
Dorsal mesentary of esophagus

Diaphragmatic hernia --> abdominal contents herniate into thorax
*May cause hypoplasia of thoracic organs (compression)

Front 712

Bladder or cloacal extrophy

Back 712

Failure of caudal abdominal fold

Front 713

Gastrochisis

Back 713

Failure of LATERAL abdominal folds to fuse

Extrusion of abdominal contents

Front 714

Omphalocele

Back 714

Peritoneum-enclosed organs

Herniation of abdominal contents into umbilical cord

Front 715

Mesonephros becomes

Back 715

Male anatomy

Forms SEVE of SEVEN UP:
Seminal vesicles
Epididymis
Vas deferens
Ejaculatory duct

Originally functions as secondary kidney

Origin of metanephros

Front 716

Metanephros becomes...

Back 716

Functional kidney

Starts as a bud from mesonephros

Induces metanephric blastema

Later changes attachment point to UG sinus (bladder, ureters, allantois)

Front 717

Allantois

Back 717

Endodermic evagination of hidgut

Becomes surrounded by mesoderm that will form umbilical vasculature

Endoderm + mesoderm becomes umbilical cord

Front 718

Paramesonephric/Mullerian duct becomes...

Back 718

Fallopian tube
Uterus
Upper vagina

Front 719

SRY

Back 719

Gene that induces testes

Front 720

MIF

Back 720

Secreted by testes, along with androgens, to cause male development

Front 721

Male vs. Female genital origins

Back 721

Genital tubercle
*Glans penis
*Glans clitoris

Corpus cavernosum
*Erectile tissue of penis
*Erectile tissue of clitoris

Urogenital sinus
*Corpus spongiosum (urethra)
*Vestibular bulbs

*Bulbourethral glands of Cowper
*Greater vestibular glands (Bartholin)

*Prostate
*Urethral, paraurethral glands of Skene

Urogenital folds:
*Ventral shaft of penis
*Labia minora

Labioscrotal swelling
*Scrotum
*Labia majora

Front 722

Techoic acid and LPS induce

Back 722

TNF and IL-1

Front 723

Anthrax capsule

Back 723

D-glutamate

(All other encapsulated organisms have polysaccharide capsules)

Front 724

Spores

Back 724

Provides resistance to dehydration, heat and chemicals
*Must autoclave to kill

Autoclave ~ 1 hr >100C

Keratin-like coat

DiPIColinic acid in core = Keeps em from dying when life isn't a PICnic

Gram POSITIVE organisms
*Clostridium (Perf, Tet, Bot)
*Bacillus anthracis

Front 725

Bad gram stainers

Back 725

These Rascals May Microscopically Lack Color

Treponema (thin)

Rickettsia (intracellular)

Mycoplasma (no cell wall)

Mycobacteria (lipids)
*Acid fast

Legionella (intracellular)
*Silver stain

Chlamydia (intracellular)

Front 726

What is the only gram (+) bacteria to have an ENDOtoxin?

Back 726

Listeria

Front 727

Endotoxins

Back 727

Permanent structure on gram (-) bacteria
*AND LISTERIA

LPS --> Stable at 100C for 1hr

Induces fever, shock
Induces TNF and IL-1
*So does Teichoic acid (Gram +)

Poorly antigenic

No vaccines

Front 728

Exotoxins

Back 728

SECRETED from gram (+) and (-) bacteria
*Tetanus
*Botulism
*Diptheria
*Staph

Polysaccharide --> Destroyed at 60C
*Except staph exotoxin

DNA is NOT intrinsic to genome
*Plasmid or bacteriophage

HIGHLY toxic

Induces ANTITOXINS (high titer Abs)

Vaccines: Toxoids

Front 729

S. Aureus protein A

Back 729

Binds the Fc region of IgG

A bacterial virulence factor

Front 730

IgA protease

Back 730

Secreted by encapsulated bacteria, which already have a capsule to inhibit phagocytosis (Strep pneumo, H. Influenza, Neisseria)

Cleaves IgA

Front 731

Group A streptococcal M protein

Back 731

Helps prevent phagocytosis

Mediator of rheumatic fever

Front 732

S. Aureus: Exotoxins and Virulence factors

Back 732

Exotoxins:

TSST-1: Superantigen
*Fever
*Rash
*Shock

Enterotoxins --> Food poisoning
Exfoliatin --> SCALDED SKIN

Virulence factor = Protein A: Grabs Fc of immunoglobins

Front 733

TSST-1: Origin

Back 733

Exotoxin (superantigen) from S. Aureus

Front 734

Exfoliatin: Origin

Back 734

Exotoxin from S. Aureus

Scalded skin syndrome

Front 735

S. Pyogenes: Exotoxins

Back 735

1. Scarlet fever-erythrogenic toxin
*Superantigen
*Toxic shock-like syndrome

2. Streptolysin O
*Hemolysin
*Diagnose rheumatic fever w/ASO Ab

Front 736

Streptolysin O: Origin

Back 736

Exotoxin from S. Pyogenes

Causes hemolysis

Diagnostic for rheumatic fever

Front 737

Corynebacterium diptheriae:
Exotoxins

Back 737

CD = EF

ELONGATION FACTOR 2 (EF-2)
*A.k.a. Diptheria toxin

EF-2 is ADP ribosylated
*Inhibits protein synthesis

Gram positive rods
METACHROMATIC granules

Causes pseudomembranous pharyngitis (grayish-white membrane)

Lymphadenopathy

ABCDEFG:

ADP Ribosylation of EF-2
Beta-prophage encoding of exotoxin
Corynebacterium
Diptheriae
EF-2
Granules (metachromatic)

Front 738

Vibrio cholerae: Exotoxins

Back 738

Cholera toxin

G protein is liked to adenylate cyclase
*Cholera toxin ADP ribosylates it

Overactivity ensues:
*Cl pumped into gut
*Na+ absorption reduced

RICE WATER DIARRHEA

Comma shaped bacterium

Front 739

E. coli: Exotoxins

Back 739

Both cause WATERY DIARRHEA

Labile like the AIR (Labile-A)
Stable like the GROUND (Stable-G)

Heat labile: Activates Adenylate Cyclase
*Increases cAMP

Heat stable: Activates Guanylate Cyclase

Front 740

Bordatella pertussis: Exotoxins

Back 740

Pertussis toxin
Causes whooping cough

Inhibits an inhibitory G protein
*Increases cAMP

Inhibits a chemokine receptor --> Lymphocytosis

Front 741

Clostridium perfringens: Exotoxins

Back 741

Alpha toxin

Causes GAS GAGRENE

DOUBLE ZONE of hemolysis on blood agar

Front 742

Clostridium tetani: Exotoxins

Back 742

Tetanus toxin

Blocks release of inhibitory neurotransmitters (GABA, glycine)

Causes "lockjaw"

Front 743

Clostridium botulinum: Exotoxins

Back 743

Botulinum toxin

Blocks release of Ach --> CNS paralysis
*Especially CRANIAL NERVES

Spores in canned food, honey
*Floppy baby

Front 744

Bacillus antrhacis: Exotoxins

Back 744

Toxin COMPLEX exists

EDEMA FACTOR = adenylate cyclase
*Increases cAMP

Front 745

Shigella: Exotoxin

Back 745

Shiga toxin

1. Cleaves host cell rRNA
2. Enhances cytokine release
*HUS = Hemolytic uremic syndrome

Front 746

E. coli 0157:H7: Exotoxin

Back 746

Shiga toxin

1. Cleaves host cell rRNA
2. Enhances cytokine release
*HUS = Hemolytic uremic syndrome

Front 747

Gram positive bacteria: Rods

Back 747

Little Bacilli Compared to Cocci, No Argument

Listeria
Bacillus
Clostridium (anaerobe)
Corynebacterium
Norcardia
Actinomyces
*Acts like fungus, formes hyphae

Front 748

Gram positive bacteria: Cocci

Back 748

Catalase test: Breaks down peroxide
Staph (+)
Strep (-)

Staph: Clusters
Strep: Strips

Front 749

Staphylococcus

Back 749

Catalase (+)
Clusters

Coagulase test: Fibrinogen--> Fibrin
S. Aureus (+)
S. Saprophyticus (-)
S. Epidermidis (-)

S. Saprophyticus and S. Epidermidis can be distinguished using NOVOBIOCIN

"NO StRES:"
Saprophyticus = Resistant
Epidermitis = Susceptible

Front 750

Catalase

Back 750

H2O2 --> H2O

Differentiates Strep from Staph

Front 751

Coagulase

Back 751

Fibrinogen --> Fibrin

Differentiates S. Aureus from other type of Staph

Front 752

Novobiocin

Back 752

Differentiates Coagulase negative staph

NO StRES:

Saprophyticus = Resistant

Epidermidis = Susceptible

Novobiocin and Staph:
Think of a NOVICE STAFF

Front 753

Streptococcus

Back 753

Catalase (-) strips/chains

Hemolysis differentiates:

Partial hemolysis (green) = Alpha
*Differentiate further using Optochinin

Complete hemolysis (clear) = Beta
*Beta clear out, people
* Differentiate further using Bacitracin

No hemolysis = Gamma

Front 754

Alpha Hemolytic Strep

Back 754

Catalase (-) chains
Alpha hemolysis (green)

Strep pneumoniae:
*Optochinin sensitive
*Capsule (and Quellung +)
*Bile soluble

Strep viridans
*Optochinin resistant
*No capsule
*Not bile soluble

OVRPS (Overpass):
Viridans = Resistant
Pneumoniae = Sensitive

Front 755

Beta Hemolytic Strep

Back 755

Catalase (-) chains
Beta hemolysis (clear)
*Beta clear out, people

Group A (Pyogenes)
*Bacitracin sensitive
*M PROTEIN (prevents phagocytosis)
*Erythrogenic toxin encoded by prophage

Group B (S. agalactiae)
*Bacitracin resistant

BBRAS:
B = Resistant
A = Sensitive

Front 756

Gram + bacteria tests:

Back 756

Catalase:
*Strep (-)
*Staph (+)

Coagulase:
*S. Aureus (+)
*S. Saphrophyticus/Epiderm (-)

Novobiocin: NO StRES
*S. Saprophyticus = Resistant
*S. Epidermidis = Sensitive

Optochinin: OVRPS
S. Pneumoniae = Sensitive
*Capsule, bile solubility
S. Viridans = Resistant
*No capsule, no bile solubility

Bacitracin: B-BRAS
*Group B = Resistant
*Group A (pyogenes) = Sensitive

Front 757

Gamma hemolytic strep

Back 757

No hemolysis

Enterococcus
Peptostreptococcus

Front 758

Gram negative cocci

Back 758

Neisseria meningitidis (Maltose + Glucose)

Neisseria gonorrhoeae (Glucose)

Front 759

Gram negative "coccoid rods"

Back 759

Hang Between Balls and Pills

H. Influenza
Bordatella --> Like "between"
Brucella --> Doesn't have balls
Pasteurella

Front 760

Gram negative rods: Lactose non-fermenters

Back 760

2 S, 2 P

Oxidase +: Pseudomonas aeruginosa

Oxidase (-):
*Shigella
*Salmonella
*Proteus

Front 761

Gram negative rods: Lactose fermenters

Back 761

Fast: EEK!
*E. Coli
*Enterobacter
*Klebsiella

Slow: S sounds
*Citrobacter
*Serratia

Front 762

H. Influenzae culture

Back 762

"Go to the 5&10 store for chocolate"

Chocolate agar w/
factors V and X

Front 763

N. Gonorrhoeae culture

Back 763

Thayer & Gonorrhea are inexplicably linked...by a guy named Martin?

Thayer-Martin media

Front 764

Bordatella Pertussis culture

Back 764

Bordat-Bordet

Bordet-Gengou (potato) agar

Front 765

C. Diptheriae culture

Back 765

Double dipping with the letters

TeLLurite plate
LoFFler's media

Front 766

M. Tuberculosis culture

Back 766

Lownstein-Jenson agar

Front 767

Lactose-fermenting enterics culture

Back 767

Milky pink CONK shell

PINK colonies on MacConkey's agar

Front 768

Legionella culture

Back 768

Charcoal yeast extract

Buffered w/iron and cysteine

Front 769

Fungus culture

Back 769

Sabouraud's agar

Front 770

Congo red stain

Back 770

Used for amyloid

Apple-green birefringence in polarized light (B-pleated sheets)

Front 771

Geimsa's stain

Back 771

BCT P ~ Bacteria + Protozoans
(Actually 2 + 2)
*BORing CLAss--lets TRYP on PLASMA

Borellia
Chlamydia

Trypanosomes
Plasmodium

Front 772

PAS stain

Back 772

Stains glycogen and mucopolysaccharides

Used to diagnose Whipple's disease

Front 773

Zeihl-Neelsen

Back 773

Sounds like a fast European car

ACID-FAST STAIN

Mycobacteria
Cryptosporidium (Protozoan)

Front 774

India ink

Back 774

Cryptococcus neoformans

Front 775

Silver stain

Back 775

Legionella

Fungi

Front 776

Conjugation

Back 776

2 things make conjugation possible:

F+: Plasmid w/conjugation genes
*Plasmid is what is transferred through pilus

HFR: F+ plasmid has incorporated into bacterial chromosome
*Transfer of plasmid + chromosomal genes

Front 777

Transduction

Back 777

Introduction of new bacterial DNA via a virus

Generalized: Random parts of chopped up host DNA gets incorporated

Specialized: Following lysogenic stage, flanking bacterial genes excised along w/viral DNA

Front 778

Exotoxins encoded in LYSOGENIC phages

Back 778

ABCDE

ShigA-like toxin
Botulinum
Cholera
Diptheria toxin
Erythrogenic toxin (S. Pyogenes)

Front 779

Obligate aerobes

Back 779

Nasty Pests Must Breathe

Norcardia
Pseudomonas aeruginosa
Mycobacterium TB
Bacillus anthracis

Front 780

Obligate anaerobe

Back 780

ABC

Actinomyces --> Soil
Bacteriodes --> Gut
Clostridium --> Soil

Generally foul smelling (SCFAs)

Produce gas in tissue --> Gas gangrene
*H2 and CO2
*C. Perfringens

Front 781

Obligate intracellular bugs

Back 781

Stay inside when its Really Cold (RC)

Obligate intracellular: Can't make ATP
*Rickettsia
*Chlamydia

Front 782

Facultative intracellular bugs

Back 782

Some Nasty Bugs May Live FacultativeLY (8)

Salmonella
Neisseria
Brucella
Mycobacterium
Listeria
Francisella
Legionella
Yersinia

Front 783

Encapsulated bacteria

Back 783

Capsule = anti-phagocytic virulence factor

Capsular bacteria also have IgA protease

POSITIVE QUELLUNG RXN
=Capsular swelling when specific anticapsular sera are added

SpINK

Strep pneumo
H. Influenza
Neisseria meningitidis
Klebsiella

Front 784

Urease positive bugs

Back 784

Hockey PUK:

H. Pylori
Proteus
Ureaplasma
Klebsiella

Can cause struvite (ammonium magnesium phosphate) crystals by alkalinizing urine

Treat w/acetazolamide

Front 785

Beta hemolytic bacteria (not just strep)

Back 785

Strep:
*Strep pyogenes (Group A)
*Strep agalactiae (Group B)

STAPH AUREUS
LISTERIA (Unpasteurized milk)

Front 786

Staph Aureus: Manifestations

Back 786

Inflammatory manifestations:
*Skin infections, abscesses +/-MRSA
*Pneumonia
*Acute bacterial endocarditis
*Osteomyelitis

Toxin-mediated disease:
*TSST1
*Scalded skin syndrome
*Food poisoning

Front 787

Strep pyogenes

Back 787

Inflammatory manifestations
*Pyogenic skin infections (impetigo, cellulitis)
*Toxigenic skin infections (scarlet fever, toxic shock syndrome)

IMMUNOLOGIC:
*PHaryngitis: PHever, NePHritis
*Rheumatic fever
*Post-streptococcal Glomerulonephritis

Bacitracin sensitive

Antibodies to PROTEIN M (phagocytosis inhibitor) enhance host defenses, but can give rise to rheumatic fever

ASO titer detects recent S. Pyogenes infection

Rheum for SPECCulation
*Subcutaneous nodules
*Polarthritis
*Erythema marginatum
*Chorea
*Carditis

VS.

FEVERSS:
Fever
ESR
Valvular damage (Mitral > A > T)
Erythema marginatum
Red hot joints (polyarthritis)
Subcutaneous nodules (Aschoff) + Anitz
St. Vitus' dance (Chorea)

Aschoff = Webby area that contains anitschow cells (nuclei look like a football stitch)

Front 788

Strep pneumoniae

Back 788

Rusty sputum

Most common cause of MOPS:
MENINGITIS
OTITIS MEDIA
PNEUMONIA
SINUSITIS

May cause SEPSIS w/no spleen (or sickle cell anemia)

Encapsulated--IgA protease
Optochinin sensitive

Front 789

Group B streptococci

Back 789

B is for BABIES

Beta-hemolytic
Bacitracin resistant

Babies have PMS?
Pneumonia
Meningitis
Sepsis

Front 790

Staph epidermidis

Back 790

Infects prosthetic devices and catheters

Component of normal skin flora

Contaminates blood cultures

Front 791

Enterococci

Back 791

Part of Lancefield group D
*Subset of gamma-hemolyic strep
*Based on C carbohydrate on cell wall
*Variable hemolysis
*Hardy: can grow in 6.5% NaCl

UTI
Subacute endocarditis

Penicillin G resistant
Some VANCOMYCIN resistant strains

Front 792

Viridans

Back 792

Alpha hemolytic
Optochinin resistant

Normal flora of oropharynx

Strep mutans = CARIES
Strep Sanguis = Subacute endocarditis
*Sanguis = "Blood"
*Lots of blood in HEART

Front 793

Clostridia

Back 793

Gram positive
Spore forming
Obligate anaerobe

Tetani: Blocks glycine, GABA release from RENSHAW cells of spinal cord
*Exotoxin encoded by prophage

C. Botulinum: Inhibits Ach release @NMJ
*Adults = Pre-formed toxin
*Babies = Spores (honey, cans)
*Exotoxin encoded by prophage

C. Perfringens: Alpha toxin (lecithinase)
*Myonecrosis (gas gangrene)
*Hemolysis
*Perfringens PERFORATES a gangenous leg

C. difficile: Cytotoxin
*Endotoxin that kills enterocytes
*Pseudomembranous colitis
*CLINDAMYCIN or AMPICILLIN use

Front 794

Renshaw cells

Back 794

Inhibitory nerves emerging from spinal cord

C. Tetani blocks their release of glycine

Front 795

C. Difficile: Exotoxin

Back 795

Cytotoxin

Kills enterocytes
Causes pseudomembranous colitis

Most often after AMPICILLIN OR CLINDAMYCIN
*AMPed up necrosis = CLIND out

Treat w/METRONIDIAZOLE

Front 796

Anthrax

Back 796

Woolsorter's disease--spore inhalation

Caused by bacillus anthracis
Gram positive
Spore forming

ONLY bacterium w/a PROTEIN capsule
*D-glutamate

Skin contact:
1. Malignant pustule (painless ulcer)
2. Black skin lesion
*Vesicular pustule
*Covered in black eschar

Inhalation:
1. Flu-like symptoms
2. Massive pulmonary edema, hemorrhage
3. Mediastinitis, shock

Front 797

Listeria

Back 797

Acquisition:
1. Birth (vaginal)
2. Unpasteurized dairy

ACTIN ROCKETS to move between cells

Healthy: Mild gastroenteritis

Immunocompromised: Meningitis

Pregnancy: pain in the ASS
*Amnionitis
*Septicemia
*Spontaneous abortion

Infancy:
*Meningitis
*Granulomatous infantiseptica

Front 798

Actinomyces israelii

Back 798

Gram positive rod
Obligate anaerobe

Forms long branching filaments (resembles fungi)

NORMAL oral flora
Can cause ORAL/FACIAL abscesses
*Forms YELLOW sulfur granules in sinus tracts

Treat w/PENICILLIN

SNAP:
Sulfa for Norcardia
Actinomyces uses Penicillin

Front 799

Nocardia

Back 799

Gram positive rod

Causes PULMONARY infection in immunocompromised patients

SNAP:
Sulfa for Norcardia
Actinomyces uses Penicillin

Front 800

Neisseria

Back 800

Gram negative cocci
BOTH produce IgA proteases

Meningococci:
*RESPIRATORY and ORAL secretions
*Meningococcemia, Waterhouse-Freidrichson syndrome
*Polysaccharide capsule --> Vaccine
*Maltose + glucose fermentation

Gonococci
*Sexually transmitted
*Gonorrhea + PID, septic arthritis, neonatal conjunctivitis
*No capsule --> No vaccine
*Glucose-only fermentation

Front 801

H. Influenza

Back 801

Gram negative coccobacillus
Aerosol transmission
Capsule--IgA protease

Chocolate agar w/factors 5+10
*When you have the FLU, mom goes to the 5&10 to buy CHOCOLATE

MOPE (vs. MOPS for Strep Pneumo)
*Does NOT cause the flu

Meningitis--ceftriaxone
Otitis media
Pneumonia
Epiglottitis

Vaccine: Given 2-18 months
*Type B capsular plolysaccharide + protein (diptheria toxoid, etc.)

Front 802

Enterobacteria

Back 802

All gram negative rods except PSUDOMONAS
*All ferment glucose
*All are oxidase negative

K antigen: virulence factor
*Kapsular
*KILLER factor

O Antigen: POlysaccharide component of endOtoxin

H antigen: Flagella
*HUSTLE factor
*Motile species

Front 803

Klebsiella

Back 803

Currant jelly sputum

3 A's
Alcoholics
Abscess in lungs
Aspiration pneumonia

Also pneumonia in diabetics
*Alcoholics + diabetics = People who hate their pancreas club

Front 804

Salmonella

Back 804

Gram negative rod
Non-lactose fermenting

Invades intestinal mucosa to cause BLOODY DIARRHEA

Less virulent than Shigella (another non-lactose fermenting GNR that causes bloody diarrhea)

STINKY SALMON SWIM:
*H2S production
*Animal reservoir
*Flagella--can disseminate hematogenously

Typhoid fever =
*Diarrhea
*Fever, headache
*ROSE SPOTS on abdomen
*Can remain in GB chronically

Transmission via the 4 Fs:
Food
Fingers
Feces
Flies

Front 805

*Diarrhea
*Fever, headache
*ROSE SPOTS on abdomen

Back 805

Typhoid fever

Salmonella typhi

Front 806

Shigella

Back 806

Gram negative rod
Non-lactose fermenting

Invades intestinal mucosa to cause BLOODY DIARRHEA

More virulent than Salmonella (another non-lactose fermenting GNR that causes bloody diarrhea)

Does not disseminate
Propels itself via actin polymerization

Transmission via the 4 Fs:
Food
Fingers
Feces
Flies

Front 807

Yersinia entercolitica

Back 807

Transmitted via:
*PUPPIES (pet feces)
*PORK
*Milk

Outbreaks common at DAY CARE centers

Can mimic Crohn's or appendicitis

Front 808

Reheated rice food poisoning

Back 808

Bacillus cereus

"Food poisoning from REHEATED RICE? B. CEREUS!"

Front 809

Custard food poisoning
Mayonnaise food poisoning

Back 809

S. Aureus

Front 810

Seafood poisoning

Back 810

Vibrio parahaemolyticus

Vibrio VULNificus
*Skin is also VULNerable to infectio

Front 811

Meat food poisoning

Back 811

S. Aureus
Salmonella

C. Perfringens (if reheated)
E. Coli O017:H7 (if undercooked)

Front 812

Poultry, egg poisoning

Back 812

Salmonella

Front 813

Pork food poisoning

Back 813

Yersinia entercolitica

Front 814

Milk food poisoning

Back 814

Listeria

Yersinia entercolitica

Front 815

Bloody diarrhea

Back 815

YE ESC, ESC

Yersinia entercolitica

E. Coli O157:H7
*Makes shiga-like toxin
*Can cause HUS

Enteroinvasive E. coli (invades mucosa)

Salmonella

Campylobacter
*S or comma shaped organism
*CAMPS (grows) in your FRIDGE
*Oxidase positive

Entamoeba Histolytica (Protozoan)

Shigella

C. difficile
*Can be bloody OR watery

Front 816

Watery diarrhea

Back 816

They RAN to GUARD the CRYPTic PCD Emblem

RAN = Virusis
*Rotavirus
*Adenovirus
*Norovirus

Guard = Giardia (Protozoan)

Cryptic = Cryptosporidium (Protozoan)--mild

P = C. Perfringens

C = Cholera
*Comma shaped
*Rice water diarrhea

D = C. Difficile

Emblem = E. coli (Enterotoxigenic)
*Traveler's diarrhea
*ST and LT toxins

Front 817

Bacterial cAMP modifiers

Back 817

They increase camp somehow

3 ADP ribosylators:
1. Cholera: Stimulates Gs
2. Pertussis: Inactivates Gi
3. E. coli heat labile: Stimulates AC

Anthrax: Actually IS an AC

Front 818

Legionella

Back 818

Gram negative rod
Requires silver stain
Requires charcoal yeast medium w/Fe, Cysteine

Transmission = Aerosol from water source
*No PERSON-TO-PERSON transmission

Manifestations:

1. Legionnaire's disease = Severe pneumonia
2. Pontiac fever = Mild influenza

Treatment: Erythromycin

Picture: Legionnaire with his SILVER IRON dagger, sitting around a CHARCOAL fire. He's no SISSY (cysteine)

Front 819

Pseudomonas

Back 819

Gram negative rod
OXIDASE (+) --> Aerobic

Exotoxin A (like diptheria): Inactivates EF-2

Associations:
Cystic fibrosis
Burns

Associations = PSEUDO
P = Pneumonia (cystic fibrosis)
S = Sepsis (w/BLACK lesions on skin)
E = External otitis (swimmers ear)
U = UTI
D = Drug use
O = Osteomyelitis (diabetic)
*HOT TUB FOLLICULITIS

Blue-green color (pyocyanin)
GRAPELIKE odor

Produces Exotoxin A (inactivates EF-2)

Treat: Aminoglycoside + extended spectrum penicillin (piperacillin, ticarcillin)

Front 820

H. Pylori

Back 820

Gram negative rod
Urease positive (neutralizes acid)

Hangs out in the antrum

Complications:
*Type B gastritis --> AdenoCA, MALT lymphoma
*~100% of duodenal ulcers
*~70% of PUD

Triple therapy: Make Tummy Better
*Metronidiazole or PPI
*Tetracycline or amoxicillin
*Bismuth

Front 821

Cat scratch fever

Back 821

Bartonella henselae

Front 822

Brucella

Back 822

Brucellosis/UNdulant fever

UNpasteurized dairy products
Contact w/animals

UNpasteurized dairy products ~ Undulant fever

Front 823

Francisella tularensis

Back 823

Tularemia

Tick bite
*Lives on deer and rabbits

Front 824

Gardnerella vaginalis

Back 824

Gram VARIABLE rod
Sexually transmitted

Gray vaginal discharge w/fishy smell

CLUE cells (vaginal epithelial cells covered w/bacteria)

Treat w/metronidiazole

Front 825

Primary TB

Back 825

Nonimmune host (usually a child)

1. Ghon focus (granulomas) in lower lung

2. Lobar and perihilar node involvement

Outcomes:
1. Healing (PPD+)
*2nd exposure --> fibrocaseous cavitary lesion in UPPER lung

2. Progressive lung disease (death, rare)

3. Miliary TB (death)

4. Pre-allergic lymphatic dissemination --> Reactivation TB
*CNS (parenchyma, meningitis)
*POTT'S DISEASE (vertebral body)
*Lymph nodes
*Renal
*GI
*Lung --> Fibrocaseous cavitary lesion in upper lung

Front 826

Secondary TB

Back 826

REACTIVATION
or
2nd INFECTION

Fibrocaseous cavitary lesion
UPPER LUNG

(Ghon focus of primary TB is in lower lung)

Front 827

PPD+

Back 827

Current infection
Past exposure
BCG vaccinated

FALSE POSITIVE: Anti-phospholipid antibody (SLE)

Front 828

PPD-

Back 828

No infection
Anergic = SIMS
* Sarcodosis
*Immunocompromised
*Malnutrition
*Steroids

Front 829

Mycobacteria

Back 829

TALKS

All are acid fast

M. tuberculosis

M. Avium-intracellulare
*Avium ~ AIDS (Disseminated disease)
*Often resistant to multiple drugs

M. Leprae (Hansen's disease)
*Infects skin and superficial nerves
*Leonine facies: Lost eyebrows, nasal collapse, lumpy earlobe
*Armadillo reservoir
*Lepromatous = Worse; cell-mediated immunity, lethal
*Tuberculoid = Self-limited
*DAPSONE do be a dapper son again

M. Kansasii
*Pulmonary TB-like symptoms

M. Scofulaceum
*Cervical lymphadenitis in kids

Front 830

Hansen's disease

Back 830

Leprosy

Not very HANSEM

Front 831

Leonine facies

Back 831

Leprosy

Lost eyebrows
Lumpy earlobe
Nasal collapse

Front 832

Rickettsiae

Back 832

Obligate intracellular parasites

Transmitted by arthropod vector
*Except coxiella--aerosol

CLASSIC SYMPTOMS:
Headache
Fever
Rash: Differs by type
*Rickettsia starts on HANDS + FEET (Rickettsia on the RISTS)
*Typhus on the TRUNK

RICKET --> TET (Tetracycline)

PQR(S)T:

Prowazekii = Epidemic typhus
*Human body louse
*PROWling around your BODY
*(+) Weil-Felix

Coxiella burnetti: Q fever

Rickettsiii = Rocky Mtn spotted fever
*Rash: Hands and feet
*Endemic to EAST COAST
*(+) Weil-Felix

Typhi = Endemic typhus (fleas)
*Rash on trunk
*(+) Weil-Felix

Erlichia: Erlichiosis (TICK)
*Lick the tick

Front 833

Chlamydia

Back 833

Obligate intracellular parasites
*Seen w/GEIMSA (BCTP) or fluorescent ab

Unusual cell wall: lack muramic acid

2 forms:
*ELEMENTARY BODY (small, dense): Enters cells via endocytosis
*RETICULATE BODY = Replicates in cell

Chlamydia trachomatis

*Types A-C: Africa/blindness/chronic

*Types D-K: Everything else
*Urethritis and PID
*Arthritis
*Conjunctivitis

Types L1-L3: Lymphogranuloma venereum
*(+) Frei test (Ab from egg)
C. Pneumoniae: Atypical pneumonia

C. Psittaci: Atypical pneumonia
*Avian reservoir

Front 834

Chlamydia serotypes A-C

Back 834

Africa
Blindness
Chronic

Front 835

Chlamydia serotypes D-K

Back 835

Everything types A-C and L1-L3 aren't

Urethritis/PID
Neonatal conjunctivitis
Arthritis

MOST COMMON CAUSE OF PREVENTABLE BLINDNESS

Front 836

Chlamydia serotypes L1-L3

Back 836

Lymphogranuloma venereum

Positive Frei test (egg Ab)

Rectal strictures

Front 837

Spirochetes

Back 837

BLT, and B = Big

Borrelia (large)
*Geimsa stain

Leptospira

Treponema
*Dark field microscopy

Front 838

Leptospira interrogans

Back 838

Question-mark shaped bacteria

Water contaminated w/animal urine

Flu-like (Fever, Headache, Abdominal pain)
+
JAUNDICE

Weil's disease:
+ Kidney dysfunction
+ Anemia, hemorrhage

Front 839

Lyme disease

Back 839

Borrelia burgdorferi (Ixodes tick)
*Deer required for tick life cycle
*Mice

BAKED a key lime pie:
Bell's palsy
Arthritis
Kardiac block
Erythema migrans
Doxycycline

1. Erythema chronicum migrans (bulls-eye rash)

2. Neurologic + cardiac symptoms

3. Arthritis (chronic mono, migratory poly)

Front 840

Treponema pertenue

Back 840

YAWS

It's PERTINent that sex is not involved

Tropical infection that is NOT an STD

but VDRL test is positive

Front 841

VDRL

Back 841

Syphilis test

(+) With either kind of Treponema
*T. Pallidum: Syphilis
*T. Pertenue: Tropical disease (non-STD)

Not as good as FTA-ABS

Possible false positives: VDRL
V=Viruses
D = Drugs
R = Rheumatic FEVER
L = Lupus and leprosy

Front 842

Syphilis

Back 842

Primary = Painless chancre

Secondary = Disseminated disease
*Constituional symptoms
*Palm and sole rash
*Condyloma lata (rash consolidations)

Tertiary syphilus = More severe symptoms

*GoT CRABS?
*Gummas (inflammatory skin balls)
*Tabes dorsalis (DC and DRG degeneration)
*Charcot joints (lost proprio = degeneration)
*Robertson (Argyll) pupil
*Aortitis
*Broad based gait
*Stroke w/o HTN

Treat w/Penicillin G

Front 843

PALM AND SOLE RASHES

Back 843

ROCKY
SACKIE
SYPHILUS

Rickettsia rickettsii
*Rocky Mtn spotted fever (E coast)

Coxsackie A (Hand Foot and Mouth disease)

Syphilus

Front 844

Congenital syphilis

Back 844

SSHH

Saber shins (anterior bowing)

Saddle nose

Hutchinson teeth (small, widely spaced)

Hearing problems (CNVIII deafness)

Front 845

Argyll-Robertson pupil

Back 845

"Accomodates but doesn't react"

...EWW (Edinger-Westpal nucleus)

Constricts w/accomodation

Does not constrict in response to light

Front 846

FTA-ABS

Back 846

Test for treponemes

More specific than VDRL
(+) earlier
(+) later (after treatment)

If FTA-ABS is (-) while VDRL is (+), probably a false (+)

Front 847

Mycoplasma pneumoniae

Back 847

No cell wall -- no gram staining
ONLY bacterium w/cholesterol in membrane

Looks like fungus

Classic cause of atypical (walking) pneumonia
*Prisons, military
*Insidious, w/non-productive cough
*Diffuse INTERSTITIAL infiltrate

High titer of COLD AGGLUTININS (IgM)

Grown on Eaton's agar

Treatment: Tetracyclin or erythromycin
*No cell wall for penicillin to break down

Front 848

Eaton's agar

Back 848

Medium for mycoplasma pneumoniae

Front 849

Atypical pneumonia

Back 849

"Walking pneumonia"

Interstitial infiltrate

Mycoplasma pneumoniae
Chlamydia psittaci
Chlamydia pneumonia

Treat w/erythromycin or tetracycline

Front 850

Candida

Back 850

GERM TUBE TEST DIAGNOSTIC

May be superficial or systemic

Transmission = Spore inhalation
*No person-to-person spread

20C: Budding yeast w/pseudohyphae
*Pseudohyphae = like incomplete buddings

37C: Germ tube formation
*Look like BALLOONS
*By 37, not many GERM (cells) in a fallopian TUBE

IV drug users: Endocarditis

Immunocomp: Thrush esophagitis

Antibiotics, DM: Vaginitis

Babies: Diaper rash

Front 851

Histoplasmosis

Back 851

Systemic mycosis --> PNEUMONIA

Mississippi and Ohio river valleys
Bird or bat droppings

Invades MACROPHAGES
*Histo HIDES
*Tiny yeast can be seen within them

Front 852

Blastomycosis

Back 852

Systemic mycosis

East of the Mississippi River
Central america

**East coast and Central america both got BLASTed by swine flu too**

BROAD BASED BUDS
BUMPS: Granulomatous nodules

1. Pneumonia
2. Skin and bone

Front 853

Coccidiomycosis

Back 853

Systemic mycosis

a.k.a. San Joaquin or desert valley fever

California (Southwestern US)

Always a SPHERULE filled w/endospores
*Coccidio CONSTANT

1. Pneumonia
2. Skin and bone
3. Meningitis

Front 854

Paracoccidiomycosis

Back 854

Systemic mycosis

Rural Latin america

Para ~ Pinweel
*"Captain's wheel appearance"

Front 855

Cutaneous mycoses

Back 855

1. Tinea versicolor
*KOH: Spaghetti and meatball
*Malassezia FURFUR (affects head "fur")
*Seen w/hot, humid weather
*Tx: Miconazole, Selenium sulfide (Selsun)

2. Tinea EVERYTHING ELSE
*Pruritic lesions w/central clearing
*DERMATOPHYTES (Microsporum, Trichophyton, Epidermophyton)
*KOH: Mold hyphae
*Pets may be a reservoir (Microsporum)
*Tx: Azoles

Front 856

Aspergillus fumigatus

Back 856

ALWAYS A MOLD
*Septate hyphae
*45 degree branching

Allergic bronchopulmonary aspergillosis

Lung cavity aspergilloma (fungus ball)

Invasive aspergillosis *Immunocompromised
*Chronic granulomatous disease/NADPH oxidase def

Front 857

Cryptococcus neoformans

Back 857

Brink LATEX + SOAP to INDIA

Heavily encapsulated YEAST
*Narrow based budding

Found in pigeon droppings (and thus soil)

Stains w/INDIA INK

LATEX AGGLUTINATION TEST detects relevant capsular antigens

Cryptococcal meningitis
*SOAP BUBBLE lesions in brain

Cryptococcosis (blood)

Front 858

Mucor and Rhizopus

Back 858

Mold
*Non-septate hyphae
*Branching at wide angles (>90)

**Ketoacidotic diabetic and leukemic patients**

1. Rhinocerebral, frontal abscesses

2. Fungi proliferate in walls of blood vessels
*Infarction of distal tissue

Front 859

Septate, 45 degree hyphae

Back 859

AspergiLLus

Front 860

Non-septate, wide branching hyphae

Back 860

Mucor, rhizopus

Front 861

Pseudohyphae

Back 861

Candida

Front 862

Pneumocystis jiroveci

Back 862

Inhaled YEAST (not spore)

Most infections are asymptomatic

Associated w/HIV, AIDS
*Prophylaxis when CD4 <200

Diffuse interstitial pneumonia
*Diffuse, bilateral CXR
*Diagnose w/biopsy, lavage

Stains w/METHENAMINE SILVER

Front 863

Pneumocystis jiroveci stain

Back 863

Methenamine silver

Front 864

Sporothrix schenki

Back 864

Dimorphic fungus that lives on plants
*Cigar-shaped budding yeast
*Unequal budding

"Rose gardner's disease":
*Local pustule/ulcer
*Nodules along draining lymphatics

Treat w/schenckII
Itraconazole
Potassium iodide

Front 865

Constant molds

Back 865

MAD

Mucor
Aspergillus
Dermatophytes

Front 866

Constant yeasts

Back 866

PC

Pneumocystis
Cryptococcus

Front 867

Giardia

Back 867

Protozoan

Cysts in water--when ingested:
*Foul diarrhea
*Bloating and flatulence

Diagnosis: Trophozoites or cysts in stool
*Look like double nuclei (2 eyes)

Treat w/metronidiazole

Front 868

Trichomonas

Back 868

Protozoan

Sexual transmision:
*Vaginitis --> Greenish discharge w/itching, burning

Diagnosis: Trophozoites on wet mount
*THEY MOVE

Treat w/metronidiazole

Front 869

Trypanosoma Cruzi

Back 869

Protozoan
Chagas disease (SA)

Transmitted via Reduvid bug:
Dilated cardiomyopathy
Megacolon
Megaesophagus

Diagnosis: Blood smear shows worm-like things w/flagella

Treat w/Nifurtimox

Front 870

Trypanosoma gambiense
Trypanosoma rhodesiense

Back 870

Protozoan
African sleeping sickness

Transmitted by TseTse fly

Diagnosis: Blood smear

Treat w/:
Suramin -- blood borne disease
Melarsoprol --CNS penetration

Front 871

Leishmania Donovani

Back 871

Protozoan
Visceral Leishmaniasis
*HOT in the DESERT

Transmitted by Sandfly:
*Hepatosplenomegaly --> Spiking fevers, pancytopenia

Diagnosis: Blood smear
*Macrophages w/amastigotes
*Egypt: will they MASSACRE the GOATS in case they have disease inside?

Treat w/Sodium stibogluconate

Front 872

Plasmodium

Back 872

Protozoans
Malaria

Transmitted by mosquito:
*Splenomegaly --> Cyclic fever, headache, anemia

P. malariae

P. ViVax/OVale have dormant forms in liVer
*Called hypnozoites
*Relapsing malaria

P. Falciparum is severe, possibly fatal
*Don't FAL prey to falciparum

Diagnosed w/blood smear:

*RBCs w/TROPHOZOITE "ring form" (feeding stage, becomes a SHIZONT)

*RBCs w/merozoites (after SHIZONT undergoes rapid replication)

Treatment:
*Primaquine to PREVENT (relapse)
*Chloroquine
*Sulfadoxine + pyrimethamine
*Mefloquine
*Quinine

Front 873

Babesia

Back 873

Protozoan
Babesiosis

Primarily in NE US (same as Lyme)

Transmitted by Ixodes tick (same as Lyme)
*Fever + hemolytic anemia (same as malaria)

Diagnosis: Blood smear

*RBCs w/ring trophozoites

*RBCs w/MALTESE CROSS

Treat w/Quinidine, Clindamycin
*QUEEN CLINDA

Front 874

What protozoans cause diarrhea?

Back 874

Watery:
Giardia
Cryptosporidium

Bloody:
Entamoeba histolytica

Front 875

Cryptosporidium

Back 875

Protozoan
Diarrhea

Cysts in water--when ingested:
*Mild watery diarrhea
*AIDS: Severe diarrhea

Diagnosis: Cysts on acid-fast stain

NO TREATMENT

Front 876

Toxoplasma gondii

Back 876

Protozoan
Brain abscess
Birth defects: Ring-enhancing brain lesions

Cysts in MEAT or CAT FECES:
*Crosses placenta

Diagnosis: Biopsy, serology

Treat w/Sulfadiazine, Pyrimethamine
*"Sulfa and its peer"

Front 877

Entamoeba Histolytica

Back 877

Protozoan
Bloody diarrhea
Liver abscesses (RUQ pain)

Cysts in water--when ingested:
*Bloody diarrhea
*Liver abscesses (invades GI, stops @liver)

Diagnosis: Stool
*Trophozoites w/RBCs INSIDE
*Cysts w/4 NUCLEI

Treat w/:
Metronidiazole
Iodoquinol

"IOD METRONIDIAZOLE one, because it treats so many things"

Front 878

Naegleria Fowleri

Back 878

Entamoeba Histolytica

Front 879

Trematodes (3)

Back 879

a.k.a. flukes

Treat ALL w/Praziquantel

Shistosoma: HSMEGALY
*CERCARIAE penetrate skin
*SNAIL host
*Spleen + Liver: Granulomas, inflammation

Clonarchis sinensis
*Undercooked FISH
*Enflames, CLOGS biliary tract
*Pigmented gallstones
*CHOLANGIOCARCINOMA

Paragonimus westermani
*Undercooked CRAB
*Lung: Inflammation, 2 infection

Front 880

Praziquantel

Back 880

Treatment for all TREMATODES
+
GI Taenia solium

Front 881

Cestodes (2)

Back 881

a.k.a. tapeworms
*Cestode ~ Sticky
*Sticky situations (Brain lesions, anaphylaxis)

Treat both w/Albendazole
*Praziquantel for intestinal taenia

Taenia solium
*Undercooked pork
*Larvae (too big to cross GI) --> intestinal
*Eggs --> Cysticercosis (inc BRAIN)
*Neurocysticercosis: Swiss cheese

Echinococcus granulosus: IgE, Eggs
*Eggs in dog feces
*Cysts in liver --> spontaneous anaphylaxis w/antigen release

Front 882

Nematodes treated w/Mebendazole

Back 882

Pinworm (E)
Giant roundworm (E)
Hookworm

1. Enterobius vermicularis (pinworm)
*Food contaminated w/Eggs
*GI infection only
*Anal pruritis (SCOTCH TAPE TEST)

2. Ascaris lumbricodes: Giant roundworm
*Eggs visible in feces
*GI infection only

3. Ancylostoma dodenale (Hookworm)
*Penetrate skin of feet
*GI infection only
*ANEMIA ("southern laziness")

Front 883

Nematodes treated w/Thiabendazole

Back 883

Trichinella spiralis
*Undercooked pork
*Larvae encyst in MUSCLE

*Thiabendazole so you can BEND the THIGH again*

Strongyloides stercoralis
*Larvae in soil penetrate skin
*"STAND-STRONG"
*STRONG effect: N/V/D, Anemia

Front 884

Nematodes treated w/Ivermectin

Back 884

IVER for RIVER

Onchocerca Volvulus:
*Female blackflies
*River blindness
*Lizard skin (skin nodules)

*IVAN the strong
Strongyloides stercoralis
*Larvae in soil penetrate skin
*"STAND-STRONG"
*STRONG effect: N/V/D, Anemia

Front 885

Nematodes treated w/Niridazole

Back 885

Dracunculus medinensis
*In drinking water
*Skin inflammation, ulceration

*Dracula drank the water, then he leaked blood

*But you'll never be RID of him (Niridazole)

Front 886

Nematodes treated w/Diethylcarbamazine

Back 886

Loa Loa --> That's a grossa
*Transmitted by flies (deer, horse, mango)
*Skin swelling
*See worm CRAWLING in conjunctiva

Wucheria bancrofti:
*Female mosquito (W for woman)
*Blockage of lymphatic vessels
*ELEPHANTIASIS

Toxocara canis
*Food contaminated w/Eggs
*Granulomas (possible blindness)
*Visceral larva migrans

Front 887

Nematodes which infect via EGGS

Back 887

EAT eggs:

Enterobius vermicularis (Pinworm)--GI

Ascaris lumbricodes (Giant roundworm)--GI

Toxocaris canis (granulomas, visceral migrans)

Front 888

Worm: Brain cysts, seizures

Back 888

Taenia solium

Cestode
Eggs cause cystercercosis
Larvae = GI only

Treat eggs w/Albendazole

Front 889

Worm: Liver cysts

Back 889

Echinococcus granulosus

Cestode
Eggs in dog feces

Treat w/Albendazole

Front 890

Worm: B12 deficiency

Back 890

Diphyllobothrium latum

Front 891

Worm: Biliary tract disease

Back 891

Clonarchis sinensis

Trematode
Undercooked seafood
Enflames biliary tract
Pigment stones
Cholangiocarcinoma

Treat w/Praziquantel

Front 892

Worm: Hemoptysis

Back 892

Paragonimus westermani

Trematode
Undercooked crab
Causes lung inflammation
Secondary bacterial infection

Treat w/Praziquantel

Front 893

Worm: Portal HTN

Back 893

Shistosoma mansoni

Trematode
Penetrates skin
Snail host

HSmegaly due to fibrosis, inflammation, granuloma formation

Treat w/Praziquantel

Front 894

Worm: Hematuria and Bladder cancer

Back 894

Shistosoma haematobium

Trematode

Haema ~ Hematuria
Bium ~ Bladder

Treat w/Praziquantel

Front 895

Worm: Microcytic anemia

Back 895

Anclyostoma (Nematode)
*Enters foot skin
*Treat w/Mebendazole

Strongyloides (Nematode)
*Enters food skin
*Treat w/Ivermectin (or thiabendazole)

Front 896

All DNA viruses are double stranded except _______

Back 896

Parvovirus

Single stranded

"Part of a virus"

Front 897

All DNA viruses are linear except...

Back 897

POLYOMA got a PAPILLOMA and asked for HEP

She didn't follow the STRAIGHT AND NARROW (linear)

Polyoma
Papilloma
Hepadnavirus (HPV)

Front 898

All RNA viruses are ssRNA except ___

Back 898

Reovirus = REPEATOvirus

Double stranded

Front 899

Viral genomic material that is infectious by itself

Back 899

ALL DNA viruses except HBV, Pox
*HBV and Pox have most complicated genomes

ssRNA (+)

Front 900

Viral genomic material that needs viral enzymes to be infectious

Back 900

Viral genomic material that is infectious by itself

Front 901

Non-enveloped viruses

Back 901

Naked CPR and PAPP smear

RNA: CPR
Calicivirus
Picornavirus
Reovirus

DNA: PAPP
*Polyoma
*Adenovirus
*Papilloma
*Parvovirus

Front 902

Viral envelopes: Source

Back 902

Plasma membrane

Exception: HBV (nuclear membrane)

Front 903

All DNA viruses replicate in the nucleus except for...

Back 903

Pox

Largest virus--needs room?

POX likes to DOT the cytoplasm

Front 904

All RNA viruses replicate in the cytoplasm except for...

Back 904

All DNA viruses replicate in the nucleus except for...

Front 905

DNA viruses

Back 905

HHAPPPPy viruses

Hepadnavirus (HBV)
*Partial circular
*Has reverse transcriptase (?)
*Acute or chonic hepatitis
*Vaccine available

Herpes
*HSV-1, HSV-2, VZV, EBV, CMV, HHV-6, HHV-8

Adenovirus
*Sore throat w/fever
*Pneumonia
*Pink eye (conjunctivitis)

Polyoma
*Circular DNA
*"JC virus:" PML in HIV

Papilloma (HPV)
*Circular DNA
*Warts, Cervical cancer

Pox
*Largest DNA virus
*Replicates in cytplasm
*Smallpox
*Vaccinia--cowpox (milkmaid's blisters)
*Molluscum contagiosum

Parvovirus (B19)
*Smallest DNA virus
*Aplastic crisis in sickle cell disease
*Hydrops fetalis
*Slapped cheeks rash/5th's disease

Front 906

What virus has reverse transcriptase, even though it isn't a retrovirus?

Back 906

HBV

Front 907

HSV

Back 907

DNA virus
Linear, enveloped

HSV-1: Respiration, saliva
*Oral > genital lesions
*Keratoconjunctivitis
*Temporal encephalopathy

HSV-2: Sexual contact, perinatal
*Genital > Oral lesions
*Neonatal herpes

VZV: Respiratory secretions
*Chickenpox
*Zoster
*Shingles

EBV: Respiratory secretions, saliva
*Mononucleosis
*Burkitt's lymphoma

CMV: BODY FLUIDS (including urine)
*Infection in immunosuppressed patients (esp after transplant)
*Congenital defects

HHV-6: Roseola (exanthem subitum)

HHV-8: Sexual
*Kaposi's sarcoma

Front 908

Icosahedral viruses

Back 908

All SS (+) + Reovirus (ds)

POSITIVE ICOns

CPR--No envelope
FRT--Envelope

Calicivirus: CRUISE SHIP hazards
*Hepatitis E
*Norwalk virus

Picornavirus: PERCH
*Poliovirus
*Echovuris (aseptic meningitis)
*Rhinovirus (common cold)
*Coxsackie (Aseptic meningitis, febrile pharyngitis/herpangina, HFM disease)
*Hepatitis A

Reovirus (ds)
*Rotavirus: #1 fatal diarrhea in children
*Colorado tick fever

Flavivirus
*Hepatitis C
*Yellow fever
*Dengue
*St. Louis encephalitis
*West nile virus

Retrovirus
*HIV
*HTLV

Togavirus
*Rubella (German measles)
*EEE
*WEE

Front 909

Helical RNA viruses

Back 909

All SS (-) except for Coronavirus (SS +)

BAD COP FR sale
*That's a NEGATIVE thing

BAD = Circular

B = Bunyavirus
*Hantavirus (hemorrhagic fever, pneumonia)
*California encephalitis
*Rift valley fever/Sandfly fever
*Crimean-Congo hemorrhagic fever

A = Arenavirus:
*LCV--lymphocytic choriomeningitis
*Lassa fever encephalitis--spread by mice

D = Deltavirus: Hepatitis D

C = Coronavirus: "Common cold" + SARS

O = Orthomyxovirus: Influenza

P = Paramyxovirus: PaRaMyo (PRMM)
*Parainfluenza (Croup)
*RSV (bronchiolitis in babies)
*Measles (Rubeola)
*Mumps

F = Filoviruses: Ebola/Marburg

R = Rhabdovirus: Rabies

Front 910

Paramyxovirus

Back 910

SS (-) Helical
Cause disease in CHILDREN

PaRaMyxo = PRMM

Parainfluenza (Croup)

RSV (bronchiolitis in babies)

Measles (Rubeola)
*Buccal KOPLIK SPOTS (red w/white-blue)
*Rash: HEAD --> TOE
*3C's: Cough, Coryza (nasal congestion), Conjunctivitis

Mumps
*Makes parotids, testes swell like POM-POMs
*POM: Parotitis, Orchitis, Meningitis

Front 911

Vaccines

Back 911

Live attenuated: B and T cells
*MMR
*Sabin (livin)
*VZV
*Yellow fever
*Smallpox

Killed: RIP Always
*B cells only (but less dangerous)

R = Rabies
I = Influenza
P = Polio--Salk (salK = Killed)
A = Hepatitis A

Recombinant: HBV (HBsAg)

Front 912

Viral reassortment

Back 912

Occurs w/SEGMENTED genomes

BOAR:
*Bunyavirus
*Orthomyxovirus: Influenza
*Arenavirus
*Reovirus

Viruses exchange segments

Cause of worldwide influenza pandemics

Front 913

Hepatitis

Back 913

HAV = Picornavirus

HBV = DNA

HCV = Flavivirus
*C how flavorful?

HDV = Deltavirus

HEV = Calicivirus
*Cruise ships

Front 914

Phenotype mixing

Back 914

Viral co-infection

DNA from one virus can be packaged in the capsid for another

Front 915

EBV diagnosis

Back 915

Infects B CELLS
*Hodgkin's and Burkitt's lymphoma

Spread via respiratory and saliva
Peak age 15-20

Detect w/monospot test:
*HETEROPHIL ANTIBODIES

Presentation:
*Abnormal circulating CD8 CELLS
*Fever
*HSmegaly
*Pharyngitis
*Lymphadenopathy (posterior auricular nodes)

Front 916

Yellow fever

Back 916

Flavivirus

Aedes mosquitos
Monkey or human reservoir...watch out John!

Really YELLOW, BLACK and RED:
Jaundice
Black vomit
Fever

Front 917

Rubella

Back 917

a.k.a. German measles
*Togavirus

Fine truncal rash (hidden under clothing...still look BELLA)
+
SUB-OCCIPITAL LYMPHADENOPATHY
+
Fever,arthralgia

Children: Mild disease
Congenital: Severe defects (PDA, Pulmonary artery stenosis, etc)

Front 918

Rotavirus

Back 918

A reovirus...dsRNA

Major cause of acute diarrhea in US

#1 cause of fatal childhood diarrhea worldwide

VILLOUS DESTRUCTION
*Decreased absorption of Na+, H20

Front 919

Rabies

Back 919

Rhabdovirus
SS (-) Helical

Night creatures: Bat, racoon skunk

Virus has BULLET shaped capsid

NEGRI bodies: Cytoplasmic inclusions in affected neurons

Presentation:
1. Siezures
2. Hyperactive oropharynx
*Hypersalivation
*Pharyngeal spasm --> Hydrophobia

Front 920

Hepatitis A

Back 920

RNA Picornavirus

ASYMPTOMATIC
ACUTE
ALONE (no carriers)

Fecal oral
Short incubation (3 weeks)

Front 921

Hepatitis B

Back 921

DNA virus

BLOOD BORNE (parenteral, sexual)

Long incubation (3 months)

Contains REVERSE TRANSCRIPTASE to circumvent cell transcription

GROUND GLASS HEPATOCYTES

Front 922

Hepatitis C

Back 922

RNA Flavivirus SS (+), Icosahedral

Chronic (80%) --> CIRRHOSIS, CA

Transmitted primarily via BLOOD
Most common hepatitis among IV drug user

Front 923

Hepatitis D

Back 923

RNA Deltavirus SS (-), Helical

Requires HBsAg as its envelope

Superinfection worse than coinfection

Front 924

Hepatitis B

Back 924

RNA calicivirus SS (+), Icosahedral

Fecal-oral (water-born epidemics)

Resembles HAV, except w/respect to PREGNANT WOMEN (high mortality):
Acute
Asymptomatic
Alone (no carriers)

HBsAg (surface) --> Carrier state

HBcAg (core) --> Carrier state

HBeAg (core) --> Active viral replication and TRANSMISSABILITY

HBsAb (surface) -->Immunity
*Recovery
*Vaccination

HbcAb (core) --> Infection happened
*Seen almost immediately
*Present in recovered OR carrier state
*IgMcAb = Recent infection
*IgGcAb = Awhile ago

HBeAb --> Indicates low transmissability

Front 925

HIV surface proteins

Back 925

Outside to inside:
gp120 = Envelope protein
gp41 = Envelope protein (holds gp120)
p17 = matrix protein
p24 = Rectangular capsid protein

Infection:
*CD4 T cells: CXCR4
*CD5 Macrophages: CCR5

CCR5 mutation:
*Heterozygous = Slower course
*Homozygous = Immunity

Front 926

HIV, AIDS diagnosis

Back 926

1. ELISA -- Low threshold
2. Western blot (protein) --High threshold

False negatives: 1-2 mo post-infection
False positives: Babies born to HIV-infected mothers (anti-gp 120 crosses placenta)

AIDS =
CD4 under 200
CD4:CD8 ratio under 1.5
HIV w/AIDS indicator (PCP)

Front 927

Chronic hepatitis states

Back 927

Carrier state = No symptoms

Chronic persistent:
*Minimal symptoms, LFTs
*Portal inflammation but NO NECROSIS

Chronic active:
*Symptoms, LFTs
*Portal inflammation and necrosis

Cirrhosis:
*Bridging fibrosis
*Portal HTN
*Ascites

Front 928

Low CD4 counts: Associated conditions

Back 928

**Throat, lungs, brain**

Under 100:
Candida esophagitis
Histoplasmosis
Toxoplasmosis

Under 50:
CMV retinitis and esophagitis
M. avium-intracellulaire
Cryptococcal meningoencephalitis

Front 929

Normal flora: Nose

Back 929

Staph epidermidis (also normal on skin)

Staph aureus

Front 930

Normal flora: Oropharynx

Back 930

Strep Viridans

Strep Mutans (subgroup of viridans)
*Cavities, plaque

Front 931

Normal flora: Colon

Back 931

Bacteriodes fragilis > E. coli

Front 932

Normal flora: Vagina

Back 932

LEG BS
LEG BS

Lactobacillus > E. coli, Group B strep

Front 933

Neonatal pneumonia (<4 weeks)

Newborn meningitis (0-6 mo)

Back 933

Pathogens are vaginal flora:

E. coli
Group B strep

+ Listeria (milk) for meningitis

Front 934

Pneumonia: Most common pathogens

Back 934

Neonates (Up to 4 weeks):
*E. coli
*Group B strep

Non-neonate children (up to 18):
*Runts May Cough Sputum

RSV
Mycoplasma
C. Pneumoniae
Strep pneumoniae

Adults 18-40: Just remove RSV

Adults 40-65: Remove C. pneumoniae
*Add H. Influenzae
*Add Anaerobes
*Add Viruses

Elderly: Remove mycoplasma
*Add GNRs

Front 935

Meningitis: Most common pathogens

Back 935

Up to 6 months:
*E. coli
*Group B strep
*Listeria (milk)

6 mo-6 years: HIB (v) + S.E.N.
*Strep pneumo
*Enteroviruses
*Neisseria

Adults 6-60: Remove HIB

Adults 60: Listeria returns
*Step pneumo only SEN remnant
*Add GNRs

Front 936

UTIs

Back 936

Risk factors:
*Flow obstruction/surgery/catheter
*Gynecologic abnormalities
*DIABETES
*PREGNANCY (stasis)

SSEEK PP
*Atypicals are "nocosomial, drug resistant"

S. Saprophyticus: #2 UTI cause in sexually active women

Serratia marcesens:
*Some produce red pigment

E. Coli: #1 cause
*METALLIC SHEEN on EMB AGAR

Enterobacter cloacae

Klebsiella: #3 cause
*Mucoid capsule, viscous

Proteus mirabilis:
*Motile --> Swarming
*Struvite stones

Pseudomonas: Blue-green, fruity

Front 937

TORCHS

Back 937

Toxoplasma:
*Intracranial CALCIFICATIONS (also CMV)
*HYDROCEPHALUS
*Chorioretinitis

[Other]

Rubella: Isolated
*HEART defects (PDA, PA stenosis)
*Mental retardation
*Deafness
*CATARACTS

CMV: 90% asymptomatic at birth
*CALCIFICATION (also toxo)
*Mental retardation
*HSmegaly, JAUNDICE, petechiae

HSV-2: Often asymptomatic at birth
*ENCEPHALITIS
*Conjunctivitis
*VESICULAR skin lesion

HIV:
*HSmegaly
*Frequent INFECTIONS
*Neurologic abnormalities

Syphilis
*Cutaneous lesions
*HSmegaly, JAUNDICE
*SADDLE NOSE
*SABER CHIN
*Hearing loss (CN VIII)
*HUTCHINSON teeth

Front 938

Chancroid

Back 938

Haemophilus ducreyi

Painful genital ulcer
Inguinal lymphadenopathy

Front 939

PID: Most common causes

Back 939

C. trachomatis (3-4 million cases/yr)
*Subacute, often undiagnosed
*Chandelier sign (cervical motion tenderness)
*Purulent discharge

Neisseria Gonorrhoeae
*Acute, high fever
*Purulent discharge

Front 940

Most common nosocomial UTIs

Back 940

Risk factor = Catheterization

E. coli --> Most common anyway
Proteus --> Can swim

Front 941

Most common infection while on respiratory therapy equipment

Back 941

Pseudomonas aeruginosa

Front 942

Most common infection w/hyperalimentation (overfeeding)

Back 942

Candida albicans

Front 943

Most likely to infect pus, empeyema, abscess

Back 943

S. Aureus

Front 944

Traumatic open wound

Back 944

Clostridium perfringens

Front 945

Surgical wound

Back 945

S. aureus

Front 946

Sepsis/meningitis in a newborn

Back 946

Group B strep

Front 947

Bacteriostatic anti-microbials (5)

Back 947

We're ECSTaTiC (ECSTTC) about bacteriostatics

Erythromycin --> 50s
Clindamycin --> 50s
SMP-TMX --> Nucleotide synthesis
Tetracyclines --> 30s
Chloramphenicol --> 50s

Front 948

Bacteriocidal anti-microbials

Back 948

Very Finely Proficient At Cell Murder

Vancomycin --> Peptido synthesis
Fluoroquinolones --> DNA toposomerase
Penicillin --> Peptidoglycan X-linking
Aminoglycosides --> 30S
Cephalosporins --> Peptidoglycan X-linking
Metronidiazole

Front 949

Penicillin

Back 949

Prototype B-lactam

Penicillin G (IV)
Penicillin V (oral) --> Packman mouth

Binds PENICILLIN BINDING PROTEINS
*Blocks TRANSPEPTIDASE cross-linking of cell wall

Activates autolytic enzymes

Uses: Bactericidal
*Gram (+) organisms
*Gram (-) cocci (Neisseria)
*Spirochetes (Borellia, Leptospira, SYPHILUS)

SE:
*Hypersensitivity (all B-lactams)
*HEMOLYTIC ANEMIA

Front 950

Penicillinase resistant penicillins

Back 950

Methicillin, Nafcillin, Dicloxacillin
*On the MeND

**Use NAF for STAPH**

Bulkier R group = Penicillinase resistance

Use: STAPH
*Not MRSA; altered penicillin binding site

SE:
*Hypersensitivity (all B-lactams)
*Methicillin: Interstitial nephritis

Front 951

Aminopenicillins

Back 951

Ampicillin
Amoxicillin (more oral bioavailability)

Penicillinase sensitive: combine w/clavulanic acid (penicillinase inhibitor)

Uses: HELPS
*H. Influenza
*E. coli
*Listeria
*Proteus
*Salmonella

SE:
*Hypersensitivity (all B-lactams)
*Ampicillin: Rash
*C. DIFFICILE

Front 952

Antipseudomonal penicillins

Back 952

TCP: Takes Care of Pseudomonas
Ticarcillin
Carbenicillin
Piperacillin

Penicillinase sensitive: combine w/clavulanic acid (penicillinase inhibitor)

Use: PSEUDOMONAS

SE:
*Hypersensitivity (all B-lactams)

Front 953

Cephalosporins: General info

Back 953

B lactam drugs that inhibit cell wall cross-linking
*Less susceptible to penicillinases

Bactericidal

SE: All about other drugs

1. 5-10% cross reactivity w/penicillins

2. Alcohol: Disulfram-like reaction

3. Aminoglycosides: > nephrotox
*Take Aminoglycosides w/Aztreoam instead (synergistic)

Front 954

1st generation cephalosporins

Back 954

B lactams

CefaZOlin, CefaLEXin
*Zoe and Lexi

Uses: Gram (+) cocci + PEcK
*Proteus
*E. coli
*Klebsiella

Front 955

2nd generation cephalosporins

Back 955

B lactams

CeFAClor, CeFOXitin, CeFURoxime
*FAKE FOX FUR

Uses: Gram (+) cocci + HEN PEcKS
*H. Influenza
*Enterobacter aerogenes
*Neisseria
*Proteus
*E. coli
*Klebsiella
*Serratia

Front 956

3rd generation cephalosporins

Back 956

B lactams

CefTriaxone, CefoTaxime, CeTazidime
*Cef-T

Uses:
*Meningitis (crosses BBB)
*Serious/resistant gram (-) infections (Pseudomonas, gonorrhea

Front 957

4th generation cephalosporins

Back 957

B lactams

CefiPime ~ Pseudomonas

Uses: PSEUDOMONAS (just like 4th class of penicillins)

Front 958

Aztreonam

Back 958

Monobactam

Binds to PBP3, but resistant to B lactamases

Synergistic w/aminoglycosides
No penicillin cross-reactivity

Uses: Gram negative rods
*PEcKS without the E --> Proteus, Klebsiella, Serratia

Front 959

Imipenem/Cilastatin, Meropenem

Back 959

Carbapenems
B-lactamase resistant

Imipenem always administered w/CILASTATIN
*Inhibits renal dihydropeptidase I
*Prevents inactivation in renal tubules

Uses: ENTEROBACTER
*IMIpenem--if death is IMInent
*MEROpenem--merrier option

SE:
*SEIZURES (more w/Imipenem)
*GI distress, skin rash

Front 960

Vancomycin

Back 960

Bactericidal

Inhibits cell wall MUCOPEPTIDE:
*Binds D-ala D-ala portion of cell wall
*Resistance: D-ala changed to D-lac

Use: GRAM (+) multidrug resistant
*MRSA
*Clostridium difficile

SE: N.O.T. many problems
N = Nephrotoxicity
O = Ototoxicity
T = Thrombophlebitis + Red man

Red man = Diffuse flushing
*"Red man VANquished by dz"
*Prevented w/antihistamines

Front 961

Aminoglycosides

Back 961

Bacteriocidal--binds 30s subunit

Gentamycin, Neomycin, Amikacin, Tobramycin, Streptomycin
*GNATS

Inhibits formation of initiation complex --> misreading if mRNA

Synergistic w/B-lactams, but DON'T take w/cephalosporins

Use: Severe GNR infections
*Bowel surgery = Neomycin
*Requires O2 for uptake: ineffective against anaerobes

SE: "Mean GNATS can NOT kill anerobes"
*N = Nephrotoxicity (esp. w/cephalosporins)
*O = Ototoxicity (esp. w/loop diuretics
*T = Teratogen

Front 962

Tetracyclines

Back 962

Tetracyclines--bacteriostatic

The CYCLINES: Tetracycline, doxycycline, demeclocycline, minocycline

30S binder
Blocks subsequent tRNA binding after Met

*Limited CNS penetration: doesn't affect the "tet"

*Doxycycline--OK w/renal failure
*Dimeclocycline--SIADH (ADH antagonist)

*Absorption VERY susceptible to Ca2+, Fe2+ in stomach

Uses: VACUUMS THe Bed Room
*Vibrio cholerae
*A = Acne
*Chlamydia
*Ureaplasma
*Urealyticus
*Mycoplasma
*S = SIADH (Dimeclocycline)

*Tularemia (francisella)
*H. Pylori
*Borellia burdorferi
*Rickettsia

Tox:
*Contraindicated in pregnancy
*GI distress
*Photosensitivity
*Discoloration of teeth
*Inhibits bone growth in children

Front 963

Macrolides

Back 963

THROMYCINs (remember that aminoglycosudes have "mycins")
*Erythromycin
*Azithromyin
*Clarithromycin

Bacteriostatic

Binds to 50s subunit and blocks translocation
*Macrolides = NO SLIDES

Use: Gram (+) cocci + MLCN it (Milkin it)
*Mycoplasma
*Legionella --> Fac intracellular
*Chlamydia --> Ob intracellular
*Neisseria --> Fac intracellular

SE: "No slide" = Friction = IRRITATION
*Eosinophilia and rashes
*GI DISCOMFORT (#1 noncompliance)
*Acute CHOLESTATIC hepatitis --> Theophyllines, Anticoagulants higher

Front 964

Chloramphenicol

Back 964

Bacteriostatic

Binds to 50s subunit and blocks PEPTIDYLTRANSFERASE

Uses: MENINGITIS, including HIB
*Conservative (toxicity)
*HIB, S. Pneumo, Neisseria

SE:
1. CLORAMPHENICOL CLEANS OUT the marrow:
*Dose-dependent anemia
*Dose-independent aplastic anemia

2. GRAY BABY (chrome)
*Premature infants lack UDP-glucuronyl transferase

Front 965

Clindamycin

Back 965

Bacteriostatic

Binds to 50S subunit and blocks peptide bond

Uses: CLINDA in the CLOUDS (treats inf above diaphragm), but no AIR (anaerobes)
*Actinomyces
*Bacteriodes
*Clostridium

SE: Treats above the diaphragm, but SE are below
*Pseudomembranous colitis
*Fever

Front 966

Sulfonamides

Back 966

Bacteriostatic

Sulfamethoxasole, sulfisoxazole, triple sulfas, sulfadiazine

Inhibits (folate) nucleotide synthesis:
DihydroPTEROATE SYNTHETASE

Uses: Simple UTI
*HUGE RANGE (gram +/-)
*Norcardia
*Chlamydia

SE:
*Hypersensitivity reactions
*Tubulointerstitial nephritis
*Photosensitivity
*HEMOLYSIS w/G6PD
*KERNICTERUS (infants)
*Interactions w/warfarin (albumin)

Front 967

Trimethoprim

Back 967

Basteriostatic

Inhibits (folate) nucleotide synthesis:
DihydroFOLATE REDUCTASE

Uses: Recurrent UTI + Super Serious Problems (SSP)
*Shigella
*Salmonella
*Pneumocystis jirovecii pneumonia

SE: TMP =TREATS MARROW POORLY
*Megaloblastic anemia
*Leukopenia
*Granulocytopenia

Try supplemental folinic acid

Front 968

Sulfa drug allergies

Back 968

Celecoxib--Cox 2 inhibitor

Sulfonamides --Broad spectrum antibiotic

Sulfasalazine (5-ASA) -- IBD

Sulfonylureas -- Induce Beta cell insulin release in DM II (K+ channel)

Thiazide diuretics -- BP, urine Ca2+ loss, nephrogenic DI

Loop diuretics

Acetazolamide -- Glaucoma, altitude sickness, uric acid stones

Front 969

Flurodoquinolones

Back 969

Bactericidal

The FLOXACINS + nalidixic acid (quinolone)

Inhibits DNA topoisomerase II
*Must not be taken w/antacids

Use: GNRs, Neisseria

SE: QUINOLONES hurt attachments to BONES
*Adults = tendonitis, rupture
*Children = leg cramps, myalgias
*Pregnancy = cartilage damage

Superinfection
GI upset --> DON'T take antacid!
Skin rash
Headache, dizziness

Front 970

Metronidiazole

Back 970

Bactericidal

Forms toxic metabolites--damage bacterial DNA

Uses: GET GAP on the Metro, not trashed!
GET = Protozans
G = Giardia
E = Entamoeba
T = Trichomonas

GAP = Bacteria
G = Gardnerella
A = Anaerobe (Acti, Bacteri, Clostridi)
P = H. Pylori

Part of "make tummy better"
*Metronidiazole or PPI
*Tetracycline (or amOxicillin)
*Bismuth

SE:
*Disulfram-like reaction
*Metallic taste (metro~metal)

Front 971

Polymixins

Back 971

Polymixin B and E

Cationic, basic proteins that act like detergent

POSITIVE MOLECULES that kill GRAM NEGATIVE bacteria

SE: NRTN (norton)
*Neurotoxicity
*Renal tubular necrosis (RTN)

Front 972

TB drugs

Back 972

INH-SPIRE

Ethambutol = ETHICAL, but the world may not look as BUTIFUL
*No hepatotoxicity
*Red-green color blindness

All others = Hepatotoxicity

INH: PROPHYLAXIS and treatment
*INH ~ injures neurons + hepatocytes

Streptomycin (aminoglycoside)
*NOT: Neurotoxicity, Ototoxicity, Teratogen

Pyrizinamide

Rifampin--treats all mycobacteria
*Rapid resistance if used alone

Ethambutol
*Red-green color blindness

Front 973

INH

Back 973

soniazid

Decreases synthesis of mycolic acids

Uses: TB treatment + prophylaxis

INH ~ injures NEURONS + HEPATOCYTES
*Prevent neurotoxicity w/B6
*Highly variable t1/2 (acetylation)

Anion gap metabolic acidosis

G6PD hemolysis

SLE-like syndrome

Front 974

Rifampin

Back 974

Inhibits DNA-dependent RNA polymerase

4R's:
*RNA polymerase inhibitor
*RAPID resistance if used alone
*REVS up p-450 (minor hepatotox)
*RED/orange body fluids

Uses: Always in combo (rapid resistance)

1. All mycobacteria (TB, leprosy, MA-I)

2. Meningitis prophylaxis: Neisseria, HIB

SE:
*REVS up p-450 (minor hepatotox)
*Red/orange body fluids

Front 975

Most common form of resistance to macrolides

Back 975

Methylation

Front 976

Most common form of resistance to tetracyclines

Back 976

Transport

Increased removal or decreased uptake

Front 977

Drug of choice for meningococcal prophylaxis

Back 977

Rifampin

Front 978

Drug of choice for gonorrhea prophylaxis

Back 978

Ceftriaxone

Don't even TRI

Front 979

Drug of choice for prevention of recurrent UTIs

Back 979

TMP-SMX

Front 980

Drug of choice for Pneumocystis jirovecii prophylaxis

Back 980

TMP-SMX

Front 981

Drugs of choice for VRE

Back 981

Very pristine striped linoleum
*Very = VRE
*Pristine = Pristins
*Striped = Streptogramins
*Linoleum = Linezolid

Linezolid
Streptogramins (PRISTINS)

Front 982

Amphotericin B

Back 982

AmphoTERicin TEARs holes:
*Binds ERGOSTEROL (unique to fungi)
*Forms a membrane PORE

Does not cross BBB

Uses:
*Systemic mycoses, Candida, Crypto
*ASPERGILLIS, MUCOR
*Give intrathecally for meningitis

Liposomal amphotericin reduces toxicity

SE: "Amphoterrible"
*SHAKE and BAKE (fever, chills)
*Nephrotoxicity: Reduce w/H2O
*Hypotension, phlebitis
*ANEMIA, arrhythmia

Front 983

Nystatin

Back 983

*Binds ERGOSTEROL (unique to fungi)
*Forms a membrane PORE

Too toxic for systemic use

Uses: Topical candida
*Oral candidiasis (swish and swallow)
*Diaper rash
*Vaginal candidiasis

Front 984

Azoles

Back 984

AZOLES

Inhibit fungal ergosterol SYNTHESIS

Uses: Doesn't get aspergillus, mucor
*Fluconazole: Candida + Cryptococcal meningitis in AIDS patients (crosses BBB)
*CloTRIMazole, MIconazole: Topical
*Ketoconazole: Systemic mycoses, candida

SE:
*Also SHAKE and BAKE (like ampho)
*DESMOLASE inhibition (Cholesterol --> Pregnenolone); gynecomastia
*Inhibits p-450

Front 985

Flucytosine

Back 985

Inhibits fungal DNA synthesis by conversion to FLUOROURACIL
*Competes w/uracil

Uses: Add-on to amphotericin B

SE:
*Bone marrow suppression (w/AmphoB = 2 hits toward anemia)
*N/V/D

Front 986

Caspofungin

Back 986

Inhibits cell wall synthesis

ASPERGILLUS

SE: GI upset, FLUSHING (not like casper)

Front 987

Turbinafine

Back 987

"Squealing turbine"

Inhibits SQUALENE EPOXIDASE

DERMATOPHYTES
Esp. Onychomycosis (toe fungus

Front 988

Griseofulvin

Back 988

Interferes w/microtubule function

"GREASY NAILS": Deposits in keratin-containing tissues

Use: Oral treatment of superficial infections
*Tinea, ringworm, etc.

SE:
*CARCINOGEN
*Teratogen
*P-450, warfarin metabolism stimulator
*Confusion, headaches

Front 989

Amantidine

Back 989

Influenza A drug

90% resistance

Front 990

Zanamivir, Oseltamivir

Back 990

Inhibit influenza NEURAMINIDASE
*Both influenza A and B

Decreases RELEASE of progeny virus

Mivir ~ Come here (don't go out)

Front 991

Ribavirin

Back 991

Inhibits IMP DEHYDROGENASE
*Guanine synthesis ~ GIMP

Uses: RSV, Chronic HCV

SE:
Hemolytic anemia
Severe teratogen

Before birth --> Teratogen
After birth --> Cure RSV, but may lower RBCs

Front 992

Acyclovir, Famciclovir

Back 992

Needs to be phosphorlyated by HSV/VZV THYMIDINE KINASE
*No thymidine kinase ~ resistance

Inhibits viral DNA polymerase by chain termination

Not effective on latent forms

Acyclovir: EBV, HSV (lesions, encephalitis)
Famiciclovir: VZV

SE: Well tolerated

Front 993

Ganciclovir

Back 993

Needs to be phosphorlyated by CMV VIRAL KINASE (or HSV/VZV thymidine kinase)

Inhibits viral DNA polymerase

Uses: CMV (esp. w/transplant)

SE: Worse than acyclovir, famciclovir
*Bone marrow suppression
*Renal toxicity

Front 994

Foscarnet

Back 994

VIRAL DNA POLYMERASE inhibitor that does NOT require phosphorylation (acyclovir, famciclovir, and gancyclovir all do)

PyroFOSphate analog: Binds to the pyrophosphate binding site of VIRAL DNA POLYMERASE

Uses: BACKUP
*CMV retinitis when Gancyclovir fails
*Acyclovir-resistant HSV

SE: NeFron --> Renal toxicity

Front 995

HIV therapy types (3)

Back 995

Protease inhibitors
*Prevents assembly of a new virus

Reverse transcriptase inhibitors
*Nucleosides
*Non-nucleosides

Fusion inhibitors (Enfuvirtide)
*Bind GP41--block fusion w/CD4

Front 996

Protease inhibitors

Back 996

HIV treatment

"NAVIRs" --> NAVIR TEASE a proTEASE

Inhibit assembly of a new virus

SE: GILTY
*GI intolerance
*Lipodystrophy
*Thrombocytopenia (indinavir)
*hYperglYcemia

Use: HAART therapy (RTI + PI)
*CD4 < 500
*High viral load

Front 997

Reverse transcriptase inhibitors

Back 997

HIV treatment

Inhibit reverse transcriptase
Prevent viral incorporation into genome

Nucleosides: Lactic acidosis
*Competitive inhibitors of RT

Zidovudine (ZDV a.k.a. AZT)
*Pregnancy prophylaxis
*Megaloblastic anemia
Didanosine (ddI)
Zalcitabine (ddC)
Stavudine (d4T)
Lamivudine (3TC)
Abacavir

Non-nucleosides: Rash
**Never Ever Deliver nucleosides**
*NON-competitive inhibitors of RT

*Nevirapine
*Efavirenz
*Delavirdine

Use: HAART therapy (RTI + PI)
*CD4 < 500
*High viral load

SE:
*Bone marrow suppression
*Peripheral neuropathy

Front 998

Fusion inhibitors

Back 998

HIV therapy

**EnFUvirtide**

Bind viral gp41 to prevent fusion w/CD4

Use: 2nd line--persistent viral replication despite anti-retroviral therapy

SE:
*Hypersensitivity
*Bacterial pneumonia

Front 999

Lymph node structure

Back 999

Secondary lymphoid organ
*Many afferents (enter cortex) *1+ efferent (exits by artery, vein)

**BTMP**
(Cortex to medulla)

Cortex: B cells
*Primary follicles are dense, dormant
*Secondary follicles (active) have pale germinal centers

Paracortex: T-cells and HEVs
*HEV: Where B and T cells enter from blood
*Not well-developed w/DiGeorge

Medulla: Medullary cords and sinuses
*Cords = Plasmas, lymphocytes
*Sinuses = Macrophages, reticular cells

Macrophages ~ Mobile (sinuses)

Front 1000

Stomach lymphatic drainage site

Back 1000

Celiac nodes

Cecelia, you're breakin my STOMAC

Front 1001

Duodenum, jejunum lymphatic drainage site

Back 1001

Superior mesenteric nodes

DJ = Tallest (superior) sister

Front 1002

Sigmoid, rectum and anal canal lymphatic drainage

Back 1002

Signmoid: Colic nodes --> Inferior mesenteric nodes

Sigmoid says there's an INFERIORITY complex behind the COLIC

Rectum and upper anal canal (above pectinate line): Internal iliac nodes

Lower anal canal: Superficial inguinal nodes

Front 1003

Scrotum, superficial thigh and lower anal canal lymphatic drainage

Back 1003

Superficial inguinal nodes

Front 1004

Lateral dorsum of foot lymphatic drainage site

Back 1004

Popliteal nodes

Front 1005

Right lymphatic duct drainage

Back 1005

Right arm
Right half of head

Front 1006

Thoracic duct drainage

Back 1006

Everything except what right lymphatic duct drains (right arm, right half of head)

Front 1007

Primary and secondary lymphoid organs

Back 1007

Primary: Lymphoid organs that develop early immune cells

Bone marrow
Thymus

Secondary: Lymphoid organs that house mature immune cells

Lymph nodes --> Encapsulated
Spleen --> Encapsulated
MALT, GALT --> Unencapsulated

Front 1008

Spleen structure

Back 1008

MBTA (Outside to inside)

MACROS, APCs, T cells--red pulp
B cells (Follicles)--white pulp
T cells (PALS)
Central arteriole

Red pulp:
*Vascular channels w/fenestrated BM ("BARREL HOOP")
*Macrophages (remove encapsulated bacteria)

PALS = Periarterial lymphatic sheath

Arises from dorsal mesentary but fed by branches of the celiac artery (splenic a)

Front 1009

"Barrel hoop" basement membrane

Back 1009

Red pulp of the spleen

Front 1010

Thymus

Back 1010

3rd branchial pouch origin

Encapsulated

Cortex = Immature T cells

Corticomedullary junction
*Positive selection (MHC restriction)
*Negative selection (nonreactive to self)

Medulla = Mature T cells (pale)
*Epithelial reticular cells
*HASSALL'S CORPUSCLES (granular cell center, concentric epithelial layers)

Front 1011

Differentiation of T cells

Back 1011

After creation in marrow DIRECTLY to thymus
*No receptors or other defining features

Thymus:
1. CD4+ CD8+
2. CD4+ OR CD8+ (cytotoxic)
3. CD4+ T cells further differentiate:
*IL-12 --> TH1
*IL-4 --> TH2

Front 1012

TH1 cells

Back 1012

Differentiation induced by IL-12
*Origin: B cells and macrophages

Secretes:

IL-2
*Stimulates CD8 cells
*Autostimulation

IFN-gamma
*Stimulates MACROS

Inhibits TH2 cells via: IFN-gamma

Front 1013

TH2 cells

Back 1013

Differentiation induced by IL-4
*Origin: Other TH2 cells

Secretes:

IL-4
*Activates B cells
*Induces class switching to IgE > IgG

IL-5
*Promotes differentiation of B cells
*Induces class switching to IgA
*Stimulates eosinophils (production, activation)

Inhibited by: IFN-gamma

EOSINOPHIL STIMULATION AND IGE CLASS SWITCHING ARE NOT PART OF THE SAME IL FUNCTION

Front 1014

What cells control TH1 differentiation?

Back 1014

B cells and macrophages (secrete IL-12)

Front 1015

What cells control TH2 differentiation?

Back 1015

TH2 cells

Front 1016

MHC-1

Back 1016

Encoded by 3 genes:
HLA-A
HLA-B
HLA-C

Expressed on almost all nucleated cells

Reflects material from RER
*Mostly intracellular

MEDIATES VIRAL IMMUNITY

Pairs w/B2 MICROGLOBULIN to form complete receptor

Front 1017

MHC-II

Back 1017

Encoded by 3 genes:
HLA-DP
HLA-DQ
HLA-DR

Expressed only on APCs
*B cells
*Macrophages
*Dendritic cells

Reflects material from acidified endosome
*Extracellular material

Receptor has alpha and beta subunits
*Roughly equal in size

Front 1018

Immune cells and hypersensitivity

Back 1018

Type 1 = IgE (B cells)

Type 2 = IgG (B cells)

Type 3 = IgG (B cells)

Type 4 = CD8 T cells

Front 1019

APCs

Back 1019

My BaD (MBD)

Macrophages
B cells
Dendritic cells

Have MHC II complexes
Bind to CD4 T cells

Front 1020

CD4 T cells: Costimulatory signa

Back 1020

After binding to MHC II...

CD28 on CD4 cell
+
B7 on B cell (or other APC)

(7 x 4 = 28)

Front 1021

CD8 T cells: Costimulatory signal

Back 1021

After binding to MHC 1...

Cytotoxic T cell needs IL-2 from a TH1 helper cell

Front 1022

Antibody structure

Back 1022

2 light chains + 2 heavy chains
*Each have variable (antigen-recognizing) and constant regions
*Each have inter-chain and intra-chain disulfide bonds

Fab = Upper half
*Binds antigen
*Amino end

Fc = Lower half
*Completely constant (vs. partially)
*Carboxy terminal
*COMPLEMENT binding (IgG + IgM only)
*Carbohydrate chains

Front 1023

Antibody diversity

Back 1023

Recombination of VJ (light chain) or VDJ (heavy chains) genes
*Addition of nucleotides occurs via terminal DEOXYNUCLEOTIDYL TRANSFERASE

Random combination of established heavy and light chains

Somatic hypermutation (post-antigen recognition)

Front 1024

Isotype switching is mediated by...

Back 1024

Cytokines

CD40 ligand
*Midlife crisis?

Front 1025

Complement binding Abs

Back 1025

IgG
IgM

Driving a GM gets you COMPLEMENTS?

Front 1026

Mature B cells originally express what Abs?

Back 1026

IgM

IgD

Front 1027

IgG

Back 1027

Crosses the placenta (UNIQUE)

Fixes complement (IgG + IgM only)

Promotes opsonization

Neutralizes bacterial toxins and viruses

Front 1028

IgA

Back 1028

Monomer or dimer found in secretions

Prevents attachment of bacteria/viruses to mucous membranes

Picks up SECRETORY COMPONENT from epithelial cells before secre

Front 1029

IgM

Back 1029

Monomer on B cell
Pentamer in serum

Produced in the PRIMARY response to an antigen (IgG later)

Fixes complement (IgG + IgM only)

Front 1030

IgD

Back 1030

Unclear function

Found on surface of many B cells and in serum

Front 1031

IgE

Back 1031

Lowest concentration in serum

1. Activates mast cells and basophils (induces mediator release)
*Type 1 hypersensitivity reactions

2. Activates eosinophils during parasitic infection

Front 1032

Ig Allotype

Back 1032

POLYMORPHISM

Immunoglobin epitope that differs among members of the same species

Constant regions of light chains or heavy chains

Front 1033

Ig Isotype

Back 1033

Immunoglobin epitope that is common to a class

IgA, IgM, IgG, etc.

Determined by heavy chain

Front 1034

Ig Idiotype

Back 1034

Determined by VARIABLE REGION

Immunoglobin epitope determined by antigen binding site

Front 1035

Cytokines released by macrophages

Back 1035

IL-1
IL-6 (also TH cells)
IL-8
IL-12 (also B cells)
TNF

Front 1036

Cytokines secreted by B cells

Back 1036

IL-12 (also macrophages)

Front 1037

Cytokines secreted by regulatory T cells

Back 1037

IL-10

Front 1038

Cytokine released by both cytotoxic and helper T cells

Back 1038

IL-3

Front 1039

Cytokine released by all helper T cells

Back 1039

IL-6 (also macrophages)

Front 1040

IL-1

Back 1040

Secreted by macrophages
*Possibly in response to techoic acid or LPS

ACUTE INFLAMMATION

*Induces chemokines --> WBC taxis

*Induces endothelium to express adhesion molecules

Front 1041

TNF

Back 1041

Secreted by macrophages
*Possibly in response to techoic acid or LPS

Mediates SEPTIC SHOCK
*WBC recruitment
*Vascular leak

Front 1042

IL-2

Back 1042

Secreted by TH1 cells

Stimulates growth of CD8 and TH1 cells

Front 1043

IL-3

Back 1043

Secreted by activated T cells

Supports growth and differentiation of BONE MARROW

Front 1044

IL-4

Back 1044

Secreted by TH2 cells

Promotes B cells

Class switching to IgE, IgG
*IgE > IgG

Front 1045

IL-5

Back 1045

Secreted by TH2 cells

Promotes B cells
Class switching to IgA

Promotes Eosinophils

Front 1046

IL-6

Back 1046

Secreted by TH cells and macrophages

Stimulates acute-phase reactants and immunoglobins

Anemia of chronic disease: IL-6 increases liver production of Hepcidin
*Hepcidin stops ferroportin from releasing iron stores

Front 1047

IL-8

Back 1047

Secreted by macrophages

Neutrophil recruitment

"Clean-up on aisle 8"
*Neutrophils recruited by IL-8 to clear infections

Front 1048

IL-10

Back 1048

Secreted by regulatory T cells

Inhibits all other T cells

Front 1049

IL-12

Back 1049

Secreted by B cells and macrophages

Activates TH1 cells

Activates NK cells

Front 1050

IFN-gamma

Back 1050

Secreted by TH1 cells

Activates macrophages

Front 1051

Helper T cell surface proteins

Back 1051

TCR/CD3 --> T cell

CD4 --> HELPER T cell
*Binds to MHC II

CD28 --> HELPER T cell
*Costimulatory signal

CD40L --> HELPER T cell
*General APC activation
*B cell class switching

Front 1052

CD8 cell surface proteins

Back 1052

TCR/CD3 --> T cell

CD8 --> Cytotoxic T cell

Front 1053

B cell surface proteins

Back 1053

Unique:
IgM
CD 19-21

Others are in common w/macrophage:

MHC II
*APC

B7: Costimulatory signal

CD40
*Class switching

Front 1054

Macrophage surface proteins

Back 1054

Unique:
CD14
Receptors for Fc and 3b

Others are in common w/B cell:

MHC II
*APC

B7: Costimulatory signal

CD40
*Activation by TH cell

Front 1055

NK cell surface proteins

Back 1055

Unique:
CD16
CD56

MHC I

Front 1056

Opsonins in bacterial defense

Back 1056

IgG

C3b

THAT'S IT

Front 1057

Decay accelerating factor

Back 1057

Deficiency leads to complement-mediated lysis of RBCs

Paroxysmal nocturnal hemoglobinuria (PNH)

Paroxysmal ~ I don't get it
*Are you DAFt?

Front 1058

C1 esterase

Back 1058

Inhibitor of complement activation

Protects self cells along w/DAF

Deficiency causees HEREDITARY ANGIOEDEMA
*Aunt ESTER and ANGIE in the HEREDITARY tree

Front 1059

Anaphylaxins

Back 1059

C3a, C5a

C5a also participates in neutrophil chemotaxis

Front 1060

Neutrophil chemotaxis

Back 1060

IL-8 (macrophages)

C5a (complement)

Front 1061

C3 deficiency

Back 1061

Severe, recurrent pyogenic sinus and respiratory tract infections

Front 1062

Deficiency of C6-8

Back 1062

Neisseria bacteremia

6-8 is never a NICE time to call

Front 1063

C5b-9

Back 1063

MAC

Responsible for complement-induced lysis

Front 1064

C1-4

Back 1064

Responsible for viral neutralzation

Front 1065

Classic complement pathway

Back 1065

C1 binds to Ag-Ab complex (IgG or IgM)

C1-C4b-C2a-3b-5b-6789

The only #out of place is 4

The only "a" is w/complement #2
*"B usually STAYS; A usually floats AWAY"

The point where 3b attaches is where opsonization (viral neutralization) can occur

Front 1066

Lectin complement pathway

Back 1066

Lectin binds to mannose on pathogen

Lectin-4b-2a-3b-5b-6789

Front 1067

Alternative complement pathway

Back 1067

C3 w/B and D bind to endotoxin or other part of microbial surface

C3b-Bb-C3b-5b-6789

DOUBLE C3b

Front 1068

Interferons

Back 1068

Put uninfected cells in an antiviral state

Induce ribonuclease that degrades viral mRNA

Increase activity of NK cells

Gamma interferon: Increase all MHC I, II expression and antigen presentation

Alpha: Alpha BC, KLM
*Hep B/C
*Kaposi's
*Leukemia
*Malignant melanoma

Beta: Multiple sclerosis

Gamma: NADPH oxidase deficiency
(Chronic Granulomatous Disease)

Inferferon SE = NEUTROPENIA

Front 1069

Passive immunity

Back 1069

Preformed Abs given after exposure to:

Tetanus toxin
Botulinum
HBV
Rabies

"TO BE HEALED RAPIDLY

Front 1070

Type 1 Hypersensitivity: Examples

Back 1070

AAA:
Anaphylaxis
Atopy
Allergic rhinitis

Front 1071

Type 2 Hypersensitivity

Back 1071

Cy-2-toxic

IgM, IgG bind to fixed antigen on "enemy" cell --> Complement-mediated lysis or phagocytosis

Vascular:
*Hemolytic anemia
*Idiopathic thrombocytopenic purpura
*Erythroblastosis fetalis

Heart: Rheumatic fever
Kidney, Lung: Goodpasture's
Skin: Bullous Pemphigoid (BM)
Thyroid: Grave's disease
NMJ: Myasthenia gravis

Front 1072

Type 3 Hypersensitivity

Back 1072

Immune complex mediated
*Immediately attracts COMPLEMENT, which attracts NEUTROPHILS

SHARPPS

SLE

Hypersensitivity pneumonitis

Arthus reaction: Local, subacute
*Intradermal injection of Ag

Rheumatoid arthritis

Post-streptococcal glomerulonephritis

Polyarteritis nodosa

Serum sickness: Abs form in 5 days
*Usually caused by drugs
*IC's deposited systemically

Front 1073

Type 4 Hypersensitivity

Back 1073

Sensitized T cells encounter antigen, activate macrophages

Examples: 5 T's
TB (PPD test)
Thyroid (Hashimoto)
Touching (Contact dermatitis)
Transplants (Graft vs. host)
Type 1 diabetes

+ MSG: MS + Guillain Barre

Front 1074

Bruton's agammaglobulinemia

Back 1074

X-linked recessive

Defect in a tyrosine kinase gene

**Low B cells**
**Low levels of all Abs**

Infections after 6 months of age (maternal IgG declines)

Front 1075

Thymic aplasia

Back 1075

Feature of DiGeorge syndrome (22q11)

THC:
T = Thymus --3rd pharyngeal pouch
*Viral and fungal infections

H = Hypocalcemia
*Parathyroids --3rd (inf) and 4th (sup) pouch

C = Cardiac defects
*Tetralogy
*Truncus arteriosus

Front 1076

SCID

Back 1076

Low B cells and T cells

Defect in stem-cell differentiation due to one of several causes
*MHC II presentation defect
*Defective IL-2 receptors
*Adenosine deaminase deficiency
(Purine pathway--toxic accumulations kill lymphocytes)

Recurrent infection of all kinds (bacterial, viral, fungal, protozoal, etc)

Front 1077

IL-12 receptor deficiency

Back 1077

Diminished TH1

DISSEMINATED MYCOBACTERIAL INFECTION

Front 1078

Hyper IgM syndrome

Back 1078

Defect in CD40 ligand (CD4 T helper cells)
*No CD40-CD40L binding =inability to class switch
*B cells make only IgM

Severe PYOGENIC infections early in life

Front 1079

Wiskott-Aldrich syndrome

Back 1079

X-linked recessive

Inability to mount an IgM response to capsular polysaccharides
*Low IgM
*High IgA

Wiscott = WIPE
*W= Wiscott
*I = Infections (pyogenic)
*P =Purpura (thrombocytopenic)
*E = Eczema

Aldrich = IgA (very high)

Front 1080

Job's syndrome

Back 1080

Failure if IFN-gamma production by TH1 cells
*Responsible for stimulating macrophages

Poor macrophage function --> Low IL-8 --> Poor neutrophil response

FATED:
F = Facies (coarse)
A = Abscesses (cold, noninflamed)
T = Teeth (retained primary)
E = IgE (high)
D = Dermatologic prob (eczema

Front 1081

Leukocyte adhesion deficiency

Back 1081

LFA-1 integrin defect

Recurrent bacterial infections
NO PUS

DELAYED SEPARATION OF UMBILICUS

LAD:
Lots of infections
Absent pus
Delayed separation of umbilicus

Front 1082

Chediak Higashi diease

Back 1082

Autosomal recessive

Defect in microtubular function
Poor lysosomal emptying of phagocytic cells

Recurrent pyogenic infections
*Staph, strep

Partial ALBINISM (pigment release)

Peripheral NEUROPATHY (axonal transport)

Front 1083

Chronic granulomatous disease

Back 1083

Lack of NADPH oxidase (or similar enzymes) --> Defect in phagocytosis

Marked susceptibility to opportunistic infection
*S. aureus
*E. coli
*Aspergillus

Diagnosis = Negative TETRAZOLIUM dye reduction test

Treatment: Gamma interferon

Front 1084

Chronic mucocutaneous candidiasis

Back 1084

T cell dysfunction against CANDIDA

Skin and mucous membrane candida infections

Front 1085

Selective Immunoglobin Deficiency

Back 1085

Deficiency in a specific Ig class

IgA most common
*Sinus and lung infections
*Milk allergies
*Diarrhea
*DEATH POSSIBLE W/TRANSFUSION

Front 1086

Ataxia-telangiectasia

Back 1086

DNA repair enzymes defect

**Associated w/IgA deficiency**

Ataxia (cerebellar)
Telangiectasia (spider angiomas)

Front 1087

Common variable immunodeficiency

Back 1087

B cells don't MATURE into plasma cells
*Normal B cell #s
*Low plasma cells and Igs

Can be acquired in 20s-30s

Front 1088

Cyclosporine

Back 1088

Immunosuppressant

Binds to cyclophilins --> Inhibits CALCINEURIN --> IL-2 inhibition

Use: TRANSPLANTS

Viral infection
Lymphoma
Nephrotoxicity --> Prevent w/MANNITOL

Front 1089

Tacrolimus

Back 1089

Immunosuppressant

Similar to cyclosporine (IL-2 inhibition)
*Binds to FK-BINDING PROTEIN rather than calcineurin

Use: TRANSPLANTS

SE: Significant
Nephrotoxicity
Peripheral neuropathy
HTN, pleural effusion
Hyperglycemia

No lymphoma risk like cyclosoprine, but the nephrotox isn't preventable w/mannitol

Front 1090

Azathioprine

Back 1090

Anti-metabolite precursor of 6 mercaptopurine
*Interferes w/purine metabolism
*Toxic to lymphocytes
*ALLOPURINOL PROLONGS
(does the same thing to 6-MP, which treats all leukemia except CLL and all lymphoma except Hodgkins)

Uses:
Kidney transplantation
Glomerulonephritis
Hemolytic anemia

SE: Marrow suppression

Front 1091

Muromonab

Back 1091

A.k.a. OKT3

CD3 antibody
Blocks T cell signal transduction

Uses: Kidney transplantation

SE:
Cytokine release syndrome
Hypersensitivity

Front 1092

Sirolimus

Back 1092

a.k.a. Rapamycin

Binds to mTOR

Inhibits T cell prolif in RESPONSE to IL-2
*IL-2 is calling, but T cells not there for ROL call

Use: Kidney transplantation

SE:
*"Rolls" --> Hyperlipidemia
*Thrombocytopenia, leukopenia

Front 1093

Mycophenolate mofetil

Back 1093

GUANa tell the story of Ms. Mofet?

Inhibits guanine synthesis

Block lymphocyte production

Front 1094

Daclizumab

Back 1094

IL-2 receptor antibody

Front 1095

Filgrastim

Back 1095

G-CSF

Used for BM recovery

Front 1096

Sargramostin

Back 1096

GM-CSF

Used for BM recovery

Front 1097

Oprelvekin

Back 1097

a.k.a. IL-11

Thrombocytopenia

Front 1098

Aldesleukin

Back 1098

IL-2 activator

Metastatic renal cell carcinoma
Metastatic melanoma

Front 1099

Hyperacute rejection

Back 1099

Pre-formed ANTIBODIES in the transplant recipient

Occurs within minutes

Front 1100

Acute rejection

Back 1100

Occurs weeks after transplantation

Cytotoxic T CELLS react against foreign MHCs

REVERSIBLE w/cyclosporine, OKT3, etc.

Front 1101

Chronic rejection

Back 1101

Occurs within months to years

ANTIBODY mediated vascular damage --> Fibrinoid necrosis

IRREVERSIBLE

Front 1102

Graft vs. host disease

Back 1102

Transplanted T cells attack the host

Maculopapular rash
Jaundice, hepatomegaly
Diarrhea

Front 1103

Types of necrosis

Back 1103

*Coagulative (Heart, liver, kidney)--tons of blood in all of these organs

*Liquifactive (Brain)

*Caseous (TB)

*Fat (pancreas)

*Fibrinoid (blood vessels)

*Gangrenous (limbs, GI)

Front 1104

Caspases mediate...

Back 1104

Apoptosis

Front 1105

Irreversible cell injuries

Back 1105

CMPLN --> Complain

Ca2+ influx
Mitochondrial permeability
Plasma membrane damage
Lysosomal rupture
Nuclear changes (pyknosis, karyolysis, karyorrhexis)

Front 1106

Granulomas

Back 1106

May feature granulomas = Nodular collections of epithelioid MACROPHAGES and GIANT CELLS

STBL CSF --> STaBLe CSF

Syphilis
TB
Bartonella
Leprosy

Crohn's disease
Sarcoidosis
Fungal pneumonias (some)

Front 1107

Leukocyte activation

Back 1107

LEUKOCYTE FACTORS HAVE CAPITAL L IN THEM

Emigration:

1. Rolling
*Endothelial E-selectin, P selectin
*Sialyl Lewis-X on leukocyte

2. Binding
*Endothelial ICAM-1
*Leukocyte LFA-1 (Integrin)

3. Diapedesis: Exits blood vessel

4. Migration/Chemotaxis

Front 1108

Granulation tissue

Back 1108

Highly vascularized
Fibrotic

Front 1109

Abscess

Back 1109

Fibrosis surrounding pus

Front 1110

Fistula

Back 1110

Abnormal communication

Front 1111

Scarring

Back 1111

Collagen deposition resulting in an altered structure and function

Front 1112

Transudate

Back 1112

TRANSFORMED from source composition

Due to:
*Increased hydrostatic P
*Increased oncotic P
*Na+ retention

Hypocellular
Protein poor --> SG <1.012

Front 1113

Exudate

Back 1113

Merely EXITS the source

Due to:
*Lymphatic obstruction
*Inflammation

Cellular
Protein rich --> SG >1.020

Front 1114

Amyloidosis

Back 1114

All cause apple-green birefringence of Congo red stain under polarized light

Secondary (AA)
*AA = Acute phase reactant
*From serum amyloid-associated protein (SAA)
*Seen w/chronic inflammatory disease

Medullary thyroid carcinoma (A-CAL)
*CAL = Calcitonin

DM Type 2 (AE)
*E = Endocrine
*Derived from Amylin

Senile cardiac (AF)
*F =Fogies (familial)
*Derived from transthyretin

Primary (AL)
*L = Light chain (Bence-Jones)
*Light chains derived from IgG
*Seen w/multiple myeloma (bone lesions)

Alzheimer's disease (APP)
*APP= Amyloid precursor protiein
*Derived from B-amyloid

Dialysis-associated (B2-microglobulin)
*Derived from MHC-I

Front 1115

Dysplasia

Back 1115

Abnormal proliferation of cells w/loss of size, shape and orientation

Often pre-neoplastic

Front 1116

In situ carcinoma

Back 1116

Monoclonal neoplastic cells encompass entire thickness, but do not invade BM

High nuclear/cytoplasmic ratio

Clumped chromatin

Front 1117

Tumor invasion enzymes

Back 1117

Collagenases

Hydrolases

Front 1118

Reversible plasias

Back 1118

Hyperplasia (number)
Dysplasia (size, shape, orientation)
Metaplasia (tissue type)

Front 1119

Irreversible plasias

Back 1119

Anaplasia (lack differentiation)

Neoplasia ("uncontrolled and excessive" proliferation)

Desmoplasia (Fibrous tissue formation in response to neoplasm)

Front 1120

Tumor grade

Back 1120

Degree of cellular DIFFERENTIATION

Based on histologic appearance of tumor

Usually graded I-IV based on:
*Degree of differentiation
*# of mitoses per HPF

LESS PROGNOSTIC than tumor stage

Front 1121

Tumor stage

Back 1121

Degree of spread
TNM description

Based on:
*Site and size of primary tumor
*Spread to lymph nodes
*Presence of distant mets

MORE PROGNOSTIC than grade

Front 1122

Epithelial neoplasms: Nomenclature

Back 1122

Benign --> Malignant

Adenoma --> Adenocarcinoma

Papilloma --> Papillary carcinoma

Front 1123

Multi-cell type neoplasms

Back 1123

Benign = Mature teratoma (women)

Malignant:
*Immature teratoma
*Mature teratoma (men)

Front 1124

Skeletal muscle neoplasms

Back 1124

Benign = Rhabdomyoma

Malignant =Rhabdomyosarcoma
*Most common soft tissue tumor of childhood

Front 1125

Malignancies associated w/Down synrome

Back 1125

ALL
AML

Front 1126

Malignancies associated w/Xeroderma pigmentosum and albinism

Back 1126

#1 Squamous cell carcinoma

Others:
*Melanoma
*Basal cell carcinoma

Front 1127

Malignancies associated w/atrophic gastritis

Back 1127

Gastric adenocarcinoma

Front 1128

Malignancies associated w/pernicious anemia

Back 1128

Gastric adenocarcinoma

Front 1129

Malignancies associated w/postsurgical gastric remnants

Back 1129

Gastric adenocarcinoma

Front 1130

Barrett's Esophagus

Back 1130

Associated w/esophageal carcinoma

Stratified (esophagus) --> Columnar (stomach) epithelium due to acid exposure

BARR = Becomes Adenocarcinoma, Results from Reflux

Front 1131

Malignancies associated w/Plummer-Vinson syndrome

Back 1131

Squamous cell carcinoma of the esophagus

P-V:
*Glossitis (atrophic)
*Iron deficiency anemia
*Esophageal webs

Front 1132

Malignancies associated w/ulcerative colitis

Back 1132

Colonic adenocarcinoma

Front 1133

Malignancies associated w/Paget's disease of bone

Back 1133

Osteosarcoma and fibrosarcoma

Front 1134

Malignancies associated w/Immunodeficiency states

Back 1134

Malignant lymphomas

Front 1135

Malignancies associated w/autoimmune diseases (Hashimoto's thyroiditis, myasthenia gravis)

Back 1135

Lymphomas

Front 1136

Malignancies associated w/Acanthosis nigricans

Back 1136

= Hyperplasia of stratum spinosum

Visceral malignancy, esp. stomach cancer

Acanthosis nigricans = Hyperpigmentation and epidermal thickening (stratum spinosum)

Front 1137

Malignancies associated w/radiation exposure

Back 1137

Sarcoma

Front 1138

Malignancies associated w/erb-B2

Back 1138

B2 ~ 2 breast-related cancers
erb ~ HERB in your stomach

Breast carcinoma
Ovarian carcinoma
GASTRIC carcinoma

Front 1139

Malignancies associated w/ras

Back 1139

Colon cancer

RASpberry in the colon

Front 1140

Malignancies associated w/L-myc

Back 1140

Lung tumor

Front 1141

Malignancies associated w/N-myc

Back 1141

Neuroblastoma

Front 1142

Malignancies associated w/ret

Back 1142

MEN are RETten

MEN II and III

MEN II: The pear (parathyroids) pheals (pheo) good + medullary

MEN III: Pheo + mucosal medullary + nodular disease

Front 1143

MEN

Back 1143

MEN II and III associated w/ret gene (Autosomal DOMINANT)

MEN 1 (WERMER'S): Pitt (pituitary) the pear (parathyroids) and put it in the pan (pancreas)

1. Parathyroid
2. Pituitary (Prolactinoma)
3. Pancreas (Z-E, Insulinoma, VIPoma)

MEN II (SIPPLE'S): The pear (parathyroids) pheals (pheo) good + medullary thyroid CA

1. Parathyroid
2. Pheochromocytoma
3. Medullary Thyroid CA

MEN III: Pheo + medullary + mucosal neuromas

1. GI ganglioneuromatosis (mucosal neuromas)
2. Pheochromocytoma
3. Medullary Thyroid CA

Front 1144

Malignancies associated w/c-kit

Back 1144

C? KIT gets the GIST of it

Gastrointestinal stromal tumor (GIST)

Front 1145

BRCA mutations

Back 1145

TUMOR SUPPRESSORS

BRCA1 = Breast and ovarian cancer
*#1 fear (more cancer risk)
*Chomosome 17q (same chrom as p53)

BRCA 2= Breast cancer
*Chromosome 13q (same chrom as Rb)

Front 1146

Malignancies associated w/p16

Back 1146

TUMOR SUPPRESSOR

Chromosome 9p

Melanoma

Front 1147

Malignancies associated w/WT1

Back 1147

TUMOR SUPPRESSOR

Chromosome 11p
*111 (WT 1, Chrom 11)

Wilm's tumor

Front 1148

Malignancies associated w/DPC

Back 1148

TUMOR SUPPRESSOR

Chromosome 18q
*Went to the DNC when I was 18

Pancreatic cancer

DPC = "Da pancreatic cancer"

Front 1149

Malignancies associated w/DCC

Back 1149

TUMOR SUPPRESSOR

Chromosome 18q
*Went to the DNC when I was 18

Colon cancer

DCC = "Da colon cancer"

Front 1150

Prostate cancer markers

Back 1150

PSA

Prostatic acid phosphatase

Front 1151

Elevated CEA

Back 1151

Nonspecific

C = Colon (70%) and gastric
EA = BrEAst, PancrEAs (70%)

Front 1152

Elevated alpha fetoprotein w/o pregnancy may indicate...

Back 1152

Yolk sac tumor

Hepatocellular carcinoma

Front 1153

Elevated B-hCG may indicate...

Back 1153

Hydatifrorm moles
Choriocrcinoma
Gestational trophoblastic tumors

Front 1154

CA-125 may indicate...

Back 1154

Ovarian
Malignant epithelial tumors

Front 1155

S-100 may indicate

Back 1155

Brain (neural tumors, astrocytomas)
+
#1 metastasis to brain--Melanoma

Front 1156

Alkaline phosphatase may indicate...

Back 1156

Mets to bone

Paget's disease of bone (nl Ca2+, PO4, PTH)

Obstructive biliary disease

Front 1157

Bombesin may indicate...

Back 1157

When a bomb goes off...

Headache --> NeuroBLASToma
Air quality --> Lung
Nervous --> Gastric cancer

Front 1158

CA 19-9 may indicate...

Back 1158

Pancreatic adenoacarinoma

Front 1159

Nasopharyngeal carcinoma can be caused by what virus?

Back 1159

EBV

Front 1160

Cervical carcinoma can be caused by what virus?

Back 1160

HPV (16, 18)

Front 1161

Aflatoxins can cause...

Back 1161

Hepatocellular carcinoma

Front 1162

Vinyl chloride can cause...

Back 1162

Angiosarcoma of the liver

"Vinyl vessel"

Front 1163

CCl4 can cause...

Back 1163

CL ~ CentriLobular necrosis of the liver

Fatty change in the liver

Front 1164

Cigarette smoke can cause...

Back 1164

Larynx
Lung
Renal cell
Transitional cell (bladder, ureters, renal pelvis)

Front 1165

Asbestos can cause...

Back 1165

Bronchogenic carcinoma

Mesothelioma

Front 1166

Aresnic can cause...

Back 1166

Squamous cell carcinoma

Front 1167

Aklylating agents can cause...

Back 1167

Leukemia

Front 1168

Napthalene (aniline) dyes can cause..

Back 1168

Transitional cell carcinoma (bladder, ureters, renal pelvis)

Front 1169

Paraneoplastic effects: Small cell lung carcinoma

Back 1169

ACTH
ADH
Ab's against NMJ Ca2+ channels (presynaptic)
*Lambert-Eaton syndrome

Front 1170

Paraneoplastic effects: Intracranial neoplasms

Back 1170

ADH

Front 1171

Paraneoplastic effects: Squamous cell lung carcinoma

Back 1171

Hypercalcemia: PTH-related peptide

Or possibly TGF-beta, TNF, IL-1

Front 1172

Paraneoplastic effects: Renal cell carcinoma

Back 1172

EPO

Hypercalcemia due to PTHrP, TGF-beta, TNF, or IL-1

Front 1173

Paraneoplastic effects: breast carcinoma

Back 1173

Hypercalcemia due to PTHrp, TGF-beta, TNF or IL-1

Front 1174

Paraneoplastic effects: Thymoma

Back 1174

Abs against NMJ Ca2+ channels (presynaptic)

a.k.a. Lambert-Eaton syndrome

Can also cause Myasthenia

Front 1175

Paraneoplastic effects: Leukemia and lymphoma

Back 1175

Hyperuricemia due to cytotoxic therapy --> excess nucleic acid turnover

Gout
Urate nephropathy

Front 1176

Most common mets to bone

Back 1176

Bone metastases > Primaries

PT(t) Barnum Loves Kids

Prostate Testes Thyroid Breast Lung Kidney

Most likely: PB (Prostate and breast)

Lung lesions = Lytic
Prostate = Blastic
Breast = Both

Front 1177

Psammoma bodies

Back 1177

Laminated, CONCENTRIC, CALCIFIC spherules

PSAMM

P = Papillary adenocarcinoma--thyroid

SA = Serous papillary cystAdenocarcinoma of the ovary

M = Meningioma

M = Mesothelioma (malignant)

Front 1178

Cancer epidemiology shortcuts

Back 1178

Male:
~1/3 Prostate --> Deaths < 50%
*32% --> 13%

~1/6 Lung --> Deaths 2x
*16 --> 32

Colon cancer: ~13% for both men and women

Women:
~1/3 Breast --> Deaths >50%
*32% --> 18%

Lung and colon are tied--13%
*Lung deaths almost 2x (23%)

Front 1179

Carotid sheath

Back 1179

Contains 3 structures (follows VAN rule)

Internal jugular vein
Common carotid artery
VAGUS nerve

Front 1180

Left coronary artery

Back 1180

1. Left anterior descending (LAD)
*MOST LIKELY TO OCCLUDE
*Apex
*Anterior interventricular septum

2. Circumflex artery
*Supplies posterior LV

3. 20%: CFX gives off PD artery
*Supplies posterior septum
*Supplies inferior LV
*In 80%, PD artery comes from RCA

Front 1181

Right coronary artery

Back 1181

1. Supplies SA and AV nodes

2. Acute marginal artery
*Supplies right ventricle

3. 80%: Posterior descending/IV artery
*Supplies posterior septum
*Supplies inferior LV

"That's a RAP": RCA, Acute marginal, PD/interventricular

Front 1182

Where are septal defects heard?

Back 1182

Right heart

Atrial septal defect = Pulmonic

Ventricular septal defect = Tricuspid

Front 1183

Cardiac output during exercise: what increases first?

Back 1183

STROKE VOLUME

HR increases after prolonged exercise

Front 1184

Factors influencing myocardial O2 demand

Back 1184

~CO

HR
SV:
*Contractility
*Afterload
*Preload VIA hypertrophic wall tension

Front 1185

Factors influencing stroke volume

Back 1185

SV CAP

*Contractility and preload increase SV
*Afterload decreases SV

1. Contractility
+ = High Ca2+ (i), low Na+ (o)
- = B1 block, low O2, high Co2, acidosis

2. Afterload ~ MAP
*VaZodilators decrease afterload (HydralaZine)

3. Preload ~ ventricular EDV
*Venodilators decrease preload (VeNo-Nitroglycerin)

Front 1186

Factors influencing contractility

Back 1186

CANa Increase contractility:

High intracellular Ca2+
*Catecholamines (stimulate Ca2+ pump in sarcoplasmic reticulum)

Low extracellular Na+
*Digitalis/digoxin blocks Na+ pump, causing higher intracellular Ca2+

Decrease: GAB
*Gases (low O2, high CO2)
*Acidosis
*B1 and Ca2+ channel blockers

Front 1187

Starling curve

Back 1187

Force of contration is proportional to INITIAL LENGTH of cardiac muscle fiber

CO vs. Preload/Ventricular EDV

Front 1188

Hydralazine reduces...

Back 1188

Afterload

HydralaZine = VaZodilator

Front 1189

Nitroglycerin reduces...

Back 1189

Preload

VeNodilator: VeNo-Nitro

Front 1190

Resistance and viscosity

Back 1190

ARTERIOLES are the greatest contributor to PVR

R = P/Q
(If you don't want R, mind your P's and Q's)

R = 8nl/(Pi)(r^4)
*n = viscosity (usually ~Hct)

Increased viscosity states:

*Lots of RBCs: Polycythemia
*Fat RBCs: Hereditary spherocytosis
*Lots of protein: Multiple myeloma, etc

Front 1191

S1 and S2

Back 1191

S1: Mitral and tricuspid valve closure

Loudest at mitral valve (higher P)

S2: Aortic and pulmonary valve closure

Loudest at L STERNAL BORDER

Front 1192

S3

Back 1192

Ken-tuck-y (S1-S2-S3)

Occurs in early diastole
*RAPID ventricular filling phase

Associated w/increased filling pressures
*Dilated ventricle

NORMAL FINDING in children

Front 1193

S4

Back 1193

Tenn-ess-ee (S4-S1-S2)

Occurs in late diastole
*SLOW ventricular filling phase

Sound is from atrial kick (high atrial P)
*Hypertrophied/stiff ventricle

Front 1194

Jugular venous pulse

Back 1194

Occur in alphabetical order

A wave (A is for ATRIA): Atrial contraction

C wave (C is for CLOSED): RV contraction

Even though flow from RV to jugular vein is blocked, the tricuspid valve BULGES into atrium

V wave (V is for VOLUME): Increased atrial P as it fills w/blood

Front 1195

Wide S2 splitting: Cause

Back 1195

Splitting w/o inspiration is wide
Splitting w/inspiration is even wider

Still A2 P2

PULMONIC STENOSIS

Front 1196

Fixed S2 splitting: Cause

Back 1196

Splitting is constant

Still A2 P2

ATRIAL SEPTAL DEFECT (extra volume of inspiration gets evenly dispersed between L and R heart)

Front 1197

Paradoxial S2 splitting:

Back 1197

Splitting is P2 A2

Split SHRINKS w/inspiration

AORTIC STENOSIS

Front 1198

Mitral/Tricuspid regurg

Back 1198

Occurs during systole

Immediate, holosystolic
High pitched blowing murmur

Mitral regurg
*Loudest at apex
*Radiates to axilla

Tricuspid regurg
*Loudest at tricuspid area
*Radiates to right sternal border

Front 1199

Ventricular septal defect

Back 1199

Occurs during systole

Immediate, holosystolic
Harsh sounding murmur

Heard best in R heart (tricuspid area)

Front 1200

Aortic stenosis

Back 1200

Occurs during systole

Ejection click +
Crescendo-decrescendo sound

PULSUS PARVUS ET TARDUS--> Pulses weak and late compared to heart sounds

Front 1201

Mitral valve prolapse

Back 1201

Occurs during LATE systole

Mid-systolic click + Crescendo sound that stops @S2

Most common valvular lesion

Front 1202

Aortic regurg

Back 1202

Occurs during diastole

Immediate
High pitched blowing murmur

Presents w/wide pulse pressure when chronic

Front 1203

Mitral/Tricuspid stenosis

Back 1203

Occurs during diastole

Opening snap + murmur

Tricuspid stenosis gets LOUDER w/inspiration

Front 1204

Navigating heart sounds

Back 1204

Systole (4), diastole (2) or continuous (1)?

Continuous = PDA
*Machine-like murmur

Diastole:
*Immediate, HP blowing --> Aortic regurg
*Opening snap --> Mitral/TC stenosis
*Louder during inspriation --> TC stenosis

Systole:
*Immediate, HP blowing --> Mitral/TC regurg
*Immediate, harsh, louder at TC --> VSD
*Ejection click, cres/decres --> Aortic stenosis
*Mid-systolic click --> MVP

Front 1205

Ventricular action potential

Back 1205

Phase 0 = Rapid upstroke
*Voltage-gated Na+ channels open

Phase 1=Initial repolarization
*Inactivation of voltage-gated Na+ channels
*Voltage-gated K+ channels open

Phase 2: Plateau
*Voltage-gated Ca2+ channels
*Balance w/K+ efflux
*Ca2+ gated Ca2+ release (SR)

Phase 3: Rapid depolarization
*Slow voltage-gated K+ channels
*Voltage-gated Ca2+ channels close

Phase 4: Resting potential
*High K+ permeability

Front 1206

Pacemaker action potential

Back 1206

Occurs in SA and AV nodes

Phase 0: Upstroke
*Voltage gated Ca2+ channels

Phase 3:
*Inactivation of Ca2+ channels
*Voltage-gated K+ channels

Phase 4: Slow diastolic depolarization
*I-f channel (Na+)
*Slope determines heart rate

Front 1207

Electrocardiogram

Back 1207

P wave = Atrial depolarization
*Repolarization masked by QRS

PR interval = Conduction delay through AV
*Includes P wave, ends at QRS
*< 200 msec

QRS complex: Ventricular depolarization
*< 120 msec

QT interval: Ventricular contraction
*Includes QRS and T wave

ST segment: Ventricles depolarized
*Isoelectric
*From end of QRS to beginning of T wave
*Elevation: Pericarditis or transmural MI
*Depression: Subendocardial MI

T wave: Ventricular repolarization

Isoelectric line: After T wave

U wave: Hypokalemia, bradycardia, transmural MI

Front 1208

Torsades de Pointes

Back 1208

A type of ventricular tachycardia
Shifting SINUSOIDAL waveforms

Can progress to ventricular fibrillation

Treat w/Mg2+

Risk factors: Long QT

1. Class IA--Na+ (quinidine) antiarrythmics
2. Class III--K+ (sotalol) antiarrythmics
3. Cisapride (5HT4 agonist, a gastroprokinetic agent)

Front 1209

Wolf-Parkinson-White syndrome

Back 1209

Wolff, Parkinson and White from Kent (snobby county) to try to BYPASS the rules

Caused by a BUNDLE OF KENT
*Accessory conduction pathway
*Bypasses AV node

Ventricles partially depolarize earlier --> DELTA WAVE on ECG

May lead to RE-ENTRY current --> SUPRAVENTRICULAR tachycardia

Treatment: Amiodarone

Front 1210

Atrial fibrillation

Back 1210

No P waves

Irregularly irregular QRS complexes

Front 1211

Prolonged PR interval

Back 1211

1st degree AV block

No dropped QRS complexes

Front 1212

1st degree AV block

Back 1212

Asymptomatic

PR interval is prolonged
*Normally < 200 msec

Repolarization of P wave visible

NO DROPPED QRS COMPLEXES

Front 1213

2nd degree AV block type 1: Wenckebach

Back 1213

A.k.a. Mobitz type 1

Usually asymptomatic

Progressive lengthening of PR interval until a beat is DROPPED

Front 1214

2nd degree AV block type 2

Back 1214

Pathologic/Symptomatic

No change in the PR interval (<200 ms)

QRS complexes abruptly dropped

Often 2 P waves to 1 QRS

Front 1215

3rd degree AV block

Back 1215

Atria and ventricles beat independently of one another

Atrial rate > Ventricular rate

Treat w/pacemaker

Front 1216

Ventricular fibrillation

Back 1216

COMPLETELY ERRATIC RHYTHM

No identifiable waves

FATAL arrhythmia w/o CPR, defibrillation

Front 1217

Baroreceptors

Back 1217

Aortic arch --> INCREASED BP
*BP will never really be low here
*CN X --> Near the heart anyway

Carotid sinus --> High or Low BP
*CN IX --> In the neck anyway
*NINE IN THE NECK

Front 1218

Chemoreceptors

Back 1218

Aortic arch and carotid BODY
*High CO2
*Low O2 (< 60 mm Hg)
*Low pH

Brain chemoreceptors:
*CO2
*pH
*NOT O2 (can be naturally low in brain)
*Responsible for CUSHING RXN

Front 1219

Cushing reaction

Back 1219

Inciting event: Increased ICP

Brain Ischemia = Sympathetic activation
*Vasoconstriction --> Systemic HTN

Peripheral baroreceptors detect HTN and induce bradycardia

Result = CUSHING'S TRIAD
*HTN (from brain ischemia)
*Bradycardia (from periphery)
*Resp depression (brainstem hypoperfusion)

Front 1220

Normal heart pressures

Back 1220

RA: < 5 mm Hg

RV
Diastolic: < 5 mm
Systolic: < 25 mm Hg

Pulmonary artery
Diastolic: < 10 mm Hg
Systolic: < 25 mm Hg

LA: 12

LV:
Diastolic: 10
Systolic: 130

Front 1221

Hypoxia causes vasoCONSTRICTION in the...

Back 1221

Lungs

Front 1222

Congenital heart disease: Right to Left shunts

Back 1222

Causes early cyanosis (blue babies)

Children may squat --> increase PVR (compress femoral arteries), which allows L heart P to approach R heart P --> directs more blood to lungs

The 5 T's:

1. Tetralogy of Fallot
*Most common
*22Q

2. Transposition of great vessels
*Maternal diabetes
*Not compatible with life unless there is 2nd mutation (VSD, PDA, patent foramen ovale)

3. Truncus arteriosus
*22Q

4. Tricuspid atresia

5. Total anomalous pulmonary venous return (TAPVR)

Front 1223

Congenital heart disease: Left to Right shunts

Back 1223

Late cyanosis (blue kids) w/clubbing and polycythemia

*Cyanosis only after R--> L transition (Eisenmenger's)

Pumping extra fluid into RV --> Increased pulmonary resistance --> ARTERIOLAR THICKENING --> R to L shunt

In order of frequency:

VSD --> Down

ASD --> Down
*Fixed split S2

PDA --> Rubella
*Close w/indomethacin

Front 1224

Tetralogy of fallot

Back 1224

Anterosuperior displacement of the infundibular septum

Cyanotic spells

PROVe:

Pulmonary artery stenosis
*MOST important determinant for prognosis

RVH (boot heart)

Overriding aorta

VSD

Front 1225

Coarctation of the aorta: Infantile

Back 1225

INfantile = IN close to the heart

Aortic stenosis is proximal to insertion of ductus arteriosus

Front 1226

Coarctation of aorta: Adult type

Back 1226

ADult = Distal to Ductus

Associated w/Turner's syndrome

Associations:
*Notching of the ribs (overuse of collateral circulation)
*HTN in upper extremities
*Weak pulse in lower extremities (check femoral pulse)

Front 1227

Patent ductus arteriosus

Back 1227

Direction of flow in fetal period: R --> L

Direction of flow post-natally: L --> R
*Extra blood in pulmonary outflow means increased RV pressure --> RVH

Continuous machine-like murmur
*Loudest at S2 (highest P time)

Close w/indomethacin
Keep open w/PGE
*May be necessary w/transposition of GV

Front 1228

HTN

Back 1228

BP > 140/90

Controllable factors:
*Smoking
*Obesity, DM

Uncontrollable factors:
*Age
*Race/Genetics: Black > White > Asian

90% of HTN is primary (CO, PVR)
10% is secondary to renal disease

Complications:
*Atherosclerosis
*Stroke
*CHF
*Renal failure
*Retinopathy
*Aortic dissection

Front 1229

Monckeberg arteriosclerosis

Back 1229

"PIPESTEM ARTERIES"

CALCIFICATION in the media of the arteries

Usually benign

Front 1230

Arteriolosclerosis

Back 1230

Complication of primary HTN

Hyaline thickening of the small arteries

Malignant HTN --> hyperplastic onion skinning

Front 1231

Arteriolosclerosis vs. Atherosclerosis

Back 1231

Arteriolosclerosis:
*Small vessels
*THICKENING of vessel walls

Atherosclerosis:
*Medium and large arteries
*PLAQUES (atheromas)

Front 1232

Aortic dissection

Back 1232

Longitudinal intraluminal tear
*Forms a false lumen
*TEARING chest pain radiating to BACK

CXR shows mediastinal WIDENING

Associations:
*HTN
*Cystic medial necrosis (Marfan's)

Front 1233

Atherosclerosis

Back 1233

Disease of elastic arteries + large and medium muscular arteries

Possible symptoms:
*Angina
*Claudication (cramping pain in legs)

Risk factors:
*HTN (Obesity, DM, Smoking, Genetics)
*Hyperlipidemia

Process:
*Endothelial dysfunction
*Macrophage and LDL accumulation
*Foam cell formation
*Fatty streaks
*Smooth muscle migration
*Fibrous plaques
*Complex atheroma

Complications:
ANEURYSMS
Ischemia
Infarcts
Peripheral vascular disease
Thrombus
Emboli

Front 1234

Angina

Back 1234

CAD narrowing >75%

Stable: ATHEROSCLEROSIS
*Retrosternal chest pain w/exertion

Prinzmetal's variant: SPASM
*Occurs at rest

Unstable/Crescendo: THROMBOSIS
*Activity-independent worsening chest pain
*No necrosis (otherwise would be an MI)

Front 1235

Most common cause of sudden cardiac death

Back 1235

Arrhythmia


Death from cardiac causes within 1 hour of symptoms

Front 1236

Chonic ischemic heart disease

Back 1236

Progresive onset of CHF over many years

Due to chronic ISCHEMIC myocardial damage

Front 1237

Red "hemorrhagic" infarcts

Back 1237

Loose tissues w/collaterals

"a LIL red" -->
*Liver
*Intestine
*Lung

Front 1238

Pale infarcts

Back 1238

Tissues w/single blood supply

"SHeiK" -->
Spleen
Heart
Kidney

Front 1239

Coronary artery occlusions: Frequency

Back 1239

"The LAD wanted an RCA CFX radio"

LAD > RCA >CFX

Front 1240

Coronary artery occlusions: Symptoms

Back 1240

Pain:
*Retrosternal
*L arm
*L jaw

Adrenergic symptoms:
*Diaphoresis
*N/V

Hypoxic symptoms:
*SOB
*Fatigue

Front 1241

MI: First day

Back 1241

2-4 hours: NO visible change on LM

4+ hours: Initial necrosis and contraction bands
*Coagulative necrosis
*CONTRACTION BANDS

Gross appearance:
*Dark mottling
*Tetrazolium stain: Light

Front 1242

MI: 2-4 days

Back 1242

ARRHYTHMIA RISK

**Acute inflammation and more necrosis**
Dilated vessels
Neutrophil emigration

Extensive coagulative necrosis

Gross appearance: Hyperemia
*Due to inflammation

Front 1243

MI: 5-10 days

Back 1243

FREE WALL RUPTURE RISK

**Macrophages (the new red) surround neutrophils**

Gross appearance:
*Red border
*Yellow-brown center

Front 1244

MI: 7 weeks

Back 1244

VENTRICULAR ANEURYSM RISK

Contracted scar complete

Gross appearance: Gray-white

Front 1245

MI diagnosis

Back 1245

0-6 hours: ECG
*Transmural: ST elevation, Q waves
*Subendocardial: ST depression

Troponin I:
*1st to rise (4 hours)
*1 origin (heart)

CK-MB:
*2nd to rise
*2 origins: Heart, skeletal muscle

AST:
*3rd to rise
*3 origins: Heart, skeletal muscle, liver

Front 1246

MI Complications

Back 1246

DR. SALAD

D = Dressler's syndrome:
*Autoimmune fibrinous pericarditis
*Several weeks post-MI
*Fibrinous pericardis can also occur 3-5 d post-MI (friction rub)

R = Rupture (5-10 days)
*Ventricular free wall --> Tamponade
*Interventricular septum --> VSD
*Papillary muscle --> Mitral regurg

S = Shock (cardiogenic)
A = Arrhythmia (2-4 days)
L = LV failure and pulmonary edema
A = Aneurysm (7 wks)
*Decreased CO
*Risk of arrythmia
*Mural thrombi
D = Death

Front 1247

Dilated (CONGESTIVE) cardiomyopathy

Back 1247

#1 cardiomyopathy (90%)

SYSTOLIC DYSFUNCTION
Heart looks like a balloon on CXR

Causes: ABCCCD
Alcohol abuse
Beri-Beri (B1)
Coxsackie B virus
Cocaine
Chagas
Doxorubicin toxicity

Peripartum cardiomyopathy

Front 1248

Dilated/congestive cardiomyopathy features systolic or diastolic dysfunction?

Back 1248

Systolic

S3 may be heard during diastole (blood rushing in quickly from atrium)

Front 1249

Hypertrophic cardiomyopathy

Back 1249

50% genetic (autosomal dominant)
Cause of sudden death in young athletes

Diastolic dysfunction

Normal heart size, but inside:
*Hypertrophy
*Often involves IV septum

Findings:
*Loud S4
*Apical impulses

Treatment: REDUCE CONTRACTILITY
*Beta blocker
*Ca2+ blocker (Verapamil)

Front 1250

Hypertrophic cardiomyopathy features systolic or diastolic dysfunction?

Back 1250

Diastolic

Loud S4

Front 1251

Restrictive/Obliterative cardiomyopathy

Back 1251

Restrictive ~ Fibrosis
Obliterative ~ Deposits

Causes:

Deposits:
*Sarcoidosis
*Amyloidosis
*Hemochromatosis

Fibrosis:
*Post-radiation
*Endocardial fibroelastosis (kids)
*Loffler's (prominent eosinophil infiltrate)

Front 1252

CHF Features

Back 1252

Dyspnea on exertion
*Failure of LV output to increase

Pulmonary edema
*LV failure --> Increased pulmonary venous pressure --> Transudation of fluid

HEMOSIDERIN-LADEN MACROPHAGES IN LUNG
*"Heart failure cells"

Orthopnea
*Increased venous return in supine position worsens pulmonary vascular congestion

Hepatomegaly/Nutmeg liver
*Increased central venous pressure --> Increased resistance to portal flow

Edema and JVD:
*RV failure increases peripheral venous pressure
*Edema = transudation

Front 1253

Emboli

Back 1253

An embolus moves like a FAT BAT

Fat --> Long bone fracture, liposuction
Air
Thrombus

Bacteria
Amniotic fluid --> DIC risk
Tumor

95% of PEs arise from deep leg veins

Symptoms:
*Chest pain
*Tachypnea
*Dyspnea

Front 1254

Bacterial endocarditis

Back 1254

Acute = S. Aureus
*Large vegetations on previously normal valves
*Rapid onset

Subacute = Strep viridans
*Smaller vegetations on abnormal/diseased valves
*Insidious onset
*Associated w/DENTAL procedures

Bacteria FROM JANE:
Fever
Roth spots (white spots on retina)
Osler's nodes (finger/toe pad bumps)
Murmur
Janeway lesions (red lesions on palm/sole)
Anemia
Nail-bed/splinter hemorrhage
Emboli

Front 1255

Rheumatic heart disease

Back 1255

Consequence of pharyngeal S. Pyogenes (Group A Beta-hemolytic) infection

Type 2 hypersensitivity reaction

FEVERSS:
F = Fever
E = Erythema marginatum
V = Valvular damage
*Mitral > aortic >> tricuspid
E = ESR
R = Red hot joints (polyarthritis)
S = Subcutaneous nodules (Aschoff bodies) + Anitchkow's cells
S = St. Vitus' dance (chorea)

ASCHOFF BODY = granuloma w/giant cells

ANITSCHKOW'S cells = activated histiocytes

Front 1256

Cardiac tamponade

Back 1256

Compression of heart by fluid in pericardium

EQUILIBRATION of diastolic pressures in all 4 chambers

Findings:
*PULSUS PARADOXUS: Decreased strength of pulse during inspiration
*Hypotension
*JVD
*Soft heart sounds
*ELECTRICAL ALTERNANS (height of QRS complex varies)

Front 1257

Pulsus Paradoxus

Back 1257

Decreased strength of pulse during inspiration

Seen with:
*Pericardial issues -->
Tamponade, pericarditis

*Esophageal inflammation -->
Asthma, croup

Front 1258

Electrical alternans

Back 1258

Seen in cardiac tamponade

Height of QRS changes

Front 1259

Pericarditis

Back 1259

3 types:
*Serous --> Uremia, RA, SLE, Virus
*Fibrinous --> Uremia, RF, Dressler
*Hemorrhagic --> TB, neoplasm

Findings:
*PULSUS PARADOXUS
*ST segment ELEVATION
*FRICTION RUB
*Pericardial pain
*Soft heart sounds

+/- Chronic adhesive/constrictive pericarditis

Front 1260

Syphilus and the heart

Back 1260

Tertiary syphilis disrupts the vasa vasorum of the aorta

Dilation of the aorta and valve
+/- Calcification ("tree bark")

Possible complications:
Aneurysm of the ascending aorta
Aortic valve incompetence

Front 1261

Kussmaul

Back 1261

Kussmaul's Sign: Increase in JVP w/inspiration

Cardiac tumor

Kussmaul's Pulse: Pulsus paradoxus

Decrease in pulse strength w/inspiration

Pericarditis, tamponade, asthma, croup

Front 1262

Telangiectasia

Back 1262

SMALL VESSELS

Arteriovenous malformations that look like dilated capillaries

May present as part of Osler-Weber-Rendu syndrome:
*AD
*Nosebleeds
*Skin discolerations

Front 1263

Wegener's granulomatosis

Back 1263

SMALL VESSELS

c-ANCA (+)
*CANCA sores will put a WEGE in your relationship

Focal necrotizing:
1. Vasculitis

2. Granulomas in lung, upper airway
*Perforation of nasal septum
*Otitis media (up Eustachian?)
*Chronic sinusitis
*Cough, dyspnea
*Hemoptysis
*CXR: Possibly NODULAR DENSITIES

3. Glomerulonephritis
*Hematuria
*Red cell casts

Treatment:
*Cyclophosphamide
*Corticosteroids

Front 1264

Sturge-Weber disease

Back 1264

Congenital SMALL VESSEL DZ (Capillary size)

Sturge --> Sturgeon --> Port
*PORT WINE STAIN on face

Web --> in brain
*INTRACEREBRAL AVM
(leptomeningeal angiomatosis)

Front 1265

Henoch Schonlein Purpura

Back 1265

SMALL VESSELS

#1 childhood systemic vasculitis

Common triad of symptoms AFTER URI:

1. Skin (purpura--appear + age together)

2. Joints (arthritis)

3. GI (Intestinal hemorrhage)
*Abdominal pain and melena

Henoch = NOCH knees (joints)
Schonlein = Stomach
Purpura = Purpura

Front 1266

Microscopic polyangitis

Back 1266

SMALL VESSELS

Like Wegeners, but LACKS granulomas

P-ANCA (+)

Lung and UR symptoms
Glomerular disease

Front 1267

Primary pauci-immune crescentic glomerulonephritis

Back 1267

SMALL VESSELS

Vasculitis LIMITED to kidney

Pauci immune = Paucity of Abs

ANCA (+)

Front 1268

Churg-Strauss Syndrome

Back 1268

SMALL VESELS

p-ANCA (+)

GRANULOMATOUS vasculitis w/EOSINOPHILIA
*Strauss~spouse of Wegeners (only 2 small vessel vasculitis diseases to form granulomas)
**Churg ~ Urg to scratch**
(Seen in atopic patients)

Affects lungs, heart, skin, kidneys, nerves

Front 1269

Kawasaki disease

Back 1269

Kawasaki ~ Coronary
Red motorcycle ~ Strawberry tongue

SMALL AND MEDIUM VESSELS

ACUTE necrotizing vasculitis

Affects infants and kids
*More dangerous than Henoch-Shonlein Purpura

CORONARY ANEURYSMS
+
Very inflammatory:
*Strawberry tongue
*Fever, lymphadenitis
*Congested conjunctiva

Front 1270

Polyarteritis Nodosa

Back 1270

MEDIUM VESSELS
*Only disease to affect strictly mediums

**Unique**
Immune complexes
30% HBV seroposiitive

Kind of an adult version of Henoch-Schonlein purpura + necrotizing, aneurysm features of Kawasaki
*Myalgia (vs. arthritis)
*GI damage, melena
*Skin eruptions (BUT age differently)

Tx: Same as that of Wegeners
Cyclophosphamide
Corticosteroids

Front 1271

Takayasu's arteritis

Back 1271

MEDIUM AND LARGE ARTERIES

a.k.a. Pulseless disease
Primarily Asian females <40

Granulomatous thickening of the aortic arch and/or proximal vessels
*Increased ESR (lg artery involvement)

FAN MY SKIN on Wednesday:
Fever
Arthritis
Night sweats
MYalgia
SKIN nodules
Ocular disturbances
Weak pulses in extremities

Front 1272

Temporal arteritis

Back 1272

MEDIUM AND LARGE ARTERIES

Primarily affects elderly females

Granulomatous inflammation of (usually) carotids
*Increased ESR (lg artery involvement)
*50% of patients have systemic involvement, polymyalgia rheumatica

Unilateral headache
Jaw claudication
Opthalmic artery occlusion

Treat w/high dose steroids

Front 1273

Hydralazine

Back 1273

Vasodilates arterioles > veins
*Increases cGMP (sm relaxation)

Uses:
*Severe HTN (1st line in pregnancy)
*CHF

SE:
*LUPUS LIKE SYNDROME
*Compensatory tachycardia (bad w/angina)
*Fluid retention

Front 1274

Minoxidil

Back 1274

Vasodilates
*Opens K+ channels (sm relaxation)

Uses:
*Severe HTN
*Baldness

SE:
*Hair overgrowth (hypertrichosis)
*PERICARDIAL EFFUSION
*Compensatory tachycardia (bad w/angina)
*Fluid retention

Front 1275

Ca2+ channel blockers

Back 1275

We FED at the FRAPPE MILL until DIL was TIAd of ZEM

Nifedipine
Verapimil
Diltiazem

Block L-type (voltage-gated) channels in:
*Smooth muscle (vessels)
*Cardiac muscle
*Cardiac AV nodal cells

Vessel effect: N > D >V
*Nice if you are doing something to vessels

Heart effect: V > D > N

Uses:

1. Vascular relaxation: HTN + Raynaud's

2. Heart: Decrease rate and contractility
*Angina (even Prinzmetals)
*SVT (not N--too weak)

SE:
*Heart: CARDIAC DEPRESSION (AV block, bradycardia, CHF)

*CUTANEOUS FLUSHING

*Vascular: Fluid retention, dizziness

Front 1276

Nitroglycerin, Isosorbide dinitrate

Back 1276

Releases nitric oxide
*Venodilation > Arteriolar dilation

Uses: APE
Vasodilation: Angina, Erections
Preload reduction: Pulmonary edema

SE:
*Reflex tachycardia, flushing, headache
*Industrial tolerance: MONDAY DISEASE

Front 1277

Malignant HTN: Treatments

Back 1277

Malignant HTN is a FieND (FND)

1. Fenoldopam

Dopamine D1 receptor agonist

Relaxes renal vascular smooth muscle

2. Nitroprusside

Directly releases NO
*Increases cGMP --> sm relaxation

SE: CYANIDE TOXICITY

3. Diazoxide: Like minoxidil
*K+ channel opener

Front 1278

Beta blockers + Nitrates

Back 1278

When taken together, the following are lowered:
**Heart rate**
**Blood pressure**
**MVO2**

BP
EDV
Contractility
HR
Ejection time
MVO2

Nitrates lower everything except HR and contractility (increased as a reflex response)

Beta blockers lower everything except EDV and ejection time

Front 1279

Statins

Back 1279

HMG-CoA reductase inhibitors
*Prevent synthesis of MEVALONATE (cholesterol precursor)

Affects all 3 lipids in a good way, but major effect is LDL

Side effects:
Elevated LFTs (reversible)
Myositis

Front 1280

Niacin

Back 1280

Inhibits lipolysis in adipose tissue

Reduces hepatic VLDL secretion into circulation

Affects all 3 lipids in a good way, but major effect is HDL

Side effects: FLUSHING (part of VANC)

Front 1281

Cholestyramine, Cholestipol

Back 1281

a.k.a. Bile acid resins

Prevents intestinal reabsorption of bile acids

ONLY CONTRAVERSIAL EFFECT
*Slight increase in TGs

LDL significantly lowered
HDL rises slightly

SE: Patients hate it
*Tastes bad
*GI discomfort
*Possible ADEK deficiency

Front 1282

Ezetimibe

Back 1282

E ~ Early, Easy (1 effect)

Prevents reabsorption of cholesterol @brush border

1 effect: Decreases LDL

1 SE: Rare LFTs

Front 1283

Fibrates

Back 1283

Gemfibrozil, Clofibrate, Bezafibrate, Fenofibrate

Upregulates LPL to increase TG clearance

Good effects on all 3 lipids, but main effect is TGs

SE: Like statins
*Myositis
*LFTs

Front 1284

Mg2+

Back 1284

Torsades de pointes
*Class 1A: Quinidine
*Class IC: Sotalol
*5HT4 agonist/prokinetic: Cisapride

Digoxin antidote

Front 1285

Adenosine

Back 1285

Very short-acting (15 seconds)

Use: 1st line for AV nodal arrhythmias

Causes K+ to leave cells --> hyperpolarization
*AV node cells
*Vascular smooth muscle cells

SE: Flushing, hypotension, chest pain

Front 1286

Amiodarone

Back 1286

Class I-IV Antiarrhythmic (Na+, K+, Ca2+)

Used for Wolf-Parkinson-White syndrome

SE:
PULMONARY FIBROSIS
PHOTOSENSITIVITY

**MAKE SURE TO CHECK:***
PFTs (risk of fibrosis)
LFTs (risk of hepatotoxicity)
TFTs (risk of hypo/hyperthyroid)

Front 1287

Class III Anti-arrhythmics

Back 1287

Decreases myocyte activity

K+ channel blockers

BIAS:
*Bretylium
*Ibutilide
*Sotalol
*Amiodarone --> WPW

Block K+ channel, but act like 1A antiarrhythmics
*Increased AP duration
*Long QT, ERP

Uses: Atrial and ventricular arrhythmias (backup)
SE:
*Bretylium = Arrhythmia, hypotension
*Ibutilide = TDP
*Sotalol = TDP, excessive B block
*Amiodarone--> Photsensitivity, pulmonary fibrosis, PFTs, LFT,s TFTs

Front 1288

IC Anti-arrhythmics

Back 1288

PROP, FLECK and ENter the goal
Propafenone
Flecainide
Encainide

As with all Class I drugs, slow rate of CONDUCTION of the action potential, but no effect on AP duration

Really good at prolonging refractory period in the AV node

Last resort: Ventricular arrythmias

SE: C is for contradiction
*Actually pro-arrhythmic (esp post-MI)

Front 1289

IB Anti-arrhythmics

Back 1289

I'd Buy LIDdy's MEXican Tacos

I'd buy = IB
L = Lidocaine
M = Mexiletine
T = Tocainide

Binds both activated and inactivated Na+ channels --> K+ can flow in unchallenged, and AP is SHORTENED
*Decreased AP (and QT, ERP)
*Acts on Purkinje fibers in ventricle

Uses:
Ventricular arrhythmia (esp w/MI)
Digitalis arrhythmia

SE: U feel numb when UR depressed
*Local anaesthetic
*Cardiac depression

Front 1290

1A Anti-arrhythmics

Back 1290

QUeen AMy PROClaims DISO's PYRAMID

Quinidine
Amiodarone--class 1-4, actually
Procainamide
Disopyramide

Increase AP duration --> long QT
*Increased effective refractory period
*Caused by prolonged phase 0 AND prolonged phase 3 via a small interaction with K+ channels

Use:
Atrial arrhythmias
Ventricular arrhythmias

SE:
Quinidine = Cinched belt, pale
*Cinchonism (headache, tinnitus)
*Thrombocytopenia
*Torsades de pointes (from long QT)

Procainamide = SLE-like syndrome

Front 1291

Lipophilic/Steroid hormones

Back 1291

PET CAT:

Progesterone
Estrogen
Testosterone
Cortisol
Aldosterone
Thyroxine and T3

Vitamin D is also a steroid hormone!

Front 1292

Adrenal cortex layers

Back 1292

GFR:
Glomerulosa --> Salt (Aldosterone)
*Angiotensin II regulates

Fasciculata --> Sugar (Cortisol)
*ACTH (CRH) regulates

Reticularis --> Sex (Aldosterone)
*ACTH (CRH) regulates

Medulla: Secretes catecholamines (E, NE)
*Preganglionic sympathetic fibers
*Ach w/nicotinic receptors

Front 1293

Pituitary hormones

Back 1293

FLAT PiG

Beta cells -->
FH
LH
ACTH
TSH

Alpha cells -->
Prolactin
GH

Front 1294

Hormone Subunits

Back 1294

1. Alpha = "All the same" for the FLAT (Beta cell) hormones where A is replaced by HCG
FH
LH
HCG
TSH

Beta = "Be specific" --> Each hormone has its own beta subunit

Front 1295

Pancreas cell types

Back 1295

Alpha cells: Release glucagon when the sugar is All gone
*Alpha--> ALL gone
Beta cells: Release insulin when some sugar needs to go Bye bye
*Beta --> BYE bye
Delta cells: Release somatostatin to slow the digestive system Down
*Delta --> slow DOWN

Front 1296

Hypothalamic hormone control

Back 1296

(+) effects:
GnRH --> FSH, LH
CRH --> ACTH
TRH --> TSH, Prolactin
GHRH --> GH

(-) Effects:
Dopamine --> Prolactin

Front 1297

Adrenal Steroid Synthesis: Starting reaction

Back 1297

Cholesterol --> Pregnenolone

Catalyzed by DESMOLASE
*ACTH stimulates
*Ketoconazole inhibits

Front 1298

Mineralocorticoid excess:
17B-hydroxylase deficiency

Back 1298

17B-hydroxylase handles:
Pregnenolone --> 17OH-Pregnenolone
Progesterone --> 17OH-Progesterone

Result:
Mineralocorticoids --> Increased Na+ resorption in DCT (HTN, Hypokalemia)
x-Glucocorticoids
x-Sex hormones: Female phenotype w/o maturation

Front 1299

Adrenal Hyperplasia (sex hormone excess):

21-OH hydroxylase deficiency

Back 1299

21-OH hydroxylase handles:

Progesterone --> 11-deoxycorticosterone
17-OH progesterone --> 11-deoxycortisol

Result:
x-Mineralocorticoids --> No Na+ resorption in DCT (hypotension, Na+ wasting, hyperkalemia)
x-Glucocorticoids
Sex hormones --> Masculinization, female pseudohermaphrodism

Front 1300

Adrenal Hyperplasia (sex hormone excess
+ 1 mineralocorticoid):
11-OH deficiency

Back 1300

11-deoxycorticosterone --> Corticosterone
11-deoxycortisol --> Cortisol

Result:
Mineralocorticoids: A lot of 11-deoxycorticosterone (HTN)
x-Glucocorticoids
Sex hormones --> Masculinization

Front 1301

PTH release

Back 1301

Chief cells of parathyroid gland respond to low serum [Ca2+]

Bone: Overall resorption to release Ca2+, PO4
*Direct stimulation of osteoblasts
*Indirect stimulation of osteoclasts

Kidney:
1. Ca2+ sparing with PO4 excretion
2. Vitamin D (1,25 OH-D)
*Increased intestinal absorption of Ca2+ and PO4
*Bone resorption to release Ca2+ and PO4 (Not significant?)

Front 1302

Hyperparathyroidism:
Ca2+, PO4, PTH, AP findings

Back 1302

Ca2+: High
PO4: Low
AP: High
PTH: High

Front 1303

Vitamin D excess:
Ca2+, PO4, PTH, AP findings

Back 1303

Ca2+: High
PO4: High
AP: Normal
PTH: Low

Front 1304

Osteomalacia:
Ca2+, PO4, PTH, AP findings

Back 1304

Ca2+: Low
PO4: Low
AP: High
PTH: High

Front 1305

Osteoporosis:
Ca2+, PO4, PTH, AP findings

Back 1305

Ca2+: Normal
PO4: Normal
AP: Normal
PTH: Normal

Front 1306

Paget's disease:
Ca2+, PO4, PTH, AP findings

Back 1306

Ca2+: Normal
PO4: Normal
AP: VERY HIGH
PTH: Normal

Front 1307

Calcitonin

Back 1307

Parafollicular cells (C cells, thyroid gland) in response to high serum Ca2+

Result: Reduced Ca2+ loss from bone

Front 1308

Alkaline phosphatase: Sources

Back 1308

Bone: Osteoblasts

Liver: Cells lining bile ductules

Front 1309

Effect of SHBG

Back 1309

Binds testosterone --> Reduces effect

Males: Increased SHBG causes gynecomastia
Females: Reduced SHBG causes hirsutism (PCOS)

Front 1310

Functions of T3

Back 1310

T4 converted to T3 in periphery

The 4 B's:

1. Brain maturation
2. Bone growth
3. Beta adrenergic effects
*HR, SV, contractility
4. Basal metabolic rate
*Encourages IMMEDIATE E:
Gluconeogenesis, glycogenolysis, lipolysis

Front 1311

T4 synthesis

Back 1311

1. Thyroglobulin (TG) and I2 made by follicular cell, released into lumen
2. TG + I2 --> MIT or DIT
3. DIT + DIT/MIT --> T4/T3
4. Cell re-entry and secretion in to blood
5. Most grabbed (inactivated) by TBG
*Reduced TBG: Liver failure
*Increased TBG: Pregnancy (Estrogen)
5. T4 converted to T3 in periphery

Front 1312

Functions of cortisol

Back 1312

BIMB

1. Bone breakdown
2. Immunodeficiency
3. Metabolic effects: Immediate E
*Gluconeogenesis, glycogenolysis, lipolysis, PROTEOLYSIS
4. Blood pressure maintenance (increase)

Thus, symptoms of Cushing's disease: BIMBO

Bone: Osteoporosis
Immune: Immunosuppression
Metabolic: Weight gain, insulin resistance, truncal obesity, moon facies, buffalo hump
Blood pressure: HTN
Other: Purple striae

Front 1313

Hormones using cGMP mechanisms

Back 1313

Vasodilators --> cANE

ANP
NO
EDRF

Front 1314

4 causes of Cushing Syndrome

Back 1314

. Pituitary tumor (Cushing's DISEASE)--> ACTH
(HD Dexamethasone suppressible)
2. Ectopic tumor (SSLC) --> ACTH
(Not suppressible)
3. Primary adrenal tumor --> Cortisol
(Not suppressible)
4. Exogenous cortisol --> Cortisol

Front 1315

What can low dose dexamethasone suppress?

Back 1315

Pituitary ACTH tumors only
Not ectopic ACTH secreting tumors

N/A cortisol secreting tumors or exogenous cortisols

Front 1316

Lab finding that distinguishes primary and secondary aldosteronism

Back 1316

Plasma renin levels

Primary (Conn's syndrome): Low renin
Secondary: High renin (kidney perceives low intravascular vol)

Front 1317

Hyperaldosteronism treatment

Back 1317

Spironolactone

Front 1318

Addison's disease

Back 1318

Loss of adrenal cortex

AAA:
Atrophy
All cortical layers lost --> No hormones
ACTH high (along with MSH--pigmentation)

Front 1319

Hyperthyroid vs. Hypothyroid

Back 1319

Temperature: Cold intolerance, cool dry skin
Energy: Fatigue, hypoactivity, weakness
GI: Decreased appetite, weight gain, constipation
Hair: Coarse and brittle
Myxedema: FACIAL, PERIORBITAL


Temperature: Heat intolerance, warm moist skin
Energy: Hyperactivity
GI: Weight loss, diarrhea
Hair: Fine
B agonist: Chest pain/palpitations, ARRHYTHMIA, REFLEXES
Myxedema: PRETIBIAL (Graves)

Front 1320

Thyroid Storm

Back 1320

Graves disease + Stress -->
Catecholamines --> Arrhythmia --> Deat

Front 1321

Graves symptoms

Back 1321

GOP:

Goiter
Opthalmopothy (proptosis, EOM swelling)
Pretibial myxedema

Front 1322

Hashimoto's thyroiditis

Back 1322

Hashimoto's Thyroiditis: Slow autoimmune hypothyroidism

Thyroid moderately enlarged, NONTENDER during lymphocyte invasion
*HURTHLE cells
*Germinal centers

AUTOANTIBODIES: Antimicrosomal + Anti-TG

Associated with LYMPHOMA

Distinguish from Lymphocytic subacute thyroiditis (variant of Hashimotos?) which does not feature FOLLICLES and SCARRING

Distingish from Subacute Thyroiditis (deQUervain's), which is painful, features granulomas instead of lymphocytic invasion and follows flu-like illness

Front 1323

Toxic Multinodular Goiter Features

Back 1323

Hyperthyroidism following iodine repletion

Iodine restoration--T3/T4 release

In the context of relocation--Jod-Basedow phenomenon

Front 1324

Thyroid cancers

Back 1324

FLUMP

FLUMP:

1. Follicular: Good prognosis (follicles)
2. Lymphoma: Assoc. w/Hashimotos
3. Undifferentiated: Older ppl, bad
4. Medullary: Parafollicular C cells
*Calcitonin
*MEN II and III
5. Papillary: Excellent prognosis
*Ground glass/orphan annie
*Psammoma
*Childhood Radiation

Front 1325

5P's of Cretinism

Back 1325

Pale
Puffy Face
Pot bellied
Protruding umbilicus
Protuberant tongue

Matches w/Marasmus in a lot of ways (not protuberant tongue, retardation)

Front 1326

Acromegaly

Back 1326

GH excess:

Large tongue, hands, feet
Deep voice
Coarse features
IMPAIRED GLUCOSE TOLERANCE

Front 1327

Growth hormone regulators

Back 1327

Stress
Exercise
Hypoglycemia

Front 1328

Primary hyperparathyroid

Back 1328

"Bones, stones and groans," but often asymptomatic

1. Bone breakdown raises Ca2+, PO4
*Alkaline phosphatase high
*Causes cystic bone spaces filled w/brown fibrous tissue (OSTEITIS FIBROSA CYSTICA/Von Recklinghausen's)

2. Ca2+ retained, while PO4 excreted
*Enough Ca2+ in urine --> stones
*Hypophosphatemia

3. Weakness, constipation --> groans

Front 1329

Secondary hyperparathyroid (CRF)

Back 1329

PTH's objectives are reversed by kidney, even though PTH levels are high

Ca2+: Low
PO4: High
AP: High
PTH: High

Leads to RENAL OSTEODYSTROPHY (bone lesions due to 2 hyperparathyroidism)

Front 1330

Hypoparathyroid signs

Back 1330

Signs: Low Ca2+ tetany
*Chvostek's --> Facial tapping
*Trusseau --> BP cuff causes carpal spasm

Front 1331

Pseudohypoparathyroid

Back 1331

It's as if PTH wasn't there...

Autosomal dominant

Kidney ignores PTH --> Hypocalcemia

Shortened stature and 4th/5th digits

Front 1332

Hypercalcemia: Causes

Back 1332

CHIMPANZEES:

Calcium (milk-alkali)
Hyperparathyroid
Hyperthyroid
Iatrogenic (Thiazides)
Multiple Myeloma
Paget's disease
Addison's disease
Neoplasms
Z-E
Excess vitamin D
Excess vitamin A
Sarcoidosis

Front 1333

Prolactinoma

Back 1333

Galactorrhea
GnRH inhibition: Amenorrhea/infertility
Bitemporal hemanopsia

Treatment: Bromocriptine (DA agonist)

Front 1334

Diabetes tests

Back 1334

Fasting serum glucose
Glucose tolerance test
HbA1c (long-term control)

Front 1335

Diabetes: Chronic vessel sign

Back 1335

Mechanism: Nonenzymatic glycosylation

1. Small vessels:
-Retinopathy
-Glaucoma
-Nephropathy
*Ateriosclerosis --> HTN, Kimmelstiel-Wilson nodules
*Progressive Proteinuria --> CRF
2. Large vessels:
-CAD
-Cerebral vessels
-Peripheral vascular disease --> Gangrene

Front 1336

Diabetes: Signs of osmotic damage

Back 1336

Neuropathy (motor, sensory and autonomic)

Cataracts (Sorbitol accumulation)

Front 1337

Zollinger-Ellison Syndrom

Back 1337

Gastrin secreting tumor in pancreas or duodenum

May be responsible for recurrent ulcers

Front 1338

Type 1 vs. Type 2 diabetes

Back 1338

Insulin dependence: Always vs. Sometimes
Age: < 30 vs. >40
Genetics: Weak vs. Strong (both polygenetic)
HLA association: DR-3, DR-4 vs. none
B cell numbers: Low vs. variable
Insulin levels: Low vs. variable
Coma: DKA vs. Hyperosmolar

Hyperosmolar coma: Presence of SOME insulin inhibits ketone synthesis, but it's not enough to keep sugars low--> diuresis, volume contraction, hemo concentration

Front 1339

SIADH: Causes

Back 1339

1. Ectopic ADH (small cell LC)

2. CNS release (head trauma, PULMONARY stressors)

3. Drugs (cyclophosphamide)

Front 1340

SIADH: Signs

Back 1340

**Urine osmolality > Serum osmolality**

Hyponatremia

Excessive water retention (oliguria)

Tx: Dimeclocycline or H20 restriction

Front 1341

Ketoacidosis

Back 1341

Stress (infection) --> GH --> IR --> Increased insulin demand --> Inability to suppress lipolysis --> B-hydroxybutyrate (ketone) synthesis

Labs:
Ketoacids --> Anion gap acidosis
Leukocytosis
Hyperkalemia --> K+ leaves cells w/low insulin

Kussmaul respirations: Hyperventilation
N/V and abdominal pain
Dehydration from polyuria
Fruity breath odor

Front 1342

Ketoacidosis: Complications

Back 1342

Mucormycosis and Rhizopus

Cerebral edema (osmotic changes)

Arrhythmia and heart failure (hyperkalemia)

Front 1343

Ketoacidosis treatment

Back 1343

WIP it good:

"Water" to reverse dehydration
Insulin to reduce glucose levels
Potassium to replete intracellular store

Front 1344

Diabetes insipidus: Causes

Back 1344

Central: No ADH secreted
*Tumor/trauma
*HISTIOCYTOSIS X

Tx: Desmopressin (ADH analog)

Nephrogenic:
*Hereditary
*High Ca2+
*Lithium
*Dimeclocycline (tx for SIADH)

Tx: Hydrochlorothiazide, indomethacin, amiloride

Front 1345

Diabetes insipidus: Labs

Back 1345

Urine specific gravity under 1.006
Serum osmolality over 290

Water deprivation test--> does urine concentrate?
*If no, DI

Give desmopressin--does it concentrate now?
*If no, nephrogenic

Front 1346

Carcinoid syndrome

Back 1346

NEUROENDOCRINE cell tumor
--> GI (usually SI)

DENSE CORE secretory bodies (vesicles) seen on EM

Often releases serotonin:
**URINE 5-HIAA**

ForWaRD to problems:
Flushing
RH valvular damage/murmur
Wheezing (Bronchoconstriction)
Diarrhea

Treatment: OCTREOTIDE (Somatostatin)

1/3 met
1/3 present w/2nd malignancy
1/3 multiple carcinoids

Front 1347

Insulin

Back 1347

S = Short acting: LiSpro,ASpart
Intermediate: NPH
Long acting: Lente, Ultralente

All cause anabolism via Tyrosine Kinase receptor: glycogen synthesis (liver, muscle), protein synthesis (muscle), TG storage (adipose)

Front 1348

Sulfonylureas

Back 1348

sulFONamides: Not much FON (1st gen), then the glucose is GON (2nd gen)

Sulfa drug
Type 2 diabetes only (need some islet function)

1st generation: Tolbutamide, Chlorpropamide
*DISULFRAM-LIKE REACTION

2nd generation: GL__IDE Glyburide, Glimepride, Glipizide
*HYPOGLYCEMIA

Binds to Beta cell K+ channel to increase Ca2+

Promotes depolarization and release of Insulin

Front 1349

Biguanides

Back 1349

Metformin
Met-formula (lactic acidosis)

Used as an oral sugar-dropper
Can be used +/- islet function

Probably reduces gluconeogenesis

SE: Lactic acidosis

Front 1350

Glitazones

Back 1350

Glit ~ Glutton (weight gain)

DMII
Not really used anymore due to SE

Pioglitazone
Rosiglitazone

Increases cell response to insulin
(think GLIT-->GLUT)

Hepatotoxicity, CV toxicity, Weight gain

Front 1351

Alpha-glucosidase inhibitors

Back 1351

DMII
Acarbide
Miglitol

Inhibit brush border alpha-glucosidase to slow sugar spike

Possible GI disturbances

Front 1352

Orlistat

Back 1352

Long-term obesity management
Inhibits pancreatic lipase

SE: GI discomfort, steatorrhea, reduced ADEK absorption, headache

Front 1353

Sibutramine

Back 1353

"Boot camp" for the brain (and heart)

SSRI and NERI
Long-term obesity management

SE: Hypertension, tachycardia

Front 1354

Anti-thyroids

Back 1354

Propylthiouracil, methimazole

Both inhibit T4/T3 synthesis

Propylthiouracil ALSO decreases peripheral conversion of T4 --> T3

Front 1355

Somatostatin/Octreotide: Use

Back 1355

Shuts down GH and the GI

PGA:

Pancreas: Z-E (gastrinoma),

Glucagonoma
GI: Carcinoid
Acromegaly (inhibition of GHRH)

Front 1356

Somatostatin/Octreotide: Use

Back 1356

Shuts down GH and the GI

PGA:

Pancreas: Z-E (gastrinoma),

Glucagonoma
GI: Carcinoid
Acromegaly (inhibition of GHRH)

Front 1357

Prostaglandins

Back 1357

Inhibits the CLAP:
Cox-2 expression
Leukotrienes
Phospholipase A2
Prostaglandins

Toxic CUD:
Cushing's syndrome
Ulcers (peptic)
Diabetes (chronic use)

Front 1358

Abdominal Layers: Skin--> Peritoneum

Back 1358

Susan Sarandon Eats Italian Toddlers To Enlarge Peritoneum

Skin
Superficial fascia
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Extraperitoneal tissue
Peritoneum

Front 1359

Lower back muscles

Back 1359

Ventral

Quadratus Psoas Psoas Quadratus
Lats Erector Spinae Erector Spinae Lats

Dorsal

Front 1360

Retroperitoneal Structures (10)

Back 1360

GI: Parts of duodenum, ascending colon, descending colon, rectum

Kidneys, adrenals, ureters

Pancreas (except tail)

Aorta and IVC

Front 1361

Foregut --> Hindgut

Back 1361

Foregut: TUMMY AT TWELVE
Start: Stomach
End: Ampulla of Vater (duodenum)
Includes liver, pancreas, GB

Artery: Celiac
Parasympathetics: Vagus
Spinal levels: T12/L1

Midgut:
Start: Ampulla of Vater (duodenum)
End: 2/3 point of transverse colon

Artery: Superior mesenteric
Parasympathetics: Vagus
Spinal levels: L1

Hindgut: Lets 3 things out (L3)

Start: Last 1/3 of transverse colon
End: Upper rectum

Artery: Inferior mesenteric
Parasympathetics: Pelvic
Spinal levels: L3

Front 1362

Celiac artery: Branches

Back 1362

Calmly (COM LE) splain (SPLEN)

Common hepatic artery
*Hepatic proper --> R gastric, R/L hepatic
*Gastroduodenal --> R epiploic, Panc-duod

Left gastric artery

Splenic artery
*Short gastric branches
*Splenic branches
*L gastroepiploic

*Cystic artery comes off the R hepatic proper

Front 1363

Celiac anastamoses

Back 1363

L and R gastric
L and R gastroepiploic

Front 1364

Abdominal anastamoses (matter when abdominal aorta is blocked)

Back 1364

Anterior diaphragm and abdomen: Superior + Inferior epigastrics
*Superior epigastric from Internal thoracic/mammary (a branch of the subclavian)
*Inferior epigastric from External iliac

Head of the pancreas: Superior + inferior pancreaticoduodenal
*Superior is from celiac trunk
*Inferior is from SMA

3. Transverse colon
Middle + Left colic
*Middle colic is from SMA
*Left colic is from IMA

4. Rectum: Superior and Middle rectal
*Superior is from IMA
*Middle is from internal iliac

Front 1365

Portal-systemic venous anastamoses

Back 1365

Butt, gut, caput

Butt: Hemorrhoids
Superior rectal vein <----> Middle and inferior rectal veins

Gut: Esophageal varices
Left gastric <----> Esophageal

Belly: Caput medusae

Paraumbilical <----> SUPERFICIAL and inferior epigastric

Front 1366

Surgical tx for portal hypertension

Back 1366

Shunt between splenic vein (portal circulation) and renal vein (systemic)

Front 1367

Centrilobular vs. Periportal zone

Back 1367

Centrilobular zone: Zone surrounding the hepatic vein

PITA:
P-450 system location
Ischemia (most susceptible)
Toxic injury (most susceptible)
Alcaholic hepatitis site


Periportal zone: Zone surrounding portal vein, hepatic artery, and bile duct

Affected 1st by viral hepatitis

Front 1368

Splenorenal ligament

Back 1368

The name LIES!

Contains splenic artery and vein

Connects spleen to posterior abdominal wall

Front 1369

Greater curvature ligaments

Back 1369

Structure named first = contains artery coming from there

Only the falciform and splenorenal ligament are not omental

Gastrocolic: Contains gastroepiploic arteries and connects to transverse colon (part of greater omentum)

Gastrosplenic: Contains short gastrics and connects to spleen (separates greater and lesser sacs)

Front 1370

Hepatic Ligaments

Back 1370

Structure named first = contains artery coming from there

Only the falciform and splenorenal ligament are not omental

1. Falciform: Contains ligamentum teres (former umbilical vein) and connects anterior liver to abdominal wall

2. Hepatoduodenal: Contains HEPATIC ARTERY, portal vein, bile duct; separates greater and lesser omental sacs
*Pinch in epiploic foramen of Winslow to control bleeding

3. Gastrohepatic: Contains gastric arteries (lesser curvature), separates greater and lesser omental sacs

Front 1371

Gut wall layers

Back 1371

MSMS

Mucosa
Submucosa (w/Meissner's)
Muscularis externa
Serosa/adventitia

Mucosa = ELM

Epithelium --> Absorption
Lamina propria --> Support
Muscularis mucosa --> Motility

Front 1372

Meissner's and Auerbach's plexi

Back 1372

Meissner (A.k.a. Submucosal)
*meiSSner
*Located between mucosa and inner circular layer
*Secretions/absorption, blood flow

Auerbach (A.K.A. Myenteric)
*Located between inner circular and outer longitudinal layers
*Motility along entire gut wall

Front 1373

Arteries, veins, and innnervation of rectum

Back 1373

**Above pectinate line**

Vessels: Superior rectal a/v (IMA)

Innervation: Visceral (no pain)

Internal hemorrhoids
Adenocarcinoma


**Below pectinate line:**

Vessels: Inferior rectal a/v
*From internal pudendal, a branch of the internal iliac

External hemorrhoids (painful)
Squamous cell carcinoma

Front 1374

Femoral triangle

Back 1374

Borders: Sartorius muscle (lateral), Adductor longus muscle (medial), inguinal ligament (superior)

Contents: NAVEL

Femoral nerve, artery, vein
Empty space
Lymphatics

The L side is NOT lateral!

Front 1375

Femoral sheath

Back 1375

_AVEL

Femoral artery, vein and lymphatics (deep inguinal LN drainage)

NOT THE FEMORAL NERVE

Front 1376

Diaphragmatic hernia

Back 1376

Most common pop = Infants (pleuroperitoneal membrane development)

Most common form = hiatal hernia
*Sliding: Most common; GE junction intact

*Paraesophageal: GE junction is normal, but cardia has moved into thorax (blood supply?)

Front 1377

Indirect vs. direct inguinal hernia

Back 1377

Indirect: Most common pop = Infants (failure of processus vaginalis to close), males

Travels through deep inguinal ring (LATERAL to inferior epigastrics) --> Scrotum

Direct: Most common pop = Older males

Protrusion through inguinal (Hasselbach's) triangle:
*Rectus abdominis (medial)
*Inguinal ligament (inferior)
*Inferior epigastric artery (lateral)

Covered in transversalis FASCIA

Front 1378

Femoral hernia

Back 1378

Most common pop = Women

Most common cause of bowel incarceration/trapping

Protrusion through femoral canal (below inguinal ligament)

Front 1379

Peyer's patches

Back 1379

Unencapsulated collections in lamina propria and submucosa

M cells take up antigen
Activated B cells travel to mesenteric LN's and differentiate into IgA plasma cells

Return to epithelial cells via Poly-Ig receptor (attaches secretory component)

Front 1380

Salivary glands

Back 1380

Sympathetic (T1-T3)
Parasympathetic (VII, IX)

Serous on the SIDES
Mucinous in the MIDDLE

High flow = Isotonic (Highsotonic)
LOw flow = HypOtonic

Parotid (most serous)
*CN VII runs through it
Submaxillary
Submandibular
Sublingual (most mucinous)

Front 1381

THe ONLY GI submucosal gland

Back 1381

Brunner (bicarbonate)

Connect to crypts of Leiberkuhn in the mucosa

Front 1382

Parietal cells

Back 1382

1. Intrinsic Factor (for vitamin B12 absorption)
*No regulation

2. Gastric acid (for digestion)
*Tons of regulation

Acid regulators: HAG GIPPSy

Increase: HAG
Histamine
Ach (vagus)
Gastrin

Decrease: GIPPSSy
GIP
Prostaglandin
Secretin
Somatostatin

Front 1383

Chief cells

Back 1383

Pepsinogen --> Pepsin

Released in response to:
1. Vagal (the "man upstairs"
2. Local H+ (the "locals))

Front 1384

Gastrin

Back 1384

Released by G cells in stomach antrum

Gastrin's effects: GAS

Growth--of the gastric mucosa
Acid--H+ secretion by parietals
Smooth muscle--Gastric motility

Postivie reg: Think of GAS again
Stomach distention
Amino acids (Phe, Trp)
Vagal stimulation

Negative reg: pH <1.5

Front 1385

Small intestine hormones

Back 1385

SIK MV = SIcK MoVe:

S cells --> Secretin
*Acids

I cells --> CCK
*Fatty acids + amino acids

K cells --> GIP
*Fatty acids + amino acids + glucose

also

Motilin from "Small intestine"
VIP from Parasympathetic ganglia

Front 1386

Somatostatin

Back 1386

Released by D cells in GI and PANCREATIC islets

Regulation: Same factors as chief cells, but different effects
1. Local acid increases (same as Chiefs)
2. Vagal input DECREASES

Functions:
1. Anti-growth hormone

2. Shuts down:
A. Stomach (parietal, chief cells)
B. SI mucosal secretion
C. Gall bladder contraction
D. Pancreas (enzymes, insulin, glucagon)

Used to treat VIPoma and carcinoid tumors

Front 1387

Secretin

Back 1387

**BICARBONATE and BILE**
Makes every organ secrete something

Released from S cells in Duodenum

Regulation:
Increased by local Acids (including fatty acids)

Actions:

1. Stomach: Inhibits parietal cells, increases bicarbonate
2. SI: Increases bicarbonate
3. GB/Liver: Increases bile
4. Pancreas: Increases bicarbonate

Front 1388

Cholecystokinin

Back 1388

**SI DIGESTION**
Released from I cells of Duodenum, Jejunum

Regulation:
Fatty acids
Amino acids

Actions:
1. Stomach: Decreases gastric emptying
2. SI mucosa: None
3. GB: Increased contraction
4. Pancreas: Increased secretion

Front 1389

GIP

Back 1389

*Insulin*
Secreted from K cells of duodenum and jejunum

Regulation:
Fatty acids
Amino acids
Oral glucose (used faster than IV glucose)

Actions:
1. Stomach: Inhibits parietal cells
2. SI: None
3. GB: None
4. Pancreas: Insulin release

Front 1390

What does the LES need to avoid achalasia?

Back 1390

NO

Smooth muscle relaxation at LES

Loss of nitric oxide @ LES --> achalasia

Front 1391

VIP

Back 1391

Released from parasympathetic ganglia:
1. Sphincters
2. Small intestine
3. GB

Positive Regulation: Like GASTRIN
1. Distention
2. Vagal stimulation

Negative regulation: Adrenergic input

Actions:
1. Sphincter relaxation
2. Water and electrolyte secretion

VIPoma (pancreas) = Copious diarrhea

Front 1392

Enterokinase/Enteropeptidase

Back 1392

Duodenal mucosa enzyme that converts trypsinogen (from pancreas) --> trypsin

Trypsin activates more trypsin
Trypsin activates other zymogens

Front 1393

Pancreatic and salivary amylases

Back 1393

NOT rate limiting

Alpha amylases: Hydrolyze alpha-1,4 linkages
*Unable to hydrolyze alpha-1,6 linkages (branches)

Starch --> Maltose (2 glucose), maltotriose (3 glucose), limit-dextrans, other oligo and disaccharides

The rest is taken care of by oligosaccharide hydrolases from the BRUSH BORDER

Front 1394

Sugar absorption

Back 1394

GI lumen to enterocyte:
1. Glucose/galactose --> SGLT-1
*Na+ dependent
2. Fructose --> GLUT-5

Enterocyte to blood: GLUT-2 for fructose, glucose and galactose

Front 1395

What makes a bile salt water soluble?

Back 1395

Congugation with glycine or taurine

Front 1396

Bilirubin cycle: Reabsorption sites

Back 1396

RES + liver enzyme products --> Biliverdin --> Indirect Bilirubin (insoluble)

Liver adds glucuronic acid (conjugation) --> Excretion as Direct Bilirubin

Bile salts partially reabsorbed by the distal ileum

Urobilinogen (some) and Uncongugated bilirubin reabsorbed in colon

Absorbed urobilinogen --> Urobilin (urine)

Non-absorbed urobilinogen --> Stercobilin (feces)

Front 1397

Achalasia-like syndrome

Back 1397

Part of scleroderma or CREST

Esophagus features smooth muscle atrophy and fibrous replacement of CT

Result: "Tightening" that resembles, but is not related to a Myenteric plexus defect

LOW PRESSURE proximal to the LES rather than high

Front 1398

Achalasia

Back 1398

Dysfunctional myenteric plexus
1. High LES opening pressure
2. Uncoordinated peristalsis

Barium swallow = bird's beak (dilated esophagus w/distal stenosis)

ESOPHAGEAL CARCINOMA RISK

Front 1399

Mallory-Weiss

Back 1399

Mallory, why do you drink/purge?

Severe vomiting lacerates the GEJ

PAINFUL + Hematoemesis

Alcoholics and bulemics

Front 1400

Boerhaave syndrome

Back 1400

VIOLENT retching causes transmural esophageal rupture

Severe pain, often vomiting, possible mediastinitis (dyspnea) and septic shock

Front 1401

Esophageal strictures: Cause

Back 1401

Lye (base) ingestion

Front 1402

Esophagitis: Causes

Back 1402

Irritants: Reflux, chemicals

Infection (CatCH):
Candida
CMV
HSV-1

Front 1403

Tracheoesophageal fistula

Back 1403

Abnormal connection between esophagus and trachea

Most common:
Upper esophagus = Blind pouch
Lower esophagus = Connected to trachea

AIR BUBBLE on CXR
Polyhydramnios in utero
Cyanosis
Choking and vomiting w/feeding

Front 1404

Congenital pyloric stenosis

Back 1404

1/600 live births, especially 1st born males

Hypertrophy of the pylorus causes obstruction

Epigastric OLIVE MASS (hypertrophied pylorus)

Nonbilous projectile vomiting @ 2 weeks

Tx =Surgical incision

Front 1405

Esphageal cancer risk factors

Back 1405

ABCDEF
Alcohol/Achalasia
Barrett's esophagus
Cigarettes
Diverticuli
Esophageal webs, Esophagitis
Familial

Squamous = Upper 2/3
*Most common worldwide
*50% in US

AdenoCA = Lower 1/3 (closer to glandular tissue of stomach)

Front 1406

Tropical Sprue

Back 1406

Like celiac sprue but is caused by bacteria (treatable w/antibiotics)

Affects WHOLE small bowel, rather than just jejunum

Front 1407

Whipple's disease

Back 1407

Tropheryma Whippelii (gram +)

Most often in older men

CAN be CANned as typical "older man" complaints:
1. Cardiac symptoms
2. Arthritis
3. Neurological symptoms

Look for PAS POSITIVE macrophages in lamina propria + mesenteric LN's

Front 1408

Pancreatic insufficiency

Back 1408

Obstruction (CYSTIC FIBROSIS, stones), or pancreatic damage (pancreatitis) leads to low enzymes

Malabsorption:
1. Protein
2. Fat
3. Fat-soluble vitamins

Front 1409

Celiac sprue

Back 1409

HLA-DQ 8
Most common in N. European pops

Gliadin + MHCII --> B and T cell activation

Elevated GLIADIN AB and TISSUE TRANSGLUTAMINASE

Primarily jejunum

Blunted villi w/decreased absorption

Lymphocytes in lamina propria

Steatorrhea
Dermatitis herpetiformis
Increased risk of T cell lymphoma

Front 1410

Acute gastritis vs. Chronic gastritis: Which is erosive?

Back 1410

Acute gastritis

Front 1411

Causes of acute gastritis (5)

Back 1411

Things that disrupt the mucosal barrier in some way

1. NSAIDs (reduce Cox-1 PGs)

2. Alcohol (erodes lining)

3. Uricemia (Hypoxanthine --> free radical damage)

4. Curling's ulcer (burns) --> NECROSIS
*Low plasma volume, ischemia, sloughing

5. Cushing's ulcer (ICP, brain injury) --> Vagal stimulation of H+ SECRETION

Front 1412

Chronic gastritis type A + B

Back 1412

Type A(B): Autoimmune ABs to parietal cells
*Gastritis
*Pernicious anemia (low IF)
*Achlorhydria (low H+)

Type B(A): Bacteria in the Antrum
*H. Pylori

Front 1413

Menetrier's disease

Back 1413

"Might rain" mucus...

Increased mucus cells
Atrophy of parietal cells

Rugae enlarge to look like brain gyri

PRECANCEROUS CONDITION

Front 1414

Stomach Cancer (AdenoCA): Features and risk factors

Back 1414

Aggressive with early spread

Virchow's node: Left supraclavicular node (indicates stomach met)

Krukenberg's tumor: BILATERAL ovarian met w/signet cells

Risk factors: MOM (type A blood, gastritis), eating beef jerky

Type A blood
Chronic gastritis (esp if type A, which features achlorhydria)
Nitrosamines (smoked food)

Front 1415

Linitis plastica

Back 1415

Diffusely infiltrative stomach cancer

"Leather, not plastic" --> Leather bottle appearance of stomach lining

Nuclei LINE the edges of signet cells

Skin LINING affected: Acanthosis nigricans (hyperpigmentation of body folds also seen w/IR)

Front 1416

PUD

Back 1416

Pain GREATER w/meals --> Weight loss

H. Pylori (70%) and NSAIDS

Front 1417

DUD

Back 1417

Pain REDUCED with meals --> weight gain

H. pylori (100%) and Z-E

Brunner's glands hypertrophy to counteract poor protection (HP) or increased acid (ZE)

Studded appearance ("DUD WILL STUD") --> clean, regular margins

Front 1418

PUD and DUD: Causes

Back 1418

PUD: H. pylori (70%) + NSAIDS
*Pain increased w/meals

DUD: H. pylori (100%) + ZE
*Pain reduced w/meals

Front 1419

Crohn's disease

Back 1419

Postinfectious ("CATCH Crohn's")

Any age, but peaks = 13-30, 50-80

3x risk in smokers

ANYWHERE IN GI, but usually: Terminal ileum (absorption probs)
Colon

TRANSMURAL inflammation
Creeping fat
Granulomas
Skip lesions (not continuous)
Linear ulcers (+ fissures, fistulas)
Cobblestone mucosa

"String sign" on barium swallow xray

"CATCH a FAT GRANny SKIPping down a LINEAR COBBLESTONE path with an old crone, away from the REC"

Diarrhea: Bloody OR nonbloody

Joints: Migratory polyarthritis, ankylosing spondylitis

Skin: Erythema nodosum

Eye: Uveitis

Gallbladder: Cholesterol STONES

Tx:
*Sulfasalazine
*Infliximab (pain on TNF)
*Corticosteroids

Front 1420

Ulcerative colitis

Back 1420

Autoimmune

Peaks 15-25, 60-70

Reduced risk in smokers

Colon only
Continuous and retroactive from rectum

Mucosal and submucosal inflammation only
*Creates hanging polyps
*Lead pipe appearance on imaging

Instead of creeping fat --> Friable pseudopolyps

Instead of granulomas --> Crypt abscesses and ulcers

Instead of skip lesions --> Continuous

Diarrhea: ALWAYS BLOODY

PSC: Bile ductule (intrahepatic) and bile duct (extrahepatic) onion skinning and beading (2x men)

Skin: Pyoderma gangrenosum (deep, necrotic leg ulcers)

Tx: Sulfasalazine

Front 1421

Appendicitis

Back 1421

Occurs in all age groups

Elderly: Similar to diverticulitis
Women: Similar to ectopic pregnancy (check B-hCG)

Symptoms:
Periumbilical pain --> McBurney's point (RLQ) once infection has irritated the peritoneum

Nausea, fever

Front 1422

Diverticulum

Back 1422

True = 3 layers
*Mucosa
*Submucosa
*Muscularis externa

False = 2 layers
*Muscularis externa reduced or absent
*Likely in places where vasa recta perforate muscularis externa

Front 1423

Diverticulosis vs. Diverticulitis

Back 1423

DIVERTICULA USUALLY IN SIGMOID COLON

Diverticulosis = Many diverticula
*50% of people over age 60
*Low fiber diets --> intraluminal P

Diverticulitis: Bacterial infection of diverticulum
*LLQ pain, fever, WBCs

Front 1424

Zenker's diverticulum

Back 1424

FALSE DIVERTICULUM

Herniation of mucosal tissue @pharynx, esophagus junction

Dysphagia, obstruction
Bacterial accumulation --> HALITOSIS

Front 1425

Meckel's diverticulum

Back 1425

MOST COMMON CONGENITAL ANOMALY OF THE GI (2% of pop)

Persistent vitelline duct/yolk sac

The five "2's" -->
1. 2 inches long
2. 2 feet from the ileocecal valve
3. 2% of pop
4. Presents in 1st 2 years of life
5. 2 possible types of epithelia inside (gastric, pancreatic)

Complications: Obstruction, volvulus, intussusception

Front 1426

Intussusception

Back 1426

"Telescoping" of proximal bowel segment into distal one

Usually infants w/an intraluminal mass

Possible blood supply issue

Front 1427

Volvulus

Back 1427

Twisting of bowel (around mesentary)

Obstruction, infarction

SIGMOID COLON (redundant mesentary)

Front 1428

Hirschprung's Disease

Back 1428

Missing plexi (Auerbach + Meissner) due to poor NEURAL CREST MIGRATION

Increased risk with Down Syndrome

Creates:
1. Constricted segment (at site of missing plexus)
2. Dilated megacolon (proximal)

Front 1429

Duodenal atresia

Back 1429

Early BILOUS vomiting
"Double bubble" --> Duodenal distention + proximal stomach distention

Assoc w/Down Syndrome: "DOUBLE DOWN"

Front 1430

GI adhesion

Back 1430

Acute bowel obstruction

Most common cause is surgery

Front 1431

Angiodysplasia

Back 1431

Usually seen in elderly patients

Ascending colon and cecum --> "ANGels ascend"
Tortuous vessel dilation --> bleeding

Front 1432

Sigmoid colon problems

Back 1432

Polyps (rectosigmoid)
Volvulus
Diverticuli

Front 1433

Colon polyps

Back 1433

90% benign hyperplastic hamartomas (benign, focal growth that resembles a neoplasm of that tissue)

10% malignant

Tubular: Rounded
Villous (more likely to be malignant): Fingerlike projections
*Villous = Villainous

Front 1434

Colorectal cancer

Back 1434

3rd most common cancer

APPLE CORE lesions on barium enema X-ray (narrowing from either side--like a C ring)

Risk factors:
Age >50

PMH:
Previous CRC or villous polyps
Ulcerative colitis

Family history: FAP, HNPCC, P-J

Front 1435

Portal HTN: Classic signs

Back 1435

1. Butt, gut, caput:
*Esophageal varices --> Hematemesis, melena
*Hemorrhoids
*Caput medusae

2. Splenomegaly (backup into splenic vein)
3. Ascites
4. Peptic ulcer --> Melena
*Stasis of L gastric vein?

Front 1436

Liver failure: Signs

Back 1436

Liver failure signs

Fetor hepaticus: Mecaptan backup into lungs

Bilirubin: Jaundus, scleral icterus

Hepatoencephalopathy: Asterixis, coma

Decreased prothrombin, clotting factors, erythropoietin: Bleeding, anemia

Diminished andostenodione catabolism: Spider nevi, testicular atrophy, gynecomastia

Front 1437

Micronodular vs. Macronodular cirrhosis

Back 1437

Micronodular = METABOLIC INSULTS
*Chemicals or deposits

Alcohol
Wilson's disease
Hemochromatosis

Macronodular = LIVER INJURY
*> 3 mm

Infection
Drug toxicity

Increased risk of hepatocellular carcinoma

Front 1438

Hepatocellular carcinoma: Causes (7)

Back 1438

Causes --> AB(H)C

Alcohol
Anti-trypsin def
Aflatoxin
Hepatitis B, C
Hemochromatosis
Copper (Wilson's disease)

Symptoms:
Hepatomegaly
Function: Hypoglycemia, ascites
Ischemia --> Erythropoietin

Front 1439

Causes of increased AST or ALT

Back 1439

Viral hepatitis (ALT > AST)

Alcoholic hepatitis (AST > ALT)
*ToASTed

Myocardial infarction

Front 1440

Causes of increased Alkaline Phosphatase

Back 1440

BOB:

Bone degeneration

Obstructive liver disease (CA)

Bile duct disease

Front 1441

Causes of increased serum amylase

Back 1441

Acute pancreatitis (pancreatic amylase)
Mumps (salivary amylase)

Front 1442

Causes of increased serum lipase

Back 1442

Acute pancreatitis

Serum amylase is also elevated--but both pancreas and parotids secrete it

Front 1443

Reye's syndrome pathogenesis

Back 1443

Viral infection (VZV, Influenza B)
+
Salicylates

Result: Hepatoencephalopathy
*Fatty liver
*Hypoglycemia
*Coma

Front 1444

Hepatic steatosis

Back 1444

Stage preceding hepatitis

Moderate alcohol intake
+
Cessation

Result: Macrovesicular fatty change (reversible)

Front 1445

Alcoholic hepatitis

Back 1445

Stage preceding cirrhosis

Long-term alcohol intake

Cells feature cytoplasmic inclusions --> Mallory bodies

NECROSIS has started --> Neutrophils

Front 1446

Alcoholic cirrhosis

Back 1446

Long-term alcohol intake
Zone III (around central vein)

Add FIBROSIS to ongoing cell death --> "HOBNAIL" appearance

Symptoms (jaundice, low albumin, etc.)

Front 1447

Budd-Chiari syndrome

Back 1447

Vascular OUTPUT of the liver is obstructed
*Hepatic vein
*IVC

Causes: Pregnancy, hepatocellular carcinoma, polycythemia vera

Centrilobular congestion, ischemia and necrosis

*Hepatomegaly, varices + visible stomach/back veins
*Ascites, liver failure

**NO JVD**

Front 1448

Urine bilirubin levels w/hyperbilirubinemia:
Hepatocellular, Obstructive, and Hemolytic

Back 1448

Hepatocellular = Conjugated bilirubin
Obstructive = Conjugated bilirubin
Hemolytic = Unconjugated bilirubin

Urine bilirubin:
*Only conjugated can be secreted in urine

Hepatocellular: High
Obstructive: High
Hemoltyic: Absent

Urine urobilinogen:
*Must go to GI and be reabsorbed

Hepatocellular: Normal or low
Obstructive: Low
Hemolytic: High

Front 1449

Gilbert's syndrome

Back 1449

Benign congenital UNCONJUGATED hyperbilirubinemia

During stress -->
1. Decreased w/bilirubin uptake or
2. Decreased UDP-glucuronyl transferase

No clinical consequences

Front 1450

Dubin-Johnson syndrome

Back 1450

Problem with bilirubin excretion

Elevated CONJUGATED bilirubin
Black liver, but asymptomatic

Front 1451

Wilson's Disease

Back 1451

Copper does not enter circulation as ceruloplasmin --> poor excretion

ABCD:

Asterixis
Basal ganglia degeneration
*Parkinsonian symptoms
*Chorea
Ceruloplasmin (low), Cirrhosis/Carcinoma, Corneal deposits
Dementia

Front 1452

Hemochromatosis

Back 1452

Association with HLA-A3

Hemochromatosis Can Cause Crappy Deposits (HCCD):

CHF
Cirrhosis
Carcinoma
Diabetes

Treatment: Phlebotomy, DeFERoxamine (chelator)

Front 1453

Primary Sclerosing Cholangitis

Back 1453

2x Men:Women
Associated w/ulcerative colitis

Intrahepatic (ductules) and extrahepatic (duct) fibrosis of bile ducts
*Concentric layers --> Onion skinning

BEADING on ERCP (endoscopic retrograde cholangiopancreatography)

Increased ALP

Front 1454

Primary biliary sclerosis

Back 1454

9x Women
Associated w/scleroderma, CREST

INTRAHEPATIC (ductules) autoimmune reaction causing severe OBSTRUCTION

Increased ALP
Anti-mitochondrial antibodies (AMA)

Front 1455

Secondary biliary sclerosis

Back 1455

Extrahepatic biliary obstruction

Often causes ascending cholangitis
Increased ALP

Front 1456

Intrahepatic vs. Extrahepatic biliary diseases

Back 1456

Primary sclerosing cholangitis: Both

Primary biliary cirrhosis: Intrahepatic

Secondary biliary cirrhosis: Extrahepatic

Front 1457

Gallstone pathogenesis

Back 1457

Promote Solubility: Bile acids + lecithin

Promote Insolubility: Cholesterol, bilirubin

Stones: Cholesterol, bilirubin
> Bile salts, lecithin

The 4 "F's" of cholesterol stones:

Female --> Estrogen

Fat --> Obesity, rapid wt loss, Clofibrate (cholesterol)

Fertile --> Multiparous

Forty --> Age (also a RF for pigment stones)

+ Crohn's
+ Cystic fibrosis
+ Native American

Pigment stones: HIGH CONCENTRATIONS OF BILIRUBIN, ESP UNCONJUGATED

RBC hemolysis

Biliary infection (stasis?)

Alcoholic cirrhosis (predisposes to > unconjugated bilirubin in bile duct)

Front 1458

Acute pancreatitis

Back 1458

Many more causes than chronic (alcohol, gallstones)

Symptoms:
*Epigastric abdominal pain radiating to BACK
*Anorexia, nausea

Causes = GET SMASHeD
Gallstones
Ethanol
Trauma

Steroids
Mumps
*Take amylase seriously--not just parotid
Autoimmune disease
Scorpion bite
Hypercalcemia
*Modifies secretion, predisposes to plugs
Hyperlipidemia
Drugs (sulfa)

Complications are SAD:
Soap deposits --> Hypocalcemia
ARDS--> Direct leakage
DIC --> Direct leakage

Front 1459

Pancreatic cancer

Back 1459

Aggressive cancer--usually spread by discovery

Risk factors:
Jewish, African american descent
Cigarettes (but not EtOH)

CEA and CEA 19-9 markers

Pancreas pain: Epigastric abdominal pain radiating to BACK

Weight loss (malabsorption + anorexia)

TROUSSEAU's syndrome: Extremity redness and tenderness (due to venous thrombosis)

COURVOISIER'S sign: Palpable gallbladder (implies quick obstruction)

Front 1460

H2 blockers

Back 1460

Take H2 before you DINE: Cimeditine, Ranitidine, Famotidine, Nizatidine

Uses: Gastritis, GERD, PUD

SE:
Cimeditine sucks:
*P450 (Inhibitor)
*Anti-androgen (GYNECOMASTIA)
*Crosses BBB, placenta

Increase serum CReatinine: Cimdeditine and Ranitidine

Front 1461

PPIs

Back 1461

PRAZOLES: Omeprazole, lansoprazole

Block parietal H+/K+ ATPase

Uses: Gastritis, GERD, PUD
ZOLLINGER-ELLISON

SE: None listed

Front 1462

Bismuths

Back 1462

Bismuth, Sucralfate

Healing: Protect mucous layer and promote HCO3- secretion

SE: None listed
Uses: Ulcer healing, traveler's diarrhea

Front 1463

Traveler's diarrhea

Back 1463

Bismuths (Bismuth, Sucralfate)

E. coli (Enterotoxigenic)
*Traveler's diarrhea
*ST and LT toxins

Front 1464

Misoprostol

Back 1464

PGE-1 analog

Uses:
1. PUD prevention: Replaces the COX-1 PG's lost by taking an NSAID

2. Maintains a patent ductus arteriosus

3. Abortifacient, Induces labor

Decreases acid production
Increases mucus production --> Diarrhea

Front 1465

Muscarinic antagonists for PUD

Back 1465

PR__ine

Pirenzipine, propantheline:

Use = PUD treatment

Bind to M3 receptor of parietal cells (stop H+)

Bind to M1 receptor of ECL cells (stop histamine)

SE: Just like atropine, they inhibit DUMBBELSS -->
Diarrhea
Urination
Miosis
Bradycardia
Excitation (CNS)
Lacrimation
Salivation
Sweating

Front 1466

Antacids (3)

Back 1466

Aluminum Hydroxide
Magnesium Hydroxide
Calcium Carbonate

ALL CAUSE HYPOKALEMIA

Aluminum --> Constipation, Phosphate binding (bone loss, proximal muscle weakness, seizures)

Magnesium --> Diarrhea, Muscle depression (Hyporeflexia, Hypotension, Cardiac arrest)

Calcium --> Acid rebound, hypercalcemia, CHELATION (tetracycline--part of H. Pylori treatment)

Front 1467

What SE can all antacids cause?

Back 1467

Hypokalemia

Front 1468

Infliximab

Back 1468

Anti-TNF antibody

Uses:
*Crohn's disease
*Ulcerative colitis
*Rheumatoid arthritis
*Ankylosing spondylitis
*Psoriasis

SE:
*"Serum sickness" (hypotension, fever)
*Predisposition to infection, esp respiratory (TB reactivation)

Alternative = Etanercept (recomb TNF receptor-binds TNF)

Front 1469

Sulfasalazine

Back 1469

Sulfapyridine (antibacterial) + mesalamine (anti-inflammatory)
*Melasamine is activated to 5-ASA in colon

Activated by colonic bacteria

Uses: Crohn's, Ulcerative colitis

SE:
Oligospermia
Sulfonamide toxicity
Malaise, nausea

Front 1470

Odansetron

Back 1470

Dancing from 5 to 3...weak in the knee

5-HT3 antagonist --> Acts at central emetic center
*"Go dancing"

Uses: Chemotherapy, post-operative vomiting prevention

SE: Constipation (GI suppression), headach

Front 1471

Metoclopramide

Back 1471

Prokinetic agent: D2 antagonist

*Increased tone and motility
*Increased LES tone
*SAME TRANSIT TIME in colon

Uses: Gastroparesis, either post-surgery or due to diabetes

SE:
CNS: PD, restlessness, fatigue, depression
GI: Nausea, diarrhea

"D CONFLICTS"
*D2 receptor (antagonist)
*Digoxin/Digitalis
*Diabetes medications

Front 1472

Metoclopramide

Back 1472

Prokinetic agent: D2 antagonist

*Increased tone and motility
*Increased LES tone
*SAME TRANSIT TIME in colon

Uses: Gastroparesis, either post-surgery or due to diabetes

SE:
CNS: PD, restlessness, fatigue, depression
GI: Nausea, diarrhea

"D CONFLICTS"
*D2 receptor (antagonist)
*Digoxin/Digitalis
*Diabetes medications

Front 1473

Cisapride

Back 1473

Prokinetic agent: 5HT4 agonism --> Ach at myenteric plexus
*NOT USED ANYMORE (Torsades)

*Increased tone and contractility
*Increased TRANSIT TIME

Interactions:
Ketoconazole/Fluconazole
Nefazodone

Front 1474

Erythrocyte formation

Back 1474

Pluripotent hematopoietic stem cell
--> Proerythroblast
--> Reticulocyte
--> Erythrocyte

Front 1475

Granulocyte formation

Back 1475

Neutrophil, Eosinophil, Basophil

Pluripotent hematopoietic stem cell
--> Myeloid stem cell
--> Myeloblast
--> Promyelocyte
--> Myelocyte
--> Metamyelocyte
--> Band/Stab cell
--> Neutrophil/Eosinophil/Basophil

Front 1476

Progeny of a hematopoietic stem cell

Back 1476

Myeloid stem cell --> Neutro, Eos, Baso

Lymphoid stem cell --> B, T cells

Pro-Erythroblast --> Erythrocyte

Front 1477

RBC energy source

Back 1477

Glucose (via GLUT-1)

90% fermented
10% used in HMP shunt

Front 1478

Chloride shift

Back 1478

Chloride/Bicarbonate transporter in RBCs

When bicarbonate (CO2) needs to diffuse out, Cl- keeps it isoelectronic

Front 1479

Basophil properties

Back 1479

Exist in BLOOD

Bilobed nucleus

Basophilic granules contain:
Heparin (anticoag)*
Histamine, etc. (vasodilators)*
LTD-4

* = Mast cells too

Front 1480

Mast cell properties

Back 1480

Exist in TISSUE

Bind IgE

Basophilic granules contain:
Heparin (anticoag)*
Histamine (vasodilators)*
Eosinophil chemotactic factors

*Basophils too

Mast cell degranulation is prevented by Cromolyn sodium

Front 1481

Prevents mast cell degranulation

Back 1481

Cromolyn Sodium (Asthma)

Front 1482

Eosinophil properties

Back 1482

EOSINOPHIL EATS

Defends against helminthic, protozoan infections

Rapidly phagocytoses antigen-antibody complexes

Bilobed nucleus
Uniform granule size

Granules contain:
Major basic protein
Histaminase
Arylsulfatase

Causes of high eosinophils: NAACP

Neoplasm
Asthma
Allergic process
Collagen vascular diseases
Parasites (Protozoans, helminths)

Front 1483

Allergic cells

Back 1483

Basophils
Eosinophils
Mast cells (Type I)

Front 1484

Neutrophils

Back 1484

Acute inflammation response:
1. Granule release
2. Phagocytosis

Multilobed nucleus
Hypersegmented w/B12, folate deficiency

Granules ("lysosomes", azurophilic):
*Hydrolytic Enzymes
*Lysozyme
*Lactoferrin
*Myeloperoxidase

Front 1485

Large cell w/FROSTED GLASS cytoplasm

Kidney shaped nucleus

Back 1485

Monocyte

Front 1486

Macrophage

Back 1486

Arrive after neutrophils
1. Phagocytosis, antigen presentation
2. Cleanup (debris, senescent red cells)

Activated by gamma-interferon

Long life in tissue

Front 1487

Dendritic (Langerhan's-skin) cells

Back 1487

Act solely as APCs

Responsible for primary antibody response

Front 1488

Plasma cells

Back 1488

Plasma cell malignancy is responsible for MULTIPLE MYELOMA (bone)

Appearance:
Off-center nucleus
"Clock face" chromatin
Well-developed RER and Golgi

Front 1489

Extrinsic pathway

Back 1489

A sole EXILED clotting factor

Tissue factor converts 7 --> 7a

7a then converts 10 --> 10a

10 --> 10a (5a joins)
2 --> 2a (thrombin)
1 --> 1a (fibrin)
13a produces cross-links in fibrin

Fibrinogen (1) bridges platelets via GP2b/3a --> converted to fibrin (1a) in place

Front 1490

Factor 12

Back 1490

1st step of intrinsic pathway (PTT)

2 things convert it to 12a:

1. Injured endothelium (collagen, BM, activated platelets)
2. HMW Kinin

Factor 12a has 2 functions:
1. 11 --> 11a
2. Pre-kallikrein --> Kallikrein

Front 1491

Intrinsic pathway

Back 1491

12 --> 12a (by endothelium or HMWK)
11 --> 11a
9 --> 9a (8a joins)
10 --> 10a (5a joins)
2 --> 2a (thrombin)
1 --> 1a (fibrin)
13a produces cross-links in fibrin

Fibrinogen bridges platelets via GP2b/3a --> converted to fibrin in place

Front 1492

Protein C

Back 1492

1. Thrombomodulin converts Ci --> Ca
2. Protein S joins

Protein C and S are vitamin K dependent

Ca inactivates joiners (5a, 8a) to affect both intrinsic and common pathway

Resistance = Factor V Leiden

Front 1493

Anti-thrombin III activation

Back 1493

Heparin converts ATIIIi ---> ATIIIa

ATIII inactivates thrombin (2a), 9a, 10a, 11a

Front 1494

Plasmin activation

Back 1494

Tissue plasminogen activator (or kallikrein) converts plasminogen --> plasmin

Cleaves fibrin clots
Converts C3 to C3a (complement)

Front 1495

HMWK and Kallikrein

Back 1495

HMWK:
*Converts Factor 12 --> 12a
*Kallikrein converts HMWK to
Bradykinin

Kallikrein (from Prekallikrein, catalyzed by factor XIIa):
*Converts HMWK to Bradykinin
*Converts Plasminogen ---> Plasmin (like tPA)

Front 1496

Stages of thrombogenesis

Back 1496

1. Adhesion: Platelet GP1B bonds to endothelial vWF

2. Aggregation: TXA2 from platelets
*Inhibited by endothelial NO,
PGI2

3. Swelling: ADP and Ca2+ released to strengthen plug

Fibrin deposition can now occur

Front 1497

Spherocytosis: Causes

Back 1497

Hereditary spherocytosis
Autoimmune hemolysis

Front 1498

Elliptocytosis: Causes

Back 1498

Hereditary elliptocytosis

Front 1499

Macro-ovalocytes: Causes (2)

Back 1499

Megaloblastic anemia
Marrow failure

Front 1500

Helmet cells/Shistocytes: Causes

Back 1500

DIC, traumatic hemolysis

Fibrin severs RBCS

Front 1501

Bite cells: Cause

Back 1501

G6PD (Heinz body removed by spleen)

Front 1502

Teardrop cells: Cause

Back 1502

MYELOID METAPLASIA w/myelofibrosis

Squeezing through fibrous marrow causes shape

Front 1503

Target cells: Causes (4)

Back 1503

Ring of pallor around central Hb

HALT, said the hunter to his target

Hemoglobin C (abnormal beta chains that precipitate)

Asplenia (weird cells not removed)

Liver dz (low LCAT causes high cell cholesterol, big plasma membranes)

Thalassemia (low Hb levels

Front 1504

Poikilocytes: Causes

Back 1504

Poikilocytes --> Different sizes

Fibrin: DIC, trauma

TTP/HUS (ADAMTS13 deficiency --> vWF clumps)

Front 1505

Basophilic stippling: Causes (4)

Back 1505

TAIL = The 3 microcytic anemias + Anemia of Chronic disease

Thalassemia
Anemia of chronic disease
Iron deficiency
Lead poisoning

Front 1506

Microcytic anemias

Back 1506

ALL are HYPOCHROMIC
MCV < 80

Causes: TAIL w/o the A

Thalassemia --> Target cells
Iron deficiency
Lead poisoning, sideroblastic anemias

Front 1507

Iron-moving compounds

Back 1507

Ferroportin: moves iron through cells
*Inhibited by hepcidin

Transferrin: Carries iron around in blood

Stored iron (in cell): Ferritin, hemosiderin

Front 1508

Signs of hemolysis

Back 1508

Decreased serum HAPTOGLOBIN
*Haptoglobin binds free Hb in blood --> Overwhelmed

INCREASED SERUM LDH
*Lactate dehydrogenase
*RBCs get nutrition anaerobically

Front 1509

Aplastic anemia

Back 1509

NORMAL looking cells, just not enough of them

Bone marrow is hypocellular
*Stem cells have been lost
*Stem cells that remain are not producing/releasing enough

Causes:
Radiation

Virus: B19, EBV, HIV

Fanconi's anemia (AR, assoc. w/short stature and other malignancies)

Drugs:

Antimetabolites

Alkylating agents

Propylthiouracil (anti-thyroid, prevents iodination of thyroglobulin --> thyroxine)

Methimazole (anti-thyroid, prevents iodination of thyroglobulin --> thyroxine)

NSAIDS

Chloramphenicol (Bacteriostatic 50S inhibitor)
*Meningitis: HIB, Neisseria, Strep pneumo

Benzene (various materials)

Front 1510

"Crew cut skull"

Back 1510

Sign of increased erythropoeisis (marrow expansion) on X-ray

Sickle cell
Thalassemias

Front 1511

Sickle cell anemia

Back 1511

8% of AA population = Trait
0.2% = Disease

Complications: SARVS

Salmonella osteomyelitis (vs. S. Aureus)
Aplastic crisis (B19)
Renal papillary necrosis
Veno-occlusive crises
Spleen destruction, sequestration

Treatments:
Bone marrow transplant
HYDROXYUREA (increases HbF)

Front 1512

TTP/HUS: Cells

Back 1512

Burr cell (really looks like a burr)

Poikilocytes

Front 1513

Alpha thalassemia

Back 1513

Asian and African populations

3 missing copies = Hemoglobin H
*H4 tetramers seen

4 missing copies = Hemoglobin Barts
*Hydrops (cardiac overpumping)
*Intrauterine death

Front 1514

Beta thalassemia

Back 1514

Mediterranean populations

Fetal hemoglobin becomes elevated in either case

1 missing copy = Minor
Both copies missing = Major
*Severe anemia requiring transfusions
*Hemochromatosis --> heart failure

Front 1515

Hemolytic anemia: Types

Back 1515

All cases:
**Increased serum bilirubin (unconjugated) --> Jaundice, pigment gallstones**

**Increased reticulocytes**

1. Autoimmune (EV)--extravascular
*Coomb's positive
*Warm/Cold agglutinins
*Erythroblastosis fetalis--Rh+ baby w/Rh- mother

2. Hereditary spherocytosis (EV)
*Extravascular
*Spectrin or ankyrin defect
*Small, round cells --> High MCHC, RDW

3. Paroxysmal nocturnal
*Intravascular
*DAF

4. Microangiopathic: Shistocytes/helmets
*DIC, TTP/HUS, Malignant HTN
*SLE
*Intravascular

EV: Spleen and Kuppfer cell destruction

Front 1516

Autoimmune hemolytic anemia

Back 1516

Coombs positive, Extravascular

Warm weather is GGGreat (IgG)
MMM (IgM), cold icecream

1. Warm agglutinins:
"Silly (SLE) dope (dopa), cold (CLL) is warm!"

SLE
CLL
Alpha methyldopa

2. Cold: MMM
IgM
Mononucleosis
Mycoplasma bacterium

3. Eryhroblastosis fetalis: Maternal Ab attack fetal RBCs

Front 1517

Paroxysmal Nocturnal Hemoglobinuria

Back 1517

Intravascular hemolysis

Membrane defect in RBC increases susceptibility to complement

Increased urine HEMOSIDERIN

Commonly a problem w/ the GPI anchor (allows Decay Accelerating Factor to attach, which then inhibits alternative complement pathway)

Front 1518

DIC: Causes and Labs

Back 1518

STOP Making New Thrombi!

Sepsis (gram NEGATIVE)
Trauma
Obstetric complications
Pancreatitis (acute)
Malignancy
Nephrotic syndrome
Transfusion

Labs: Microthrombi --> consumption of platelets and coagulation factors

Elevated PT, PTT
Elevated fibrin split products (D-dimers)
Low platelets
Helmet cells and schistocytes

Front 1519

Platelet problem signs

Back 1519

MICROhemorrhage

Mucous membrane bleeding (including epistaxis--nosebleed)

Petechiae (pin), Purpura (larger)

Front 1520

Clotting factor problem signs

Back 1520

MACROhemorrhage

Increased PTT and/or PT

Hemarthroses
Easy bruising

Front 1521

Platelet problems

Back 1521

Platelet deficiency/malfunction = increased bleeding time

PTT/PT do not change!

Bernard Soulier disease (GP 1b)
*Defect of platelet ADHESION
*Low platelets (?), high bleeding time

Glanzmann's (AgGregation, GP2b-3a)
*High bleeding time

ITP (antiplatelet Abs)
*Low platelets, high bleeding time

TTP (platelet aggregation)
*Low platelets, high bleeding time

DIC
*Low platelets, high bleeding time
*CF consumption: High PTT, PT

Aplastic anemia
*Low platelets, high bleeding time

Drugs
*Low platelets, high bleeding time

Front 1522

Clotting factor problems

Back 1522

Hemophilia A --> Factor 8 deficiency
*Increased PTT

Hemophilia B --> Factor 9 deficiency
*Increased PTT

Von Willebrand's disease
*Shortened factor 8 survival --> PTT
*Poor platelet adhesion --> Bleeding time

Front 1523

Hodgkin's Lymphoma vs. Non-Hodgkin's Lymphoma

Back 1523

Req R-S cells (CD15, CD30) vs. No cells req'd

Localized node group w/continuous spread (often Mediastinal) vs. Multiple nodes w/non-contiguous spread

Common constitutional B symptoms vs.
Fewer constitutional symptoms

100% B cell origin vs. mostly B cell origin

Associated w/EBV (50%) and men (ex.nodular sclerosing) vs. HIV and immunosuppression

Bimodal (15-30, 55+) vs. Peak 20-40

Front 1524

Hodgkin's lymphoma vs. non-hodgkin's

Back 1524

All tumors feature lymphocytes and R-S cells

Nodular sclerosing (65-75%)
*Excellent
*Young WOMEN
*Collagen banding
*LACUNAR CELLS (R-S variant) seen

Mixed cellularity (25%)
*Intermediate
*NUMEROUS R-S cells

Lymphocyte predominant (6%)
*Excellent
*Young MEN

Lymphocyte depleted (rare)
*Poor
*Older men w/disseminated disease

Front 1525

Multiple myeloma

Back 1525

Most common bone tumor >40-50
*Always originates from bone

Malignant PLASMA cells release IgG (55%) or IgA (25%) --> Monoclonal Ab spike

Complications of bone lesions:
*Punched-out lesions on X ray
*Hypercalcemia --> Renal insufficiency
*Rouleaux formations (stacked RBCs) and anemia

IgG or IgA output:
*Primary amyloidosis (light chains) --> renal insufficiency
*Susceptibility to infection

Front 1526

Non-hodgkins Lymphomas

Back 1526

"The San Francisco MD's BilL" --> SF MD BL

Small lymphoblastic (Adults, B)
*Low grade
*Like CLL with a mass

Follicular (Adults, B)
*Most common
*Low grade, but often incurable
*Involves bcl-2 activation (14;18)

Mantle cell (Adults, B)
*High grade, poor prognosis
*CD5+
*11:14

Diffuse large cell (80% adult, 80% T)
*High grade, but up to 50% curable
*Mature T cells

Burkitt's (Children, B cell)
*8:14 (c-myc --> Ig heavy chain gene)
*Starry Sky: Macros in lympho sea
*Associated w/EBV
*Endemic/African--Jaw lesion
*Sporadic--Pelvis or abdomen

Lymphoblastic (Children, T cells)
*Very aggressive
*Immature T cells
*Often presents w/ALL
*Often presents w/mediastinal mass

Front 1527

11:14 Translocation

Back 1527

Mantle cell lymphoma

Adult, B cell
CD5
Poor prognosis

Front 1528

11-->22 translocation

Back 1528

Ewing's Sarcoma

Front 1529

14 --> 18 Translocation

Back 1529

Follicular lymphoma

Mutation in Bcl-2 inhibits apoptosis
Adult, B cell
Low grade but often incurable

Front 1530

Leukemoid reaction: Features

Back 1530

Response to stress or infection

Bands (left shift)

**High Leukocyte alkaline phosphatase**
*Low w/CML

Front 1531

ALL

Back 1531

Children <15

LymphoBLASTS = Tdt+
(Pre-B, Pre-T)

ALL: BRAINS to BALLS
*High level of spread to CNS, testes

Prognosis: Most responsive

Front 1532

AML

Back 1532

Children and adults 5-40

MyeloBLASTS: Several subtypes

M3 type (promyelocytic) features 15 --> 17 translocation
*Auer rods
*Responsive to ALL-TRANS RETINOIC ACID

Front 1533

CLL

Back 1533

Adults > 60

B Lymphocytes (no Ab made)

SMUDGE cells (fragile)

WARM Ab autoimmune hemolytic anemia
*Silly (SLE) dope (methyldopa), cold (CLL) is warm!

Front 1534

CML

Back 1534

Adults 30-60

Philadelphia chromosome 9-->22
*Bcl-Abl fusion

Myeloid stem cells --> Neutrophils, Metamyelocytes
(mature cells found too)

Possible blast crisis (acceleration to AML)

Front 1535

Hairy cell leukemia

Back 1535

"TRAP a Hairy animal"

Elderly population
B cells w/HAIRLIKE FILAMENTS inside

Stains TRAP+ (tartrate-resistant acid phosphatase)

Front 1536

B cells w/ hairlike filaments inside

Back 1536

Hairy cell leukemia

Front 1537

Histiocytosis X

Back 1537

Malignancy of the MONOCYTE lineage affecting YOUNG adults

Langerhans cells (usually in skin) infiltrate lung
*Worse with SMOKING; pro-monocyte/macrophage environment

Cells contain Birbeck granules (tennis rackets) on EM

Front 1538

What is a histiocyte?

Back 1538

A type of monocyte

Front 1539

Heparin

Back 1539

Catalyzes the formation of ATIII
*Immediate anticoagulation
*Factors 2a (thrombin) and 10a are the most important reductions
*LMW Heparins more selectively reduce 10a

Uses: CLOT BREAKUP or PREVENTION
Pulmonary embolism
Stroke
Angina, MI
DVT
Obstetric problems (doesn't cross placenta)

Toxicity:
Bleeding
OSTEOPOROSIS
Drug-Drug interactions

HIT: Heparin-induced TCP
*Heparin + platelet = Hapten
*Destroyed platelets
*Remaining platelets activated (hypercoagulable)

Front 1540

Heparin: Monitoring

Back 1540

Regular heparin must be monitored by watching PTT

Low molecular weight heparins (Enoxaparin) are administered subQ w/o monitoring
*Better bioavailability
*Longer t1/2 (2-4x)
*Also work more selectively on Xa

Front 1541

Lepirudin, Bivalirudin

Back 1541

Hirudin derivatives

Directly inhibit thrombin

Do not cause HIT: Use as heparin alternative

Front 1542

Warfarin/Coumadin

Back 1542

Warfarin/Coumadin

The "EX-PaTriot went to WAR(farin) and came back w/scars (necrosis"

Vitamin K antagonist: Interferes w/synthesis and gamma-carboxylation of 2, 7, 9, 10, C, S
*Consider EXTRINSIC the only pathway affected

Long, and extremely VARIABLE t 1/2
*Metabolized by P-450

Use: Chronic anticoagulation

*Crosses placenta--TERATOGENIC

Toxicity: Skin/tissue NECROSIS, drug-drug interactions

Front 1543

Heparin vs. Coumidin

Back 1543

Large acidic anion polymer (t 1/2=hours) vs. Small, lipid soluble molecule (t 1/2=days)

Parenteral (IV, SQ) vs. oral

Acts in blood vs. in liver

Monitor PTT vs. PT/INR

No placental crossing vs. Placental crossing + teratogen

Front 1544

Thrombolytics

Back 1544

Increases PLASMIN
*Breaks up fibrin clots
*Breaks down fibrinogen (prevents more fibrin)

Increases PT, PTT (not bleeding time)

Uses:
Early MI
Early stroke

APSAC: Complex of Streptokinase + Plasminogen

Front 1545

Aspirin (ASA)

Back 1545

Aspirin: Irreversibly acetlyates COX-1, COX-2
*Prevents conversion of arachidonic acid to TXA2 (needed for aggregation step)

Bleeding time is increased (platelet-only effect)

Uses: Inhibit many COX-2 products
*TXA2: Anti-platelet
*Anti-pyretic
*Anti-inflammatory
*Analgesic

SE:
COX-1 inhibition: Gastric ulcers
Metabolic acidosis: hyperventilation
Reye syndrome (+VZV, Influenza)
Tinnitus (CN VIII)

Front 1546

Clopidogrel, Ticlopidine

Back 1546

CLOPIDogrel, TiCLOPIDine

Interferes w/the 1st (GP1B) and 3rd (ADP, Ca2+) steps of aggregation

1. Irreversibly blocks ADP receptors
2. Blocks GP2b/3a expression

Uses:
*Acute coronary syndromes, stenting
*Thrombotic stroke prevention

Toxicity: Ticlopidine causes neutropenia

Front 1547

Abciximab

Back 1547

AbCIXimab keeps em from sticking so bad

Binds GP2b/3a receptor on platelets

Uses (A+A): Acute coronary syndrome, coronary Angioplasty

Front 1548

Abciximab

Back 1548

AbCIXimab keeps em from sticking so bad

Binds GP2b/3a receptor on platelets

Uses (A+A): Acute coronary syndrome, coronary Angioplasty

Front 1549

Cell cycle specific anti-cancer drugs

Back 1549

By 56, a M wants to BE a VP

5-FU --> Thymidine synthesis
6-MP --> Purine synthesis
Methotrexate --> Thymidine synthesis
Bleomycin --> DNA breakage
Etoposide --> DNA breakage (T2 inh)
Vinca alkaloids --> MT synthesis
Paclitaxel --> MT disassembly

Microtubule drugs --> M phase
Antimetabolites (56M) --> S phase
DNA breakage --> S and G2

Front 1550

Methotrexate

Back 1550

FOLIC ACID analog -->
"tricks" dihydrofolate reductase

Reduced dTMP --> Reduced DNA

Non-cancer uses (immune): Psoriasis, RA

Cancer uses:
BM: Leukemia, lymphoma
Muscle: Sarcoma
Uterus: Choriocarcinoma, abortion, ectopic pregnancy

Toxicity: THE THREE M'S
Myelosuppression --> LEUCOVORIN RESCUE
Mucositis
Macrovesicular liver changes

Front 1551

5-FU

Back 1551

Pyrimidine (URACIL) analog that forms 5F-duMP in vitro, then grabs FOLIC ACID
*THYMIDYLATE SYNTHASE is inhibited --> low dTMP --> low DNA
*Synergy with methotrexate

Uses:
Colon cancer (+ other solid tumors)
Basal cell carcinoma (topical)

Toxicity:
Myelosuppression --> THYMIDINE RESCUE
Photosensitivity

Front 1552

Leucovorin rescue

Back 1552

Myelosuppression associated w/Methotrexate

Folic acid analog, DHF reductase inhibitor

BM: Leukemia, lymphoma
Muscle: Sarcoma
Uterus: Choriocarcinoma, abortion, ectopic pregnancy

Front 1553

Thymidine rescue

Back 1553

5-FU (fluorouracil)

Uracil analog that grabs folic acid
~ inhibits thymidylate synthase

Colon cancer + other solid tumors
Basal cell carcinoma (topical)

Photosensitivity

Front 1554

6-MP

Back 1554

6-mercaptoPURINE

Activated by HGPRTase to block purine synthesis (A, G)

Uses:
Leukemia (not CLL)
Lymphoma (not Hodgkins)

Toxicity: Bone marrow, GI, liver

6-MP is metabolized by xanthine oxidase
*Allopurinol (XO inhibitor) is bad

Front 1555

Cytarabine (ara-C)

Back 1555

Inhibits DNA polymerase

Uses: AML (little beans/kids)

Toxicity: Pancytopenia
*Anemia is megaloblastic

Front 1556

Alkylating agents

Back 1556

DNA CROSS LINKERS

Biased Christian News Channel (the 700 club)

1. Busulfan

2. Cyclophosphamide, ifosfamide

3. Nitrosureas: Carmustine, Lomustine, Semustine, Streptozocin

4. Cisplatin, carboplatin
*"Act" like alkylating agents

Only 1 group causes myelosuppression: cyclophosphamide, ifosphamide

2 groups need bioactivation: Nitrosureas, cyclophosphamide + ifosphamide

Front 1557

Cyclophosphamide, Ifosfamide

Back 1557

*Crosslink interstrand DNA at guanine N-7

Uses: "Women's issues"
Lymphoma (non Hodgkins)
Breast and ovarian cancer
Wegeners, polyarteritis nodosa

SE:
Myelosuppression
Hemorrhagic cystitis (take MESNA)
Can cause SIADH

Front 1558

Nitrosureas

Back 1558

Alkylating agent
*Requires bioactivation like cyclophosphamide, but NO myelosuppression

Carmustine
Lomustine
Semustine
Streptozocin

Use: Brain tumors (crosses BBB)

SE: CNS effects (dizziness, ataxia)

Front 1559

Cisplatin, Carboplatin

Back 1559

LIKE alkylating agents

Uses: BOLT
Bladder
Ovarian
Lung
Testicular

Toxicity:
Acoustic nerve damage
Renal damage

Front 1560

Busulfan

Back 1560

Alkylating agent

CML

Pulmonary fibrosis
Hyperpigmentation

Busulfan: While riding the CML...
*You might get a tan (hyperpigment)
*You might want a fan (cause it's hard to breathe)

Front 1561

Doxorubicin/Adriamycin
Daunorubicin

Back 1561

1. DNA Intercalation
2. Generate free radicals --> Breakage

Uses: ABVD regimen
HMS LOB:
*Hodgkin's lymphoma
*Myeloma
*Sarcoma
*Lung
*Ovary
*Breast

Toxicity:
CARDIOTOXICITY
MYELOSUPPRESSION
Alopecia
Toxic extravasation

Front 1562

Dactinomycin

Back 1562

A.k.a. Actinomycin D

DNA intercalator

Uses: CHILDHOOD tumors (children ACT out)
*Ewing's sarcoma
*Wilm's tumor
*Rhabdomyosarcoma

SE: Myelosuppression

Front 1563

SE Common to all intercalators

Back 1563

Myelosuppression

Intercalators = Doxorubicin/Adriamycin
Daunorubicin
Dactinomycin

Front 1564

SE common to all anti-metabolites

Back 1564

Myelosuppression

Methotrexate
5-FU
6-MP

Front 1565

Bleomycin

Back 1565

Induces free radicals --> DNA breakage

Uses: ABVD cancers (HMS LOB) + Testicular

Toxicity: Same as bisulfan
Pulmonary fibrosis
Skin changes

Front 1566

Hydroxyurea

Back 1566

Inhibitor of RIBONUCLEOTIDE REDUCTASE

*DNA synthesis (S phase) reduced

Non cancer use: Sickle cell (fetal Hb)
Cancer uses:
Melanoma
*HYDROXYtone: Save the skin
CML
*HYDROXYcut: Fight the CreaML cheese

Toxicity: Marrow suppression

Front 1567

Etoposide

Back 1567

Inhibitor of topoisomerase II (DNA breakage/degradation)

Uses: "Men's cancers"
Prostate
Testicular
Small cell lung (historically >men get lung cancer)

Toxicity: Like Doxo/Dauno but with
no cardiotoxicity
Myelosuppression
Alopecia

Front 1568

Prednisone and cancer

Back 1568

Fights cancer by triggering apoptosis

Uses B CELLS: CLL, Hodgkins

Front 1569

Imatinib

Back 1569

Ab to Bcr-abl tyrosine kinase

Uses: CML
GI stromal tumor!

Toxicity: Fluid retention

Front 1570

Vinblastine, Vincristine

Back 1570

Block polymerization of microtubules
*Bind to TUBULIN

Uses: MOPP regimen
Choriocarcinoma
Wilm's
Lymphoma

Toxicity depends on drug:
Vinblastine "BLASTS" the marrow

Vincristine causes neurotoxicity: arreflexia, peripheral neuritis, paralytic ileus

Front 1571

Paclitaxel (and other taxols)

Back 1571

Block breakdown of mitotic spindle
*Bind to TUBULIN

Uses: Ovarian and breast carcinoma

Toxicity: PACks a punch against marrow (Myelosuppression)

Front 1572

ABVD regimen

Back 1572

Adriamycin/Doxorubicin
Bleomycin
Vincristine/Vinblastine
Dacarbazine

HMS LOB:
Hodgkin's
Myeloma
Sarcoma
Lung
Ovarian
Breast

Front 1573

MOPP regimen

Back 1573

B cell things: CLL, lymphoma
Choriocarcinoma, Wilm's tumor

Mustardgen (Nitrosurea)
Oncovin (Vincristine)
Prednisone
Procarbazine

Front 1574

Epithelial cell junctions:

Back 1574

Sides = Cadherin
Bottom = Integrin

Top = Actin
Bottom = Keratin (intermediate filament)

Front 1575

Paclitaxel

Back 1575

Block breakdown of mitotic spindle
*Bind to TUBULIN

Uses: Ovarian and breast carcinoma

Toxicity: PACks a punch against marrow (Myelosuppression)

Front 1576

Trastuzumab

Back 1576

a.k.a. Herceptin

Monoclonal Ab against HER-2

Ab-dependent cytotoxicity?

Used for metastatic breast cancer

CARDIOTOXICITY

Front 1577

Skin layers

Back 1577

Californians like girls in string bikinis

Stratum corneum
Stratum lucidum
*Thick skin only
Stratum granulosum
Stratum spinosum
Stratum basalis

Front 1578

Macula adherens

Back 1578

3rd highest part of epithelial junction

Consists of DESMOSOMES
CADHERIN bridges across

KERATIN (intermediate filament) and
Desmoplakin plaque anchor

Desmoplakin --> Desmosome

Front 1579

Hemidesmosomes

Back 1579

Connects keratinocyte to basement membrane

INTEGRIN bridges across
*LAMIN on BM side
*Keratin on cell side

Front 1580

Knee injury from lateral clipping

Back 1580

MCL
Medial meniscus
ACL

Front 1581

Rotator cuff muscles

Back 1581

SItS

Supraspinatous --> Abduction

Infraspinatous --> Lateral rotation

Teres minor --> Adduction, lateral rotation

Subscapularis --> Adduction, medial rotatio

Front 1582

Brachial plexus

Back 1582

Roots: C5-T1
Trunks:
Upper (C5-C6)
Middle (C7)
Lower (C8-T1)

Divisions

Cords
Lateral
Posterior
Medial

Branches
Musculocutaneous (LC)
Medial (LC, MC)
Ulnar (MC)
Axillary (PC)
Radial (PC)

Front 1583

Brachial plexus problems

Back 1583

Upper cord: Erb's palsy (waiter's tip)

Lower cord: Klumpke's palsy (claw hand)

Posterior cord: Wrist drop

Axillary: Deltoid muscle

Radial: Wrist drop (Sat night palsy)

Musculocutaneous: Trouble flexing elbow, variable sensory loss

Median: Can't make a "thumbs up" (Pope's blessing)
*Unopposed radial n action

Ulnar: Intrinsic hand muscles (Claw hand)
*Weakness of index, middle interosseous muscles causes them to curl
*Can't make a "four" (adduct thumb, adduct/abduct fingers)

Front 1584

Winged scapula

Back 1584

Problem with long thoracic nerve (C5-C7)

SERRATUS ANTERIOR

Front 1585

Erb-Duchenne palsy

Back 1585

Loss of upper cord of the brachial plexus

Deltoid
Lateral rotators (infraspinatus, teres minor)
Biceps

Front 1586

What protects the brachial plexus from injury, even if clavicle is broken?

Back 1586

Subclavius muscle

Front 1587

Shoulder dislocation

Back 1587

Inability to abduct the arm >90 degrees

Front 1588

Mid-shaft humeral fracture

Back 1588

Extensor: Rradial n
Wrist drop
Sensory deficit in posterior arm, dorsal hand (grabs the back of median n fingers)

Flexor: Musculocutaneous n
Can't flex elbow
Sensory deficit in lateral arm

Front 1589

Fracture around elbow condoyles or wrists

Back 1589

Flexor: Median n

MEDIAN NERVE MAKES A THUMBS UP:
Can't flex fingers
Can't abduct/oppose thumb

Sensory deficit on palm + dorsal tips of 3.5 fingers

OR

Flexor: Ulnar n

ULNAR NERVE MAKES A WIGGLY 4:
Can't adduct thumb
*Move thumb toward ulnar side

Can't adduct or abduct remaining fingers

Sensory deficit on palm + dorsal tips of 1.5 fingers

Front 1590

Klumpke's palsy/Thoracic outlet syndrome

Back 1590

Congenital/embryologic defect

Compression of lower trunk (C8, T1)
*Thenar and hypothenar atrophy
*Interosseous atrophy
*Sensory deficits on ulnar forearm, 1.5 fingers

Compression of subclavian artery
*Radial pulse disappears when head turned toward opposite side (increases compression)

Front 1591

Radial nerve structures

Back 1591

GREAT EXTENSOR NERVE

Innervates the BEST:

Brachioradialis
Extensors of wrist and fingers
Supinator
Triceps

Front 1592

Thenar and hypothenar muscles

Back 1592

OAF:
Opponens pollicis/digiti minimi
Abductor pollicis/digiti minimi brevis
Flexor pollicis/digiti minimi brevis
*Joint thenar innervation

Thenar = Thumb
*Median nerve innervates all 3 muscles
*Ulnar nerve innervates flexor

Hypothenar = Pinkie
*Ulnar n innervates all

Front 1593

Interosseus muscles of the hand

Back 1593

Innervated by ulnar nerve

DAB: Dorsal = ABduction
PAD: Palmar = ADduction

Front 1594

Anterior hip dislocation

Back 1594

Obturator nerve injury:
External obturator
Adductor longus/brevis/magnus
Gracilis

Can't adduct thigh
Sensory deficit in medial thigh

Front 1595

Posterior hip dislocation

Back 1595

Superior gluteal or inferior gluteal nerves

No sensory deficits

Superior: gluteus MEDIUS, MINIMUS
*Iliac crest to greater trochanter
*Can't abduct thigh (Trendelenberg sign)

Inferior: gluteus MAXIMUS
*Lumbar fascia to iliotibial tract (mid femur)
*Can't climb stairs, rise from seated position, jump

Front 1596

Lateral leg injury (fibular neck)

Back 1596

Common peroneal nerve injury

PED: PERONEAL EVERTS, DORSIFLEXES
*As a result, food is droPED

Can't extend toes

Sensory deficit in anterolateral leg, dorsal foot

Front 1597

Knee trauma

Back 1597

Tibial nerve injury

TIP= Tibial Inverts, Plantar flexes

NO BALLET W/O A TIBIAL NERVE

Can't flex toes

Sensory deficit on sole of foot

Front 1598

Pelvic fracture

Back 1598

Femoral nerve

No more ROCKETTES practice
Can't flex thigh or extend leg

Sensory deficits:
Anterior thigh
Medial leg (medial thigh covered by obturator nerve)

Front 1599

Peroneal vs. Tibial nerves

Back 1599

PED: Peroneal Everts and Dorsiflexes
*If injured, foot is dropPED

TIP: Tibial Inverts and Plantarflexes
*If injured, unable to TIPtoe

Front 1600

Ca2+ coupling in muscle cells

Back 1600

Voltage gated Ca2+ channel (DIIHYDROPYRIDINE receptor) in T tubule membrane

Ca2+ gated Ca2+ channel (RYANODINE) in sarcoplasmic reticulum

Front 1601

Skeletal, Cardiac muscle contraction

Back 1601

Ca2+ binds to troponin C

Tropomyosin complex moves out of actin's myosin binding groove

Myosin, w/ADP and Pi present, attaches

Pi is spent on power stroke

Myosin head is not released until ADP traded for ATP

ATP --> ADP + Pi to achieve "cocked" state

Front 1602

Smooth muscle contraction

Back 1602

Voltage gated Ca2+ channels
Ca2+ binds Calmodulin

Calmodulin-Ca2+ activates MLCK (myosin light chain kinase)

MLCK converts Myosin + actin --> Myosin-P + actin (contraction)

MLC Phosphatase returns to Myosin + Actin

Front 1603

Endochondral ossification

Back 1603

Longitudinal bone growth

Cartilage (chondrocytes) --> Woven bone (osteoblasts/clasts) --> Lamellar bone

Front 1604

Membranous ossification

Back 1604

Flat bone growth
*Skull and facial bones
*Axial skeleton (skull, ribcage, SC)

Woven bone formed directly (no preceding cartilage)

Remodeling to lamellar bone (like endochondral)

Front 1605

Achondroplasia

Back 1605

Achondroplasia

AD mutation in FGF (fibroblast growth factor) receptor

Poor endochondral ossification --> Short limbs

Membranous ossification is okay --> Normal lifespan and fertility

Front 1606

Osteoporosis: Features

Back 1606

Definition: Reduction in bone mass DESPITE normal mineralization
*Sparse trabeculae
*Susceptibility to fracture

Type 1: Postmenopausal (low E2)
Type 2: Senile (age >70)

Typical consequences:
*Vertebral crush fractures (height, pain, kyphosis=hump)
*Vertebral wedge fractures
*Colles' (distal radius) fractures

Prophylaxis: Exercise and Ca2+ before age 30

Treatment:
*Estrogen (controversial)
*Calcitonin
*Severe: BISPHOSPHONATES (encourage osteoclast apoptosis) or pulsatile PTH

Front 1607

Colles fractures

Back 1607

Osteoporosis-associated

Distal radius

Front 1608

Osteopetrosis

Back 1608

Genetic deficiency of CARBONIC ANHYDRASE II
*Used by osteoclasts

Poor OSTEOCLAST function --> bone buildup
*Thickened, dense bones
*"Erlenmeyer flask" epiphyses

Complications:
*Marrow space lost --> pancytopenia
*Narrowed foramina --> CN palsies

Front 1609

Osteomalacia/Rickets

Back 1609

Defective mineralization of osteoid (soft bones)

Osteomalacia in adults
Rickets in children

Cause = Vitamin D deficiency
Low Vitamin D --> low Ca2+ --> high PTH --> low serum P --> not enough P to build bone

Front 1610

Osteitis Fibrosa Cystica

Back 1610

a.k.a. Brown tumor of bone
a.k.a. Von Recklinghausen's disease of BONE

*Osteolytic cysts (brown due to hemorrhage--fibrous stroma or blood inside)

Lined w/OSTEOCLASTS

High serum Ca2+, low serum P
PTH high
ALKALINE PHOSPHATASE HIGH

Front 1611

Paget's disease

Back 1611

Cause = unknown (possibly viral)

Osteoblastic and osteoclastic activity is abnormally HIGH

ALKALINE PHOSPHATASE HIGH
*Distinguishes Paget's from osteopetrosis, another bone expanding disease

Blood levels of Ca2+, P, and PTH are normal
*Also true of osteopetrosis

Features:
*Mosaic bone pattern w/chalk-stick fractures (cut across lamellae)
*High output CHF (pumping blood to affected bone)
*Osteogenic sarcoma and fibrosarcoma
*Hearing loss (foramen narrowing)

Front 1612

Mosaic bone pattern w/chalk-stick fractures (cut across lamellae)

High output CHF

Osteogenic sarcoma and fibrosarcoma

Hearing loss

Back 1612

Paget's disease

Also: High AP w/normal Ca2+, P, PTH

CHF = Pumping blood to affected bone

Hearing loss = foramen narrowing

Front 1613

Polyostotic fibrous dysplasia

Back 1613

McCune-Albright syndrome (sporadic mutation in GNAS1) is an example

Areas of bone lesion replaced by fibroblasts, collagen, irregular trabeculae

Cafe-au-lait/Coast of Maine spots
Precocious puberty

Front 1614

Benign bone tumors

Back 1614

1. Osteoma: New (skull) bone on old
*Gardner's (FAP; features other tissue tumors)

2. Osteoid osteoma: Men under 25
*Woven bone surrounded by osteoblasts
*< 2cm
*Usually in diaphysis of tibia, femur

3. Osteoblastoma ("blastoma in the back")
*An osteoid osteoma bigger than 2 cm
*In VERTEBRAL column

4. Osteochondroma/Exostosis: Men under 25
*CHONDROMA COMMON
*Most common tumor
*Metaphysial
*Mature w/cartilaginous cap
*Malignant transformation rare

5. Osteoclastoma/Giant cell tumor (20-40)
*Aggressive epiphyseal tumor
*Occurs near KNEE --> double bubble/soap bubble
*Giant cells + spindle cells

6. Enchondroma
*Cartilaginous/Intramedullary
*DISTAL extremities

Front 1615

Malignant bone tumors

Back 1615

Chonology and Diaphysis --> Metaphysis

1. Ewing's sarcoma--Men <15>s triangle, sunburst
*Risks: Paget, infarct/radiation, familial RETINOBLASTOMA

3. Chondrosarcoma (Men 30-60)
*Cartilaginous/Intramedullary
*Glistening mass
*PROXIMAL skeleton + humerus, femur, tibia

Front 1616

Osteoarthritis

Back 1616

Causes: Weight-bearing wear + tear
*Many years
*Many pounds
*Joint deformity

Articular CARTILAGE only destroyed:
*Subchondral cysts (cartilage breakdown)
*Slerosis (bone hardening)
*Osteophytes (bone spurs)
*Eburnation (reactive bone w/abrasion)
*Thickened capsule w/slight synovial hypertrophy

Heberden's nodes = DIP
Bouchard's nodes = PIP
*Neither of these have weird punctuation (accents, hyphens like RA does)

Front 1617

Rheumatoid arthritis

Back 1617

Classic presentation: 4 S's
*Stiffness (morning)
*Symmetric involvement
*Systemic symptoms: fever, fatigue
*Serositis included in systemic symptoms--pleuritis, pericarditis

Joints show pannus formation

Subcutaneous rheumatoid nodules
Ulnar deviation
Subluxation (joint dislocation, slippage)

Swan-neck deformity: Hyperextended PIP, hyperflexed DIP
*Comes w/Z-thumb deformity: hyperextended PIP

Boutonniere deformity: Hyperflexed PIP, hyperextended DIP

Front 1618

Sjogren's

Back 1618

When estrogen gets the AXX (age 40-60)

Ribonucleoporotein antibodies:
SS-A (ro) and SS-B (la) +
*Remember B cell lymphoma assoc

A = ARTHRITIS (rheumatoid)

X = Xerostomia
*Dry mouth, dysphagia
*Dental caries
*Parotid enlargement

X = Xeropthalmia
*Dry eyes
*Conjunctivitis

Front 1619

Sicca Syndrome

Back 1619

Overlap w/Sjogren's

DRYNESS OF ALL MUCOUS MEMBRANES EXPOSED TO AIR

Dry eyes
Dry mouth

Dry nasal passage
Dry bronchi --> chronic bronchitis
Dry esophagus --> reflux esophagitis

Vaginal dryness

Front 1620

Gout

Back 1620

Monosodium urate crystals deposited in body

Asymmetric swollen, red joint(s)
*MTP of foot often involved --> PODAGRA

TOPHI (crystal deposits) in joints, ACHILLES, EXTERNAL EAR

Crystals: Needle shape, negatively birefringent
**SHAPED LIKE MINUS SIGNS**
**YeLLow when paraLLel to light**

URIC ACID buildup:
*Increased cell turnover (tumor lysis syndrome of leukemia, lymphoma)
*Decreased excretion (THIAZIDES, LOOPS)
*Lesch-Nyhan (HGPRT deficiency)

Front 1621

Gout: Treatments

Back 1621

Allopurinol (Xanthine oxidase inh)
*Affects PURine breakdown
*Lymphoma/Leukemia: Prevents tumor lysis syndrome nephropathy

Probenecid
*Competes w/uric acid for anion channel reabsorption in PCT
*SE: Inhibits secretion of penicillin
*Probenecid --> Prevents reentry

Colchicine
*Depolymerizes MTs to stop leukocyte chemotaxis, degranulation
*SE: GI
*Colchicine: Stops WBCs from coming

NSAIDS for inflammation, pain
*Indomethicin w/acute gout

Front 1622

Chronic Infectious arthritis

Back 1622

TB
Lyme

Front 1623

Psoriatic arthritis

Back 1623

HLA-B27 (MHC1) association
More common in males

< 1/3 of patients w/psoriasis

Papules and plaques w/silvery scaling on EXTENSOR surfaces

Acanthosis
*Decreased stratum granulosum
*Increased stratum spinosum

Parakeratosis (hypertrophied corneum w/retained nuclei) --> Scales

Auspitz sign: Bleeding when scales are scraped off

PSoriasis:
Pain
Pencil in cup deformity (xray)
*Erosion@DIP

Stiffness
Sausage fingers (Dactylitis)
*Entire nail bed may be lost

Front 1624

Sausage fingers

Back 1624

Psoriatic arthritis

Front 1625

Pencil in cup deformity

Back 1625

Psoriatic arthritis

Front 1626

Ankylosing spondylitis

Back 1626

HLA-B27 (MHC1) association
More common in males

"Bamboo spine": Inflammation of spine + sacroiliac joints

Uveitis
Aortic regurgitation (aortitis)

Front 1627

SLE

Back 1627

90% female
Black = More common, severe
Age 14-45

I'M DAMN SHARP

Immunoglobins (ds, sm, pl, nuc)
Malar rash

Discoid rash
ANA
Mucositis (oropharyngeal ulcers)
Neurologic disorders

Serositis (pleuritis, pericarditis)
HEMATOLOGIC/HILAR/HEART
*Hilar adenopathy
*Verrucous endocarditis (LSE)
Arthritis
Renal disorders/Reynaud's
*Wire loops, ICs + nephrotic syndrome
Photosensitivity

Front 1628

Sarcoidosis

Back 1628

Young adults (esp black females)

MAShED GRAIN + Uveitis

Macrophages-epitheliod
Asteroid bodies in macros
ScHaumann bodies in macros (Ca2+, protein inclusions w/large empty space around debris)
Erythema nodosum
D-Vitamin D activation

Gammaglobinemia
Rheumatoid arthritis
ACE increase
Interstitial fibrosis-hilar adenopathy
Noncaseating granulomas

Front 1629

Polymyalgia rheumatica

Back 1629

Adults >50

Mimics rheumatoid arthritis of the shoulder, hips, but NO BONE EROSION
*Stiffness and pain
*Symmetrical
*Systemic symptoms (fever, malaise, weight loss)

No bone or muscle damage: just inflammation
*ESR elevated (inflammation)
*CK normal (no muscle damage)

ASSOCIATED W/TEMPORAL ARTERITIS
*Also causes high ESR

Front 1630

Shawl and face rash

Heliotrope rash (whole orbital area)

Back 1630

Dermatomyositis

= Polymyositis (Proximal muscle weakness) + Rash

Front 1631

Polymyositis + Dermatomyositis

Back 1631

CD8 T cells attack myofibers

Increased CK, aldolase (muscle enzymes)
+ ANA
+ Anti-Jo-1 (a type of ANA)

Polymyositis --> Proximal muscle weakness

Dermatomyositis --> Polymyositis + rashes
*Heliotrope rash (whole orbital area)
*Shawl and face rash (V-shaped rash over anterior neck, chest)

Treat w/steroids

Front 1632

Polymyositis + Dermatomyositis: What cell attacks myocytes?

Back 1632

CD8

Front 1633

Myasthenia gravis

Back 1633

Antibodies against Ach receptor at NMJ
*Treat with AchE inhibitor

May be caused by a thymoma

Symptoms worsen w/use:
*Ptosis
*Diplopia
*General weakness

Treat w/indirect cholinergics (Ach inhibitors):
Neostigmine (bowels and bladder)
Pyridostigmine (crosses BBB, glaucoma)
Edrophonium (short-acting)

Front 1634

Lambert-Eaton syndrome

Back 1634

Antibodies to NMJ presynaptic Ca2+ channel
*Reduced Ach release

May be caused by small cell lung cancer (or thymoma)

Muscle weakness improves w/use
*AchE inhibitors alone will not help

Front 1635

CREST

Back 1635

CREST

Cacinosis
Reynaud's
Esophageal dysmotility
Sclerodactyly
Telangiectasia

Front 1636

Diffuse Scleroderma

Back 1636

FIBROSIS and COLLAGEN deposition

Diffuse: Anti-scl-70
Widespread skin involvement (taut)
Rapid progression
VISCERAL involvement
*Kidneys, Lungs, GI, CV

Crest: Anti-centromere
Calcinosis
Reynaud's
Esophageal dysmotility
Sclerodactyly
*Skin involvement = face + hands
Telangiectasia

Front 1637

Rhabdomyosarcoma

Back 1637

Most common soft tissue tumor of childhood (soft tissue = muscle, fat, CT?)

SKELETAL muscle origin
Usually head/neck

Front 1638

Macule

Back 1638

FLAT discoloration < 1 cm

If >1 cm = patch

Front 1639

Papule

Back 1639

ELEVATED lesion < 1 cm

If > 1 cm = plaque

Front 1640

Vesicle

Back 1640

SMALL FLUID containing blister

If TRANSIENT = wheal
If LARGE = bulla
If it contains PUS = pustule

Front 1641

Keloid

Back 1641

Scar tissue hypertrophy forming an IRREGULAR, RAISED lesion

Especially common w/African Americans

Front 1642

Crust

Back 1642

Dried exudates from a BLISTER *vesicle, bulla or pustule

Front 1643

Hyperkeratosis vs. Parakeratosis

Back 1643

Hyperkeratosis: Increased thickness of the stratum CORNEUM (top layer)

Parakeratosis: A.k.a. psoriasis

Increased thickness of the stratum CORNEUM (hyperkeratosis)
+
Retention of NUCLEI in the stratum corneum

Causes SCALES

Front 1644

Acantholysis

Back 1644

Separation of epidermal cells

Front 1645

Acanthosis

Back 1645

Epidermal hyperplasia

All 5 layers

Front 1646

Verrucae

Back 1646

Warts: Cauliflower-like, tan, soft

Acanthosis w/hyperkeratosis
Koilocytosis

Hands: Verruca vulgaris
Genitals: Condyloma accuminatum (HPV)

Front 1647

Urticaria

Back 1647

Hives

Mast cell degranulation --> Pruritic wheals

Front 1648

Urticaria

Back 1648

Hives

Mast cell degranulation --> Pruritic wheals

Front 1649

Ephelis

Back 1649

Freckles

Dark color = Increased melanin pigment

Front 1650

Seborrheic keratosis

Back 1650

Common benign neoplasm in older ppl

Flat, pigmented epithelial proliferation that looks "pasted on"
*Greasy appearance
*Microscopic keratin filled cysts (horn cysts)

Front 1651

Pigmentation disorders

Back 1651

Albinism: Defective melanin production

Vitiligo: Irregular areas of complete depigmentation
*Loss of melanocytes

Melasma: Hormonally-driven hyperpigmentation
*Pregnancy
*OCP use

Front 1652

Impetigo

Back 1652

Very superficial skin infection--> highly contagious

**S. aureus or S. pyogenes**

HONEY COLORED CRUSTING

Front 1653

Cellulitis

Back 1653

Acute, spreading infection

Dermis and subcutaneous tissue
*Reaches the "cellulite"

S. Aureus and S. pyogenes
(same as impetigo)

Front 1654

Necrotizing Fasciitis

Back 1654

Deep tissue injury

Lower O2 content: S. pyogenes and ANAEROBES

Methane and CO2 production --> CREPITUS
*Flesh-eating bacteria is CREEPY

Front 1655

Scalded skin syndrome

Back 1655

Seen in newborns and kids

Staph aureus exotoxins (A, B) responsible

Stratum GRANULOSUM keratinocyte attachments are destroyed by exotoxin
*Granulosum = Highest layer w/nuclei that is guaranteed to be there

Fever
Erythemetous rash w/sloughing

Front 1656

Hairy Leukoplakia

Back 1656

Seen w/HIV
Caused by immunodeficiency (EBV)

White, painless plaques on tongue

CAN'T be scraped off

Front 1657

Bullous pemphigoid

Back 1657

He got a HEMI? That's BULL

IgG antibody against HEMIDESMOSOMES
*Subepidermal bullae

Linear immunofluorescence below epidermis

Oral mucosa NOT involved

Front 1658

Pemphigus vulgaris

Back 1658

Vulgar mouth

IgG antibody against DESMOSOMES
*Acantholysis --> Intraepidermal bullae

Immunogluorescence throughout epidermis

Oral mucosa IS involved

Front 1659

Dermatitis herpetiformis

Back 1659

Dermal deposits of IgA --> Pruritic papules and vesicles

IgA is deposited at tips of dermal PAPILLAE (highest point of dermis)

Associated w/celiac disease

Front 1660

Erythema multiforme

Back 1660

Associated w/many causes and takes on many forms

Causes: Infections, drugs, cancers, autoimmune disease

Forms: All SMALL
Macules (vs. patches)
Papules (vs. plaques)
Vesicles (vs. bullae)
TARGET lesions (red papule w/pale center)

Front 1661

Stevens-Johnson

Back 1661

Adverse drug reaction

Fever
Bulla formation --> necrosis --> sloughing

High mortality rate, but not as severe/not as much epidermal involvement as TOXIC EPIDERMAL NECROLYSIS

Front 1662

Lichen planus

Back 1662

Lymphocytes infiltrate the DEJ

4Ps:
Pruritic
Purple
Polygonal papules

Front 1663

Squamous cell carcinoma

Back 1663

RED

Caused by SUN and ARSENIC exposure

Precursor is ACTINIC KERATOSIS
Rarely metastasizes

RED lesion w/microscopic keratin pearls

Front 1664

Basal cell carcinoma

Back 1664

Caused by SUN

Almost never metastasizes

Pearly lesion

Rolled (raised) edges w/central ulceration

Front 1665

Melanoma

Back 1665

Caused by SUN
More common in fair-skinned people

S-100 tumor marker

Dark w/irregular borders

Precursure is DYSPLASTIC NEVUS

DEPTH of tumor correlates w/risk of metastasis

Front 1666

PGI2

Back 1666

"Platelet gathering inhibitor"

Stops platelet aggregation and promotes vasodilation

Stops thromboxane production in platelets (same step as aspirin)

Front 1667

Leukotrienes

Back 1667

LTB4 --> Neutrophil chemotactic agent
*Neutrophils arrive "B4" others

LTC4, LTD4, LTE4:
*Contraction of smooth muscle: vasoconstriction, bronchoconstriction
*Increased vascular permeability

Front 1668

Prostacyclins

Back 1668

Soothing

Decrease everything:

Platelet aggregation

Smooth muscle (broncho, vasoconstriction)

Uterine tone

Front 1669

Prostaglandins

Back 1669

Decrease:
Smooth muscle (broncho, vasoconstriction)

Increase (get a glandular organ going):
Uterine tone

Front 1670

Thromboxane

Back 1670

"Upper for the blood":

Platelet aggregation

Smooth muscle (broncho, vasoconstriction)

Front 1671

Zileuton

Back 1671

5-Lipoxygenase inhibitor
*Prevent leukotrienes from being synthesized

Asthma prophylaxis

SE: P-450 induction, leukopenia (1%)

Front 1672

Zafirlukast, Montelukast

Back 1672

Antibodies to leukotriene receptor

Asthma prophylaxis

Front 1673

Zafirlukast, Montelukast

Back 1673

Antibodies to leukotriene receptor

Asthma prophylaxis

Front 1674

NSAIDS

Back 1674

Ibuprofen, naproxen, indomethacin, ketorolac

Block COX-1 and COX-2
Objective: Inhibits PG synthesis

Uses: Antipyretic, anti-inflammatory, analgesic
*Indomethacin: Close PDA

Toxicity: RAG
*RENAL DAMAGE
*APLASTIC ANEMIA
*GI distress, ulcers

Front 1675

Acetaminophen

Back 1675

Reversibly inhibits COX
*Mostly in CNS, due to peripheral activation

Uses: Antipyretic, analgesic
*NOT AN ANTI-INFLAMMATORY (aspirin and NSAIDS are)

Tox: Hepatic necrosis following depletion of glutathione
*N-acetylcysteine = antidote

Front 1676

Astrocyte functions

Back 1676

Support/repair

K+ metabolism
BBB

Marker: GFAP

Front 1677

Microglia

Back 1677

Macrophages of the brain
Mesodermal (like macrophages)
Multinucleated giant formation (HIV)

Small nuclei
Little cytoplasm --> Ameboid with injury

Not very visible on Nissl stain

Front 1678

Oligodendrocytes

Back 1678

Myelinates up to 30 axons

Destroyed in MS

Small nuclei w/little cytoplasm
Fried eggs on H&E stain
Visible on Nissl stain

Front 1679

Peripheral nerve wrappings

Back 1679

Endoneurium = Single axon

Perineurium = Bundle of axons
*PERMEABILITY BARRIER
*Rejoin during surgery

Epineurium = Vessels and bundles

Front 1680

Blood brain barrier layers (3)

Back 1680

1. Endothelial cells (tight junctions)
*Damage/destruction = vasogenic edema

2. Basement membrane

3. Astrocyte processe

Front 1681

Areas w/o blood brain barrier (2)

Back 1681

Area postrema (informational blood sampling)

Neurohypophysis/PP: Excretion of oxytocin, ADH

Front 1682

Hypothalamic functions

Back 1682

The hypothalamus wears TAN HATS:

Thirst --> Supraoptic nucleus
*ADH also secreted from here

Adenohypophysis
Neurohypophysis + median eminance

Hunger and satiety
*Ventromedial = Satiety
*Hunger = Lateral

Autonomic regulation, circadian rhythm
*pArasympathetic = Anterior
*Sympathetic = Posterior
*Circadian = Suprachiasmatic

Temperature regulation
*Cooling = Anterior (A/C)
*Heating = Posterior (pH)

Sexual urges and emotions
*Septal nucleus = Control

Front 1683

Posterior pituitary hormone sources

Back 1683

Oxytocin: Paraventricular

Vasopressin/ADH: Supraoptic
*Area controlling thirst

Front 1684

Thalamus supplying arteries

Back 1684

1. Posterior communicating arteries
2. Posterior cerebral
3. Anterior choroidal

Front 1685

Thalamus functions

Back 1685

LGN --> "Light" (visual relay)
MGN --> "Music" (audio relay)

VA/VL --> Motor

VPL --> Body sensation
*From dorsal columns + spinothalamic tract

VPM --> Face sensation
*From CN V
*"Makeup on your face"

Front 1686

Limbic system

Back 1686

CHFM

Cingulate gyrus
Hippocampus
Fornix
Mammillary bodies

The 5 F's:
Fight, Flight
Feeding, feeling...

Front 1687

Cerebellar fibers

Back 1687

Climbing, mossy = Input

Purkinje = Output

Front 1688

Basal ganglia: Excitatory pathway

Back 1688

D1 receptor binding = Excitement of excitatory pathway

1. Striatum (caudate, putamen) inhibits GPi

2. GPi stops inhibiting thalamus

3. Thalamus can stimulate cortex

Striatum (-) --> GPi (-) ---> Thalamus

Front 1689

Basal ganglia: Inhibitory pathway

Back 1689

D2 receptor binding = Inhibition of inhibitory pathway

1. Striatum is inhibited from inhibiting GPe
2. GPe is free to inhibit STN
3. STN stops stimulating GPi
4. GPi stops inhibiting Thalamus
5. Thalamus can stimulate cortex

Striatum(-) --> GPe (-) --> STN (+) --> GPi (-) --> Thalamus

Front 1690

Primary auditory cortex location

Back 1690

Heschl's gyrus

Just under posterior Sylvian fissur

Front 1691

Wernike's area is...

Back 1691

Associative auditory cortex

Superior temporal gyrus

Front 1692

"Arteries of stroke"

Back 1692

Lateral striate arteries (from MCA)

Supply striatum (caudate, putamen), globus pallidus, internal capsule

Front 1693

Most common sites of aneurysm

Back 1693

Anterior communicating artery
*Most common circle of Willis aneurysm site
*May cause visual field defects

Posterior communicating artery
*May cause CNIII palsy

Front 1694

Anterior cerebral artery stroke

Back 1694

Anterior circle = Sensory and motor dysfunction:

*ACA: Leg-foot area sensory and motor deficits

*MCA:
*Trunk-arm-face sensory and motor deficits
+ Wernike's area
+ Broca's area

Posterior circle =
*CN deficits: Ocular (CNIII), vertigo
*Visual disturbances
*Cerebellar deficits
*Coma

Front 1695

CSF path through ventricles

Back 1695

Lateral ventricles --> 3rd ventricle
*Via foramen of Monro

3rd ventricle --> 4th ventricle
*Via cerebral aqueduct

4th ventricle --> Subarachnoid space
*Lateral = Luschka
*Medial = Magendie

Monro vs. Magendie: Shorter name for smaller ventricle # (ventricle 3 vs. 4)

Front 1696

Most common site of vertebral disk herniation

Back 1696

L5-S1

Why don't you balance a circle on a triangle!

Front 1697

Lumbar puncture

Back 1697

L3-5 keeps the spinal cord alive

SC extends to lower border of L1-L2

CSF extends to lower border of S2

Ligaments pierced in the following order: Supraspinous, interspinous, ligamentum flavum

Front 1698

Arachnoid granulations

Back 1698

Allow CSF to travel through arachnoid + meningeal layer of dura (periosteal layer not crossed)

Front 1699

Fasciculus gracilis

Back 1699

Allow CSF to travel through arachnoid + meningeal layer of dura (periosteal layer not crossed)

Front 1700

Fasciculus cuneatus

Back 1700

Arms, upper body

Dorsal, lateral placement

Front 1701

Spinothalamic tract and corticospinal tract vs. posterior columns

Back 1701

Posterior columns: Gracilis is MEDIAL

Everywhere else: Legs are lateral while arms are medial

Front 1702

Path of a dorsal column signal

Back 1702

Sensory nerve (CB @ dorsal root):
*1 end connects to sensory site
*Other end ascends ipsilateral cord and synapses in ipsilateral medulla
*Synapse site: Nucleus cuneatus or gracilis

2nd neuron decussates travels from nucleus cuneatus/gracilis to VPL of thalamus

3rd neuron travels from VPL to cortex

Front 1703

a spinothalamic tract signal

Back 1703

Sensory nerve (CB @ dorsal root):

*1 end connects to sensory site
*Other end stops in ipsilateral gray matter

2nd neuron travels from ipsilateral gray matter across anterior white commissure and up cord to VPL

3rd nerve travels from VPL to thalamus

Front 1704

Path of a corticospinal signal

Back 1704

UMN ~ Unitary neuron

UMN leaves cortex and descends ipsilaterally through brain

Decussation at the caudal medulla and continuation to the anterior horn

2nd cell starts at anterior horn (LMN) and continues to NMJ

Front 1705

Cervical dermatome landmarks

Back 1705

C2: Posterior 1/2 of a "skull cap"
*Includes most of ear and underneath chin

C3: Neck of a turtleneck shirt

C4: Turleneck - Boat neck shirt

Front 1706

Thoracic dermatome landmarks

Back 1706

T4: "teat pore" (nipple)

T7: Xiphoid process

T10: Belly butTEN (Umbilicus)
*Detection of early appendicitis

Front 1707

Lumbar/Sacral dermatome landmarks

Back 1707

L1: Inguinal ligament
L4: Includes the kneecaps

S2,3,4: Erection and sensation of genitals, anal zone
*"S2-4 keeps the penis off the floor"

Front 1708

Gall bladder pain referral

Back 1708

Right shoulder

Via phrenic nerve (C3-5)

Front 1709

Golgi tendon organ

Back 1709

Found at muscle insertion points

Monitors tension --> if too high, sends inhibitory feedback to alpha motor neurons

**Drop the suitcase that is going to tear the muscle**

Front 1710

Muscle spindle

Back 1710

Found in parallel with regular muscle fibers

Spindles = Intrafusal
*Intrinsic tension is guided by gamma motor neurons
*Gamma neuron stimulation increases the sensitivity of reflex arc

Stretch causes 1a sensory transmission to cord --> returns an alpha motor neuron signal to contract

Regular muscle fibers = Extrafusal

Front 1711

Biceps reflex: Involved spinal levels

Back 1711

C5 --> C6

Think about musculocutaneous nerve damage: trouble flexing elbow (problem w/biceps)

Front 1712

Triceps reflex: Involved spinal levels

Back 1712

C7 --> C8

Think about radial nerve: damage causes problems w/arm extensors (wrist drop, elbow extension)

Front 1713

Patellar reflex: Involved spinal levels

Back 1713

L4 --> L3

L4: L is 4 for Leg

Front 1714

Achilles reflex: Involved spinal levels

Back 1714

S1 --> S2

Achilles: "All the way down"

Front 1715

Cranial nerve placement

Back 1715

Most medial: All motor
3 (x2)
6 (x2)
12

Midbrain: 3-4-5
*Just anterior to cerebellum

Pons: 6-7-8
*Just behind cerebellum

Medulla: 9-10-11-12
*Down sides brainstem

Front 1716

Superior colliculus function

Back 1716

Conjugate vertical gaze center

Lesion (such as pinealoma) -->
Vertical conjugate gaze palsy

Conjugate gaze palsy: Inability to move both eyes in a particular direction

Front 1717

Only CN without a thalamic relay to cortex

Back 1717

CN 1

Front 1718

Cranial nerves: Sensory and Motor

Back 1718

1: Some --> Smell
2: Say --> Sight
3: Marry --> Eye
4: Money --> Eye
5: But --> Mastication, facial and anterior 2/3 tongue sensation
6: My --> Eye movement
7: Bro --> Facial movement, taste (anterior 2/3), etc
8: Says --> Hearing, vestibular
9: Big --> Pharynx movement, taste (posterior 1/3), etc.
10: Brains --> Pharynx, taste (pharynx), etc.
11: Matter --> Head turn, shrug
12: Most --> Tongue

Front 1719

Cranial Nerve 2

Back 1719

Optic nerve

Entirely sensory

Enters brain between anterior communicating artery and MCA

Front 1720

Cranial Nerve 3

Back 1720

Oculomotor nerve
Entirely motor

Enters brain behind PCA

1. All oculomotor muscles EXCEPT:
*Lateral rectus (CN VI)
*Superior oblique (CN IV)
2. Pupil constriction (Sphincter Pupillae)
3. Accomodation (Ciliary muscle)
4. Eyelid opening (Levator Palpebrae)

Loss: Eye appears "down and out"
*Pupil dilation
*Poor accomodation
*Drooping eyelid

Front 1721

Cranial Nerve 4

Back 1721

Trochlear nerve
Entirely motor

Superior oblique muscle: AIDs the eye
*Abducts
*Intorts
*Depresses

Loss:
*DEFECTIVE downward gaze
*Diplopia

Front 1722

Cranial Nerve 5

Back 1722

Trigeminal nerve
Sensory and motor

Sensory:
Facial sensation (includes CORNEA)
Palate/teeth/gums
Parts of meninges

Motor: Muscles of TTT MAD MOUTH

TTT MAD:
Tensor tympani
Tensor veli palatini
anterior Tongue (Two-thirds)

Mylohyoid
Anterior belly of Digastric

Mouth =Mastication (Masseter, pterygoids, temporalis)

[Mouth =Meckel's cartilage

Malleus (+incus)
Mandible
SphenoMANDIBULAR ligament]

Front 1723

Cranial nerve 9

Back 1723

Glossopharyngeal
Sensory and motor

Sensory:
Pharynx
Posterior 1/3 of tongue
Carotid body and sinus

Salivation (Parotid)

Branchial arch 3:
Cartilage --> Greater horn of hyoid
*Great enough to have its own arch

Tongue: Posterior 1/3 (with arch 4)

Muscle: Stylopharyngeus

Front 1724

Cranial Nerve 7

Back 1724

Facial nerve
Sensory and motor

Sensory:
Taste from anterior 2/3 of tongue

Lacrimation
Salivation (submandibular, sublingual)

Motor: SS FACES the PD (branchial arch 2)
Stapedius
Stylopharyngeus (w/LH, styloid process)
Facial muscles --> EYELID CLOSURE
Posterior belly of the digastric

Front 1725

Cranial Nerve 10

Back 1725

Vagus nerve
Sensory and motor

Sensory:
Somatic: Posterior 1/3 tongue (w/9)
Taste from epiglottis region
Thorax/abdomen (visceral)
Aortic arch chemo/baroreceptors

Branchial arch 4 structures: S. recurrent laryngeal nerve
*Posterior 1/3 of tongue
*Levator veli palatini: palate elevation
*Constrictors: Swallowing
*Cricothyroid: Talking

Branchial arch 6 structures: I. Recurrent laryngeal nerve
*Internal muscles of larynx: Talking

Front 1726

Cranial nerve 11

Back 1726

Spinal accessory nerve
Purely motor

SCM
Trapezius

Front 1727

Clinical reflexes

Back 1727

Corneal: 5(1) --> 7 (Orb oris)
Lacrimation: 5(1) --> 7

Pupillary: 2 --> 3 (sphincter pupillae)

Jaw jerk: 5(3) --> 5(3)

Gag: 9 --> 9, 10

Front 1728

Vagal nuclei

Back 1728

Nucleus Solitarius: SPECIAL SENSORY 7, 9, 10
*Taste
*Baroreceptors
*Visceral sensory (gut distention)

Nucleus ambiguus: 9, 10, 11
*Motor innervation of pharynx, larynx, upper esophagus

Dorsal motor nucleus: 10 only
*The CRANIO of craniosacral
*Parasympathetic fibers
*Heart, lungs, upper GI

Front 1729

Skull foramina

Back 1729

Optic canal:
*CN II
*Opthalmic artery
*Central retinal vein

Superior orbital fissure:
*CN 3, CN 4, CN 5-1, CN 6
*Opthalmic vein

Foramen rotundum: CN V-2

Foramen ovale: CN V-3

Foramen spinosum: Middle meningeal artery
*SPIN a MENINge

Internal auditory meatus: CN VII-VIII

Jugular foramen (CN 9-11)

Hypoglossal canal CN 12

Foramen magnum:
*Spinal roots of 11
*Brainstem
*Vertebral arteries

CN V mnemonic:
*SRO (standing room only)
or
*V-1 for your S.O.F. eyes
*V-2 for your ROUND cheeks
*V-3 for your OVAL mouth

Front 1730

Muscles of mastication

Back 1730

CN V-3

M's munch
Medial pterygoid
TeMporalis
Masseter

Lateral lowers: Lateral pterygoid

Front 1731

KLM Sounds

Back 1731

Kuh = Palate elevation = CN X
La = Tongue = CN 12
Mi = Lips = CN

Front 1732

Glossus and Palat rules

Back 1732

All muscles w/GLOSSUS in the name are innervated by CN 12

Exception: PALATOGLOSSUS
*Fight between palat and glossus
rules--CN X wins

All muscles w/PALAT in the name are innervated by CN 10

Exception: TENSOR VELI PALATINI (too "tense" to go to vagus)
*CN V-3

Front 1733

Sensory corpuscles (4)

Back 1733

1. Free nerve endings (A-delta, C)
*Pain, temp
*All skin

2. MeiSSner's corpuscles (40% fingertip)
*SMOOTH SKIN (glabrous)
*Dynamic fine touch (impeded by hair?)

3. Pacinian corpuscles (15% fingertip)
*Feels powerful forces (VIBRATION)
*Deep skin layers, ligaments, joints

4. Merkel's disks (25% fingertip)
*STATIC TOUCH
*Cup-shaped --> hair follicle

Front 1734

Inner ear components

Back 1734

Outer shell = Bony labyrinth *3 compartments: cochlea, vestibule, semicircular canals
*Filled with perilymph (ECF, Na+)

Membranous labyrinth = cochlear duct, utricle, saccule, semicircular canals
*Filled w/endolymph (ICF, K+)

STRIA VASCULARIS makes endolymph

Utricle/Saccule: Otolith organs
*Maculae --> Thickened platforms
*Detect LINEAR acceleration

Semicircular canals
*Ampullae: Cupula sitting over hair cells
*Detect angular acceleration

Organ of corti: Contains hair cells

Cochlear membrane: Scuba flipper
*High frequency = base

Front 1735

Hearing loss: Conductive vs. Sensorineural

Back 1735

CONDUCTIVE LOSS: Sounds louder when it's touching

Weber
*Conductive: louder on affected side
*Sensorineural: softer on affected side

Rinnie:
Conductive: bone > air
Sensorineural: air > bone

Front 1736

Canal of Schlemm

Back 1736

Collects aqueous humor from front chamber of eye and delivers to blood

Front 1737

What enters eye w/the optic nerve?

Back 1737

Central retinal artery and vein

Optic nerve, opthalmic artery and central retinal vein go through the optic canal
*Central retinal artery is a branch of the opthalmic artery

Front 1738

Ocular testing

Back 1738

Look lateral = Lateral rectus
Look medial = Medial rectus

Look up and lateral = Superior rectus
*Lateral circumvents influence of inferior oblique

Down up and lateral = Inferior rectus
*Lateral circumvents influence of superior oblique

Front 1739

Ocular testing

Back 1739

Look lateral = Lateral rectus
Look medial = Medial rectus

Look up and lateral = Superior rectus
*Lateral circumvents influence of inferior oblique

Down up and lateral = Inferior rectus
*Lateral circumvents influence of superior oblique

Front 1740

Pupillary light reflex

Back 1740

CN II sends a signal to pretectal (before Sup Colliculus) nuclei in midbrain

Pre-tecal nuclei activate Edinger-Westphal nuclei

Bilateral accomodation via CN III
*Ciliary ganglion (lens), sphincter pupillae muscle (pupil)

Front 1741

Visual field defects

Back 1741

Optic nerve: 1 entire eye
Optic chiasm: Bitemporal hemanopsia

Optic tract (past chiasm): L/R field from EACH eye

Dorsal optic radiations (parietal lobe): Lower L/R quadrant of EACH eye
*Dorsal down
Meyer's loop (temporal lobe): Upper L/R quadrant of EACH eye
*Temoral upper: Mrs. Meyers bought TUPperware

Late Meyer's loop (Calcarine fissure): Everything EXCEPT for macula

Front 1742

Internuclear opthalmoplegia

Back 1742

Defects associated w/MS

When looking left, the left eye lateral rectus muscle fires

Signal is sent to MLF of the right eye

Tells Medial Rectus Subnucleus of CN III to contract R medial rectus

If this does not happen, laterally looking eye has nystagmus

Front 1743

Spina bifida: Subtypes

Back 1743

All feature elevated alpha-fetoprotein

OCCULTA: Failure of bony spinal canal to close, but NO structural herniation
*TUFT OF HAIR on back
*Dura is intact (others are not totally enclosed by dura)

MENINGOCOELE:
Failure of bony spinal canal to close
+
Meninges herniate through defect

MENINGOMYELOCOELE:
Failure of bony spinal canal to close
+
Meninges AND spinal cord herniate through defect

Front 1744

Brain derivatives

Back 1744

Telencephalon
*Cerebral hemispheres
*Lateral ventricles

Diencephalon:
*Thalamus, hypothalamus
*3rd ventricle

Mesencephalon:
*Midbrain
*Cerebral aqueduct (along w/pons)

Metencephalon: pons + cerebellum MEET
*Pons, cerebellum
*Pons --> Cerebral aqueduct (along w/midbrain)
*Cerebellum --> 4th ventricle

Front 1745

Holoprosencephaly

Back 1745

Failure of hemispheres to separate

May cause cyclopia

Causes:
Fetal alcohol syndrome
Trisomy 13 (Patau's syndrome)

Front 1746

Multiple sclerosis: SC Damage

Back 1746

Random damage
Usually in the CERVICAL cord

Motor: UMNs and LMNs can be affected

Sensory: Dorsal columns and spinothalamic

Front 1747

ALS: Spinal cord lesions

Back 1747

Motor only

UMNs and LMNs

Front 1748

Poliomyelitis

Werdnig-Hoffmann disease (Infantile Spinal Muscular Atrophy)

Back 1748

Anterior horn destruction: LMNs

Wednig-Hoffmann disease is a genetic (AR) disease (a.k.a. Infantile Spinal Muscular Atrophy, or SMA Type 1)
*SMN gene
*Floppy baby w/tongue fasciculations
*Median age of death = 7 months

Front 1749

Anterior spinal artery occlusion

Back 1749

Atrophy of all neurons in cord EXCEPT:
*Dorsal columns

Front 1750

Tabes dorsalis

Back 1750

Tertiary syphilis

Dorsal roots AND dorsal columns destroyed

Diminished sensation:
*Proprioception/touch below highest lesion point --> locomotor ataxia

*P/T information at every level of dorsal root destruction

Front 1751

Syringomyelia

Back 1751

Enlargement of the central canal of the spinal cord
*Associated w/Arnold-Chiari formation
*Most common in C8-T1

Damages anterior white commissure
*Local (extremities) bilateral loss of pain and temperature sensation

Front 1752

Horner's Syndrome

Back 1752

Occurs w/CERVICAL lesions
(lesions above T1)

1. Descending sympthatic input from hypothalamus synapses in lateral horn of T1

2. 2nd neuron enters cervical chain (adjacent to cord) and synapses in superior cervical ganglion (at level of T2)

3. 3rd neuron goes to:
*Eyelid --> Ptosis if lost
*Facial sweat glands --> Anhidrosis if lost
*Pupil --> Constriction if lost

"PAM is horny"

Pancoast's tumor (superior lung)
Brown sequard
Sever syringomyelia

Front 1753

Symptoms of arcuate fasciculus lesion

Back 1753

Arcuate fasciculus connects Broca's and Wernike's area

Conduction aphasia = Poor repetition

Good comprehension
Fluent speech

Front 1754

Re-emergency of primitive reflexes

Back 1754

Frontal lobe lesion

Front 1755

Cerebellar structure and defects

Back 1755

Hemispheres: IPSILATERAL limb effects
*Intention tremor

Vermis lesion = TRUNCAL effects
*Dysarthria (speech)

Front 1756

Subthalamic nucleus

Back 1756

Contralateral hemiballismus (violent thrashing movements)

Front 1757

PPRF lesions and FEF lesions

Back 1757

PPRF

Paramedian pontine reticular formation (PPRF) lesions:

Eyes look AWAY from lesion ("blemish")...only wants to see PPRFect things


FEF lesions:
Eyes look TOWARD lesion
Saccades, eye movements

Front 1758

Broca's area

Wernike's area

Back 1758

Inferior frontal gyrus

Superior temporal gyrus

Front 1759

Alzheimer's: What correlates w/the degree of dementia?

Back 1759

Neurofibrillary tangles

Phosphorylated Tau

Intracellular

Front 1760

Alzheimer's Disease

Back 1760

Diffuse CORTICAL atrophy

Extracellular: B-amyloid plaques

Intracellular: Neurofibillary tangles
*Abnormally phosphorylated Tau protein
*CORRELATES w/degree of dementia

Down syndrome
Familial (10% of cases)
*APO-E: Chromosomes 1, 14, 19
*p-App gene: Chromosme 21

Front 1761

Alzheimer's Disease

Back 1761

Diffuse CORTICAL atrophy
Decreased Ach

Extracellular: B-amyloid plaques

Intracellular: Neurofibillary tangles
*Abnormally phosphorylated Tau protein
*CORRELATES w/degree of dementia

Down syndrome
Familial (10% of cases)
*APO-E: Chromosomes 1, 14, 19
*p-App gene: Chromosme 21

Front 1762

Pick's Disease

Back 1762

Frontotemporal lobe atrophy
*Pick bodies (aggregated TAU)

Dementia
Parkinsonism (Basal ganglia)
APHASIA (Broca involvement)

Front 1763

Lewy body dementia

Back 1763

Dementia
Parkinsonism
HALLUCINATIONS

Lewy bodies are made of Alpha synuclein

Front 1764

Huntington's

Back 1764

Chromosome 4 (Hunting 4 food)
Autosomal dominant

CAG triplet repeat:
*Caudate atrophy
*Anticipation

*GABAergic neurons lost
*Decreased Ach

Front 1765

Freidrich's Ataxia

Back 1765

AR mutation of chromosome 9 (FRATAXIN)
*Increased trinucleotide repeats

Seen in children 5-15 years old

1. Posterior column, corticospinal and spinocerebellar degeneration
*Gait ataxia (seen early)
*Kyphoscoliosis, PES CAVUS (fixed plantar flexion), hammer toes

2. >50% develop hypertrophic cardiomyopathy
*Arrhythmias
*CHF

3. ~10% develop DM

Front 1766

MS

Back 1766

PERIVENTRICULR plaques: Oligodendrocyte loss and reactive gliosis

Classic symptoms: GOSHIN
*IgG in CSF
*Optic neuritis
*Scanning speech
*Hemiparesis/sensory
*Intention tremor
*Incontinence
*Internuclear opthalmoplegia
*Nystagmus

Treatment: Beta interferon or immunosuppressants

Front 1767

Albuminocytologic dissociation

Back 1767

CSF finding w/Guillian Barre

Probably due to Ab content
*High Protein
*Normal WBCs (no "pleocytosis")
*Papilledema

Front 1768

Partial Seizures

Back 1768

Involve 1 region of the brain
Can secondarily generalize

Simple = Consciousness intact
*Motor, sensory
*Autonomic
*Psychic

Complex: Impaired consciousness

Front 1769

Generalized seizures

Back 1769

Diffuse involvement

*Tonic ~ stiffening
*Clonic ~ movement

1. Absence (petit mal) = blank stare

2. Myoclonic = Quick, repetitive jerks

3. Tonic-clonic (grand mal) = Alternating stiffening and movement

4. Tonic = Stiffening

5. Atonic = Drop seizures
*Commonly mistaken for fainting

Front 1770

#1 Causes of seizures

Back 1770

Children: Genetics
Adults: Tumor
Elderly: Stroke

Front 1771

Epidural hematoma

Back 1771

Middle meningeal artery

Often after fracture of temporal bone

Biconvex disk
DOES NOT cross suture lines

Front 1772

Subdural hematoma

Back 1772

Bridging veins

Less pressure than epidural hematoma --> Delayed onset of symptoms

Crescent-shaped hemorrhage that crosses suture lines

Risk factors: Brain atrophy, shaking, whiplas

Front 1773

Subarachnoid hematoma

Back 1773

Aneurysm or AVM rupture

"Worst headache of life"

Spinal tap: Bloody or yellow (Xanthochromic--broken down RBCs)

Front 1774

Parenchymal hematoma

Back 1774

Vessel issues:
*HTN
*Amyloid angiography
*DM

Tumor

Front 1775

Charcot-Bouchard Microaneurysms

Back 1775

Associated with chronic HTN

Affects small vessels

Front 1776

Berry Aneurysms

Back 1776

Occur at bifurcations in the Circle of Willis
*Most commonly ACA

Rupture --> SAH

Risk factors:
1. HTN + smoking
2. Advanced age

Populations:
1. More common in blacks
2. Diseases:
*Adult PCKD --> Generalized collagen and ECM abnormality
*Ehlers-Danlos --> Collagen 3
*Marfan --> Fibrillin

Front 1777

Normal pressure hydrocephalus

Back 1777

No obstruction = communicating
*Arachnoid GRANULATION prob

NORMAL opening pressure
Enlarged ventricles

Symptoms: "Weird GAIT, can't WAIT, and a little CRAZED"
*Gait problems
*Urinary incontinence
*Dementia

Front 1778

Adult brain tumors: Supra or infratentorial?

Back 1778

Supratentorial

Adults are taller than kids (infratentorial)

Front 1779

Adult brain tumors

Back 1779

Supratentorial

GOP MS
G > M > S > O

1. Glioblastoma multiforme:
*Grade IV Astrocytoma (stains GFAP)
*CEREBRAL HEMISPHERES
*PSEUDOPALISADING cells border areas of necrosis, hemorrhage

2. Oligodendroglioma
*Rare, slow growing
*FRONTAL LOBES
*Chicken-wire capillary pattern
*OLIGO ~ OCTAGON (chicken-wire capillaries)

3. Pituitary adenoma (Rathke's pouch)
*Usually prolactinoma
*Bitemporal hemanopsia
*Hyper or hypoactive

4. Meningioma (Arachnoid origin)
*Found on surface of brain
*Concentric, whorled spindle cells
*Psammoma bodies (concentric calcifications)

5. Schwannoma (Schwann cells)
*Often CN VIII
*NF2: Bilateral schwannomas

Front 1780

Childhood primary tumors (5)

Back 1780

CHEMP
FIRST AND LAST are supratent, benign

Hydrocephalus ~ Rosettes

1. CranioPHARYNGIOMA (benign)
*Most common childhood supratentorial
*Origin: RATHKE'S POUCH remnants
*Tooth enamel-like calcification
*Confused w/pituitary tumor

2. Hemangioblastoma
*Cerebellar
*FOAMY cells w/high vascularity
*EPO SECRETION --> Polycythemia
*VON-HIPPEL-LANDAU

3. Ependymoma (Poor prog)
*Usually in 4th ventricle --> hydroceph
*Perivascular pseudorosettes

4. Medulloblastoma (Poor prog)
*Cerebellar: can compress 4th ventricle
*Considered a PNET tumor
*Rosettes or perivascular pseudorosettes

5. Pilocytic astrocytoma (benign)
*PILE OF STARS
*Posterior fossa (but supratentorial)
*ROSENTHAL fibers (pink, corkscrew)

Front 1781

Posterior fossa malformation

Back 1781

Arnold chiari malformations:
Small posterior fossa --> Cerebellar displacement, medulla deformity

Chiari 1: Often asymptomatic
*Tonsils descend
*Medulla compressed (CSF flow)

Chiari 2: Fatal
*Tonsils and VERMIS descend
*MEDULLA descends

Dandy walker:
*Large posterior fossa
*Cerebellum replaced by cyst

Front 1782

Physical signs and cranial nerve lesions

Back 1782

Ipsilateral (4):

CN 12: Tongue deviates TOWARD lesion
*"Lick your wounds"

CN 11: Shoulder droops on SAME side
*Trouble turning head toward contralateral side

CN V: Jaw deviates toward SAME side

Cerebellum: Patients fall TOWARD lesion

Contralateral signs (1)

CN X: Uvula deviates AWAY from lesion

Front 1783

Bell's Palsy

Back 1783

Facial motor nucleus has BILATERAL input for upper face (ipsilateral intact) but CONTRALATERAL input for lower face and orbicularis oris (lost)

UMN: Lost movement on contralateral side, LOWER FACE ONLY
*Includes ability to close eye

LMN: Hemiparesis of face

Causes: ALexander (BELL) has an STD:

AIDS
Lyme
Sarcoidosis
Tumors
Diabetes

Front 1784

Cingulate herniation

Back 1784

A.k.a. subfalcine herniation

Herniation through falx cerebri

May compress anterior cerebral artery

Front 1785

Uncal herniation

Back 1785

A form of transtentorial herniation

Uncus = Medial temporal lobe/hippocampus

DURET hemorrhages
*Paramedian artery rupture
*Caused by caudal displacement of brainstem

Signs: TRUST THE EYES

Ipsilateral dilated pupil/ptosis
*Stretching of CNIII

Contralateral homonymous hemanopia
*Compression of ipsilateral PCA

Ipsilateral paresis
*FALSE localizing sign
*Contralateral crus cerebri are compressed
*KERNOHAN'S notch (indentation in peduncle) is formed

Front 1786

Opiod analgesics

Back 1786

Methodone - addiction maintenance
DEXTROmethORPHAN - cough
*Sick right-handed orphan

Loperamide - diarrhea
DIPHENOXYLATE - diarrhea
Morphine
FENTANYL
Codeine
Heroin
MEPERIDINE

General uses:
1. Pain
2. Acute pulmonary edema (respiratory depression)

Toxicity:
Miosis (PINPOINT)
Constipation
Respiratory depression
CNS depression
Addiction

Antidote: Naloxone, naltrexone

Front 1787

Topiramide

Back 1787

Anti-seizure med

Increases GABA action (like benzodiazepines, phenobarbitol)

Blocks Na+ channels (like Lamotrigine)

Uses: Partial and tonic-clonic seizures

SE: Part of GTP
Sedation
Kidney stones (toppling stones)
Weight loss (good if you top scales)

Front 1788

Lamotrigine

Back 1788

Blocks Na+ channels (like Topiramide)

Uses: Partial and tonic-clonic seizures

SE: Stevens-Johnson

Front 1789

Gabapentin

Back 1789

Anti-seizure and neuropathy med

Increases GABA release (unique)

Uses:
1. Partial and tonic-clonic seizures
2. Peripheral neuropathy (pain)

SE: Gab that AS
Ataxia
Sedation (part of GTP)

Front 1790

Valproic acid

Back 1790

Anti-siezure med

Increases GABA concentration (unique)

Inactivates Na+ channels (like carbamazepine, phenytoin)

Uses:
*Partial and tonic-clonic seizures
*Myoclonic seizures
*Absence seizures (2nd line)

SE:
*Hepatotoxicity (like carbamazepine)
*Not for use in pregnancy (like carbamazepine, phenytoin)--NTD defects
*Weight gain (gain VALume), despite GI effects
*Tremor

Front 1791

Carbamazepine

Back 1791

Inactivate Na+ channels (like phenytoin, valproic acid)

Uses:
1. Partial and tonic-clonic seizures
2. Trigeminal neuralgia

SE:
*DAP: Diplopia, Ataxia, P-450
*Hepatotoxicity (like valproic)
*Teratogen (valproic, phenytoin)
*Blood changes (like phenytoin), including aplastic anemia, agranulo

Front 1792

Phenytoin

Back 1792

Inactivates Na+ channels (like carbamazepine, valproic acid)
*USE-DEPENDENT

Uses:

1. Partial and tonic-clonic seizures
2. Class IB anti-arrhythmic
3. Prevention of status epilepticus

SE:
*DAPS: Diplopia, ataxia, P-450, sedation
*Teratogen (like carba, valproic)-Fetal Hydantoin
*Blood changes (like carba): MB anemia
*Phenny looking: Nystagmus, SLE-like, Hirsutism, Gingival hyperplasia

Front 1793

Ethosuxamide

Back 1793

Anti-seizure drug

Blocks T-type Ca2+ channels
*Thalamus

Uses: 1st line for absence seizures

SE: EFGHIJ
Fatigue
GI distress
Headaches
Itching (urticaria)
J: Stevens-Johnson

Front 1794

Anaesthetics: Influential properties

Back 1794

BlOOd solubility ~ SlOwness of induction, recovery

LiPid solubility ~ Potency
*Proportional to 1/MAC
(minimum alveolar concentration)

Front 1795

IV anaesthetics

Back 1795

B.B. King on OPIATES PROPOses FOOLishly

Barbiturate: Thiopental
*Induction: high potency, short acting

Benzo: Midazolam
*Most common drug for ENDOSCOPY: "Midazolam to look at your MIDDLE"
*Used in conjunction w/gaseous anesthetics and narcotics

Ketamine/Arylcyclohexylamines
*PCP analog --> dissociative
*Disorentation, hallucination
*Bad dreams
*Cardiovascular stimulant --> INCREASES cerebral blood flow like an inhaled anaesthetic would

Opiates: Used during general anesthesia

Propofol:
*Short acting
*Less nausea than thiopental

Front 1796

Parkinson's drugs

Back 1796

BALSA:

1. Bromocriptine, pramipexole, ropinirole --> DA agonists (also used for prolactinoma)

2. Amantadine --> Increase DA release
*Influenza A and rubellA (90% resistance)
*Ataxia (cerebellA)

3. Levodopa--> Converted to DA in CNS
*Carbidopa = peripheral decarboxylase inhibitor (increases CNS availability)
*Peripheral conversion ~ arrhythmia

4. Selegiline (MAO-B inhibitor)
Entacapone, tolcapone (COMT inhibitor) --> Prevent DA breakdown
*Both may increase L-dopa SE

5. Antimuscarinics (Benztropine) *BenzTROPine: calm your TREMOR before you PARK your BENZ
*Calms excess Ach activity in CNS
*Parkinson's disease--tremor, rigidity
*Has little effect on bradykinesia

Front 1797

Sumatripan

Back 1797

5HT-1D agonists
*D for heaDache

Short-term vasoconstrictor
*T1/2 = < 2 hours

SSS: Sumatripan --> Like serotonin --> Makes vessels SMALL

Uses:
1. Acute migraine
2. Cluster headache attacks

SE:
*Vasospasm (not for CAD/Prinzmetal)
*Mild tingling
*Hypertensive emergencies

Front 1798

Infant deprivation

Back 1798

Severe deprivation --> Possible death

Deprivation > 6 mo --> Irreversible changes

4 W's:

Weak
*Muscle tone
*Physical illness, weight loss

Wordless
*Poor language skills

Wanting
*Poor socialization skills

Wary
*Basic lack of trust

Front 1799

Regression: Children

Back 1799

Regression: Children

Younger behavior under conditions of STRESS

Physical: Physical illness, fatigue

Emotional: Punishment, new sibling

Front 1800

ADHD treatment

Back 1800

Methylphenidate (Ritalin)

Front 1801

Conduct disorder

Back 1801

Converts to antisocial personality disorder @18

REQUIRES CRIMINALITY
*Otherwise, oppositional defiant

Aggression (including physical)
Destruction
Deceit
Serious rule breaking <13 yoa

Front 1802

Tourette's Syndrome

Back 1802

***Onset <18***

Motor/vocal tics
Involuntary profanity

Associated w/OCD

Treatment: Haloperidol

Front 1803

Separation Anxiety Disorder

Back 1803

Onset usually 7-8

Factitious physical complaints to avoid school

Fear of loss of attachment figure

Front 1804

Autism and Aspergers

Back 1804

DR CUB

Difficulty forming relationships
Repetitive behavior

Communication problems
Unusual abilities
Below normal intelligence (usually

Aspergers: DR
1. Difficulty w/relationships
2. Repetitive behavior

Front 1805

Rett's disorder

Back 1805

RETT-WRINGING

X-linked disorder --> FEMALES only
*Males die in utero

Age 4:
*Loss of development --> MR
*HAND WRINGING

Front 1806

Childhood disintegrative disorder

Back 1806

A lot like AUTISM, but accompanied by loss of muscle control

Onset age 2-10
Multiple areas of REGRESSION

Some autistic-like symptoms:

*Difficulty w/relationships (social skills, adaptive behavior, play)

*Communication (expressive and/or receptive language)

+

NEUROLOGICAL symptoms:

*Motor control
*Bladder/bowel control

Front 1807

Abuse

Back 1807

Physical: Female abusers

Sexual: Male abusers
*Peak 9-12

Front 1808

Neurotransmitter changes w/disease

Back 1808

DOPAMINE DISEASES:
Schizophrenia: (+) DA
Parkinsons: (+) DA, (-) ACH

ACH DISEASES:
AD: (-) Ach
Huntingtons: (-) Ach, (-) GABA

SEROTONIN DISEASES
Depression: (-) 5HT, (-) NE
Anxiety: (-)5HT, (+) NE, (-) GABA

Front 1809

Delirium

Back 1809

Knowledge of:
Time
Place
Person

Also lost in that order

Front 1810

Anosognosia

Back 1810

Defect in orientation

Me, sick? Ah, NO SO!
Lack of awareness that one is ill

Front 1811

Autotopagnosia

Back 1811

Defect in orientation

Inability to locate one's own body

Front 1812

Depersonalization

Back 1812

Defect in orientation

Body seems unreal or dissociated

Front 1813

Delirium

Back 1813

"Changes in sensoRIUM"

Most common psychiatric illness on medical and surgical floors
*RAPID
*Often reversible
*Often caused by drugs w/anticholinergic effects (mimics etiology of Alzheimers Disease)

ABNORMAL EEG
Varying levels of consciousness

Signs:
1. Disorganized thinking/cognitive dysfunction

2. Hallucinations/Illusions/Misperception

3. Disturbance in sleep-wake cycle

Front 1814

Dementia

Back 1814

"DeMEMtia characterized by MEMory loss"

Gradual decline in cognition
Usually irreversible

NO CHANGE in CONSCIOUSNESS/ALERTNESS

Front 1815

Pseudodementia

Back 1815

Depression in an elderly patient that presents like dementia

NORMAL EEG

Front 1816

Hallucination vs. Illusion vs. Delusion

Back 1816

H: Perception in the ABSENCE of external stimuli

I: Misperceptions of ACTUAL external stimuli

D: False beliefs

D: Not shared w/other members of culture/subculture
AND
Firmly maintained in spite of obvious proof to the contrary

Front 1817

Schizophrenia: Hallucination types

Back 1817

Visual and auditory

Front 1818

Psychomotor epilepsy hallucination types

Back 1818

Olfactory

Front 1819

Delirium Tremens and cocaine withdrawal hallucination types

Back 1819

Tactile--formulations
*Sensation of ants crawling on skin

Front 1820

Schizophrenia

Back 1820

Lifetime prevalence = 1.5%
*Presents earlier in men, but M=F

Genetic factors > Environmental

Schizophrenia: At least 2 of the possible 5 symptoms for 6 MONTHS

1-6 months: Schizophreniform disorder

< 1 month: Brief psychotic episode
*Usually stress-related

1. Delusions
2. Hallucinations

3. Disorganized THOUGHT
4. Disorganized or catatonic BEHAVIOR
*Catatonic: No activity, waxy paralysis, automatisms possible

5. Negative symptoms
*Flat affect
*Social withdrawal
*Lack of motivation
*Lack of speech or thought

Subtypes:
*Paranoid
*Disorganized
*Catatonic
*Undifferentiated (elements of all types)

Residual (diminished symptoms compared to acute)

Front 1821

Schizoaffective disorder

Back 1821

Schizophrenia (2+ weeks) +

Manic episode = Bipolar schizoaffective

+Depressive episode = Depressive Schizoaffective

Front 1822

Manic episode

Back 1822

3+ symptoms for 1 WEEK

DIG FAST:
Distractibility
Irresponsibility (hedonistic)
Grandiosity (inflated self-esteem)

Flight of ideas (racing thoughts)
Agitation/Increased Activity (goal directed)
Sleep--decreased need
Talkativeness/pressured speech

Front 1823

Bipolar disorder

Back 1823

Lithium is the drug of choice

1 manic or hypomanic episode
+
1 major depressive episode

Manic = Bipolar type 1
Hypomanic = Bipolar type 2

Front 1824

Cyclothymic disorder

Back 1824

2 YEARS of:

Hypomanic episodes
+
Depressive symptoms
*Does not qualify as depressive episode

If depressive episode achieved --> Bipolar 2

Front 1825

Major depressive episode

Back 1825

Major depressive disorder: 2+ depressive episodes SEPARATED by 2+ months

5+ for 2 weeks: SIG E CAPS(D)

Sleep disturbance
Interest--loss of
Guilt or feelings of worthlessness

Energy--loss of

Concentration--loss of
Appetite/weight--change
Psychomotor retardation/agitation
Suicidal ideations
Depressed mood

Front 1826

Dysthymia

Back 1826

Depressive symptoms (not episodes) lasting 2+ years

Front 1827

Sleep changes w/depression

Back 1827

REM:
*Starts earlier
*More of it
*SWS: Less by default

Awakenings:
*More throughout night
*Early morning --> start the day

Front 1828

Panic disorder

Back 1828

1+ panic attacks

Panic attack = 4+ symptoms
*Peaks in 10 minutes

Palpitations
Paresthesia

Abdominal distress

Nausea

Intense fear of dying/losing control
LIght-headedness

Chest pain
Chills
Choking
disConnectedness

Sweating
Shaking
Shortness of breath

Front 1829

Phobias

Back 1829

Fear of a specific object/situation that:
1. Is excessive
2. Interferes w/normal routine

Person RECOGNIZES the fear as uncalled for, yet still experiences it

Treatment: Systematic desensitization

Gamophobia = Fear of marriage
Algophobia = Fear of pain (algesics)
Acrophobia = Fear of heights
Agoraphobia = Public places

Front 1830

PTSD

Back 1830

2-4 weeks of symptoms = Acute Stress Disorder

4+ weeks of symptoms = PTSD

Process:
Nightmares and/or flashbacks
Acute fear, helplessness, horror
Avoidance of triggers, persistent arousal
Distress, impairment

Front 1831

Adjustment disorder

Back 1831

Psychosocial stressor (divorce, moving)

< 6 months of emotional symptoms:
*Anxiety, depression
*Causes IMPAIRMENT

Front 1832

Generalized anxiety disorder

Back 1832

At least 6 months of UNCONTROLLABLE anxiety

Unrelated to a specific event/situation

Sleep disturbance -->
Fatigue
Difficulty concentrating

Front 1833

Factitious disorder

Back 1833

Munchausen's Syndrome (or by proxy)

Faking a medical problem for "primary gain" (medical attention)

Reward = sick role

Willingness to receive INVASIVE procedures

Front 1834

Types of gain

Back 1834

Types of gain

Primary: What the symptom does for patient's internal psychic economy

Secondary: What the symptom gets for the patient (sympathy, attention, money)

Tertiary: What the caretaker gets

Front 1835

Somatiform disorders

Back 1835

Conversion disorder: Stressor --> specific motor/sensory symptoms
*Tests and physical exam negative
*Paralysis, pseudoseizure

Somatization disorder: Variety (non-specific) of complaints involving multiple organ systems
*Tests and physical exam are negative

Pain disorder --> Pain disproportionate to illness

Hypochondriosis --> Proccupation, fear of serious illness

Body dysmorphic disorder: Preoccupation w/minor or imagined physical flaws
*Frequent cosmetic surgery

Pseudocyesis
*False belief of being pregnant
*Accompanied by some physical signs

Front 1836

Cluster A personality disorders

Back 1836

"Weird"
Genetics --> Schizophrenia

Odd or eccentric demeanor

Cannot develop meaningful social relationships

Paranoid:
*Distrust and suspiciousness
*Main defense mechanism: PROJECTION
*Accuse others of having/carrying out own temptations

Schizoid
*Social withdrawal --> Content
*Limited emotional expression

Schizotypal (Schizoid +)
*Schizoid behavior (social withdrawal, limited emotional expression)
*Interpersonal awkwardness
*Eccentric appearance
*Odd beliefs or magical thinking

Front 1837

Cluster B personality disorders

Back 1837

Wild ~ "Rule" breaking (crime, sexual boundaries, mean)

Genetics --> Mood disorders, substance abuse

Dramatic, emotional OR erratic

Antisocial (sociopaths; > males)

Borderline (> females)
*Unstable moods featuring feelings of emptiness
*Impulsivity, splitting --> Unstable relationships
*Main defense mechanism: SPLITTING

Histrionic
*Attention seeking
*Sexually provocative, overly concerned w/appearance
*Excessive emotionality

Narcissistic
*Sense of entitlement --> Grandiosity
*May react to criticism w/RAGE
*May demand "top" medical personnel

Front 1838

Cluster C personality disorders

Back 1838

"Worried"
Genetics --> Anxiety disorders

Anxious or fearful

Avoidant
*Sensitive to rejection
*Socially inhibited, timid --> Not content
*Feelings of inadequacy

Obsessive-Compulsive

Dependent
*Fear of abandoment --> Submissive, clinging
*Low self-confidence --> Excessive need to be taken care of

Front 1839

Anorexia

Back 1839

Primarily adolescent girls
Commonly coexists w/depression

Behaviors:
*Abnormal eating
*Body image distortion
*Exercise

Signs:
*Metatarsal stress fractures
*Anemia
*Severe weight loss, amenorrhea
*Electrolyte disturbances (also seen w/bulimia)

Front 1840

Bulimia nervosa

Back 1840

Individuals of normal body weight

Behaviors:
*Binge eating
*Self-induced vomiting or laxitive use

Signs:
*Parotitis
*Enamel erosion
*RUSSELL'S SIGN: Dorsal hand calluses
*Electrolyte disturbances
*Alkalosis (Loss of H+ from stomach)

Front 1841

Russell's sign

Back 1841

Dorsal hand calluses (from vomiting)

Bulimia

Front 1842

Substance Dependence vs. Substance abuse

Back 1842

Physical dependence:
1. Tolerance
2. Withdrawal

Use wins out over desire:
3. Substance used in larger amounts or for longer time than desired
4. Persistent desire or attempts to cut down

Problems and spite:
5. Significant energy spent obtaining, using or recovering from substance
6. Important social, work or recreational activities reduced
7. Continued use in spite of knowing problems it causes

SIMILARITIES to substance abuse: Continued use in spite of problems

How substance abuse differs: NEVER MET CRITERIA FOR DEPENDENCE

No physical dependence (T/W)

Okay with level of use:
*No attempts/desire to cut down
*No use in excess of desires

Must feature recurrent use in presence of BIG problems:
*Major obligations missed (vs. activities reduced)
*Physically hazardous
*Legal problems

Front 1843

Alcohol withdrawal

Back 1843

Intoxication:
*Slurred speech
**SERUM GGT**

Withdrawal:
*Delirium tremens, seizures
*Tachycardia (unique as a WD symptom)

Front 1844

Opiod intoxication and withdrawal

Back 1844

Seizures --> n/a

n/a --> Piloerection (cold turkey)

Pinpoint pupils --> Dilated pupils

Vomiting, constipation --> Diarrhea

Front 1845

Amphetamine intoxication and withdrawal

Back 1845

Prolonged wakefulness --> Hypersomnolence
*Also cocaine

Dilated pupil, hallucinations --> n/a
*Also Cocaine/LSD/Marijuana

Cardiac arrhythmia --> n/a
*Also Cocaine/Caffeine/Nicotine

No cocaine "euphoria"

Front 1846

Cocaine intoxication and withdrawal

Back 1846

Euphoria --> Depression and suicidality
*Marijuana has euphoria

Arrhythmia --> n/a
*Also amphet/nicotine/caffeine

Dilated pupil, hallucinations --> n/a
*Also amphet/lsd/marijuana

Front 1847

PCP Intoxication and Withdrawal: Most important features

Back 1847

Nystagmus
Hallucinations/PsychosisBelligerence/Homicidality

Withdrawal: Recurrence as drug is reabsorbed in GI

Front 1848

Marijuana Intoxication and Withdrawal:
Most Important features

Back 1848

Euphoria --> n/a
*Cocaine also has euphoria, but followed by severe crash/suicidality

Dilated pupil, Hallucinations
*Amphet/Cocaine/LSD

Slowed time
Social withdrawal
Appetite

Withdrawal: None listed

Front 1849

LSD

Back 1849

Marked anxiety or depression --> n/a

Dilated pupil, Hallucinations
*Also Amphet/Cocaine/LSD

Front 1850

Barbiturate Intoxication and Withdrawal: Most important features

Back 1850

Respiratory depression --> Life-threatening cardiovascular collapse
*Benzos do not cause CV collapse

n/a --> Delirium
*Benzos do not cause delirium

n/a --> Seizures
*Also alcohol, benzos

Front 1851

Benzodiazepine intoxication and withdrawal: Most important features

Back 1851

Amnesia --> n/a

Mild respiratory depression --> n/a
*Barbiturates cause much more depression

n/a --> Seizures
*Also alcohol, barbiturate withdrawal

n/a --> Insomnia
*Also opiate WD

Front 1852

Caffeine Intoxication and Withdrawal: Most important features

Back 1852

Intoxication:
*Diuresis (unique)
*Muscle twitching
*Arrythmia (also Amphet/Cocaine/Nicotine)

Withdrawal:
*Weight gain (also nicotine)

Front 1853

Nicotine Intoxication and Withdrawal: Most important features

Back 1853

Intoxication:
*Arrhythmia (alsp amphet/cocaine/caffeine)
*Anxiety (also a WD SYMPTOM)

Withdrawal
*Wieght gain (also caffeine)
*Anxiety

Front 1854

Delirium tremens

Back 1854

Peaks 2-5 days after cessation

First: Autonomic hyperactivity
*Tachycardia
*Tremors
*Anxiety

Second: Psychotic symptoms
*Delusions
*Hallucinations
*Confusion

Front 1855

Operant conditioning

Back 1855

Particular ACTION produces a REWARD

Positive reinforcement: Press button to get food
*ELICITS button pressing

Negative reinforcement: Press button to avoid shock
*ELICITS button pressing

Punishment: Shock when button is pressed
*EXTINGUISHES button pressing

Front 1856

Transference/Countertransference

Back 1856

Involves PROJECTION of feelings
about formative/important person onto another

Transference: Physician ~ parent (etc.) from the PATIENT'S perspective

Countertransference: Patient ~ parent (etc) from the PHYSICIAN'S perspective

Front 1857

Social learning

Back 1857

A.k.a. modeling

Behavior acquired by watching others and assimilating actions into ones own repertiore

Front 1858

Immature ego defenses:
Acting out
Dissociation
Denial
Displacement
Fixation
Identification
Isolation

Back 1858

Acting out: The unacceptable is expressed (ex. tantrum)

Dissociation: Effort to avoid emotional stress
*Temporary, drastic change
*Personality, memory, consciousness, motor
*Extreme = multiple personality/ dissociative identity disorder

Denial: Occurs w/painful reality
*Avoidance of awareness
*Ex. Cancer and AIDS patients

Displacement: Avoided ideas and feelings
*Neutral target receives them (vs. true target)
*Ex. Angry at A, yells at B

Fixation: REMAINING, in part, at a more childish level of development
*This part never "grew"
*Men fixating on sports games

Identification: Modeling behavior
*Modelee is powerful (+/- liked)
*Ex. Abused child --> abuser

Isolation: Feelings removed
*Recount a murder w/o emotion

Front 1859

Primitive Ego Defenses:
Projection
Rationalization
Reaction formation
Regression
Repression
Splitting

Back 1859

Projection: Accuse/suspect others of your own unacceptable temptations
*Man who wants to cheat accuses wife of cheating

Rationalization: Changing the reasons behind an event to something w/less self-fault
*Fired --> Didn't want job

Reaction formation: Unacceptable idea/feeling spurs UNCONSCIOUS emphasis on opposite
*Sexual thoughts --> join monastery

Regression: Progressing beyond a developmental point, then returning there w/stress
*Dialysis patient --> Crying

Repression: Idea/feeling kept out of conscious awareness INVOLUNTARILY
*Voluntary = Suppression (mature)

Splitting: Belief that ppl are 100% good or bad

Front 1860

Mature Ego Defenses:
Sublimation
Altruism
Suppression
Humor

Back 1860

Sublimation: Unacceptable wish replaced by similar, but acceptable one
*Aggressive impulses --> business ventures

Altruism: Performing acts of unsolicited charity to alleviate guilty feelings

Suppression: VOLUNTARY repression
*Idea kept out of conscious awareness on purpose

Humor: Anxiety-provoking or adverse situation --> Appreciate amusing aspects

Front 1861

Alcohol Withdrawal: Treatment

Back 1861

Benzodiazepines

Front 1862

Anorexia/Bulimia: Treatment

Back 1862

SSRI

Front 1863

OCD: Treatment

Back 1863

SSRI

Front 1864

Anxiety: Treatment

Back 1864

Benzodiazepines
Barbiturates
Busiprone (5HT1A agonist)
Nonselective MAOI (Phenelzine, tranylcypromine)

Front 1865

Panic disorder: Treatment

Back 1865

Busiprone (5HT-1A agonist)
TCA

Front 1866

Atypical depression: Treatment

Back 1866

Nonselective MAOI (Phenelzine, tranylcypromine)

Front 1867

Typical depression

Back 1867

SSRI
TCA

(MAOI reserved for atypical)

Front 1868

Depression w/insomnia

Back 1868

Mirtazapine
*Alpha-2-antagonist --> NE, 5HT
*5HT2, 5HT3 antagonist
*Sedation, weight gain

Trazodone
*SSRI w/sedation, vasodilation, priapism

(normally, SSRIs and TCAs used)

Front 1869

Antipsychotics

Back 1869

D2 blockers (also Ach, NE, Histimine)

Haloperidol + "-AZINES"

*THIORIDazine, CHLORPROMazine --> Low potency, no neurological SE

HALOPERIDOL, TRIFLUPERazine --> High potency, neurological SE

Uses:
Schizophrenia
Tourettes (Haloperidol)
Psychotic episodes/acute mania

SE:

1. Extrapyramidal
*4h = Dystonia (muscle spasm, stiffness, oculogyric crisis)
*4d= Akinesia (reduced movement, parinksonism)
*4 wk = Akathisia (urge to move)
*4 mo = Tardive dyskinesia (DA receptor sensitization --> stereotypic oral-facial movements)

2. DA blockade --> Prolactinemia

3. Ach muscarinic blockade --> Dry mouth, constipation

4. NE alpha blockade --> hypotension

5. Histamine blockade --> Sedation

Front 1870

Atypical antipsychotics

Back 1870

Block DA AND 5HT-2 receptors

It's not ATYPICAL for OLd CLOsets to RISPER QUIETly
*Risper --> Zipra

Olanzapine, Clozapine,Risperidone, Ziprasidone, Qietapine, Ariprazole

Uses:
1. Schizophrenia (+ and -)
2. Olanzepine:
*Tourettes (not 1st line)
*Psychosis/Mania
*Replaces MAOI? Anxiety
*Replaces SSRI? Depression, OCD

SE:
*Less EPS and anticholinergic effects
*CLOZAPINE = AGRANULOCYTOSIS (weekly WBC monitoring)

Front 1871

Lithium

Back 1871

Mechanism not clear

Clinical use: Bipolar disorder

SE: LMNOP
L = Lithium
M = Movement (tremor)
N = Nephrogenic diabetes insipidus
O = HypOthyroid
P = Pregnancy problems (teratogen)

Front 1872

Busiprone

Back 1872

Mechanism: Stimulates 5HT-1A receptors

Uses: Anxiety or panic disorder

No sedation, addiction
No interaction w/alcohol

Front 1873

SSRIs

Back 1873

Fluoxetine, paroxetine, citalopram, sertraline

Serotonin-specific reuptake inhibitors

Uses:
*Depression
*OCD
*Anorexia/bulimia

SE: Better than TCAs
*GI distress
*Sexual dysfunction
*Interaction w/MAOIs: Serotonin syndrome

Serotonin syndrome: Hyperthermia and muscle rigidity, cardiovascular collapse

Front 1874

Antidepressants

Back 1874

Block reuptake SSRI and NE
*An SSRI and then some

The PRAMINES, TRIPTYLINES and Doxepin, Amoxapine

Secondary = DNA
*Desipramine
*Nortriptyline
*Amoxapine

Uses: Major depression
*Imipramine = Bedwetting
*Clomipramine = OCD

SE:

1. Toxicity = The TRI-C's
*Convulsions (from hyperpyrexia)
*Coma (from resp depression)
*Cardiotoxicity (from arrhythmia)

2. Sedation (Desipramine least)

3. NE (alpha) blocking --> Hypotension

4. Ach (muscarinic) blocking:
*Tachycardia
*Urinary retention
*Elderly: Confusion, hallucinations
*Tertiary > Secondary

Front 1875

MAOIs

Back 1875

Nonselective MAO inhibition
(MAO-B inhibitor gets DA--Selegiline for PD)

Accomplishes the same thing as TCAs: increased NE, 5HT levels

Phenelzine, Tranylcypromine

Use: Atypical depression
*Mood reactivity
*Sensitivity to rejection
*Hypersomnia
*Anxiety
*Hypochondriosis

SE:
1. Hypertensive crisis
*TYRAMINE ingestion (wine, cheese)
*Beta agonists

2. Serotonin
*SSRIs
*Meperidine (opiod)

Front 1876

Methylphenidate

Back 1876

ncreases PRESYAPTIC NE release (same w/amphetamines)

Use: ADHD

Mechanism unknown

Front 1877

Other antidepressants

Back 1877

You need BUtane in your VEINs to MURder for a MAP of alcaTRAZ

All are sedating except for bupropion (stimulant)

#neurotransmitters declines!

Buproprion (unknown mech):
*Uses: Depression, Smoking cessation
SE: STIMULANT, SEIZURES (if bulimic)

Venlafaxine:
*Triple reuptake block: Dopamine, Serotonin, NE
*Uses: Depression
*SE: Sedation AND Stimulant
*Constipation

Mirtazapine:
1. NE alpha-2 antagonist --> Increases release of NE and 5HT
2. 5HT-2 and 5HT-3 antagonist

Uses: Depression w/insomnia
SE: SEDATION, Appetite, WEIGHT GAIN

Maprotiline: Blocks NE reuptake
*Sedation, orthostatic hypotension

Trazodone: SSRi + viagra
*Use: Insomnia
*SE: Sedation, priapism, hypotension

Front 1878

Nephrotic syndrome is caused by loss of basement membrane ___

Back 1878

Negative charge

Heparan sulfate

Front 1879

If clearance is < GFR...

Back 1879

There is net tubular reabsorption of X

Front 1880

Proximal tubule activities

Back 1880

ISOTONIC ACTIVITY

CABANG

Cl/Base antiport
Ammonia (SECRETED as H+ buffer)
Bicarbonate (absorbed as CO2, H20)
AA carrier system
Na/Glucose symport + Na/H antiport
Glucose/Na symptort

Front 1881

Renin-Angiotensin system

Back 1881

JG cells secrete renin in response to:
*Low BP
*Low Na+
*Increased sympathetic tone

Renin cleaves angiotensinogen (from liver) to ATI

ACE (in lungs) converts ATI to ATII

Actions of ATII: HEAt

1. Hypothalamus: ADH, thirst
2. Efferent arteriole: Vasoconstriction
3. Adrenal cortex: Aldosterone

Front 1882

Kidney endocrine functions

Back 1882

PERP

Prostaglandins
*Vasodilate afferent arterioles

Erythropoietin
*Secreted by endothelial cells of PERITUBULAR capillaries during hypoxia

Renin: Activates Angiotensinogen to yield AT1, then ATII
*ADH, thirst
*Efferent arteriole constriction
*Aldosterone

PTH-mediated activation of 25-OHD to 1,25-OHD
*Converting enzyme = 1-alpha-hydroxylase

Front 1883

The 2 ways aldosterone can be secreted

Back 1883

1. Angiotensin II

2. High plasma K+
*Aldosterone facilitates Na+/K+ trade in collecting tubule

Front 1884

Parathyroid actions on kidney

Back 1884

PTH is released in response to low Ca2+

Induces 1-alpha-hydroxylase
*Conversion of 25-OHD to 1,25-OHD

Promotes Ca2+ resorption in the early DCT

Inhibits phosphate absorption in the PCT

Front 1885

The 2 ways ADH can be secreted

Back 1885

ATII

Senses increased plasma osmolarity
*ADH has a diluting effect on plasma

Front 1886

Horseshoe kidney

Back 1886

2 kidneys are fused at inferior pole

During ascension, they get stuck under INFERIOR MESENTERIC ARTERY

Front 1887

Nephritic syndromes: Symptoms

Back 1887

BAHO
NephrItic = INFLAMMATION

Blood in urine
Azotemia
Hypertension
Oliguria

Front 1888

Nephrotic syndromes: Symptoms

Back 1888

NephrOtic = PrOteinuria

PAL

Proteinuria
Albumin (low--edema)
Lipids (high)

Front 1889

Nephritic syndromes

Back 1889

GRAMPI

Goodpasture's syndrome
*Linear anti-GBM antibodies
*Hemoptysis accompanies hematuria

Rapidly proliferative (crescentic) glomerulonephritis
*Renal failure
*Crescent-moon shapes (LM, IF)

Alport's syndrome
*Genetic collagen mutation --> Split BM
*Nerve deafness, ocular disorders

Membranoproliferative
*Subendothelial humps (EM): TRAM TRACK
*Renal failure

Post-streptococcal (acute)
*Lumpy-bumpy w/neutrophils (LM)
*Subepithelial humps (EM)
*Children; spontaneous remission

IgA nephropathy (Berger's)
*Most com rec. hematuria in young pts
*Mesangial IgA (IF and EM)
*Mild, usually post-infectious

Front 1890

Nephrotic syndromes

Back 1890

DAMSFL (Like damsel) but missing the bottom of the E

Diabetic nephropathy
*LM: Kimmelsteil-Wilson nodular lesions
*Basement membrane thickening

Amyloidosis: Apple-green birefringence
*Associated w/multiple myeloma, chronic conditions, TB, RA

Membranous glomerulonephritis
*Most common adult nephrotic syndrome
*EM: Subepithelial deposits, spike + dome

SLE: 5 patterns of involvement
*Membranous = subepithelial deposits w/WIRE LOOP lesions
*Can also be subendothelial

Focal segmental:
*Focal = certain glomeruli
*Segmental = Only part of the glomerulus
*LM: Sclerosis and hyalinosis
*More severe: HIV and IV drug users

Lipoid nephsosis:
*#1 cause of childhood nephrotic syndrome
*EM: Podocyte foot effacement
*Responds well to steroids

Front 1891

Kidney stones

Back 1891

Stones SUCC

C = CAN see it (even if faint)
U = Can't see U

Struvite (Ammonium Mg Phosphate)
*#2 kidney stone; +/- radiopaque
*Urease + inf: Proteus, Staph, Kebsiella
*STAGHORN CALCULI --> UTIs
*Worsened w/alkaluria (opp of cystinuria)

Uric Acid:
*CAN'T SEE U (radiolucent)
*Hyperuricemia: Gout, cell turnover

Cystine:
*FAINTLY radiopaque
*Usually occurs w/cystinuria
*Hexagonal shape
*Treat w/acetazolamide (alkalinize urine)

Calcium (Oxalate, Phosphate)
*#1 stone (75-85%); seen clearly
*Ca-Oxalate, Ca-P or both
*Ca: Cancer, PTH, Vitamin D, milk-alkalai
*Oxalate: Vitamin C abuse, antifreeze

Front 1892

Renal cell carcinoma

Back 1892

Cancer of renal tubule cells
Most common renal malignancy

Risk factors:
*VHL (chromosome 3)
*Most common in men 50-70
*Smoking and obesity

Course:
1. Tubule cells become POLYGONAL CLEAR CELLS
*Tendency to cause paraneoplastic syndromes (EPI, ACTH, PTHrP, prolactin)

2. Invade IVC and spread hematogenously

Symptoms:
*Hematuria
*"Pyelonephritis": Flank pain, fever
*Polycythemia

Front 1893

Wilm's Tumor

Back 1893

#1 renal malignancy of early childhood
*Children 2-4
*Often part of WAGR complex

Caused by deletion of WT1 (tumor suppressor) on chromosome 11

LARGE palpable flank mass
*Recapitulation of embryonic kidney: Glomerular structures

WAGR: DOUBLE DOWN ON 11
*Wilm's tumor
*Aniridia (no iris)
*Genitourinary malformation
*Retardation (mental-motor)

Front 1894

WAGR complex

Back 1894

DOUBLE DOWN ON 11

Caused by deletion of several genes on chromosome 11, including WT1 (Wilm's tumor suppressor gene)

*Wilm's tumor
*Aniridia (no iris)
*Genitourinary malformation
*Retardation

Front 1895

Transitional cell carcinoma

Back 1895

#1 tumor of the urinary tract system
*Bladder
*Ureters, renal pelvis, calyces

Associated w/Pee SAC (PSAC) risk factors:
*Phenacetin (withdrawn from market)
*Smoking
*Aniline dyes
*Cyclophosphamide (Leukemia/lymphoma, SLE)

Painless hematuria --> Bladder CA

Front 1896

Acute pyelonephritis

Back 1896

Glomeruli/vessels are SPARED
*Scarred in chronic pyelonephritis

**WBC casts in urine**
*NEUTROPHIL-filled abscesses in INTERSTITIUM (chronic = lymphos)
*Abscesses can rupture into tubules

Fever, CVA tenderness

Front 1897

Chronic pyelonephritis

Back 1897

Glomeruli/vessels are SCARRED (vs. spared w/acute), and so is cortex

Primarily lymphocytes (vs. neutrophils for acute)

Eosinophilic casts

THYROIDIZATION of the kidney
*Fibrosis

Front 1898

Diffuse cortical necrosis

Back 1898

Acute generalized infarction of the cortex (both kidneys)

Vasospasm + DIC

Associations:
*Septic shock
*Obstetric catastrophes (abruption)

Front 1899

Drug-induced interstitial nephritis

Back 1899

Type 1 Hypersensitivity reaction
*Acute interstitial inflammation

Caused by drugs:
*NSAIDs
*Methicilln
*Loop diuretics

Hematuria 2 weeks after administration

Eosinophil based :
*Rash
*Fever

Front 1900

Acute tubular necrosis

Back 1900

#1 cause of ACUTE renal failure
*Reversible (in 2-3 weeks)
*Fatal if untreated (usually initial oliguric stage)

Causes:
*Renal ischemia
*Crush injury (myoglobinuria)
*Toxins

Course:

1. Inciting event
*Loss of cell polarity + necrosis
*Epithelial detachment --> Granular/muddy brown casts

2. Maintenance (low urine)
3. Recovery

Front 1901

Acute renal failure: How to decide

Back 1901

1. Look at urine osmolality or Na+

If osmolality 500+ --> Azotemia
If Na under 1%: Azotemia

2. Look at BUN/Cr

If under 15 --> Intrinsic renal
If over 15 --> Post-renal

Front 1902

Consequences of renal failure

Back 1902

HTN possible (renin)
Chronic pyelonephritis (stasis)

Hormone functions of kidney:
*EPO --> Anemia
*1-alpha-hydroxylase --> Renal osteodystrophy

Failure to filter:
1. K+ --> Hyperkalemia -->Arrhythmias

2. H+ --> Metabolic acidosis (also less HCO3 prod)

3. BUN, Creatinine --> Encephalopathy

4. Na, H2O --> CHF, Pulmonary edema

Front 1903

Most common causes of chronic renal failure

Back 1903

Diabetes

HTN

Front 1904

Fanconi's syndrome

Back 1904

Defect in proximal tubule transport of...everything

AA's, glucose, phosphate, uric acid, protein, electrolytes

1. Hypothosphatemic rickets/osteomalacia

2. Hypokalemia

3. Metabolic acidosis due to BICARBONATE wasting (like type 2 renal tubular acidosis)

Front 1905

RTAs

Back 1905

Type 1: Failure of H+ secretion
*Hypokalemia

Type 2: Bicarbonate wasting
*Associated w/Fanconi's syndrome

Type 3: HypOaldosteronism
*Hyperkalemia

Front 1906

Juvenile PKD

Back 1906

Infantile presentation of cysts in kidney parenchyma

Liver involvement too

Autosomal RECESSIVE

Front 1907

Simple cysts

Back 1907

Simple cysts = Surface cysts

Cortex only
Incidental finding

Front 1908

Medullary sponge vs. cystic disease

Back 1908

Medullary cystic disease
*Parenchyma
*Poor prognosis

Medullary sponge disease
*Cortical collecting duct
*Good prognosis

Front 1909

Na+

Back 1909

ALL NEUROLOGIC
BOTH HIGH AND LOW --> COMA

High = Irritability, delirium, coma

Low = Disorientation, stupor, coma

Front 1910

K+ disturbances

Back 1910

ALL MUSCULAR
BOTH HIGH AND LOW --> Arrhythmia

Low ~ muscle depression
*Flattened T waves
*U waves
*Paralysis
*Arrythmia

High ~ Muscle excitement
*Big T waves
*Wide QRS
*Arrhythmia

Front 1911

Ca2+ and Mg2+ disturbances

Back 1911

Low ~ Hyperactive muscle
*Tetany/NM irritability
*Arrythmia

High ~ Delirium

+ deposits (Ca2+)
*Abdominal pain
*Stones

+ muscle depression (Mg2+)
*DTRs reduced
*Cardiopulmonary arrest

Front 1912

PO4- disturbances

Back 1912

Low = Bone loss

High =
Metastatic calcification
Stones (Calcium phosphate)

Front 1913

Ovary/Testicular lymphatic drainage

Back 1913

Peri-aortic nodes

Front 1914

Contents of suspensory ligament of ovary

Back 1914

Ovarian a/v

Front 1915

Contents of transverse cervical/cardinal ligament

Back 1915

Uterine artery and vein

Front 1916

Contents of inguinal canal: males vs. females

Back 1916

Males: Spermatic cord (external fascia, cremaster muscle, internal fascia)

Females: Round ligament of the uterus (connects area near start of fallopian tube to labia majora)--NO STRUCTURES CONTAINED

Front 1917

Sperm origins and properties

Back 1917

Uses FRUCTOSE as fuel
Mitochondria in MIDDLE piece

Acrosome = Golgi apparatus
Tail = Centriole

Front 1918

Sperm origins and properties

Back 1918

Uses FRUCTOSE as fuel
Mitochondria in MIDDLE piece

Acrosome = Golgi apparatus
Tail = Centriole

Front 1919

Spermatogenesis

Back 1919

Spermatogonium in basal (bottom, sealed off by sertoli cells) compartment
*These germ cells are always unreplicated (2N vs. 4N)
Development occurs in adluminal compartment

Front 1920

Sperm path

Back 1920

SEVEN UP

Seminiferous tubules
Epididymis
Vas deferens
Ejaculatory duct
(Nothing)
Urethra
Penis

Front 1921

Leydig vs. Sertoli secretions and feedback

Back 1921

Leydig: Induced by LH
*Secretes testosterone
*Feeds back at hypothalamus (a LITTLE HIGHER up than FSH)

Sertoli: Induced by FSH
*Secretes ABP and inhibin
*Feeds back (via inhibin) at anterior pituitary

Front 1922

Testosterone types and function

Back 1922

Testes: Testosterone, DHT
Adrenals, theca cells: Androstenedione

5-alpha reductase converts testosterone to DHT

Aromatase converts testosterone and androstenedione to estrogen

Development:
1. Differentiation of Wolffian duct
2. Secondary sexual characteristics

Adulthood:
1. Spermatogenesis
2. Libido
3. Muscle, RBCs (increased hematocrit)

Front 1923

Estrogen types and functions

Back 1923

Potency:
Estradiol (ovary) > Estrone > Estriol (placenta)

Estradiol and estrone --> 50x in pregnancy

Estriol --> 1000x in pregnancy

Menstrual Cycle: Follicle development and endometrial proliferation

Hepatic synthesis of transport proteins (such as SHBG)

Myometrial excitability

Better lipids: Increased HDL, lower LDL

Front 1924

Progesterone

Back 1924

Produced by corpus luteum (and later placenta if pregnancy)

Adrenal cortex, Testes
*Part of testosterone synthesis
Menstrual cycle: Secretory development and spiral arteries + thick cervical mucus (inhibits sperm entry)

DECREASES myometrial excitability

Feedback on LH, FSH

INCREASES BODY TEMP

Front 1925

Oocyte development

Back 1925

Primary oocytes are in PROPHASE 1

Secondary oocytes are in METAPHASE II

Primary oocytes become secondary oocytes @ovulation (leave prOphase to Ovulate)

Secondary oocytes become Ova w/sperm entry (leave METaphase when they MEET a sperm)

No tetrads formed until after ovulation

Front 1926

B-hcg

Back 1926

Secreted by syncytiotrophpblast
Maintains corpus luteum (and thus progesterone production) until placenta can make enough progesterone for itself

Detectable in blood by 1 week, urine by 2 weeks after conception

HcG peaks in 1st trimester

Elevated w/hydatiform mole or choriocarcinoma

Front 1927

Menopause

Back 1927

Average age: 51

Hormone changes: GnRH, FSH, LH high (unresponsive ovaries)

Symptoms = HAVOC
Hot flashes
Atrophy of the vagina (AV)
Osteoporosis
CAD

Front 1928

Bicornuate uterus: Cause

Back 1928

Incomplete fusion of paramesonephric ducts

Possible UT abnormalities
Possible infertility

Front 1929

Hypospadias vs. Epispadias

Back 1929

Hypospadias (more common): URETHRAL FOLDS fail to close
*Ventral opening
*UTI (down ~ dirty)

Epispadias: Faulty positioning of the GENITAL TUBERCLE
*Assoc. w/extrophy of bladder

Front 1930

Klinefelter's Syndrome

Back 1930

XXY = The girly boy (1/850)

Tall w/long extremities, BUT...

*Testicular atrophy w/dysgenesis of seminiferous tubules (low inhibin, high FSH)

*Leydig dysfunction leading to low testosterone (high LH --> high E2)

*High estrogen --> Gynecomastia, female hair/fat distribution

Front 1931

Turner's Syndrome

Back 1931

XO (1/3000 --> 95% spontaneous abortion rate)

Short stature
Ovarian dysgenesis (high FSH, LH)
Webbing of the neck
Preductal coarctation of the aorta
Widely spaced nipples

Front 1932

XYY males

Back 1932

XYY (1/1000)

NORMAL fertility

Very tall
Very severe acne
1-2% antisocial behavior

Front 1933

Pseudohermaphroditism

Back 1933

Genetic gender clear
Phenotypic gender ambiguous or incorrect

Female: CAH or exogenous androgens

Male: Androgen insensitivity

Front 1934

True hermaphroditism

Back 1934

2 X chromosomes necessary (XX or XXY only)

Testicular and ovary tissue present

Front 1935

Androgen insensitivity

Back 1935

Androgen receptor defect

Rudimentary vagina only
Testes usually in labia majora
*Removed to prevent malignancy

Since testosterone responses not observed (no feedback), high LH, testosterone, and ESTROGEN (via aromatase)

Front 1936

Hydatiform mole

Back 1936

TREAT WITH METHOTREXATE (folate analog--chemo, mucositis, myelosuppression, macrovesicles in liver)

Cystic swelling of chorionic villi
Proliferation of trophoblast --> HIGH B-HCG (syncytio in origin)

Looks like "bunch of grapes" or "honeycombing"

Complete = Empty egg + 2 sperm (XX)
*COMPLETELY PATERNAL
*No fetus
*Commonly enlarged uterus

Partial = Triploid or tetraploid
Possible fetal parts

Front 1937

Hydatiform mole treatment

Back 1937

Methotrexate

Dilatation and curettage

Front 1938

Pregnancy-induced hypertension

Back 1938

Timespan = 20 weeks gestation to 6 weeks post-partum

Definition of pre-eclampsia = HEP

Hypertension --> Headache, blurred vision, cerebral hemorrhage, mentation

Edema --> Esp face and hands
Proteinuria

Eclampsia = HEP + Siezure

Additional complications:
*Placental ischemia due to poor spiral artery invasion
*HELLP syndrome: Hemolysis, Elevated LFTs, Low Platelets)

Pre-eclampsia:
*Delivery as soon as possible
*Bed rest and salt restriction

Eclampsia treatment = Prevent seizures
*IV magnesium sulfate
*Diazepam (benzodiazepine)

Front 1939

Abruptio placentae

Back 1939

Usually 3rd trimester
PAINFUL

Premature detachment of placenta, possibly leading to DIC

Increased risk w/blood pressure elevators (smoking, HTN, cocaine)

Front 1940

Placenta Accreta

Back 1940

Defective decidual layer allows placenta to attach to myometrium

Possible massive bleeding post delivery

Risk factors:
1. Prior C section
2. Inflammation

Front 1941

Pre-eclampsia risk factors

Back 1941

1. Pre-existing hypertension

2. Trouble excreting fluid: chronic renal problems

3. Diabetes (causes hypertension AND renal problems)

4. Autoimmune disorders

Front 1942

Placenta previa

Back 1942

Attachment of placenta to lower uterine segment

PAINLESS bleeding in any trimester (compare to Placenta Abuptio, which is painful and usually 3rd trimester)

Risk factor: Prior C section

Front 1943

Polyhydramnios

Back 1943

Causes:
1. Esophageal/dodenal atresia
2. Anencephaly

Unswallowed fluid accumulates to >1.5-2 L

Front 1944

Oligohydramnios

Back 1944

Causes: No pee
1. Bilateral renal agenesis, other renal problems
2. POSTERIOR URETHRAL VALVE (males) or other urinary obstruction

Inability to excrete urine causes Potter's syndrome (compressed nose, pulmonary hypoplasia)

Front 1945

Endometriosis

Back 1945

Endometrial glands/stroma outside the uterus (usually ovary, peritoneum)
*Endometriosis in myometrium = Adenomyosis
*Relation to retrograde menstrual flow

Any endometrial tissue (normal or pathologic) features CYCLIC BLEEDING --> Chocolate cysts
*Severe menstrual pain

Infertility

Front 1946

Endometrial Hyperplasia

Back 1946

Causes: EXCESS ESTROGEN
1. Hormone replacement therapy
2. PCOS, other anovulatory cycles
3. Granulosa cell tumor

Symptoms = Buildup to the point of hemorrhage --> Bleeding (repeat indefinitely)

Increased risk for endometrial CA

Front 1947

Mittelshmerz

Back 1947

When ovulation occurs, blood from ruptured follicle causes peritoneal inflammation

Mimics peritonitiz

Front 1948

Leiomyoma

Back 1948

Most common tumor in women (more often black women)

Peak age = 20-40

Benign tumor of whorled smooth muscle bundles (rare transformation)

ESTROGEN SENSITIVE (grows w/pregnancy, shrinks w/menopause)

Front 1949

Leiomyosarcoma

Back 1949

Higher incidence in blacks

De novo appearance (NOT FROM FIBROIDS)

Highly aggressive

Front 1950

Gynecological tumor epidemiology

Back 1950

Incidence:
Endometrial > Ovarian >Cervical

Worst Prognosis:
Ovarian > Cervical > Endometrial

Front 1951

PCOS

Back 1951

Obsesity --> Insulin resistance --> Increased GnRH pulses (LH >>FSH) --> Theca cell stimulation --> Androgen production (hirsutism), low estrogen (amenorrhea, decreased SHBG)

Treatment:
1. Weight loss (lose IR)
2. OCPs, gonadotropin analogs (inhibit GnRH)
3. Clomiphene (fertility drug)
*Partial estrogen receptor agonist @pituitary (increases GnRH)
4. Surgery (cyst removal)

Spironolactone, Ketoconazole for hirsutism

Front 1952

Ovarian cysts

Back 1952

Follicular cyst: Unruptured graffian follicle
*Often secretes ESTROGEN

Corpus luteum cyst: Persistent CL w/hemorrhage
*Secretes PROGESTERONE

Theca-lutein cyst: Bilateral, yellow
*Caused by hCG (and other hormones)

Chocolate cyst: Endometriosis
*Varies w/menstrual cyle

Front 1953

Germ cell tumors

Back 1953

Germ cell tumors:
*95% of testicular tumors
*~30% ovarian tumors

All malignant except female mature teratoma
*Luckily, mature teratoma = 90% of ovarian germ cell tumors

Discord among Young Things (DCYT)

1. Dysgerminoma/Seminoma
*hCG
*Fried eggs
*Males: Painless enlargement, 15-35

2. Choriocarcinoma
*hCG
*Syncytioblast and trophpblast
*Women: Theca-lutein cysts

3. Yolk sac
*AFP
*Primitive glomeruli w/Schiller-Duvals
*Aggressive, children

4. Teratoma (2+ germ cell types)
*Mature = benign in women
*Immature = malignant
*Struma ovari = thyroid tissue

5. Embryonal (no female equivalent)
*Painful
*Focal GLANDULAR differentiation in a sea of undifferentiated cells

Front 1954

Ovarian non-germ cell tumors

Back 1954

~70% of ovarian tumors

1. Serous: BILATERAL, fallopian
*Cystadenoma = 20% of ovarian tumors
*Cystadenocarcinoma = 50% of ovarian tumors
*PSAMMOMA BODIES!

2. Mucinous: Cervical
*Cystadenoma = Multilocular
*Cystadenocarcinoma = may cause PSEUDOMYXOMA PERITONEI from mucous leakage

3. Brenner: Benign, bladder

4. Fibroma: Spindle fibroblasts
*MEIG'S: Pulling sensation in groin, ascites, hydrothorax

5. Granulosa: Granulosa cells
*Estrogen secretion
*Call-Exner bodies: Follicles w/no oocyte, eosinophilic fluid

6. Krukenberg: A met from the GI
*Signet cells secreting mucin

*P.P. = intraperitoneal accumulation of mucinous material

Front 1955

Sarcoma botryoides

Back 1955

Rhabdomyosarcoma variant --> Spindle shaped tumor cells

Aggressive cancer affecting girls <4

Cells are DESMIN positive
(muscle intermediate filaments)

Front 1956

Benign Breast Tumors (3)

Back 1956

1. Fibroadenoma: Most common tumor if < age 25
*Small, well demarcated
*Estrogen sensitive, but no CA risk

2. Intraductal papilloma
*Serous or bloody nipple discharge

3. Phyllodes tumor (CT and cysts)
*Large, bulky mass
*Possible "leaf-like" projections

Front 1957

Breast cancer facts

Back 1957

ER/PR positive = Tamoxifen
Erb-B2/Her-2 (EGF receptor) = Bad

MOST IMPORTANT prognostic indicator = Axillary node involvement

Risk factors: FH and ESTROGEN

NOT INCREASED by fibroadenoma, non-hyperplastic cysts

Front 1958

Most likely cause of breast "lumps" from age 25-menopause

Back 1958

Fibrocystic disease

Epithelial hyperplasia (>30, increased layers in terminal duct lobule) ~ increased cancer risk

Front 1959

Most likely breast tumor <25

Back 1959

Fibroadenoma

Small, mobile, firm

Front 1960

Malignant breast cancers

Back 1960

1. Invasive ductal (76%): Worst
2. Invasive loBular (8%): Often bilateral
3. Medullary (1-10%): Best prognosis
4. Comedocarcinoma: Ductal, caseous
5. Inflammatory: Orange peel
6. Paget's disease of the breast: Eczema, halo cells

Front 1961

Fibrocystic disease of the breast

Back 1961

Most common cause of "breast lumps" age 25-menopause

Diffuse breast pain (multiple lesions)

No CA risk except for epithelial type
1. Fibrosis: Stromal hyperplasia
2. Cystic: Fluid filled, "blue dome"
3. Sclerosing: Increased acini, fibrosis between lobules
4. Epithelial: Terminal duct layers increase
*If ATYPICAL cells, increased CA risk
*Women >30

Front 1962

Acute mastitis

Back 1962

Breast abscess usually caused by S. Aureus

Usually associated w/breast feeding

Front 1963

Fat necrosis of the breast

Back 1963

Injury to breast tissue leaves a painless lump

Front 1964

Gynecomastia

Back 1964

Hyperestrogenism
(Cirrhosis, Testicular tumor, Puberty, Old age, XXY)

Drugs: SOME DRUGS CREATE AWESOME KNOCKERS

Spironolactone
Digitalis
Cimeditine
Alcohol
Ketoconazole

Front 1965

Prostatitis

Back 1965

Symptoms = Dysuria, urgency/frequency, lower back pain

Acute: E. COLI
Chronic: Abacterial > Bacterial

Front 1966

Cryptoorchidism

Back 1966

Undescended testes --> More likely if premature

Low spermatogenesis (temperature)

Increased risk of GERM CELL tumors

Front 1967

Benign Prostatic Hyperplasia

Back 1967

Some features common to prostatits: dysuria, frequency/urgency

Add: difficulty starting and stopping stream

Possible mechanisms:
1. Increased E2 with age
2. Increased prostate sensitivity to DHT

PERI-URETHRAL nodular enlargement (middle and lateral lobes)

Increased PSA

Front 1968

Prostate cancer

Back 1968

Same pop as BPH: > 50

Usually in POSTERIOR lobe

Labs:
1. Increased Prostatic Acid Phosphatase (PAP)
2. Increased PSA (decreased free PSA)
3. Bone met (common): High AP

Front 1969

Testicular Non-Germ Cell Tumors (3

Back 1969

5% of testicular tumors
BENIGN

Leydig cell: REINKE crystals and androgen production (also gynecomastia)

Sertoli cell

Testicular lymphoma: Most common testicular cancer in older men

Front 1970

Tunica Vaginalis Lesions (3)

Back 1970

1. Varicocele ("bag of worms") --> Dilated vein in pampiniform plexus
*Infertility

2. Hydrocele: Incomplete fusion of PROCESSUS VAGINALIS (TUNICA VAGINALIS) allows fluid

3. Spermatocele: Dilated epididymis

Front 1971

Peyronie's Disease

Back 1971

Fibrous tissue formation bends peni

Front 1972

CIN of the penis (3 types)

Back 1972

1. Bowen's: "Old, gray and single"
*Men in 5th decade
*Single gray plaque on shaft or scrotum
*10% SCC

2. Bowenoid papulosis: Papules on younger men
*NOT invasive

3. Erythroplasia of Queyrat: Red, velvety plaques on the glans
*Otherwise similar to Bowens

Progression to SCC usually involves HPV and lack of circumcision

Front 1973

Anti-androgen drugs

Back 1973

ALL ENCOURAGE GYNECOMASTIA

1. Finasteride: 5-a reductase inhibitor
*BPH and Male pattern baldness
*Possible gynecomastia

2. Flutamide: Competes w/androgens at receptor
*Prostate CA--use w/leuprolide

3. Ketoconazole: Inhibits desmolase (steroid synthesis)
*PCOS hirsutism
*Also inhibits fungal steroid synthesis

4. Spironolactone: Competes for androgen receptor
*PCOS hirsutism
*Also competes for aldosterone receptor

Front 1974

Leuprolide

Back 1974

GnRH analog (in "leu" of GnRH")

Pulsatile use: Increase fertility
Continuous: Prostate CA, fibroids

Front 1975

Mifepristone (RU-486)

Back 1975

Used w/misoprostol (PGE-1)
*Competes w/PGE-2, PGI-2 at prostaglandin receptor

Competes at progesterone receptor

Used for termination of pregnancy

SE:
Heavy bleeding
GI (N/V) and abdominal pain
*PGE-2 and PGI-2 are suppressors of Parietal cells--if blocked, STOMACH ACID

Front 1976

Oral contraception effects

Back 1976

(+) ICE: (Infection, cancer, ectopic)

Decreased pelvic infection
Decreased endometrial, ovarian CA
Decreased ectopic pregnancy

(-) COLD: Coagulation, Overweight, Lipids, Depression

Hypercoagulable state
Weight gain --> HTN
Increased TGs
Depression

Front 1977

Anastrazole

Back 1977

Aromatase inhibitor

Used for breast cancer post-menopause

Front 1978

Testosterone: Uses

Back 1978

Uses:
1. Hypogonadism, development
2. Burns
3. ER+ breast cancer

SE/Tox:
1. Inhibition of Leydig cells --> gonadal atrophy
2. Premature epiphysial plate closure
3. Increased HDL, low LDL

Front 1979

Estrogen: Uses

Back 1979

Uses:
1. Hypogonadism, development, HRT
2. Menstrual abnormalities
3. Androgen-dependent prostate CA

Toxicity:
1. Endometrial hyperplasia, CA
2. Clear cell carcinoma (if DES)
3. Thrombi

Front 1980

Progesterone: Uses

Back 1980

Stabilizes endometrium by increasing vascularization

Uses:
1.Oral contraceptives
2. Abnormal uterine bleeding
3. Endometrial cancer

Front 1981

Tamoxifen

Back 1981

Used in ER/PR+ breast cancer

Estrogen antagonist on breast tissue

Estrogen agonist on endometrium --> increased risk of endometrial CA

Front 1982

Raloxifene

Back 1982

Estrogen agonist on bone
Estrogen antagonist on endometrium

Treats Osteoporosis
No increased risk of endometrial CA

Front 1983

Trastuzumab

Back 1983

Monoclonal ab against HER-2 (erb-B2)

Uses: Metastatic breast cancer

CARDIOTOXICITY

Front 1984

Respiratory conducting zone

Back 1984

Warms, humidifies, filters air
NO GAS EXCHANGE
Contain smooth muscle
Pseudocolumnar cell lining
Contain goblet cells (ex. TB's)

Nose
Pharynx
Trachea--C rings
Bronchi--O rings
Bronchioles--loses cartilage
Terminal bronchioles--loses goblets

Front 1985

Alveolar cells

Back 1985

Type 1: SQUAMOUS diffusers
*97% of surface
*Type 1 ~ 1 job (GAS exchange)

Type 2: Surfactant + stem cells
*Secrete dipalmitoyl phosphatidylcholine (SURFACTANT)
*Lamellar bodies
*CUBOIDAL and clustered
*Source of reserve cells

Clara cells: Surfactant + stem cells + toxin clearing
*COLUMNAR cells w/secretory granules
*Secrete component of surfactant
*CLEAR TOXINS
*Source of reserve cells

Front 1986

Bronchi

Back 1986

Primary: Mainstem bronchi
Left and right

Secondary: Lobar bronchi
R: Superior, middle, inferior
L: Superior, inferior

Tertiary: egmental bronchi

Several per lobe

Each has 2 arteries running w/it:
*Pulmonary
*Bronchial

Veins and lymphatics drain along BORDERS of bronchopulmonary segment

Front 1987

Which bronchopulmonary segment is most likely to contain an aspiration?

Back 1987

R lower lobe --> Superior segment

This is the most posterior part of the lobe

Front 1988

Where is the right pulmonary artery in relation to the bronchus?

Back 1988

Anterior to the bronchus (RALS)

Front 1989

Where can pain from the diaphragm be referred?

Back 1989

Pain can radiate to shoulder

Front 1990

Diaphragm perforations

Back 1990

T8 = 8 letters
VENA CAVA (IVC)

T10 = 10 letters

Esoph-vagus
Esophagus + vagus nerve

T12 = 12 letters

Aortic Hiatus
*Aorta (red)
*Azygous vein (blue) --> Drains to SVC
*Thoracic duct (white)

Front 1991

Muscles of heavy/exercise breathing

Back 1991

Inspiration:
*External intercostal --> EXPAND ribcage
*Scalene muscles --> Lift ribcage
*Sternomastoids --> Lift ribcage

Expiration
*Internal intercostals --> Bring ribcage INWARD
*Abdominal muscles

Front 1992

Fetal lung maturity

Back 1992

Lecithin (dipalmitoyl phosphatidylcholine): Sphingomyelin ratio = > 2

Front 1993

Surfactant

Back 1993

Produced by type II pneumocytes

Decreases alveolar surface tension

Increases compliance (reduces work of inspiration)

Front 1994

What does the air pressure have to exceed to keep an alveolus open?

Back 1994

2 x surface tension
----------------------
radius

Front 1995

Things that cause a RIGHT shift in the PO2 (x) vs. Hb saturation (y) curve

Back 1995

The CADET says its right to be "generous"
*Lower saturation than you'd expect --> more O2 given away

CO2
Acid/Altitude
DPG
Exercise
Temperature

But people are BASICALLY stingy
(Basic conditions cause left shift)

Front 1996

Pulmonary HTN

Back 1996

Normal pulmonary artery P = 10-14 mm Hg

Pulmonary HTN = >25 mm Hg

Primary = Unknown cause
*Poor prognosis

Secondary:
#1 cause = COPD
#2 cause = L --> R shunt

Front 1997

Shunt

Back 1997

Physical changes in lung reduce ventilation

100% O2 does not help

Front 1998

Alveolar gas equation

Back 1998

PAO2 = PIO2 - PACO2/R

PAO2 = Alveolar O2
PIO2 = Inspired O2 (usually 150)
PACO2 = Alveolar CO2
R = Respiratory quotient (usually 0.8)

Therefore, typical equation is;

PAO2 = 150 - PACO2/0.8

Front 1999

A-a gradient

Back 1999

A-a gradient = PAO2 - PaO2

PAO2 = Alveolar O2
PaO2 = Capillary O2

Usually, artery misses out on 10-15 mm Hg of O2

Front 2000

V/Q

Back 2000

Ideally, V/Q = 1

Apex: V/Q = 3 (wasted ventilation)

Base: V/Q =0.6 (wasted perfusion)
*V and Q are greater at the base than the apex, but Q is disproportionately greater

Front 2001

Pressures in the lung

Back 2001

Zone 1 (apex): Alveolar pressure #1
*PA > Pa > Pv

Zone 2: Alveolar pressure #2
*Pa > PA > Pv

Zone 3: Alveolar pressure #3
*Pa > Pv > PA

Front 2002

Bohr effect

Back 2002

H+ in peripheral tissue shifts O2 dissociation curve to the right (CADET)

O2 is released

Front 2003

Altitude changes

Back 2003

Ventilation: Increased acutely and chronically --> Alkalosis
*Renal excretion of bicarbonate

Decreased pO2 causes pulmonary vasoconstriction --> RVH

Erythropoietin --> Hct, Hb

2,3 DPG produced (binds to Hb to shift its behavior to the right)

CELLULAR CHANGES
*More mitochondria--more places to grab and use O2

Front 2004

4 types of COPD

Back 2004

1. Increased RV
2. Decreased FEV1 and FVC
*FEV1 reduced more, so 3. FEV1/FVC also reduced
3. Decreased I/E ratio
4. Pulsus paradoxus

Chronic bronchitis: GLAND hypertrophy (mucus)

Emphysema: Destruction of alveolar walls, causing decreased recoil and enlarged air spaces

Asthma: SMOOTH MUSCLE hypertrophy w/bronchial hyperresponsiveness and mucus plugs

Bronchiectasis: Chronic necrotizing infection of bronchi

Front 2005

Hilar mas arising from bronchus
Keratin pearls
Intercellular bridge

Think S. C.:
*Sentral, Smoking
*Cavitations, Keratin/bridges

Releases parathyroid-like hormone

Back 2005

Adenocarcinoma: Bronchial and bronchioalveolar

Front 2006

Small cell carcinoma

Back 2006

Aggressive tumor
*"Sentral" and "Smoking"
*Undifferentiated neuroendocrine KULCHITSKY CELLS (small, blue)

LAK's differentiation:
L = Lambert-Eaton (autoAbs against Ca2+ channels)
A= ACTH/ADH secretion (ectopic)
K = Kulchitsky cells

Responds to chemotherapy

Front 2007

Large cell lung carcinoma

Back 2007

Aggressive tumor
*Peripheral
*Undifferentiated tumor of pleomorphic giant cells w/LEUKOCYTE fragments in cytoplasm

LESS responsive to chemo

Front 2008

Bronchopneumonia

Back 2008

Intra-bronchiolar infiltrate leaks into alveoli

SKedooSH --> A staph and a strep

S. Aureus
Klebsiella
S. Pyogenes
H. Influenza

Front 2009

Interstitial pneumonia

Back 2009

Runts may cough...legionella

Atypical pneumonia

Inflammation of interstitial walls between alveoli

Viruses (RSV, adenovirus)
Mycoplasma
Chlamydia
Legionella

Front 2010

Lung abscess

Back 2010

Aspiration (alcoholics, epileptics) or obstruction --> localized collection of pus

Staph AUREUS (gold/yellow), ANAEROBES

Front 2011

Pleural effusion: Milky

Back 2011

Triglycerides

Front 2012

Asthma drugs

Back 2012

Nonspecific B2 agonists: Relaxes bronchial smooth muscle

Methylxanthines (Theophylline): Inhibits PDE to increase cAMP, which promotes bronchodilation

Muscarinic antagonist (Ipratroprium): Competitively blocks muscarinic receptors to prevent bronchoconstriction

Cromolyn: Prevents mast cell degranulation

Corticosteroids: Inactivates NFKB (TF) to inhibit the synthesis of virtually all cytokines

Zileuton: 5-Lipooygenase pathway inhibitor (blocks LT synthesis)

Zafirlukast/Montelukast: Block LT receptors
*Good for aspirin-induced asthma

Front 2013

Effect of cAMP on bronchioles

Back 2013

Bronchodilation

When you go to CAMP, take in the fresh air

B2 agonists (increases AC)
Theophylline (inhibits PDE)

Front 2014

H1 blockers

Back 2014

1st generation: Reversible inhibitors of H1 histamine receptors

Dimenhydrate --> DIMEN
Diphenhydramine --> DIPHEN
Chlorpheniramine --> CLORPHEN

Uses:
1. Allergy --> Benadryl
2. Motion sickness --> Dramamine
3. Sleep aid

Toxicity:
1. Sedation
2. Anti-muscarinic (Ach)
3. Anti-alpha adrenergic (NE)

2nd generation: Reversible inhibitors of H1 histamine receptors

Loradatine, desloradatine
Fexofenadine
Cetirizine

Uses: ALLERGY

Toxicity: Less sedating due
to decreased CNS entry