Boards

medical tx in Conn's syndrome

Aldosterone excess will cause HTN, hypokalemia, metabolic alkalosis and depressed renin. Alternatively, hypoaldosteronism is the cause of type IV renal tubular acidosis. Aldosterone antagonists (spironolactone or eplerenone) can be used as tx in Conn's syndrome

Tx for Active TB?

All patients with active tuberculosis should begin quadruple empiric therapy with rifampin, isoniazid, pyrazinamide, and ethambutol for 2 months followed by continued therapy with rifampin and isoniazid for an additional 4 months.

Amiodarone

Amiodarone is a III/potassium channel blocking antiarrhythmic medication that increases sinoatrial node automaticity and atrioventricular node/ventricular refractory periods. It is commonly used to treat wide-complex tachycardias such as ventricular tachycardia.

Class III antiarrhythmics

Amiodarone, ibutilide, dofetilide, sotalol block K channels and inhibit outward K+ currents during phase 3 of the cardiac action potential, prolonging repolariation and total AP duration used to maintain sinus rhythm in pt with parxoysmal atrial fribrillation

treatment of phrophylaxis for recurrent migraines

Amitriptyline and NSAIDS are ABORTIVE BUT AMITRIPTYLINE is good for prophylactic (the only TCA) others include: propranolol, timolol, divalproex, sodium valproate, and topiramate - these decrease the frequency , duration, and severity of migraines attacks

exemestane

Aromatase inhibitor used to treat estrogen-responsive breast cancers in postmenopausal women. Inhibition of aromatase prevents the conversion of androgens to estrogen in peripheral tissue. Side effects include hot flashes, vaginal bleeding, CNS effusion, and bone pain.

Aspirin toxicity

Aspirin irreversibly inhibits COX enzymes, which shifts arachidonic acid metabolites down the pathway to produce leukotrienes. An excess of leukotrienes can lead to bronchospasm. Typical manifestations include hyperpnea, fever, tinnitus, vertigo, vomiting, diarrhea, and mental status changes. A variety of acid-base disturbances can occur. Most adults will have a primary respiratory alkalosis or a mixed primary respiratory alkalosis and primary metabolic acidosis. Patients will present with an abnormally high anion gap ([Na] - [Cl] + [HCO3]). Treatment includes intravenous sodium bicarbonate, hemodialysis, and volume resuscitation. At toxic levels, aspirin follows zero-order elimination kinetics. Alcohol also follows zero-order kinetics. Aspirin toxicity presents as GI distress, tinnitus, and hyperthermia. It also causes elevated leukotrienes, which could lead to bronchospasms.

drug contraindicated in gout

Aspirin is relatively contraindicated in gout because both salicylic acid and uric acid compete at renal transporters, thereby increasing the amount of uric acid in the body. However, patients on aspirin therapy for more serious conditions like coronary artery disease or stroke prophylaxis should not stop aspirin therapy due to the benefits outweighing the risks.

Schistosoma haematobium

Bladder cancer (squamous cell) - painless, gross hematuria and RF: travel to Middle East and East Africa especially with agricultural and or fresh water interaction, smoking, aniline dyes, and petroleum byproducts

Neural tube derivatives (from ectoderm)

Brain & spinal cord Post. pituitary, pineal gland Retina

anterior interosseous nerve

Branch of the median nerve that supplies isolated motor innervation to the deep muscles of the hand: flexor pollicis longus, lateral half of the flexor digitorum profundus and pronator quadratus quickest test is to make an A-OK sign: weakness in flexors of the pollex and DIP of the 2nd digit m/c mechanism of injury is through trauma to the mid-shaft and distal forearm complex (Galeazzi fracture)

Meralgia Paresthetica

-compression of the *lateral femoral cutaneous nerve * -pain & tingling sensation but *no motor loss* -cause: obesity, postural changes, tight clothing, pregnancy tx: treat anterior lumbar TP: AL2, AL3, AL4 supine flex hip to 90, SB ankles away and rotate towards

ACA strokes

C/L LE deficits

MCA strokes

C/L UE and face deficits homonymous hemianopia, aphasia, hemineglect if it is a large stroke it caninvolve BOTH upper and lower expremityies

Hereditary angioedema

C1 esterase inhbitior, DO NOT USE ACE-inhibitors due to bradykinin AD- causes episodes of painless, non-pitting, well-circumscribed edema. The face, neck, lips, and tongue are most commonly affected, but internal organs may also be involved. If affecting the tracheobronchial tree: can cause respiratory obstruction and is potentially fatal. Angiodema of the GIT = abd pain, vomiting, diarrhea.

spinal nerves that mediate the biceps and brachioradialis reflexes

C5-C6

radial nerve

C5-T1 branches of the post cord of the brachial plexus, passes to the humerus in the radial groove, between the lateral and medial heads of the triceps muscle, and continues into the cubital fossa. innervates all the muscles in the POST compartments of the arm and forearm supplies sensation to the post arm and forearm and lateral digits of the dorsum of the hand. compression: weakness in elbow extension and arm AD-duction and decreased sensation for the post arm, forearm, and lateral digits of the dorsum of the hand

Median nerve

C6-T1 courses between the humeral and ulnar heads of the pronator teres muscle (which it pierces) and then runs between the flexor digitorum superficialis and the flexor digitorum profundus muscle before crossing the wrist within the carpal tunnel. Proximal nerve lesions may result in sensory loss over the first 3 digits and impairment of thumb flexion/opposition, flexion of the second/third digits, and wrist flexion/abduction. Median nerve compression can lead to pronator teres syndrome = weak forearm muscles and decreased sensation to the lateral hand

ulnar nerve

C8-T1 branches from the medial cord of brachial plexus, passes under the arcade of Struthers and post to the medial epicondyle of the humerus, and continues along the medial aspect of the forearm of the medial hand. innervates the flexor carpi ulnaris, flexor digitorum profundus, and most intrinsic muscles of the hand supplies sensation to the medial digits of the hand. compression: cubital tunnel syndrome = weakness in the interosseus muscles and other intrinsic muscles of the hand, and decreased sensation to the medial digits of the hand

Medial cutaneous nerve of arm

C8-T1 branches from the medial cord of the brachial plexus, joins with the intercostobrachial nerve, and continues to the medial aspect of the arm. No motor innervation but supplies SENSATION to the medial arm - compression can cause decreased sensation for the medial arm

BUDDING organism

CANDIDA might also include: on gram stain elliptical, purple organisms associated with catheter

caseating granulomas of TB almost always contain large epitheloid macrophages with pale pink granular cytoplasm and what surface maker at the periphery?

CD14 - a surface marker of the monocyte-macrophage cell lineage.

Bile Acid Binding Resins

Cholestyramine Colestipol Colesevelam these drugs inhibit enterohepatic circulation of bile acids. This leads to diversion of hepatic cholesterol to synthesis of new bile acids, increased uptake of cholesterol from the circulation, and reduced blood LDL levels. However, bile acid-binding resins increase hepatic production of triglycerides and can cause hypertriglyceridemia

Donepezil

Cholinesterase Inhibitor (Alzheimer's) DONa RIVA dances at the GALA (DONepezil, RIVAstigmine, GALAntamine.

Rosacea

Chronic skin disorder of the face with red inflamed areas appearing mostly on the nose and cheeks - reddening/flushing when exposed to heat, sun, hot foods, EtOH - Persistent erythema & telangiectasia - pustule and papules - Rhinophyma: permanent thickening of the nasal skin = enlarged nose

pancreatic pseudocyst

Common complication of acute pancreatitis. A collection of pancreatic enzyme-rich fluid with walls made of granulation tissue and fibrosis. Unlike true cysts, not lined by epithelium.

probability of a female sibling (sister) of a male affected by an X-linked recessive disease will give birth to an affected child is?

1/8 0.5 (probability that the sister is a carrier) x 0.5 (probability that the offspring of a female carrier will inherit the X chromosome with the gene) x 0.5 (probability that the sister will have a boy = 1/8

Inhaled glue toxicity

14 y/o boy Bilateral aching in the temple forgetting names, dates, and places Clumsy w/ frequent falls Broad Based Ataxic Gate

Esophageal squamous cell carcinoma

2 most importnat risk factors in the United states are smoking tobacco and drinking alcohol. Consumption of foods containing N-nitroso compounds are importnat risk factors in Asian countries histo: solid nests of neoplastic squamous cells with abundant eosinophilic cytoplasm and distinct borders. Areas of keratinization and the presence of intracellular bridges are characteristic. Pt present with progressive solid and then liquid dysphagia and wt loss metastasizes to teh mediastinal lymph nodes

Loop diuretics MOA

Act on ascending loop of Henle, inhibit sodium-potassium-chloride transporter; decrease renal vascular resistance

Undifferentiated (anaplastic) tumors

No resemblance to the tissue of origin; pleomorphic cells, large, hyper chromatic nuclei, disorganzed, giant tumor cells, abnormal mitoses

Follicular lymphoma

Non-Hodgkin Lymphoma ~ neoplasm of Mature B-cells *Adults* ~ indolent course Presents as "waxing & waning" lymphadenopathy *t(14;18)* ~ heavy-chain Ig & BCL-2 (inhibits apoptosis)

sevelamer

Non-absorbable phosphte binding polymer that decreases absoroption of phosphate in GI tract. used in chronic kidney dz bc this can cause hyperphosphatemia from decreased renal excretion of phosphorus

Buspirone

Nonbenzo anxiolytic for generalized anxiety disorder, slow onset, few side effects, no risk of dependence

what would be expected to be seen in athletes (for lung volumes)

Normal RV with increased TLC can be seen in highly trained athletes due to increased vital capacity.

orchiectomy would have what effects on the prostate orchiectomy: U/L or B/L removal of the testicles

Orchiectomy → ↓ testosterone production → ↓ DHT → prostate cells undergo apoptosis (this mechanism is similar to using 5a-reductase blockers to treat BPH) Apoptosis is characterized by DNA fragmentation (pyknosis, karyorhexis, karyolysis)

High maternal serum alpha-fetoprotein

Open neural tube defects: anencephaly, open spina bifida Ventral wall defects: omphalocele, gastroschisis multiple gestation

Malathion

Organophosphate insecticide cholinesterase inhibitor: pro−drug converted to malaoxon. Less toxic in mammals and birds because metabolized to inactive products

Cognitive Testing and Related Domains

Orientation: providing name, location, and current date Comprehension: following multistep commands Concentration: Reciting months of the year backwards, counting down from 100 by intervals of 3 or 7, spelling "world" backwards Short-term memory: Recalling 3 unrelated words after 5 min Long-term memory: Providing details of significant life events Language: Writing a complete sentence with noun-verb agreement Visual-spatial: Drawing intersecting pentagons Executive function: Drawing a clock oriented to the time requested

Acetaminophen and NSAIDs decrease fever by decreasing synthesis of this factor in the hypothalamus

PGE2

Tetraology of Fallot (TOF)

PROVe Pulmonary stenosis Right ventricular hypertrophy (boot shaped heart) Overiding aorta VSD

sacral tender points

PS1 - Medial to PSIS at S1 level PS2, PS3, PS4 mid-line - Mid-line on sacrum at the corresponding level PS5 bilateral- Medial and superior to ILA first and last tender points are B/L thus they have 2 points

papillary muscles blood supply

Papillary muscle rupture is a life-threatening complication that typically occurs 3-5 days after MI and presents with acute mitral regurgitation and pulmonary edema. The posteromedial papillary muscle is supplied solely by the posterior descending artery, branch of the right coronary artery (right dominant circulation) or left circumflex artery (left dominant circulation) making it susceptiable to ischemic rupture. the anterolateral papillary muscle has dual blood supply from the left anterior descending (LAD) and left circumflex arteries.

treatment for scabies

Permethrin: blocks v-gated Na channels. alt: use ivermectin: antiparasitic that bind Cl- channels in invertebrate nerve and muscle cells the combination of drugs is used in *crusted scabes*: in pt (HIV) who are immune compromised and have thousands of mites

Pertussis (whooping cough)

Pertussis should be considered in any adult who has not had updated vaccination boosters. The clinical presentation is a paryoxysmal cough lasting >2 weeks that is associated with post-tussive emesis or inspiratory whoop after a severe coughing episode. caused by gram-negative coccobacillus Bordetella pertussis,

Necrotizing enterocolitis

Pre-term infants have lower immune function, bacteria proliferate in bowel and cause ischemic necrosis and air in the bowel. Dx: X-ray: pneumatosis intestinalis (air in the bowel wall) thin curvilinear lines of lucency GI emergency of newborns - also associated with initiation of enteral feeding (feeding formula via tube)

hydatidiform mole

Preeclampsia in the first trimester, hCG levels above 100, 00 mIU/mL, and an enlarged bleeding uterus are clinical signs of what?

Protein C deficiency - warfarin induced skin necrosis

Pt started on warfarin develop a transient hypercoagulable state due to the short half life of protein C. This hypercoagulability is further exaggerated by preexisting protein C deficiency and can result in thrombotic occlusion of the microvasculature with skin necrosis

Down syndrome and early-onset AD

Pt with trisomy 21 (Down syndrom) have 3 copies of the amyloid precursor protein gene located on chromosome 21. This increases amyloid-beta accumulation in the brain, placing these pt at high risk for developing early-onset Alzheimer disease (AD < or = to 65 years of age).

Poxvirus

DNA virus aka small pox Molluscum contagiosum: flesh colored, dome-shaped papule with central *umbilication* The papules will typically show eosinophilic cytoplasmic inclusion bodies on biopsy. spread by direct contact

what acid-base disorder is associated with DKA?

Diabetic ketoacidosis is an example of metabolic acidosis. With metabolic acidosis, arterial pH and HCO3- decrease and the respiratory system compensates by increasing respiration, which decreases arterial PCO2.

REM

REM decreases with age, occurs every 90 minutes, is initiated by acetylcholine, and is reduced by NE.

lesser omentum

Double layer of peritoneum that extends from the liver to the lesser curvature of the stomach and the beginning of the duodenum. Its divided into the hepatogastric and hepatoduodenal ligaments

Viral recombination

Exchange of genes via crossing over NON-segmented 2 ds DNA molecules. the mixing of genome segments in segmented viruses that infect the same host cell

Reye's syndrome

Extensive accumulation of fat inside hepatocytes cause by using salicylates, commonly aspirin, in children. Lipid accumulation in hepatocytes can also been found in alcoholic liver disease and in metabolic abnormalities such as non-alcoholic fatty liver disease. Fatty liver is not a complication of acetaminophen toxicity.

Sertoli cells

Sertoli cells produce *Inhibin* in response to FSH from the anterior pituitary. Inhibin suppresses FSH production in the pituitary. Sertoli cells also facilitates spermatogenensis within the seminiferous tubules. Impaired Sertoli cell function would lead to decreased production of inhibin, increased FSH levels, and impaired fertility

5-alpha reductase inhibitors

Finasteride Dutasteride block conversion of testosterone to dihydrotestosterone in the prostate. These drugs dec prostate volume in pt with BPH and relieve the fixed component of bladder outlet obstruction

considerations for non-dihropyridine calcium channel blockers

First generation calcium channel blockers (CCBs; nifedipine, diltiazem) have a negative inotropic effect and have demonstrated clinical deterioration in patients with heart failure with reduced ejection fraction including increased hospitalization rates, worsening heart failure, and increased mortality. Per the American College of Cardiology/American Heart Association heart failure guidelines, it is recommended to avoid non-dihydropyridine CCBs due to lack of benefit and worsened clinical outcomes.

Anti-HBc IgM

First sign of acute infection Present during window phase prior to HBsAg and HBeAg

Retroperitoneal Organs

SADPUCKER Suprarenal (adrenal) glands, Aorta and IVC, Duodenum (2nd through 4th parts), Pancreas (not tail), Ureters, Colon (ascending and descending) Kidneys, Esophagus (thoracic portion), Rectum

Marjolin ulcer

SCC arising from chronic wound such as previous burn scar, tends to be very aggressive

major depressive disorder

SIG E CAPS Depressed mood SLEEP disturbance loss of INTEREST GUILT or feelings of worthlessness ENERGY loss and fatigue CONCENTRATION problems APPETITE/wt changes PSYCHOMOTOR retardation or agitation SUICIDAL ideation have to greater than or equal to 5 if the 9 sx and lasting for more than or equal to 2 weeks

Duloxetine

SNRI: used in tx of depression, anxiety, and chronic pain d/o. Can cause confusion but rarely causes obstructive voiding sx

first line drugs for generalized anxiety disorder

SSRIs and SNRI are first line meds. Benzodiazepines should be limited to short-term use while antidepressants take effect and avoided in pts with a history of substance abuse

clinical dx of angina pectoris

ST depression: MI that is NOT transmural ie hasnt transversed the entire cardiac wall vs ST elevation is most often associated with transmural ischemia that occurs with MI (could be seen in Prinzmetal's angina)

Sturge-Weber syndrome

STURGE Sporadic, port-wine Stain, Tram track calcifictaions, Unilateral, Retardation, Glaucoma, GNAQ gene; Epilepsy. hemipelgia, skill radiopacities: tram-track calcifications

Restriction Fragment Length Polymorphisms (RFLPs)

Sample Analyzed: DNA digested with restriction enzyme Detects: Single nucleotide changes in DNA

which childhood vaccine contains gelatin?

Gelatin is added as a stabilizer The CDC recommends extreme caution before administering the MMR or varicella vaccines to any person with a history of anaphylactic reaction to gelatin or gelatin-containing products. Skin testing for sensitivity to gelatin should be considered. Gelatin is found in MMR, influenza, rabies, varicella, and yellow fever

Leuprolide

GnRH agonist causes a tranisent increase in pituitary LH secretion, which leads to a rise in testosterone levels. However, continusous use suppresses LH and leads to a decrease in tesosteerone production

Cryptococcus neoformans

Heavily encapsulated-thick polysaccharide capsule yeast . Not dimorphic. Found in soil contaminated with pigeon droppings. primarily infects the lungs associated with Crytpcoccal meningitis: slowly worsening HA, fever, and confusion associated with immuncompromised pt to dx: India ink stain and polysaccharide antigen testing

CMV colitis

HIV CD4<50. diarrhea, abdominal pain, fever, wt loss, Dx- colonoscopy and biopsy shows erythema multiple ulcers, erosions, CMV cells with inclusion bodies. large cells with basophilic intranuclear inclusions Tx- ganciclovir 1st line, foscarnet

HLA subtype associated with Hemochromatosis

HLA-A3 Hereditary hemochromatosis (HH) is an autosomal recessive disorder in which mutations in the HFE gene cause increased intestinal absorption of iron. The presence of HLA-A3 is associated with HH. The clinical manifestations of this disorder, and of other forms of iron overload, are related to excessive iron deposition in tissues, especially the liver, heart, pancreas, and pituitary. The clinical manifestations of iron accumulation include liver disease, skin pigmentation, diabetes mellitus (bronze-diabetes), arthropathy, impotence in males, and cardiac enlargement with or without heart failure or conduction defects.

HLA subtype associated with Graves disease

HLA-B8

Hyperprolactinemia

Higher-than-normal prolactin levels, which may result in spontaneous breastmilk production and amenorrhea (inhibitory effect of prolactin on hypothalamic GnRH secretion). Causes include pituitary tumors - lactotroph adenomas (prolactinomas) *premenopausal F*: galactorrhea and amenorrhea *postmenopausal and men*: HA, bitemporal hemianopsia due to compression of the optic chiasm in the suprasellar region

Hepcidin

POLYPEPTIDE made in liver cells Major hormonal REGULATOR of iron homeostasis high iron levels and inflammaotry coniditons increase syn of hepcidin; hypoxia and increased erythropoiesis act to lower hepcidin levels. Low hepcidin levels increase intestinal iron absorption and stimulate iron release by macrophages

Multiple Endocrine Neoplasia type 1

Hyperparathyroidism (hypercalcemia, constipation, kidney stones), pituitary tumors, and pancreatic endocrine tumors (gastrinoma). *mutation in MEN1 gene*

side effect of amiodarone

Hypo/Hyperthyroid Pulmonary fibrosis/HTN Infiltrative liver disease/Elevated LFTs Iodine allergy

etiologies for secondary amenorrhea

Hypogonadotropic hypogonadism: absent/decreased ovary function due to inappropriately low serum concentrations of LH and FSH (which is an effect of GnRH deficiency) Functional hypothalamic amenorrhea can be caused by eating d/o, exercise, or high levels of prolonged physical or mental stress

bulemia nervosa - lab findings

Hypokalemia in an otherwise healthy young adult with a nl BMI with a preoccupation with body size is concerning for self-induced vomiting. Other findings: tachycardia, hypotension, painless B/L parotid gland swelling, calluses or scarring on the dorsum of the hand, and erosion of dental enamel

A 4 month-old infant brought to the ED bc she had a seizure 1 hr ago. She has had diarrhea for the past 3 days. She has consumed nothing but H2O for the past 24hrs bc parents ran out of formula. What electrolyte ablities will she have

Hyponatremia

treatment of DKA

IV normal saline and insulin. This will increase serum bicarbonate and sodium and decrease serum glucose, osmolality, and potassium

Hydroxychloroquine

Plaquenil Rheumatoid Arthritis Agent disease modifying anti-rheumatoid drug that causes pigmented retinal deposits is hydroxychloroquine. This drug has an unknown mechanism, but is thought to act through antigens responsible for hypersensitivity reactions.

Asbestosis

Pneumoconiosis that occurs with inhalation of asbestos fibers, mc in pt with occupational exposure (insulation installation, shipbuilding, pipe work). Pt are typically asx for 20-30 years after initial exposure; dyspnea, cough, and fatigue are common presenting sx Histopathology demonstrates: 1) diffuse interstitial fibrosis: B/L parenchymal fibrosis, most predominant in the *lower lungs* 2) honeycombing and upper lung involvement occur in advanced disease 3) *ferruginous bodies*: golden brown, rod or fusiform-shaped fibers coated with iron-protein complexes 4) pleural disease is common and includes *pleural plaques*, diffuse pleural thickening or benign pleural effusions Asbestos fibers have *translucent* fiber core

Acid-base disdorder pCO2 and HCO3

If pCO2 and HCO3 are going in OPPOSITE directions one elvated the other decreased = MIXED disorder.

what are the two most important opsonins

IgG and C3b

Cyclosporine

Immunosuppressant: antibiotic; inhibits IL−2 synthesis, suppresses T cells. Tox: HTN, hirsutism, nephrotoxicity (dose−limiting), seizures (in overdose). Not a myelosuppressant

Cocaine intoxication

Impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid ideations, angina, sudden cardiac death. Treatment: α-blockers, benzodiazepines. β-blockers not recommended.

Placenta accreta

Improper implantation of placenta into the myometrium with little or no intervening decidua prevents appropriate detachment after birth leading to lots of bleeding and retained placenta after delivery. Risk increases with previous C-section or placenta previa

Thiazide diuretics

Increases calcium reabsorption (can help prevent stone formation) Decreases potassium and magnesium

Desmopressin (DDAVP)

Increases circulating factor VIII, and secretion of vWF (both made by endothelial cells): Used for Mild hemophilia A and Type 1 von Willebrand dz its a synthetic analogue of ADH that does NOT induce v-constriction. only binds to the V2 receptor

lateral epicondylitis

Inflammation of the muscle attachment to the lateral epicondyle of the elbow. Often caused by strongly gripping. Commonly called tennis elbow. injuries the EXTENSOR muscles of the forearm (ie extensor carpi radialis brevis)

Focal Segmental Glomerulosclerosis (FSGS)

LM--sclerosis and hyalinosis (collagen stain) within some some glomeruli IF--negative EM--podocyte foot process effacement Associated with HIV, heroin use, sickle cell disease, african americans

Treatment of hepatic encephalopathy

Lactulose (to increase NH4 generation) which acidifies the gut lumen and rifaximin or neomycin (decrease intraluminal NH3 production) to decrease NH3 producting bacteria

broad spectrum anticonvulsants

Lamotrigine, Levetiracetam, Topiramate, Valproic acid: tx most seizure types (focal or generalized at onese). In contrast narrow spectrum: cabamazepine, gabapentin, phenobarbital, phenytoin) are generally favored for focal-onset seizures, although they can also be effective against focal seizures that evolve to B/L convulsive (tonic-clonic) seizures

Granuloma formation (in M TB)

Mycobacterium tuberculosis triggers CD4 T lymphocytes to release interferon-gamma, which leads to macrophage activation (improves intracellular killing ability) and differentiation into epithelioid histiocytes. These cells, along with horseshoe-shaped, multinucleated Langhans giant cells (fused, activated macrophages) are a key component of granuloma formation

MI on a graph with cardiac and vascular function curves

MI causes a sharp decrease in CO due to loss of function of a zone of myocardium. On a cardiac function curve, myocardial infarction would decrease both the slope and the maximal height of the line.

Methamphetamine toxicity

Methamphetamine is a stimulant that can lead to diaphoresis, hypertension, tachycardia, severe agitation, and psychosis. Patients with acute methamphetamine intoxication may abruptly develop severe agitation and use extreme violence. Maladaptive behavior, weight loss, perspiration, labile blood pressure, tachycardia, and pupillary dilation can also occur. Long term users commonly appear to be malnourished due to the appetite suppression caused by the drug. Patients typically have "meth-mouth" which is the presence of tooth decay due to decreased saliva production, bruxism, and poor dental hygiene.

tx for cryptococcal meningitis

Meningitis should be high on the differential when the triad of fever, nuchal rigidity, and altered mental status is present. Cryptococcal meningitis, an invasive encapsulated yeast most commonly occurring in those with AIDS, would have cerebral spinal fluid analysis displaying lymphocytic pleocytosis, low glucose, and increased opening pressure. Initial treatment consists of amphotericin B plus flucytosine.

Treatment for ADHD

Methylphenidate (Ritalin), Amphetamines (Dexedrine) indirect general agonist, reuptake inhibitor, also releases stores of catecholamines: NE, DA, Epi

Cant use anti-idiotypic antibody as a therapeutic reagent for the tx of a pt w/ multiple myeloma bc...

Myeloma myeloma has monoclonal plasma cells which make immunoglobulins

microsomal monooxygenase

Metabolizes steroids, alcohol, toxins and other substances rendering them soluble and easier to excrete. Unfortunately, most chemical carcinogens enter the body in an INACTIVE state as pro-carcinogens, which are then converted into ACTIVE carcinogens by cytochrome p450 monoocygenase.

third pharyngeal pouch derivative associated with Myasthenia gravis

Myasthenia gravis is associated with abnl of the thymus (thymoma or thymic hyperplasia) Also associated with muscle weakness, with the extraocular muscles commonly affected: ptosis and diplopia (weakness in her hands and "heaviness" in her eyelids) the muscle weakness worsens with activity and sx are worse at the end of the day the thymus is derived from the third pharyngeal pouch as are the inferior parathyroid glands for the pharyngeal pouch derivatives: ear, tonsil, bottom-to-top pg 607

Rabies virus

Negri bodies are characteristic cytoplasmic inclusions in neurons affected by rabies viru: has a long incubation period (wks-months), which allows for immunization after exposure. Causes fatal encephalitis w/ seizures, hydrophobia, hypersalivation, and pharyngeal spasm. Travels to CNS by migrating in a RETROGRADE fashion up nerve axons. pt exploring CAVES (in Q stem)

Cystine crystals

Six sided puffy crystals Colorless hexagonal crystals Dx: cyanide-nitroprusside test turning urine red

nucleotide excision repair

Specific endonucleases release the oligonucleotide-containing damaged bases; DNA polymerase and ligase fill and reseal the gap, respectively. (mutated in xeroderma pigmentosum)

Graves disease

Specific features: - pretibial myxedema - thickening of the skin over the skins - Graves opthalmopathy - expansion of the retro-orbital tissues displacing the globe forward aka proptosis Both of these features are directed to TRAb (thyrotropin receptor antibodies): TRAb binds and activates the TSH receptor causing an increased release of thyroid hormone by the thyroid gland which is responsible for the general sx of hyperthyroidism (fatigue, palpitations, WT loss, and insomnia). both are caused by an autoimmune response directed against the TSH receptor that results in the accumulation of glycosaminoglycans within the affected tissues.

Surgical shunt in which veins is needed to relieve the esophageal bleeding in an esophageal varicies.

Splenic and L renal vein

Watershed areas of the colon

Splenic flexure (IMA and SMA) Rectosigmoid junction (sigmoid artery and superior rectal artery) affected by ischemia

Toxic shock syndrome

Staphylococcus aureus -associated with prolonged use of tampon or wound packing - allows Staph a to replicate locally and release pyrogenic toxic SUPERANTIGENS (Toxic shock syndrom toxin-1) into blood. - Superantigens bind to MHC-II complex of APCs without processing and nonspcifically activate T-cells: release of inflammatory cytokines: hyptotension, high fever, organ failure, diffuse erythematous rash

Still murmur

Still murmur is recognized as the most common innocent murmur of early childhood. It is described as musical, vibratory, short, and high-pitched. Still murmur is a common, benign heart murmur heard in healthy children between the ages of 2 and 8 years.

Effects of low dose dopamine

Stimulation of D1 receptors in the renal and mesenteric vasculature ⤑ renal and mesenteric vasodilation ⤑ ↑ RBF and ↑ mesenteric blood flow. "Intermediate" doses of dopamine can stimulate β1 receptors ⤑ ↑ CO, ↑ pulse pressure, ↑ systolic BP. Remember, high doses of dopamine cause α1 stimulation ⤑ systemic vasoconstriction and ↓ CO (due to ↑ afterload).

DiaPEdesis (transmigration)

WBC travels between endothelial cells and exits blood vessles Facilitated by *PE*CAM-1 (CD31) PECAM-1 is found primarily at the peripheral intercellular junctions of endothelial cells

what muscle protects the brachial plexus when the clavicle fx?

Subclavius - rruns from the cartilage of the first rib to the underside of the clavicle between the costoclavicular and conoid ligaments. Fracture of the clavicle is common, and the subclavius will pull the lateral portion medial and anteriorly away from the brachial plexus.

subdural hematoma

Subdural hematoma can present with headache and gradual dementia following a head trauma. It will display a crescent-shaped hemorrhage area that crosses suture lines can occur in older patients following head trauma or due to shearing force from falls or other quick movements of the head such as experienced in a motor vehicle collision. Minor or severe head injuries can cause SDH, it can also occur spontaneously or after lumbar puncture, and it is associated with tearing of the bridging veins SDH can be acute, subacute, or chronic. Symptoms may include headache, confusion, apathy, memory loss, other dementia-like symptoms, and coma. Immediate neurosurgery consultation is needed. SDH is treated with surgical decompression and evacuation of blood. Chronic SDH with no significant mass effect or neurological signs or symptoms may be monitored for stability or resolution.

drugs for migraine prophylaxis

The use of prophylactic migraine therapy depends on the frequency and duration of attacks, effectiveness of abortive treatments, and the impact the headaches have on the person's quality of life. Drugs that have been approved for migraine prevention include amitriptyline, propranolol, timolol, divalproex, sodium valproate, and topiramate.

secondary structure of protein

The way in which the chain of amino acids of the polypeptides of a protein is folded. a change in glycine to alanine in collagen synthesis would change the secondary structure of the molecule

Cervical nerve roots (where do they exit?)

There are 8 cervical nerve roots The first 7 exit ABOVE their corresponding vertebrae (ie nerve root for C7 will exit between C6 and C7), but C8 exits below C7 and above T1. The remaining nerve roots exit below their corresponding vertebrae.

5 cofactors of pyruvate dehydrogenase

Thiamine Vit B1 Riboflavin Vit B2 Niacin Vit B3 Pantothenic Acid Vit B5 and lipoic acid

Chronic alcoholism and thiamine deficiency

Thiamine is a necessary cofactor for pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, and transketolase. Giving glucose to thamine-deficient pt can cause rapid depletion of the small amount of thiamine remaining in the circulation. This can result in neuronal injury within highly metabolic brain regions, leading to acute Wernicke encephalophathy (acute confusion, opthalmoplegia, and ataxia) Metabolism of ethanol by alcohol dehydrogenase and aldehyde dehydrogenase consumes NAD+ and increases NADH to NAD+ ratio - this inhibits all pathways requiring NAD+; this the entire citric acid cycle is inhibited

drugs associated with gout

Thiazide diuretics, loop diuretics, and niacin: lipid lowering drug

Dupuytren's contracture

Thickening and shrinking of the fascia of the palm with the 4th and 5th digits being drawn into a flexed position Highly heritable - runs in families Risk factors: increased EtOH and tobacco use, diabetes, Northern European descent, Males, older than 50 Tx: managment for pain, steroid injection, or surgery

acute stroke of the lateral medulla

This condition is called lateral medullary syndrome or Wallenberg syndrome. This occurs with occlusion or rupture of the vertebral artery or, less commonly, the posterior inferior cerebellar artery. Structures of the lateral medulla that can be lesioned include the spinal trigeminal nucleus and tract, spinothalamic tract, vestibular nuclei, hypothalamospinal tract, restiform body, and nucleus ambiguus, leading to the clinical signs in this patient. During embryonic development, the cranial end of the neural tube divides into 3 primary brain vesicles that then divide into 5 secondary brain vesicles. These differentiate into specific brain regions. The medulla, as the most caudal part of the brain, forms from the myelencephalon, the most caudal of these secondary brain vesicles.

cause and treatment of Hyperkalemia

Traumatic crush injuries can cause hyperkalemia due to potassium that is released from damaged muscles. Initial treatment of hyperkalemia if EKG changes are present include calcium gluconate, which stabilizes cardiomyocytes and prevents fatal arrhythmias. Potassium can be lowered transiently by shifting it intracellularly with insulin, bicarbonate and β-agonists ( activate the Na-K ATPase: exchanges Na for K, causing K to shift intracellularly), and removed with sodium polystyrene sulfonate, diuretics or dialysis.

Miliary tuberculosis

Type of tuberculosis caused by hematogenous spread of the disease, with a characteristic appearance similar to millet seeds, which are small, white grains subacute or chronic presentation with night sweats, Wt loss, and anorexia.

Porphyria cutanea tarda

Uroporphyrinogen decarboxylase deficiency SX: blistering cutaneous photosensitivity and hyperpigmentation. Light therapy is a C/I: ie methoxsalen and UV A

Amphotericin B

anti-fungal. HIGHLY TOXIC - infusin rxns (fever and chills) - nephrotoxicity - hypokalemia - hepatoxicity - gynecomasita - C/I with aminoglycosides (just like PCN) BINDS to ergosterol vs -azoles which INHIBIT synthesis of sterol (ergosterol)

Tricyclic Antidepressants (TCAs) toxicity

anti-muscarinic effects: dry mouth, tachycardia and dilated pupils. Cardiotoxicity is the most dangerous side effect

Folinic acid (Leucovorin)

can reverse the toxicity of methotrexate in non-cancerous cells in the GI mucosa and bone marrow if given at an appropriate time. Reduces the form of folic acid that does not require the action of dihydrofolate reductase

first line tx for trigeminal nerualgia

carbamazepine, a neuroleptic med that inhibits neuronal high-frequency firing by reducing the ability of sodium channels to recover from inactivation. Carbamazepine can cause bone marrow suppression; therefore complete blood cell counts should be monitored periodically

myxoma

benign tumor derived from connective tissue, with cells embedded in soft mucoid stromal tissue. These rare tumors occur most frequently in the left atrium. *amorphous extracellular matix with scattered stellate or globular myxoma cells within abundant mucopolysaccharide ground substance*

drugs that can cause delerium in the elderly

benzos, sedative-hypnotics, opioids, and anticholinergic meds

isoproterenol

beta 1 and beta 2 agonist increases contractilty and decreases systemic resistance

Conus medullaris syndrome (CMS)

can present similarly to cauda equina syndrome (CES) however, upper motor neuron signs, such as spasticity and hyperactive reflexes, are present. CES presents solely with lower motor neuron signs. CMS also typically presents more acutely with more back pain, saddle anesthesia, incontinence, and impotence than CES. CES typically presents more gradually with unilateral radicular leg pain and weakness. next step: order a stat MRI of the lumbar spine

Complement C5a

can enhance phagocytosis by macrophages, but it does so by binding to receptors on the phagocytes and stimulating them directly, NOT by coating the foreign cells. It is also a potent chemotactic agent, drawing more neutrophils and monocytes to the site of inflammation

Severe Tricuspid Regurgitation

can lead to R-sided HF, evidenced by jugular venous distension, hepatomegaly, LE edema, and the absence of pulomanary edema. Permanent pacemaker placement can cause TR because the RV lead passes through the tricuspid valve orifice and can disrupt valve closure.

RV infarction (R-sided HF)

can lead to shock via imparied forward blood flow to the L heart, which lowers L-sided preload (decreased pulmonary capillary wedge pressure) and decreases cardiac output. The reduced RV output also raises R atrial and central venous pressure

Vitamin E deficiency

can occur in indivudals with fat malabsorption. It is associated with increased susceptibility of the neuronal and erthrocyte membranes to oxidative stress (remember, it is important in glutathione). Clinical manifestations include ataxia, impaired proprioception and vibratory sensation and hemolytic anemia.

aspiration pneumonia

can occur when a foreign substance, such as vomit, is inhaled into the lungs frequently have R middle and lower lobe affected due to the straigther R mainstem bronchus

cyanide toxicity

can occur when patients are treated with nitroprusside (used in hypertensive emergencies). It presents with altered mental staus, seizures, lactic acidosis. Antidotal treatment invovles direct binding of cyanide ions (hydroxocobalamin), induction of methemoglobinemia (sodium nirite), and use of detoxifying sulfur donors (sodium thiosulfate- which actually helps rhodanese break it down)

Metalloproteinases

ZINC containing enzymes that degrade the extracellular matrix (collagen, laminin, fibronectin). They are essential for proper tissue remodeling during wound healing

Ascending cholangitis

a bacterial infection of the biliary tree, occurring most often as a result of a stone in the common bile duct, also known as choledocholithiasis. This biliary duct obstruction leads to bacterial proliferation with subsequent inflammation and infection, clinically manifesting as fever, jaundice, and right upper quadrant pain (Charcot triad).

Chest tube for drainage placement

a chest tube for drainage of pleural effusion is placed through the skin and subQ fat into the 4th or 5th intercostal space in the anterior axillary or midaxillary line. The tube traverses through the serratus anterior muscle, intercostal muscles, and parietal pleura.

Endometriosis

adhesions may interfere with ovulation and fallopian tube function resulting in infertility. Implants and adhesions involving the uterosacral ligament can result in a fixed

atrophic gastritis

can result in profound hypochlorhydria, inadequate intrinsic factor production, Vit B12 deficiency, and elevated methylmalonic acid levels. The reticulocyte count increases dramatically once B12 replacement therapy is initiated in an individual with pernicious anemia. Hemoglobin and RBC count levels rise more gradually and take up to 8 weeks to normalize

traztuzumab side effect

cardiotoxicity: decrease in myocardial contractility without cardiomyocyte destruction or myocardial fibrosis

General sensation from the anterior 2/3 of the tongue

carried by the mandibular division of the trigeminal nerve. Gustatory innervation of the anterior 2/3 of the tongue is provided by the chorda typmani branch of the facial n

Posterior limb of internal capsule

carries descending corticospinal tract and all ascending somatosensory pathways. Lesions leads to C/L hemiparesis and hemianesthesia

maxillary division of trigeminal nerve

carries mainly sensory fibers from the cheek, nares, upper lip and teeth, the pharyngeal palate, and the maxillary sinuses

sunlight exposure

catalyzes conversion of 7-dehydrocholesterol to cholecalciferol (vitamin D3) in the skin. Subsequent 25-hydroxylation in the liver 1-hydroxylation in the kidneys produces final 1,25-dihydroxyvitamin D active form. Vit D deficiency = bone pain/tenderness, muscle weakness/cramps, gait abnl, and increased fx risk

The Meissner corpuscle

detection of light discriminatory touch by the palms and digits of the hands and soles of the feet found in abundance within the superficial dermis of hairless integument tested by assessing if the pt can perceive a cotton swab stroked along the soles of the feet

Dihydrotestosterone (DHT)

develops prostate and male external genitalia deficiency in a 46 XY pt would lead to female external genitalia with male genital ducts

herpes zoster (shingles)

devleops due to reactivation of varicella zoster virus in the DRG. On light microscopy, intranuclear inclusions in keratinocytes and multinucleated giant cells can be seen.

proof reading of amino acids in a growing polypeptide chain

dictated by the interaction of the mRNA codon with the tRNA anticodon. tRNA that is mischarged with the incorrect amino acid (and not corrected by aminoacyl-tRNA synthetase proofreading) will incorporate the wrong amino acid into the growing polypeptide chain.

lead poisoning

difficulty concentrating , fatigue, mild hypochromic anemia and increased serum [creatinine]

eccentric ventricular hypertrophy

dilated cavity with relatively thin ventricular walls due to the addition of myocaridal contractile fibers in series in response to chronic volume overload. Chronic aortic regurgitiation can result from aortic root dilation and is common cause of eccentric hypertrophy

varicose venis

dilated, tortuous veins m/c found in the superifical veins of the leg. Caused by chronically increased intraluminal pressure and or loss of tensile strength in the vessel wall, leading to incompletece of the venous valves. Common complications: edema, stasis dermatitis, skin ulcerations, poor wound healing, and infections

cleft lip

due to maxillary prominence fails to fuse with the intermaxillary segment during the 5-6th week of embryonic development. Cleft palate occurs when the palatine shelves fail to fuse with one another or with the primary palate. Cleft lip and palate can occur together or independently.

IgE independent mast cell degranulation

due to meds: opioids, radiocontrast agents, and some abx (vancomycin) Sx: diffuse itching and pain, bronchospasm, localized swelling (urticaria)

Heparin induced thrombocytopenia and thrombosis

due to production of IgG antibodies against complexes of heparin and platelet factor 4. The Fc Component of these antibodies binds to platelets, resulting in widespread platelet activation and a prothrombotic state tx: argatroban

allocation bias

due to the way the pts were assigned to the tx and control groups. It may occur when pt are nonrandomly assigned to the study groups of a clinical trial

Prinzmetal variant angina

episodic, transient attacks of coronary vasospams (at rest and at night) temporary transmural myocardial ischemia with ST-segment elevation trigger: smoking, cocaine/amphetamine, dihydroergotamines/triptans tx: tobacco/drug cessation and vasodilator therapy (nitrates, Ca channel blocker)

third mandibular branch of the trigeminal nerve

exits the skull through the foramen ovale and innervates the *muscles of mastication*, including the masseter, the medial and lateral pterygoids, and the temporalis muscles and the single muscle that opens the jaw (lateral pterygoid)

Right-sided colon cancer

exophytic masses and present with occult bleeding and sx of iron deficiency anemia. L-sided colon cancers tend to infiltrate the intestinal wall and encircle the lumen, causing constipation and sx of intestinal obstruction. Rectosigmoid involvement often causes hematozchezia

cross-sectional study

exposure and outcome are measured simultaneously at a particular point in time ("snapshot study"): frequently used in surveys, mostly because it is inexpensive and easy to perform

long term treatment for specific phobias

exposure based cognitive-behavioral therapy where pt systematically confront thier feared objects or situations

acute intersitial nephritis (AIN)

fever, maculopapular rash and acute renal failure occuring 1-3 weeks after beginning a new med (abx, PPI, diuretics, NSAID, sulfonamindes, rifampin, beta-lactam abx) Peripheral eosinophilia, sterile pyruia, eosinophiluria, and WBC casts may also be seen leukocyte infiltration (lymphocytes, macrophages, eosinophils) and edema of the renal interstitum due to type I or type IV HSN rxn

Deformations

fetal structure anomalies that occur due to extrinsic mechanical forces. The pressure applied by the uterus is one of the most common deforming forces. Ex: uterine constraint on a fetus in breech position can cause developmental dysplasia of the hip

highly active antiretroviral therapy (HAART)

for HIV associated with *body fat redistribution* Subq lipoatrophy involving the face and extremities is associated with nucleoside reverse transcriptase inhibitors (esp stavudine and zidovudine) and protease inhibitors

Thoracentis procedure

for a large pleural effusion on the R, place the needle in the 9th intercostal space in midaxillary line for mid-axillary line the lungs end at 8th and pleura at 10th 6-8: midclavicular line 8-10: mid axillary line 10-12: midscapular (posteriorly)

Analgesic nephropathy

form of chronic kidney disease caused by prolonged heave intake of NSAIDs and or acetaminophen. Pathologic characteristics include chronic interstitial nephritis and a papillary necrosis - kidneys appear shrunked with irregular contours and distortion of the caliceal architecture. LABS: modest elevation in serum creatinine, mild proteinuria, and evidence of tubular dysfunction (polyuria, nocturia)

DVT (deep vein thrombosis)

formation of a blood clot in a deep vein of the body, occuring most commonly in the legs or thighs tx: embolectomy

The first step in tissue repair involves ________.

formation of the fibrin clot

Lysergic Acid Diethylamide (LSD)

hallucinogenic or "psychedelic" drug that produces hallucinations and delusions similar to those occurring in a psychotic state alteration of *sensory perception, mood, and thought patterns* Synesthesia is a blending of senses wherein pt report hearing colors or seeing sounds

indications of poor px in cirrhotic pt

hypoalbuminemia, elevated bilirubin levels, and prolong PT

Acute acalculous cholecystitis

is an acute inflammation of the gallbladder in the absence of gallstones. It typically occurs in critically ill patients (sepsis, severe burns, trauma, immunosuppression). manifests with fever, RUQ pain, leukocytosis. Inflamed and enlarged gallbladder.

alcohol based disinfectant

kills enveloped viruses (influenza) by dissolving thier outer lipid envlope. Nonenveloped viruses are less susceptible to some alcohol-based disinfectants bc they have no lipid envelope to target

drugs that can be used in pregnant females to decrease HTN

labetaol hydralazine top 2 are first line nifedipine methyldopa

Risk factors for penile squamous cell carcinoma of the penis

lack of circumcision, phimosis, HPV types 16 and 18, tobacco use, and carcinoma in situ

PPIs

parietal cells release H+ ions into the gastric lumen by means of the H/K ATPase, which requires hydrolysis of ATP and is therefore an active transport mechanism. PPIs suprress the activity of the gastric parietal cell H/K ATPase leading to an increase in the pH of the gastric lumen

acute hepatitis B virus

partially double-stranded DNA genome and contains a viral DNA polymerase with reverse transcriptase activity. Reverse transcriptase serves a crucial step in viral replication; it converts transcribed positive sense ss-RNA into the partially ds-DNA genome of viral progeny

Hepatitis B virus

partially ds-DNA genome and contains a viral DNA polymerase with reverse transcriptase activity. Reverse transcriptase serves a crucial step in viral replication; it converts transcribed positive sense ss-RNA into the partially ds-DNA genome of viral progeny

passage of the ureters

passes posterior to the ovarian (gonadal) vessels within the retroperiotoneum and cross anterior to the common/external iliac arteries to reach the true pelvis. within the TRUE pelvis the ureters lie anterior to the internal iliac artery and posterior to the uterine artery

Central lines

placed in the central venous system to allow rapid infusion of IV fluids, blood, and vasopressors. The catheter is usually inserted into the neck (internal jugular vein) or chest (subclavian vein) and is advanced until the catheter tip enteres the superior vena cava.

Platelet-derived growth factor (PDGF)

plays a role in CML

subthalamic nucleus

plays an important role in the modulation of basal ganglia output. lens-shaped structure located ventral (inferor) to the thalamus, dorsal (superior) to the substantia nigra, and medial to the internal capsule. Damage to this structure (due to lacunar stroke. which is often a consequence of long standing HTN and DM) may result in C/L hemiballism, characterized by wild, involuntary, large-amplitude firing movements of the proximal limbs (arm and/or leg) on one side of the body.

function of rough ER

plays an important role in the synthesis and modification of targeted proteins, including secretable polypeptide hormones.

Ricin

potent natural toxin that can cause lethal pulmonary edema and destruction. potent toxin that inhibits synthesis by cleaving the rRNA component of the eukaryotic 60S subunit best initial tx: supportive with airway support and adequate ventilation

Craniopharyngioma

remnants of rathke's pouch occurs in ages 5-15 and >50 suprasellar calcifications : causing hypo or hyperfunction of pituitary

mechanism by which inhaled particles are cleared from the bronchial tree

removed via proximal transport by ciliated epithelial cells (mucociliary clearance). Mucus-secreting cells are present to the level of the larger bronchioles, after which club cells become the prominent secretory cell type.

Methotrexate

the preferred disease-modifying treatment for patients with moderate to severe rheumatoid arthritis. Significant adverse effects include stomatitis (inflammation invovling the mouth or lips like an ulcer), bone marrow suppression, and liver function abnormalities.

Conditional Probability

the probability that one event happens given that another event is already known to have happened

proximal tubules

the proximal tubules reabsorb >60% of the water filtered by the glomeruli, regardless of the pts hydration status

pregnant woman with DVT has of cerebral infarction w/ hemiplegia: paralysis of one side of the body. How did the embolus end up in systemic circulation?

the pt had to have a patent foramen ovale: opening between the R and L chambers of the heart.

Glucose-6-phosphate dehydrogenase

the rate-limiting enzyme in the pentose phosphate pathway, the major source of *NADPH*, which is necessary to reduce glutathione but also the biosynthesis of cholesterol, fatty acids, and steroids.

Reid index

the ratio of the thickness of the mucous gland layer in the bronchial wall submucosa to the thickness of teh bronchial wall BETWEEN THE RESPIRATORY EPITHELIUM AND BRONCHIAL CARTILAGE. progressive mucous gland enlargment is the major contributer to this thickness increase in bronchitis.

trigger of DIC in pregnancy

the release of tissue factor (thromboplasin) from an injured placenta (placental abruption)

the splenic vein drains from

the short gastric vein

serum tissue transglutaminase

used to dx celiac dx

chi-square test for independence

used to evaluate the association between 2 categorical variables.

methoxsalen and UV A light (PUVA)

used to treat psoriasis, vitiligo, escezma, and some cutaneous lymophomas uses light therapy

Lamotigrine

used to tx partial and generalized seizures and acts by blocking voltage-gated Na channels. Stevens-Johnson syndrom and toxic epidermal necrolysis are rare, lifethreatening SE characterized by flu-like sx followed by widespread mucocutaneous epidermal necrosis

MAO inhibitors (MAOIs)

useful in pt with tx-resistant major depressive d/o with atypical features. increased appetite and sleep, leaden paralysis, rejection sensitivity and mood reactivity are hallmarks of atypical subtype

immunization against Hepatitis B virus

uses recombinant HBsAg to generate protective immunity against the virus. HBsAg is a collection of envelope glycoproteins found on the surface of HBV; these glycoproteins mediate attachment of the virus to hepatocytes and subsequent viral entry. Pt who adequately respond to the HBV vaccine generate *anti-HBs antibodies*, which bind to circulating viral particles and prevent attachment to and penetration of hepatocytes. Note: pt who have been immunized against HBV as well as those who have cleared the virus after acute infection wil have anti-HBs antibodies. These 2 populations are distinguished by the presence of anti-HBc antibodies, which are seen only in those who have been exposed to the virus (NOT in immunized pt)

causes of nosocomial bloodstream infection

usually associated with intravascular catheters, which allow skin commensals (Staph aureaus, coagulase-negative Staphylococci, Enterococci, and Candida species) to enter the blood stream

Esophageal adenocarcinoma

usually occurs in the distal esophagus due to underlying Barrett esophagus. Long-standing gastoesophageal reflux dz is the most important risk factor. Obesity, smoking, use of meds that lower esophageal spincter pressure, and consumption of foods containing nitroso compounds also increase the risk.

Lower motor neuron disease

usually presents with a foot drop and lower motor neuron signs of hyporeflexia and hypotonia In these patients with foot drop, the gait is high stepping. The hip flexors gradually become strong enough to compensate for the weakness and allow foot clearance. There may also be an audible slap as the foot hits the ground.

Henoch-Schonlein Purpura (HSP)

usually self-limited disease primarily of children. It is a systemic IgA vasculitis that presents with a purpuric rash, arthritis, GI pain and perhaps bleeding, and mesangial IgA deposition in the glomeruli producing hematuria.

Prinzmetal angina

vasospastic cornoary artery d/o: spontaneous episodes of angina in association with ST segment elevation on ECG. The cause is a transient reduction in the luminal diameter of a coronary artery due to spasm, leading to transient MI

vestibular dysfunction

Dizziness can be caused by several neurologic disorders affecting different areas of the nervous system. Oscillopsia: objects in the visual field appearing to oscillate, especially during rapid head movements., coupled with the positive Romberg test and a wide-based gait but normal limb coordination

Early onset Alz dz Late onset Alz dz

Early onset- 3 gene mutations: 1) Amyloid precursor protein APP on chromosome 21 2) presenilin 1 on chromosome 14 3) presenilin 2 on chromosome 1 Late onset: familial Alz dx: associated with apolipoprotein E4 genotype

Terminal deoxynucleotidyl transferase (TdT)

Enzyme that adds untemplated nucleotides at the V-D and D-J junctions of B and T cell receptor genes.

vessels involved in epidural vs subdural

Epidural: traumatic rupture of the middle meningeal artery, lens shaped, should be suspected after blunt-force trauma to the head followed by a lucid interval and subsequent oculomotor nerve palsy Subdural: bridging veins rupture, crescent-shaped,

Gravida/Para

G - number of times they have been pregnant ever P - number of babies delivered In Ob: it is split into 4 numbers: 1) Full term, 2) preterm, 3) Abortions-elective or spontaneous and total children 4) living at present. term - after 37wks premature - 20-37wks Example G4 P2 1 1 3 Is a female, not pregnant at present with 2 full term deliveries, 1 premie and 1 abortion with 3 living children.

Median nerve: hand muscles innervated

"The LOAF muscles": Lumbricals 1 and 2 Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis · Alternatively: LLOAF, with 2 L's, to recall there's 2 lumbricals. · To remember that these are the Median nerve muscles, think "Meat LOAF".

Vitamin B12 deficiency - associated with myelopathy aka Subacute combined degeneration

"combined" refers to myelin degeneration of both the ascending (dorsal columns) and descending (corticospinal tract) pathways. Loss of position and vibration sensation, sensory ataxia, and spastic paresis are common (from damage to the lateral corticospinal tracts: positive Babinski sign. Axonal degeneration of the peripheral nerves, leading to numbness, paresthesia, and depressed motor reflexes.

Relative risk reduction

(Absolute risk of control - absolute risk of treatment)/absolute risk of control

Net filtration pressure equation

(Glomerular capillary hydrostatic pressure - Bowman's capsule hydrostatic pressure) - (Glomerular capillary oncotic pressure - Bowman capsule oncotic pressure)

Moro reflex

(also known as the startle reflex) occurs when a supine infant's head drops 1-2 cm suddenly. The upper extremities AB-duct at the shoulders and extend at the elbows, followed by AD-duction with flexion. This reflex is present at birth and then disappears at approximately 3 months of age.

Direct thrombin inhibitors

(argatroban, -gatrans, -irudins) Directly inhibit thrombin by binding thrombin active site Uses = acute and chronic anti-coagulation *Argatroban--DOC to tx HIT* SE = bleeding PT and PTT are both increased

calmodulin

(calcium modulated protein) is a Ca-binding messenger protein that is present in all cells and mediates many of the regulatory effects of Ca2+. Calmodulin is important for excitation-contraction coupling in smooth muscle cells, which lacks troponin, unlike cardiac and skeletal muscles. In cardiac muscle, calmodulin is not directly involved in excitation-contraction coupling; rather, it helps regulate intracellular Ca activity and transcription factor signaling.

CT pulmonary angiography

(chest CT with contrast) is the most specific diagnostic test for pulmonary embolism. Possible risk factors include recent surgeries, estrogen replacement, obesity, decreased ambulation, hypercoagulable disorders, smoking, and previous incidences of deep venous thromboses.

Vitamin B12 deficiency

(cobalamin deficiency): frequently associated with pernicious anemia. Classic presentation of pernicious anemia: older, mentally slow woman of Northern European descent who is "lemon colored" (anemic and icteric), has a smooth, shiny tongue indicative of atrophic glossitis, and demonstrates a shuffling broad-based gait. Neurofindings: subacute combined degeneration of the dorsal columns and lateral corticospinal tract. Elevations in methylmalonic acid and homocysteine levels occur due to decreased metabolism of these molecules

Polyhydramnios

(excessive amniotic fluid) presents with increased abdominal circumference out of proportion to gestational age. The etiology is decreased fetal swallowing or increased fetal urination. Fetal anomalies associated with impaired swallowing include GI obstruction (duodenal, esophageal, or intestinal atresia) and anencephaly. Causes of increased fetal urination include high cardiac output due to anemia or twin-twin transfusion. Materal diabetes and multiple gestations tend to cause milder polyhydramnios.

renal artery stenosis

(severe HTN, abd burits) causes decreased renal perfusion which activates RAAS. increased renin = increased production of Ang I and Ang II, which causes increased peripheral resisitance and elevated systemic blood pressure. Increased aldosterone secretion causes increased renal Na+ reabsp and K+ and H+ excretion = hypokalemia and metabolic alkalosis

Hunter's syndrome

* Symptoms: *Mild Hurler's (developmental delay, airway obstruction due to macroglossia, gargoylism, hepatosplenomegaly), hearing loss, aggressive behavior, no corneal clouding or mental retardation.* Lab Values: *Increased heparan sulftae, dermatan sulfate.* Pathophysiology: *X-linked recessive. Defect in iduronate sulfatase.*

polymyositis

* Symptoms: *Symmetric axial/proximal muscle weakness.* Lab Values: *Anti-Jo-1 antibodies, ANA+, elevated CK and aldolase* Pathophysiology: *CD8+ T-cell induced injury to myofibers.* Treatment: *Steroids over-expression of MHC class 1 on the sarcolemma leading to infiltration with CD8+ T lymphs and myocyte damage.

Two cases of cellulitis

*Nonpurulent cellulitis*: skin warmth, edema, erythema, with NO FLUCTUANT NODULES. Caused by beta-hemolytic streptococci (groups A,B,C,G,and F) group A accounts for the majority *Purulent cellulitis*: painful, fluctuant nodule in the dermis and subQ tissue with or without surrounding erythema. The most common cause is Staph aureus; strains that express the virulence factor Panton-Valentine leukocidin are likely to cause skin abscess.

Wallenberg's Test

*Test vertebral artery insufficiency* - supine position flexion pts neck, holding it for 10 sec. then extends the neck holding it for 10 sec. (+) test = pt complains of dizziness, visual changes, lightheadedness, or eye nystagmus occurs *Underberg's test: same thing neck backward bent w/ head fully rotated to either side, if pt has neuro/vascular symptoms then HVLA contraindicated

cystic medial degeneration (necrosis)

*classic for aortic dissection* as it weakens the aortic wall and allows a small intimal tear to readily propagate. Collagen, elastin, and smooth muscle are replaced by a basophilic mucoid extracellular matrix with elastic tissue fragmentaion and cystic collections of mucopolysaccharide

Sporotrichosis

- *Sporothrix schenckii* - Dimorphic fungus; in soil and on plants (rosebushes and mulches); worldwide - Occupational disease of *gardeners, florists, farmers etc* days to weeks after cutaneous inoculation, a papule develops at the site of inoculation produces hyphae at room temp and exists as a yeast at 37C/ 98.6F in vitro and in vivo

Acute Intermittent Porphyria (AIP)

- AD - HMG synthase/porphobilinogen deaminase gene deficiency - Urine turns dark upon standing, abdominal pain, agitation, tachycardia, breathing problems, N/V, confusion, lower extremity weakness, peripheral neuropathy, neuropsych sx - Haploinsufficiency - tx: IV glucose or heme preparations which donwnregulates ALA synthase activity Giving dextrose inhibits peroxisome proliferator-activated receptor-gamma, a transcription factor that induces synthesis of ALA synthase

Primary Myelofibrosis

- Chronic myeloproliferative disorder associated with bone marrow fibrosis Extramedullary hematopoiesis leads to marked expansion of the splenic red pulp with hematopoietic progenitor cells and results in massive splenomegaly. Pt also usually have hepatomegaly, cytopenias, and peripheral smear abnormalitis (dacrocytes, nucleated red cells, immature granulocytes) - Pancytopenia is common - Symptoms include enlarged spleen, fatigue, pruritus, bone pain, weight loss, infection, bleeding, and cachexia - Splenectomy may be used to control significant problems - Nursing care focused on nutrition, pain control, fatigue, and body image disturbance

Decreased mixed venous oxygen/ Venous Admixture

- Clinically the patient's lung must add more oxygen to the blood; the presence of pulmonary disease may prevent this. - Heart failure is most common cause. - Clinically, patient presents signs and symptoms of CHF and/or underlying pulmonary disease - A cause of Hypoxemic Respiratory Failure B/L crackles, decreased CO, severe CP, decreased BP, ST segment selevation in leads V4-V6

Typhoid strains of Salmonella

- Contain capsular antigen (Vi) that inhabits neutrophil phagocytosis, neutrophil recruitment, and macrophage-mediated destruction. - Thus these strains are able to undergo extensive replication within the intracellular space of macrophages with subsequent spread through the lymphatic and reticuloendothelial system, leading to a widespread systemic disease (typhoid fever)

mutation associated with Cystic fibrosis

- DeltaF508 is the mc mutation in the cystic fibrosis transmembrane regulator (CFTR) protein in pt with cystic fibrosis. - This mutation leads to protein misfolding and failure of glycosylation, followed by proteasome-mediated degradation and significantly decreased number of transmembrane CFTR proteins - Lumacaftor and ivacaftor are CFTR-modulating medications that cen potentially help pts with CF by restoring CFTR proteins to the membrane and also by enhancing protein function (chloride transport) at the membrane respectively. The combo of these 2 drugs in pt with homozygous mutation (deltaF508) has improved forced expiratory volume (FEV) and decrease rates of pulmonary exacerbations.

Sjogren's syndrome

- Immune mediated destruction of the lacrimal and salivary glands - Can occur as primary disease or secondary with other autoimmune disorders (SLE, RA) Features: - Dry eyes (keratoconjunctivitis sicca) grittty sensation - Dry mouth (xerostomia), insufficient saliva production - Dry skin (xerosis) - Raynaud phenomenon - Cutaneous vasculitis - Positive anti-Ro (SSA) &/or anti-La (SSB) (SSA/SSB = Sjogren syndrome (antibody A/B) Complications: - *Non-Hodgkin lymphoma: marginal zone lymphoma, diffuse Large B-cell lymphoma* - Corneal damage - Dental caries (also higher rates of thrush, and other odontogenic infections: osteomyelitis of the mandible) Can also have loss of vaginal lubrication in female pt is associated with dyspareunia (painful intercourse) and frequent infections (candidal, bacterial) Biopsy of the salivary glands is diagnostic and shows *lymphocytic infiltrate*, often with germinal centers.

loperaminde

- anti-diarrheal - agonist at mu opiod receptors, slows gut motility. POOR CNS Penetration!

Upper motor neuron lesions

- cause C/L spastic rigidity, hyperreflexia, and paresis - Can affect any part of the pyramidal motor system, including the corticospinal tracts of the spinal cord; medulla, pons, and midbrain; the internal capsule; and the precentral gyrus (primary motor cortex)

ankylosing spondylitis

- chronic inflammatory d/o of the sacroiliac joints and axial skeleton. - common in young, middle-aged men and presents with middle-aged men and presents with morning stiffness and low back pain. - destruction of articular cartilage with resulting stiffness and fusion of axial joints. - Ankylosing spondylitis, reactive arthritis, arthritis associated with inflammatory bowel dz, and psoriatic arthritis are *seronegative spondyloarthropathies* due to absence of serum rheumatoid factor. Pt with these dz have a higher incidence of *human leukocyte antigen (HLA) B27* allele compared to the general population.

4 month old w/ AR skeletal dysplasia involving abnl endochondral bone formation. Genetic analysis shows null mutations in a gene for a protein that controls the traffic of vesicles into the Golgi complex. Electron microscopy of cells will show?

- dilated rough endoplasmic reticulum Massively dilated RER is an ultrastructural indication of improper processing associated with a d/o where a mutation prevents proper folding and extrusion of protein products.

Histoplasma capsulatum

- dimorphic fungus that exists as a small, ovoid yeast at tissue temperatures. - replicates within macrophages and spreads through the lymphatic and retuculoendothelial system - ImmunoCOMPETENT pt: have asx pulmonary infection - ImmunoCOMPRIMISED pt: develop disseminated disease to the liver, spleen, and bone marrow

Chikungunya

- mosquito borne viral illness (*aedes* type) - S america / *caribbean* - high fever, *polyarthalgias*, *low WBC* low platelets elevated LFTs - *maculopap rash* - cervical LAD - dx: serology - tx: supportive - can rarely cause persistent arthritis

General features that aid in localizing a transverse spinal cord section:

- moving rostrally, spinal levels have increasing amounts of white matter, decreasing amounts of gray matter, and are more oval-shaped - lower cervical and lumbosacral regions have large ventral horns - thoracic and early lumbar sections contain lateral gray matter horns (intermediolateral cell columns) - Gracile and cuneate fasciculi are present above the T7 spinal level, whereas only the gracile fasciculus is present below this level

Mesoderm derivatives

- muscle (skeletal, cardiac, and smooth) - CT, bone, cartilage - Serosal linings (periotoneum) - CV and lymphatic system - Spleen and Hemopoietic cells - Kidney & ureters, internal genitalia - adrenal cortex

Menopause

- occurs on average at age 51 - Diagnosable retrospectively after 12 months of amenorrhea - An elevated serum FSH level confirms the dx (due to resistant ovarian follicles and lack of feedback from inhibin) - Absence of menstrual cycles is associated with hypoestrogenic sx: hot flashes, vaginal dryness

Mallet Finger

- rupture of the terminal extensor tendon at the DIP joint. - It results from a traumatic blow to the distal phalanx resulting in hyper flexion of the extensor digitorum tendon - may be assoc with an avulsion fx of the distal phalanx - seen in ball sports (softball, basketball, football, volleyball) - PEx: fingertips that rests in slight flexion and the pt will be unable to actively extend the DIP.

management of somatic symptom disorder

- schedule regular visits with the same doctor - limit unnecessary workup and referral to specialists - Reassure that serious illness has been ruled out - Legitimize symptoms but make functional improvement the treatment goal: - decrease stress - improve coping strategies - Mental health referral only once physician-pt relationship is well established

Physostigmine

-Anticholinesterse - increases ACh -Used in anticholinergic toxicity -Crosses the blood-brain barrier (CNS) - used in glaucoma

Chloramphenicol

-Blocks peptidyltransferase at 50S ribosomal subunit. -Bacteriostatic. -Use: Meningitis (Haemophilus influenzae, Neisseria meningitidis, Streptococcus pneumoniae) and Rocky Mountain spotted fever (Rickettsia rickettsii). Limited use owing to toxicities but often still used in developing countries because of low cost. -Toxicity: anemia (dose dependent), aplastic anemia (dose independent), gray baby syndrome (in premature infants because they lack liver UDP-glucuronyl transferase). -Resistance: plasmid-encoded acetyltransferase inactivates the drug.

Pasteurella multocida

-Cellulitis, osteomyelitis -Animal bite, cats, dogs - Gram (-) coccobacilli, nonmotile, and nonspore-forming

examples of multifactorial disorders

-Cleft palate -Cleft lip -Coronary artery disease -HTN -diabetes mellitus

Romano-Ward syndrome

-Congenital long QT syndrome -Autosomal dominant, pure cardiac phenotype (no deafness).

Jervell and Lange-Nielsen syndrome

-Congenital long QT syndrome -Autosomal recessive, sensorineural deafness

IL-4

-From Th2 cells -Induces differentiation into Th2 cells which produce: IL-4, IL-5, IL-13 -Promotes growth of B cells. -Enhances class switching to IgE and IgG.

Heroin overdose

-Narcotic: opiod- resp depression, seizures, dysrhythmias, euphoria, then anxiety, sadness, insomnia, sexual indifference, pinpoint pupils, stupor, coma.... -Maintain airway, control seizures, check LOC & VS, start IV, bolus glucose, tx of hyperthermia, narcan for resp depression... N, rhinorrhea, HTN, and tachycardia

major depressive disorder with atypical features

-SPECIFIER status applied when individual meets criteria for maj. dep. epis. and also has symptoms of MOOD REACTIVITY--mood brightens in response to potential positive events--plus 2 or more of 4 symptoms: 1) significant weight gain or increase in appetite 2) hypersomnia (Sleeping too much) 3) leaden paralysis (heavy feeling in arms/legs) 4) long-standing pattern of being acutely sensitive to interpersonal rejection *disproportionate number of individuals w/atypical features are female and tend to show suicidal thoughts *linked to mild form of bipolar disorder associated w/hypomanic rather than manic episodes *those with atypical symptoms are more likely to respond to MAO inhibitors than nonatypical

IL-2

-Secreted by all T cells - signal for survival, activation, and proliferation of T cells. -Stimulates growth of helper, cytotoxic, and regulatory T cells, and NK cells.

IL-3

-Secreted by all T cells -Supports growth and differentiation of bone marrow stem cells. Functions like GM-CSF. - involved with growth and developemnt

IL-1

-Secreted by macrophages, PMNs, endothelial cells, and some epithelial cells. - pro-inflammatory -Also called osteoclast-activating factor. Causes fever, acute inflammation. -Activates endothelium to express adhesion molecules E&P selectin - acts as a pyrogen - stimulates acute phase protein production by the liver -Induces chemokine secretion to recruit WBCs.

Acute hemolytic transfusion reaction

-Type II hypersensitivity reaction. -Intravascular hemolysis (ABO blood group incompatibility) or extravascular hemolysis (host antibody reaction against foreign antigen on donor RBCs). -Presents with fever, chills, hypotension, tachypnea, tachycardia, flank pain, hemoglobinuria (intravascular hemolysis), jaundice (extravascular). may also develop DIC and renal failure

Pilocytic astrocytoma

-benign tumor of astrocytes -MC CNS tumors in children -usu arises in cerebellum -PIC - CT - cystic lesion with mural nodule growing on wall -PIC - HISTO - Rosenthal fibers - thick eosinophilic processes -GFAP pos

Rodenticides

-contain brodifacoum - long acting 4-hydroxycoumarin derivative. A pt who has ingested a quantity of rodenticide sufficient to cause coagulopathy and abnormal bleeding (similar to warfarin toxicity) requires immediate treatment with fresh frozen plasma in addition to vitamin K

Interstitial pulmonary fibrosis

-from tissue repair process following inflammation or necrosis of tissue -can be idiopathic Honeycomb lung on CT/CXR has greater maximal expiratory flow rate than predicted because of increased radial traction on airways

pulmonary infarcts

-typically hemorrhagic (red) and wedge-shaped in the periphery of the lung. IVDU are at increased risk of tricuspid valve endocardidits which can cause multiple septic pulmonary infacts due to embolization of tricuspid valve vegetation framents

Behcet syndrome

1) Recurrent aphthous ulcer 2) genital ulcers 2)uveitis and can present with erythema nodosum - Due to immune complex vasculitis involving small vessels - seen after viral infection - seen in (prevalent) people of Turkish and Middle Eastern descent autoimmune vasculitis

Salmeterol, formoterol

-β2-agonists -Long-acting agents for prophylaxis. -Adverse effects are tremor and arrhythmia.

IgA nephropathy

1 hematuria after an upper respiratory tract infection 2 less than 5 days. 3 Serum complement levels are normal

Handling medical nonadherence

1) acknowledge the difficulty of taking meds daily, address misunderstandings about tx in a NON-judgemental manner take a pt centered approach in discussing treatment of nonadherence

what 3 enzymes are associated with biotin

1) pyruvate carboxylase: pyruvate to oxaloacetate (gluconeogenesis) 2) Acetyl-CoA carboxylase: Acetyl-CoA to malonyl-CoA (fatty acid syn) 3) Propionyl-CoA carboxylase: Propionyl-CoA to methylmalonyl-CoA (fatty acid oxidation)

3 mitochondrial syndromes

1. Leber hereditary optic neuropathy: leads to B/L vision loss 2. Myoclonic epilepsy with ragged-red fibers: myoclonic seizures and myopathy associated with exercise. Skeletal muscle biopsy shows irregularly shaped muscle fibers (ragged red fibers) 3. Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS): sezuire disorder with stroke-like episodes with residual neurological deficits, muscle weakness, elevated serum lactate mitochondrial dz affect both male and female offspring with equal frequency (100%) but there are variable degrees of severity (heterosplasmy)

C/I for oral contraceptive pills

1. Prior hx of thromboembolic event or stoke 2. Hx of an estrogen-dep tumor 3. Women over 35 who smoke heavily 4. Hypertriglyceridemia 5. Decompensated or active liver disease (would impair steroid meatabolism) 6. Pregnancy

5alpha-reductase deficiency

5alpha-reductase converts testosterone to DHT (dihydrotestosterone), which mediates development of the external genitalia in the male fetus. Male neonates with 5alpha-reductase deficiency are born with feminized external genitalia that typically masculinize at puberty. A small phallus and hypospadias are common. *normal serum testosterone levels

MEN1

3Ps primary hyperParathyroidism: m/c manifestiation of MEN1 with nearly 100% penetrance by age 40-50yrs. If symptomatic: kidney stones, constipation, psychosis, and osteoporosis Pituitary adenomas: seen in 20% of pt with MEN1. Prolactinoma is the m/c and can cause bitemporal hemianopsia due to optic chiasm compression; however, somatotroph, corticotroph, gonadotroph, and clinically nonfunctioning tumors can also occur Pancreatic islet tumors: 1/3 of pt may have functional pancreatic/gastrointestinal endocrine tumors, w/ Zollinger-Ellison (gastrinoma) syndrome being the most common. Symptomatic insulinomas also occur less freq, while vasoactive intestinal peptide tumors (VIPoma) and glucagonomas are rare.

Work of Breathing (WOB)

A common term used to express extra respiratory effort in a variety of pulmonary conditions. minimized in pt with increased elastic resistance (pulmonary fibrosis) when their resp rate is high and tidal volume is low (fast, shallow breaths) vs pt with dz that increase airflow resistance (asthma, COPD) breathe at a lower respiratory rate and higher tidal volume shlow, deep breaths to minimize the work of breathing

Epiglottitis

A disease in which the epiglottis becomes inflamed and enlarged and may cause an upper airway obstruction. thumb sign Haemophilus influenzae type B

parathyroid hormone

A hormone of the parathyroid gland that regulates the metabolism of calcium and phosphorus in the body. works by upregulating RANKL which would cause paracrine stimulation of osteoclasts by osteoblasts

oxytocin

A hormone released by the posterior pituitary that stimulates uterine contractions during childbirth and milk ejection during breastfeeding. syn in the HYPOTHALAMUS

sickle cell disease

A human genetic disease caused by a recessive allele that results in the substitution of a single amino acid in the hemoglobin protein; characterized by deformed red blood cells that can lead to numerous symptoms. caused by a point mutation of the hemoglobin β gene on chromosome 11p15.5. This mutation causes a substitution of valine for glutamic acid on the β-globulin gene. This substitution causes the deoxygenated form of hemoglobin to distort the red blood cell into the classic sickle shape Initial tx for sickle cell crisis: hydration, antibiotics, analgesia, respiratory support, and possible exchange transfusion

alanine

A major amino acid responsible for transferring nitrogen to the liver for disposal. During the catabolism of proteins, amino groups are transferred to alpha-ketoglutarate to form glutamate. Glutamate is then processed in the liver to form urea, allowing for disposal of nitrogen in humans. After alanie is transanimated, it can be used for gluconeogenesis.

predictive value positive

A measure of the predictive value of a reported case or epidemic; the proportion of cases reported by a surveillance system or classified by a case definition which are true cases.

Treatment options for scoliosis

A mild idiopathic scoliosis of < 20° should be carefully watched with serial radiographs every 6-12 months. Bracing is appropriate for curves of 20°-45° and surgery should be considered for curves > 45°. All patients should be evaluated for sacral base unleveling, a short leg, and muscle imbalances before being given an idiopathic scoliosis diagnosis.

what is a pt at risk of developing with gestational HTN?

A patient with gestational hypertension has an increased risk for developing preeclampsia. Women with preeclampsia are at an increased risk for life threatening events including placental abruption, acute renal failure, cerebral hemorrhage, hepatic failure, pulmonary edema, disseminated intravascular coagulation, and progression to eclampsia.

anterior cruciate ligament injury

A patient with lateral knee pain with such a mechanism (sudden knee hyperextension in a low-velocity setting or quick deceleration/significant rotation) is at risk of ACL sprain and thus requires imaging to assess the degree of injury. Quick special tests that can be done on exam are the Lachman and anterior drawer tests. Counterstrain can be used to treat knee pain in acute and chronic settings. To treat any tender point, the physician should take the tender point to its position of maximum ease. For the ACL, the tender point is located in the superior aspect of the popliteal fossa either medial or lateral to the hamstring tendons.

dissociative identity disorder

A rare dissociative disorder in which a person exhibits two or more distinct and alternating personalities. Also called multiple personality disorder. associated with severe trauma

conversion disorder

A rare somatoform disorder in which a person experiences very specific genuine physical symptoms for which no physiological basis can be found. diagnosed in people who have one or more symptom of altered motor or sensory function (ie. blindness, weakness, numbness, seizure, etc) not explained by another medical or neurological condition. Conversion disorder presents with neurological symptoms that are incompatible with any known medical diagnosis and usually coincide with periods of increased stress Patients suffering from conversion disorder are commonly unaware that their physical symptoms are due to some inner psychological conflict. Psychotherapy is the treatment of choice for these patients because it guides them in making this connection. Once the patient is aware of this, the psychologic currency of the symptom loses value, and the symptom may be allowed to improve.

Volume of distribution (Vd)

A ratio used to estimate the distribution of a drug within the body relative to the total amount of fluid in the body. It is calculated as the amount of drug administered divided by the plasma concentration of the drug (Co) Vd= dose/Co a large Vd indicates that the drug is distributed widely throughout the body. Thus a smaller % remains in the plasma (small Co), making the plasma concentration relatively low.

Jersey Finger

A rupture of the flexor digitorum profundus tendon from the distal phalanx because of the rapid extension of the finger while actively flexed. pain and tenderness over the volar distal finger. The finger will lie in slight extension, and the pt will be unable to actively flex the DIP joint

locus coeruleus

A small area of the brain that seems to be active in the regulation of emotions. Many of its neurons use norepinephrine. located in the dorsal pons

Osler-Weber-Rendu syndrome

AD - recurrent epistaxis, mucocutaneous telangiectasia, and iron deficiency anemia Hereditary hemorrhagic telengiectasia *Telengiectasias* epistaxis, GI bleed, hematuria AV malformations (bleeding) in the lungs, brain, and liver Aneurysms (bleeding) can also have GI bleeding which is more common in pt over 40

Huntington's disease

AD caused by a mutation in chromosome 4: trinucleotide repeats result in impaired axonal transport and decreased and ineffective transcription of a number of genes CAG repeat due to instability during paternal meiosis Genetic disorder that causes progressive deterioration of brain cells. caused by a dominant allele. symptoms do not appear until about the age of 30. can pass it on to your children chorea: involuntary, jerky movements of face and extremities Behavioral: aggressiveness, depression progressive dementia Imaging: caudate atrophy with enlargement of the lateral ventricles affects the Caudate nucleus and putamen, leading to chorea, dementia, and death. pt usually have an affected parent inhibitory GABAergic neurons in the caudate are most suscptible

pt with a AV fistula you would expect to have

AV Fistulas re-rout blood from the arterial system to the venous system, by-passing the Arterioles = Increase PL --------> INCREASE VR. All in all = *Increase CO*

Neurofibromatosis type 1

AD caused by mutations in NF1 tumor suppressor gene on chromosome 17 inheritance: single-gene AD NF-1 has high penetrance but the presentation is highly variable develop: 1) numerous cutaneous neurofibromas made of Schwann cell which are derived from neural crest cells - short, sessile, or pedunculated lesions that vary in size. multiple and distributed throughout the body 2) Cafe-au-Lait spots: hyperpigmented lesions with either smooth or irregular borders. presence of axillary or inguinal freckels is another feature. 3) Lisch nodules: pigmented, asx hamartomas of the iris. Optic nerve gliomas may occur and cause visual loss 4) bony abnl: sphenoid dysplasia, congenital *pseudoarthrosis*, and scoliosis 5) other associated tumors: meningiomas, astrocytomas, gliomas, and pheochromocytomas

Myotonic Dystrophy

AD, CTG trinucleotide repeat Frontal balding, testicular atrophy, muscle wasting (no fatty deposits) sustained muscular contractions, or myotonia. Myotonic dystrophy type 1 is a result of a trinucleotide repeat expansion, and thus exhibits anticipation, which is an important feature of all trinucleotide repeat disorders. In DM1, anticipation occurs due to instability during the maternal meiosis, meaning that it will occur when inherited from the mother

Small cell carcinoma of the lung

ADH (hyponatremia), ACTH (ectopic Cushing's), SIADH: hyponatrtremia, decreased serum osmolaity, and urine osmolality >100 mOsm/kg H20 round cells with little cytoplasm that are 2x the size of lymphocytes. They are arranged in infiltrating sheets and have neither glandular nor squamous organizations neuroendocrine orgin (neural cell adhesion molecule, chromogranin, synaptophysin)

Central Diabetes Insipidus

ADH deficiency due to hypothalamic or psoterior pituitary pathology (tumor, trauma, infection, inflammation) Treatment is with desmopressin, an ADH analogue.

Primary biliary cholangitis

AI dz presents classically in middle-age F Sx: pruritus, jaundice, dark urine, light stools, and hepatosplenomegaly pt often have concurrent AI dz (CREST syn)

Primary central nervous system lymphoma

AIDS defining illness confusion, memory loss, seizures mass lesions on MRI can be seen in transplant recipients; multiple brain lesions involving the deep grey matter, white matter, and cortex

Atrial natriuretic peptide (ANP) and Brain natriuretic peptide (BNP)

ANP and BNP are secreted by the atrial and ventricular cardiomyocytes in response to myocardial stretching induced by hypovolemia. These natriuretic peptides inhibit the RAAS and stimulate peripheral vasodilation and increased urinary excretion of Na and H2O. *Neprilysin inhibitors (sacubitril)*: prevent the degradation of ANP and BNP, enhancing their effect in HF

Kartagener's syndrome

AR a form of primary ciliary dyskinesia characterized by: - situs inversus (reversed R/L positioning of internal organs - ex: cardiac point of maximal impulse is at the 5th R intercostal space) from impaired ciliary movement during embryogenesis - chronic sinusitis - bronchiectasis - infertility in men and women the latter 2 are from impaired mucociliary clearance due to mutations that impair the structure or function of cilia: ie failure of dynein arms to develop normally

Homocystinuria

AR defect in Cystathione beta-synthase resulting in an inability to form cysteine from homocysteine, requires Vit 6 (pyridoxine) as a cofactor cystine becomes essential in affected pt, and homocysteine buildup leads to elevated methionine. Homocysteine is prothrombotic, resulting in premature thromoboembolic events (atherosclerosis, acute coronary syndrome) in these pt. HIGH RISK OF thromboembolic occlusion in brain, kidney, and heart (major cause of morbidity and mortality) Lens subluxation, *thrombosis*, *marfanoid habitus*, intellectual disabiliity Tx: pyridoxine

Cystinuria

AR due to defective dibasic amino acid (Cystine, Orthithine, Lysine, and Arginine (COLA)) transport in intestinal and proximal renal tubular epithelial cells. Recurrent stone formation at a young age due to decreased reabsorption of cysteine from the urine. Urinalysis: hexagonal cystine crystals, and the sodium cyanide-nitroprusside test can be used to detect excess cystine in the urine

Attributable risk

AR = [a/a + b] − [c/c + d] or AR= [(RR-1)/RR] x 100% difference between risk in the exposed and risk in the unexposed

ApoC-II deficiency

AR d/o where ApoC-II is absent. Clearance of chylomicrons from the blood is greatly impaired and TAGS accumulate in plasma. VLDL may be elevated. Dx: in children or adults based on recurrent attacks of pancreatitis or detection of milky fasting plasma on screening. Sx: eruptive xanthomas over the UE and LE and hepatosplenomegaly

Maple Syrup Urine Disease

AR defective breakdown of branched-chain aa (leucine, isoleucine, and valine). Degradation of theses aa involves transamination to their respective alpha-ketoacids, which are metabolized by several enzymes: branched-chain alpha-ketoacid dehyrogenase complex (BCKDC) Mutations in MCKDC result in accumulation of branched-chain aa in serum and peripheral tissues: Neurotoxicity-seizures, irritability, lethargy, poor feeding. A metabolite of isoleucine gives urine a distinctive sweet odor. MSUD can lead to brain swelling or death if untx. Branched-chain alpha-ketoacid dehydrogenase requires 5 cofactors: Tender Loving Care For Nancy Thiamine Lipoate Coenxyme A FAD NAD some pt improve with Thiamine tx but most require restriction of leucine, isoleucine, and valine

cystic fibrosis

AR disease caused by mutations in the (delta F508) CF transmembrane conductance regulator protein. The channel pore opens after binding *2 ATP molecules*, allowing transport of chloride ions down the electrochemical gradient. Defects in the CFTR reduce Cl secretion and increases Na absorption by the respiratory epithelia, resulting in dehydrated mucus. When saline is applied to the nasal mucosa, the increased Na absorption in pt with CF causes more negative nasal transpithelial potential difference, which can be used to dx CF.

Classic galactosemia

AR disorder Leads to complete enzymatic absence of galactose-1-phosphate uridyl transferase. Newborns preset within days of birth with jaundice, vomiting, and hepatomegaly. In general, most enzyme deficiency conditions follow AR inheritance pattern whereas diseases due to defective noncatalytic proteins follow an AD pattern.

Ataxia Telangiectasia

AR disorder, cerebellar ataxia, telangiectasias, and increased risk of sinopulmonary infections constitute a characteristic triad of ataxia telangiectasia. AR, Defect is in gene that codes for ATM gene - plays a role in DNA break repair. Manifests as an IgA deficiency and predisposes to infections of the upper and lower airways.

Chediak-Higashi syndrome

AR syndrom consisting of immunodeficiency, albinism, and neurologic defects that is most commonly diagnosed in childhood. Neurologic defects associated with this condition includeL nystagmus, peripheral and cranial neuropathies. Immunodeficiency is due to a defect in neutrophil phagosome lysosome fusion. Causing abnl giant lysosomal inclusions that are visible on light microscopy of a peripheral blood smear. The immunodeficiency leads to recurrent pyogenic infections most commonly cause my Staphylococci and Streptococci. Abnl melanin storage in melanocytes causes partial oculocutaneous albinism.

Wide fixed and split S2-

ASD - can produce chronic pulmonary HTN as a result of L-to-R shunting. Eisenmenger syndrom is the late onset reversal of L-to-R shunt due to pulmonary vascular sclerosis resulting from chronic pulmonary HTN Closure of the ASD may be req to prevent irreversible pulmonary vascular sclerosis and permanent Eisenmenger synd

Innominant Outflare

ASIS lateral, I/L posterior innominant rotations, ischial tuberosity medial, increased distance to umbilicus + flexion test, ASIS restricted to compression

Innominant Inflare

ASIS medial, ischial tuberosity lateral, decreased distance to umbilicus + flexion test, ASIS restricted to compression

Anterior tenderpoints for T9-T12

AT9: 3/4th of the distance from the tip of the xyphoid to the umbilicus AT10: located 1/4th the distance from the umbilicus to the pubic symphysis AT11: halfway btw the umbilicus and pubic symphysis AT12: inner ala of the ilium in the mid-axillary line B/L *AT1-6: midline, AT7: has a midline and 2 points lateral to midline, AT8-12: 2 points lateral to midline*

Wilson disease (hepatolenticular degeneration)

AUTOSOMAL RECESSIVE inheritance [chromosome =13] Inadequate hepatic copper excretion and failure of copper to enter into circulation as ceruloplasmin COPPER ACCUMULATION in: 1. Liver 2. Brain 3. Cornea 4. Kidneys [Fanconi syndrome] 5. Joints Copper is normally excreted into bile by hepatocyte copper transporting ATPase [ATP7B] Clinical Manifestations: 1. *↓ Ceruloplasmin*, Cirrhosis, Corneal deposits [Kayser-Fleischer rings], Copper accumulation, Carcinoma [HCC] 2. Hemolytic anemia 3. Basal ganglia degeneration [Parkinsonian symptoms] 4. Asterixis 5. Dementia, Dyskinesia, Dysarthria Copper is Hella BAD Treatment: Chelation w/ penicillamine or trientine, oral zinc

drugs that have a mortality benefit in chronic Heart failure

Ace inhibitors (prils) ARBs (-sartans) B-blockers (metoprolol) Spironolactone: mineralcorticoid R antagonist

drugs that increase warfarin effect

Acetaminophen, NSAIDS, antibiotics/antifungals, cimetidine, amiodarone, cranberry juice, ginkgo biloba, vit E, omeprazole, SSRI thyroid hormone CYP450 inhibitors

Danazol

Agonist at androgen and progesterone receptors-->decreased LH and FSH secretion-->decreased endometrium and breast growth Use = tx endometriosis, hereditary angioedema SE = androgenic SE in women (hirsutism, acne, etc)

androgenic alopecia

Also known as androgenetic alopecia; hair loss characterized by miniaturization of terminal hair that is converted to vellus hair; in men, it is known as male pattern baldness.

Fetal hydantoin syndrome

Also: dilantin embryopathy Maternal use of anti-seizure drug phenytoin Growth deficiencies, underdeveloped fingertoenails, mild dev delays, some cleft palate, small head, finger toe malformations, cardiac defects, dysmorphic craniofacial features, microcephaly

hemophilia

An X-linked recessive disorder in which blood fails to clot properly, leading to excessive bleeding if injured. bleeding after a tooth extraction and history of hemarthrosis are suggestive. Decreased levels of factor VII or IX lead to failure to convert prothrombin into thrombin and deficient thrombus formation. The addition of thrombin to blood of a pt with hemophilia results in clotting

amniotic fluid embolism

An extremely rare, life-threatening condition that occurs when amniotic fluid and fetal cells enter the pregnant woman's pulmonary and circulatory system through the placenta via the umbilical veins, causing an exaggerated allergic response from the woman's body hypoxia, hypotensive shock, DIC fetal squamous cell are seen in pulmonary vasculature

low maternal serum AFP

Aneuploidies: Trisomy 18 and 21

-sartans

Angiotensin II Receptor Blockers (ARBs) thus blocks vasoconstriction and aldosterone secretion in order to lower blood pressure.

nuclei of hypothalamus

Anterior: regulation of body temp Lateral: hunger center- stimulation causes increased feeding while a lesion causes decreased feeding Ventromedial: feeding responses. Stimulation causes decreased feeding while a lesion causes increased feeding Supraoptic: produces oxytocin and ADH for transport of the circulatory system. Stimulation causes increased blood volume, BP, and metabolism. Lesion causes Diabetes insipidus Dorsomedial: emotional behavior. Stimulation causes sham rage. Lesion causes decreased aggression and decreased feeding

Rituximab

Anti-CD20 antibody that is used in treating symptomatic follicular lymphoma

lab tests to confirm dx:

Anti-centromere: CREST syndrome Anti-DNA topoisomerase I: Diffuse systemic sclerosis (scleroderma) Anti-histone: Drug induced lupus erythematosus Anti-Ro: Sjögren's syndrome Anti-U1 RNP: Mixed connective tissue disease

Lambert-Eaton Syndrome

Antibodies agaisnt presynaptic calcium channels of the NMJ commonly occurs as a neoplastic syndrome in pt with small cell lung carcinoma proximal muscle weakness, depressed tendon reflexes, and autonomic changes. weakness is the major sx usu affecting the LE - pt have difficulty rising from a chair, climbing stairs, and walking dry mouth is the m/c autonomic sx while erectile dysfunction is common in men

Lamotrigine

Anticonvulsant used as a mood stabilizer in bipolar d/o Use: depressive features SE: Benign rash, SJS

Valproate

Anticonvulsant has mood-stabilizing properities and is an effective maintenance treatment for bipolar d/o. Other maintenance options for bipolar d/o are lithuim, lamotrigine, and quetiapine

Cabamazepine

Anticonvulsant mood stabilizer in bipolar d.o use: manic features SE: aplastic anemia, SIADH, neural tube defects

Valproate

Anticonvulsant- used in tx of generalized and myoclonic seizures mood stabilzer in bipolar d/o Use: manic features SE: hepatotoxicity, neural tube defects

Metoclopramide (Reglan)

Antiemetic D2 antagonist Used to increase GI activity post-op SE: Parkinson's like sx

Didanosine (ddI)

Antiviral: nucleoside inhibitor of HIV reverse transcriptase. Tox: peripheral neuropathy, pancreatitis

Apolioprotein E's association with Alzheimer dz

ApoE is found in 3 allelic variations: epsilon 2,3, and 4. Those with 1 or 2 copies of epsilon 4 alleles are at a greater risk for LATE-ONSET Alz dz

what would be the expected pulmonary function test in a pt with asthma?

Asthma is a chronic, reversible obstructive lung disease and is the most common chronic disease diagnosed in children. Diagnosis is made with pulmonary function test, most commonly spirometry, showing an obstructive pattern which consists of a reduced ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC), with improvements after a short acting bronchodilator is administered

acute myelogenous leukemia

Auer rods t(15;17): M3 variant of AML is acute promyelocytic leukemia

achalasia

Auerbach's plexus, also called the myenteric plexus, is a neural network branching between longitudinal and circular muscle layers of the gastrointestinal tract and allows for coordinated movement along the tract. Loss of these neural cells results in achalasia, which commonly presents with chest pain, heart burn, dysphagia, and regurgitation. These cells are located between the longitudinal and circular layers of *muscularis externa* in the gastrointestinal tract and are responsible for coordinating motility of the entire alimentary canal.

alopecia areata

Autoimmune disorder that causes the affected hair follicles to be mistakenly attacked by a person's own immune system; usually begins with one or more small, round, smooth bald patches on the scalp.

Bullous pemphigoid

Autoimmune dz = BULLOw the BM --> autoantibodies against hemidesmosomes seen in elderly pt, clear-fluid-filled, tense blisters over the trunk caused by IgG antibodies specific for hemidesmosomes, proteins located along the epidermal basement membrane. Skin biopsy may or may not show inflammatory cells, but direct immunofluorescence studies reveal linear deposits of IgG immunoglobulin and C3 located at the dermoepidermal junction. Negative Nikolsky: superficial skin layers do not exfoliate when slight pressure is applied across the skin tx: anti-inflammatories and immunosppressive

Immune Thrombocytopenic Purpura (ITP)

Autoimmune production of IgG against platelet antigens/glycoproteins thrombocytopenia seen in adults usually F of childbearing age sx: bleeding gums, easy bruising,

Familial dysbetalipoproteinemia (Type III)

Autosomal recessive deficiency of ApoE3 and ApoE4, leading to decreased clearance of Chylomicrons and VLDL remnant - chromosome 19 Palmar xanothams in flexor crease increase risk of coronary atherosclerosis and peripheral vascular disease increased cholesterol and TAGs, NO increase in LDL

Malignant hyperthermia

Autosomal-dominant trait characterized by often fatal hyperthermia in affected people exposed to certain anesthetic agents (halothane, succinylcholine) causes increased and sustained muscle contraction with myocyte breakdown: diffuse muscle rigidity -> hyperthermia -> possible myoglobinuria tx: dantrolene that blocks ryanodine receptors and prevents release of Ca into the cytoplams of skeletal muslce fibers

parts of Medicare and what they cover

Available for pt over 65 Medicare part A: responsible for inpt hospice care, skilled nursing, hospice, and home health care B: outpt care, doctor services, physical therapy, and occupational therapy C: aka Medicare advantage plan - combo of parts A+B D: prescription Drug coverage

subacute combined degeneration

B12 deficiency → degeneration of dorsal columns (loss of position ad vibration sensation, positive Romberg sign), Lateral corticospinal tracts (spastic paresis), spinocerebellar tracts (contributes to ataxia) - (abnormal myelin from lack of methylmalonyl-CoA mutase activity) low B12/cobalamin may occur due to pernicious anemia (autoimmune gastritis w/ deficient intrinsic factor), gastrectomy, ileal resections, infection by the tapeworm Diphyllobothrium latum, and strict vegan diets containing no animal products for a prolonged period 4-5yrs.

homologous recombination (HR) mediated repair

BRCA1

the reason for conjugated vaccines

Bacteria with polysaccharide capsules (Hib, Streptococcus pneumoniae [pneumococcus], Neisseria meningitidis) are antiphagocytic. The polysaccharide capsule provokes an antibody-mediated (B-cell) immune response and is the primary antigenic constituent of vaccines against encapsulated bacteria. However, vaccines containing the polysaccharide is conjugated with a carrier protein to amplify the patient's humoral response agaisnt the polysaccharide through T cell recruitment . The Hib conjugate vaccine contains a carrier protein that is derived from either a tetanus toxoid (TT) protein or an outer membrane protein (OMP) of Neisseria meningitidis. The polysaccharide-protein conjugate then becomes a T cell-dependent antigen. Immunogenicity is increased as a result of T cell-dependent stimulation of B lymphocytes and the production of memory B lymphocytes.

Anaerobic bacteria can also cause sinusitis

Bacteroides fragilis and Fusobacterium species must be suspected when gram-negative rods grow on anaerobic media. The first-line treatment for these anaerobes is metronidazole or clindamycin. Clindamycin is usually preferred over metronidazole for infections above the diaphragm (head and neck, skin, and soft tissue infections). Suspect bacterial sinusitis when a patient presents with mucopurulent drainage, nasal obstruction, facial pain or fullness, and a decreased sense of smell. Maintain a high suspicion for an anaerobic bacterial infection when first-line antibiotics are ineffective in the treatment of sinusitis: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, all of which are susceptible to beta-lactam antibiotics and respiratory fluoroquinolones.

Treatment of akathisia

Benzos or propranolol or decrease med dose akathisia: EPS of antipshychotic meds- inner restlessness and an inability to sit or stand in one position

mechanisms that occur in the mitochondria

Beta-oxidation of FA, TCA cylce, carboxylation of pyruvate (gluconeogenesis)

treatment of insomnia in elderly pt

Bezos, antihistamines, and sedating antidepressants (TCA) should be AVOIDED in the tx due to adverse SE. give RaMELton a MELatonin agonist has lower SE burden than other sedative hypnotic agents and is effective in decreasing time to sleep onset in the elderly

Primary sclerosing cholangitis

Biliary disease characterized by inflammation and fibrosis of intra and extra-hepatic bile ducts presents in men in their 40s, strong association with UC, Characterized by inflammation, fibrosis, and stricturing of medium and large ducts in the intrahepatic and extrahepatic billiary tree: narrowing and dilation of the bile ducts = "beading" leads to hepatic failure

cyclin-dependent kinase

CDKs 4/6 regulate the movment of cells from G1 to S phase. Cancers often have mutations that enhance the activity or downstream effects of CDK 4/6, which contribute to unregulated cellular growth inhibitors of CDK 4/6 can be used to treat certain forms of cx, however they can inhibit cellular replication in other rapidsly dividing cells such as hematologic cells in the bone marrow (neutropenia, leukopenia, and anemia)

clearance equation

CL = (0.7 x Vd) / t1/2

equation for CO with Fick principle

CO = O2 consumption ÷ difference in O2 content between the arterial and venous blood (abbreviated as Ca-Cv)

Carbon Monoxide (CO) poisoning

CO binds to hemoglobin w/ much higher affinity than O2, thereby preventing O2 binding to hemoglobin. It also reduces oxygen unloading from hemoglobin in the tissues. CO decreases the oxygen-carrying capacity and O2 content of blood but not the amount of oxygen dissolved in plasma. CO poisoning increases carboxyhemoglobin concentrations but does not affect the partial pressure of oxygen and does not precipitate methemoglobinemia -which is formed when the ferrous ion Fe2+ in heme is oxidized to ferric Fe3+. Methemoglobinemia results from drug exposure (dapsone, nitrites) as well as enzyme deficiencies and hemoglobinopathies

cardiac index

CO/TBSA TBSA= total body surface area

equations for cardiac output

CO= SV x HR Fick's: determined by a pulmonary artery (Swan-Ganz) catheter CO= (rate of O2 consumption)/((arterial O2 content)- (venous O2 content)) thus CO = rate of O2 consumption / arteriovenous O2 content difference

Tropheryma whipplei

Causative agent of Whipple's disease Whipple's disease is a rare systemic illness that involves the small intestine, joints, and CNS. four cardinal clinical manifestations, which include diarrhea, weight loss, joint pain, and abdominal pain. Other symptoms include neurological (usually cognitive dysfunction, such as dementia), dermatologic (hyperpigmentation), and cardiac (endocarditis, myocarditis, and pericarditis) problems. Later in the dz course, abdominal distension secondary to ascites as a result of chronic malabsorption may occur Histology: enlarged foamy macrophages packed with both rod-shaped bacilli and PAS-positive, diastase-resistant granules (contains lysosomes and partially digested bacteria)

C1 esterase inhibitor deficiency

Causes hereditary angioedema. ACE inhibitors are contraindicated. Unregulated activation of kallikrenin: increase bradykinin. Decreased C4 levels C1 esterase inhibitor binds activated C1r, C1s

PTH (parathyroid hormone)

Causes increased bone resorption, increased serum Ca levels, and increased renal phosphate excretion. Chronically high levels of PTH increases the risk of osteoporosis However, intermittent administration of recombinant PTH analogs (teriparatide) induces a greater increased in osteoclast activity in proportion to osteoclast activity and net increase in bone formation. Increases bone resorption and releasing Ca and phosphate into circulation. In the kindey: decreases tubular reabsorption of phosphorus while increaing reabsorption of calcium. Thus with the effects on the bone and kidney= increased serum Ca and urine phosphorus levels

Acute hypocalcemia

Causes: neck surgery (parathyroidectomy), pancreatitis, tumor lysis syndrome, Chelation: blood (citrate) tranfusion. Feat: Peripheral neuromuscular excitability (tetany): - Chvostek sign: facial muscle spasm - Trousseau sign: carpopedal spasm-frequent involuntary spasm of the hands and feet - Paresthesias, hyperreflexia Seizures Tx: IV calcium gluconate/chloride Prior to storage, donated blood is mixed with solutions containing *citrate* anticoagulant. Following transfusion, citrate is rapidly metabolized to bicarbonate in the liver; however, when large volumes of blood are transfused rapidly, the excess citrate can chelate calcium in the plasma leading to hypocalcemia due to decreased serum ionized calcium concentration. This can also be seen in at lower transfusion rates in patients with underlying hepatic insufficiency/

Caseating granuloma

Central necrosis-granular and cheesy appearance; characteristic of INFECTIOUS etiologies. (TB, leprosy, syphilis, cat scratch dz) due to cell death both macrophages and bacterial and release cellular contents

axonal reaction

Changes in neuron body after axon is cut leading to axonal loss increased protein synthesis that facilitates axon repair. Enlarged rounded cells with peripherally located nuclei and dispersed finely granular Nissl substance are seen Pathology: EDEMA - get cell body rounding, peripheral displacement of nuclei and Nissl substance.

Nonbacterial thrombotic endocarditis (NBTE)

Characterized by the deposition of small sterile thrombi on the leaflets of the cardiac valves. form of noninfectious endocarditis due to infammatory cytokines in the setting of an underlying hypercoagulable state, Occur as single or multiple vegetations along the closure of the leaflets or cusps - Lesions are 1-5 mm in size - Are noninvasive - Can be the source of systemic emboli Often encountered in debilitated patients associated with advanced malignancy (mucinous adenocarcinoma) or SLE

long-term Treatment for gout

Chronic uric acid-lowering therapy is recommened for pts with gout who have frequent gouty attacks, uric acid kidney stones, tophi, or chronic joint destruction from gout. Xanthine oxidase inhibitors are the preferred tx (allopurinol, febuxostat) Uricosuric agents (probenecid) are 2nd line agents for chronic management. These drugs *increase renal excretion of uric acid and thus are C/I in pt with a hx of renal stones*

Lecithinase (alpha toxin)

Clostridium perfringens ( gas gangrene)

cocaine toxicity

Cocaine toxicity produces an increase in heart rate and blood pressure accompanied by increased arousal, increased vigilance and alertness, and a sense of self-confidence, euphoria, and well-being. Cocaine intoxication results in the maladaptive behavior such as euphoria, hypervigilance, anxiety, anger, tachycardia, hypertension, weight loss, and pupillary dilation Cocaine is a stimulant with intoxication presenting with behavioral and/or psychological changes plus symptoms of sympathetic nervous system activation including tachycardia, hypertension, pupillary dilation, chills or sweats, psychomotor agitation, chest pain or cardiac arrhythmia, and/or confusion, seizure, or coma. Perceptual disturbances, which frequently are tactile in nature (ie, sensation of bugs crawling on or in the skin), are also common. avoid B-blockers in cocaine-induced HTN and CP b/c of unopposed alpha receptor stimulation can exacerbate HTN and vasoconstriction

Terminology regarding GI is important to understand, as it may alter the diagnostic management, as discussed below.

Coffee-ground emesis: Bleeding occurring proximal to the ligament of Treitz. The blood turns black when combined with stomach acid. Melena: This refers to black, tarry stools most often from UGIB. Hematemesis: Vomiting of red blood. This usually indicates more severe UGIB. Hematochezia: Red or maroon blood in the stool that is usually due to lower GI bleeding, such as diverticulosis. Bright red blood per rectum: This typically indicates a lower GI bleed, such as sigmoid diverticulosis or a rectal source (eg, hemorrhoids).

Increased tactile fremitus:

Conditions that consolidate the lung tissue like pneumonia will increase the transmission of sound waves.

Decreased tactile fremitus:

Conditions that decrease sound wave transmission, like pleural effusion and pneumothorax. Conditions that eliminate sound wave transmission, such as obstructive (resorption) atelectasis, as in this patient.

Urethral disruption

Consider if pelvic injury; BLOOD AT MEATUS; Prostate riding high; Don't cath patient; Eval with retrograde urethrogram with Dye in pelvis and not bladder foley catheter not able to be inserted

Pentose phosphate pathway

Consists of an oxidative (irreversible) branch and a nonoxidative (reversible) branch, and each can function independently based on cellular requirements. *Transketolase*, an enzyme of the nonoxidative branch is responsible in part for the interconversion of ribose-5-phosphate (nucelotide precursor) and fructose-6-phosphate (glycolytic intermediate)

Q fever

Coxiella burnetti is most commonly contracted through the handling of sheep placental tissue, and can cause a chronic infection that increases the risk of endocarditis, especially in immunocompromised individuals or in those with previous valvular disease. An acute infection can typically present with a self limited, flu-like illness; pneumonia; hepatitis; and pyrexia of unknown origin. Chronic Q fever is an infection that lasts ≥ 6 months and is more likely to occur in patients who are pregnant, immunocompromised, or have underlying valvular disease, as in this patient.

Cromyln sodium

Cromolyn sodium is a mast cell stabilizer that can prophylactically prevent early and late asthma episodes by interfering with chloride channels, stabilizing the mast cell membrane, and inhibiting the activation and release of mediators from eosinophils and epithelial cells. They will inhibit the release of histamines and leukotrienes released from sensitized mast cells. These drugs are not useful once the patient is having an asthma episode. Upon secondary allergen exposure, a sensitized person may experience an early and late inflammatory phase, as discussed below: *Early phase:* Sensitized individual experience bronchoconstriction within several minutes caused by release of mast cell mediators such as histamine, prostaglandin D2, and leukotrienes (C4, D4, and E4). *Late phase:* This phase occurs several hours after the early phase, and is characterized by recruitment of inflammatory and immune cells, particularly eosinophils and helper T cells (Th2) to the sites of allergen exposure.

Cystine stones

Cystine stones are the rarest form of kidney stones, accounting for 2% of nephrolithiasis. It is caused by a genetic mutation which affects cysteine reabsorption, thereby leading to excess cysteine in the renal tubules that can become supersaturated and crystalize. It typically causes recurrent nephrolithiasis at a young age, in a patient with a similar family history. Cyanide-nitroprusside testing would be positive, and cystine crystals are hexagonal.

Cytomegalovirus (CMV)

Cytomegalovirus is the most common cause of congenital infections and commonly results in periventricular calcifications, growth restriction, and sensorineural hearing loss.

Tx of schizophrenia

D2 receptor antagonism

how do the kidneys correct DKA?

DKA: decreased serum pH and HCO3 with a compensatory decrease in pCO2 Kidneys try to correct metabolic acidosis via 3 mechanisms: 1) increased HCO3 reabsorption 2) increased H+ secretion 3) Increased acid buffer excretion - The 2 most important acid buffers in urine are HPO4 2- and NH3. HPO4 2- is titratable acid that combines with H+ to form H2PO4-. NH3 is generated by the proximal tubular cells via metabolism of glutamine and combines with H+ to form NH4+. NH3 is the more important of these 2, as the kidney can greatly increase NH3 production in chronic acidosis. Urinary acid excretion occurs primarily in the form of NH4+ and titratable acids (H2PO4-). In metabolic acidosis, urinary pH decreases due to increased excretion of free H+, NH4+, and H2PO4-. Bicarbonate is completely reabsorbed from the tubular fluid in acidotic states.

thymidine dimerization

DNA damage induced by UV radiation

Methylphenidate

DOC for ADHD a mild CNS stimulant similar to amphetamines. blocks the reuptake of dopamine and norepinephrine in presynaptic neurons through inhibition of monoamine transporters. Common adverse effects include decreased appetite and insomnia. Atomoxetine is another stimulant commonly used which enhances NE activity by selectively inhibiting NE reuptake - it has little or no activity at other reuptake receptor sites.

Clozpine

DOC for tx-resistant schizophrenia. Tx requires monitoring of the absolute neutophil count due to risks of neutophenia and agranulocytosis additional SE: seizures, myocarditis, metabolic syndrome

what would be expected to be seen in pt with restrictive lung dz (pulmonary fibrosis) for lung volumes

Decreased RV and TLC, along with decreased FVC and increased or normal FEV1/FVC ratio, are seen with lung dz (pulmonary fibrosis). FEV1 decreases in this setting but to a lesser extent than FVC.

Indirect inguinal hernia

Deep inguinal ring, lateral to inferior epigastric vessels More common in Males can enter the scrotum An indirect inguinal hernia is the protrusion of an abdominal organ into a patent processus vaginalis. This failure of processus vaginalis closure can provide a potential space for abdominal contents to herniate

Fanconi syndrome

Defect in proximal tubule Can't reabsorb Low energy state Can be caused by old tetracycline Fanconi's syndrome is a hereditary or acquired proximal tubule dysfunction that leads to defective transport glucose, amino acids, sodium, potassium, phosphate, uric acid and bicarbonate. The toxic degradation product of tetracycline can cause Fanconi's syndrome. Treatment involves correcting serum losses with phosphate, potassium, alkali and salt supplementation, as well as adequate hydration.

Paroxysmal nocturnal hemoglobinuria

Deficiency in CD55 and CD59: cause complement-mediated intravascular lysis and release of hemoglobin. Anemia, hemoglobinuria, severe fatigue, abdominal pain, and thrombosis. uncontrolled complement mediated hemolysis hemolytic anemia, pancytopenia, thrombosis at atypucal cytes Chronic hemolysis can cause iron deposition in the kidney

Tabes dorsalis

Degeneration of dorsal columns and dorsal roots due to tertiary syphilis, resulting in impaired proprioception, tactile, vibratory sensation, and locomotor ataxia. Associated with charcot's joints, shooting (lightning pain) (see image 12 in First Aid), Argyll Robertson upils (Reactive to accommodation but not light), absence of DTRs, positive romberg, and sensory ataxia at night.

Dermatomyositis

Dermatomyositis is an idiopathic inflammatory disorder marked by proximal muscle weakness (gluteus muscles and shoulder girdle muscles) and characteristic skin findings. Shawl sign, Gottron's papules: which are erythematous papules on bony prominences of hands, mechanic's hands, heliotrope rash: violaceous rash under the eyes, and holster sign: a macular rash over the skin of the hips, are all cutaneous manifestations of dermatomyositis. Wt loss is a common issue due to loss of muscle mass as well as decreased caloric intake due to esophageal dysmotility Inflammatory myopathies affect mostly skeletal muscle, therefore, the proximal esophagus is affected more than the distal esophagus because it is primarily composed of skeletal muscle while the distal esophagus is almost purely smooth muscle. Patients with inflammatory myopathies (i.e., dermatomyositis and polymyositis) will usually have increased serum levels of CK-MM, aldolase, AST, ALT, and LDH. *associated with adenocarcinomas (ovary, lung, pancreas)*

Anti-HBe

Develops in cleared infection and later in chronic infection indicates decreased viral replication and infectivity

dissociative amnesia

Dissociative disorder characterized by the sudden and extensive inability to recall important personal information, usually of a traumatic or stressful nature.

How is CO2 transported in the blood?

Dissolved in plasma, bound to globin, or as bicarbonate ions in plasma

thiazides

Diuretic prototype: block Na+/Cl− transporter in distal convoluted tubule; used in HTN, CHF, chronic stone formers. Tox: K+ wasting; increased serum lipids, uric acid, and glucose raise glucose and TAGs

GI Anomalies-Down Syndrome

Down syndrome (trisomy 21): associated with decreased maternal alpha-fetoprotein and increased nuchal translucency. 47, XX, +21 Duodenal atresia: failure to recanalization of the duodenum in early gestation, is the mc abnl. Present with bilious emesis and *double bubble* sign: dilated stomach and proximal duodenum. Also at risk of imperforate anus, Hirschsprung dz, tracheoesophageal fistula, and celiac dz

Carbamazepine (Tegretol)

Drug for trigeminal neuralgia

DRESS syndrome

Drug reaction with Eosinophilia and systemic sx Drugs, Rash, Eosinophilia, Swelling (facial edema), Serum ALT life-threatening drug reaction occuring 2-8 weeks after drug exposure. Associated with anticonvulsants (phenytoin, cabamazepine) allopurinol, sulfonamides, and abd (miocycline, vancomycin). sx: fever, generalized lymphadenopathy, facial edema, diffuse morbilliform skin rash that can progress to a confluent erythema with follicular accentuation. liver - hepatomegaly, jaundice kidney - Acute interstitial nephritis lung - cough, dyspnea LABS: eosinophilia, atypical lymphocytosis, and elevated serum alanine transaminase

burn tx that causes testicular atrophy

Drug: oxandrolone anabolic-androgenic steroid derived from testosterone and used in the treatment of severe burns. Testicular atrophy is a common side effect due to negative feedback on LH, leading to decreased intratesticular testosterone production.

Tricyclic Antidepressants (TCAs)

Drugs that inhibit the reuptake of norepinephrine and serotonin by the presynaptic neurons in the central nervous system, increasing the amount of time they are available to the postsynaptic receptors. Muscarinic blockage leads to *anticholinergic effects* such as blurred vision, dry mouth, tachycardia, urinary retention, confusion, and constipation. due to SE C/I in elderly Use: insomnia or adjunctive pain management when no other meds work.

duodenal vs gastric ulcers

Duodenal pain improves with eating and worsens 2-5 hrs later and at night. Gastric is worse with eating and better without eating

pt with bronchospastic pulmonary disease has wheezing despite being on a Beta-adrenergic agonis inhaler. He is hospitalized and placed on prednisone. What is the action of prednisone in enhancing the response to B-adrenergic agonist?

Enhanced action of the agonist at B-adrenergic receptors (its a corticosteroids which also help dec inflammation)

During muscle contraction, the labeled ATP is observed to attach the sarcomere. This attachment causes immediate

During the skeletal muscle contraction cycle, ATP binding to myosin causes release of the myosin head from its binding site on the actin filament

Hydrogen breath test

Dx of Lactose intolerance

Erythropoietin

EPO is made by peritubular fibroblast cells in the renal cortex in response to decreased renal oxygen delivery (decreased blood hemoglobin content) EPO acts on erythrocyte precursor cells in the bone marrow to stimulate RBC production. Pts with chronic kidney dz have inflammatory damage to renal EPO-producing cells and often develop normocytic anemia due to insufficient EPO.

Traveler's diarrhea

ETEC plasmid-encoded heat-labile (LT, choleragen-like) and heat stable (ST) enterotoxns LT activates adenylate cyclase = increased intracellular cyclic AMP ST: activates guanylate cyclase leading to increased intracellular cyclic GMP both cause water and electrolyte loss and watery diarrhea

Primary adrenal insufficiency (Addison's disease)

Electrolyte abnormalities include hyponatremia, hyperkalemia, hyperchloremia, non-anion gap metabolic acidosis skin hyperpigmentation, hypotension, fatigue

iron deficiency anemia labs

Elevated TIBC: total iron binding capacity Elevated serum transferrin Decreased serum ferritin

TSH concentration in pregnancy

Elevated levels of TSH concentration in pregnancy can cause abnormal brain development

Sites of fetal erythropoiesis

Erythropoiesis occurs in 4 distinct sites during fetal development: - yolk sac (weeks 2-10) - liver (Weeks 6-birth) - spleen (weeks 12-28 secondary to the liver) - bone marrow (initiates approx week 18 and maximal approx Week 36 and continues after birth)

signs of portal HTN in cirrhosis

Esophageal varices splenomegaly ascites caput medusae anorectal varices

Ecological study

Evaluates the association between a potential exposure (ex: low socioeconomic status population) and a given outcome (increased cancer mortality). Uses population level (vs individual-level) data as a unit of analysis.

treatment for EPS

Extrapyramidal symptoms (EPS) of antipsychotic drugs include dystonias, akathisia, Parkinsonian syndrome, and tardive dyskinesia. Dystonias are involuntary contractions of major muscle groups and are characterized by symptoms such as torticollis or oculogyric crisis. The mainstay of treatment for EPS dystonias are medications with anticholinergic properties such as diphenhydramine and benztropine.

Transport of glucose into cells of most tissues is via what mechanism?

Facilitated diffusion Glucose moves from areas of high concentration to areas of low concentration with the help of transmembrane glucose transporter protein (GLUT). These carrier proteins are steroselective for D-glucose

factors that increase and decrease CRI

Factors that will increase the cardiac rhythmic impulse (CRI; normal between 8-14, depending upon which reference used) include systemic fever, strenuous exercise, and osteopathic manipulative treatment. Factors that decrease the CRI include stress (emotional or physical), depression, chronic fatigue, and chronic infections.

Zenker's diverticulum

False diverticulum. Herniation of mucosal tissue at junction of pharynx and esophagus. Presenting symptoms: halitosis (due to trapped food particles), dysphagia, and obstruction diminished relaxation of circopharyngeal muscles during swallowing results in increased intraluminal pressure in the oropharynx. This may eventually lead to the mucosa herniating through a zone of muscle weakness in the posterior pharynx. Pulmonary aspiration of diverticular contents may also lead to recurrent pneumonia

septic abortion

Fever, abdominal pain and tenderness; foul-smelling vaginal discharge; bleeding from scant to heavy; treated with termination of pregnancy, antibiotic therapy and monitoring for septic shock caused by Staph aureus and E coli due to seeding of the uterine cavity during instumentation

Anterior humerus dislocation

Flattening of the deltoid muscle with acromial prominence after a shoulder injury. This injury most commonly results from a blow to an externally rotated and abducted arm. There is often associated axillary nerve injury, resulting in deltoid paralysis and loss of sensation over the lateral shoulder anterior dislocations of the humerus are the most common should dislocations

Hospice model

Focus on quality of life, not cure or life prolongation Sx contol (pain, N, dyspnea, agitiation, anxiety, depression) Interdisciplinary team (medical, nursing, psychosocial, spiritual, breavement care) Services provided at home, assisted living facility, or dedicated facility Requires survival prognosis greater than or equal to 6 months. pts with advanced metastatic cancers or other terminal illnesses should be evaluated for hospice care

Loop diuretic and NSAID use

Furosemide is a loop diuretic that works by inhibiting Na-K-2Cl symporter in the loop of Henle effectively causing increased Na, Cl, and fluid excretion. Loops also stimulate prostaglandin release. By stimulating renal prostaglandin release, loops also increase renal blood flow leading to increased GFR and enhanced drug delivery Concurent use with NSAIDS (inhibit prostaglandin synthesis) with loops can result in a decreased diuretic response

Baclofen

GABA-B agonist , opens K channesls inhibits Ca influx, cAMP, and Sub P. use is a muscle relaxant - can be used to treat SPACITITY in multiple sclerosis

Endoderm derivatives

GI tract, liver, pancreas lungs thymus, parathyroids, thyroid folliclar cells Middle ear epithelium Bladder & urethra Parafollicular C cells

Haemophilus influenzae

Gram negative coccobacillus that requires both X factor (hematin) and V factor (NAD+) to grow. H influenzae type B has an antiphagocytic polysaccharide capsule, which allows it to spread hematogenously and cause invasive dz such as septic arthritis, meningitis, bacteremia. localized infections: acute otitis media, sinusitis are caused by unencapsulated (nontypeable) strains. B strains have a polyribosylribitol phosphate polysaccharide *capsule* that prevents phagocytosis - allowing the organism to invade the vasculature and spread hematogenously to distant sites. in vaccinated pt, antibodies against the type B capsule provide immunity by promoting complement fixation and opsonization.

Klebsiella granulomatis

Gram-negative bacillus. sexually transmitted infection is called granuloma inguinale and is characterized by ulcers on or around the genitals. Ulcers usually have a beefy-red, friable base comprised of exuberant granulation tissue. Microscopic examination of exudate shows aggregates of bacilli, shaped like safety-pins, inside macrophages. These intracellular aggregates are highlighted by bipolar stain and have been named "Donovan bodies." Granuloma inguinale is uncommonly seen in the United States; it is more prevalent in countries such as South Africa, India, Australia, and Papua New Guinea.

Haemophilus ducreyi

Gram-negative coccobacillus that causes chancroid. A chancroid is a sexually transmitted infection that manifests as genital ulcerations. Lesions are typically soft and painful, and lymphadenopathy may be appreciated. This disease is rare in the United States so travel to equatorial areas is a suggestive clue. By light microscopy H. ducreyi forms clumps and long parallel strands, producing a "school of fish" appearance.

chemotherapy can cause bone marrow suppression/myelosuppression, decrease in leukocytes, erythrocytes, and thrombocytes and neutropenia = pt susceptible to infections and sepsis what can you give them?

Granulocyte-colony-stimulating factor

Hemachromatosis

HFE protein mutation (primary) Inactivation of this protein = decreased hepcidin synthesis ny hepatocytes and increased DMT1 expression by enterocytes, leading to Fe overload. Pt with this are at increased risk of liver cirrhosis and hepatocellular carcinoma

Albuminocytologic dissociation

Guillain-Barre syndrome (increased protein in CSF without a significant increase in cell count) elevated CSF due to myelin breakdown products entering CSF

what acid-base disorder is associated with Guillain-Barre syndrome?

Guillain-Barre syndrome is a rapidly progressive nerve paralysis, which can cause paralysis of the respiratory muscles → leading to respiratory acidosis.

Famotidine

H2 antagonist Decreases GI acid used at night for best effects in acid reduction

HBeAg

HBV polypeptide Detectable during acute infection indicated increase viral replication and infectivity

HBsAg

HBV surface glycoprotein Detectable during acute infection Persistance >6mo = chronic infection

HLA subtype associated with Multiple Sclerosis

HLA-DR2 MS most commonly occurs in young females, between the ages of 20-40. usually have weakness of the limbs, spasticity (especially in the legs), parethesis, diplopia and visual blurring (optic neuritis), ataxia, bladder dysfunction, as well as decreased color vision (desaturation) in the central field of vision. primarily alters structures within CNS, especially oligodendrocytes. Oligodendrocytes (myelinate multiple CNS axons) are cells located within the CNS that produce myelin. Tx: Interferon-β1b has an unknown mechanism of action, but immunomodulatory effects are attributed to the enhancement of suppressor T cell activity, reduction of pro-inflammatory cytokines, down-regulation of antigen presentation, and reduced trafficking of lymphocytes into the CNS. Inteferon-β has proven to decrease the relapse rate, severity of disease, and improve MRI lesions

HPV

HPV infection of basal cervical cells can progress to premalignant and cancerous lesions. Cervical intraepithelial neoplasia refers to atypical squamous cells and is classifed as low-grade squamous intraepithelial lesions (if extending <1/3 of the epithelium) or high grade squamous intraepithelial lesions (if extending beyond). Basement membrane breach signifies invasive dz

Peutz-Jeghers syndrome

Hamartomatous (benign) polyps throughout GI tract and mucocutaneous hyperpigmentation (freckle-like spots) on lips, oral mucosa, and genital skin; autosomal dominant disorder Gene: STK-11 presents in 3rd decade of life

Coxsackie virus A

Hand-foot-and-mouth dz (oral and extremity ulcerations) and herpangina (oral ulcerations) are the most common manifestations of enteroviral infections. Myocarditis is a rare but serious complication of enterovirus that can lead to heart failure, dysrhythmia, or acute circulatory collapse

Brown-Sequard Syndrome

Hemi-section of the cord usually following penetrating trauma - I/L spastic paralysis below the lesion - I/L UMN signs - I/L of proprioception and vibration - I/L loss of touch and vibration below the lesion - C/L loss of pain and thermal sense below the lesion spinothalamic tract (pain and temp) is an ascending tract that crosses the spinal cord (decussates) within 1-2 levels after entering the spinal cord. The posterior columns (touch and vibration) ascend I/L and cross the CNS at the medulla.

Hyperaldosteronism

Hyperaldosteronism can be caused by adrenal hyperplasia, adrenal adenoma, or overactivity of the renin-angiotensin system. It will likely present with hypertension, hypernatremia, and hypokalemia. Muscle weakness, lethargy, polyuria, and polydipsia might also be present.

affects of hypercalcemia

Hypercalcemia can result when too much calcium enters the extracellular fluid when there is insufficient calcium excretion from the kidneys. Elevated calcium levels often cause a multitude of symptoms that correlate with the popular mnemonic "stones, bones, abdominal groans, and psychic tones." The most common cancers associated with hypercalcemia are breast cancer, lung cancer, and multiple myeloma

Niacin can be used to treat what?

Hyperlipidemia. It increases HDL levels and decreases LDL levels and triglycerides. Niacin causes cutaneous flushing which is mediated by *prostaglandins* and can be diminished by pre-tx with aspirin.

chronic kidney disease and vit D

In chronic kidney disease, conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D is impaired. In addition, failure of glomerular and tubular function results in phosphate retention and hypocalcemia. This leads to a compensatory rise in PTH (secondary hyperparathyroidism) that can present with weakness, muscle and joint pain, defective bone mineralization, and increased fracture risk

Clozapine

In persons with schizophrenia resistant to multiple trials of both first and second generation antipsychotics, clozapine has been found to be an effective treatment. Clozapine is an atypical antipsychotic medication, but is restricted to refractory schizophrenia due to its potentially life threatening side effect of agranulocytosis.

how can pregnancy be achieved in a pt with Turner syndrome (45, XO)?

In vitro fertilization using a donated ovum can achieve pregnancy in a woman with Turner syndrome. Pregnancy can occasionally occur spontaneously in some pt with Turner syndrome, but the risk of spontaneous abortion, Down syndrome, and Turner syndrome are all increased in such cases.

Thiazolidinediones (TZDs)

Increase insulin sensitivity in peripheral tissue by binding to PPAR-gamma -glitazones Can cause MI, hepatotoxicity, weight gain, and heart failure, fluid retnention leading to peripheral edema and wt gain

inherited defects in what prevent the ability to protect against disseminated M. TB dz?

Inherited defects involving interferon-gamma signaling pathway result in disseminated M. TB dz in infancy or early childhood. Pt require lifelong tx with antimycobacterial agents

Fomepizole

Inhibits alcohol dehydrogenase, antidote for methanol or ethylene glycol poisoning Methanol poisoning can lead to metabolic acidosis (causing hyperventilation) and visual disturbances

initial and secondary allergen stimulation in asthma results in

Initial allergen stimulation causes induction of CD4 Th2 cells to release IL-4 and IL-5. IL-4 stimulates IgE production and IL-5 activates local eosinophils. Upon secondary allergen exposure, antigens cross-link IgE antibodies on mast cells, which lead to the release of histamine.

Parvovirus B19

Initial infection may cause a nonspecific viral syndrome with HA, coryza, and GI sx. May subsequently cause 2 primary syndromes in immunoCOMPETENT pts: - Erythema infectiosum (fifth dz): found in children. Bright red rash on the cheeks with circumoral pallor and fever. Pt may also have a generalized reticular rash on the arms, legs, and trunk - Acute arthropathy: found in adults. This symmetric polyarthritis involves the proximal interphalangeal metacarpal, knee, and ankle joints. The arthritis is self-limited and nondestructive.

Cleavage of Proinsulin will make what?

Insulin and C-peptide, which are stored in granules until they are secreted in equimolar amounts

Inulin vs PAH

Inulin is the gold standard for GFR (neither secreted or reabsorbed) PAH: marker for renal PLASMA flow (100% ends up in the urine

Hx of HTN, HA, confusion, smoking, abd bruit over l abdomen w/ captopril renal radionuclide scan shows delayed L kidney function

L renal artery atherosclerosis l abd bruit is indicative of Renal artery stenosis captopril renal radionuclide scan used to evaluate for renal artery stenosis and renal-vascular HTN

Right lower quadrantanopia

Left Pareital lobe lesion, MCA

Furosemide (Lasix)

Loop Diuretic. Inhibits Na 2Cl- K+ Co-transporter in the thick ascending loop of the LOH. Also increases Ca2+ secretion in LOP. SE: Hypokalemia, nephrotoxicity, ototoxicty.

Benzodiazepines safe to use with liver disease

Lorazepam and oxazepam ( and Temazepam) are the preferred benzodiazepines in patients with liver disease. They go directly to phase II metabolism, by-passing the phase I metabolism of the P450 enzymes system, and only create inactive metabolites.

Euthyroid sick syndrome

Low T3 Normal T4 Normal TSH After an acute illness. DO NOT treat, repeated TSH later after patient gets better

treatment of congenital adrenal hyperplasia

Low doses of exogenous corticosteroids to suppress excessive ACTH secretion and reduce stimulation of the adrenal cortex

Lower Trunk of brachial Plexus Injury

Lower trunk carries nerve fibers from C8 to T1 spinal levels that are responsible for innervating all intrinsic muscles of the hand (median and ulnar nerve) Upward jerking/sudden upward streching of the arm (tree branch), damages intrinsic muscles of the hand and claw hand Also damaged with compression of nerve and subclavian vessels (extra cervical rib, pancoast tumor)

left shift caused by

Lungs shift left: decreased H+ Decreased temp Decreased 2,3-BPG increased affinity for hemoglobin O2 affinity, O2 is less available to tissues

MUDPILERS stands for...

M ethanol U remia D KA P ropylene glycol, paraaldehyde I soniazid, infection, intoxification L actic acidosis E thanol / Ethylene glycol R habdomyolysis S alicylates/sepsis, starvation In all of these situation, an acid is added to the blood stream that causes acidosis and contributes a negative anion that is not readily measured, resulting in an increase in the anion gap. The anion gap can be measured by subtracting the total concentration of anions from cations, [sodium] - ([chloride] + [bicarbonate]), and the normal range is 8-16. causes of anionic gap metabolic acidosis

maintenace dose equation

MD = (Cp x CL) / F Cp: desired plasma conc CL: clearance F: bioavailability

Class IC antiarrhythmics

MOA - Na channel blockers (MOST potent) - markedly slow conduction, decrease automaticity Flecainide (Tambocor) - A and V arrhythmias - adjust in renal dysfx Propafenone (Rythmol) - A and V arrhythmias - also NS BB properties AVOID all Class IC in pts w/ STRUCTURAL heart dz Do NOT cause TdP *have increased effect at faster HR (use-dep). makes them more effective at treating tachyarrhythmias, but can also cause prolonged QRS duration (a proarrhythmic effect) at higher HR).

treatment for legionella causing legionnaire's dx

Macrolides: azithromycin Fluroquinolones

Acute phase reactants

Made in hepatocytes: (increases ESR) CRP Complement Coagulation factors Ferritin IL1, 6, TNFalpha from macrophages

DiGeorge Syndrome

Maldevelopment of 3 (inferior parathyroid and thymus) and 4 (superior parathyroid) pharyngeal/branchial pouches. Subsequent parathyroid and thymic hypoplasia reults in hypocalcemia and T cell deficiency. CATCH-22: ardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia Additional findnings: due to hypocalcemia=tetany, carpopedial spasms, or seizures. Tapping on the facial nerve elicits twitching of the nose and lips (Chvostek sign) and inflation of the blood pressure cuff leads to carpal spasm (Trousseau sign), conotruncal cardiac anomalies (interrupted aortic arch, truncus arteriosus) may also result from failure of neural crest migration. if there is additional involvement of the 1st and 2nd pharyngeal/branchial pouches: hypertelorism, short palpebral fissures, micrognathia, bifid uvula and cleft palate.

classic non-wasting 21 hydroxylase deficiency

Males present @ 2-4 years with early virilization, increased linear growth, and elevated levels of 17-hyroxyprogesterone and androgens. Females with classic 21-hydroxylase deficiency (with or without salt-wasting) present with ambiguous genitalia at birth

Anemia of chronic disease

Microcytic anemia with ↓ serum iron, ↓ total iron-binding capacity (TIBC), and normal or ↑ ferritin. associated w/ chronic inflammatory conditions: infections and autoimmune or malignancy

Trousseau syndrome

Migratory superficial thrombophlebitis Adenocarcinomas, especially pancreatic *THINK VISCERAL CANCER*

Leber hereditary optic neuropathy

Mitochondrial inheritance (the other dz is Mitochondrial myopathies) affects all offspring of an affected mother; there is no father-child transmission. Characterized by progressive B/L optic neuropathy leading to blindness

cardiac abnormalities in marfan

Mitral valve prolapse and cystic medial degeneration of the aorta. if left untx can cause aortic dissection *has upward lens dislocation*

Hamartoma

Most common benign tumor of the lung. asymptomatic peripherally located "coin lesion" in pt 50-60 years old disorganized cartilage, fibrous and adipose tissue excessive growth of a tissue type native to the organ of involvement

Factor V Leiden

Most common hypercoagulable state, mutated factor V that is resistant to , Protein C and Protein S cleavage. mutation leads to *DVT*

Primary CNS lymphoma

Most common intracranial tumor in AIDS. Solitary or multiple enhancing mass lesions, centrally located within deep white matter or basal ganglia. Lesions usually are T2 isointense to white matter with homogeneous enhancement. Toxoplasmosis lesions usually are T2 hypointense. ASSOCIATED WITH EBV arise from b cells

myxomas

Most common primary tumor of the *adult* heart Benign neoplasm of mesenchymal cells 90% arise in the *atria* - Most commonly in the left atrium sx: mitral valve obstruction that may worsen with certain body positions, constitutional findings (fever, wt loss), or systemic embolization (strok, mesenteric ischemia, acute limb ischemia)

Papillary thyroid carcinoma

Most common thyroid malignancy Some of the nuclei are optically clear (classic 'Orphan Annie' eyes or 'ground-glass' chromatin), which is the diagnostic feature. Other histologic features include a unencapsulated or partially cystic mass with papillae consisting of 1-2 layers of tumor cells surrounding a well-defined fibrovascular core; colloid and follicles are typically absent. spread through the lymph and may present with cervical lymphadenopathy most patients do not die of this disease. Risk factors include radiation exposure during childhood, a history of thyroid cancer in a first-degree relative, or family history of thyroid cancer syndrome.

rhabdomyoma

Most frequent 1° cardiac tumor in children (associated with tuberous sclerosis: harmartomas in CNS and skin, angiofibromas, mitral regurg, ash-leaf spots, cardaic rhabdomyoma, mental retardation, renal angiomyolipoma, seizures, shagreen patches.

An enlarged coronary sinus is caused by what?

Most of the venous drainage from the myocardium traverses the coronary sinus (CS), which delivers deoxygenated blood to the RA. The CS runs transversely in the left atrioventricular groove on the posterior aspect of the heart, and opens into the RA between the IVC and tricuspid valve at the CS orifice. B/c the CS communicates freely with the RA, it will become dilated by another factor that causes dilation to the RA. The mcc of *coronary sinus dilation* evident on echo is *elevated R-sided heart pressure* secondary to *pulmonary HTN*. CS dilation also occurs in pts with anomalous venous drainage into the CS, including persistent L-SVC and total anomalous pulmonary venous return.

Mitral valve prolapse - murmur

Murmur is heard best over the cardiac apex Mid-systolic opening click, followed by a high-pitched, mid to late systolic crescendo murmur. Sx: anxiety, panic attacks, arrhythmias, exercise intolerance, palpitations, and atypical CP The mid-systolic click of mitral valve prolapse moves more toward S1 (lengthens the murmur) with maneuvers that decrease LV volume, such as standing or Valsalva maneuver. The click moves more towards S2 (becoming less prominent) with maneuvers that increase LV volume, such as squatting and lying recumbent MVP is enhanced by Valsalva and decreased by squatting. This is b/c those maneuvers that decrease the volume of the LV (Valsalva, standing) will cause the prolapse to occur sooner and more severely, whereas those that increase venous return and diastolic filling (squatting), and thereby enhancing the ventricular volume, help to maintain tension along the chordae and to keep the valve shut.

Nevirapine

NNRTI - HIV tx bind to reverse transcriptase at different sites from NRTIs SE: rash and hepatotoxicity

Didanosine (ddI)

NRT - HIV tx Antiviral: nucleoside inhibitor of HIV reverse transcriptase. Tox: peripheral neuropathy, pancreatitis

Didanosine

NRTI - HIV tx competitively inhibit nucleotide binding to reverse transcriptase and terminate the DNA chain SE: pancreatitis, peripheral neuropathy

Ibuprofen

NSAID--COX inhibition; non-selective, reversible thus would decrease syn of prostaglandins and would increase syn of Leukotrienes

Anion gap equation

Na - (Cl + HCO3) NL = 8-12

Membranous glomerulonephritis

Nephrotic syndrome aka Membranous nephropathy can be primary ( antibodies to phopholipase A2) or secondary to drugs (NSAIDS, penicillamine, gold), infections (HBV, HCV, syphilis), SLE, or solid tumors LM: diffuse capillary and GBM thickening IF: granular de to immune complex (can include: IgG and C3) EM: spike and dome of subepithelial deposits

Starling equation for net filtration

Net filtration = (Pc - Pi) - (Oc - Oi) Pc: capilallary hydrostatic pressure Pi: interstitial hydrostatic pressure Oc: capillary oncotic pressure Oi: interstitial oncotic pressure Pc and Oi: fluid moves out of the capillary Oc and Pi: draw fluid back into the capillary A positive value: net movement of fluid from the interstitium into the capillary and is called absorption or reabsorption.

Neural crest derivatives Ectoderm derived

Neural ganglia, adrenal medulla Schwann cells, pia & arachnoid mater Aorticopulmonary septum and endocardial cushions Brachial arches (bones and cartilage) Skull bones Melanocytes

neuroblastoma

Neuroblastoma is a common childhood cancer that usually arises in the adrenal medulla. The screen is urinary homovanillic acid, the breakdown product of dopamine. These tumors are composed of undifferentiated small blue cells, and many feature Homer Wright rosettes — rings of cells around little clumps of nerve fibers, without lumens, which are distinctive for this tumor. *Peak age < 2 years. Mass often crosses midline. Extrinsic to kidney on imaging (compresses but does not invade.) Calcifications are common. Rings contain neural filaments. Paraneoplastic effects (neurologic) are common.*

zidovudine

Nucleoside reverse transcriptase inhibitor (NRTI) used to prevent maternal to fetal transmission of HIV during labor (when mom is not virally suppressed) Thymidine analogue that does not have the normal 3'-hydroxyl group found on thymidine. Bc new nucleotides are added to growing DNA chains only at the 3'-hydroxyl goup, the addition of ZDT into DNA results in chain termination

Number needed to treat (NNT)

Number of individuals that need to be treated to prevent a negative outcome in 1 patient NNT= 1/ARR

cervical main motions

OA: flexion and extension AA: rotation C2-C4: can F/E and SB but MAIN: Rotation C5-C7: can F/E and SB but MAIN: SB

Peripartum cardiomyopathy

Occurs during the last trimester of pregnancy or the first 6 months after delivery PEx: jugluar venous distension, evidence of edema in the lung bases, mild hepatomegaly, and mild pitting edema of the LE, 4-chamber dilation ie

Negative selection of T cells

Occurs in medulla of thymus. T cells expressing TCRs with high affinity for self antigens or self MHC undergo apoptosis. if these cells survive and are not subject to apoptosis: they would likely induce immune and inflammatory reactions against self antigens leading to autoimmune disease

Positive selection of T cells

Occurs in thymic cortex. T cells expressing TCRs capable of binding surface self-MHC molecules survive.

malaria

P vivax is the mcc of malaria in non-African countries. It is transmitted by the female Anopheles mosquito and is associated with a latent liver phase that must be tx (with primaqine) independently of the erythrocytic phase to fully eliminate the organism described on peripheral blood smear using Giemsa stain showing intraerythrocytic ringed inclusions.

sinus rhythm

P wave before every QRS wave nl PR and QRS intervals nl P, QRS, and T waves Regular sinus rhythm R-R intervals and regularly spaced

diseases associated with HLA-B27

PAIR Psoriasic arthritis Ankylosing spondylitis IBD associated arthritis Reactive (Reiter) Arthritis

Milrinone

PDE3 inhibitor - prevents cAMP breakdown ↑ cAMP - ↑Ca++ ↑ contractility ↑ CO ↑ SV ↑ Heart rate ↑ Ejection fraction ↓ preload & ↓ afterload *used as bridge therapy in stage 4/stage D HF* waiting for transplant *SE* - ventricular arrhythmias, hypotension, headace, ↑ bruising or bleeding Excreted in urine *↑ mortality with long term use*

Misoprostol

PGE1 derivative: orally active prostaglandin used to prevent peptic ulcers in patients taking NSAIDs for arthritis. Tox: diarrhea

Radial nerve injury

Passes through axilla, crutch paralysis, wrist drop weakness of the forearm, hand, and fingers extensors (wrist drop, absent triceps reflex) and sensory loss over the posterior arm and forearm, dorsolateral hand, and dorsal thumb. More distal lesions spare the triceps brachii

Which values are influenced by disease prevalence?

Postive and Negative Predictive Values are influenced by disease prevalence in the target population; Sensitivity, specificity and likelihood ratios are not prevalence-dependent

Power equation

Power = 1-beta power is the ability of a study to detect a difference between groups when such a difference truly exists. power is related to type II error: probability of concluding there is no difference btw groups when one truly exists. substitute probability with beta

Telogen effluvium

Premature or sudden hair loss due to psychological stress, major surgery, or illness.

Heteroplasmy

Presence of both normal and mutated mtDNA (mitochondrial DNA), resulting in variable expression in mitochondrial inherited disease varability is bc during mitosis mitochondria are randomly distributed btw daughter cells thus some cells contain mitochondria with mostly damaged mtDNA, while some contain mostly normal mitochondrial genomes

depressive disorder with melancholic features

Present in approximately *25-30% of patients* with MDE and *more likely in severely ill* inpatients, including those with psychotic features. Characterized by *anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, and anorexia*. For example, you may diagnose major depressive disorder with melancholic features.

Tx for pulmonary hypertension

Presentation: progressive dyspnea and fatigue, sometimes with associated CP and exertional lightheadedness or syncope. Due to RV enlargement, a holosystolic murmur of functional tricuspid regurgitation is often present. Can be due to a primary change in the pulmonary arteries (pulmonary arterial HTN) or it can be secondary to a separate dz process such as L-sided HF (ruled out by nl pulmonary capillary wedge pressure. E Endothelian receptors antagonists (bosentan, ambrisentan) lower pulmonary arterial pressure and improve dyspnea in pt with pulmonary arterial HTN

psoas abscess presentation

Presents with fever, back pain, or flank pain, an inguinal mass, and difficulty walking. Inflammation of the psoas muscle leads to pain with extension at the hip (ie psoas sign). Psoas abscess can develop due to hematogenous or lymphatic seeding from a distant site, particularly in a pt with diabetes mellitus, IV drug use, and immunosuppression (HIV) Remember: the psoas sign can also occur in acute appendicitis when the appendix is retrocecal (located behind the cecum) as the inflamed appendix lies upon the right psoas muscle, causing irritation.

Prevalence

Prevalence = (incidence) x (duration of disease) Changing dz prevalence in a steady-state population with a constant incidence rate means that there is an additional factor affecting the duration of the condition. A factor that prolongs dz duration (improved quality of care) will increase disease prevalence, as affected patients survive longer.

malarial treatment for hypnozoites

Primaquine is approved to treat relapsing malaria dz (relapsing infection weeks to years after initial infection) associated with P ovale and P vivax

Primary hypothyroidism

Primary hypothyroidism is characterized by low thyroxine (T4) and triiodothyronine (T3) levels, with increased thyroid stimulating hormone and thyrotropin releasing hormone (TRH) levels. TRH also acts on the anterior pituitary gland to stimulate prolactin production, thereby causing decreased gonadotropin releasing hormone and subsequently decreased sex hormones (ie., follicle stimulating hormone and luteinizing hormone). This can lead to anovulation with menstrual irregularities. low T4 and increased TSH which T3 can be nl but fluxes due to its short half life

Creutzfield-Jakob Disease (CJD)

Prion diseases or transmissible spongiform encephalopathies are rare progressive neurodegenerative disorders that affect both humans and animals. due to misfolded proteins, termed "prions" that are transmissible and are able to induce abnormal folding of specific cellular proteins found most abundantly in the brain. Creutzfeldt-Jakob disease is the most common prion disease and presents with rapidly progressive dementia, ataxia, and myoclonus. characteristic EEG findings with periodic or pseudoperiodic paroxysms of sharp waves or spikes on a slow background

Omeprazole (Prilosec)

Proton pump inhibitor Inhibits enzyme that produces gastric acid Used for PUD, GERD Insignificant side effects w/ short term treatment Long term use increases risk of gastric cancer and osteoporosis

HIV strains

R5 strains (macrophage-trophic) of HIV attach to the host CD4 receptor and CCR5 chemokine coreceptor; CCR5 inhibitors such as Maraviroc can be used to tx R5 virus. X4 strains (T-lymphotrophic) of HIV bind to the CD4 receptor and CXCR4 chemokine receptor; X4 virus cannot be treated with CCR5

y descent

RA emptying into RV. Prominent in constrictive pericarditis, absent in cardiac tamponade.

REM sleep

REM sleep is characterized by dreaming and voluntary muscle paralysis, and occurs more often during the final third of the night. REM sleep is characterized by the defining feature of rapid eye movements, vivid dreaming, and voluntary muscle atonia due to inhibition of motor neurons Nightmares occur during REM sleep and can be differentiated from sleep terrors, a non-REM parasomnia characterized by incomplete arousals and lack of recall of dream content

Radial nerve injury

Radial nerve is a terminal branch of the brachial plexus that carries fibers originating in the C5-T1 nerve roots. It innervates most of the *forearm extensors* at the elbow: triceps and most of the *hand extensors* at the wrist. Also innervates the estrinsic extensors of the digits ad the brachioradialis and supinator muscles. Provides cutaneous sensory innervation to the dorsal hand, forearm, and upper arm. The deep brachial (profnda brachii) artery and radial nerve run together along the posterior aspect of the humerus. Deep Brachial artery branches off the brachial artery high in the arm, passes inferior to the teres major muscle, and courses posteriorly along the humerus in close association with the radial nerve. *MIDSHAFT FX of the humerus* risk injury to these structures.

integrase inhibitors

Raltegravir disrupt HIV genome integration, preventing synthesis of viral mRNA Integration of ds-HIV DNA into the host cells chromosomes is necessary to induce viral gene expression and prevent degradation of the viral genome

Merkel cell carcinoma

Rare neoplasm from merkel cell of epidermis *neural crest-derived cell important for tactile sensation * may resemble metastatic SCC from lung or certain lymphomas *aggressive Tx is aggressive surgery Lesions usually present as a firm, painless, nodule or mass that is flesh-colored, red, or blue. Tumors typically vary in size from 0.5 cm to more than 5 cm in diameter and usually enlarge rapidly. Although Merkel cell carcinoma may arise almost anywhere on the body, about half originate on sun-exposed areas of the head and neck, one-third on the legs, and about one-sixth on the arms. In about 12% of cases, no obvious anatomical site of origin can be identified.

Relative Risk RR

Ratio of the probability of an event occurring in the treatment group compared to the control group RR= treatment rate / control rate

Tachyphylaxis

Reduction in drug responsiveness brought on by repeated dosing over a short time

Contractile mechanism in skeletal muscle

Relies on proteins (myosin II, actin, tropomyosin, and troponin) as well as calcium ions form the sarcoplasmic reticulum. During excitation contraction coupling, Ca is released from the SR, when Ca binds to troponin C - tropomyosin shifts to expose the actin binding sites for myosin, allowing contraction to occur.

Renal clearance equation

Renal clearance = (Urine flow rate x urine concentration X) / plasma concentration X * Urine fr over [plasma] times flow

Pralidoxime

Reverses AChE inhibitor binding to Ach-->allows AChE to function normally again Use = tx of organophosphate/AChE inhibitor poisoning This is the ONLY med that reverses both the muscarinic AND nicotinic side effects of organophosphates!!! (Atropine only reverses muscarinic side effects) "Have a Parade because your AChE is back"...weeeaak

A 30-year-old woman gives birth to a healthy baby boy. It is her first pregnancy and first child. Earlier in the pregnancy, her obstetrician administered Rh(D) immunoglobulins (RhoGAM) at 28 weeks' gestation. Upon delivery, the neonate's blood is tested, and based on this test, the obstetrician administers a second dose of RhoGAM. Which of the following is the most accurate statement concerning the treatment of the mother with RhoGAM?

RhoGAM is given to Rh(D)-negative mothers to prevent Rh(D) alloimmunization. Since the mother was treated with RhoGAM, she must be Rh(D) negative. Since the blood test shortly after delivery resulted in a second dose of RhoGAM then the neonate must have been Rh(D) positive. [There would be no risk of Rh(D) alloimmunization if the neonate tested Rh(D) negative.] Since the mother is Rh(D) negative, this baby must have inherited the gene for the Rh-antigen from his father; therefore, *the father is Rh(D) positive*. The Rhesus factor is inherited in a typical Mendelian fashion. Fathers who are heterozygous have a 50% chance of passing the gene and fathers who are homozygotes have a 100% chance of passing the gene. Hemolytic disease of the newborn is caused by the presence of antibodies in the Rh(D)-negative mother crossing the placenta and attacking the Rh(D)-positive red blood cells of the fetus. In this case, RhoGAM will prevent hemolytic disease in the next Rh(D)-positive child, not the current one. In other words, her newborn son was not at risk for hemolytic disease. This is because any immunoglobulin produced at first sensitization (first pregnancy) does not cross the placenta. In subsequent pregnancies, a second encounter with Rh(D) antigen results in rapid production of immunoglobulin (IgG anti-D) that can cross the placenta and attack the fetus. The goal of RhoGAM during a first pregnancy is to prevent Rh(D) alloimmunization, which thus lowers the chance of the cascade of immune events that could harm the fetus in a subsequent pregnancy. RhoGAM does not contain Rh(D) antigen, but the antibody prevents sensitization of the mother's immune system to the Rh(D)-positive surface antigen in fetal blood.

Anterior rib tenderpoints

Rib 1: Below the clavicle on first chondrosternal articulation TX: Patient supine; using the cervical-thoracic spine, flex, side-bend, and rotate towards the point Rib TP2: Superior aspect of second rib at midclavicular line TX: same as above AR3-10: On the rib at the anterior axillary line TX: In seated position, flex, side-bend, and rotate towards the point

drugs that decrease warfarin effect

Rifampin, phenytoin, phenobarbital carbamazepine, Ocps, ginseng, st john's wort, green veges (CYP450 inducers)

scleroderma

Scleroderma is used to describe shiny, hard, thickened skin. Scleroderma may occur alone, but when the sclerosis involves internal organs it is called systemic sclerosis (SSc). It can be further defined as limited or diffuse. In diffuse SSc anti-topoisomerase (anti- Scl 70) antibody is positive and the antibody is associated with development of interstitial lung disease and reduced survival. Diffuse SSc skin changes involve entire extremities, chest, abdomen, and face. Before ACE inhibitors, scleroderma renal crisis was the major cause of morbidity and mortality. Difficulty swallowing occurs in both limited and diffuse. Limited SSc typically involves the distal extremities and face. Anti-centromere antibody is very specific for limited SSc. Pulmonary hypertension occurs in limited SSc. 'CREST' syndrome is a feature of limited SSc (Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasias). In limited SSc there is an association with primary biliary cirrhosis (PBC) and positive anti-mitochondrial antibody.

Secondary disease prevention

Screening early for disease (e.g., Pap smear)

Secondary Lactase deficiency- cause

Secondary or acquired lactose intolerance can be due to inflammation (celiac dz) or infection (giardiasis) of the small intestine, both of which can cause cellular damage to the intestinal lining (damages the microvilli). The damaged cells are slough off and are replaced by immature cells with low lactase concenrations, resulting in a decreased ability to convert lactose to galactose. Presentation:abd distension, cramping, flatulence, and diarrhea Secondary lactose intolerance is common after giardial infections.

Septic arthritis

Septic arthritis occurs in 2% of patients who undergo total knee replacements. The prosthesis provides a surface for bacteria to adhere, therefore, this infection needs to be treated aggressively with surgery and prolonged antibiotics. Septic arthritis occurring > 1 year after implantation of a prosthetic joint (late onset) occurs most often from hematogenous spread from another site. In contrast, infections occurring within 1 year (early and delayed onset) are due to inoculation of bacteria during implantation of the joint.

Toxoplasma encephalitis

Setting: - exposure to cat feces w/ subsequent ingestion of oocysts - Reactivation in setting of immunosuppression - Primarily AIDS w/ CD4+ <100/mm^3 Sx: - HA, confusion, fever, focal neurologic deficits/seizures Dx: - Positive IgG - Multiple *ring-enhancing* brain lesions Tx: - Sulfadiazine & pyrimethamine (leucovorin) - Antiretroviral initiation - Prophylaxis: *TMP-SMX* (CD4 <100/mm^3)

1,25-dihydroxycholecalciferol

Should be checked first in a pt with an elevated Ca level and presenting with 2-week history of fever, malaise, dyspnea, erythema nodosum, parotid enlargement, hepatosplenomegaly, and CT showing hilar adenopathy

sickle cell crisis

Sickle cell crises usually present with joint pain, acute chest syndrome, and splenomegaly. Acute chest syndrome can present like pneumonia with chest pain and pulmonary infiltrates.

Serotonin Syndrome

Similar to NMS but caused by serotonin medications, and has HYPERreflexive muscle activity (AMS, autonomic hyperactivity, and neuromuscular excitation). Tryptophan is a precursor for serotonin can treat with cyproheptadine: an antihistamine with antiserotonergic properties when pt does not respond to supportive measures. (nonspecific 5-HT1 and 5-HT2)

Squmaous cell carcinoma of the lung

Smoker Central Syndrome: PTHrP keratin pearls or intercellular bridges

Effects of smoking on FEV1

Smoking is the stronges RF for COPD and is responsible for accelerated decline in FEV1 in pt with COPD. Smoking cessation will slow the accelerated decline in FEV1, but FEV1 will NOT return to the level it would have been had the pt never smoked

Main branches of the external carotid artery

Some Anatomists Like Freaking Out Poor Medical Students Superior thyroid artery, arising from its anterior aspect Ascending pharyngeal artery - arising from medial, or deep, aspect Lingual artery - arising from its anterior aspect Facial artery - arise from its anterior aspect Occipital artery - arising from its posterior aspect

carotid baroreceptors

Special sensors in the carotid arteries that are sensitive to transluminal (across the wall) stretch. These elastic vessels send signals to the brain indicating blood pressure changes. sens increase pressure: if BP is low would decrease number of impulses from carotid baroreceptor, increase sympathetic efferent activity and decrease parasympathetic efferent activity increased BP cause firing of the carotid and arotic baroreceptors at a higher than normal rate, these signals are sent via glossopharyngeal nerve and vagus nerve to nucleus tractus solitarius in the brain stem: this activates the PSNS and inhibits SNS

von Hippel-Lindau disease

Sporadic and hereditary (assoc w/ von Hippel-Lindau dz) renal cell carcinomas are associated with mutations involving the VHL gene on chromosome 3p. The VHL gene is a tumor suppressor that inhibits hypoxia-inducible factors; mutations lead to constitutive activation of these proteins, resulting in activation of multiple angiogenic and tumorgenic growth factors AD *cerebellar hemangioblastoma, congenital cysts of the kidneys, liver, and/or pancreas*

Antioxidant enzymes

Superoxide dismutase, glutathione peroxidase, catalase convert ROS to oxygen and water, neutralizing their capacity for cellular damage. ROS generated during cellular respiration are typically neutralized by antioxidants before they become problematic. However, in a post-ischemic repurfusion state the production of ROS exceeds the neutralizing capabilities of antioxidant enxymes (high oxidatve stress) leading to increased cell injury and death

Supination and pronation of the foot

Supination: adduction, inversion, and plantar flexion pronation: abduction, eversion, and dorsiflexion

apocrine glands

Sweat glands in the pubic and underarm areas that secrete thicker sweat, that produce ODOR when come in contact with bacteria on the skin

Polymyositis/Dermatomyositis

Symmetric progressive proximal muscle weakness (occurs in legs first ) and myalgias, muscle atrophy in later stages of disease associated with antinuclear and anti-tRNA synthethase (anti-Jo-1) autoantibodies. Biopsy in polymyositis:patchy endomysial inflammatory infiltrate-direct invation of individual muscle fibers desmatomyositis: causes perifascucular inflammation - localized around blood vessels and the septa btw muscles fasciciles

The murmur of aortic stenosis

Systolic ejection type, crescendo-decrescendo murmur that starts after the first heart sound and typically ends before the A2 component of the second heart sound. The intensity of the murmur is proportional to the magnitude of the LV to aorta pressure gradient during systole. radiates to the neck; ↑ with ↑ preload (Valsalva maneuver).

control of M Tb

T-helper subtype 1 cells release interferon-gamma leading to the activation of macrophages, a process important in controlling M Tb. Activated macrophages from mature phagolysosomes that destroy phagocytosed mycobacteria and can differentiate into epithelioid and Langhans giant cells to wall off extracellular mycobacteria within caseating granulomas. Interferon-gamma, IL-12, and TNF-alpha are cytokines for the formation & maintenance of granulomas.

Negative Predictive Value (NPV)

TN/(TN+FN) probability of not having a dz given a negative test result. Inversely proportional to prevalence of a disease.

Fluorescence in situ hybridization (FISH)

Technique used to detect a given nucleotide sequence within intact cells on a microscope slide analyzes chromosomes Presence/absence of specific DNA sequence in a specific chromosome location

Phase I clinical trial

Testing of drug on SMALL NUMBER OF healthy volunteers for dose-ranging Researchers test a new drug or treatment in a small group of people for the first time to evaluate its safety, determine a safe dosage range, and identify side effects.

Phase 4 clinical trials

Testing that continues after drug has already been approved and gone to market (being sold) to test long term safety

heterophile antibody-negative mononucleosis-like syndrome

The Monospot test is + in most cases of EBV associated mononucleosis. In immunocompetent pt with heterophile antibody-negative mono-like syndrome the most likely dx is CMV CMV can be acquired during the transfusion of leukocyte-laden blood products, as the virus infects leukocytes of granulocyte macrophage lineage. Irradation helps reduce this risk. Other causes of heterophile antibody-negative mononucleosis-like syndrome include HHV-6, HIV, and toxoplasmosis

What can be visualized on PA CXR

The R middle lobe is seen adjacent to the R border of the heart, which is primarily formed by the RA. Consolidation in the R middle lobe can obscure the CXR silhouette of the R heart boarder.

Names of vitamins may be provided either with the vitamin letter/number or the vitamin name. Create a list or remember the B vitamins with this mnemonic:

The Rhythm Nearly Proved Contagious (B1 = Thiamine, B2 = Riboflavin, B3 = Niacin, B6 = Pyridoxine, B12 = Cobalamin).

where is the most common site for ectopic pregnancy?

The ampulla of the oviduct aka Fallopian tube

Clear cell carcinoma

The most common type of renal cell carcinoma made up of cells with clear or granular cytoplasm. originates from epithelial cells of the proximal renal tubules sphere-like mass made of golden-yellow cells (high lipid content) with areas of necrotic cells and focal hemorrhage

conduct aphasia

The arcuate fasciculus is a dense neural tract that connects Wernicke's area in the superior temporal gyrus with Broca's area in the inferior frontal gyrus. Damage to this area leads to conduction aphasia. Patients with conduction aphasia are able to speak correctly and fully understand speech. However, they are unable to repeat unfamiliar words that are spoken to them. These patients are fully aware of their difficulties.

external carotid artery

The artery that supplies blood to the anterior (front) part of the scalp, ear, face, neck, and side of the head is the:

systemic lupus erythematosus (SLE)

The characteristic "butterfly rash" in systemic lupus erythematosus is caused by deposition of DNA and anti-DNA complexes in the skin (type III HSN rxn) the vast majority of SLE patients are females, commonly African American. Other symptoms include fever, fatigue, weight loss, hilar adenopathy, and Raynaud phenomenon. Renal failure due to immune complex deposition previously was the most common cause of death; however, cardiovascular disease has surprised renal failure as cause of death. The *ANA test* is highly sensitive (95%) while the *anti-dsDNA test* is highly specific for SLE. The most specific test for SLE is the *anti-Sm/anti-Smith antibody*. Other common autoantibody tests that may be positive include anti-SSA (Ro) or anti-SSB (La) seen in Sjogren's, anti-ribosomal P, anti-RNP seen in scleroderma and myositis, and anti-histone seen in drug-induced lupus (procainamide or hydralazine).

clear cell carcinoma

The most common type of renal cell carcinoma made up of large, rounded, or polygonal cells with clear cytoplasm. detected in advanced stage, Lunge are the m/c site for metastasis then bone and liver.

odds ratio

The likelihood of a disease among individuals exposed to a risk factor compared to those who have not been exposed (case-control study) Odds ratio = (# of patients with the disease and risk factor present/# patients with no risk factor present) / (# controls with risk factor present/# controls with no risk factor present).

differentiating primary or secondary TB

The lung area that is affected depends upon whether this patient has primary or secondary (reactivation) TB. The Ghon complex of primary TB favors the upper part of the lower lobe and the lower part of the upper lobe. Primary TB would result in findings of viscerosomatic changes from T4-7, anterior Chapman points in the fourth intercostal space, and dysfunction in the lower ribs and diaphragm. Reactivation TB affects the upper lung and would result in viscerosomatic changes from T2-5, Chapman points anteriorly located in the third intercostal space, rib somatic dysfunction in the most superior ribs, and tissue changes around the pathology due to local inflammation (trapezius and supraclavicular fossa). Secondary TB preferentially affects the apices because M. tuberculosis is an obligate aerobe and prefers the higher oxygen pressure found there. In particular, M. tuberculosis prefers the right apex, which has the highest oxygen pressure of all regions. The cavitary lesions of secondary TB are caused by the release of cytokines from memory T cells.

intersitital pneumonia

The most common type of amiodarone-induced pulmonary toxicity is interstitial pneumonitis, also commonly referred to as nonspecific interstitial pneumonia, a type of interstitial lung disease. Interstitial lung diseases are a heterogenous group of disorders that affect the interstitium of the lung. causes of interstitial lung disease: drugs, radiation exposure, and autoimmune processes Patients can present with dyspnea, digital clubbing, and crackles on auscultation. Examination may reveal increased use of accessory respiratory muscles, viscerosomatic changes from T2-T6, and poor chest wall motion secondary to the restrictive nature of this lung disease. Typically, pulmonary function testing will reveal a restrictive pattern and a low carbon monoxide diffusion capacity.

guidelines for HIV testing

The new human immunodeficiency virus (HIV) testing guidelines include an initial HIV-1/2 antigen/antibody combo immunoassay followed by an HIV-1 vs HIV-2 antibody differentiation immunoassay. Nucleic acid testing then follows as necessary.

mismatch repair

The newly replicated DNA is scanned for mistakes by other proteins, and mismatches can be corrected.

exception to informed consent

The only exception to informed consent is the emergency presumption, under which patients with life-threatening emergencies can be treated without their consent or the consent of a surrogate. Since the necrotic bowel threatens the patient's life, no patient or surrogate consent to remove the necrotic bowel is required.

GG is a 37-year-old male who immigrated to the United States from Bolivia when he was 7 years of age. He visits his primary care physician in anticipation of surgery sometime in the next 6 months. As part of his examination, he is given a 12-lead ECG. The dominant peak of the QRS wave is positive in leads I, II (Wenchkebach), and aVF; negative in lead aVR; and isoelectric in lead aVL. Which of these statements best describes membrane characteristics during the action potential of the pacemaker cells in his sinoatrial node?

The pacemaker potential (phase 4) of the sinoatrial node develops because of the increasing membrane permeabilities of Na+ (ie, the "funny" channels) and Ca++ and the decreasing membrane permeability of K+ that gradually depolarize the membrane until the membrane potential reaches the threshold for an action potential.

prevalence rate

Total number of cases in the population over a given period

Tertiary disease prevention

Treatment to reduce disability from disease (e.g., chemotherapy, medicine, therapy)

syphilis

Treponema pallidum (spirochetes) pathology associated with ISCHEMIA due to PROLIFERATIVE ENDARTERITIES of small blood vessels associated with PLASMACYTIC inflammation (plamsa cells and lymphocytes)

Paroxysmal nocturnal hemoglobinuria (PNH)

Triad: hemolytic anemia, hypercoagulability (hepatic vein thrombosis) and pancytopenia results from an acquired mutation in the PIGA gene that causes absence of the glycosylphosphatidylinositol anchor and associated deficiency of CD55 and CD59 complement inhibitor proteins.

Fat embolism syndrome

Triad: of acute-onset neurologic abnl, hypoxemia, and petechiae in a pt with traumatic bone fx (long bone or pelvic) Pulmonary: hypoxemia, dyspnea, and tachypnea Neuro: AMS, seizures, and focal deficits Rash: Red-brown, petechial rash on head, neck, chest, and axilla occurs 24-72 hrs after a long-bone/pelvic fx the event dislodges fat globules from the bone marrow and allows them to enter disrupted marrow venules where they can go to the systemic veins and deposit in pulmonary microvessels. the pulmonary capillary occlusion impairs gas exchange and induces hypoxemia; release of free fatty acids from fat globules can cause local toxic injury to endothelium, potentially leading to ARDS

Wernicke encephalopathy

Triad: ophthalmoplegia, ataxia, and confusion, and can lead to coma and death if left untreated. Foci of *hemorrhage and necrosis* in the *mammillary bodies* and periaquductal gray matter are typically found on autopsy. This condition occurs due to chronic thiamine deficiency which is common in pt with *alcoholism* Thiamine (vit B1) participates in glucose metabolism and is a cofactor for the following enzymes: 1. Pyruvate dehydrogenase: converts pyruvate (glycolysis end product) into acetyl-CoA (enters the citric acid cycle) 2. alpha-Ketoglutarate dehydrogenase, an enzyme of the citric acid cycle 3. Branched-chain alpha-ketoacid dehydrogenase, which is essential for catabolism of branched-chain amino acids (leucine, isoleucine, valine) 4. Transketolase: an enzyme of the pentos phosphate pathway that helps convert ribulose 5-P (derived from glucose) to glycolysis intermediates (glyceraldehyde 3-P) Thiamine deficiency can be dx if baseline erythrocyte transketolase activity is low but increases after addition of thiamine pyrophosphate

what are 3 drugs that inhibits dihydrofolate reducatase the enzyme needed to convert dihydrofolic acid to THF

Trimethoprim (bacteria) Methotrexate (humans- specific for the S phase prevents purine and pryimidine synthesis) Pyrimethamine (protazoa: malaria and toxoplamosis)

Mycobacteria tuberculosis

Tuberculin skin test (TST): common screening test for M tb exposure. It involves injection of tuberculin antigens under the skin, which provokes a T-cell mediated, delayed HSN rx in those who have been previously exposed: induration at 48-72 hrs. B/c the cell-mediated response takes several weeks to form, recently exposed pt often have negative initial TST testing. Conversion usually occurs within 8 weeks. M tb replicated within the phagosome, leading to display of myocobacterial antigens on major histocompatibility complex class II. Resulting in the activation of CD4 cells and subsequent control of the infection with macrophages.

BRCA1 and BRCA2

Tumor Suppressor (2 hit) Breast and ovarian cancer DNA repair protein

Types of Spondylolisthesis

Type 1 - Dysplastic -Congenital malformation of upper sacrum and neural arch of L5. Risk of slippage increases with the degree of S1 rounding Type 2 - Isthmic -A= Pars fatigue fracture -B= elongation of pars -C= lowerlumbar hypertension common in young athletes Type 3 - Degenerative -Most common at L4-L5 -3 F's (Female, Fat, Forty) - associated with osteophyte formation, intervertebral disc space narrowing, subchondral sclerosis, and subchondral cystic change Type 4 - Traumatic (MVA) -Not pars, but NEURAL ARCH FRACTURE - OCCURS AT ANY LEVEL Type 5 - Pathogenic -Generalized or system disorder Type 6 - Iatrogenic -Surgery

5 min after graft blood vessels are anastomosed to host vessles, pt develops hemorrhage and thrombotic occlusion of the graft vessels. most likey mediator?

Type II HSN reaction-hyperacute transplant rejection. would have IgG and complement activation

cluster headache

Unilateral, severe periorbital headache with tearing and conjunctival erythema, lacrimation, and rhinorrhea. last btw 15min - 3 hrs common in M recurrent over a short period of time Tx: 100% oxygen, SubQ/IV sumatriptan can be use to abort the HA, long-term prevention: prophylaxis with verapamil, methysergide, or lithium

Enterococcus species are more resistant to to what?

VRE is a substitution of D-lactate in the place of D-alanine during the process of peptidoglycan cell wall synthesis. Preventing the binding of vancomycin to its usual D-alanyl-D-alanine binding site in the cell wall

third heart sound (S3)

Ventricular gallop which occurs AFTER S2. (Lub-dub-by!!) Heard because of *rapid PASSIVE filling of ventricles in diastole*. It is commonly associated with *increased left ventricular end-systolic volume* because of *left ventricular systolic failure*. Also associated with systolic HF, Mitral regurgitation, and High output states Can be heard by listening at the END of expiration and lying in the left lateral position, with the BELL over the apex!!! NORMAL in pt <40 years of age and pregnancy

pyridoxal phosphate

Vit B6 acts as a cofactor for alanine transaminase: catalyzes the reversible reaction btw pyruvate and glutamate to alanine and alpha-ketoglutarate in the liver and muscle tissue

Rickets

Vit D deficiency osteomalacia in children; causes bone deformity frontal bossing and flattening of back of skull, defects in enamel of teeth, chest wall with a groove, bowed legs, would see: increased proportions of osteoid

Budd-Chiari syndrome

What is the term for the syndrome consisting of hepatomegaly, ascites, and abdominal pain due to hepatic vein thrombosis/ compression of hepatic veins

life of RNA in the nucleus and cytoplasm

When mRNA is first transcribed from DNA, it is an unprocessed form called pre-mRNA or heterogeneous nuclear mRNA (hnRNA). Several processing steps are required before finalized mRNA molecules can leave the nucleus, including 5'- capping, poly A tail addition, and intron splicing. Cytoplasmic P bodies play an important role in mRNA translation regulation and mRNA degradation co

side effects of morphine/ opioids

While opioids are a common prescription for chronic pain especially in patients with cancer, they carry several adverse effects. These include decreased respiratory rate, miosis, constipation, nausea, and somnolence. However most of these usually disappear in a manner of days to weeks in chronic opioid users as they build tolerance to the drug. Constipation is a likely side effect that may remain in chronic users. Chronic use of opioids usually leads to tolerance of nausea and decrease in respirations; however, abruptly increasing the dose may cause these symptoms to reemerge.

Wiskott-Aldrich syndrome

X-linked d/o triad: 1) thrombocytopenia: petechiae, purpura, hematemesis and epistaxis 2) immunodeficiency: recurrent infections, combined B-lymphocyte and T-lymphocyte d/o 3) eczema unable to mount a humoral immune response against org with a polysaccharide capsule such as N. meningitidis, Haemophilus influenzae, and Strep pneumonia - seen in children 6-12 months of age when mom's IgG and IgA are degraded T-cell defect leads to infections with opportunistic pathogens such as Pneumocystis jiroveci and herpesviridae due to a defect in cytoskeleton rearrangement tx: HLA-matched bone marrow transplantation

Chronic Granulomatous Disease (CGD)

X-linked d/o resulting from deficiency of NADPH oxidase, the enzyme responsible for formation of ROS in phagosomes. Neutrophils affected by this d/o are unable to kill catalase-positive-producing organisms, resulting in recurrent bacterial and fungal infections that frequently involve the lungs, skin, and lymph nodes.

Rett Syndrome

X-linked dominant d/o affecting females (affected males die in utero) that presents in early childhood with progressive neurodegeneration and stereotypical hand movements. X-linked dominant conditions are characterized by a lack of father-son transmission whereas all daughters of an affected father are affected. Half of all offspring of an affected mother are also affected.

G6PD deficiency

X-linked recessive d/o causes hemolytic anemia and jaundice secondary to increased oxidative stress due to the lack of NADPH. oxidant stressors include: sulfonaminde, antimalarial drugs, infection) Glutathione reductase deficiency has a similar clinical consequence as its absence results in an inability to use NADPH to reduce glutathione G6PD is an enzyme of the pentose phosphate pathway, it generates the reducing agen NADPH See Heinz bodies and bite cells

Lesch-Nyhan syndrome

X-linked recessive d/o characterized by the development of dystonia, choreoathetosis, self-mutilation, and hyperuricemia within the first few years of life. The condition is caused by a deficiency of *hypoxanthine-guanine phosphoribosyltransferase (HGPRT), and enzyme that normally functions in the purine salvage pathway to convert hypoxanthine back to inosine monophosphate and guanine back into guanosine monophosphate. The absence of HGPRT = increased degradation of guanine and hypoxanthine bases into uric acid, which increases the demand for de novo purine synthesis. *failure of the purine salvage pathway, leading to increased degradation of hypoxanthine and guanine to uric acid. De novo purine synthesis must increase to replace the lost bases, necessitating an increase in phosphoribosyl pyrophosphate (PRPP) amidotransferase activity.

Hemophilia A

X-linked recessive factor VIII deficiency Emicuzimab- bispecific monoclonal antibody-mimics the activity of factor VII by binding both IXa and factor X, bridging them into close proximity to allow for factor X activation

Primary biliary cirrhosis

a chronic liver disease characterized by autoimmune destruction of the intrahepatic bile ducts and cholestasis (elevated alk phos). The condition is most common in middle-aged women, with severe *pruritis* usually being the first symptom reported. Can be associated with *Sjogren's syndrome and other autoimmune diseases.*

Asymptomatic Left ventricular systolic dysfunction

a common stage in the progression of HF Neurohormonal mechaisms, including the sympathetic nervous system and RAAS hepl maintain the asymptomatic period by increasing volume retention and peripheral resistance to maintain organ perfusion. Although these mechanisms are beneficial in the short term, they are ultimately deleterious increaing hemodynamoc stress and cardiac remodeling that eventually lead to decompensated HF

Neonatal Abstinence Syndrome (NAS)

a condition in which a child, at birth, goes through withdrawal as a consequence of maternal drug use presents with neuro, gastro, and autonomic sx tremors, irritability, diarrhea and poor feeding tx: opioid therapy (morphine, methadone)

premature ejaculation

a condition in which the male reaches climax too soon, usually before, or shortly after, penetration of the female recurrent episodes of early ejaculation accompanied by a sense of lack of control. Evaluation of any sexual d/o requires taking careful medical and substance use hx and assessing psychosocial stressors and comorbid psychiatric conditions. prostatitis and thyroid dz are linked to premature ejaculation Dx: ejaculation within *one minute* of penetration, occurring most of the time for at least 6 months. Diagnostic criteria are based on ejaculation during partnered sexual activity

Gastroparesis

a condition in which the muscles in the stomach slow down and work poorly or not at all, preventing the stomach from emptying normally common probelm of uncontrolled DM, presents with early satiety, heartburn, and vomiting of undigested food within a couple of hours of eating treat with Metoclopramide to increase gastric motility by sensitizing the gastric mucosa to Ach.

Acute renal allograft rejection

a condition that develops in some kidney transplant patients in which the recipient's immune system attacks the cells of the transplanted organ, leading to loss of kidney function diffuse lymphocytic infiltration of the renal vasculature (endotheliitis), tubules, and interstitum

Decreased CO in HF

a decreased CO in HF causes a number of compensatory mechanisms. RAAS gets activated and also sympathetic output which raises arterial resistance (afterload) and therefore exacerbates HF by making it more difficult for heart to pump to tissues.

Secondary hyperaldosteronism with increased renin levels may indicate

a defect in the juxtaglomerular apparatus of the kidney.

Malassezia furfur

a dimorphic fungus with yeast and hyphae, causes tinea versicolor or pityriasis versicolor, a dermal infection causing numerous, well-marginated, hypopigmented or hyperpigmented macular skin lesions that do not itch nor are they erythematous. common in hot humid climates seen in the upper body The lesions of are not painful. Skin scrapings following KOH treatment reveal a "spaghetti and meatball" arrangement with both round yeast and rectangular hyphal forms.

Oppositional Defiant Disorder (ODD)

a disorder characterized by age-inappropriate and persistent displays of angry, defiant, and irritable behaviors pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness for >6mo - argues with adults, defies authority figures, refuses to follow rules, - Deliberately annoys others - blames others for own mistakes/misbehaviors - easily annoyed, angered, resentful, or vindictive - not due to another mental d/o

depersonalization/derealization disorder

a dissociative disorder marked by the presence of persistent and recurrent episodes of depersonalization, derealization, or both feeling detached from one's body or surrounding and/or feelings of unrealtity

Cheyene-Stokes breathing

a distinct pattern of breathing characterized by quickening and deepening respirations followed by a period of apnea

Eikenella corrodens

a fastidious gram-negative rod that can exist as normal flora of the mouth. It can also cause subacute infective endocarditis; however, it is not as common as S. sanguinis.

perineal body

a fibromuscular tissue between the urogenetial and anal triangle. A midline episiotomy is a vertical incision from the posterior vaginal opening to the perineal body. it transects that vaginal submucosal tissue but not the external anal sphincter or the rectal mucosa

Escherichia coli

a frequent cause of neonatal meningitis, second only to group B streptococci. E coli strains that cause neonatal meningitis posses the K1 capsular antigen. The K1 capsule is a virulence factor that allows the bacteria to survive in the bloodstream and establish meningeal infection.

Isoniazid is metabolized by

acetylation. the speed with which a pt is able to acetylate drugs depends on whether they are a "fast" or "slow" acetylator

Huntington's disease

a hereditary disease marked by degeneration of the brain cells and causing chorea and progressive dementia. CAG trinucleotide repeat

la crosse virus

a mosquito-transmitted member of the Bunyaviridae family, causes encephalitis characterized by mental status change, neurologic defects, and fever. most common and most pathogenic of the California encephalitis serogroup of bunyaviruses. These viruses are enveloped with a negative sense, circular, single-stranded RNA genome with helical nucleocapsids and are transmitted through the bite of the Aedes triseriatus mosquito and have rodent reservoirs in nature. most prevalent in the Southeastern and Midwestern US. This disease begins with a prodromal phase, lasting 1-4 days, consisting of fever, chills, nausea, vomiting, headache, and abdominal pain. This is followed by fever, somnolence, and mental status change or obtundation. Physical findings include focal neurologic deficits, such as aphasia, incoordination, focal motor abnormalities, and paralysis. Diagnosis is made by clinical history, virus isolation, or detecting specific IgM in cerebrospinal fluid samples. Supportive care is the mainstay treatment. Most patients with clinical symptoms recover completely. However, 20% of patients develop behavioral problems or recurrent seizures. Mortality rates are < 1%. The other serogroup of medically relevant bunyaviruses is hantavirus, which is transmitted by exposure to rodent excrement and cause a severe pulmonary infection with mortality rates near 50%.

Buprenorphine

a partial opioid agonist that binds with high affinity but low intrsisic activity. iN patients on longterm opiod therapy, buprenorphine can displace other opioids and preciptate withdrawal.

actinic keratosis

a precancerous skin growth that occurs on sun-damaged skin. Small, rough, erythematous or brownish papules or plaques. Risk of squamous cell carcinoma is proportional to degree of epithelial dysplasia

Erythema multiforme

abundant lymphocytes without specific immunofluorescence may be due to medications, herpes, or mycoplasmal infections elsewhere, or just happens. It has many appearances, with the *target lesions* being most familiar, and large blisters being seen in Stevens-Johnson syndrome, considered by many to be a more severe version of erythema multiforme. it is caused by the deposition of infectious antigens in keartinocytes leading to a strong cell-mediated (Cytotoxic T-cells) immune response The epidermal-cell separation in Stevens-Johnson is full thickness and the Nikolsky test is positive.

resorption (obstructive) atelectasis

a result of a postoperative mucus plug which prevents air from reaching the terminal alveoli or due to decreased inhalations, preventing air from reaching the terminal alveoli, which eventually causing the collapse of the lung after preexisting air is reabsorbed back through the alveoli. Increased risk for mucus plugs include decreased respiratory effort due to pain and noncompliance with an incentive spirometer. Patients with resorption atelectasis have both an ipsilateral diaphragm elevation and ipsilateral tracheal deviation due to lung collapse. Other findings include fever, dyspnea, absent tactile fremitus ipsilaterally, and inspiratory lag caused by a collapsed lung that does not expand on inspiration.

detection bias

a risk factor may lead to extensive diagnostic investigation and increase the probability that a disease is identified

genital herpes

a sexually transmitted infection caused by the herpes simplex virus swollen labium with multiple and PAINFUL vesicles and ulcers

sphenoethmoidal recess

a small space in the nasal cavity where the sphenoidal sinus and posterior ethmoid sinus open. Located posterior and superior to the superior concha.

Buccal smear

a test for evaluating chromosomes; this test is performed by obtaining squamous epithelial cells from the buccal cavity, staining the cell, and microscopically observing for X chromosomes called Barr bodies (positive test) negative test: male XY

electroconvulsive therapy (ECT)

a treatment that involves inducing a mild seizure by delivering an electrical shock to the brain SE: HA, confusion, anterograde or retrograde amnesia

Diffuse Axonal Injury (DAI)

a type of brain injury that results from disruption of white matter tracts. Visible as widespread axonal swelling, most pronounced at the grey-white matter junction, with accumulation of transport proteins (amyloid precursor, alpha-synuclein) at the site of injury direct bunt force injury (head hitting windshield) or abrupt changes in acceleration-deceleration (restrained passenger coming to a sudden stop after a collision). pt may present as comatose or concussive sx: HA, amnesia

Farmer's lung

a type of hypersensitivity pneumonitis resulting from exposure to thermophilic actinomycetes in moldy hay. Patients present within 4-6 hours of antigen exposure with sudden onset, flu-like symptoms including fever, tachypnea, chills, malaise, cough, and chest tightness. High-resolution CT displays characteristic bilateral ground glass opacities. Imaging: Reticular, nodular, or ground-glass opacity on chest radiograph (see image below) or HRCT. Spirometry: Pulmonary function testing may reveal a restrictive pattern with reduced lung capacity and forced vital capacity. Laboratory: Serum blood work is nonspecific but may reveal leukocytosis with an elevated c-reactive protein or erythrocyte sedimentation rate.

compression of the C5 and C6 spinal nerves: sx: numbness of his R hand. Sensation to pinprick is decreased in the thumb and over portion of the anterior forearm. What movement could confirm the dx?

abduction of the UE

Accuracy (validity)

ability of a test to measure what it is supposed to measure. For a new test to be accurate, its results should be equivalent to the results obtained with a "gold standard" (best conventional test available) on the same individual.

first generation antihistamines (chlorpheniramine, diphenhydramine)

able to block histamine receptors, are antimuscarinic, anti-alpha adrenergic, and antiserotonergic properties. Anticholinergic effects on the ocular ciliary muscles impair accommodation and cause blurring of vision for close objects.

upper motor neuron signs

abnl plantar flexion (Babinski sign), spastic paralysis, increased muscle tone, clasp-knife rigidity, hyperrelflexia, pronator drift, and pyramidal weakness (weakness more pronounced in lower extremity flexors and UE extensors).

Fibromuscular dysplasia

abnormal growth of tissue within arterial walls, resulting in stenotic and tortuous arteries that can cause tissue ischemia and are prone to aneurysm formation. alternating fibromuscluar webs and aneurysmal dilation with *absent internal elastic lamina* (string of beads appearance). Renovascular HTN occurs due to renal artery stenosis and activation of the RAAS Sx: resistant HTN + CNS(HA, TIA, stroke, ruptured aneruysm) Dx: angiography (CT, MRI, percutaneous) most F <55

Atrial flutter

abnormal rhythm that classically appears as a saw-tooth pattern on ECG due to the rapid sequence of p waves causing an atrial rate of 250-350 beats/min. In an unstable patient, emergent direct-current (electrical) cardioversion is indicated. In a hemodynamically stable patient, rate control is the most appropriate next step in the management of rapid atrial flutter.

unbalanced robertsonian translocation

account for a minority of Down syndrome cases Karyotyping shows: 46 chromosomes with a translocation between 2 acrocentric nonhomologous chromosomes [46, XX, t(14;21)] 46 chromosomes and 3 effective copies of chromosome 21

Tay-Sachs disease

accumulation of GM2 hexosaminidase A deficiency startle reflex is exaggerated, muscle weakness, cherry-red spots on retina NO Liver/spleen involvement

myasthenia gravis

acquired autoimmune d/o caused by an autoantibody-mediated attack on the acetylcholine receptors of the postsynaptic neuromuscular junction, leading to a reduced number of acetylcholine receptors. It is characterized by fatigable weakness of the skeletal muscles, *respiratory failure* can occur due to diaphragmatic weakness. leading to hypoventilation and respiratory failure

L4 dermatome

across the knee, and into the medial surface of the foot.

Fructose-2,6-bisphosphate (F2,6BP)

activates PFK-1 which increases glycolysis and inhibits fructose 1,6-bisphosphatase (decreasing gluconeogenesis). F2, 6BP concentration is regulated by a bifunctional enzyme complex: phosphofructokinase-2 increases F2, 6BP levels in response to insulin and fructose 2,6-bisphosphatatse decreases F2, 6BP levels in response to glucagon Insulin causes an increase in PFK-2 which causes an increase in Fructose 2,6-bisphosphate.

interferon gamma

activates macrophages, increases MHC expression, and promotes TH1 differentiation. interferon gamma is the tx for chronic granulomatous dz (recurrent infections by catalase + fungi and bacteria)

Biotin (B7)

acts as a CO2 carrier on the surface of carboxylase enzymes and is an essential cofacor for many reactions including conversion of pyruvate to oxaloacetate and fatty acid metabolism. Excess ingestion of avidin, found in egg whites, has been associated with biotin deficiency which presents as mental status changes, myalgias, anorexia, macular dermatitis, and lactic acdiosis.

Sildenafil

acts by inhibiting phosphodiesterase 5 (PDE-5), an enzyme that normally converts cGMP to 5'-GMP. As a result, cGMP accumulates allowing increased blood flow to occur in the corpus cavernosum. Sildenafil also weakly inhibits PDE-6, which is required for the transformation of light into electrical signals. A major side effect seen with sildenafil is cyanopsia or blue vision.

Epstein-Barr virus (EBV)

acute infection which causes sore throat, fever, fatigue, and enlarged lymph nodes; also called mononucleosis associated with increase in lymphocytes

DOC for treating Supraventricular tachycardia (SVT)

adenosine MOA: increasing K+ shift out of atrial myocaridal and AV nodal cells (shortens phase 3 on a pacemaker action potential curve) and leads to hyperpolarization of pacemaker cells. At high doses, adenosine decreases conduction velocity, prolongs the refractory period, and decreases automaticity in the AV node (causes prolongation of PR interval on ECG). has a short duration of action (15 seconds) but may cause flushing, CP, and hypotension

Isotretinoin (Accutane)

administered orally to tx severe acne associated with significant scarring. it is also indicated in pts who fail therapy with topical tretinoin/benzoyl peroxide and antibiotics. Isotretinoin is a potent teratogen and is absolutely C/I in pregnancy. Exposure can cause spontaneous abortion and a variety of severe fetal anomalies. A negative pregnancy test (urine or serum) is required prior to prescribing and abstinence/contraception is recommended. Monthly pregnancy testing is required during tx.

adolescents and treatment adherence

adolescents have low tx adherence rates due to issues with autonomy, rebellion against authority, increased self-consciousness, and lack of understanding of potential risks. Peer behavior has a strong influence on adherence due to adolescents' desire to fit in with their social groups

mammillary bodies

affected in Korsakoff syndrome: amnesia, vit B1 def, confabulations are characteristic!! associated with alcoholics

Trigger fingers

affects single digits, most often affecting the second digit. In this condition, pt have pain and popping sensation with trying to extend the hand. associated with DM and RA

Chronic rejection in lung transplant

affects small airways causing bronchiolitis obliterans. lymphocytic inflammation, fibrosis, and destruction of the bronchioles

somatic mosaicism

affects the cells forming the body, causing disease manifestations to develop in affected individuals Mosaicism is defined as the presence of multiple, genetically different cell lines within the body

Germline mosaicism

affects the cells that give rise to gametes, allowing the affected genes to pass to the offspring. The chance of a child being affected depends on the proportions of gametes that carry the mutation. When mosaicism is limited to the germline, the affected parent does not develop clinical manifestations. mosaicism is defined as the presence of multiple, genetically different cell lines within the body

Gerstmann syndrome

agraphia: inability to write, aclaculia: inability to carry out mathematical calculations, finger agnosia: inability to identify individual fingers on the hand, left-right disorientation. Damage to the angular gyrus of the dominant- parietal lobe - supplied by the middle cerebral artery lesions to the angular gyrus may also be associated with alexia (inability to read) and aphasia (impaired speech)

characteristics of COPD and lung volumes

air-trapping - OBSTRUCTIVE cant get air out increase in residual volume (RV), total lung capacity (TLC), and RV/TLC ratio Airway obstruction causes a decrease in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and FEV1/FVC ratio

common medical conditions with POLYgenic inheritance

androgenetic alopecia (male pattern baldness) epilepsy glaucoma HTN Ischemic heart dz schizophrenia Type II DM

airway resistance

airway resistance at each level of the lower respiratory tract is inversely related to the total cross-sectional area of all the airways at that level. Airway resistance is high in the trachea and reaches a peak in the medium-sized bronchi, where total cross-sectional area is at a minimum. Airway resistance then progressively decreases as total cross-sectional area increases through the smaller bronchioles, terminal bronchioles, and alveoli

Primary adrenal insufficiency

aka Addison dx Pt with type I DM are at increased risk of other AI endocrinopathies, including Addison dz. Electrolyte abnl in primary adrenal insufficiency: Hyponatremia, hyperkalemia, hyperchloremia, and nonanion gap metabolic acidosis

Churg-Strauss Syndrome

aka allergic granulomatous angiitis, aka eosinophilic granulomatosis with polyantiitis Asthma Eosinophilia > 10% Sinusitis Pulmonary infiltrates Vasculitis Polyneuropathy Churg-Strauss will be positive for antineutrophil cytoplasmic antibodies (ANCA), most commonly perinuclear-ANCA (p-ANCA)

Hemophlia B

aka christmas Dz X-linked recessive d/o Affects MALES cause factor IX deficiency with easy bruising and bleeding (hemarthrosis, oral bleeding, intracranail hemorrhage) Affected males will have asx mothers

adhesive capsulitis

aka frozen shoulder characterized by both shoulder pain and severely reduced range of motion in all planes, with both active and passive movements. It primarily affects middle-aged and elderly patients. Patients with diabetes mellitus or history of prolonged shoulder immobilization (from injury or postoperatively) are also at a greater risk. The pathophysiology thought to be from an underlying pathologic process that is primarily an inflammatory or fibrosing condition. This leads to *thickening and contracture of the glenohumeral joint capsule* which causes restrictions in all planes of motion, with external rotation and abduction most affected. Diagnosis is made clinically based on history and physical examination findings, and should be suspected in patients complaining of predominantly unilateral shoulder pain and stiffness. No specific physical tests Imaging is unremarkable in adhesive capsulitis

contracture of first and third digit

aka gamekeeper thumb injury to ulnar collateral ligament = weakness and carpal instability tendonitis/traumatic scarring

illness anxiety disorder

aka hypochondriasis is diagnosed in people who have a preoccupation with having or acquiring a serious illness. pts have a high level of anxiety about their health and may perform excessive health-related behaviors. People with this condition are generally seen in primary care settings because patients are highly distressed that they may have a medical condition(s). Since the patients genuinely believe they are or may be ill, they are usually resistant to the suggestion of therapy or psychiatric evaluation Treating physicians should attempt to develop an alliance with the patient and provide regular medical evaluations without performing any unnecessary or invasive medical treatments.

Nonbullous impetigo

aka impetigo contagiosa, is caused by Staphylococcus aureus or Streptococcus pyogenes and is characterized by honey-colored crusts on the face and extremities. Bullous impetigo is caused exclusively by S aureus and results in large, flaccid bullae. The exfoliative toxin produced by some strains of S aureus causes the skin to split at the superficial granulosum layer of the epidermis, resulting in painful blisters that easily erupt and extrude serous fluid containing many bacteria

Idiopathic Intracranial Hypertension

aka pseudotumor cerebri increased intracranial pressure usually seen in young obese women with daily HA (worse with Valsalva), B/L symmetric papilledema, and transitent visual disturbances. Increased intracranial pressure compresses the optic nerves, causing imparied axoplasmic flow and optic disc edema

Pygmalion effect

aka: observer-expectancy bias/ eperimenter-expectancy bias groups alter their outcomes to meet external expectations. when research participants know the expected outcome, they tend to modify their behavior in ways that make such an outcome more likely

treatment of pinworms (Enterobius vermicularis)

albendazole or pyrantel pamoate

chronic alcoholic pancreatitis

alcohol-realted chronic pancreatitis develops in part due to alcohol-induced secretion of protein-rich fluid. These secretions can precipitate within the pancreatic duct to form ductal plugs that may calcify. Ductal obstruction = exocrine insufficiency due to atrophy of the pancreatic acinar cells and pancreatic fibrosis. Pancreatic exocrine insufficiency=failure to secrete adequate amylases, proteases, and lipases which leads to malabsorption with consequent diarrhea/steatorrhea. Wt loss and bulky, frothy stools are typical clinical findings.

polyol pathway

aldose reductase converts glucose into sorbitol, which is slowly metabolized into fructose by sorbitol dehydrogenase. Chronic hyperglycemia overwhelms this pathway causing intracellular sorbitol accumulation and increased osmotic/oxidative stress. This accelerates cataract development in pt with diabetes and contributes to diabetic retinopathy, neuropathy, and nephropathy

Formation of cataracts in uncontrolled DM

aldose reductase converts glucose ti sorbitol at a rate faster than sorbitol can be metabolized. Sorbitol accumulates in certain cells (lens cells), causing an influx of water and resulting in osmotic cellular injury. Depletion of NADPH by aldose reductase also increases oxidative stress, which accelerates development of cataracts and diabetic microvascular complications (neuropathy, retinopathy)

A stroke of the anterior cerebral artery will affect?

all or part of the lower extremity but not the upper extremity

Entamoeba histolytica

amoeba that causes colitis characterized by ulcers with *undermining edges* (flask-shaped) that may contain cysts and trophozoites. Trophozoites can invade the colonic wall and disseminate through the blood to the liver, brain, or lungs. Amebic hepatic abscess is the m/c extraintestinal manifestation

Coronary autoregulation

allows coronary blood flow to be primarily driven by myocardial oxygen demand over a wide range of perfusion pressures (60-140 mm Hg). It is mostly accomplished by alterations in vascular resistance via release of adenosine (released from cardiomyocytes as ATP is broken down for energy) and nitric oxide (synthesized by endothelial cells in response to chemical mediators and mechanical stress) in response to myocardial hypoxia.

Blanching of a vein into which norepinephrine is being infused together w/ induration and pallor surrounding the IV site tissue are signs of NE extravasation and resulting vasoconstriction. Tissue necrosis is best prevented by local injection of what kind of drug?

alpha 1 blocking like phentolamine causing v-dilation

acarbose

alpha-glucosidase inhibitor used in the tx of DM2 Acarbose inhibits the intestinal brush border enzyme α-glucosidase, which normally acts to break down starch and disaccharides into glucose. This delays sugar hydrolysis and glucose absorption, leading to a decrease in postprandial glucose levels. SE: abd pain, flatulence, and diarrhea

Methotrexate

and other folic acid antagoinists adversely affect rapidly dividing cells (epithelial cells, stem cells, neural tube cells) by limiting the production of precursors essential to DNA synthesis and repair. If used in the first trimester of preg, these drugs can cause major congenital abnormalities (cardiovascular abnormalities, urinary tract abnlities. neural tube defects) MOA: competitively inhibits dihydrofolate reductase which produces nucleic acid precursosr that are essential to DNA synthesis and repair

Laryngotracheobronchitis

also known as croup, is a common cause of illness in children < 4 years of age and has a classic seal-like, barky cough, and when more severe, the patient exhibits inspiratory stridor. Parainfluenza viruses are mainly responsible for croup, although many other viruses can cause this syndrome An anteroposterior radiograph of the neck may show a "steeple" sign, which is a subglottic narrowing of the trachea, although this is rarely helpful as croup is a clinical diagnosis.

MDMA toxicity

also known as ecstasy can lead to an increase in alertness, reduction in fatigue, and feelings of intense euphoria. Agitation, bruxism, diaphoresis, tachycardia, and hypertension can also occur. Hyperthermia may result from prolonged physical exertion such as dancing all night at a "rave". Agitation, hyperactivity, anxiety, delirium, and seizures can occur

acute opioid overdose

altered level of consciousness, pinpoint pupils, and central respiratory depression. Pt expected to have acute respiratory acidosis (low pH, high PaCO2) due to hypoventilation. serum bicarb is typically near normal (no time for metabolic compensation) in acute setting

absorption atelectasis

alveolar collapse that occurs when high concentrations of oxygen are given and oxygen replaces nitrogen in the alveoli; if airway obstruction occurs, the oxygen is absorbed into the bloodstream and the alveoli collapse. Thus can give PEEP (positive end-expiratory pressure) which will keep some pressure in the alveoli preventing them from collapsing

Glucose-6-phosphate dehydrogenase deficiency (G6PD)

an X-linked recessive hereditary disease. G6PD is an enzyme that normally protects cells from oxidative damage by converting nicotinamide adenine dinucleotide phosphate (NADP+) to NADPH. When an oxidative stress is introduced, like the classic case of a sulfa drug, infection, or fava beans, these patients undergo considerable physiologic distress.

patent ductus arteriosus (PDA)

an abnormal opening between the pulmonary artery and the aorta caused by failure of the fetal ductus arteriosus to close after birth associated with higher than normal LV cardiac output

Procalcitonin

an acute phase reactant with positive and negative properites levels rise in response to bacterial toxins and fall in response to viral infection useful for finding the etiology of community acquired pneumonia

insulin

an anabolic hormone that acts via RTK signaling to increase the synthesis of glycogen, proteins, FA, and nucleic acids. Tyrosine kinase/phophatidylinostiol-3-kinase stimulation promotes glycogen synthesis by activating protein phosphatase, an enzyme that dephosphorylates (activates) glycogen synthase.

Tamoxifen

an antagonist for estrogen that is used in the treatment of breast cancer partial agonist at the uterus

Capitation

an arrangement in which a payor pays a fixed, predetermined fee to provide all the services required by a patient. Payors may negotiate a capitated contract with an insurance company that then pays the providers, or a large medical group may negotiate directly with the payor.

pepsin

an enzyme produced by chief cells of the stomach and act to break down proteins in food Hydrochloric acid is responsible for the conversion of pepsinogen to pepsin

Methionine

an essential amino acid PVT TIM HaLL

linoleic acid

an essential polyunsaturated fatty acid of the omega-6 family ask a pt on a low fat low carb diet to take this to maintain good health

Enterococcus

an important cause of UTIs. These organisms are gram + cocci in pairs and chains and when grown on agar they do not cause hemolysis (gamma-hemolytic) part of the normal flora also cause bacteremia/endocarditis, biliary infection, wound infection, intraabdominal/pelvic infection in the nosocomial setting VRE

Brucellosis

an infection caused by brucella bacteria that can cause disease in animals and man transmitted through direct contact with infectious animal fluids or ingestation of unpasteruized milk/cheese. undulating fever, profuse sweating, and joint pain

Abetalipoproteinemia

an inherited inability to synthesize apolipoprotien B, thus lipids absorbed in the small intestine cannot be transported by chylomicrons and therefore it builds up in enterocytes. lipids absorbed by the small intestine cant be trasnported into the blood an accumulate in the intestinal epitherlim resulting in enterocytes with clear or foamy cytoplasm

Case-control study

an observational study; it begins with selecting individuals who have the outcome ("cases") and individuals who do not have the outcome ("controls") and then retrospectively comparing their history of exposure to risk.

ventricular spetal defect (VSD)

an opening in the septum separating the ventricles associated with midsystolic ejection murmur and fixed split of S2. surgical repair is at risk of injurying the ATRIOVENTRICULAR BUNDLE

Pseudomonas aeruginosa

an oxidase positive, non-lactose-fermenting, Gram negative organism common cause of UTI in pt with indwelling bladder catheters

Karyotype analysis

analyzes chromosomes and gross abnormalities in the chromosomes are detected (duplication or deletion)

Aromatase inhibitors

anastrozole, letrozole, exemestane Estrogen is the main hormone responsible for the growth and development of estrogen receptor positive breast tumors. Aromatase inhibitors decreased the synthesis of estrogen from androgens, suppressing estrogen levels and slowing the progression of ER-positive tumors

interscalene nerve block

anesthetizes the brachial plexus as it passes through the scalene triangle. It is used to provide anesthesia for the shoulder and upper arm. Nearly all patients will develop transient ipsilateral diaphragmatic paralysis due to involvement of the phrenic nerve roots (C3-C5) as they pass through the interscalene sheath.

Anovulatory cycle

anovulation is common in the first several years after menarche and the last few years before menopause. It manifests with marked menstrual cycle variability. In most F age 20-40 yo, menstrual cycles are consistent and last 24-35 days, with menstrual flow ranging from 4-6 days. However, adolescents typically have an immature hypothalamic-pituitary-ovarian axis for several years following menarche. During this time they may have longer menstrual cycles and irregular bleeding patterns due to the presence of anovulatory cycles. In the absence of ovulation, the ovarian follicle does not degenerate and becomes the corpus luteum. As a result, no progesterone is produced and estrogen levels remain persistently high, causing the endometrium to remain in the proliferative phase. Chronically proliferative endometrium becomes disorganized and fragile with unstable venous capillaries, resulting in irregular periods of stromal breakdown with variable, but often heavy, bleeding

8 year old female shows breast bud development and few pubic hairs - mother asks if this development is nl

ans: YES this is Tanner stage II: pubic hair appears, testicular enlargement, breast bud forms ages 8-11.5

Surface ectoderm derivatives derivied from ectoderm

ant pituitary (rathke pouch) lens & cornea Inner ear sensory organs, olfactory epithelium nasal and oral epithelial linings, salivary glands epidermis, sweat, and mammary glands

ligaments involved with an inversion sprain

anterior talofibular ligament (ATF) (grade 1 only ligament involved) and calcaneofibular ligament (CFL) ( grade 2: both ligaments involved) grade 3: ATF, CFL, and posterior talofibular ligament, commonly associated with a nerve injury

L2 dermatome

anterior thigh does NOT cross the knee partial motor innervation to the quadratus lumborum and iliopsoas

Colchicine

anti gout drug binds and stabilizes tubulin to inhibit microtubule polymerization

ipratropium

anticholinergic agent and derivative of atropine, treats obstructive lung disease by blocking acetylcholine at muscarinic receptors, which prevents bronchoconstriction and reduces mucus secretion from tracheobronchial submucosal glands

Fomepizol

antidote to ethylene glycol toxicity (found in anti-freeze). intoxication with anti-freeze occurs in young children or those attempting suicide Alt antidote is is ethyl glycol (aka ethanol) Fomepizol is an inhibitor of alcohol dehydrogenase, the enzyme that is responsible for the metabolism of ethylene glycol and methanol. Ethylene glycol toxicity causes N/V, anion gap metabolic acidiosis, coma, seizures, and cardiovascular depression

Praziquantel

antihelmintic agent that increases cell membrane permeability in helminths leading to disintegration of the parasite. It is used to treat infections caused by Clonorchis sinensis, as well other trematodes and cestodes.

nonnucleoside reverse transcriptase inhibitors

antiretroviral drugs that do not require activation via intracellular phosphorylation. ex: Nevirapine and Efavirenz

scotoma

any visual defect surrounded by a relatively unimpaired field of vision. involves parts of the reitina or optic nerve

Marfan Syndrome

aortic dissection (intimal tear connecting the aortic media with the aortic lumen) causing CP in a pt with marfanoid body habitus: tall stature, long extremities, spindly fingers, and hypermobile joints. Caused by a defect of fibrillin due to FBN1 gene on CHROMOSOME 15

caspases

apoptosis can occur through either the intrinsic (mitochondria-mediated) pathway or the extrinisic (receptor-initiated) pathway. Both pathways converge in the activation of caspases. Caspases are responsible for enzymatic cell death in apoptosis; proteases and endonucleases proteolytic enzymes that destroy cell components. They contain cysteine and are able to cleave aspartic acid residues. Two types initiator or effector caspases- initiator caspases activate the effector caspases, which then cleave the cellular proteins

Calcium sensing receptor (CaSR)

are G protein-coupled receptors that regulate the secretion of PTH in response to changes in circulating calcium levels. Familial hypocalciuric hypercalcemia is a benign AD d/o caused by defective Ca-sensing Receptors in the parathyroid gland and kidney.

Target cells

are RBCs with a dark center, surrounding halo of pallor, and dark peripheral ring. They form in erythrocytes with an excessive surface area-to-volume ratio, which results in redundant erythrocyte cell membrane folding upon itself (thereby breating the appearance of a target). Target cells occur in pts with the following: 1) reduced erythrocyte cell volume from deficient hemoglobin synthesis (thalassemia, iron deficiency) or structural mutations to hemoglobin (sickle cell) 2) excessive erythrocyte cellular membrane due to greater cholesterol-to-phospholipid ratios (obstructive liver dz) or splenectomy Macrophages in the red pulp of the spleen remove excess membrane from RBCs, a process called *splenic conditioning*. Pts who undergo splenectomy are unable to prune erythrocytes and generally develop target cells a few weeks following the procedure. However, over time, macrophages in nosplenic tissue (liver) take up the task of pruning erythrocytes, which typically eliminates or diminishes the presence of targe cells in circulation.

Xanthelasmas

are a type of xanthoma on the medial eyelids. Yellowish macules/papules they are dermal accumulations of macrophages containing cholesterol and triglycerides and are generally associated with primary or secondary hyperlipodemia or dyslipidemia. due in part to insulin resistance promoting increased VLDL production, diabetics may develop a secondary Type IV or V hyperlipidemia (increased VLDL, chylomicrons) and/or a secondary diabetic dyslipidemia with elevated LDL cholesterol and low HDL cholesterol An LDL receptor is the m/c cause

Reactive (atypical) lymphocytes

are activated, pathogen-specific cytotoxic T cells or natural killer cells that form in response to certain intracellular infections. In contrast to normal lymphocytes, reactive lymphocytes are large, scalloped, and have abundant cytoplasm. Reactive lymphocytosis is a dx feature of infectious mononucleosis (EBV), and they contain *cytotoxic granules composed of perforin (creates a hole in the infected cells membrane) and granzymes (enter the cytoplasm of infected cells and trigger cell death), which are released in response to foreign antigens on the surface of (MHC class I receptors) of infected host cells.

second generation antipsychotics

are associated with metabolic adverse effects (eg. weight gain, dyslipidemia, hyperglycemia, and increased risk of diabetes). As such they should be monitored for changes. Olanzapine and clozapine carry the greatest risk. lower risk of EPS vs first generation pharm

Neurophysins

are carrier proteins for oxytocin and vasopressin (ADH). They are carried form teh paraventricular and supraoptic nuclei of the hypothalmus to the axon terminals in the posterior pituitary. A point mutation in neurophysins could be the reason for hereditary diabetes insipipidus (No ADH)

Sertoli cell tumors

are derived from the Sertoli cells located within the seminiferous tubules and can occur in both children and in middle-aged adults. They are less common than Leydig cell tumors, and presentation rarely includes symptoms of virilization. Feminizing symptoms, however, may occur in 20%-30% of patients. Histology will reveal uniform tall, polyhedral cells that are arranged in sheets and cords that resemble spermatic tubules. The presence of perinuclear aggregates of intermediate filaments is pathognomonic of a Sertoli cell tumor.

Pancreatic zymogens

are normally converted into their active form by trypsin in the duodenal lumen. Premature cleavage of trypsinogen to trypsin within the pancreas leads to uncontrolled activation of these zymogens, causing pancreatic autodigestion and acute pancreatitis

ADH (vasopressin) and oxytocin

are synthesized within magnocellular neurons found in the supraoptic and paraventricular nuclei of the hypothalamus and are released into circulation from axon terminals in the posterior pituitary. Neurophysins are involved in the posttranslational processing and stabilization of oxytocin and vasopressin within neurosecretory vesicles during transport to the posterior pituitary

Intracranial Schwannomas

are usually located in Cerebropontine Angle, which is between lateral Pons and Cerebellum U/L hearing loss/tinnitus and vertigo in the setting of facial numbness and weakness via trigeminal and facial nerve dysfunction these are called acoustic schwannomas from crainial nerve VIII B/L acoustic neruomas are assoicated with neruofibromatosis type 2.

Glucagonomas

arise in the pancreas and typically present with diabetes, glossitis, and a necrotizing rash esp in the groin

AML M6 subtype

arises from erythroid percursors and typically affects elderly pts

AML M7 subtype

arises from primitive megakaryoblasts and is associated with t(1;22) and Down syndrome in children

obturator nerve

arises from the L2-L4 nerve roots, innervates the skin of the medial thigh and provides motor for the adductor muscles of the LE

Enteroviruses is the most common cause of

aseptic meningitis sx: fever, meningeal signs (HA, neck stiffness); and CSF shows lymphocytic pleocytosis, a modestly elevated protein level, and normal glucose are suggestive of aseptic meningitis

Candidal antigen skin test

assesses the activity of T-cell mediated immunity through the recruitment of macrophages, CD4+, and CD8+ T-lymphs in a type IV Hypersensitivity rxn. Anergy aka failure to respond to candida antigen testing is typical in pt with severe combined immunodeficiency

Hepatic angiosarcoma

assoaicted with exposure to arsenic, thorotrast, and polyvinyl chloride. Tumor cells express CD31 as a marker. (endothelial cell marker)

Alpha-fetoprotein (AFP)

assocated with hepatocellular carcinoma and germ cell tumors elevated in pt with chronic hepatitis (Hep C)

Defective CD40L

associated with an inability to class switch, resulting in *hyper-IgM syndrome*. Patients present with recurrent infections and diarrhea but have normal levels of B and T lymphocytes. It is the reduced levels of lymphocytes that distinguish our patient from one with hyper IgM syndrome.

pernicious anemia

associated with antibodies against parietal cells and intrinsic factor inactivation of intrinsic factor by autoantibodies results in Vit B12 deficiency and commonly manifests as megaloblastic anemia with hypersegmented PMNs and NEUROLOGIC signs

bacterial vaginosis

associated with grayish-white vaginal discharge with a "FISHY" odor. The etiology involves an overgrowth of Gardnerella vaginalis, an anaerobic gram-variable rod. CLUE cells (squamous epithelial cells covered with bacterial organisms) are seen on wet mount microscopy or cytology

Deficiencies in T cell-mediated immunity

associated with infection following live vaccines

Down syndrome lab values

associated with low maternal serum alpha-fetoprotein and unconjugated estriol levles correlate with decreased fetal levels increased beta-hCG and inhibin A

CLL

associated with overexpression of BCL-2 (anti-apoptotic protein) on the mitochondrial membrane Tx with a BCL inhibitor causes cancer cell death by promoting cytochrome c release from the mitochondria, which activates caspases

Complex atypical hyperplasia of the endometrium

associated with prolonged exposure to estrogen without opposing progesterone, which may develop from chronic anovulation over many years. This condition is most common in obese older women or those who are on estrogen without progesterone during hormone replacement therapy

High altitude

associated with reduced alveolar and arterial PO2, causing increased ventilation through activation of the carotid chemoreceptors, which acutely causes *respiratory alkalosis*. Physiological responses include increased release of erythropoietin, increased excretion of bicarbonate, and increased sympathetic activity.

benign prostatic hyperplasia (BPH)

associated with stromal and glandular growth in the periurethral and transitional zone of the prostate. The hyperplastic cells are supported by the formation of new blood vessels, which are friable and prone to bleeding. thus BPH is associated with microscopic or gross hematuria

Amyloid Light Chain Amyloidosis

assoicated w/ multiple myeloma

Osteoarthritis (OA)

asymmetric joint involvement with pain that worsens with increased activity. Patients frequently have Heberden (high=DIP) and Bouchard nodes (below=PIP), which are bony hypertrophy of the distal and proximal interphalangeal joints, respectively. The metacarpophalangeal joints are spared. X-ray findings characteristic of OA include subchondral sclerosis, joint space narrowing, and osteophytes.

Fourth heart sound (S4)

atrial gallop; Heard immediately after *atrial contraction* as blood is forced into a stiff ventricle Abnl: younger adults, children, diastolic dysfunction (LVH) Nl: Healthy *OLDER* adults best heard with the bell of the stethoscope over the cardiac apex while the pt is in the L lateral decubitus position at END expiration

Side effects of corticosteroids used for eczematous dermatitis

atrophy of the dermis with loss of dermal collagen, drying, cracking, and/or tightening of the skin. May also see: telangiectasias, ecchymoses from mild trauma, and atrophic striae

Rispiradone (Risperdal)

atypical antipsych used for schizophrenia Positive Sx: hallucination, delusions, unusal thoought processes, disorganized speech, bizarre behavior Neg: flat or blunted affect, apthay, anhedonia, alogia, social w/drawal

dysplastic nevi

atypical moles that can develop into malignant melanoma

good pasture syndrome

autoantibodies against aplha 3 chain of type IV collagen in glomerular and alveolar BM (anti-GMB antibodies). Pt present with rapidly progressive glomerulonephritis (nephritic syn) and alveoplar hemorrhage (SOB, hemoptysis)

Types 1 diabetes

autoimmune insulitis with progressive beta cell loss is the m/c cause of type 1 DM. Insulin resistance accompanied by relative insulin deficiency is the main cause of type 2 DM.

Stickler Syndrome

autosomal dominant disease affecting collagen synthesis and is characterized by craniofacial abnormalities, as well as hearing loss. Additional findings include ocular problems as well as joint problems. Patients present with a flattened facial appearance as a consequence of underdeveloped bones in the middle part of the face, including the cheekbones and the bridge of the nose. Ocular problems consist of nearsightedness and eye pain or discomfort due to increased intraocular pressure. Easy bruising and flat feet are not features of this syndrome, making this a less likely diagnosis.

Metachromic leukodystrophy inheritance

autosomal recessive Deficiency of Arylsulfatase A usually onsets by age 18-24 months and presents as gradual loss of motor skills such as walking, peripheral neuropathy, seizures, blindness and loss of hearing. The patient here is only age 7-months-old and does not display any of this enzyme deficiency features.

Friedreich ataxia

autosomal recessive degenerative disorder affecting the CNS, spinal cord, peripheral nerves, heart, and pancreas. Many have a GAA repeat occurring during both paternal and maternal meiosis. Present with neurologic dysfunction (limb and gait ataxia), cardiomyopathy, and diabetes mellitus. Pes cavus and kyphoscoliosis Additional manifestations include: swallowing dysfunction, UMN weakness, loss of position and vibration sensation, and peripheral neuropathy. degeneration of spinocerebellar tracts = ataxia " post columns and dorsal root ganglia = imparied joint and vibration sense

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

avoid using anticholinergics (fisrt gen antihistamines), alpha blockers, TCA, benzo (and other sedating meds), antipsychotics, most antiarrhythmics, and skeletal muscle relaxants

Leptospirosis

bacterial disease transmitted through contact with contaminated urine spirochete, thin, gram negative, motile aerobic organisms with hooks allowing them to burrow into tissues sx: fever, rigors, sudden HA, N/V/D, anorexia, cough, pharyngitis, nonpruritic skin rash, and muscle pain.

internal capsule

band of projection fibers that runs between the basal nuclei and the thalamus dosal optic radiation motor

Likelihood of plaque rupture

based on STABILITY vs plaque size or degree of luminal narrowing. Stability depends on strength of the fibrous cap. Inflammatory macrophages in the intima may reduce the plaque stability by secreting metalloproteinases, which degrade matrix proteins

magnesium salts and aluminum hydroxide

basic mineral salts used to neutralize gastric acid and relieve GI reflux sx. SE: diarrhea and constipation respectively. Therefore, these meds are combined to offset the adverse effects of individual meds

hypo-acetylated histones

bind tightly to DNA and prevent transcription of genes in their associated regions. Alteration of gene expression in Huntington dz occurs in part due to deacetylation of histones. This prevents the transcription of certain genes that codes for neurotrophic factors, contributing to neuronal cell death

benzodiazepines

bind to GABA A receptors resulting in an increased freq of Cl channel opening in the presence of GABA. Indications for prescribing include short term tx of anxiety d/o and ETOH withdrawal sx

Mycoplasma pneumoniae

binds an oligosaccharide on the respiratory epithelium that is also present on RBCs, leading to the generation of cross-reacting IgM antibodies (cold agglutinins). Pt with M. pneumoniae often develop mild, transient hemolytic anemia that resolves as IgM antibody titers decline (6-8 weeks after infection begins).

Enfuvirtide

binds gp41, inhibiting fusion of HIV CD4+ Th cell

Sirolimus

binds to the immunophilin FK-506 binding protein (FKBP) in the cytoplsm, forming a complex that binds and inhibits mTOR. Inhibition of mTOR signaling blocks interleukin-2 signal transduction and prevents cell cycle progression and lymphocyte proliferation

etanercept

binds tumor necrosis factor, an important mediator for joint destruction. Its adverse effects include hypersensitivity reactions and infections

Atropine poisoning

blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, the bowel and the bladder lose their tone, the heart runs alone. It is a reversible cholinergic antagonists that acts selectively on muscarinic receptors. Its effects can be reversed by tertiary amines cholinesterase inhibitors (physostigmine, galantamine, donepezil, rivastigmine) which cross the BBB and reverse the CENTRAL and PERIPHERAL effects

quantitative variables

body wt, glucose levels, numerical values

Mifespristone

both a glucocorticoid and progesterone antagonist and is used with misoprostol (PGE1) to terminate a pregnancy.

what can use ketones for energy

brain, kidney, cardiac muscle, and skeletal muscle. Erythrocytes lack mitochondria and there for can NOT use ketones. and the liver can NOT use ketones because it lacks the enzyme succinyl CoA-acetoacetate CoA transferase which is required to convert acetoacetate to acetoacetyl CoA

internal pudendal artery

branch of internal iliac artery supplies blood to the external genitalia

c-myc oncogene

burkitt's lymphoma; gene product is a transcription factor (chromosome 8) long arm of chromosome 14: heavy chain region

Skeletal muscle contraction

calcium is released from the sarcoplasmic reticulum and binds troponin C allowing the binding of actin to myosin

medicare

federal socialized medical insurance program that covers indivisuals age 65 and older who have a work hx AND younger ppl with disabilities, end-stage renal dz, or ALS

Arteriovenous (AV) shunts

can be congenital or acquired; acquired forms can result from medical interventions or penetrating injuries. AV shunts increase preload and decrease afterload by routing blood directly from the arterial system to the venous system, bypassing the arterioles (the major source of resistance in the vascular system). High-volume AV shunts can eventually result in high-output cardiac failure.

Angioedema

can be hereditary (AD) or acquired (associated with ACE inhibitor tx). In hereditary angiodema low C1 esterase inhibitor activity leads to increases in bradykinin activity. ACE inhibitors should NOT be used in these pts. ACE inhibition increases bradykinin levels: increases vascular permeability = angioedema

Severe Combined Immunodeficiency (SCID)

can be inherited in an X-linked recessive or AR pattern caused by a *deficiency in adenosine deaminase* genetic defect in T cell development and B cell dysfunction. defect in T cell development = leading to loss of both cellular and humoral immunity. Pt presents in infancy with recurrent bacterial, viral, fungal, and opportunistic infections (Pneumocystis jriovecii) as well as *failure to thrive*, *chronic diarrhea*, and recurrent sinopulmonary bacterial infections (pneumonia, otitis media).

Ranson Criteria for assessing the severity of acute pancreatitis.

can be used at admission and again at 48 hours to determine disease severity and predict mortality in acute pancreatitis. Prognosis declines with findings of significant hypovolemia, namely an elevated BUN. *BUN is the most reliable routine laboratory test to predict the mortality in acute pancreatitis.* At Admission • Age > 55 years • Leukocyte count > 16 x 103/mcL • Blood glucose > 200 mg/dL • Serum LDH > 350 IU/L • Serum AST > 250 IU/L At 48 hours • Decrease in hematocrit > 10% • Increase in BUN of > 8 mg/dL • Serum calcium less than 8 mg/dL • PaO2 < 60 mm Hg • Base deficit > 4 mEq/L • Estimated fluid sequestration > 6,000 mL

alanine and glutamine

can be used in gluconeogenesis and maintain normal glycemia in a pt who has fasted for 20 hrs

Niacin (B3)

can be used to inhibit lipolysis (hormone sensitive lipase) in adipose tissue, decreases hepatic VLDL synthesis

SCID (severe combined immunodeficiency)

can be x-linked as well as due to AR deficiency os adenosine deaminase, an enzyme necessary for the elimination of excess adenosine within cells. Adenosine deaminase is involved in the purine salvage system; lack of it results in the intracellular *accumulation of deoxyadenosine triphosphate*, which in turn inhibits ribonucleotide reductase. This prevents deoxynucleoside triphosphate synthesis in lymphocytes Toxic levels of adenosine accumulate within lymphocytes in this condition, leading to lymphocyte cell death and rsultant cellular and humoral immune deficiency. tx: retroviral vectors to infect pt stem cells with genes coding for adenosine deaminase

Ruptured ectopic pregnancy

can cause abdominal pain, vaginal bleeding, and hemodynamic instability, with a positive pregnancy test. Primary risk factor for ectopic pregnancy is tubal scarring Pelvic inflammatory disease is a common cause which itself is commonly caused by infeciton witih N. Gonorrhoeae or Chylamydia trachomatis and significantly increases the risk of ectopic pregnancy

Hypovolemia

can cause acute kidney injury due to reduced blood flow (prerenal azotemia). Urine Na and fractional excretion of Na levels are low, and the BUN/creatinine ration is elevated. In severe cases, acute tubular necrosis can occur and cause an intrinsic renal injury pattern (high urine Na, nl BUN/creatinine ratio) with muddy brown casts

Crohn disease (Crohn's) with ileal resection or extensive ileal involvement

can cause bile acid malabsoption, which may lead to impaired absorption of fat-soluble vitamins (A-KED) vit K def can lead to imparied coagulation with easy bruising, large hematoma formation in deep tissues and joints (hemarthrosis) after minor trauma, and prolonged bleeding after surgery

TCA overdose

can cause fatal cardiac arrhythmias and refractory Hypotension due to inhibition of fast Na channels in cardiac myocytes

Staphylococcus aureus

can cause hepatic abscesses via hematogenous seeding of the liver. Enteric bacteria (E. coli, Klebsiella and enterococci) can cause hepatic abscesses by ascending the biliary tract (ascending cholangitis), portal vein pyemia (bowel or peritoneal sources), or direct invasion from an adjacent area (cholecystitis or peritonitis). Pyogenic bacteria can gain access to the liver via the routes above and including: Hepatic artery (systemic hematogenous seeding) & penetrating trauma or injury

Left sided HF

can cause secondary Pulmonary HTN via elevated L-sided diastolic filling pressures transmitting backwards to the pulmonary veins, resulting in pulmonary venous congestion. Overtime pulmonary arterial remodeling (medial hypertrophy and intimal thickening with fibrosis) can occur, but not to the extent that occurs in primary pulmonary arterial HNT

Gastric bypass surgery

can cause small intestine bacterial overgrowth (SIBO) due to excessive bacterial proliferation in the blind-ended gastroduodenal segment. SIBO results in a deficiency in most vitamins: (B12, A, D) and iron BUT increased production of folic acid and Vit K from the bacteria

Effects of prolactinoma

can compress the optic chiasm = B/L hemianopsia - elevated prolactin levels suppress GnRH, leading to decreased LH secretion and subsequently impaired testosterone production in men

Maternal IgG

can cross the placenta and provide protection to a neonate

CT myelogram

can dx spinal stenosis or other vertebral pathology (including osteomyelitis), is preformed by injecting contrast into the lumbar spine prior to CT imaging. However, it is more invasive than MRI and usually reserved for pts who can't undergo MRI (pt with pacemaker, metallic implants)

Bluish neoplasm under nail bed - tender and small

can either be a glomus tumor or a subungual melanoma both are rare dx Melanomas: composed of melanocytes (pigment) Glomangioma is a tumor of the modified smooth muscle cells of a glomus body. Oiginates from the modified smooth muscle cells that control the thermoregulatory functions of dermal glomus bodies.

qualitative varibales

categories or groups

HIV pt with 3 day history of generalized reddening skin involoving palms, arms, legs, and soles. Rapid plasma regain (RPR) rest: +

causative agent is syphilis tx with penicillin

nitrates

cause formation of NO -> venous dilation and decreased preload

statins

cause hepatocytes to increase their LDL receptor density, leading to increased uptake of circulating LDL

PCA strokes

cause ischemia in lateral medullla aka Wallenberg syndrome and inferior cerebellar peduncle, dysphagia, hoarseness, and vestibulocerebellar symptoms: ataxia, dizziness, nystagmus

Amiodarone and other class III and class IA antiarrhytmics

cause lengthening of the cardiac AP, manifests as QT interval prolongation of ECG QT prolongation caused by amiodarone is assocaiated with a *very low risk of torasdes*

Membranous Glomerulopathy

cause of nephrotic syndrome in adults and can occur in association with solid malignancy, viral hepatitis, and SLE. Immune complex deposition in the subepithelial protion of the glomerular capillary wall causes diffuse thickening of the glomerular basement membrane without increased cellularity; these deposits have a spike and dome appearance when stained with silver stains

Terazosin, Prazosin, Doxazosin

cause smooth muscle relaxation through inhibition of alpha-1 receptors. These agents lower blood pressure by relaxing the arterial smooth muscle and improve the symptoms due to benign prostatic hyperplasia (BPH) by relaxing the smooth muscles found in the bladder neck and prostate

Acute lesions to the cerebellar vermis

cause truncal and gait ataxia due to impaired modulation of the medial-descending motor systems. Involvment of the lower vermis and the flocculonodular lobe also causes vertigo/nystagmus due to dysregulation of the vestibular nuclear complex

typhoid fever

caused by Salmonella Typhi or Paratyphi and presents with escalating fever, followed by abd pain, formation of rose spots on the chest/abd, and hemorrhagic enteritis with possible bowel perforation. Trasmission is fecal-oral and due to ingestion of food or water contaminated by feces

peripheral vascular disease (PVD)

caused by a narrowing of arteries, usually due to atherosclerosis, which leads to a decrease in blood flow in all areas distal to the narrowing. A lack of blood flow to the muscle causes pain. When this occurs in skeletal muscle, it is known as claudication. This is the same mechanism that causes coronary artery disease, and when it occurs in cardiac muscle, it is much more dangerous and is referred to as angina. if referring to skeletal muscle: presents with pain in the legs that is exacerbated by walking or exercise and relieved by rest.

Transudative effusion

caused by alterations in hydrostatic or oncotic pressure (heart failure, cirrhosis, nephrotic syndrome) vs exudative effusions typically result from inflammation and consequent increased vascular membrane permeability (infection, malignancy, rheumatologic disease). Exudative effusions are characterized by a high ratio of pleural fluid to serum total protein (>0.5) or lactate dehydrogenase (>0.6), or high absolute levels of lactate dehydrogenase

Syringomyelia

caused by an enlargement of the central canal of the spinal cord from a collection of fluid (syrinx), most often due to a Chiari malformation. Patients present with, most notably, *bilateral loss of pain and temperature sensation* due to damage of the crossing fibers of the spinothalamic tract *at the ventral white commissure*. Also UE lower motor neuron signs, and/or LE upper motor neuron signs in the setting of scoliosis *include loss of pain and temperature sensation across the shoulders and upper torso anteriorly and posteriorly in a shawl-like distribution*

Drug-induced parkinsonism

caused by dopamine (D2) receptor blockade in the nigrostriatal pathway. tx: decrease/discontinue the offending med and tx with anticholinergic

stress related mucosal disease

caused by local ishcmeia in the setting of severe physiologic stress (shock, burns, sepsis, trauma). ulcers that arise in the setting of trauma/burn: curling ulcers Ulcers from intracranial injury: caused by direct vagal stimulation are called Cushing ulcers

erythroblastosis fetalis

caused by massive hemolysis induced by antibodies against the D antigen on fetal RBCs. Rho(D) immune globulin is given to Rh-negative mothers to prevent sensitization in subsequent pregnancies.

Erythema Infectiosum (Fifth Disease)

caused by parvovirus B19 and presents with nonspecific prodrome (malaise, fever, congestion) followed by a classic slapped-cheeck facial rash and a lacy, reticular body rash. Parvovirus is highly tropic for erythroid precursos cells and replicates in the bone marrow

vesicouretral reflux (VUR)

caused by retrograde urine flow from bladder into ureter. the hydrostatic pressure of the refluxing urine along w/ infections due to ascending bacteria causes inflammation. The compound papillae in the upper and lower poles of the kidney are most susceptible to reflux-induced damage, which appears as dilated calyces w/ overlying renal cortical scarring

Alkapronuria

caused by the absence of homogentisate 1,2 dioxidase, and thus, homogentisate accumulates in tissues, such as connective tissue, joints, and the spine, blood, and urine. This can lead to ochronotic arthritis. AR disorder This disorder is also characterized by the excretion of urine that appears normal when fresh but turns dark brown or black if left standing or after alkalinization. The dark color is caused by oxidation of homogentisate, which is why alkaptonuria has also been called black urine disease. homogentisate accumulates in tissues over time and during the third decade, deposits of the brownish or bluish pigment become apparent, typically first in the ear cartilage and sclerae.

Antibody mediated hemolysis

caused by transfusion of ABO-incompatible blood. Characteristic clinical findings include fever, back, or flank pain, acute kidney injury, and hemoglobinuria. The primary electrolyte complication is hyperkalemia due to release of intracellular potassium. Hyperkalemia can also be seen due to leakage of potassium from red cells during storage. However, hypocalcemia would not occur.

mitral insuffiency

causes LV volume overload as regurgitant flow through the mitral valve during systole increases the amt of blood returning to the LV during diastole. The net structural consequence is enlargement of the LV cavity and eccentric hypertrophy

Insulin

causes a decrease in serum potassium levels - increase cell membrane K+ uptake

ethylene glycol ingestion

causes acute tubular necrosis with vacuolar degeneration and ballooning of the proximal tubular cells sx: AMS, renal failure, high anion gap meabolic acidosis, increased osmolar gap, and Ca oxalate crystals in urine

Parvovirus B19 infection

causes aplastic crisis in sickle cell disease in adults leads to pure RBS aplasia and RA-like sx

HPV 16

causes changes in squamous cell differentiation and growth which starts in the basal layer of the epithelium

appendicitis - pain progression

causes dull visceral pain at the umbilicus due to afferent pain fibers entering at the T10 level in the spinal cord. Progressive inflammation in the appendix irritates the parietal peritoneum and abd wall to cause more severe somatic pain shifting from the umbilicus to McBurney pt

Methemoglobinemia

causes dusky discoloration to the skin (similar to cyanosis) and becaues methemoglobin cannot carry oxygen, a state of functional anemia is induced. The blood partial pressure of 02 however is unnchaged (amount of 02 dissolved in plasma is still the same) Nitrites are poison in that they oxidize iron creating methemoglobin

Aldolase B deficiency

causes hereditary fructose intolerance. accumulation of toxic metabolite Fructose-1-phosphate. Pt have hypoglycemia and vomiting when fructose or sucrose is consumed: lethargy, sweating, vomiting, and dehydration. sx after eating formula or fruit Tx: removal of fructose and sucrose/ carbs from diet.

Adenosine

causes hyperpolarization of the nodal pacemaker to briefly block condunction through the AV node. It is effective in the initial tx of paroxysmal supraventricular tachycardia. Common adverse effects include flushing, chest burning (due to bronchospams), Hypotension, and high-grade AV block

acute ventilation/perfusion mismatch (PE or pneumonia)

causes hypoxemia and triggers hyperventilation because the removal of CO2 is directly dep on ventilation but the absoption of O2 is capped by the high baseline saturation of hemoglobin, the hyperventilation response typically leads to respiratory alkalosis (low arterial partial pressure of CO2) with persistent hypoexmia

Primary mineralocorticoid excess (hyperaldosteronism)

causes increased renal Na reabsorption, leading to HTN, hypokalemia, and metabolic alkalosis. Freq caused by adrenal adenoma or B/L hyperplasia

Giardia lamblia

causes injury to the duodenal and jejunal mucosa by adhereing to the intestinal brush boarder and releasing molecules that induce a mucosal inflammaotory response. *Secretory IgA* (impairs adherence) is the major component of adaptive immunity against G lamblia infection. Conditions causing IgA deficiency predispose pt to chronic giardiasis. Also involves CD4+ helper cells children with IgA deficiency: X-linked agammaglobulinemia, and common variable immune deficiency have a predisposition for chronic giardiasis

Urinary Tract Obstruction

causes reflux of urine into the renal tubules and increased tubular hydrostatic pressure. The intraglomerular capillary hydrostatic pressure is unchanged, resulting in a decreased hydrostatic pressure gradient across the glomerular capillary wall and a reduction in glomerular filtration. Oncotic pressure is maintained by large plasma proteins which are not filtered across the glomerular capillary basement membrane; it is unaffected by a urinary tract obstruction

streptococcus gallolyticus (formerly S. bovis)

causes subacute bacterial endocarditis signs of infective endocarditis: weight loss, fatigue, night sweats, and weakness. Fever may be present in more acute cases and a physical examination may reveal a new cardiac murmur. Classic ocular and cutaneous manifestations known by their eponyms are discussed below. Roth Spots: Retinal hemorrhages with white or pale centers seen on fundoscopic exam. Janeway Lesions: Nontender, macular (flat) lesions found on the palms or soles. Osler Nodes: Painful, erythematous, raised lesions related to immune complex deposition, found on the distal extremities including fingers and toes. part of the nl flora of the colon and bacteremia or endocarditis is associated with colonic cx

Irreversible ischemic injury to brain tissue

causes tissue digestion by hydrolytic enzymes (liquefactive necrosis). The infacted CNS tissue is eventually replaced with a cystic astroglial scar. in other organs - COagulative necoris

Neisseria gonorrhoeae

causes urethritis in men, cervicitis or pelvic inflammatory disease in women, or pharyngitis in either sex. symptoms present in women, may include vaginal pruritus, mucopurulent discharge, or lower abdominal discomfort. Untreated, N. gonorrhea may enter the bloodstream and disseminate, causing fever, septic arthritis, and a localized rash. The arthritis may involve one or few joints in an asymmetric and migratory presentation. The rash typically has an acral distribution and is comprised of erythematous patches with solitary or few hemorrhagic pustules. Disseminated N. gonorrhea (gonococcemia) is a common cause of acute-onset arthritis in healthy, young, sexually active adults. A deficiency in late complement components (C5 - C9) may predispose to infection with this Gram-negative diplococcus.

Bordetella pertussis

causes whooping cough, releases pertussis toxin that causes ADP ribosylation of the inhibitory Gi protein, leading to increased intracellular cAMP. tracheal cytotoxin: destroys ciliated epithelial cells = loss of airway protection, subsequent microaspiration and development of paryoxymal cough inpiratory whoop followed by vomiting

Pineal gland mass

causes: - obstructive hydrocephalus from aqueductal stenosis (papilledema, HA, and V) - Dorsal midbrain (Parinaud) syndrome: due to direct compression of the pretectal region of the midbrain. Parinaud syndrome is characterized by limitation of upward gaze with a downward gaze preference, B/L eyelid retraction (Collier sign, sclera visible above the superior corneal limbus), and light-near dissociation (pupils that retract to accommodation but not to light). MC pineal mass = *Germinoma*: midline malignant tumor from embryonic germ cells. Can also arise in the gonads or mediastinum. more common in young boys - common sites: pineal gland and suprasellar region. Due to their proximity to the pituitary gland and hypothalamus, supersellar germinomas do not lead to Parinaud syndrome, but they are more likely to present with endocrinopathies (central precocious puberty, diabetes insipidus)

drugs that can cause disulfram-like reactions to alcohol

cefoperazone and cefamandole, which are third generation and second generation cephalosporins, as well as with procarbazine, first generation sulfonylureas, and metronidazole.

trehalose dimycolate

cell wall component and major virulence factor in M. TB- protects from being killed by macrophages and stimulates granuloma formation

MS

central demyelinating AI dz targets oligodendrocytes, the cells that make myelin in the CNS Charcot triad: scanning speech, intention tremor, and Nystagmus

squamous cell carcinoma of the lung

central, hilar mass arising from the bronchus. Cavitation, Cigarettes, hyperCalcemia keratin pearls and intercellular bridges

Squamous cell carcinoma of the lungs

centrally located, associated with smoking, cavitations, PTH related protein mediated hypercalcemia Biopsy: keratin pearls and intracellular bridges

intention tremor

characteristic of damage to cerebellum or cerebellar pathways, esp the output from the dentate nucleus of the cerebellum to the ventral lateral nucleus of the thalamus m/c cause of the tremor: stroke, multiple sclerosis of the cerebellum, or midbrain trauma that affects cerebellar outflow. this tremor increases in severity as the hands move closer to its target, which is in contrast to postural/action tremors that tend to remain constant throughout the range of the motion. large in amplitude due to the involvement of proximal muscles.

Mitochondrial disease

characterized by "Red ragged" muscle fibers are seen / blotchy red muscle fibers on Gomori trichrome stain. In these conditions, abnormal mitochondria accumulate under the sarcolemma of muscle fibers. The fibers have an irregular shape and size on cross section. Electron microscopy of the affected muscle reveals an increased number of enlarged, abnormally shaped mitochondria. Examples: - MERRF: Mitochondrial myopathies are myoclonic epilepsy w/ ragged red fibers + proximal muscle weakness - MELAS: Mitochondrial encephalopathy with stroke-like episodes and lactic acidosis Muscle fibers have this appearance because abnormal mitochondrial accumulate under the sarcolemma. Mitochondrial disease shows maternal inheritance

Congenital Torticollis

characterized by a unilateral contracture of the SCM muscle. causative factors include malposition in utero, breech position and birth trauma. usually dx'd within first three weeks of life. lateral flexion to same side as contracture, rotation toward opposite side. treatment conservative for the first year with emphasis on stretching, active ROM, position and caregiver education. possible surgery. noted 2 to 4 weeks of age, child prefers to hold the head tilted to one side. Soft-tissue mass may be palpable in the inferior 1/3 of the affected SCM

sleepwalking (somnambulism)

characterized by abnormal behavior, emotions, perception, and dreams that occur unknowingly during sleep. It can be treated by a short-term course of TCA, benzodiazepines, or SSRI once non-pharmacological treatments have been exhausted, the episodes are affecting their daily life or the child is endangering themselves or others.

Systemic mastocytosis

characterized by abnormal proliferation of mast cells and increased histamine secretion. This increases the production of gastric acid by parietal cells. Gastric acid hyper secretion therefore commonly occurs. hypotension, flushing, puritus mast cell proliferation is associated with mutations to KIT receptor tyrosine kinase

occupational asthma

characterized by airway inflammation, bronchial hyperreactivity, and variable airflow obstruction triggered by workplace exposure. Exposure can be immunologic (atopic), due to exposure to a workplace aeroallergen causing Th2-mediated IgE formation, or nonimmunologic, due to exposure to workplace irritants that lead to denudation (removal of surface layers) of the bronchial mucosa

Dandy-Walker malformation

characterized by aplasia or hypoplasia of the cerebellar vermis, cystic dilation of the fourth ventricle, and enlargement of the posterior fossa. non-communicating hydrocephalus Truncal ataxia is associated with cerebellar vermis dysfunction, although it is not a common finding in Dandy-Walker malformation

Paget disease of bone (osteitis deformans)

characterized by disorganized bone formation deformity: bowing of the legs, bone pain, arthritis or adjacent joints and focal warmth from increased blood flow or bruits thickening of the skull, long bones of extremeites, and verterbal column. can lead to pinal stenosis, nerve compression and compression fx thickening of cortical and trabecular bone increased serum *Alkaline phosphatase* due to new bone production but calcium and phosphorus is NORMAL *X-ray: lytic or mixed lytic-sclerotic lesions, thickening of cortical and trabecular bone and bony deformitities*

Plummer-Vinson syndrome

characterized by dysphagia and iron deficiency anemia. Pt develop weakness, fatigue, and dyspnea secondary to the anemia; dysphagia develops due to esophageal web formation. Other findings associated with iron deficiency include koilonychia (spoon-shaped nails) and a shiny red tongue secondary to atrophy of lingual papillae. Tx: iron supplementation.

Primary (psychogenic) polydypsia is commonly seen in?

characterized by excessive intake of free water leading to hyponatremia and production of large volumes of dilute urine. Water restriction normalizes serum levels and increases urine osmolality

Septic shock

characterized by hypotension, high cardiac output that becomes depressed as the symptoms progress, low systemic vascular resistance, and low cardiac filling pressures. The key to treatment for these patients is antibiotics and vasopressors, such as norepinephrine, if needed. Gram-negative rod septic shock is caused by the lipid A portion of lipopolysaccharide.

obstructive sleep apnea (OSA)

characterized by recurrent episodes of upper airway collapse during sleep. Anatomical and neuromuscular mechanisms have been implicated in OSA. Neuromuscular weakness as a pathogenic mechanism in OSA is supported by the fact that apneas occur during sleep a time muscle relaxation. The upper airway dilator muscles weaken during the transition from wake to sleep, leading to airway narrowing and ultimately collapse in individuals with OSA. Stimulation of the hypoglossal nerve using an implantable nerve stimulator causes the tongue to move forward slightly, increasing the anteroposterior diameter of the airway. Decreasing the number of obstructive events during sleep. relaxation of the oropharyngeal and/or soft palat musculature during sleep results in a functional collapse of the airway, producing periods of reduced (hypopnea) or absent (apnea) airflow despite continued breathing efforts

Tetralogy of Fallot (TOF)

characterized by right ventricular hypertrophy, pulmonic stenosis, overriding aorta, and ventricular septal defect. A characteristic 'boot-shaped heart' is seen on chest x-ray. Tet spells are characteristic, resulting in episodic cyanosis in the setting of a right-to-left shunt, often occurring with exertion or crying fits. In older children, tet spells are often improved with squatting to increase the systemic vascular resistance, decreasing the right-to-left shunt and, thereby, improving oxygenation.

ankylosing spondylitis

characterized by stiffness and fusion of axial joints (ankylosis) and inflammation at the site of insertion of tendons into bones (enthesitis). Involvement of the spine and thoracic spine and costovertebral and costosternal junctions can limit chest wall expansion, leading to hypoventilation.

McCune-Albright syndrome

characterized by triad of fibrous dysplasia of the bone, endocrine abnormalities (such as early puberty (before age 8 in girls) or hyperthyroidism) and cafe-au lait macules (CALM): these are susualy the first manifestion. Coast of Maine border with the cafe-au-lait macules (irregular border): large, U/L Condition results from an activating mutation in the G protein/CAMP/adenylate cyclase signaling pathway. mutation in GNAS

liver cirrhosis

characterized by upper GI bleeding and ascities

natural ligand for HIV coreceptor (ccr5 receptor inhibitors)

chemokine

IL-8

chemokine produced by macrophages that induces chemotaxis and phagocytosis in neutrophils. Other significant chemotactic agents include n-formylated peptides, leukotriene B4, 5-HETE (the leukotriene precursor) and complement component C5a.

Leukotriene B4

chemotactic agent that increases the ability of leukocytes to cross from the serum into the tissues as part of an inflammatory response

Reye Syndrome (RS)

children tx with salicylates (aspirin) hepatic failure and encephalopathy: microvesicular steatosis of hepatocytes without inflammation- small fat vacuoles in the cytoplasm and cerebral edema

Thayer-Martin agar

chocolate sheep blood argar infused with vancomycin to inhibit gram + bac; with colistrin and trimethoprim to inhibit gram neg bac; and nystatin to inhibit yeast used to isolate Neisseria species

Congenital toxoplasmosis

chorioretinitis, hydrocephalus, intracranial calcifications also hydrocephalus, jaundice, and hepatosplenomegaly pregnant women should avoid raw or undercooked meat to prevent infection which can spread across the placenta to the fetus

Flow of CSF through the brain

choroid plexus > lateral ventricles > foramen of monroe (interventricular foramen) > 3rd ventricles > aqueduct of sylvius (cerebral aqueduct) > 4th ventricles > 2 foramen of lushka/foramen of magendie > subarachnoid space > brain > arachnoid villi

Ulcerative colitis

chronic inflammation of the large intestine/colon with presence of ulcers. continuous colorectal carcinoma, crypt abscesses, extends proximally, bloody diarrhea, sclerosing cholangitis

Takayasu arteritis

chronic larger-artery vasculitis involves the aorta and its branches. Constitutional sx: fever, WT loss, arterio-occlusive: claudication-exertional pain due to limited blow flow reserve, BP discrepancies, pulse deficits, Granulomatous inflammation of the vascular media Female, Asian, Age <40

diarrhea, WT loss, and epigastric calcifications in a pt with chronic EtOHism suggest?

chronic pancreatitis with pancreatic exocrine insufficiency and malabsorption.

Narcolepsy

chronic sleep disorder characterized by - excessive daytime sleepiness - cataplexy (sudden loss of muscle tone that occurs in response to intense (usually positive) emotions - REM sleep-related phenomena: - intrusions of REM sleep phenomena during sleep-wake transitions including *hyponagogic* (upon falling asleep) and *hypnopompic* (upon waking) *hallucinations* - *sleep paralysis*: inability to move immediately after awakening Results from the depletion of hypocretin (aka orexin)-secreting neurons in the lateral hypothalamus that are involved in maintaining wakefulness Dx: *low CSF levels of *hypocretin-1* or shortened REM sleep latency on polysomnography

Acquired QT prolongation is most frequently caused by electrolyte imbalance (hypokalemia, hypomagnesia) and the pharmacologic agents:

class IA and III antiarrhythmics (quinidine, sotalol), abx (macrolides, fluoroquinolones), methadone and antipsychotics (haloperidol)

Multiple myeoloma

clock-face nuclei, multiple plasma cells neoplastic plasma cells crowd the bone marrow = impairs nl hematopoiesis. B-cell development is affected, decreased plasma cell diversity and limits the generation of targeted immunoglobulins. increased risk of recurrent bacterial infections, esp urinary tract, lungs, and sinuses.

Primary Myelofibrosis (PMF)

clonal expansion of megakaryocytes. bone marrow fibrosis accounts for most of the major manifestation, including hepatosplenomegaly, cytopenias, and blood smear evidence of dacrocytes. bone marrow aspiration is usually dry, but bone marrow biopsy will show marked fibrosis with occasional clusters of atypical megakaryocytes

Schizoid

cluster A personality d/o marked by withdrawal and inability to form close relationships, flat affect

RAS gene

codes for a family of small G-proteins involved in signal transduction in the Ras-MAPK pathway. Ras proteins exist in 2 states: 1) inactive GDP-bound state 2) and active GTP-bound state Ras becomes activated when a growth factor ligand binds to a receptor tyrosine kinase on the cell membrane, causing atuophsphorylation of the receptor. This triggers binding of adapter proteins that interact with Ras, promoting GDP removal and GTP binding. Activated Ras then beings a phosphorylation cascade that results in the activation of mitogen-activated protein kinase (MAPK), which enters the nucleus to influence gene transcription. Ras proteins have intrinsic GTPase activity that allows them to hydrolyze GTP; this mechanism prevents accumulation of active Ras (GTP-bound) in the absence of hormonal signaling. RAS gene mutations can lead to decreased intrinsic GTPase activity GTPase activity; this results in a consitiutively acidvated Ras protein that causes constant and unregulated cell proliferation. RAS mutations are commonly ID in cancerous tumors, specifically colorectal and pancreatic malignancies.

Iron overload (hemochromatosis)

common and serious complication of chronic hemolytic anemia and frequent blood transfusions. Hemosiderin accumulation is the cardinal histoglogic finding. Chelation therapy is indicated to reduce parenchymal iron depostion

RSV

common cause of cough, fever, and respiratory distress due to bronchilitis in infants during winter months

Anovulation

common cause of infertility Menotropin (human menopausal gonadotropin) is a tx option that acts like FSH and triggers the formation of a dominant ovarian follicle. Ovulation is then induced by administration of hCG, which mimics the LH surge. can be used for pt with PCOS

decompensated heart failure

common cause of secondary (functional) mitral valve regurgitation. Increased LV end-diastolic volume causes dilation of the mitral valve annulus and restricted movement of the chordae tendineae with subsequent regurgitation. Treatment with diuretics and vasodilators

hypertrophic cardiomyopathy

common cause of sudden cardiac death in young adults cardiomyocyte hypertrophy and myofiber disarray with increased interstitial fibrosis. The structural disarray creates a substrate for ventricular arrhythmia (ventricular tachycardia, v-fibrillation) that can lead to SCD AD mutation in sarcomere genes: in *beta-myosin heavy chain and myosin-binding protein C gene*

pulmonary arterial hypertension

common complication to systemic sclerosis, resulting from proliferation of T cells with release of cytokines (TFG-beta) and consequent progressive thickening and occlusion of the small and medium-sized pulmonary arteries/arterioles. Pt have progressive dyspnea and loud pulmonic component of S2 and may devlop signs of R-sided HF (hepatomegaly, peripheral edema)

Left sided heart failure and its effects on the lungs

common following MI affecting the LV. The resulting accumulation of edema in the pulmonary interstitium makes the lungs heavy and stiff, restricting inspiratory expansion and decreasing lung compliance

Anticholinergic side effects

common in older adults and can include: urinary retenention, constipation, imparied memory, confusion, hallucinations, dry mouth, blurry vision, impaired sweating, tachycardia, and increased risk for falls. can be due to combination of amitriptyline and diphenhydramine

Tibial Stress Fracture

common in patients who start a new, intense exercise routine. Symptoms include focal pain in the area of fracture that is reproduced with activity. MRI is becoming the most commonly used imaging modality for diagnosis, but bone scintigraphy may still be used. emale runners are at a higher risk of developing tibial stress fractures, as are patients with bilateral pes planus (flat-footed), unequal leg lengths, and weak calf muscles.

Hand-foot-mouth disease

common viral illness in children painful vesicular mouth lesions, ulcers on the extremeities, and low grade fever due to ingestion and subsequent disseminiation of an enterovirus (COXSACKIE)

cutaneous strawberry-type capillary hemangioma (juvenile hemangioma)

common, benign, congenital tumors made of unencapsulated aggregates of closely packed thin-walled capillaries. initially grow in proportion to the growth of the child, before eventually regressing. Ususally regresses by age 7.

orbital floor fracture

commonly due to direct frontal trauma to the orbit. The infraorbital nerve (continuation of the maxillary nerve) runs along the orbital floor in a groove in the maxilla before exiting the skull just inferior to the orbit. Damage can result in paresthesia of the upper cheek, upper lip, and upper gingiva. In addition, the inferior rectus muscle can become entrapped, limiting vertical gaze fx of the orbital floor which is made up of the zygomatic bone and maxilla

Small Bowel Obstruction (SBO)

commonly presents with abrupt onset of crampy and colicky abdominal pain, nausea, and vomiting. Physical examination includes abdominal distention with high-pitched bowel sounds, with a lack of peritoneal signs. Abdominal x-ray is the preferred initial test of choice, with classic findings demonstrating multiple dilated loops of bowel and air-fluid levels. In the absence of signs of bowel perforation, conservative therapy should be initiated, which includes IV hydration, electrolyte repletion, and making the patient NPO (nil per os; nothing by mouth). Decompression of the distended stomach with a nasogastric tube put to suction is indicated in the setting of a bowel obstruction with significant distension, nausea, or vomiting.

Assessment of decision making capacity, pt should be able to

communicate a choice (clearly indicate preferred tx option), understand information given (understands condition & tx option), appreciate consequences (acknowledges having condition and likely consequences of tx options, including no tx), rational is given for a decision (able to weigh risks and benefits and offer reasons for decision)

t-test

compares mean value between 2 groups dependent variable is quantitative

Analysis of Variance (ANOVA)

compares means between 2+ groups dependent variable tis a quantitative determine whether the measurements among 3 or more groups are statistically similar or different. The grouping variables (independent variables) are nominal and the measured variable (dependent variable) is continuous (either interval of ratio scale).

Potassium Iodide

competitively inhibits thryoid uptake of radioactive-iodine isotopes and is often administered following nuclear accidents to protect the thyroid and prevent development of radiation-induced thyroid carcinoma. In adiditon the large increase in serum iodide levels wil inhibit iodine organification (Wolff-Chaikoff effect) and reduce thyroid hormone release

Hemolytic transfusion reaction

completment activation w/ lysis of transfused RBCs due to recipient antibody to donor RBC antigen ABO incompatibility Labs: DAT positive Indicated by low back pain and apprehension

Transtentorial herniation

complication of I/L mass lesion (hemorrhage or tumor) Sx: fixed and dilated pupil on the side of the lesion. I/L paralysis of oculomotor muscles, C/L or I/L hemiparesis, and C/L homonymous hemianopsia with macular sparing

Transfusion - mediated acute lung injury

complication of blood transfusion. ARDS within 6 hrs of blood administration units from multiparous female donors usually implicated. Hypoxemia and pulmonary infiltrates

zinc-finger motif

composed of chains of aa bound together around a zinc atom via linkages with cysteine and histidine residues. They recognize specific DNA sequences and are used by many transcription factors to bind DNA and alter activity of target genes. *Intracellular receptors* that bind steroids, thyroid hormone, and fat-soluble vitamins (A-KED) act directly to transcription factors and contain zinc-finger binding domains.

Neural crest cells

composed of parallel strips of cells arising from the ectoderm at the margin of the neural tube. Structures derived from neural crest cells include Schwann cells, odontoblasts, melanocytes, enterochromaffin cells, spinal membtranes, adrenal medulla/ganglia, laryngeal cartilage, and tracheal cartilage

Androgen Insensitivity Syndrome (AIS)

condition during prenatal development in which androgen receptors malfunction in genetic males (XY), impeding the formation of male external genitalia; in these cases, the child may be born with female external genitalia never had menstrual period, vagina ends blindly, no uterus or ovaries palpated, buccal smear: chromatin-neg nuclei

Wernicke's aphasia

condition resulting from damage to Wernicke's area (damage to the posterior superior temporal gyrus) intact fluency, impaired repetition, and impaired comprehension. Patients are able to speak rather effortlessly, but they have difficulty understanding and repeating words and phrases. In addition, they often exhibit paraphasia, the tendency to substitute incorrect words in speech (eg, when "sword" was substituted for "knife" in the scenario above).

Swyer Syndrome

congenital absence of testes in genotypical male; phenotypical picture similar to ovarian agenesis, because testes never develop, MIF not released and patients have both internal and external female genitalia. XY

Tricuspid Atresia

congenital agenesis or absence of the tricuspid valve with no direct communication between the right atrium and ventricle. Atrial and ventricular septal defects that bypass the tricuspid valve are associated with this condition. It is strongly associated with genetic conditions such as trisomy 21 (Down syndrome).

Mutlifactorial abnormalities

congenital heart defects, anencephaly, cleft lip, syndacyly

acute pulmonary edema

consequence of acute MI affecting the LV. Elevated hydrostatic pressure in the pulomary venous system leads to engorged alveolar capillaries with transudation of fluid into the alveoli, appearing as acellular pink materal on histology Hemosiderin laden macrophages are indicative of CHRONIC lung congestion and not present acutely

Anti-Rh immune globulin

consists of IgG anti-D antibodies that opsonize Rh+ fetal erthrocytes, promoting clearance by maternal reticuloendothelial macrophages and preventing maternal Rh sensitization. Usually given at 28 weeks and immediately post-partum if the woman is Rh-negative

integral membrane proteins

contain transmembrane domains composed of alpha helices with hydrophobic aa residues (alanine, valine, leucine, isoleucine, phenylalanine, tryptophan, methionine, proline, glycine). These transmembrane domains help anchor the protein to the phospholipid bilayer of the cell membranes

brain abscess

contained area of liquefactive necrosis with a surrounding inflammatory capsule and marked vasogenic edema. It usually appears on imaging as a ring-enhancing lesion and often presents with a HA, fever, and/or focal neurologic findings (seizure) most cases are bacterial (Strep viridans/Staph aureus) and stem from an underlying adjacent/distant infection. Single absecess: - usually due to the direct invasion of a contiguous infection. - *Temporal lobe abscess*: usually a result of otitis media that has spread to mastoid air cells - *frontal lobe abscess*: due to ethmoid or frontal sinusitis Multiple abscesses: - indicate hematongenous dissemination of a distant infection heart (endocarditis) or lungs (abscess, empyema)

HIV genome

contains 3 major structural genes that are translated as polyproteins and cleaved by host protease (env gene products) or viral protease (gag-pol gene products) into the individual proteins that compose the HIV virus. Protease inhibitors block viral protease from cleaving gag-pol polyproteins which results in formation of immune virions that are noninfectious

Mandibular division of trigeminal nerve

contains BOTH motor and sensory supplies sensation to the TMJ and mandibular teeth as well as the floor of the mouth, inside of the cheeks, anterior tongue, and much of the skin of the lower part of the face. The motor fibers innervate the muscles of mastication (medial and lateral pterygoid, masseter, temporalis), muscles of the floor of the mouth (mylohyoid), tensor veli palatini, and tensor tympani in the middle ear.

posterior column pathway

contains I/L ascending neurons that convey sensations of light touch, vibration, and proprioception. includes the medial gracile fasciculus (LE) and lateral cuneate fasciculus (UE) the post columns would be most susceptible to a lower back stab injury due to their posterior location

alveolar fluid

contains neutral proteases (elastases) that are derived from the alveolar macrophages and infiltrating neutrophils. These proteases can cause destruction of terminal lung parenchyma (emphysema) when secreted in excess of if left unchecked by deficient antiprotease activty

Hemoglobin S

contains valine in place of glutamic acid at the 6th aa position of the beta globin chain. this promotes hydrophobic interaction among Hb molecules resulting in HbS polymerization and erythrocyte sickling

Contracture of the digits 2-5

contracted like a claw indicates a lesion of the median and/or ulnar nerve

cytosolic acetyl CoA

converts acetyl-CoA to malonyl-CoA during the rate-limiting step of de novo fatty acid synthesis. Malonyl-CoA also inhibits the action of mitochondrial carnitine actyltransferase, thereby inhibiting beta-oxidation of newly formed fatty acids

wilson disease

copper accumulation in the liver, brain, and cornea. presents in childhood / adolescence with abnl liver function tests and or neuropsychiatric sx which include personality changes, depression, mania, and or psychosis

base excision repair

corrects single-base DNA defects induced spontaneously or exogenously by chemicals. Steps: -glycoslylases removes the defective base - the corresponding empty sugar-phosphate site is cleaved and removed by the action of the endonuclease (cleaves the 5' end) and lyase (cleaves the 3' end). -DNA polymerase replaces the missing nucleotide - ligase seals the final remaining nick

placement of Left ventricular leads in biventricular pacemakers

course through the coronary sinus, which resides in the arterioventricular groove on the posterior aspect of the heart

L3 dermatome

courses anteriorly across the thigh and into the medial calf, ending ~halfway down the calf L3 root supplies partial motor innervation to the quadratus lumborum, iliopsoas, and obturator externus muscles.

L5 dermatome

coursing laterally across the thigh and knee and into the anterior leg and dorsum of the foot. The L5 root supplies motor innervation to all three gluteus muscles, the tensor fascia lata, the tibialis anterior and posterior, extensor digitorum brevis, and extensor hallucis longus muscles. There is no spinal reflex associated with the L5 dermatome.

Articulatory technique

defined as direct, Low-velocity, moderate - to - high amplitude technique where a joint is put through full motion with the goal of increasing overall range of motion. accomplished by an activating force through springing/repetitive movement of the joint through the barrier

Transforming growth factor-beta (TGF-beta)

critical for fibroblast migration, proliferation, and CT synthesis. Increased TGF-Beta is responsible for the hypertrophic/keloid scarring and fibrosis of the lung, liver, and kidney that occur with chronic inflammation

orbitofrontal cortex (OFC)

damage to this area causes personality changes, disinhibition, and irritability located in the frontal lobe and has strong modulatory connections to the limbic system (ie the brain's emotional system); it is involved in behavioral and emotional regulation Pathological behavioral and emotional changes are more commonly seen with B/L, rather than U/L injury to the OFC. Disinhibition may be associated with significant impulsivity and loss of social etiquette, whereas increased irritability in the context of disinhibition may lead to frank, aggressive behavior.

11B-hydroxylase deficiency

dec cortisol & aldosterone Inc testosterone inc 11-deoxycorticosterone and 11-deoxycortisol ambigous genitalia in girls Fluid and salt retention, HTN

normal changes in the aging heart

decreased LV chamber apex to base dimension sigmoid shaped ventricular septum Myocardial atrophy with increased collagen deposition accumulation of cytoplasmic lipofuscin pigment within cardiomyocytes

21-hydroxylase deficiency

decreased cortisol & aldosterone Increased testosterone Increased 17-hydroxyprogesterone Ambigous genitalia in girls Salt wasting syndrome (vomiting, hypotension, dec Na, inc K)

Diastolic heart failure

decreased ventricular compliance and is characterized by nl LV ejection fraction, nl LV end-diastolic volume, and elevated LV filling pressures. HTN, obesity, and infiltrative d/o (transthyretin-related amyloidosis, sarcoidosis) are important causes of DHF

Rifaximin

decreases intraluminal ammonia production used to treat hepatic encephalopathy use with lactulose to increase conversion of ammonia to ammonium

Strep pneumo vaccine

decreases risk of invasive disease and is recommended for young pt and the elderly Pneumococcal polysaccharide vaccine is an unconjugated vaccine that induces T-cell independent humoral immune response (for adults) vs Pneumococcal conjugate vaccine: polysaccharide material attached to a protein antigen, creating a robust T cell mediated humoral immune reponse (young pt)

methimazole

decreases the formation of thyroid hormones via inhibition of thyroid peroxidase, the enz responsible for both iodine organification and coupling of idotryosines. PTU decreases peripheral conversion of T4 to T3

Vitamine E

deficiency = neurologic sx mimic Friedreich ataxia and include ataxia (degeneration of spinocerebellar tracts) loss of position and vibration (degeneration of doral columns), and loss of deep tendon reflexes (due to peripheral nerve degeneration)

Congenital albinism

deficiency in tyrosinase, the enzyme responsible for converting tyrosine into melanin Pt presents with varying degree of skin and hair hypopigmentation, translucent irises, and ocular complications

Pseudoexstrophy

describes a patient with classic findings of bladder exstrophy, including anomalies of the bones and musculature, however, there is no involvement of any portion of the urinary tract.

placenta previa

defined by the presence of placental tissue near or directly overlying the internal cervical os. This occurs when there is an abnormal implantation of the placenta near the cervical os, and puts the patient at risk of severe hemorrhage due to placental damage and fetal distress Risk factors include a previous cesarean section, grand multiparity (usually > 5 deliveries), multiple gestation, increased maternal age, infertility treatment, previous surgery to the uterus, and smoking. The symptoms include painless, bright red bleeding that ceases within 1-2 hours with or without uterine contractions. Placenta previa should be suspected in any pregnant women who experiences vaginal bleeding after 20 weeks, especially when the bleeding is painless. When suspected, the most appropriate first step in management is always a transvaginal ultrasound to identify the placental location. However, if pelvic examination is performed, sterile speculum may be used, while digital examination *should be absolutely avoided* for risk of perforating the placenta.

several months to years after ischemic brain infarction, the necrotic area appears as a cystic cavity surrounded by a wall composed of what?

dense fibers formed by astrocytic processes (glial scar)

Onset of action of a gas anesthetic depends on what?

depends on its solubility in the blood (blood/gas partition coefficient). Drugs with high blood/gas partition coefficients are more soluble in blood, demonstrate slower equilibrium with the brain, and have longer onset times.

vestigial intermediate lobe of the pituitary gland

derived from the posteror wall of Rathke's pouch during embryonic development. It is not a significant source of secretory products in humans, but can secrete a small amount of melanocyte-stimulating hormone.

Sporothix schenckii

dimorphic fungus that causes subQ mycosis. Often transmitted by a thorn prick. The dz manifests with nodules that spreads along lymphatics

ulcerative colitis (UC)

disease characterized by inflammation of the colon with the formation of ulcers, which can cause bloody diarrhea continuous involvement limited to the colon, beginning in the rectum and stopping at some point proximally inflammation is usually confined to the mucosa and submucosa *Crypt abscesses (clusters of PMNs within the colonic crypts) "pseudopolyps" portions of surviving nonulcerated mucosa btw ulcers; not specific but are prominent in severe UC

pneumoconioses

diseases resulting from the inhalation of fine dust particles that reach the respiratory bronchioles and alveoli. Particles that lodge in this region are normally cleared by alveolar macrophages. High particulate burden can cause the excessive release of cytokines from macrophages, resulting in progressive pulmonary fibrosis.

Hodgkin's lymphoma

distinguished from other lymphomas by the presence of large, cancerous lymphocytes known as Reed-Sternberg cells Reed-Sternberg cells express CD15 and CD30 (+): CD 15 is found on neutrophils and is responsible for the phagocytosis and chemotaxis of neutrophils. CD 30 is a tumor necrosis factor receptor protein that leads to activation of NF-kappaB. NF-kappaB prevents apoptosis and promotes cell proliferation

anorexia nervosa in the context of functional hyposthalamic amenorrhea

distorted body image, inadequate diet, dry skin, and lanugo hair. Anorexic females commonly have imparied GnRH release from the hypothalamus, leading to low levels of LH, FSH, and estrogen aka functional hypothalamic amenorrhea

side effect of using metronidazole and alcohol

disulfiram-like reaction

Internal iliac artery

divides into anterior and posterior divisions to supply the organs and muscles within the pelvis. The arteries that supply the bladder branch from the anterior division of the internal iliac.

bromocriptine

dopamine agonist and is used to treat hyperprolactinemia. This drug is contraindicated in patients with Sheehan syndrome.

haloperidol

dopamine blocker - blocks postsynaptic D1 and D2 can be used to suppress tics in Tourette d/o, psychosis, delirium (waxing and waning mental status changes in impaired attention), post-op N/V, and tranquilization of severely agitated pt. (1st line Tourettes tx: fluphenazine, pimozide, tetrabenazine: all are DA receptor antagonists)

pulsus paradoxus

drop in blood pressure >10 mmHg with inspiration seen in pt with cardiac tamponade, asthma, COPD, and constrictive pericarditis

side effect of scopolamine

dry mouth, blurry vision, urinary retention, and constipation

Risk of wrong site surgery can be reduced by requiring?

dual identifiers to indep check they have the correct pt, site, and procedure

Marfan Syndrome

due to a defect in Fibrillin-1, an extracellular glycoprotein that acts as a scaffold for elastin. it is abundant in the zonular fibers of the lens, periosteum, and aortic media. Aortic root dilation with dissection and rupture is a common cause of death fibrillin-1: major component of microfibrils that form a sheath around elastin fibers. Fibrillin in the extracellular space acts as a scaffold for deposition of elastin extruded from connective tissue cells. Defects in fibrillin-1 cause mechanical weakening in the CT and abnl activation of transforming growth factor beta.

Potter sequence

due to a renal anomaly that causes decreased fetal urine output leading to oligohydramnios. The lack of anmiotic fluid causes compression of the fetus = characteristic facies and limb abnl & pulmonary hypoplasia: m/c cause of death

aplastic anemia

due to a toxic effect or autoimmune response causing apoptosis of pluripotent stem cells (pancytopenia). Bone marrow biopsy reveals hypocellularity with an abundance of fat cells *Triad: low hemoglobin, thrombocytopenia, and absent hematopoietic cells in the bone marrow* Compensatory increase in circulating erythropoeitin levels would be expected in pt with normal renal function

Acute intermittent porphyria

due to accumulation of aminolevulinate (ALA) and porphobilinogen (PBG), resulting from inherited PBG deaminase deficiency combined with ALA synthase induction (typically due to certain meds, alcohol use, or low-calorie diet). Management with glucose or hemin inhibits ALA synthase activity.

Autoimmune Hemolytic Anemia (AIHA)

due to altered immune response and the production of antibodies against erythroctes. can follow infections with Mycoplasma pneumoniae and EBV

Leukocyte adhesion deficiency (type 1)

due to an absence of CD18 antigens necessary for the formation of integrins. Clinical features: failure of leukocyte chemotaxis and include recurrent skin and mucosal infections without purulence, delayed separation of the umbilical cord and persistent leukocytosis no pus (lack of neutrophils at inflammation site and poor wound healing)

Aminoglycoside resistance

due to antibiotic-modifying enzymes. These enzymes add chemical groups (acetyl, adenyl, phosphate) to abx which diminishes its ability to bind to the 16S ribosomal RNA within the 30S ribosomal subunit.

Erectile dysfunction in older men

due to block of blood flow to the penis due to atherosclerosis or DM.

Kallmann syndrome

due to decreased synthesis of GnRH in the hypothalamus (hypogonadotrophic hypogonadism) - defective migration from the olfacotry placode hypogonadism and anosmia with delayed puberty although females are rarely affected, those with the condition present with primary amenorrhea, no secondary sexual characteristics, and an olfactory sensory defect

Galactosemia

due to deficiency of galactose-1-phosphate uridyl transferase. Clinical feat: vomiting, lethargy, jaundice, and *E. coli sepsis* Cessation of breastfeeding and switching to soy milk-based formula is recommended bc it is metabolized to glucose and fructose which do not need GALT or GALK to enter the glycolytic pathway and generate energy

Hyperestrinism in liver cirrhosis

due to increases in androstenedione production, androgen aromatization, and sex hormone-binding globulin concentration (preferentially binds testosterone) Decreased free testosterone/estrogen ratio lead to gynecomastia, testicular atrophy, decreased body hair, and spider angiomata

type 2 diabetes

due to insulin resistance and relative insulin deficiency. Chronically elevated free fatty acid levels contribute to insulin resistance by impairing insulin-dependent glucose uptake and increasing hepatic gluconeogenesis.

which nerve mediates referred shoulder pain due to an inflamed gallbladder

due to irritation of the diaphragm phrenic C3, C4, C5 innervates the diaphragm and includes the dermatomes of the shoulder

Bipolar I Disorder Criteria

dx in pt with one or more episodes of mania Manic episodes: elevated/irritable mood, impulsivity, hyperactivity, decreased need for sleep, pressured speech, and grandiosity and may occur with psychotic features

precursor lesion for malignant melanoma

dysplastic nevi

porphyrin synthesis

early step deficiencies cause neuropsychiatric manifestations without photosensitivity, whereas late step derangements lead to photosensitivity. Phostosensitivitiy manifests as vesticle and blister formation on sun-exposed areas (ex: back of hands and forearms) as well as edema, pruritus, pain, and erythema.

premature ventricular contraction (PVC)

early, wide QRS complexes that are not preceded by a P wave and are followed by a compensatory pause. common in adolescent males usually asx but can present with palpitations if sx tx with beta-blockers

signs of hepatic synthetic dysfunction in cirrhosis

ecchymosis and edema

multiple sclerosis

ecurrent episodes of limb weakness, vision changes, and loss of bladder control. It is caused by localized autoimmune destruction of myelin in the central nervous system. These lesions appear as white plaques on brain imaging.

celiac disease

elevated IgA against tissue transglutaminase Duodenal biopsy is CONFIRMATORY

exogenous hyperthyroidism

elevated free thyroxine (T4) and suppressed TSH, and low/undectecable thyroglobulin. It can occur with levothryoxine abuse, use of animal sourced thyroid supplements and erroneous dosing of thryoid replacement therapy. overtime a lack of TSH stimulation causes the thyroid follicles to become atrophic

Pulmonary hypertension

elevated pulmonary pressure resulting from an increase in pulmonary vascular resistance to blood flow through small arteries and arterioles. decreased alveolar PO2 *loud pulmonic component of S2 and an accentuated, palpable impulse at the L sternal boarder (L parasternal lift due to RV heave)* the lungs are the only exception to decreased blood flow = dilation of the vessels. When there is decreased O2 the vessles constrict to shunt blood to better perfused areas. Since the whole lung (in the case of the Q where a pt moves from sea level to higher elevation and has pulmonary HTN w/ nl CO): is exposed to lower O2 when he moved = lower alveolar O2, all the vessels constrict and cause RV hypertrophy - can then lead (eventually) to cor pulmonale

isolated mitral stenosis

elevates left atrial diastolic pressure and can therefore cause elevated pulmonary capillary wedge pressure, pulmonary hypertension, decreased pulmonary vascular compliance, right ventricular dilation, and functional tricuspid regurgitation. Diastolic pressure in the left ventricle is usually near normal or even decreased with severe mitral stenosis

aortic regurgitation

end-diastolic volume increases above normal because of the backward flow of blood during diastole, which causes increased stroke volume and an elevation of systolic blood pressure.

transketolase

enzyme of the pentose phosphate pathway that uses thaimine (vit B1) as a cofactor to shuttle 2-C fragments between sugar molecules.

mechanisms that occur in the cytosol

enzymes involved in glycolysis, fatty acid syn, pentose phosphate pathway which uses trasnketolase

Langerhans cells

epidermal dendritic cells found in the skin and act as APCs. Derived from the myeloid cell line and have racquet-shaped intracytoplamic granules aka Birbeck granules

migraine

episodic d/o: severe, often U/L HA, N/V, sensitivity to light and sound. Tx is divided into abortive therapy (mild analgesics, triptans, antiemetics, ergotamines) for acute sx and preventive therapy (beta blockers, TCA, anticonvulsant (topiramate, valproate) to decrease freq of HA.

migraines

episodic neurologic d/o that results in severe U/L, throbbing HA often associated with photophobia, phonophobia, and N/V. Migraines typically last 4-72 hrs and up to 25% of pt develop an aura (focal, reversible neuro dx that precede or accompany the HA: (positive: bright spots, noises, paresthesia, movements) or (negative: vision/hearin/sensation loss)

Intertrigo

erythematous plaques with satellite vesicles or pustules in warm, moist skin areas (axillae, groin, under breast, skin folds). The infection is due to candida albicans m/c after abx use or in immunocompromised states (uncontrolled dm)

Dermatitis herpetiformis

erythematous puritic papules, vesicles, and bullae that appear B/L and symmetrically on EXTENSOR surfaces (elbows, knees) upper back, butt. - microabscesses containing fibrin and PMNs at the dermal papillae tips - formation of IgA antibodies against gliadin (protein unique to gluten) or a gliadin/tissue transglutaminase complex in the intestine associated with CELIAC DZ: increased intraepithelial lymphs, loss of villus height, crypt hyperplasia = malabsorption, flatulence, greasy stools

Bleeding esophageal varices from cirrhosis and portal HTN

esophageal varices develop due to portal HTN occur btw the L gastric vein (which drains into the hepatic protal vein) and the azygos vein (systemic vein connecting the SVC and IVC)

tricyclic antidepressants

esp amitriptyline have stong anticholinergic effects: hot as a hare, dry as a bone, red as a beet, blind as a bat, mad as a hatter, full as a flask, fast as a fiddle

acute pancreatitis due to alcohol abuse

etoh is the second cause of acute pancreatitis after gallstones. alcohol-related acute pancreatitis is clinically indistinguishable from pancreatitis due to other causes except: 1) macrocytosis- enlarged RBCs with a MCV >100 fL 2) AST:ALT ration >2 are indirect indicators of chronic alcohol consumption. Acohol-reated macrocytosis can occur independently of folate deficiency. *ethanol induces pancreatic secretions with high [protein] and low fluid content

Acute extrapyramidal symptoms (EPS)

ex: dystonia, akathisia, parkinsonism due to D2 blockade in the nigrostriatal pathway. First-generation high-potency antipsychotics (haloperidol, fluphenazine) strongly block D2 receptors and are most likely to cause EPS

Discriminant ability

examines the characteristics of a test: (sensitivity + specificity) / 2 both sensitivity and specificity indicate a test's effectiveness. Not useful to assess the effectiveness of a prevention program bc there is no comparison of dz incidence between the groups

giagantism

excess growth hormone during childhood: accelerated linear growth, prognathism and bony enlargemnt of hands and feet. GH has direct effects on target tissues and indirect effects mediated by insulin-like growth factor-1 secretion from the liver

3 most important predisposing factors for hypoglycemia in pt with type I DM

excessive insulin dose, inadequate food intake, and physical activity uptake of glucose in skeletal muscle is mediated by the GLUT4 trasnporter which is translocated to the cell membrane in response to insulin and musc cont

generalized anxiety disorder

excessive uncontrollable worry about multiple issues with a sx duration of >6 months. Associated sx: restlessness, muscle tension, fatigue, sleep disturbance, irritability, and difficulty concentrating

Exposure to ionizing radiation (gamma rays, x-rays) may

exposure of ionizing radiation, including therapeutic and palliative radiation therapy, induces DNA damage through double strand fractures- breakage of both strands is generally required, as single strand breaks are readily repaired by polymerase and the formation of free radicals: reactive oxygen species are formed by ionization of water; oxygen free radicals are then able to cause cellular and DNA damage. the effect of radiation is most pronounced in malignant cells as they are rapidly dividing and consequently less able to repair DNA damage. Epithelial surfaces (bowel mucosa, skin) are also severely affected because they are rapidly dividing.

Class II HLA proteins (DR, DP, DQ alleles)

expressed by APC (macrophages, dendritic cells) and present predominantly foreign antigens to CD4+ helper T cells. Ex: rheumatoid arthritis, type I DM, and celiac dz

MHC class II

expressed on the surface of APC and functions by presenting antigen that is foreign to the body. This antigen is taken into the APC by phagocytosis or endocytosis and is loaded onto MHC class II within acidified endosomes, and the MHC Calss II protein-antigen complex is then expressed on the surface for subsequent interaction with T-lymphocytes. Failure to acidify lysosomes would lead to deficient expression of MHC Class II bound to foreign antigen and subsequent lack of interaction between APCs and T-cells.

lung apices

extend above the level of the clavicle and first rib through the superior thoracic aperture. Penetrating injury in this area may lead to pneumothorax, tension pneumothorax, or hemothorax.

microglial cells

extremely small glial cells that remove cellular debris from injured or dead cells stain with SILVER stain MESOderm derived

facial nerve nucelus

facial nerve is responsible for innervating the muscles of facial expression its nucleus is found in the caudal pons near the 4th ventricle

Hyperchylomicronemia (Type I)

familial lipoprotein lipase deficiency is an inherited hyperlipidemia due to a deficiency of Lipoprotein lipase, an abnormality in lipoprotein lipase, ore defect in apolipoprotein CII. The result is elevated chylomicrons, VLDL, and triglycerides within circulation, placing the pt at increased risk for pancreatitis.

type II muscle fibers

fast twitch generate rapid forceful pulses of movement Type IIb: derive ATP energy through anaerobic glycogenolysis and subsequent glycolysis Type IIa ("fast twitch"): are intermediate between Type I and IIb fibers; they generate ATP via aerobic metabolism

global aphasia

features of Broca and Wernicke aphasia including loss of fluency and language comprehension. The m/c etiology of global aphasia is a stroke of the proximal L MCA. Broca and Wernicke are located in the inferior frontal gyrus and superior temporal gyrus, and typically the arcuate fasciculus affected (connection between Wernicke and Broca)

shrunken eosinophilic (red) neurons

findings are indicative of acute neruonal injury and subsquent apoptosis/necrosis. Found 12-24 hours after an ischemic injury ie stroke

IgM

first antibody produced found on the surface of naïve B cells and is produced during the early primary response to pathogens. In serum, it is a pentamer with ten antigen binding sites, thus, it has the highest avidity of the immunoglobulins. Maternal IgM is not transferred to the neonate in a significant amount to offer protection to pathogens. It is also elevated in certain acute infections.

Bupropion

first line antidepressant that is not associated with sexual side effects or WT gain. However, it is assocaiated with an increased seizure risk at high doses an is C/I in pt with seizure d/o, anorenxia nervosa, and bulima

Pityriasis Rosea

first presents with a primary lesion called *Herld patch* And then a secondary eruption within 1-2 weeks: *Christmas tree" pattern. Herld patch: oval, slightly raised 2cm-5cm plaque/patch with a peripheral scaly appearance. Second eruption: lesions of the same appearance but smaller and in a tree-like pattern. Involves the trunk and proximal aspects of the extremities. The face is generally spared. Tx: supportive, rash resolves within 6-10 weeks.

Mutation in APC tumor suppressor gene

first step in the classic adenoma-to-carcinoma seq. it is found in most cases of sporadic colon cancer and in all pt with familiarl adenomatous polyposis. The microsatellite instability pathway is characterized by mutations in DNA mismatch repair genes and is implicated in the development of hereditary nonpolyposis colorectal cancer (lynch syndrome)

metformin

first-line oral antihyperglycemic medication that causes gastrointestinal upset and, of more importance, can lead to lactic acidosis, which is most likely to occur in patients who experience kidney or liver failure or who are in acute congestive heart failure. decrease hepatic gluconeogenesis, increase glycolysis, decrease the intestinal absorption of glucose, and improve insulin sensitivity by promoting glucose uptake and utilization. This medication is never used in patients with renal failure because it can cause lactic acidosis because without proper kidney function, the pH imbalance cannot be corrected. Metformin inhibits hepatic gluconeogenesis from lactate, pyruvate, and alanine, resulting in elevated lactate and lactate substrates.

mechanism of action of metformin

first-line treatment for type II diabetes mellitus. It decreases hepatic gluconeogenesis, sensitizes tissues to insulin, and does not usually cause hypoglycemia

lower motor neuron signs

flaccid paralysis, weakness with hypotonia and muscle atrophy, fasciculations, suppressed or absent reflexes

Granuloma Annulare

flesh-colored or erythematous, asymptomatic (without pruritus or pain) annular plaques with a firm, ropy border and central clearing. begin as small lesions and may show slow, centrifugal growth. The most common sites include the dorsal surfaces of the hands and feet, wrists, and ankles. Up to 50% of patients with localized granuloma annulare will present with multiple lesions. Although no exact cause is known, various antecedent events are suspected, including trauma, insect bites, vaccinations, drugs, and sun damage. possible associations include diabetes mellitus, malignancy, and dyslipidemia, and thyroid disease.

Primary disease prevention

focus on prevention of the initial occurence of disease or injury. Includes vaccination to prevent dz, nutrition counseling, family planning, smoking cessation, safety education (seat belt helmet use), prenatal classes, wearing sunscreen

moderately elevated alkaline phosphatase of unclear etiology

follow up with gamma-glutamyl transpeptidase

von Willebrand factor deficiency

following endothelial damage, vWF binds glycoprotein Ib receptors on platelets to mediate platelet adherence. The *ristocetin cofactor assay* measures platelet agglutination via binding of glycoprotein Ib receptors to vWF; it will be abnormal in vWF deficiency but will correct with the addition of normal vWF-containing plasma

obstructed right brachiocephalic (innominate) vein

formed from the union of the R subclavian vein and R internal jugular vein. The R external jugular vein drains into the R subclavian vein so obstruction of the R brachiocephalic vein will also cause venous congestion of structures drained by the external jugular vein. The R brachiocephalic vein also drains the R lymphatic duct, drains lymph from the R UE, R face and neck, R hemithorax, and RUQ of abd.

Metrodinazole

forms toxic free radical metabolites

Brown Recluse Spider

found in North and South America. In about 10% of brown recluse spider bite cases, the venom is responsible for progressive, necrotic wounds; this necrosis is clinically termed 'loxoscelism.' These spiders are typically found in sheltered areas inside of homes like a basement, attic, or bookshelf. Its venom contains many enzymes and biologically active substances, most notably phospholipase D and sphingomyelinase.

Interstital myocaridal granulomas (aschoff bodies)

found in carditis due to acute rheumatic fever which develops after untx group A strep pharyngeal infection Aschoff bodies contain plump macrophages with abundant cytoplasm and central, slender ribbons of crhomatin

brown adipose tissue

found in newborns and in hibernating mammals brown adipose cells contain several intracytoplasmic fat droplets and many more mitochondira than white adipose cells. They function to produce heat by uncoupling oxidative phosphorylation with the protein thermogenin.

IgA nephropathy (Berger disease)

frequently presents as recurrent, self-limited, painless hematuria within 5 days of an URI (bacterial or viral). Kidney biopsy will show mesangial IgA deposits on IF.

Penicillins and cephalosporins

function by irreversibly binding to penicillin-binding proteins. Transpeptidases are one form of penicillin-binding protein that function to cross-link peptidoglycan in the bacterial cell wall. Inhibition of transpeptidase leads to cell wall instability and bacteriolysis a change in the structure of penicillin-binding proteins that prevents cephalosproin binding is one mechanism of bacterial resistance to cephalosporins.

Vascular smooth muscle cells

functions = vasoconstriction and dilation in response to normal or pharmacological stimuli (neural or hormonal) -> elaboration of growth factors and cytokines -> migration to the intima and proliferation responsible for fibrous cap formation

RNA polymerase I

functions exclusively within the nucleolus to transcribe the 45S pre-rRNA gene, which codes for most of the ribosomal RNA components (18S, 5.8S, and 28S rRNA)

The common hepatic artery provides blood supply to the

gallbladder, liver, biliary ducts, stomach, duodenum, and pancreas. It originates in the celiac trunk. It subsequently bifurcates into the right and left hepatic arteries.

2 common causes of acute pancreatitis

gallstones and EtOH abuse Macrocytosis (MCV >100fL) and AST:ALT ration >2 are indirect indicators of chronic alcohol consumption. Alcohol-related macrocytosis can occur independently of folate deficiency

hypercalcemia causes

gastrin release. thus in a pt with elevated gastrin, place pt on PPI and check Ca

Zollinger-Ellison syndrome

gastrinoma found in the SI/pancrease and present with peptic ulcers (eps distal duosdnal ulcers), Heart burn, and *diarrhea*. Pt has elevated gastrin levels that rise in resp to exogenous secretin administration (abnl adenylate cyclase activation) in contrast secretin inhibitis release of gastrin from nl gastric G cells and increases pancreatic bicarb secretion associated with MEN1

GIST tumors

generally present in the sixth decade as gastric bleeding or obstruction, and would show *spindle-shaped cells* on histology. Though the majority of GIST are sporadic, they have been associated with inherited mutations in the KIT gene.

Pseudocholinesterase deficiency

genetic disorder increased sensitivity to certain muscle relaxant drugs like succinylcholine or mivacurium - the muscles that work the lungs may become paralyzed

Genitofemoral nerve (L1-L2)

genital branch: sensation of upper anterior thigh and motor function to parts of the genitalia through DEEP inguinal ring Cremasteric muscle and skin in Anterior part of scrotum Female: w/ round ligament to mons pubis labium major femoral branch: lateral to ext iliac artery to posterior to inguinal ligament, pierces the femoral sheath skin of sup ant thigh

Li-Fraumeni syndrome

germline mutation of one TP53 gene. Autosomal Dominant multiple malignancies at an early age aka: SBLA: scarcoma, breast, Leukemia, Adrenal gland (cortex), brain

Sulfonylureas

glipizide, glyburide, glimepiride increase insulin secretion by pancreatic beta cells indep of blood glucose conc. Have a high incidence of HYPOglycemia esp in the elderly

insulin vs glucagon

glucagon: stimulates hepatic glycogenolysis and gluconeogenesis insulin: increases peripheral glucose uptake and inhibits lipolysis and ketoacid formation. also SUPRESSES glucagon release

After 12-18 hours of fasting what becomes the principal source of blood glucose?

gluconeogenesis becomes the principal source of blood glucose. Gluconeogenesis uses many glycolytic enzymes, but hexokinase, phosphofructokinase, and pyruvate kinase need to be bypassed as they are unidirectional. The initial steps of gluconeogenesis involve the conversion of pyruvate to oxaloacetate and oxaloacetate to phosphoenolpyruvate by pyruvate carboxylase and phophoenolpyruvate carboxykinase respectively

what is responsible for glucose for the first 12-18 hours of fasting?

glycogenolysis

Enterococcus faecalis

gram positive cocci in chains causes UTI, biliary tract infections, and endocardititis

androstenedione is converted to estrone by aromatase within which cells?

granulosa lutein cells

Myeloperoxidase

green discoloration of pus or sputum seen during bacteral infection is MPO is a blue-green heme based enz that is released from PMN azurophilic granules and forms hypochlorous acid (bleach)

Ehrlichia chaffeensis

harbored by white-tailed deer in SW, SE, and Mid-Atlantic US. Transmitted to humans via Lone Star tick bite and spreads to mononuclear cells (bone marrow, lymph nodes, liver, spleen) = nonspecific sx: fever, chills, myalgia, HA + maculopapular rash, lymphopenia, thrombocytopenia, elevated aminotransferases. replicates in membrane-bound vacuoles within cytoplasm of monocytes and can be visulaized on peripheral blood or buffy coat as mulberry-shaped, intraleukocytic inclusions tx: doxcycline

Interferon beta

has anti-inflammatory effects that suppress the proinflammatory cytokine, improves the integrity of the blood-brain barrier can be used to treat multiple sclerosis

internal illiac artery ligation

has been used for stopping postpartum hemorrhage

pt w/ advanced emphysema

have chronic CO2 retention leading to chronic respiratotory acidosis w/ metabolic compensation (high PaCO2, compensatory high Bicarb, slighly acidic pH) often with hypoxemia (PaO2 <75 mmHg on room air)

Klinefelter Syndrome (XXY)

have primary hypogonadism characterized by low testosterone and elevated gonadotropin (FSH, LH) Levels. In addition, elevated estradiol results in gynecomastia (learning and socialization), small/firm testes, absent secondary male characteristics, tall stature

signs of renal cell carcinoma

hematuria, abd mass, flank pain, wt loss U/L hypercalcemia and erythrocytosis are commonly associated

High levels of dietary aflatoxin exposure is associated w/ a G:C ---> T:A transversion in codon 249 of the p53 gene, a mutation thought to greatly increase the risk of developing?

hepatocellular carcinoma

Pulmonary arterial hypertension (PAH)

hereditary PAH occurs in 2 steps: 1) abnl BMPR2 gene predisposes affected individuals to excessive endothelial and smooth muscle cell proliferation. 2) An insult (infection, drugs) is thought to activate the dz process, resulting in vascular remodeling, increased pulmonary vascular resistance and progressive pulmonary HTN

Hemochromatosis

hereditary disorder with an excessive iron apsorbtion in intestines thus it buildups up in the body causing iron deposits in the body, bronzing of the skin, weakness and fatigue

Sheehan syndrome

high estrogen levels during pregnancy cause enlargement of the pituitary gland without a proportional increase in blood supply. Peripartum hypotension (likely from blood loss) can cause ischemic necrosis of the pituitary leading to panhypopitutiarism. Patients commonly will develop failure of lactation due to deficiency in prolactin.

Tx of psoriasis

high-potency topical corticosteroids and vitamin D analogs Vit D analogs inhibit T-cell and keratinocyte proliferation and stimulate keratinocyte differentiation. Coricosteroids also have anti-inflammatory and anti-proliferative protperites

Sarcoidosis

hilar adenopathy, reticulonodular infiltrates, pulmonary infiltrates, noncaseating granulomas, erythema nodosum, uveitis, polyarthritis, weight loss, high ACE. Tx- systemic steroids biopsy: noncaseating granulomas made of epitheliod cells (activated macrophages) and multinucleasted cells tx: oral glucocorticoids

what are three stimulators of gastric parietal cells to secrete hydrochloric acid

histamine vagal output gastrin

Phencyclidine (PCP) toxicity

horizontal and vertical nystagmus, altered mental status, agitation, choreoathetosis, seizures, or acute psychosis. Tachycardia and hypertension are found in the majority of PCP intoxication. Patients may demonstrate violent and unpredictable behavior that is exacerbated by decreased pain perception, hallucinations, paranoid delusions, and delusions of super-human strength.

polycystic ovary syndrome

hormonal disturbance characterized by infrequent/prolonged menstrual periods, excess male hormones (androgen) levels = hirsutism, ovaries may develop many small collections of fluid follicles and fail to regularly release eggs *amenorrhea, infertility, obesity, hirsutism, and often DM due to insulin resistance. Due to high levels of LH, low FSH, high testosterone, and high estrogen* associated with increased BMI, *associated with ENDOMETRIAL HYPERPLASIA/carcinoma*

aortic dissection

hx of sudden substernal CP radiating to the back, severe HTN, and asymmetrical UE pulses widening mediastinum on x-ray, aortic regurgitation, asymmetrical UE blood pressures

Brain metastasis

hx: unintentional wt loss and a risk factor of smoking multiple and B/L lesions at the junction of the grey and white matter, and vasogenic edema 20% of brain mets present with seizure M/C origins of brain mets are systemic cx of the lungs, breast, skin (melanoms), or GI Sx: HA, seizures, cognitive dysfunction, and stroke

nephrotic syndrome

hyper-coagulable state sudden onset of abd or flank pain, hematuria, and L-sided varicoceles suggest *renal vein thrombosis* loss of anticoagulant factors, esp antithrombin III is responsible for the thrombotic and thromboembolic complications of nephrotic syndrome

Facial nerve palsy

hyperacusis (increased sensitivity to sound) is an indacation of damage to the facial nerve close it its origin from the brainstem. Paralysis of the stapedius muscle (inc senstivity) other feats: dec lacrimation, salivation, and loss of tast in the ant 2/3 of the tongue

Glucagonoma

hyperglycemia, necrolytic migratory erythema: elevated painful puritic rash on the face, groin, and extremeities, diarrhea/weight loss. Usually malignant. Dx- elevated fasting glucose and glucagon, pancreatic mass on CT. Tx- surgery, not responsive to chemotx

Psoriasis

hyperkeratosis and confluent parakeratosis of the stratum corneum (silvery scales seen on gross exam), diffuse epidermal hyperplasia with elongated clubbed rete ridges (typical erythematous plaques) and dilated capillaries in dermal papillae common in areas exposed to pressure or firction (extnesor surfaces of elbows and knees and minor trauma can precipitate lesions *Koebner phenomnono*

the characteristic histopathology of psoriasis includes

hyperkeratosis, parakeratosis, thickening of the spiny layer, elongation of the rete pegs, small accumulations of neutrophils in the epidermis, and increased mitotic activity in the epidermis. The dermal papillae are elongated and hypervascular.

long term effects of lithium

hypothryoidism and nephrogenic diabetes insipudus

De Quervain's Disease

hypothyroidism that is typically seen following a viral, flu-like illness caused by release of preformed thyroid hormone from an inflamed thyroid gland. *only type of thyroditis that presents with a painful, enlarged goiter* Tx: supportive, NSAID, beta blockers

cervical adenocarcinoma in situ management

hysterectomy, esp for those pt who have completed childbearing as it allows the greatest reduction in risk of developing invasive adenocarcinoma

unusual interstitial pneumonia

idiopathic pulmonary fibrosis progressive dyspnea on exhertion and rest, (associated with bacterial infection?) chronic inflammation and fibrous thickening of the alveolar septa

Anterior spinal artery

if occlusion in the lumbosacral region would cause extremity weakness w/ hyporeflexia (ishemia of ant horns and corticospinal tracts) and loss of pain and temp sensation (ischemia of the spinothalamic tracts) below the level of the lesion

A study is conducted on pts w/ asthma to compare new asthma tx with a placebo. After 12 weeks the mean sx scores were 2.8 +- 0.1 in the treated vs 3.1 +- 0.1 in the placebo group. p value = 0.035. The investigators of this study state that they chose a sample size of 100 in each group to have 80% power of detecting a mean difference of 0.4 at a significance level of 5%. What is the meaning of 80% power?

if treatment really changes the mean asthma score by 0.4, there is an 80% chance that a study of this size will find a p-value of < equal to 0.05.

inhalent intoxication

immediate onset of euphoria, lethargy, ataxia, and/or loss of consciousness followed by rapid recovery within 45 min. perioral and perinasal dermatitis (glue sniffers rash) may also be seen in chronic users)

Tumor necorsis factor-alpha inhibitors

impair cell-mediated immunity. In particular, TNF-alpha is necessary for effective sequestration of mycobacteria within granulomas. As a result, TNF-alpha inhibitor therapy should have a basline tuberculin skin test or interferon-gamma release assay to screen for latent tuberculosis. TNF-alpha inhibitors also increase susceptibility to other infectious agents, including fungi and atypical mycobacteria, and should not be used in any pt with an underlying infection.

Carnitine deficiency

impairs fatty acid transport from the cytoplasm into mitochondria, preventing Beta-oxidation of FA. This leads to caridac muscle and skeletal muscle injury (lacking ATP) and impaired ketone body (acetoacetate) production in fasting periods

17 alpha hydroxylase deficiency

impairs the syntheiss of androgens, estrogens, and cortisol but does not inhibit mineralcorticoid production. Boys appear phenoytpically female at brith but lack internal female genitalia, but girls develop normal genitalia both internal and external. Pts present with hypogonadism, hypertension, and hypokalemia.

hydrophilic bile acids (ursodeoxycholic acid)

improve cholesterol solubility by decreasing the amt of cholesterol secreted into the bile and increasing biliary bile acid concentration

aortic coarctation

in a child/young adult presents with lower extremity claudication (pain an cramping with exercise), blood pressure discrepancy between the upper and lower extremities, and delayed or diminished femoral pulses. Turners syndrome (45 X) is associated with this condition in up to 10% of cases.

lead poisoning

in adults is usually due to occupational exposure. Sx: colicy abd pain, constipation, lead line on gum, peripheral neuropathy, and anemia. Labs: microcytic anemia w/ normal iron studies and peripheral blood smear may reaveal basophilic stippling ring sideroblasts formed from preciptation of iron granules in delveloping erythrocytes due to defects in heme synthesis ptwy, including enzymatic inhibition induced by lead poisoning. Ring sideroblasts are seen in bone marrow but NOT in peripheral blood smear

Gout treatment

in pt with a first episode of gout that appears to be drug-induced, the best tx after acute management is to discontinue the offending drug and only initiate therapy if the pt has a second attack. Thiazide diuretics decrease uric acid secretion and therefore increase the risk of gout flares. Antiinflammatories such as NSAIDS, colchicine, or steroids should also be given acutely to decrease and reduce inflammation.

HIV structural genes

in the HIV replication cycle, polyprotein precursors are encoded by the structural genes gag, pol, and env. Only the env gene polyprotein product (gp160) is glycoylated. This polyprotein is subsequently cleaved in the Golgi apparatus to form the envelope glycoproteins gp120 and gp41.

Rabies encephalitis

in the US bats are the main source of rabies (only transmitted by mammals: raccoons, skunks, foxes In the developing world: Dogs Sx: agitation and spasms progressing to coma within weeks of exposure is strongly suggestive of rabies encephalitis. Encephalitic: hydrophobia, aerophobia, pharyngeal spasm, spastic paralysis, agitation Paralytic: Ascending flaccid paralysis Prophylactic vaccination is recommended for pts at high risk for exposure to rabid animals or their tissues + rabies immune globulin The approved rabies vaccines consist of various rhabdovirus strains grown in tissue cell culture and then inactivated.

tenderpoint for popliteus

in the belly of the popliteus muscle just inferior to the popliteal fossa

Tenderpoint for the posterior cruciate ligament (PCL)

in the center/slightly below the center of the popliteal fossa

Hypertensive emergency sx in kidney (>180/120)

in the kidneys: malignant nephrosclerosis: fibrinoid necrosis and hyperplastic arterolosclerosis (onion-skin appearance). a microangiopathic hemolytic anemia can occur due to RBC fragmentation and platelet consumption at the narrowed arteroral lumen

UTIs in women

in women sexual intercourse facilitates bacterial ascent up the relatively short urethra and into the bladder, which has several antibacterial defenses, including: - the bladder mucosa normally does not allow bacterial attachement - Normal urine is bactericidal due to high urea content and osmolarity - Urine flow washed the bacteria downstream suppression of endogenous flora, colonization of the distal urethra by pathogenic gram-negative rods, and attachment of these pathogens to the bladder mucosa are the stages of pathogenesis in lower UTIs. Anatomic or functional vesicourethral reflux is almost always necessary for the development of acute pyelonephritis

pt w/ mild dementia wants to leave the hospital but does is not oriented to time, place, or name of her nurse. most appropriate for the doc to question the pts capacity to make a decision regarding her medical care if mental staus exam showed what?

inability to understand the severity and prognosis of her dz/condition

Fetal hydronephrosis

inadequate canalization of the ureteropelvic junction, the connection site between the kidney and the ureter, is the most common cause of U/L fetal hydronephrosis

signs and sx of hypocalcemia

include abdominal pain, muscle spasm, and positive Chvostek and Trousseau signs. Medications such as furosemide may lead to low serum calcium.

signs of Right heart failure

include dependent edema, venous stasis, hepatojugular reflux, and jugular venous distension The right-sided abdominal pain can be caused by liver congestion, which is another sign of RHF, as is hepatomegaly and fluid buildup in the abdomen.

Risk factors for a pulmonary embolism

include immobility and vascular injury (such as surgery). A fibrin degradation product, D-dimer, is generated from cross-linked fibrin within the clot. Therefore, an elevated plasma concentration of D-dimer indicates recent or ongoing intravascular blood coagulation. Other classic findings include an arterial blood gas displaying hypoxemia with respiratory alkalosis, sinus tachycardia, and a filling defect noted on computed tomography angiography of the pulmonary arteries.

Multiple Myeloma lab finding

increased bone resorption due to production of tumor-related cytokines. Increased serum Ca levels, which reduce PTH production. Low PTH decreases renal calcium reabsorption (hypercalciuria) and in combination w/ renal insufficiency reduces 1,25-dihydroxyvitamin D synthesis

Hepatic encephalopathy

increased levels of ammonia and other neurotoxins in the circulation that lead to increased inhibitory neurotransmission and impaired excitatory NT release. Hepatic encephalopathy is frequently precipitated by a stressor (GI bleed-vomiting bright red blood, infection) that increases blood ammonia levels. Tx to lower blood ammonia: oral disaccharide

lowering cutoff value of test

increased sensitivity, decreased specificity

swelling in gout is due to

increased vascular permeability

helpful side effect of erythromycin

increases gastrointestinal motility. It often causes diarrhea but because of this SE it has been used to treat gastroparesis

human placental lactogen (hPL)

increases maternal insulin resistance during the second and third trimesters, leading to a rise in serum glucose that helps provide adequate nutrition to the growing fetus. Gestational diabetes occurs when the compensatory rise in maternal insulin secretion is inadequate to prevent serum glucose levels from reaching excessively high levels.

Glucagon

increases serum glucose by increasing hepatic glycogenolysis and gluconeogenesis. Glucagon also stimulates insulin secretion from the pancreas. unlike epinephrine, glucagon has an insignificant effect on glucose homeostasis in the skeletal muscle, adipose tissue, and renal cortex

progesterone

increases the most in concentration after ovulation. during the latter half of the menstural cycle, the corpus luteum secretes high levels of progesterone, which thickens the endometrium and prepares it to receive and nourish a blastocyst

action of direct factor Xa inhibitors (apiXAban, rivaroXAban)

increases the prothrombin and activated partial thromboplastin times but do not affect the thrombin time. Unfractionated heparin and direct thrombin inhibitors (dabbigatran) prolong the thrombin time.

Stage 2 sleep

indicated by *sleep spindles*: frequency of 12-16 Hz and *K complexes*: high-amplitude, widespread, broad, diphasic slow waves that also contain sleep spindles.

Belomycin

induces free radical formation causing breaks in DNA strands use: testicular cx and Hodgkin lymphoma SE: hyperpigmentation of the skin, pulmonary fibrosis (diffuse infiltrates)

Toxocariasis

infection characterized by white, elevated granuloma in posterior pole/peripheral retina, vitreous traction bands with macular dragging infection caused by the dog roundworm *EOSINOPHILIA*

diverticulitis

inflammation of colonic diversticula. Pt has abd pain, N/V, and changes in bowel habits. Low-grade fever and leukocytosis are common and PEx: may demonstrate a tender mass in the LLQ

Diverticulitis

inflammation of the diverticula with wall thickening. causing LLQ pain w/ fever and leukocytosis NOT associated with bleeding due to lodged feocolith (less common) Erosion (from high pressures) Tx: abx, high fiber diet. surgical removal

Synovitis

inflammation of the synovial membrane that lines synovial joint cavities. This causes pain, particularly when the joint is moved, and may lead to joint effusions. Synovitis often occurs in the setting of autoimmune disease, such as rheumatoid arthritis or systemic lupus erythematosis, as well as crystal arthropathies including gout and pseudogout. Range of motion would remain intact, although painful, in these pathologies.

Osgood-Schlatter disease

inflammation or irritation of the tibia at its point of attachment with the patellar tendon. focal pain and swelling at the *tibial tuberosity* and shows calcifications on x-Ray

Crohn's disease

inflammatory bowel disease characterized by patchy inflammation that can occur throughout the entire GIT. Pathology: skip lesions, cobble-stoning of the mucosa: serpiginous(wavy, snakelike) depressed ulcerations that separate elevated islands of healthy tissue, bowel wall thickening: due to inflammation involving all layers of the bowel wall leading to edema, hypertrophy of the muscularis mucosa, and fibrosis, and creeping fat: mesenteric fat becomes wrapped around the bowel, possibly in response to intestinal bacteria translocation. *may or may not have bloody diarrhea in addition the transmural inflammation frequently leads to complications such as abscesses, strictures, and fistulas. Tx: Tumor necrosis factor-alpha (TNF-α) inhibitors used to treat inflammatory diseases, such as Crohn disease, include etanercept (recombinant human TNF receptor), infliximab (antibody), and adalimumab (antibody). These agents predispose patients to bacterial, viral, and fungal infections due to impaired macrophage activation and phagocytosis.

pathogenesis of secondary bacterial pneumonia

influenza infection alter the respiratory epithelium and can increase the risk of secondary bacterial pneumonia. The leading pathogens are Strep pneumoniae, Staph aureus, and H influenzae The elderly are affected most commonly, but S aureus can cause secondary pneumonia in young, previously healthy patients

L1 dermatome

inguinal ligament partial motor to quadratus lumborum and iliopsoas muscle

Pyruvate dehydrogenase complex deficiency

inherited inborn error of metabolism causing lactic acidosis and neurologic defects. Pt are unable to convert pyruvate into Acetyl-CoA, leads to shunting of pyruvate to lactic acid. In these pt, metabolism of exclusively ketogenic amino acids (lysine, leucine) can provide energy in the form of acetyl-CoA without increasing lactate production

activity of loop diuretics

inhibit Na-K-2Cl cotransporter in thick ascending limb of loop of henle. increasing Na, Cl and H2O excretion. first line for rapid relief of sx in pt with acute decompinsated HF

effect of alpha-2 adrenergic receptors

inhibit insulin secretion beta-2 adrenergic receptors stimulate insulin secretion. The alpha-2-mediated inhibitory effect is generally predominant, causing sympathetic stimulation to lead to overall inhibition of insulin secretion

Angiotensin converting enzyme inhibitors

inhibits ACE: dec AngII = dec in GFR by preventing constriction of EFFERENT ARTERIOLES

Hydrochlorothiazide Thiazide diuretic

inhibits NaCl reabs in early DCT, dec diluting capacity of nephron and Ca excretion. can cause Hypokalemia, metabolic alkalosis, hyponatremia, hyperGlycemia, hyperLipdiemia, hyperUricemia, hyperCalcemia.

MOA of cilastatin

inhibits renal dehyropeptidase I co-administered with imipenem to decrease the excretion rate of the drug

Acute H. pylori infection

initially causes nonatrophic antral gastritis and an increased risk for duodenal ulcers. Chronic infection: patchy, multifocal, atrophic gastritis w/ loss of parietal cells and G cells in the gastric body; this is associated w/ decreased acid secretion and an increased risk of gastric ulcers, gastric adenocarcinoma, and MALT lymphoma

ketorolac

injection form powerful NSAID used as a short-term management for moderate to severe acute pain that requires analgesia at the opioid level

Invasive breast carcinoma

irregularly shaped adherent breast mass, m/c in the upper outer quadrant. Malignant infiltration of suspensory ligaments of the breast cause dimpling of the overlying skin - signifys that the suspensory ligaments of the breast are involved

musculocutaneous nerve

innervates the major forearm flexors (biceps brachii, brachialis) and coracobrachialis (flexes and adducts the arm) pierces the coracobrachialis muscle provides sensory innervation to the lateral forearm via the lateral cutaneous nerve of the forearm It is derived from the upper trunk of the brachial plexus (C5-C7) and can be injured by trauma (shoulder dislocation) or strenuous UE exercise (baseball pitching) compression: weakness in elbow flexion and decreased sensation for the lateral forearm

trochlear nerve

innervates the superior oblique muscle, causes the eye to intort (internally rotate) and depress while ad-ducted. trochlear nerve palsy: vertical diplopia that worsens when the affected eye looks down and toward the nose (walking downstairs, up close reading). pt compensates by tucking the chin and tilting the head away from the affected eye

intercostal nerves innervate

innervates visceral pleura of the thoracic cavity. Enables them to control the contraction of muscles and provide sensory information about the skin and parietal pleura.

Maternal diabetes

insulin release by pancreatic beta cells is stimulated by increased glucose metabolism and ATP production. *Gluockinase* functions as a glucose sensor in pancreatic beta cells by controlling the rate of glucose entry into the glycolytic pathway. Mutations in the glucokinase gene lead to a state in which higher glucose levels are required to stimulate insulin secretion and are a cause of maturity-onset diabetes in the young

synergistic effect

interaction of two or more medicines that results in a greater effect than when the medicines are taken alone - exceeding the sum of the individual effects

Vimentin

intermediate filament of mesenchymal cells used to dx sarcomas

intestinal atresia

intestinal atresia distal to the duodenum occurs due to vascular accidents in utero. "Apple-peel" atresia occurs when the superior mesenteric artery is obstructed. The result is a blind-ending proximal jejunum; a length of absent bowel and mesentery; and finally a terminal ileum spiraled around a ileocolic vessel

Mitochondrial vacuolization is a sign of

irreversible cellular injury permenatnly cant make ATP

leukamoid reaction

is a benign leukocytosis *(>50,000/mm3)* thats due to an underlying condition: severe infection/hemorrhage, malignancy (leukemia) or acute hemolysis. Leukocyte alkaline phosphatase levels are normal or increased. Peripheral smear can show increased bands, early mature PMN precursors (myelocytes) and granules (Dohle bodies) in PMN. Dohle body in the image

Neonatal tetanus

introduction of Clostriduim tetani spores to the infant, generally from unhygienic deliveries of cord care. Sx begin 5-7 days after birth and can progress more rapidly than in adults. Infected infants become irritable and have difficulty feeding and suckling due to tonic spasm of the masticatory muscles (trismus). As the dz progresses, spasms and hypertonicity become more generalized. prevention of neonatal tetanus focuses on vaccinating women who are pregnant or may become pregnant with inactivated tetanus toxin (tetanus toxoid) Appropriately vaccinated women provide transplacental IgG to the fetus, which decreases the incidence of neonatal tetanus by 95%.

renal cell carcinoma

invades the renal vein; IVC obstruction can occur by intraluminal extension of the tumor. Obstruction of the IVC produces symmetric B/L LE edema assoicated with the development of venous collaterals in the abd wall RCC can cause erythrocytosis due to elevated EPO Hypercalcemia may also occur due to the overproduction of PTH-related peptides or from lytic bone metastases

lacunar strokes

involve penetrating branches of the PCA and can cause PURE motor weakness however typically cause hemiparesis weakness in face, arm, leg on the side C/L to the ischemic area (r-sided hemiparesis w/ L PCA branch occlusion)

function of smooth ER

involved in the synthesis and processing of hydrophobic compounds, including lipids, phospholipids, and cholesterol derivatives (steroid hormones). cholesterol is initially converted to pregnenolone in the mitchondria and then transferred to the SER, where the remaining steps of steroidogenesis occur.

Urge incontinence

involves a hyperactive detrusor muscle that causes incontinence regardless of bladder urine volume. Patients present with increased urgency, frequency, and nocturia. The most common cause is idiopathic. Other common causes include infection, cancer, and bladder stones.

DIC

involves both excess bleeding and widespread thrombosis Fibrinogen is decreased Fibrin split products are elevated

contractile mechanism of smooth muscle

involves calmodulin and myosin light chain kinase

COPD

involves components of chronic bronchitis and emphysema. Bronchial airway obstruction from chronic bronchitis and decreased alveolar elasticity from emphysema result in air-trapping and lung hyperinflation. The Functional Residual Capacity (FRC) is increased, as are residual volume and total lung capacity (TLC) forced vital capacity is decreased due to expiratory airflow obstruction limiting the total expiratory volume.

adjustment disorder

involves emotional or behaviroal sx occuring within *3 months* of an identifiable stressor. The dx is indicated when the pt has significatn distress and impariment but does not meet full criteria for another mental d/o.

Crohn's disease / Granulomatous colitis

involves the terminal ileum and colon, skip lesions, rectal sparing, cobblestone mucosa, creeping fat, NON-caseating granulomas

Diptheria toxin

is an AB toxin that ribosylates and inactivates EF2. This action inhibits protein synthesis (translation) and ultimately leads to cell death.

Otosclerosis

is a cause of bilateral conductive hearing loss. autosomal dominant with incomplete penetrance and typically occurs between the late teen years to the fourth decade of life. It is equally common in men and women, and women may have onset of symptoms during pregnancy. I n this disease, fixation of the middle ear bones, most commonly the stapes, interferes with sound conduction. The Rinne test is performed with a tuning fork. It is first held on the mastoid process, then when the sound is no longer heard, it is moved to in front of the ear canal. In healthy individuals, the patient hears the air conduction more than the bone conduction, but this is reversed in conductive hearing loss, as seen in this patient.

Epidermophyton floccosum

is a common agent of tinea corporis, a superficial dermatophyte infection characterized by inflammatory or non-inflammatory lesions. It is a dermatophytic fungus that prefers to inhabit the cornified layer of skin, as well as the nails and hair. A pruritic, painless, annular plaque is the characteristic skin lesion found in symptomatic patients. Dermatophytes are not dimorphic organisms and will not present with yeast. Skin scrapings after KOH treatment reveal hyphae but no yeast forms.

Bladder exstrophy

is a congenital malformation in which the bladder is open through the abdominal wall and the urethra is open through the dorsal aspect of the penis.

HF with preserved ejection fraction

is a diastolic dysfunction and frequently occurs in the setting of prolonged systemic HTN due to concentric LV hypertrophy. Pt with longstanding HTN have increased systemic vascular resistance

Takayasu arteritis

is a granulomatous vasculitis of large vessels. It is seen in young females, especially those of Asian descent. It is referred to as pulseless disease because peripheral pulses will be weak or absent in the affected arteries.

Nonstress test

is a measure of fetal well being. It is considered formally reactive (a reassuring sign) if there are 2 accelerations of the fetal heart rate in 20 minutes. Thus, a nonstress test may be appropriate to assess the well being of the fetus, but it would not give any information on the mother's magnesium toxicity levels.

Trihexyphenidyl

is a muscarinic antagonist used for Parkinson's disease. It may cause blurred vision from cycloplegia, which is a common side-effect of any anti-cholinergic drug

Diffuse large B-cell lymphoma

is a non-Hodgkin lymphoma that occurs in patients aged 70-80 years and is the most common testicular tumor in older men. It can present with systemic symptoms of fever, night sweats, weight loss, and fatigue. Patients typically present with a rapidly enlarging mass. Diagnosis is often made on unilateral orchiectomy. Due to high rates of CNS involvement and contralateral testicular relapse, patients are also often treated with systemic and intrathecal chemotherapy. Histology would reveal a lymphoid infiltrate within the testis.

Post-herpetic neuralgia

is a painful condition that lasts weeks to months after a shingles outbreak has resolved, caused by nerve damage from the varicella zoster virus. The most appropriate treatment is a tricyclic antidepressant (amitriptyline), gabapentin, pregabalin, or a lidocaine patch.

Clomiphene

is a partial estrogen agonist used in the induction of ovulation in anovulatory patients that have PCOS. Patients taking this medication will commonly experience enlarged and "cramping" ovaries, hot flashes, vasomotor flushing, multiple gestations, and visual disturbances. They will also have multiple enlarged ovarian follicles secondary to the hyperstimulation from increased gonadotropin levels.

axillary lymph node dissection

is a risk factor for the development of chronic lymphedema involving the I/L arm. Chronic lymphedema predisposes to the development of angiosarcoma (Stweart-Treves syn)

Influenza virus

is a segmented, negative sense RNA virus that is enveloped within a host-derived plasma membrane. Interaction with the host cell is dependent upon a viral surface glycoprotein called hemagglutinin, which binds to the sialic acid receptor on human respiratory epithelial cells. Influenza strains that are unable to infect humans (avian/swine influenza) encode for hemagglutinin that cannot bind to human cells. However, influenza is prone to *antigenic changes* in its surface glycoproteins due to: - poor proofreading of viral RNA-dependent RNA polymerase, which results in the introduction of genetic mutations during replication (antigenic drift) - reassortment of the segmented genome when 2 influenza viruses infect the same cell, which results in dramatic alterations to the genome (antigenic shift)

Churg-Strauss

is a small vessel vasculitis similar to polyarteritis nodosa and microscopic polyangiitis histologically because all involve immune destruction of small blood vessel walls. Churg-Strauss is further characterized by massive eosinophil invasion, primarily of the lung vasculature and surrounding tissues. It is seen in patients with a history of asthma.

Autosomal Dominant Polycystic Kidney Disease (ADPKD)

is a systemic disorder mutation in PKD1 and or PKD2: abnormal levels of polycystin-1 and polycystin-2 cysts and other anomalies in different organs Intracranial berry aneurysms arise in the circle of Willis, and when these aneurysms rupture they cause subarachnoid hemorrhage. most common cause of death is cardiac disease

Adson's Test

is a test for thoracic outlet syndrome. Begin by monitoring the radial pulse of the ipsilateral arm that is being tested. The physician will extend that arm at the elbow, while simultaneously extending, externally rotating and slightly abducting the shoulder. The physician then asks the patient to take a deep inhalation and turn his/her head toward the ipsilateral arm. The test is positive if the radial pulse becomes markedly decreased or absent.

Granulomatosis with polyangiitis (GPA)

is a vasculitis affecting small vessels. The clinical triad is sinusitis, glomerulonephritis, and lung cavitary lesions. Commonly, this will present as hemoptysis, hematuria, and chronic sinusitis.

Herpes simplex virus (HSV)

is an enveloped, double-stranded DNA virus. HSV causes multiple small vesicles on an erythematous base that may rupture to form painful erosions or shallow ulcers. Patients can also have dysuria, fever, tender local inguinal lymphadenopathy, and headache. HSV may be transmitted by sexual or non-sexual contact. latent infection in dorsal root ganglia A microscopic technique called a Tzanck smear may be utilized to characterize epithelial cells infected with HSV. It will show *multinucleated giant cells with viral inclusion bodies, ground-glass opacities, acantholytic cells, keratinocyte ballooning, and nuclear molding*

Silo filler's disease

is an irritant lung disease caused by exposure to nitrogen dioxide, a gas that accumulates in grain silo's due to bacterial fermentation. This gas causes direct alveolar damage causing symptoms including wheezing, tachypnea, and tachycardia within 2 hours of exposure. Chest radiography may reveal pulmonary edema, nodular densities, or diffuse miliary mottling.

polyethylene glycol

is an osmotic laxative. Diarrhea associated with lactase deficiency is also osmotic and occurs due to accumulation of nonabsorbable lactose in the intestinal lumen.

Trichophyton rubrum

is another common cause of tinea corporis. Like Epidermophyton floccosum, it causes a superficial dermatophyte infection characterized by inflammatory or non-inflammatory lesions. It is a dermatophyte and it prefers to inhabit the cornified layer of skin, as well as the nails and hair. A pruritic, painless, annular plaque is the characteristic skin lesion found in symptomatic patients. Skin scrapings after KOH treatment reveal hyphae but no yeast forms

Chronic valvular inflammation and scarring

is assoicated with rheumatic herat disease and predispose to infective endocaritits, which is charadcterized by valvular vegetionas wiht destruction of underlying cardiac tissue. vegetations are caused by bacterial colonization and growth on a sterile fibrin-platelet nidus that forms on the damaged/disrupted endothelial surface of the valvular apparatus

Somatic symptom disorder

is characterized by 1 or more somatic symptoms (typically persistent for more than 6 months) that are distressing or significantly disrupt daily life. Patients with this disorder may 1) have thoughts about the seriousness that are disproportionate and persistent in relation to one's symptoms, 2) produce continuously high levels of anxiety about health matters, or 3) devote excessive time and energy on symptoms or health concerns.

Aortic stenosis (AS)

is characterized by a crescendo-decrescendo systolic ejection murmur that sometimes follows an ejection click. Maneuvers that increase either stroke volume or positively increase the gradient between the left ventricle and aorta will increase the intensity of the murmur of AS. In contrast, decreased preload or increased afterload, such as sustained isometric handgrip contraction, leads to diminished intensity of the AS murmur.

Eisenmenger syndrome

is considered a late cyanosis due to its progressive and chronic nature, with symptoms presenting 2 to 3 decades into life. It results from an uncorrected left-to-right shunt that ultimately leads to right ventricular hypertrophy and reversal of the shunt, causing deoxygenated blood to be pumped into the systemic circulation. Eisenmenger syndrome can present with signs and symptoms of congestive heart failure later in life. diffuse cyanosis, and clubbing of the digits. The patient in this case has a fixed split S2 on examination consistent with an atrial septal defect

preventable adverse event

is defined as injury to a patient due to failure to follow evidence-based best practice guidelines. act of ommission or commission

Coronary dominance

is determined by the coronary artery supplying the posterior descending artery (PDA), which also supplies blood to the AV node via the AV nodal artery. The PDA usually originates form the right coronary artery (70%), but also from both (20%) and the left cirucmflex artery: 10% (left dominant circulation)

Galactose-1-phosphate (G-1-P) uridyltransferase

is important in the breakdown of galactose, it catalyzes the formation of glucose-1-phosphate from G-1-P. Hereditary deficiency of this enzyme leads to hepatosplenomegaly, mental retardation, jaundice, and cataract formation. Treatment requires complete elimination of lactose and galactose from the patient's diet.

Gilbert syndrome )

is likely a diagnosis in patients with no apparent liver disease who have mild unconjugated hyperbilirubinemia that appears provoked by one of the classic triggers: hemolysis, fasting, physcial exertion, febrile illness, stress, and fatigue.

Chronic Graulomatous Disease (CGD)

is most commonly due to an X-linked mutation affecting NADPH oxidase. Deficiency of this enzyme leads to an inability of neutrophils to from the oxidative burst necessary to kill organisms in their phagolysosmes. CGD can be dx by absence of the normal blue and fluorescent green pigment produced by the nitroblue tetrazolium test (NBT) and dihydrorhodamine (DHR) flow cytometry test, respectively NBT testing: involves adding NBT to a sample of the pt's PMNs-properly functioning PMNs will produce ROS that can reduce the yellow NBT to *dark blue* formazan that precipitates within cells. DHR flow cytometry assesses the production of superoxide radicals by measuring the conversion of DHR to rhodamine, a fluorescent gree compound that can be detected by flow cytometry machines. Cells with deficient NADPH oxidase activity will exhibit decreased fluorescence.

additive response

is one in which the antimicrobial effect of the combination is equal to the sum of the effects of the two drugs alone

Porcelain gallbladder

is potential manifestation of chronic cholecystitis and is often found in association with multiple gallstones. It is due to dystrophic intramural deposition of calcium salts in the setting of chronic inflammation. Porcelain gallbladder is associated with an increased risk of adenocarcinoma of the gallbladder.

Berylliosis

is seen in individuals who are exposed to beryllium, a metal found in the nuclear power, aerospace, machine shop, and electronics industries. Causes noncaseating granulomas in the lungs and hilar lymph nodes, similar in presentation to sarcoidosis. Common symptoms include dry cough, shortness of breath, fever, night sweats, fatigue, and weight loss. berylliosis is a chronic condition that occurs with repeated exposure.

Choriocarcinoma

is the least common and most aggressive type of testicular germ cell tumor and typically affects younger men, aged 15-35 years. These tumors are associated with the development of gynecomastia due to the secretion of beta-human chorionic gonadotropin. Patients can present with precocious puberty, gynecomastia, impotence, or loss of libido and frequently have metastasis at diagnosis. Histologically: the presence of both syncytiotrophoblastic cells and cytotrophoblastic cells, with abundant hemorrhage and necrosis.

Von Willebrand's disease

is the most common autosomal bleeding disorder. It causes prolonged bleeding time and prolonged PTT. NOTE: Prolonged PT is associated with liver disease and warfarin therapy. Prolongation of all coagulation parameters is characteristic of disseminated intravascular coagulation (DIC).

Acute Lymphocytic Leukemia (ALL)

is the most common malignancy of childhood. B-cell ALL is responsible for ~70-80% of ALL, whereas T-cell ALL accounts for 15-17% of all cases of ALL. B-cell express CD19 T-cell ALL often presents as a mediastinal mass that can cause respiratory sx, dysphagia, or Superior vena cava syndrome. T-cells express CD3. T-cell ALL usually arise in TEENAGERS or INDIVIDUALS in their 20s. terminal deoxynucleotidyl transferase (TdT): a DNA polymerase involved in V(D)J recombination is expressed in lymphoBLASTS

Matching

is used in case-control studies in order to control confounding. Matching variables should always be the potential confounders of the study (age, race). Cases and controls are then selected based on the matching variables so that both groups have a similar distribution in accordance with the variables

communicating hydrocele

is when serous fluid accumulated in the tunica vaginalus in the setting of a patent processus vaginalis. It is painless swelling (vs. varicocele is the bag of worms and is distension of the pampinform plexus).

deletion of a hydrophobic amino acid sequence from the N terminus would lead to what?

it would impair transport of the protien into the Endoplasmic reticulum

an investigator is studying the regulation of the pulmonary lymphatic flow using an animal model. Catheters are implanted in the femoral vein, plumonary artery, and main lymphatic vessel draining the lungs in anesthetized, intubated, mechanically ventilated animals. Drugs may be injected directly into the pulmonary artery catheter and inspired gas mixtures altered at the ventilator; timed collection of lymph from the catheters is used to calculate lymphatic flow. What would increase the flow of pulmonary lymph in these animals

iv infusion of 0.9% saline for 5 min increasing hydrostatic pressure in the capillaries. 0.9% is freely filtered which increases filtration leads to increased fluid volume in the extracelluar space, and thus increased flow of lymph

Keloids and Hypertrophic Scars

keloids results from excessive collagen formation during remodeling phase of wound healing. They present as raised, painful, and pruritic nodules that grow beyond the wound borders. in Keloids, TGF-B is produced excessively without regulation, thus keloids extend beyond the boarders of the original would, do not regress, and often recur after resection. Can be in minor (ear piercing) and major (full-thickness burn) trauma and can be raised, painful, and pruritic. Keloids can have a familial tendency, particularly in Asian or African ethnicity. Unlike keloids: hypertrophic scars are limited to wound area and may regress spontaneously

Granulomas

large number of epitheloid macrophages that may fuse together to form multinucleated cells = Langhans giant cells surrounded by a band of lymphocytes. Granuloma formation involves Th1 and macrophage activation in response to difficult to eradicate antigen

"staghorn calculi" in adult

large renal stones that take the shape of the renal calyces. Made of struvite (magnesium ammonium phosphate) and are associated with recurrent upper urinary tract infections by urease-producing organisms (proteus, Klebsiella). Hydrolysis of urea yields ammonia, which alkalinizes the urine and faciliteates precipiataion of struvite crystals

Bacillus anthracis

large spore forming gram positive rod that is encased in antiphagocytic polypeptide capsule made of D-glutamic acid. Medusa head appearance Inhlalation of spores causes pulmonary anthrax: non-specific sx followed by hemorrhagic mediastinitis, shock, and death.

Nontyphoidal Salmonella

leading cause of foodborne gastroenteritis most cases are marked by 3-4 days of self-limited fever, N/V, and watery diarrhea some pt devleop invasive dz with spread to the long bones (osteomylitis), vasculature (mycotic aneurysm), or heart (endocarditis). Risk of invastion is highest with sickle cell dz or imparied immunity or extremies of age

Hypertrophic Cardiomyopathy (HCM)

leading cause of sudden death in athletes; involves an abnormally enlarged left ventricle systolic murmur in a crescendo-decrescendo fashion that is best heard from the left sternal border down to the apex that can radiate to the suprasternal notch but not to the carotid arteries or neck The HCM murmur diminishes with an increase in preload or an increase in afterload. The murmur increases with a decrease in preload or with a decrease in afterload. Increasing the ventricular volume (preload) pushes the obstructive septum and ventricular wall farther away from the aortic valve and widens the outflow tract → reduction in the intensity of the murmur. An increase in afterload reduces the stroke volume and increases the end-systolic volume → increasing the preload → reduction in the intensity of the murmur caused by genetic mutations affecting structural proteins of the cardiac sarcomere (beta-myosin heavy chain, myosin binding protien) common cause of death in young adults cardiomyocyte hypertrophy with haphazard cellular arrangement and interstitial fibrosis

Left sided heart failure

leads to chronically elevated pulmonary venous and capillary pressures w/ pulmonary edema and extravastion of RBS into alveolar parenchyma. The iron from RBCs is taken up by alveolar macrophages and stored as hemosiderin appearing as brown pigment.

Absence of B lymphocytes in X-linked agammaglobulinemia

leads to hypoplasia of lymphoid tissue, such as the tonsils or lymph nodes

Mitral valve regurgitation

leads to markedly elevated LA pressure, creating the characteristic early and large V wave on LA pressure tracing. LV systole corresponds to the time of passive filling of the LA (atrial diastole).

Phosphatidylcholine (lecithin) and sphingomyelin

lecithin and phosphatidylglycerol are major components of surfactant. Fetal lung lecithin production increases sharply after 30 weeks gestation, and phosphatidylglycerol production increases at 36 weeks gestation. The amniotic fluid sphingomyelin (S) level should remain approximately constant during the third trimester. An L/S ratio >2 indicated adequate surfactant production to avoid neonatal hyaline membrane dz

Zafirlukast

leukotriene receptor antagonist can be used with aspirin exacerbated respiratory disease leukotriene modifying agents: used in pt with a hx of asthma, nasal polyps, and aspirin insensitivity. these pt should limit their exposure to NSAIDS

prostatic plexus

lies within the fascia of the prostate and innervates the corpus cavernosa of the penis, which faciliates in penile erection. As a result prostatectomy or injury to the prostatic plexus can cause erectile dysfunction.

Neuroleptic Malignant Syndrome

life-threatening reaction to antipsychotic meds characterized muscle rigidity, hyperthermia, autonomic instability, and altered sensorium. The antipsychotic should be stopped and supportive care provided; Dantrolene, a ryanodine receptor blocker that inhibits Ca release from the SR is an effective antidote.

Neuroleptic Malignant Syndrome (NMS)

life-threatening rxn to antipsychotic meds characterized by diffuse muscle rigidity, hyperthermia, autonomic instability, and altered sensorium. The antipsychotic should be stopped and supportive care provided; dantrolene a ryanodine receptor blocker that inhibits Ca relase from the SR is an effective antidote

epithelial ovarian cancer

linked to the frequency of trauma and repair at the ovarian surface. Oral contraceptives, multiparity, and breastfeeding are protective by decreasing the frequency of ovulation. Risk factors include BRCA mutation, nullparity, and infertility

damage to primary motor cortex

located in the lateral precentral gyrus. It is the most posterior gyrus in the frontal lobe. It is responsible for conscious initiation of movement, and it provides upper motor neurons to the corticospinal tract and corticonuclear (corticobulbar) tract. Damage to the lateral precentral gyrus is usually caused by a stroke of the middle cerebral artery and will typically include upper motor neurons involved with upper extremity muscles and muscles of the face. Symptoms include weakness for the upper extremity contralateral to the lesion and dysarthria (difficulty speaking) due to damage to upper motor neurons involved with muscles of speech. Fluency, repetition, and comprehension are all intact, as lesions of this area do not produce aphasia

teichoic acid

located on the surface of Gram (+) bacterial cell walls; covalently bound to peptidoglycan layers; help maintain structure for the peptidoglycan layer

Broca's aphasia

located within Brodmann areas 44 and 45 of the inferior frontal gyrus of the left cerebral hemisphere. Damage to this area causes Broca aphasia (also called nonfluent or expressive aphasia), which is characterized by impaired fluency (patients seem to only generate speech with great effort), impaired repetition, and intact comprehension. Patients are able to comprehend speech, but have difficulty repeating words and phrases, and they appear to be aware of their difficulties. In addition, they demonstrate telegraphic speech where they omit nonessential words.

umbilical herniation

location periumbilical common in infants or surgical complication

direct inguinal hernia

location: Hesselbach's triangle, medial to inferior epigastric vessels more common in males weakened abdominal musculature can result in direct inguinal hernias. These hernias involve penetration into the Hesselbach triangle, most commonly due to a defect or weakening of the abdominal musculature.

Spigelian hernia

location: lateral border of rectus abdominis most common in middle-aged pts with high strangulation risk

femoral hernia

location: posterior to inguinal ligament in femoral canal Rare but more common in adult females

posterior thigh hamstring muscles

long and short head bicep femoris, semitendinosis, and semimembranosis (and adductor magnus/femoris) Biceps femoris only muscle that has 2 origins (long and short head) Hamstings are innervated by the tibial nerve with the exception of the short head of the biceps femoris - common fibular nerve branch of the sciatic nerve (L5-S2), while the long head is innervated by the tibial branch of the sciatic nerve (L5-S3) action: hip extension and flexion at the knee

rheumatoid arthritis

long standing RA can affect the cervical spine, causing vertebral malalignment (subluxation) that can affect the atlantoaxial joint. Extension of the neck during endotracheal intubation can worsen the subluxation -> acute compression of the spinal cord and/or vertebral arteries: areflexic, flaccid paralysis of all extremities. present with symmetrical and polyarticular joint involvement, morning stiffness lasting greater than an hour, and duration of symptoms being greater than six weeks. *Anti-cyclic citrullinated protein antibody* appears earlier than rheumatoid factor and has a specificity of 97% for RA. It is also associated with the development of erosive disease.

levodopa

long term tx for Parkinson dx can be complicated with on-off phenomenon: as a consequence of progressive nigrostriatal neurodegeneration leading to decreased therapeutic window for levodopa.

anal fissures

longitudinal tears in the mucosa distal to the dentate line, usually *posterior midline of the anal verge* (poor perfusion) due to passage of hard stool in pt with chronic constipation. most are located posterior midline, likely due to decreased bloos flow in this area B/L anal fissures are uncommon

pt with Multiple sclerosis can develop urge incontinence due to

loss of CNS inhibition of detrusor contraction in the bladder. As the dz progresses, the bladder can become atonic and dilated leading to overflow incontinence

Achalasia

loss of ganglion cells in the myenteric plexus resulting in less nitric oxide and inability of LES relaxation

Coagulative necrosis

loss of nucleus but cell shape and organ structures are preserved by coagulation of proteins. In other words, necrotic tissue that remains firm. Histology showed coagulative necrosis (preserved architecture of myocardial fibers) with neutrophil infiltration which hinted that the MI was within 24 hours. Most likely cause of death within first 24 hours of MI is arrhythmia. Myocardial rupture would also be visible on gross appearance of the heart, which they described in the stem.

LMWH

low molecular weight heparin Anti-thrombin III is activated by LMWH and acts predominantly on factor Xa

Enoxaparin

low molecular weight heparin safe to give in pregnancy and acts on factor Xa

X-linked agammaglobulinemia

low or absent CD19+ and CD20+ B cells and panhypogammaglobulinemia (very low IgG, IgM, and IgA). due to mutation in Bruton tyrosine kinase gene causes failure of bone marrow pre-B cells (CD19+ and CD20+) to develop into mature circulating B lymphocytes (CD19+, CD20+, CD21+) Affected pt have increased susceptibility to pyogenic bacteria (encapsulated),µ enteroviruses, and Giardia lamblia due to absence of opsonizing and neutralizing antibodies

the cut off value of a quantitative diagnostic test determines whether a given result is interpreted as positive or negative

lowering the cutoff point typically causes more patients with the disease to test positive, decreasing the number of false negatives and increasing test sensitivity. Consequently more pt without the dz will also test positive resulting in an increased number of false positivies and decreased specificity

Acute tubular necrosis

m/c cause of acute renal failure secondary to trauma. urinalysis = epithelial cells and "muddy brown" granular casts commonly caused by profound hypotension. Substances that may cause ATN include ethylene glycol, antibiotics, heavy metals, and urate. Patients will have a BUN:Cr< 15, hyperkalemia, inability to concentrate the urine, and brown tubular casts in the urine ATN can occur during periods of HYPOtension due to impaired renal perfusion, leading to ischemia

chronic lymphocytic (hashimoto) thyroiditis

m/c cause of hypothyroidsim. intense infiltrate often with germinal centers. Residual follicles may be surrounded by Hurthle cells (large oxyphilic cells filled with granular cytoplasm)

atrial fibrillation

m/c cause of irregularly irregular rhythm and is detected on EKG by an absence of organized P waves and varying R-R intervals precipitated by acute systemic illness or increased sympathetic tone, or after excessive EtOH use (holiday heart syndrom) systemic illnesses that can precipitate AF: long-standing HTN, heart failure, and hyperthyroidism.

Minimal change disease

m/c cause of nephrotic syndrome in children often idiopathic by may be triggered by drugs, immunization, or malignancy nl glomeruli with no immunoglobulin or complement deposits on immunofluorescent staining. diffuse podocyte foot process effacement and fusion increased filtration of plamsa proteins

diabetes mellitus

m/c cause of peripheral polyneuropathy in adults numbness and paresthesias in the stocking-glove distributaion and dec proprioception due to degeneration of *large-fiber sensory axons*

paraneoplastic hypercortisolism

m/c caused by small cell lung cx, is due to ectopic ACTH secretion. Clinical feat: HTN, hyperglycemia, edema, and hyperpigmentation. Unlike nonparaneoplastic Cushing syndrome, central obesity is uncommon

Aortic stenosis

m/c complication fo bicuspid aortic valves. Pt with bicuspid aortic valves develop clinically significant aortic stenosis on average around age 50. Bicuspid aortic valves are one of the most common congenital heart defects - the abnlly shaped valve experiences increased hemodynamic stress, which accelerates the nl aging process and causes premature atherosclerosis and calcification of the aortic valve. These calcifications begin accumulating as early as adolescence and lead to aortic stenosis in >50% of affected pt. In comparison, senile calcific stenosis of normal aortic valves generally become symptomatic age >65

Hypochromic, microcytic anemia

m/c due to iron deficiency blood loss esp occult loss from the GI must be ruled out in pt with iron def anemia

Neuroblastoma

m/c extracranial solid neoplasm in children (<2 years) tumor is from neural crest cells of the adrenal medulla and present with an abd mass and elevated catecholamine breakdown products abd mass, periorbital ecchymoses, spinal cord compression, *opsoclonus-myoclonus:spontaneous bursts of nonrhythmic conjugate eye movements in various directions*

glioblastoma multiforme

m/c primary brain tumor in adults. Areas of necrosis and hemorrhage are seen on gross exam. Light micro: pseudopalisading tumor cells around areas of necorsis

Adenocarcinoma of the lung

m/c pulmonary malignancy invasive glandular cells with abundant cytoplasm and eccentrically placed nuceli; mucin production is common discrete mass or pneumonia like consolidation at the periphery of the lung

IgA proteases

made by N meningitidis, N gonorrhoeae, Strep pneumo, and H influenzae. This enzyme cleaves secretory IgA at its hinge region, rendering it ineffective. Secretory IgA acts to inhibit the action of pili and prevent mucosal adherence and penetration

Polyribosylribitol phosphate (PRP) capsule

major virulence factor for Haemophilus influenza type B (Hib). Hib is the most common cause of epiglottitis, which presents with fever, stridor, and dyspnea

Chronic renal allograft rejection

manifests months to years afterwards and presents with worsening hypertension (ischemic kidney) and a slow progressive rise in serum creatinine. It occurs due to a chronic, indirect immune response to donor alloantigens and results in obliterative intimal thickening, tubular atrophy, and interstitial fibrosis

Chronic lung transplant rejection

marked by submucosal lymphocytic inflammation in the walls of the *small airways*. Subsequent ingrowth of granulation tissue into the lumen leads to airway obstruction and obliteration (*bronchiolitis obliterans). Pts usually present with *slowly worsening dyspnea* and dry cough that begins *months or years after transplantation*. Lung exam may reveal end-expiratory squeaks or pops, and spirometry typically demonstrates airflow limitation (obstructive pattern) with a drop in FEV1. Other forms of lung transplant rejection include: - Hyperacute rejection usually occurs on the first day of transplantation and is caused by preformed host antibodies against donor ABO or human leukocyte antigens (MHC). Histology generally shows fibrinoid necrosis with hemorrhage and ischemia (white graft reaction) - Acute rejection normally occurs within 6 mo of transplantation and is caused by a cell-mediated immune response to donor human leukocyte antigens. Histology generally shows perivascular mononuclear infiltrates in the small blood vessels of the lung, which can expand to include the alveolar walls.

cromolyn sodium

mast cell stabilizer used in anti-inflammatory asthma prophylaxis

Cromolyn and Nedocromil

mast cell stabilizing agents that inbhit mast cell degranulation independent of stimuli present. Are considered second line (first-line is inhaled glucocorticorids) for treamtnet of allergic rhinitis and bronchial asthma.

suppression

mature key defense mechanism: conscious choice not to dwell on a particular thought or feeling

tibial nerve

may be injured at the level of the popliteal fossa due to the deep penetrating trauma or knee surgery weakness on foot plantarflexion, foot inversion, and toe flexion with sensory loss over the sole

Psoas abscess

may form due to direct spread of infection from an adjacent structure (vertebral bodies, appendix, hip joint) or from hematogenous seeding from a distant site. HIV infection, IVDU, and DM are risk factors for primary psoas abscess development present with abd/flank pain, fever, and inguinal mass psoas muscle originates from the anterior surface of the transverse processes and lateral surface of the vertebral bodies and function primarily as a hip flexor

Androgenic steroid abuse

may lead to erythrocytosis (reason why men have higher hematocrit), testicular atrophy, acne, and virilization in women (clitoromegaly, hirsutism)

areas of the GI affected by nonocclusive ischemia

may occur at the margins of the ansastomotic distributions. These "*watershed*" areas are primarily in the L colon at the *splenic flexure* (border btw SMA and IMA supply) and *rectosigmoid junction* (border btw sigmoid artery and superior rectal artery). Less commonly, *occlusive ischemia* can also be caused by thromboembolic (hypercoagulable states, a-fib) or atheroembolic (aortic instrumentation events) impaired perfusion leads to ischemia and necrosis of the intestinal wall. Complications can include acidosis, sepsis, gangrene, and perforation. Colonoscopy will reveal pale mucosa and petechial hemorrhages

diabetic nephropathy

mcc of end-stage renal disease in the US. occurs in type I and II DM Earliest change is glomerular basement membrane thickening with mesangial matrix expansion. Normally,

Hepatitis A virus

mcly silent or subclinical ("anicteric = no jaundice is observed") in young children but can also present as an acute, self-limited illness characterized by jaundice, malaise, fatigue, anorexia, N/V, RUQ pain, or an anversion to smoking (in adults)

correlation coefficient

measure of linear dependence between two variables. The correlation coefficient can have values between +1 and −1, with an r of 0 indicating that there is no correlation between the two variables being measured. As the value of r approaches +1 from 0, two variables are said to be positively correlated. This indicates that as the values of one variable increase so do the values of the second variable. Conversely, as the value of r approaches -1 from 0, the two variables are said to be inversely correlated, indicating that as the values of one variable increase, the values of the second variable decrease. The strength of a correlation is usually assessed with these general guidelines: If r is 0.0 to 0.1 or if r is 0.0 to -0.1, there is no correlation, or the correlation is very weak If r is 0.1 to 0.3 or if r is -0.1 to -0.3, the correlation is weak If r is 0.3 to 0.5 or if r is -0.3 to -0.5, the correlation is moderate If r is 0.5 to 1.0 or if r is -0.5 to -1.0, the correlation is strong

gall stone ileus

mechanical bowel obstruction caused when a large gallstone erodes into the intestinal lumen. Pneumobilia (air in the biliary tract) is a common finding

Polymyalgia Rheumatica (PMR)

median age of onset 65 systemic manifestation of giant cell arteritis. multinucleated giant cells and mononuclear infiltrates seen in patients with temporal arteritis that present with arthralgias and myalgias, fevers, and a very high ESR. Some of the systemic symptoms experienced by patients with temporal arteritis are typical of PMR and PMR is found in up to 50% of patients with temporal arteritis, but patients with PMR alone typically have lower inflammatory markers and do not experience the ischemic complications seen in temporal arteritis. Roughly half of PMR patients have palpable synovitis in joints with swelling of the extremities.

treatment of chemo-induced nausea and vomiting

mediated by peripheral and central mechanisms. It can be treated with serotonin receptor antagonists (ondansetron) to prevent serotonin stimulation of afferent vagal fibers in the bowel wall (peripheral cause) and Neurokinin-1 receptor antagonists (aprepitant, fosaprepitant) to prevent the effects of substance P in the brainstem (central cause).

Hyperacute rejection

mediated by preformed anti-donor antibodies in the recipient that attack the transplanted organ (type II hypersensitivity). Ex: anti-ABO and anti-HLA antibodies. This form of rejection occurs immediately upon initial perfusion of the transplanted organ and is often diagnosed intraoperatively due to mottling and cyanosis of the organ.

internal laryngeal nerve: only sensory and autonomic fibers

mediates the afferent limb of the cough reflex above the vocal cord foreign bodies (fish bones) can become lodged in the piriform recess and may cause damage to the nerve, imparing the cough reflex

Multiple Endocrine Neoplasia type 2B

medullary thyroid cancer pheochromocytoma marfanoid habitus oral and intestinal mucosal neruomas 1Ps: pheochromocytoma 3Ms: medullary thyroid cancer +mucosal neruomas + marfanoid habitus

Waterhouse-Friderichsen syndrome

meningococcemia with bilateral adrenal hemorrhage due to DIC due to N meningitis infection

Trichotillomania

mental disorder characterized by recurrent pulling out of one's own hair from anywhere on the body, including the scalp, eyebrows, and limbs despite trying to stop hairs will be of varying lengths

Uterine and Cervical Cancer

metastasis is to the kidney

Carcinoid syndrome

metastatic neuroendocrine tumor that secretes substances such as serotonin with sx of upper body flushing, telangiectasias, diarrhea, and bronchospasms. Dx: 24 hr urinary exrection of 5-HIAA (end product of serotonin metabolism) Tx: octreotide (somatostatin analog) can lead to NIACIN (Vit B3) deficiency due to deficiency of tryptophan - precursor for production of serotonin and niacin

Treatment options for bacterial vaginosis (gardnerella vaginalis)

metronidazole or clindamycin

Hemolytic Uremic Syndrome

microangiopathic hemolytic anemia, thrombocytopenia, acute renal failure

Pelvic nerve innervates

micturition reflex

status migrainosus

migraine attack that persists for > 72 hours and often leads to hospitalization

Opioid toxicity

miosis, central nervous system depression, respiratory depression, hyporeflexia, hypothermia, bradycardia, hypotension and decreased bowel sounds due to constipation. Constipation results from decreased motility and increased sphincter tone in the rectum. Track marks can be seen frequently in those opioid users who routinely use the intravenous route for injection

Facial Nerve (VII)

mixed nerve 1. motor output to the facial muscles 2. parasympathetic innervation to the lacrimal, submandibular, and sublingual salivary glands 3. Special afferent fibers for taste from the anterior 2/3 of the tongue 4. Somatic afferents from the pinna and external auditory canal

ceruminous glands

modified sweat glands, located in external ear canal, secretes cerumen (earwax)

lithium

mood stabilizer in bipolar d/o Use: manic and depressive features SE: Diabetes insipidus (due to its ADH antagonist ability, Hypothyroidism, tremor , ebstein anomaly:downward displacement of tricuspid valves into RV (teratogenic)

Drugs of choice mania of bipolar d/o

mood stabilizer meds: first-line meds for the first episode of mania include lithium, valproate, quetiapine, and lamotrigine

Cavernous hemangioma of liver

most common benign liver tumor. They consist of cavernous, blood-filled vascular spaces of variable size lined by a single epithelial layer. The biopsy of a suspected hemangioma is not advised = can cause fatal hemorrhage and is of low dx yield

Graves disease

most common cause of hyperthyroidism and is caused by auto-antibodies against the TSH receptor (type 2 hypersensitivity). These antibodies stimulate the thyroid gland, leading to an increase in T3 and T4 with subsequent negative feedback, leading to a decrease in TSH. In addition to other symptoms of hyperthyroidism, findings specific to Graves' disease include pretibial myxedema and exophthalmos.

volvulus

most common in elderly patients who have a history of constipation and are debilitated or bedridden. It presents with an insidious onset of nausea, constipation, and abdominal distention and pain. A plain radiograph displays the characteristic findings of a U-shaped, bent inner tube appearance, with the sigmoid most commonly affected. *coffee bean appearance* Treatment includes detorsion with sigmoidoscopy followed by definitive surgical treatment to prevent reoccurrence.

yolk sac tumor

most common malignant germ cell tumor in prepubertal children (less than 3 years old), with an average age of diagnosis between 1 and 2 years. usually present with a painless testicular mass. Histologically, the presence of Schiller-Duvall bodies, which consist of a central vessel surrounded by tumor cells in a cystic space, is pathognomonic of yolk sac tumors. The tumor marker for yolk sac tumor is alpha-fetoprotein.

Epithelial ovarian cancer

most common ovarian malignancy Histo: anaplasia of epithelial cells with invasion into stroma, along with multiple papillary formations with cellular atypia. Epithelail ovarian turmors produce CA-125, which can be used as a serum marker for this

subacute infective endocarditis

most commonly caused by Strep viridans (low virulence), less friable vegetations with less valve destruction, most recover with AB histology- granulation tissue, fibrosis, calcification, chronic inflammatory infiltrate

polymyalgia rheumatica

most commonly presents in females over the age of 50 years and causes myalgias and stiffness of the shoulder and hip girdle muscles after prolonged inactivity, especially upon awakening in the morning. Laboratory analysis will reveal an elevated erythrocyte sedimentation rate, with normal creatine phosphokinase. It is associated with giant cell arteritis with associated symptoms of temporal artery tenderness, jaw claudication, and blindness. Treatment of both conditions is with steroid therapy.

pancreatic cancer

most commonly presents with abdominal pain, jaundice, and weight loss. A pancreatic head tumor may cause external compression and obstruction of the common bile duct as it traverses through the pancreas, leading to jaundice, darkened urine, pale stools, scleral icterus, pruritus, and the Courvoisier sign. Smoking is an important risk factor for pancreatic cancer.

thrombosis of the subclavian or axillary vein

most freq occurs as a complication of chronic indwelling catheter

Thoracic Outlet Syndrome (TOS)

most often caused by compression of the brachial plexus as it passes through the scalene triangle (ant and middle scalene + 1st rib). Sx: UE numbness, tingling, and weakness worsens with repetitive overhead arm movements presence of an anomalous cervical rib is a risk factor

caridogenic shock

most often due to MI, but can also be due to impairments that lead to low BP and systemic hypoperfusion Associated with high cardiac filling pressures, low cardiac index, increased peripheral resistance, and pulmonary edema

Delayed sleep-wake phase disorder

most often presents in adolescence and is characterized by intact duration and quality of sleep that is shifted to a later bedtime and wake time

cloacal exstrophy

most severe presentation of exstrophy-epispadias complex (EEC), and includes all the features of bladder exstrophy and herniation of the large intestine through the lower abdominal wall. In addition, patients with cloacal exstrophy may have additional malformations of the lower digestive system as well as more severe abnormalities of the pelvis.

opioids

mu receptor opioids like morphine can cause smooth muscle cells in the sphincter of oddi to conctract leading to spasm and increase in common bile duct pressures

Cleft lip

multifactorial

Association

multiple anamalies without a known unifying cause that occur together more frequently than chance alone would predict. Ex:vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnl (VACTERL)

Developmental field defect

multiple malformations that occur secondary to an embryonic disturbance in an adjoining group of cells. Holoprosencephaly is a developmental field defect characterized by a spectrum of fetal anomalies due to incomplete division of the forebrain

HSV

multiple painful genital ulcers and sx in a sexually active pt. dx with pcr , direct fluoresense abtibody testing, viral culture, or tzank smear

Polyarteritis Nodosa (PAN)

multisystem vasculitis characterized by episodic ischemic sx in various organs with *sparing of the lungs* dz of small to medium arteries biopsy: segmental, transmural inflammation with fibrinoid necrosis. associated with Hep B/HepC

pyloric stenosis

narrowing of the opening of the stomach to the duodenum seen in M>F, 2-6weeks, olive/oval mass in RUQ/epigastric, non-bili

aspirate in gout

needle-shaped, negatively birefringent crystals are dx pseudogout: rhomboid-shaped crystals and positively birefringent. Crystal arthropathies are inflammatory conditions with joint asipration showing moderate elevation in WBCs (>20,000), cloudy appearance, and only a few RBCs with nl glucose.

Diabetic mononeuropathy

nerve ischemia - CNIII > ptosis, down and out gaze; only somatic fibers are affected; PS are not so can still PERRLA

net renal excretion rate

net renal excretion rate = total filtration rate (GFR(equal to inulin clearance)x[plasma of substance]- total tubular reabsorption rate total filtration rate of a substance = (inulin clearance)(plasma conc of the substance) Net excretion rate for a substance = (inulin clearance)(plasma conc of the subtance) - (Tubular reabsorption of the substance)

medullary thryoid cancer

neuroendocrine tumor that arises from the parafollicular calcitonin-secreting C cells. Characterized by nests of sheets of polygonal or spindle-shaped cells with extracellular amyloid deposits derived from calcitonin. The amyloid stains with congo red. associated with MEN2: medullary thyroid cancer, pheochromocytoma, either parathyroid hyperplasia (type 2A) or marfanoid habitus and mucosal neuromas (type 2B)

pronator teres syndrome

neuropathy that is caused by compression of the median nerve between the 2 heads of the pronator teres. It causes paresthesia in the median nerve distribution and, unlike carpal tunnel syndrome, also causes loss of sensation over the thenar eminence. It is due to overuse of the pronator teres muscle and is seen in patients who do repeated forearm pronation activities such as using a screwdriver. It can be differentiated from carpal tunnel syndrome by the presence of forearm pain and negative Tinel and Phalen tests. Carpal tunnel syndrome symptoms are worse at night, unlike pronator teres syndrome symptoms, which are worsened with activity during the day.

Mercury poisoning

neurotoxicity and acute renal injury which can present with tumors or oligouria and elevated creatinine. Side effects of toxicity include interstitial pneumonitis, membranous colitis, renal failure, dementia and muscle tremors. Renal failure can present with oliguria, hyperkalemia, and elevated creatinine. The nephrotoxicity from inorganic and metallic forms of mercury is manifested by the nephrotic syndrome and signs of tubular dysfunction.

Isoniazid toxicity

neurotoxicity, hepatotoxicity, lupus, pyridoxine (B6) deficiency--supplementation can prevent neurotoxicity and maybe lupus peripheral neuropathy can occur if pyridoxine is not administered

Reactive granulocytosis

neutophilia, eosinophilia, and basophilia

noncaseating granulomas

no central necrosis typical of AUTOINFLAMMATORY conditions (Crohn Dz, sarcoidosis, common variable immune deficiency)

Leydig cell tumor

non germ cell testicular tumor; contains reinke crystals, androgen producing, gynecomastia in men, precocious puberty in boys, golden brown color A histologic examination of Leydig cell tumors will reveal the presence of Reinke crystals in the interstitial cells of the testis. Reinke crystals are rod-shaped intracytoplasmic crystal-like inclusions with rounded ends and are diagnostic of this lesion.

sleep terrors

non-REM parasomnia characterized by incomplete arousals and lack of recall of dream content occur during slow-wave sleep in the first third of the night. child does not fully awaken, is unresponsive to comfort and has no associated dream content. primarily affecting children

Shigella

non-motile, non-lactose fermenting organism. Does NOT produce H2S when grown on triple sugar iron agar. Mucosal invasion of the M cells. can escape the phagosome and spread laterally to other epithelial cells via actin polymerization

paraneoplastic syndrome

nonmalignant complications associated with an underlying malignancy. Ex: small cell lung cancers are associated with ectopic adrenocorticotropic hormone production causing Cushing syndrome, hyponatremia due to SIADH, and Lambert-Eaton syndrome. are disorders that are triggered by an altered immune system response to a neoplasm. They are defined as clinical syndromes involving non-metastatic systemic effects. These syndromes are symptoms that result from substances produced by the tumor, and they occur remotely from the tumor itself. The symptoms may be endocrine, neuromuscular or musculoskeletal, cardiovascular, cutaneous, hematologic, gastrointestinal, renal, or miscellaneous in nature.

albumin

nonpermeable plasma protein syn in the liver, maintains vascular oncotic pressure and prevents accumulation of intersitial edema. However, cirrhosis, this synthetic function is disrupted, leading to hypoalbuminemia, and therefore decreased plasma colloid oncotic pressure, causing ascites and generalized edema

Incidence

number of new cases of a disease dx in a population at risk over a given time period.

treatment for bulimia nervosa

nutritional rehabilitation, CBT, and SSRI: FLUOXETINE

Leishmania

obligate incellular protozoa that mature in macrophages and can be ID on biopsy by the presence of *rod-shaped kinetoplasts* transmitted via sand flies cutaneous leishmaniasis: chronic, pink papule evloving into a nodule or plaque

pt with jaundice, and increased serum [bilirubin] and positive urine bilirubin test. what would be associated with this positive urine test

obstruction of the bile duct

Left-sided colon cancer

obstruction: cramping, change in stool caliber, constipation, distention, n/v

Heme synthesis

occur partly in the mitochondira and partly in the cytoplasm of erythrocytes. Mitchondria are necessary for the first and final 3 steps. RBC precursors divide a number of times before finally losing their nuclei and mitochondira and forming mature RBCs that survive for ~120 days. When RBCs lose their mitochondria they lose their ability to generate heme and thus hemoglobin.

uncal herniation

occur when the medial aspect of the temporal lobe (uncus) herniates across the tentorium cerebelli. This initially results in ptosis, mydriasis, lateral strabismus, and C/L hemiparesis of the extremeties

Pleiotropy

occurrence of multiple phenotypic manifestations, often in different organ systems, which result from a mutation in a single gene.

Atheroembolic disease

occurs after an invasive vascular procedure due to mechanical dislodgement of atherosclerotic plaque, resulting in the showering of cholesterol-rich microemboli into the circulation. needle-shaped cholesterol clefts in affected vessels are dx, commonly involved kidneys: acute kidney injury, skin: blue toe syn, liveo reticularis GI: bleeding, infacttion CNS: stroke, amaurosis fugax

Boerhaave syndrome

occurs as a result of a full-thickness tear through the esophagus (as opposed to a partial thickness tear seen in a Mallory-Weiss tear). It classically presents with the Mackler triad of a history of significant vomiting, severe thoracic pain, and pneumomediastinum. On physical examination, pneumomediastinum is associated with subcutaneous emphysema and a Hamman crunch, which is a crackling sound heard with each heartbeat.

pathologic atrophy

occurs as a result of decreases in workload, pressure, use, blood supply, nutrition, hormonal stimulation, and nervous stimulation

primary spontaneous pneumothorax

occurs in people without underlying lung disease and in the absence of an inciting event large change in alveolar/intrapleural pressure results in a break in the visceral (ruptured superficial bleb) pleura and btw the pleural spaces.

Kozak consensus sequence

occurs on euk mRNA; sequence is (gcc)gccRccAUGG where R is either adenine or guanine; when the AUG is positioned near the beginning of mRNA molecule and is surrounded by the Kozak sequence, it serves as the initiator for translation (mRNA binding to ribosomes); helps initiat translation at the methionine start codon (AUG)

intrapulmonary shunting

occurs when an area of the lung is adequately perfused but poorly ventilated. PE causes intrapulmonary shunting due to redistribution of blood away from segments directly affected by the clot; the remaining accessible alveoli are unable to fully oxygenate all the blood passing through the pulmonary circulation, resulting in hypoxemia. in contrast, areas distal to the clot receive adequate ventilation but poor perfusion (ie dead space).

superior mesenteric artery syndrome

occurs when the transverse portion of the duodenum is entrapped between the SMA and aorta, causing symptoms of partial intestinal obstruction. The *vitelline arteries give rise to the superior mesenteric artery (SMA). IMA, and celiac artery*. With abdominal trauma, scoliosis surgery, or peritoneal adhesions, the angle between the abdominal aorta and SMA can shift, causing compression of the duodenum and subsequent SMA syndrome. Normally, the SMA is surrounded by peritoneal fat and lymphatic tissue that serve as a cushion between the SMA, abdominal aorta, and duodenum. Under certain circumstances, including scoliosis, surgical lengthening of the spine, retroperitoneal tumors, abdominal trauma, and peritoneal adhesions, the SMA shifts. This shift moves the peritoneal fat and lymphatic tissue that cushion the duodenum; the duodenum then becomes compressed in this narrowed angle. resulting symptoms may include nausea, vomiting, sharp postprandial abdominal pain, weight loss, and fear of eating. The symptoms are relieved when the body is in positions that elevate the root of the SMA (knees to chest, prone position, or left-lateral decubitus position).

frameshift mutation

occurs with the DELETION/ADDITION of a number of bases NOT divisible by 3 in the coding region of a gene. Frameshift mutations alter the reading frame of the genetic code, changing the protein structure and often resulting in the formation of a premature stop codon or formation of nonfunctional proteins

Replication of Hep B genome

occurs within a newly synthesized capsid through the action of reverse transcriptase on an RNA template. The mature capsid contains partially ds circular DNA and reverse transcriptase

cavernous sinus

oculomotor III, trochlear IV, abducens VI, and trigeminal V1 and V2 pass through and VI is most likely to be affected first by hemorrhage of ICA expanding aneurysm most likely to cause HA and diplopia (I/L lateral rectus weakness) via compression/stretch of CN VI

initial HIV infection

often associated with mononucleosis-like sx: (fever, lymphadenopathy, sore throat) 2-4 weeks after transmission. important dx clues: oropharnygeal ulcers and a diffuse maculopapular rash. as the humoral antibody response is not fully activated early in infection, labs show HIV in the serum (positive viral load and p24 antigen) BUT neg HIV serology

Colonic Diverticula

often involve the sigmoid and develop due to increased intralumial pressure (pulsion) created during strained bowel movements (due to chornic constipation) causing outpoucing of the mucosa and submucosa (false diverticula). Typically seen in older adults and be be aysmptomatic or present with hematochezia or diverticulitis

Uremic pericarditis

often seen with BUN > 60 and amenia complication of chronic renal failure Uremia occurs in patients with renal failure caused by an accumulation of blood urea nitrogen (BUN) and other renally excreted toxins. This can happen in patients on hemodialysis that miss multiple treatments. Uremia can subsequently cause pericarditis, the disease process resulting in inflammation of the pericardium. causes of pericarditis include infectious disease (commonly from viral syndromes), autoimmune disorders, hypothyroidism, post myocardial infarction, uremia, post-operatively after open-heart surgery, and many more. A physical exam finding is the pericardial friction rub, which is caused by the dry surfaces of the visceral and parietal membranes of the pericardium rubbing against each other. Pericarditis generally presents with sharp chest pain, worse with deep inspiration (pleuritic chest pain), and is typically worse when in the supine position due to increasing juxtaposition of the inflamed membranes due to gravity. The chest pain also improves with sitting forward. Other manifestations can include a fever. The ECG of pericarditis demonstrates diffuse ST elevations with PR depression (most prominently in lead II) and PR elevation in aVR Treatment for pericarditis is generally comprised of NSAIDs, colchicine, or steroids. In uremic pericarditis, treatment is generally hemodialysis and colchicine.

Tenderpoint for the medial meniscus and medial collateral ligament (MCL)

on the medial aspect of the knee at the medial joint line

Permissiveness

one hormone cannot exert its effects without another hormone being present - one hormone allows another to exert its maximal effect Ex: cortisol increases vascular and bronchial smooth muscle reactivity to catecholamines and increases glucose release by the liver in response to glucagon

pigmented seborrheic keratosis

one of the most common noncancerous skin growths in older adults. appear as a black, brown, or light tan growth on face, chest, shoulders, or back the growth is waxy, raised appearance

methyl malonic acidemia

organic acidemia due to complete or partial deficiency of methylmalonly-CoA mutase. Complete deficiency classically presents with lethergy, vomiting, tachypnea in a newborn. labs: hyperammonemia, ketotic hypoglycemia, metabolic acidosis. Dx confirmed by elevated urine mthylmalonic acid and propionic acid

splenic artery

orginates from the celiac artery and gives off several branches (including the pancreatic, short gastric, and left gastroepilopic artereis0. Due to poor anastomoses, the gastric tissue supplied by the short gastric is most vulnerable to ischmemia following splenic blockage

ilioinguinal nerve

originates from the L1 nerve root and accompanies the spermatic cord through the superficial inguinal ring SENSATION to the upper and medial thigh and parts of the external genitalia

Chondrosarcoma

osseous sarcoma that tends to affect adults btw the 4th and 6th decades of life. This malignancy has a predilection for flat bones in the shoulders and pelvis but may also involve the diaphysis of long bones

Mittelschmerz

ovulation-induced pain resulting from the growing size of the follicle stretching the ovarian tissue just prior to releasing the ovum. This condition presents with recurrent periovulatory lower abdominal pain along with nausea, vomiting, and diarrhea during menstruation. These symptoms usually occur 2-5 years after the onset of menstruation physical exam: no pelvic abnormalities

Nitrites

oxidizing agents that are effective in tx cyanide poisoning due to their ability to induce methemoglobinemia. Methemoglobin contains ferric (Fe3+). Cyanide binds to ferric iron more avidly than to mitochondrial cytocrome enzymes, diminishing cyanide's toxic effect

placental abruption

painful 2nd or 3rd trimester bleeding, evidence of fetal distress, bleeding is not always present though HTN, smoking, and cocaine use increase risk factors

dactylitis

painful swelling of the hands and feet a common presentation of SCD in young children. It is one of the vasoocclusive manifestaions of SCD. Sicking episodes result in hemolysis, thus increasing indirect bilirubin and LDH and decreasing *haptoglobin*

Subacute Granulomatous (De Quervain) Thyroiditis

painful thyroid enlargement usually follows a viral illness. Biopsy: mixed inflammatory infiltrate with macrophages and multinucleated giant cells

Kaposi's sarcoma

painless, red-violet/blue-violet or brownish skin plaques on the extremities and mucous membranes of HIV-positive pt caused by *endothelial proliferation* tumor arises from primitive mesenchymal cells and associated with HHV-8

testicular cancer

painless, solid, scrotal mass solid, firm, fixed nodule in the tunica albuginea that is ovoid in shape and painless to palpatation cancer of the testicle, usually occurring in men 15 to 35 years of age

Stimulant Intoxication

paranoid ideation and must be differentiated from primary psychiatric d/o Sx: mydriasis, tachycardia, HTN, diaphoresis *think college student studying for finals*

Seborrheric Keratosis

pigmented macules or palques with a greasy surface and well demarcated borders. Rapid onset of numerous leasions is an indication of internal malignancy (Leser-Trelat sign) esp GASTRIC ADENOCARCINOMA

Idiopathic pulmonary fibrosis

patchy intersitial inflammation intermixed with areas of dense fibrosis and nl lung, focal fibroblastic proliferation, and a honeycomb pattern most prominent in the periphery. Repetitive injury and disordered healing are implicated as potential causes; lung injury results in focal loss of type 1 pneumocytes and hyperplasia of type 2 pneumocytes tx: aim treatment against slowing the fibrosis by inhibiting TFG-beta and other fibrogenic growth factors (PDGF, Fibroblastic growth factor, and VEGF) with Prifenidone (inhibits TFG-beta) or Nintedanib a tyrosine kinase inhibitor which inhibits PDGF, FGF, and VEGF

UVA wavelength

penetrate deeper into the skin and cause photoaging. UVA produces ROS, which activate multiple inflammatory cell-surface receptors and nuclear transcription factors. This leads to decreased collagen fibril production, along with upregulation of matrix metalloproteinases (including collagenases) that subsequently degrade type I and III collagen and elastin. in short photoaging is a product of excess exposure to UVA wavelengths and is characterized by peridermal atrophy with flattening of rete ridges. In addition there is decreased collagen fibril production and increased degradation of collagen and elastin in the dermis.

Relative Risk Reduction (RRR)

percentage indicating relative reduction in the treatment event rate compared to the control group RRR = ARR/Control rate

Absolute Risk Reduction (ARR)

percentage indicating the actual difference in event rate between control and treatment groups ARR= control rate - tx rate

maternal serum quadruple screen

performed to assess the risk of congenital defects in fetuses. Accurate dating is important for determining whether levels of alpha-fetoprotein and other analytes are abnomral for gestaional age. Pt with hx of irregular menses are at risk for inaccurate pregnancy dating

Chronic aortic regurgitation

persistent LV volume overload triggers eccentric hypertrophy, causing a compensatory increase in SV to maintain CO. This compensatory mechanism allows for a relatively long asx period in most pt; however, LV dysfunction eventually occurs, leading to HF

cardiac myocyte AP consists of

phase 0: rapid depolarization phase 1: initial rapid repolarization phase 2: plateau phase 3: late rapid repolarization phase 4: resting potential the AP is associated with increased membrane permeability to Na and Ca and decreased permeability to K+

Porphyria cutanea tarda

photosensitive blistering bullous disease in sun exposed areas; deficiency uroporphyrinogen decarboxylase

how to engage in conversation if prescription opioids is suspected

physicians should validate the pt's concerns, have a collaborative discussion and explore reasons for the escalating use

conjugate vaccines

polysaccharides linked to proteins

PEEP

positive end-expiratory pressure - common mechanical ventilator setting in which airway pressure is maintained above atmospheric pressure

primary somatosensory cortex

postcentral gyrus of parietal lobe responsible for all somatic sensory modalities: touch, temperature/pain, vibration/proprioception of the C/L body

symptoms in schizophrenia

postive sx: delusions, hallucinations (usu auditory), disorganization negative: flat affect (lack of facial expression, poverty of speech, social withdrawl, monotone negative sx persist btw acute psychotic episodes and are more resistant to tx

methadone

potent long acting opioid agonist used in the mainteance of opioid use d/o prolonged effects suppress withdrawal sx and cravings

Endothelian

potent vasoconstrictor that promotes smooth muscle cell proliferation; typically found in high concentration in pts with pulmonary arterial hypertension (PAH) and it is an important target of therapy for the disease. Endothelian receptor antagonists (bosentan, ambrisentan) inhibit pulmonary arteriolar smooth muscle proliferation and alleviate vasoconstriction to lower pulmonary arterial pressure and improve dyspnea in pt with PAH

procelain gallbladder

potential manifestation of chronic cholecystitis and is often found in association w/ multiple gallstones. firm, palpable gallbladder with extensive calcifications throughout gallbladder wall. Pt has RUQ pain but many are asx Due to dystrophic intramural deposition of calcium salts in the setting of chronic inflammation. Associated with increased risk of adenocarcinoma of the gallbladder.

acute renal failure (ARF)

pre-renal ARF (decreased renal perfusion): nl nephron function (low urine Na level, low fractioned Na excretion, high urine osmolarity, and high BUN/creatinine ratio) vs intrinsic ARF feats (tubular epithelial or glomerular damage): diminished renal reabsorptive capacity (lower urine osmolarity, higher Na, nl serum BUN/creatinine ratio)

a test has been created for HPV infections of the uterine cervix. If the prevalence of dx increases by 50% which will increase?

predictive value of a positive test

HELLP syndrome

preeclampsia (severe variant with poor px) with thrombotic microangiopathy involving the liver; Hemolysis, Elevated Liver enzymes, and Low Platelets associated with Schistocytes Tx: for preeclampsia/eclampsia= delivery of the fetus, prevent eclampsia (seizures) with magnesium sulfate drip. Signs of magnesium toxicity = *loss of deep tendon reflexes, respiratory paralysis, and coma* increased Mg = decreases impulse transmission across the NMJ thus signs and sx of neuromuscular toxicity

poliomyolitis

preferentially infects and replicates in the anterior horn of the spinal cord leading to LMN signs

Actinic Keratosis (AK)

premalignant lesion (can progress to squamous cell carcinoma) that has a slow-developing thickening and scaling due to chronic sun exposure erythematous papules with a central scale and a rough "sanpaper-like" texture

Risks of secondhand smoke exposure

prematurity, low birth wt sudden infant death synd: impaired arousal and abnl cardiovascular responses to stimuli middle ear dx (otitis media) asthma Resp tract infections (bronchitis, pneumonia)

heteroplasmy

presence of different mitchondrial genomes (mutated and wild type) within a single cell. The severity of mitochondrial dz is often related to the proportion of abnormal to normal mitochondria.

Anti-HBc IgG

present in both acute and chronic infection NOT present after vaccination

Erysipelas

presents as a painful, raised lesion with sharply demarcated borders caused primarily by group A streptococci.

Tinea Corpis (Ringworm)

presents as a pruritic, oval, erythematous, scaling plaque with central clearing. The lesion becomes annular shaped with slightly raised borders. It is more common in preadolescents and in hot, humid climates. Tinea corporis is most often due to the fungus Trichophyton rubrum, although numerous dermatophytes, including Trichophyton tonsurans and Microsporum canis, can cause the disease. Diagnosis is via a potassium hydroxide (KOH) preparation that shows segmented hyphae and spores. Treatment of tinea corporis is with the topical antifungals miconazole, clotrimazole, or ketoconazole.

Mitochondrial dysfunction

presents as myopathy:muscle weakness, nervous system dysfunction:neuropathy, seizures, lactic acidosis, and ragged red fibers on muscle biopsy. Mitochondial myopathies due to mtDNA mutations are inherited soley via mom.

Varicella Zoster Virus

presents as vesicles with ulcerated and crusted lesions. occurs in elderly and immune compromised

type 1 diabetes treatment

presents subacutely with polyuria and polydipsia accompanied by fatigue and wt loss. The dx can be confirmed with: - fasting plasma glucose >126 mg/dL - Hemoglobin A1c >6/5% - Random (nonfasting) glucose >200 mg/dL in a pt with sx of hyperglycemia - Oral glucose tolerance test with plasma glucose >200 mg/dL 2 hours after glucose ingestion (preferred for dx of gestational diabetes)

Epidiymititis

presents w/ acute testicular pain, tenderness, and pyuria. It is caused by retrograde passage of organisms form the uretrha into the ejaculatroy duct and vas deferens. in young men: due to sexually acquired infections (Chlamydia trachomatis, N. gonorrhoeae) vs oldermen (>35) due to gram - colonic bac (E.coli)

Patellofemoral Syndrome

presents with anterior knee pain that worsens with prolonged sitting or with ambulation up/down stairs. Look for the "J sign" when suspecting this diagnosis.

Pneumothorax

presents with dyspnea, U/L CP, and decreased breath sounds over the affected lung. CXR: "pleural line" with increased lucency distal to it. Make sure to look for mediastinal shift to assess for tension pneumothorax!

Renal infarction

presents with flank pain, hematuria, elevated lactate dehydrogenase, and a wedge-shaped kidney lesion on CT. Most common cause of renal infarction is systemic thromboembolism, often due to thrombus formation during atrial fibrillation. The brain and kidneys are more likely than other organs to suffer embolic infarcts b/c they are perfused at a higher rate.

Impaired Beta-oxidation

presents with hypokektotic (low ketone bodies) hypoglycemia after prolonged (>24 hours) periods of fasting and insufficient levels of ketone bodies. This can occur with a defect in Acyl-CoA dehydrogenase or with a problem in the carnitine shuttle Acyl-CoA dehydrogenase catalyzes the first step in beta-oxidation. fasting adults require more than 1-2 days of fasting before ketones use become substantial vs children who have limited glucose reserves and begin to use ketone bodies after ~8-10hrs

hypothyroid myopathy

presents with myalgias, proximal muscle weakness, elevated creatine kinase levels, and delayed relaxation of deep tendon reflexes. The diagnosis can be confirmed with an elevated TSH level. Other common causes of myopathy with elevated creatine kinase levels include inflammatory myopathies, muscular dystrophies, and HMG-CoA reductase inhibitors.

Normal Pressure Hydrocephalus (NPH)

presents with progressive gait difficulties, cognitive disturbances, and urinary incontinence. It is a form of communicating hydrocephalus characterized by ventriculomegaly w/out persistent elevations in intercrainal pressure. Brain imaging reveals ventricular enlargement out of proportion of sulci enlargment

Primary Lateral Sclerosis (PLS)

presents with upper motor neuron signs without associated lower motor neuron signs, which are seen in amyotrophic lateral sclerosis (ALS). It typically begins in the lower extremities and affects the trunk, then upper limbs, then bulbar muscles as the disease progresses. Patients may note swallowing or respiratory difficulties late in the disease course. Hyperreflexia and positive Babinski's reflexes are frequently seen in this condition due to the presence of upper motor neuron involvement.

Conn syndrome

primary hyperaldosteronism from adrenal adenoma aldosterone secreting tumor: HTN (often resistant) unexplained hypokalemia and metabolic alkalosis renin is suppressed in response to the HTN U/L: surgical removal B/L: tx with spironolactone or eplerenone

Drug induced SLE

procainamide, hydralazine, INH, penicillamine, chlorpromazine, methyldopa, quinidine SLow acetylators are at greater risk of developing this

translation of the mRNA template

proceeds in the 5' to 3' direction b/c complementary sequences align in the anti-// fashion, during translation tRNA anticodons will be oriented in the opposite 3' to 5' direction. Stop codons (UAA, UGA, UAG) halt protein synthesis by binding a release factor; they do not add amino acids to the polypeptide chain

Viridans streptococci

produce dextrans that aid in colonizing host surface, such as dental enamel and heart valves. They can cause subacute endocarditis, classically seen in patients with preexisting cardiac valvular defects after dental manipulation.

Secretin

produced by S cells in the duodenal mucosa in response to stimulation by intraluminal acidity. Secretin stimulates the release of bicarbonate-rich secretions from the exocrine pancreas, which is a major source of acid-neutralizing bicarbonate entering the duodenum.

interferon gamma

produced by T cells - activates macrophages

5-HETE (hydroxyicosatetraenoic acid

produced by a variety of immune cells and serves as a leukotriene and lipoxin precursor. Also causes neutrophil and macrophage chemotaxis and neutrophil degranulation

Hemoglobin A1c

produced by nonenzymatic glycosylation of the hemoglobin molecule. A hemoglobin A1c assay provides an estimate of chronic glycemic control over the lifespan of the RBC (3months). however, rapid RBC turnover (hemolytic anemia) can five a misleadingly low hemoglobin A1c in relation to glycemic status

Vibrio cholerae

produces a toxin that causes ADP ribosylation of the stimulatory Gsα protein. This activates adenylate cyclase and increases intracellular levels of cAMP, leading to a secretory state and the characteristic voluminous diarrhea.

osteoarthritis

progressive fissuring and erosion of articular cartilage

Ventral posterior lateral nucleus

receives input from the spinothalamic tract and dorsal columns and ventral posterior medial nucleus (receives input from the trigeminal pathway) of the thalamus send somatosensory projections to the cortex via thalamocortical fibers. Damage to these nuclei results in complete C/L sensory loss

open angle glaucoma

progressive loss of peripheral vision from elevated intraocular pressure. Timolol and other nonselective beta blockers work by diminishing the secretion of aquous humor by the cilliary epithelium. acetazolamide a carbonic anhydrase inhibitor decreases aqueous humor secretion by the ciliary epithelium. prostaglandin F2alpha (latanoprost, travoprost) and cholinomimetics (piocarpine, cabachol) decrease intraocular pressure by increaing the outflow of aqueous humor

hydatidiform molar pregnancy

proliferation of TROPHOBLASTIC tissue which can be seen on US as a grwoing mass of cysts in the uterine cavity often described as a snowstorm appearance or honeycomb uterus

Protein kinase A

protein kinase A is responsible for the intracellular effects of the G protein-mediated adenylate cyclase second messenger system. Hormone receptors that use this system include the TSH, glucagon, and PTH receptors

BRAF

protein kinase involved in activating the signaling pathways of melanocyte proliferation

iliohypogastric nerve

provides sensation to the *suprapubic and gluteal* regions and motor function to the anterolateral abdominal wall muscles abdominal surgery (appendectomy) can damage the nerve and cause decreased sensation and/or burning pain at the suprapubic region arises from the L1 nerve root

Lichen Planus

pruritic skin eruptions assoc with Hep C and other AI dz chronic mucocutaneous disease that can affect the skin, tongue, oral mucosa, and genitalia. The most common sites of skin involvement are the volar wrists and the ankles. It commonly presents as purple, pruritic, polygonal, flat-topped papules (the "four Ps"); these papules are typically only a few millimeters in diameter, but may coalesce into large lesions. Fine white lines, or Wickham striae, are sometimes visible on the surface of the papules. foudn on the flexural surfaces of wrists and ankles, nails, oral mucous membranes, genitalia including hyperkeratosis, dense lymphocytic infiltrate in a band just below the junction of the epidermis and dermis, and hypertrophy of the granular layer of the epidermis giving wedge-like, or "sawtooth," rete ridges. 4Ps: Papular Puritic Polygonal Purple

Clostridium difficile

pseudomembranous colitis; post-antibiotics esp CLINDAMYCIN and ampicillin; toxin assay stool; Rx metronidazole other abx: most commonly implicated antibiotics include the cephalosporins, the fluoroquinolones, ampicillin/amoxicillin, and clindamycin causes watery diarrhea (may be described as greenish-yellow)

somatic symptom disorder

psychological disorder in which the symptoms take a somatic (bodily) form without apparent physical cause causes psychological distress and impairment in function due to one or more somatic symptoms that are not explained by another medical condition.

brief psychotic disorder

psychotic episodes with a duration of at least 1 day but less than 1 month onset is sudden and associated with a stressor

After a vasectomy, a man is not sterile until

pt can have viable sperm for 3 months and at least 20 ejaculations or

Von Willebrand Disease

pt present with lifelong hx of mucosal bleeding, including gingival bleeding, epistaxis, and/or menorrhagia. These pt have nl platelet levels but typically have a prolonged bleeding time due to impaired platelet functioning

Acute adrenal insufficiency (adrenal crisis)

pt with adrenal insufficiency are not able to increase glucocorticoid production in response to acute stress (illness, surgery). Adrenal crisis is characterized by severe HYPOtension, abd pain, vomiting, weakness, and fever. In addition to aggressive fluid resuscitation, tx requires immediate glucocorticoid supplementation (hydrocortisone or dexamethasone).

Mullerian aplasia (Mayer-Rokitansky-Kuster-Hauser syndrome)

pt with this have no upper vagina (short vagina) and variable uterine development. - these pt are 46, XX females with normal ovaries and secondary sexual characteristics

Chronic Kidney Disease (CKD)

pt with this often develop normocytic anemia as the GFR worsens due to inadequate production of EPO, a glycoprotein hormone produced by peritubular fibroblast cells in the renal cortex. EPO is released into the bloodstream in response to renal tissue hypoxia and acts on erythrocyte progenitor cells in the blood marrow to reduce apoptosis and increase differentiation into mature RBC. Pts with CKD are tx with synthetic forms of EPO to supplement intrinsic EPO production and stimulate erythropoiesis. B/c synthetic EPO can rapidly deplete iron stores pt should be tested for iron deficiency before tx. can cause hyperphosphatemia due to impaired renal excrection of phosphorus. Elevated blood phosphate triggers the release of fibroblast growth factor 23, which lowers calcitriol production and intestinal calcium absorption. The resulting hypocalcemia, along with hyperphosphatemia, leads to secondary hyperparathyroidism

Phthirus pubis

pubic lice tx: topical permethrin: blocks Na channels tranmitted sexually via skin to skin contact and causes intense pruritus

Where are serotonin cell bodies located?

raphe nuclei located in the midbrain, pons, and medulla

Paroxysmal Supraventricular Tachycardia (PSVT)

rapid palpitations due to stimulation of atria/AV node. Treatment can be with vagal stimulation: carotid sinus massage or the Valsalva maneuver. Maneuvers that increase vagal tone increase the refractory period in the AV node and help prevent a reentrant circuit from conducting. If valsalva measures fail, IV admin of Adenosine is recommended. The valsalva maneuver is executed by forcibly exhaling against a closed glottis. The *rectus muscles* are recruited in this process and they play the largest role in the development of the resultant elevated intraabd and intrathoracic pressure during this maneuver.

Releasing factors

recognize stop codons (UAA, UGA, UAG) and terminate protein synthesis. They facilitate release of the polypeptide chain from the ribosome and dissolution of the ribosome-mRNA complex

Cystic fibrosis

recurrent pneumonia, digital clubbing, azoospermia, and B/L absence of *vas deferens*: azoospermia (lack of sperm) and infertility via CFTR mutations: abnl development of Wolffian structures, vasal agenesis and defective sperm transport specific test for dx is nasal transepithelial potential difference pancreatic insufficiency: thick secretions in the lumen of the pancreas, resuling in obstruction, inflammation and subsequent fibrosis *distension and obstruction of the pancreatic ducts*

panic disorder

recurrent unexpected panic attacks and should be considered in young HEALTHY adults who come to the ED with unexplained CP. Administer benzodiazepine in the ED setting for rapid relief of sx Panic d/o sx: recurrent and unexpected panic attacks with >4 of the following: 1. CP, palpitations, SOB, choking 2. Trembling, sweating, N, chills 3. Dizziness, parathesias 4. Derealization, depersonalization 5. Fear of losing control or of dying - Worry about additional attacks, avoidance behavior Tx: - First-line/maintenance: SSRI/SNRI and or CBT - Acute distress: benzo

hemolytic disease of the newborn

red cells of the newborn are destroyed by maternally derived antibodies. These antibodies arise in Rh(D) negative mother who's first pregnancy resulted in an Rh(D) positive fetus hemolysis, fetus develops anemia, jaundice shortly after birth, CHF, and possibly hydrops fetalis

Intrauterine growth restriction (IUGR)

reduced growth rate (symmetrical IUGR) or abnormal growth pattern (asymmetrical IUGR) of the fetus, resulting in a small for gestational age (SGA) infant cocaine can precipitate this

nigrostriatal degeneration in Parkinson dz

reduces activity of the thalamus and its projections to the cortex, resulting in bradykinesia and rigidity. Pt w/ medically intractable sx of Parkinson dz may benefit from high-freq deep brain stimulation of the globus pallidus internus or subthalamic nucleus as it promotes thalamo-cortical disinhibition with improved mobility

The gait associated with an upper motor neuron lesion is

referred to as a spastic, scissoring gait. The patient's legs cross over each with each step. This gait is also associated with tight hip adductors.

Phenotypic mixing

refers to co-infection by two viral strains, resulting in progeny virions that contain nucleocapsid proteins from one strain and the genome of the other strain. Since there is no change in the underlying genomes (no genetic exchange), the next generation of virions revert to their original, unmixed phenotypes

Glucagon-like peptide 1 (GLP-1)

regulates glucose by slowing gastric empyting, suppressing glucagon secretion, and increasing glucose-dep insulin release. Dipeptidyl peptidase-4 inhibitors (-gliptins) decrease the breakdown of GLP-1 and improve glycemic control in pt with DM2. B/c the effect on insulin is glucose-dep these meds have LOW risk of HYPglycemia

Rhabdomyloysis

release of intracellular muscle contents (myoglobin, electrolytes) due to myocyte injury; it is common in crush injuries, seizures, or drug use (statins, amphetamine, heroin). Heme pigment (released from myoglobin after degradation in the kidney) is toxic to tubular cells and can cause acute tubular necrosis. *Positive blood on urine dipstick in the absence of RBCs on microscopic urinalysis suggest myoglobinuria* Additional Labs: HIGH creatine kinase, High potassium, High phosphorus, low ca

Tumor necrosis factor-alpha

released from activated macrophages, one of the most important mediator of the systemic inflammatory response in sepsis: peripheral v-dilation, increased cardiac output and warm extremities. other cytokines responsible for inducing the systemic inflammatory respnse include Il-1 and Il-6

what does effective discharge planning require?

requires collaboration of multiple disciplines (doctors, nurse, and social worker) A social worker can be instrumental in assessing whether the pt has adequate family or caregiver support at home

Side effect of morphine

resp. depressant, increases intracranial pressure, constricts pupils, vasodilator = hypotension, N/V, constipation, itching, bronchoconstriction, tolerance, withdrawal, physical dependence, mental confusion, highly addictive

eccrine sweat glands

respond primarily to elevated body temperature located on hands and soles the major sweat gland

Lacunar infarcts

result of small vessel occlusion (due to lipohyalinosis and microatheroma formation) in the penetrating vessels supplying the deep brain structures. Uncontrolled HTN and DM are major risk factors for this condition. Lipohyalinosis occurs secondary to leakage of plasma proteins through damaged endothelium and is characterized by hyaline thickening of the vascular wall, collagenous sclerosis, and accumulation of mural foamy macrophages. Microatheromas result from atherosclerotic accumulation of lipid-laden macrophages within the intimal layer of a penetrating artery near its origin off the parent vessel. These changes predispose to small-vessl occlusion and infarction of central nervous system tissue with liquefactive necrosis and the formation of a fluid-filled cavity.

sick sinus syndrome

results from degeneration (usually age-related) of the SA node (found in the RA wall), leading to impaired conduction and reduced CO w/ sx of dyspnea, fatigue, lightheadedness, presyncope, and syncope EGK: bradycardia with sinus pauses (delayed P waves), sinus arrest (dropped P waves), and junctional escape beats

dilated cardiomyopathy

results from direct damage to cardiomyocytes leading to myocardial contractile dysfunction (systolic dysfunction), volume overload, and ventricular dilation. Viral myocarditis is a common cause of dilated cardiomyopathy and should be suspected in young pts who develop heart failure following a symptomatic viral prodrome

Acute Cardiogenic Pulmonary Edema

results from increased pulmonary venous pressure alveolar capillaries: become engorged with blood and there is transudation of fluid plasma across the alveolar-capillary membrane appearing as pink, acellular material within the alveoli seen with acute pulmonary edema due to increased alveolar capillary hydrostatic pressure from L-sided heart failure

stable angina pectoris

results from myocardial O2 demand-supply mismatch and manifests as chest pressure, tightness, or pain that is reliably produced by exertion and relieved by rest. It most commonly occurs due to a fixed atherosclerotic plaque obstructing >70% of the coronary artery lumen that limits blood flow during exertion. Myocardial O2 demand is determined by HR, BP (afterload), LV end-diastolic volume (preload), and cardiac contractility Myocardial O2 supply is determined by coronary blood flow.

Osmotic demyelination syndrome (central pontine myelinolysis)

results from overly rapid correction of chronic hyponatremia. Sx: quadripelgia, pseudobulbar palsy, and reduced level of consciousness. MRI: focal demyelination of the pons

Peripheral edema formation

results from the accumulation of fluid in the intersitial spaces. Factors that promote edema include elevated capillary hydrostatic pressure, decreased plasma oncotoic pressure, sodium and water retention, and impaired lymphatic drainage. In chronic HF, increased lymphatic drainage initially offsets factors favoring edema, whereas acute changes (venous thrombosis, HF decompensation) are more likely to produce edema.

diabetic gastroparesis

results from the destruction of enteric neurons due to chronic hyperglycemia, leading to imparied relaxation and disordered and ineffective peristalsis. This causes delayed gastric emptying, which presents as postprandial fullness, regurgitation of undigested food, N/V.

recall bias

results from the study participants' inaccurate recall of past exposure and occurs most often in retrospective studies such as case-control studies. People who have experienced an adverse event are more likely to recall risk factors than those who have not experienced an adverse event

Wernicke encephalopathy symptoms

results from thiamine (vitamin B1) deficiency. It is characterized by bilateral abducens nerve (CNVI) palsy, horizontal nystagmus, ataxia, and a global confusion accompanied by apathy. occus in pt with alcohol abuse and may be precipitated by infusion of glucose-containing fluids focal hemorrhage or atrophy of the mammillary bodies tx with thiamne IV FIRST before glucose

Chromosome 22q11.2 microdeletion

results in DiGeorge syndrome (cardiac anomalies, hypoplastic or absent thymus, and hypocalcemia) and velocardiofacial syndrome (cleft palate, cardiac anomalies, dysmorphic facies). Fluoresence in situ hybridization is the gold standard for detecting a microdeletion.

Deficiency of terminal complement components (C5b-C9)

results in an inability to form the complement membrane attack complex. this condition predisposes to recurrent infections by *Neisseria organisms*

Chronic kidney disease

results in impaired conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D due to the following factors: 1) FGF23 (fibroblast growth factor 23) levels increase early in CKD, causing direct inhibition of 1-alpha-hydroxylase 2) Reduced glomerular filtration limits the delievery of 25-hydroxyvitamin D to proximal tubule cells 3) Reduced functional renal mass limits production of 1-alpha-hydroxylase

Primary hyperparathyroidism

results in increased secretion of parathyroid hormone, which results in hypercalcemia. Parathyroid hormone acts upon the distal convoluted tubule to increase Ca2+/Na+ exchange, which leads to Ca2+ reabsorption. "painful bones, psychic moans, abdominal groans, and renal stones." Clinical manifestations of hypercalcemia can result in calcium oxalate kidney stones, polyuria, renal colic, osteitis fibrosis cystica, muscle weakness, fatigue, depression, confusion, peptic ulcer disease, anorexia, constipation, and abdominal pai

Vitamin A overuse

results in intracranial hypertension, skin changes (dry skin, alopecia) and hepatosplenomegaly

pemphigus vulgaris.

reticular pattern of IgG located around the cells of the epidermis describes the immunofluorescent pattern of autoimmune disorder that involves the formation of antibodies directed at the cell surfaces of keratinocytes, specifically the desmosomal protein. Patients develop intraepidermal, fragile, flaccid blisters that arise on healthy-looking or erythematous skin that easily rupture, leading to painful erosions. On biopsy, the basal cells remain intact and attached to the basement membrane, forming the "tombstone" layer. Nikolsky sign is positive, indicating the involvement of the superficial skin layers.

risk

risk is the probability of developing dz over a certain period of time. To calculate this probability, divide the number of affected subjects by the total number of subjects in the corresponding exposure group.

parietal cells

secrete HCl and intrinsic factor stain pink VS chief cells (stain PURPLE)

Brain Natriuretic Peptide (BNP)

secreted from the ventricles in response to stretch. As the ventricles dilate because of congestive heart failure they release BNP. BNP has similar effects as ANP in that it is a diuretic, natriuretic, and anti-hypertensive. Its natriuretic effect is mediated by increasing glomerular filtration rate and sodium filtration while decreasing sodium reabsorption. Loss of sodium in the kidney tubules increases the osmotic pressure. The increased osmotic pressure in the kidney tubules causes water to follow the sodium resulting in diuresis. The effect of BNP on the kidneys is an increase in sodium excretion and volume loss.

Risperidone

secretion of prolactin is controlled by the inhibitory effect of hypothalamic dopamine. Risperidone and other antipsychotics cause hyperprolactinemia by blocking D2 receptors on lactotrophs. Elevated prolactin leads to amenorrhea (inhibition of gonadotropin-releasing hormone release), galactorrhea, and breast soreness

superficial fungal infections

seen under the breast and folds of skin. These are typically caused by Candida species and cause beefy-red erosions with small satellite lesions. Dx is by culture or KOH prep: budding yeast and true and pseudohyphae Tx: antifungals

Anti-HBs

seen with cleared infection/vaccination confers long-term immunity

Thromboangiitis obliterans (Buerger disease)

segmental, inflammatory vasculitis affecting small and medium arteries and vens of the distal extremeities with inflammatory, intraluminal thrombi and sparing of the vessel wall. It is usu in young, heavy smokers, and can present with digital ischemia and ulceration, extremity clauication, Raynaud phenomenon and superficial thromboplepbitis

partial seizure

seizure involving only limited areas of the brain with localized symptomsm- U/L commonly the medial temporal lobe can be simple: preserved consciousness OR Complex: impaired consciousness, automatisms, preceded by aura

Acute hepatitis A

self limited infection sx: fever, malasie, anorexia, N/V, RUQ pain followed by signs of cholestasis: jaundice, pruritus, dark-colored urine, clay-colored stool

Acute Hepatitis A

self-limited infection that typically presents acutely with prodromal symptoms: fever, malaise, anorexia, N/V, RUQ pain followed by signs of cholestasis (up to a week later these sx present): jaundice, pruitus, dark-colored urine-from increased conjugated bilirubin levels, clay-colored stool Does NOT progress to chronic hepatitis, cirrhosis, or hepatocellular carcinoma picornavirus m/c hepatits viral infection in travelers!! Prior vaccination can prevent the infection

fructose for sperm

semen has fructose which is contributed by the seminal vesicles and is normally present. Absence of fructose in the semen, low semen volume, and low pH are indicative of an obstruction of the seminal vesicle.

radial nerve

sensory innervation: to the skin of the posterior arm, forearm, and dorsal lateral hand Motor innervation: *all extensor muscles *of the upper limb below the shoulder. Damage to the proximal radial n. (at axilla or mid-shaft of humerus) may result in wrist drop

Reactive arthritis

seronegative (rheumatoid factor-negative) spondyloarthropathy affects patients age 20-40 and is associated with HLA-B27. Triad: nongonococcal urethritis, conjunctivitis, and arthritis. Occurs several weeks after a GU (Chlamydia trachomatis) or enteric infection (Salmonella, Shigella, Yersinia, Campylobacter, Clostridium, C diff) in 20% of cases can cause sacroiliitis

Chlamydia trachomatis

serotypes L1-L3 cause lymphogranuloma venereum: painless ulcers with later progression to painful inguinal lymphadenopathy (buboes) and ulceration. chlamydial includsion bodies seen in host cell cytoplasm

the muscle used in exhalation rib dysfunctions in ribs 6,7,8

serratus anterior is used to mobilize the rib in muscle energy

acute pituitary hemorrhage (pituiatry apoplexy)

severe HA, bitemporal hemianospia (compression of the optic chiasm), and opthalmoplegia (compression of the oculomotor nerve). It occurs in pre-exisiting pituitary adenoma medical emergency that req urgent tx with glucocorticoids to prevent acute adrenal cirsis and circulatory collapse

severe HTN effect on eye

severe HTN in retinal precapillary arterioles causes endothelial disruption, leakage of plasma into the arteriolar wall, and fibrinous necrosis. The necrotic vessels can then bleed into the nerve fiber layer, which can be seen on exam as dot or flame shaped hemorrhages painless, U/L visual disturbance

Obstetric conjugate

shortest antero-posterior diameter through which the fetal head must pass and extends from the sacral promontory to the closest point on the convex posterior surface of the symphysis pubis B/L sacral flexion is common in pregnancy

What to do in during the admission process of admitting a pt to the hospital

should include discussion of advance directives and code status to ensure that medical personnel adhere to the pt's specific wishes in the event that the pt becomes incapacitated.

type I muscle fibers

slow twitch perform actions requiring low-level sustained force (postural maintenance) ex: paraspinal/erector spinae, soleus Function via aerobic metabolism: high myoglobin (oxygen storage) and mitochondrial (aerobic respiration) concentrations. Red muscle fibers that derive ATP primarily from oxidative metabolism

Meningiomas

slow-growing well circumscribed, benign intracranial tumors typically found at the cerebral convexities in adults whorled pattern of cellular growth forms nests, may calicfy into round eosinophilic laminar structures called psammoma bodies can causes seizures

Adenosine

slows atrioventricular (AV) conduction velocity and increases the AV node refractory period. It is administered as a rapid intravenous bolus, has a short half-life, and is commonly used in the treatment of acute paroxysmal supraventricular tachycardias.

lacunar infarcts

small ischemic infarcts involving the deep brain structures (basal ganglia and pons) and subcortical white matter (internal capsule, corona radiata). They are most often due to hypertensive aterioslclerosis of small, penetrating arterioles, lipohyalinosis, microatheroma formation, and hardening/thickening of the vessel wall May sound very similar to a Charcot-Bouchard aneursm with hemorrhage but this would appear hyperdense on CT whereas lacunar infarct would be dark and cavitary (lacuna)

medial sacral artery or middle sacral artery

small vessel that arises posterior to the abd aorta and superior to its bifurcation. supplies blood to the coccyx, lumbar vertebrae, sacrum

risk factors for pancreatic cancer

smoking is most important advanced age chronic pancreaitits genetic predisposition Peutz-Jeghers

risk factors for esophageal squamous cell carcinoma

smoking, excessive ETOh, and intake of foods with N-nitroso compounds

cGMP

smooth muscle relaxation / dilation to cause decrease BP

TCA overdose treatment

sodium bicarbonate to tx the cardaic involvement

Angiodysplasia

submucosal dilation of venules in cecum; cause of hematochezia

conduction aphasia

spared fluency and comprehension of language but have some difficulty finding specific words. The m/c cause is a stroke to the L MCA able to speak fluently with comprehension, but have difficulty finding specific words. Repetition is lost. The pt is often aware of their language difficulties.

Niemann-Pick disease

sphingomyelinase deficiency results in macrophages that have soap-bubble appearance. Sphingomyelin accumulates in the central nervous system and in non-neural tissue and results in neurodegeneration. Patients typically present early in life with hypotonia, developmental delay, and neurodegenerative regression late in disease course Ashkenazi Jewish descent are classically more affected. cherry red macular spot, anemia, fever, neuro deterioration, hepatosplenomegaly, lymphadenopathy, bone marrow suppression

Signs of hyperestrinism in cirrhosis

spider angiomata gynecomastia loss of sexual hair (in M) testicular atrophy (in M) palmar erythema increased androstenedione production, androgen aromatization, and sex hormone-binding globulin concentration (preferentially binds testosterone) decreased free testosterone/estrogen ratio leads to these sx

Clostridium septicum

spore forming, exotoxin producing, gram Positive part of the normal commensal of the GI m/c cause of spontaneous gas gangrene (rapid-onset pain, hemorrhagic bullae, tissue crepitus). Underlying colonic malignancy is the greatest risk factor for infection

allergy medication moa

stabilize mast cell membranes

Types of chest pain

stable/exertional/typical/secondary angina: CP triggered by exertion/emotions and relieved by rest or nitrates. Coronary arterioles in the ischemic region are fully dilated and have no vasodilator reserve. Therefore, they can't meet the demand for O2 in the myocardium that's secondary to exertion, leading to myocardial pain Prinzmetal/primary/variant angina: occurs from vasopasm of a coronary artery. Episodes of angina are unpredictable and often occur at rest/during sleep, often NOT responsive to rest alone Unstable angina/acute coronary syndrome: can quickly lead to MI and is an emergency. Episodes are progressive and longer than other types of angina. Caused by blood clots that can partially or totally occlude a coronary artery

Statin-induced myopathy

statins inhibit the intracellular rate-limiting step of cholesterol biosynthesis via competitive inhibition of HMG-CoA reductase. This leads to enhanced hepatic LDL receptor recycling and increased LDL clearance from the circulation. Statin-induced myopathy (myalgia, elevated creatine kinase) is the most common complication of statin use

Trigger finger

stenosing flexor tenosynovitis of the flexor tendons that are located over the distal palmar crease at the level of the metacarpal heads. It causes a catching/locking of the finger with it is actively flexed and extended, and is one of the mcc of hand pain in the adult. Tx: NSAIDS, OMM, activity modification, splinting, and steroid injections. If these measures fail -> surgery to release the tendons

Posterior triangle of the neck

sternocleidomastoid, trapezius, clavicle the spinal accessory nerve (CN XI) passes through the post triangle of the neck and provides innervation to the SCM and trapezius. CN XI is vulnerable to penetrating trauma and iatrogenic injury (from cervical lymph node dissection). Sx of trapezius weakness: *drooping of the shoulder*, impaired AB-duction of the arm *above horizontal* (due to weakness in rotating the glenoid upward), and winging of the scapula. if the injury involves the proximal part of the nerve, weakness of the SCM may also be seen

Z drugs (zolpidem, zaleplon, eszopiclone)

stimulate stimulate specific subtypes of GABA a receptors.

pioglitazone -glitazones

stimulate the peroxisome proliferatior-activated receptor gamma

acidosis

stimulates renal ammoniagenesis: renal tubular epithelial cells metabolize glutamine to glutamate, generating ammonium what is excreted in the urine and bicarb that is absorbed into the blood.

Erythromycin

stimulates upper GI motility by acting as an agonist on motilin receptors in the muscularis externa. Can be used to tx gastroparesis (delayed gastric emptying) a condition seen in long standing Diabetes

Crossover study design

subjects are randomly allocated to a sequence of 2 or more tx given consecutively. A washout (no tx) period is often added btw tx intervals to limit the confounding effects of prior treatment.

Bell's Palsy

sudden onset U/L facial paralysis impaired eye closure, eyebrow sagging, inability to smile and frown on affected side, disappearance of the nasolabial fold, and the mouth being drawn to the non-affected side. Pt afflicted with Bell's palsy may also have decreased tearing, hyperacusis, and/or loss of taste sensation over the anterior 2/3 of the tongue. idiopathic paresis of the facial nerve

Schistocytes

suggest microangiopathic hemolytic anemia (HUS, TTP, DIC, or mechanical damage - say a prosthetic valve). IN childhood, HUS is often accompanied by bloddy diarrhea. Coagulation studies (PT and PTT) are normal in HUS and TTP (unlike in DIC)

Left MCA - superior trunk

supplies Broca's area and the lateral portion of the primary motor and somatosensory cortices. In contrast, the left MCA, inferior trunk supplies Wernicke's area but does not supply primary motor or somatosensory cortices.

deep cervical artery

supplies deep muscles on the back of the neck

Posterior inferior cerebellar artery (PICA)

supplies inferior cerebellum and lateral medulla occlusion causes: sudden onset of Horner's syndrome on R, dysphagia, and difficulty speaking. Pain and temp sensations are decreased on the R side of her face and L side of her body.

phrenic nerve (C3-C5)

supplies motor fibers to the diaphragm supplies sensory fibers to the pericardium, mediastinal pleura, and diaphragmatic peritoneum

anterior spinal artery

supplies the anterior 2/3 of the spinal cord, including the corticospinal and spinothalamic tracts. The artery of Adamkiewicz feeds into the anterior spinal artery near T8. Rupture of the artery of Adamkiewicz will cause lower extremities to suffer loss of motor strength and loss of pain and temperature sensation.

anterior cerebral artery

supplies the medial portion of the 2 hemispheres (frontal and parietal lobes). occlusion can cause C/L motor and sensory deficits of the LE (leg and foot), behavioral changes (abulia: absence of willpower), and urinary incontinence (if the frontal micturition center - medial frontal lobe/cingulate gyrus) is affected.

anterior cerebral arteries

supply the medial portions of the 2 hemispheres (frontal and parietal lobes). Occlusion can cause C/L motor and sensory deficits of the LE, behavioral changes, and urinary incontinence

Hyperprolactinemia

suppresses secretion of GnRH, which leads to reduced estrogen in women. low estrogen levels are a risk factor for accelerated bone loss

Asherman syndrome

surgical removal of stratum basalis, causing scarring and secondary amenorrhea

the common peroneal nerve

susceptible to injury at the lateral neck of the fibula caused by compresssion/fx. pt often have weakness on foot dorsiflexion (foot drop) and eversion, as well as toe extension. Sensory loss typically occurs over the lateral leg and dorsolateral foot

Temporomandibular disorder (TMD)

sx: U/L facial pain that worsens with jaw movement, HA, and ear discomfort. Sx can originate from the temporomandibular joint (TMJ) derangement, pathologic contraction of the muscles of mastication, and/or hypersensitivity of the nerves that supply the jaw b/c the mandibular division of the trigeminal n supplies the middle ear and muscles of mastication (medial and lateral pterygoid, masseter, temporalis), TMD can present with both otologic sx and jaw pain

Acetaminophen overdose

symptoms may occur within the first 24 hours. These symptoms may include nausea or vomiting, sweating, loss of appetite, and diarrhea, as seen in this patient. In the next 24 to 48 hours, the early symptoms start to disappear, but liver damage starts to occur. Because of these potentially serious effects, early treatment after an overdose is important. Acetaminophen overdose causes the generation of free radicals which damage hepatic tissue causing hepatic necrosis and subsequent liver failure and death. Treatment with N-acetyl cysteine can assist in regeneration of glutathione. Acetaminophen is a pain reliever and fever reducer. Fever reduction is achieved by reducing the production of prostaglandins which mediate the fever response. Acetaminophen is a pain reliever and fever reducer. It does NOT have anti-inflammatory or anti-platelet effects.

RA

synovial hyperplasia with inflammatory infiltrates. accelerated metabolic rate of the inflamed synovium causes local hypoxia, which leads to synovial angiogenesis, as the dz progresses the joint space is replaced by a *pannus*: invasive mass of fibroblast-like synovial cells, granulation tissue, and inflammatory cells which can destroy the articular cartilage and underlying subchondral bone.

Type II pneumocytes

synthesize surfactant (lecithin, phosphatidylcholine) ie phospholipids, glycosaminoglycans; stored in lamellar bodies surfactant serves to decrease the surface tension in the alveoli, allowing them to remain open for air exchange. also serve as precursors to type I cells and other type II cells type II cells are cuboidal vs type I which are squamous

Nitric oxide

synthesized from *arginine* , O2, and NADPH by endothelial Nitric Oxide Synthase (eNOS), NO then diffuses into adjacent smooth muscles to activate guanylyl cyclase and increase cGMP which can activate protein kinase G to decrease cytosolic Ca levels and relax vascular smooth muscle cells.

prostacyclin (PGI2)

synthesized from prostaglandin H2 by prostacyclin snthase in vascular endothelial cells. Once secreted, it inhibits platelet aggregation and causes vasodilation to oppose the functions of thromboxane A2 and help maintain vascular homeostasis.

Pramipexole

synthetic dopamine agonist used as monotherapy in early Parkinson's disease to delay levodopa initiation or used with levodopa in advanced disease to decrease the dose of levodopa directly stimulates the dopamine receptor

sarciodosis

systemic dz with a restrictive pattern in the lungs. classic findings: hilar lymphadenopathy on CXR histology: non-caseating granulomas with scant surrounding lymphatic infiltrates; these ganulomas can produce angiotensin-converting enzyme with increased levels being a common finding

aortic stenosis murmur

systolic crescendo-decrescendo murmur that can radiate to the carotid arteries. AS is a fixed lesion. When more blood is passing through the stenotic area (increase in preload), there will be a greater intensity in the murmur. Conversely, when less blood is passing through the stenotic aortic valve (decrease in preload), a less intense murmur will be auscultated. An increase in afterload (eg, sustained isometric hand grip exercise) decreases the pressure gradient between left ventricle and the aorta → decreased flow through the aortic valve → decreased intensity of the murmur.

closed loop communication

team members repeat back the information recieved to ensure that the correct information has been conveyed. This reduces the risk of medical errors in the health care setting

Mallory-Weiss tear

tear that occurs in the esophageal mucosa at the junction of the esophagus and stomach caused by severe retching and vomiting and results in severe bleeding. *due to increased intraluminal gastric pressure*

Precision (reliability)

the ability of a test to reproduce identical or similar results with repeated measurements

Giant cell arteritis

temporal artery granulomatous inflammation of the media with fragmentation of the internal elastic lamina of medium and small branches of the carotid artery ipsilateral blindness (ophthalmic artery) tx with glucocorticoid sx: HA and jaw claudication

Pleomorphic Xanthoastrocytoma

temporal lobe of kids/young adults, usually Hx seizures neoplastic, occas bizarre astrocytes (oocas lipidized) express neuronal and glial markers nuclear atypia can be extreme abundant reticulin deposits, relative circumscription, chronic inflam cells, no necrosis, no mitotic act II/IV

treatment for tension pneumothroax

tension pneumothorax is an emergency and tx cant be delayed. Gold standard: place a chest tube in the I/L 4th ICS (more time consuming and req a higher degree of skill) In the presence of unstable vital signs that are indicative of shock, the most appropriate therapy should be needle decompression which is quick and effective in the emergent setting - placement: 2nd ICS midclavicular line, followed by chest tube placement

Allen's Test

test for blood supply to the hand by the ulnar and radial arteries. The patient opens and closes his/her hand several times, and then makes a tight, clenched fist. The physician will then occlude the ulnar and radial arteries at the wrist. The patient will then open his/her hand, and the palm is expected to display pallor. The physician will release one of the arteries and assess the flushing of the hand. If the flushing occurs slowly or not at all, then that artery is not sufficiently supplying the hand.

Phase 3 clinical trials

testing the drug thousands of patients and comparing it to existing treatment. split the patients randomly into two groups, one group gets new treatment and the other gets existing treatment

lloyd sign

tests for kidney stone or pyelonephritis

Clostridium tetani

tetanospasmin is a neuro-exotoxin released by C. tetani. The toxin blocks the release of glycine and GABA from the spinal inhibitory interneruons that reuglate the lower motor neurons (Renshaw cells). These disinhibited motor neurons cause increased activation of muscles, leading to spasms and hyperreflexia.

promoters

the TATA and CAAT boxes are promoters of transcription in eukaryotic cells and are located ~25-75 bases upstream from the transcription start site, respectively. They promote initiation of transcription by serving as binding sites for transcription factors and RNA polymerase II.

U/L renal artery stenosis

the affected kidney is protected from high BP by the narrowing of its renal artery and may suffer ischemic damage. Vs C/L well-perfused kidney shows changes of hypertensive nephropathy (hyaline or hyperplastic arterolosclerosis) causes hypoperfusion and activation of RAAS. Ang II causes arteriolar vaso-constriction and increases aldosterone and ADH syn. This resultant HTN reduces the decline in GFR in the affected kidney, but causes a pressure natriuresis w/ increased Na excretion in the unaffected kidney.

Hawthorne effect

the alteration of behavior by the subjects of a study due to their awareness of being observed.

Thalamus

the brain's sensory switchboard, located on top of the brainstem; it directs messages to the sensory receiving areas in the cortex and transmits replies to the cerebellum and medulla does all sensory EXCEPT olfaction

Derivatives of the common cardinal veins

the common cardinal veins of the developing embryo drain into the sinus venosus. These cardinal veins give rise to the Superior Vena Cava and other constituents of the systemic venous circulation

Agenesis

the complete absence of an organ. Ex: renal agenesis: congenital absence of one or both kidney

Phase 2 clinical trials

the drug is tested on the target human population does it work?

pulmonary fibrosis

the formation of scar tissue in the lung, resulting in decreased lung capacity and increased difficulty in breathing gradual onset progressive dyspnea, nonproductive cough, fatigue, eventual wt loss, reticulonodular opacities on CXR. Pulmonary function test: restrictive pattern Pt with RA can develop interstitial lung dz, both from the pulmonary manifestations of the dz and from certain drugs (methotrexate, cyclophosphamide, sulfasalazine)

the genetic code

the genetic code is considered "degenerate" b/c more than 1 codon can code for a particular amino acid. Some of this degeneracy is explained by the wobble hypothesis, which states that the first 2 nucleotide positions on the mRNA codon require traditional (Watson-Crick) base pairing, wheras the third "wobble" nucleotide position may undergo less stringent (nontraditional base pairing)

the single most important limiting factor for LV myocardial blood supply during a stress test

the high systolic intraventricular pressure and wall stress of the LV prevent myocaridal perfusion during systole; therefore the majority of left ventricular myocardial perfusion occurs during diastole. Shorter duration of diastole is the major limiting factor for coronary blood supply to the LV myocardium during periods of tachycardia (exercise).

Muscle energy set up for Right inferior pubic shear

the initial setup for muscle energy treatment of a right inferior pubic shear: the patient's right leg is flexed at the hip and knee and internally rotated at the hip until resistance is felt.

hypoglossal nerve has a lesion

the ipsilateral genioglossus muscle is weak, and the protruded tongue deviates toward that weak side.

horseshoe kidney

the kidneys are fused at the poles. The isthmus of the horseshoe kidney usually likes anterior to the aorta and posterior to the IMA. During fetal development the IMA limits the ascent of the horseshoe kidney

Poliovirus vaccine

the live attenuated oral (Sabin) poliovirus vaccine produces a stronger mucosal secretory IgA immune response than does the inactivated poliovirus (Salk) vaccine. This increase in mucosal IgA offers immune protection at the site of viral entry by inhibiting attachment to intestinal epithelial cells.

Placement of a catheter in the internal jugular vein can damage what structures?

the lung and common carotid artery

dual blood supply of lungs

the lungs are supplied by dual circulation from both the pulmonary and bronchial arteries. This collateral circulation can help protect against lung infarction due to pulmonary artery occlusion (ie PE), as the bronchial circulation can continue to provide blood to the lung parenchyma bronchial arteries supply nutrients, remove waste from the bronchi, and provide collateral blood flow to the remainder of the lung parenchyma

mitral valve prolapse with regurgitation

the m/c predisposing conditions for native valve infective endocardiditis (IE) in developed nations. Rheumatic heart dz remains a frequent cause of IE in developing nations.

chloride shift

the majority of CO2 produced in the tissues is transported to the lungs as bicarbonate ion (HCO3-). Within RBCs the enzyme carbonic anhydrase forms HCO3- from CO2 and water. The excess HCO3- is then transferred out of the RBCs into the plasma via exchange with chloride ions (Cl-) using *band 3 protein*. This exchange is called the *chloride shift* and is the principal cause of high RBC chloride content in venous blood.

colon cancer screening

the more villous the polyp the higher the pt's risk of further adenomas or adenocarcinoma. Increased colonoscopy screening freq is recommended in pt with villous adenomas

cavernous hemangioma

the most common benign liver tumor. consists of cavernous, blood filledvascular spaces of variable size lined by a single epithelial layer. biopsy of a suspected hemangioma is NOT advisable as it can cause fatal hemorrhage and is of low diagnostic yield UW: vascular malformations composed of abnormally dilated capillaries separated by thin connective tissue septa. The lack of structural support gives them a tendency to bleed, and those found in the brain can present with neurologic deficits and seizures.

glioblastoma

the most common primary cerebral neoplasm of adults typically located within cerebral hemispheres and may lead to mid-line shift or cross the midline forming a "butterfly glioma". These tumors are highly malignant and grossly contain areas of necrosis and hemorrhage.

Point prevalence

the number of disease cases that are active at a *specific point in time* (ex July 31) divided by the number of people in the at-risk population.

period prevalence

the number of dz cases in a period (ex: from July 1 to July 31) divided by the number of people in the at-risk population (*prevalent cases* at the beginning of a period plus any *incident cases* during the period)

What is the most highly oxygenated blood in the fetus carried by?

the one umbilical vein, which empties directly into the inferior vena cava via the ductus venosus. Deoxygenated blood is delivered from the fetus back to the placenta by the paired umbilical arteries which originate from the fetal internal iliac arteries.

selection bias

when the method of selection used in a particular study results in selection sample of participants who are not representative of the intended population.

The main supply to the short gastric arteries originates from

the splenic artery, which originates from the celiac artery. The distribution of the splenic artery is to the superior margin of the pancreas, greater curvature and posterior stomach body, and spleen. The splenic artery arises from the celiac artery. Branches of the celiac trunk supply foregut viscera including the distal esophagus, liver, gallbladder, spleen, stomach, pancreas, and duodenum.

postcentral gyrus

the strip of parietal cortex, just behind the central sulcus, that receives somatoSENSORY information from the entire body

A Hx of previous suicide attempt is

the strongest indicator that the Pt is at increased risk to commit suicide. The risk of a 2nd attempt is the highest within 3Mo of the 1st attempt. Suicide is also common in people with a Hx of suicide in the family.

lower extremity superficial lymphatic system

the superficial lymphatic system is divided into medial and lateral tracts. The medial tract (medial foot) runs up to the superfical inguinal lymph nodes with the saphenous vein, bypassing the popliteal nodes. Consequently, lesions of themedial foot cause inguinal lymphadenopathy, whereas lateral lesions are more likely to cause lymphadenopathy in both the popliteal and inguinal areas.

Hysterectomy complications

the ureter can be injured during hysterectomy due to its close proximity to the uterine structures. The distal ureter may be severed during ligation of the uterine vessels because the ureter passes inferior and lateral to the uterine artery at the level of the internal cervical os prior to entering the bladder (water under the bridge)

What is reduced in COPD?

the vital capacity is decreased largely due to increased residual volume *overall lung compliance is usually greater than normal with COPD and less than normal with idiopathic pulmonary fibrosis and other restrictive lung diseases.

first sign of puberty in females

thelarche: development of breast buds followed by pubarche: growth of axillary hair (~11years of age)

submucosal (meissner) and Myenteric (Auerbach) autonomic plexi

they are absent in the affected segment of the bowel in HIrschsprung dz/ The submucosa of the narrowed area is the most superficial layer where the absence of ganglion cells can be seen.

hydroxylation of proline and lysine residues

this reaction in collagen helps it attain its maximum tensile strength. This process occurs in the rough ER and requires vit C as a cofactor. Impaired collagen synthesis resulting from Vit C deficiency can lead to fragile vessels, predisposing to gingival bleeding, ecchymosis and petechia

teniae coli

three bands of longitudinal smooth muscle in muscularis on the outside of the colon and converge at the root of the vermiform appendix. If the appendix cant be IDed by palpation during appendectomy, follow the teniae coli

the blood brain barrier

tight junctions between the non-fenestrated capillary endothelial cells, a thick basement membrane and astrocyte processes

kidney metastasis

to bone, liver, lungs, brain

Posterior cruciate ligament tears

to test for a tear: Quadriceps activation test- contracting the quads against resistance, causing the tibia to move back into normal position. The PCL prevents posterior translation of the tibia on the femur. When ruptured, there is no support to posterior translation thus the tibia rests in a more posterior position. PCL tears are common when the leg is in flexion bc the PCL is under most stress when the leg is in flexion.

Neisseria meningitidis

transmitted via aerosolized droplest and colonizes the nasopharyngeal epithelium. Penetration of the epithelium can lead to bloodstream infection. Spread to the meninges occurs via transcellular penetration of the cerebral capillary endothelium/entry at the choroid plexus.

Ascaris lumbricoides

transmitted via contaminated food or water. Eggs hatch into larvae in the SI, penetrate the intestinal wall, and migrate across the lung into the alveoli. Larvae are subsequently coughed up and swallowed into the FIT, where they mature into adult worms. More pt are asx, but some develop early pulmonary manifestions (loeffler syndrome) or later GI sx.

Wernicke syndrome

triad of ataxia, confusion, and ophthalmoplegia (paralysis of extraocular muscles). This is most commonly seen in alcoholics due to thiamine (vitamin B1) deficiency as a result of malnutrition, reduced gastrointestinal absorption and decreased hepatic storage/utilization of thiamine. Wernicke's encephalopathy is considered an acute and reversible condition associated with thiamine deficiency, which requires emergent intravenous thiamine replacement in order to prevent neurologic morbidity and even death. A similarly appearing chronic form, Korsakoff's syndrome, is considered irreversible and is characterized by the addition of confabulation Wernicke syndrome is diagnosed clinically, with components of the triad discussed below: Encephalopathy: This is the most common presenting symptom, which is characterized by inattentiveness, significant disorientation and apathy. Oculomotor dysfunction: Various ocular findings may be present, with the most common being horizontal nystagmus and sluggish or nonreactive pupils. Ocular findings rarely occur alone, but most often are seen in conjunction with encephalopathy or ataxia. Gait ataxia: Stance and gait abnormalities range from findings seen only on tandem gait, all the way to severe impairment with inability to walk. alcoholic patients who are hypoglycemic, thiamine must always be given before glucose, in order to prevent worsening or precipitation of Wernicke's syndrome.

ruptured aortic aneurysm

triadL acute abd pain, hypotension, and pulsitile mass aorta is a retroperitoneal structure and if ruptured can lead to retroperitoneal hemorrhage accompanied by flank pain or back pain as well as ecchymosis of the flanks (Grey Turner Sign), periumbilical (Cullen sign), or proximal thigh (Fox)

black widow spider bite

typically manifest with localized pain at the bite site due to the injected alpha-latrotoxin a neurotoxin that stimulates exocytosis in a variety of neurosecretory cells. More common systemic complications include muscle pain, twitching, and gastrointestinal symptoms. common in SW US and live outdoors or in cluttered settings like garages

COPD exacerbations

triggered by viral or bacterial URI, with rhinovirus, influenza virus, Haemophilius influenzae, Moraxella catarrhalis, and Strep pneumo being among the most commmon pt can present with green sputum which is caused by the release of myeloperoxidase from PNMs and can be present in either viral or bacterial respiratory infection

First-line treatment for acute migraine pain refractory to NSAIDs is a ...

triptan, most commonly sumatriptan. It acts by binding serotonin receptors in the brain triggering vasoconstriction, inhibiting trigeminal activation and preventing vasoactive peptide release.

Acute Tubular Necrosis (ATN)

tubular injury due to renal ischemia or direct cytotoxicity 3 stages: 1) INITIATION: initial insult 2) Maintenance: oliguiric renal failure follows in 24-36hrs 3) RECOVERY: glomerular filtration rates improve prior to restoration of renal tubular resoptive capacity, so transient polyuria and electrolyte wasting can occur (hypokalemia)

ovarian torsion

twisting of the infundibulopelvic ligament aka suspensory ligament (which contains the ovarian vessels and nerves) often due to the weight of a large adnexal mass. the resulting occlusion of the blood and nerve supply to the ovary results in severe, acute pelvic pain, and ovarian ischemia. Sudden onset, U/L pelvic pain with N and sometimes V and fever

linkage disequilibrium

two allele loci are said to be in linkage disequilibrium when a pair of alleles are inherited together in the same gamete (halotype) more often or less often than would be expected given random pairing. This most often occurs when the genes are in close physical proximity on the same chromosome.

disease associated with HLA-DR3

type I diabetes mellitus (T1DM). T1DM, one of the most common chronic diseases in childhood, is caused by insulin deficiency following destruction of the insulin-producing pancreatic β-cells. It most commonly presents in childhood, but one-fourth of cases are diagnosed in adults. Persons with type I DM can present with insidious onset of polyuria, increased thirst, and weakness. In contrast, they can also present with diabetic ketoacidosis which results in altered mental status, profound dehydration, and respiratory failure

Acid maltase deficiency

type II glycogen storage disease/Pompe's presents in infancy with cardiomegaly, macroglossia, and profound muscular hypotonia. Abnormal glycogen accumulation within lysosomal vesicles is seen on muscle biopsy - enlarged lysosomes containing periodic-Schiff positive material

influenza epidemics and pandemics

typically caused by *reassortment* of the RNA segements coding for hemagglutinin or neuraminidase proteins (major antigenic shifts). This process can occur between human and animal strains of influenza A virus in avian or swine hosts

Damage to caudate nucleus

typically causes behavioral abnormalities (agitation, psychosis, abulia), speech/language distrubances, and movement disorders (choreoathetosis)

5-hydroxyindoleacetic acid urine test

used to dx carcinoid tumors

catecholamine synthesis pathway

tyrosine --> dopa --> dopamine --> norepinephrine --> epinephrine 1) tyrosine hydroxylase 2) Dopa decarboxylase 3) Dopamine Beta-hydroxylase 4) PNMT: phenylethanolamine-N-methyltransferase cortisol increases the conversion of NE to epi in the adrenal medulla by increasing the expression of PNMT

transference

unconscious redirection of emotions associated with a significant person from one's past to a person in the present can be positive or negative

polycythemia vera

uncontrolled erythrocyte production mutation of JAK2, non-receptor (cytoplasmic) tyrosine kinase assocated with the erythropoietin receptor aquagenic pruritus, facial plethora (reddish complexion), and splenomegaly

Hepatitis E

unenveloped single-stranded RNA virus; fecal-oral transmission; high mortality rate in pregnant women; uncommon in US

Essential fructosuria

unlike hereditary fructose intolerance and classic galactosemia, this condition (fructokinase) is relatively benign. Although asymptomatic, their urine will test postitive for a reducing sugar that is not glucose due to unmetabolized fructose (copper reduction test would test for reducing sugar) UW: caused by a fructokinase deficiency. In pt with essentail fructosuria, some of the dietary fructose load is converted by hexokinase to fructose-6-phosphate, which can then enter glycolysis; this pathway is not significant in normal individuals

Fibrates: gemfibrozil, bezafibrate, fenofibrate

upregulates LPL (lipoprotein lipase) to increase TAG clearance, activates PPAR-aplha to induce HDL syn SE: MYOPATHY with STATINS!! cholesterol gallstones

Sublingual nitroglycerin

used for rapid sx relief in pt with stable angina: CP that occurs with activity and is relieved with rest or sublingual nitro. The primary anti-ischemic effect of nitrates is mediated by venodilation with a decrease in LV end-diastolic volume and wall stress, resulting in decreased myocardial O2 demand and relief of anigina sx - vaso-dilation of peripheral veins and arteries, predominantly venodilation - decreased LV wall stress due to reduced preload ( decreased LV end-diastolic volume and pressure) - modest reduction in afterload due to systemic arterial vasodilation - mild coronary artery dilation and reduction of coronary vasospasm. resulting in decreased myocardial oxygen demand, resulting in improved exercise tolerance and relief of angina sx

PCR

used to amplify small fragments of DNA (genes, exons, noncoding regions) by repeated replication. It requires primers that are complementary to the regions of DNA flanking the seqment of interest. Thermostable DNA polymerase, deoxynucleotide triphosphates, and a source DNA template are also necessary

Nitrates

via conversion to NO activate guanylate cyclase and increase intracellular levels of cGMP (cyclic guanosine monophosphate). Increased levels of cGMP lead to myosin light-chain *dephosphorylation*, resulting in vascular smooth muscle relaxation

Niacin deficiency

vitamin B3 synthesized endogenously from tryptophan and is an essential component of NAD and NADP. A deficiency results in pellegra: dermatitis, diarrhea, and dementia

Functional Residual Capacity (FRC)

volume of air remaining in the lungs after a normal tidal volume expiration ERV+RV

common peroneal nerve

vulnerable to injury where it courses around the neck of the fibula. Fibular neck fractures can injure this nerve injury causes: weakness of dorsiflexion (deep peroneal nerve), eversion (superficial peroneal nerve) of the foot as well as loss of sensation over the dorsum of the foot.

Embryogenesis occurs when?

weeks 3-8 when rapid cell division and differentiation are occuring for organogenesis during this time is when teratogens have their greatest effect

what to do when minors request contraceptive services

when a minor requests contraceptive services, physicians should encourage parental involvement but can provide contraceptive services if the patient refuses. The physician, must, "take steps to facilitate a minor patient's decision about health care services when the patient remains unwilling to involve parents or guardians, so long as the patient has appropriate decision-making capacity in the specific circumstances and the physician believes the decision is in the patient's best interest."

Abandonment of a patient

when a physician, without giving proper notice, ceases to provide care for a patient who requests medical attention. A physician is allowed to terminate the physician-patient relationship at any time, for any reason (other than those protected under state and federal law) as long as the patient is provided with a notice of withdrawal, in writing by certified mail, with a reasonable timeframe in which services will continue to be provided. The notice must inform the patient of the discharge and indicate that the physician will continue to provide emergency care for a specified period. It is recommended that the physician provides resources or recommendations for a provider of like speciality in the letter. With patient consent, the medical record must be provided to the new physician. failure to do so puts the doc at risk for litigation

procedural bias

when different groups in a study are not treated identically except for the primary factor that is used for grouping.

superior venal caval syndrome

when the SVC is obstructed. Both sides of the face, neck, and chest and both arms would be involved.

Amanita phalloides

wild mushroom poisoning, "death cap" inhibits RNA polymerase II (halting mRNA synthesis)

Lepromin skin test

will be positive in patients with tuberculoid leprosy as they exhibit a strong CD4+ TH1 cell-mediated immune response to Mycobacterium leprae. Tuberculoid leprosy with the strong response damages the skin and surroudnig nerves- loss of sensation at the spot and hypo-pigmented patch. Tuberculoid: forms an indurated nodule at the site of injection VS Lepromatous: nonreactive due to weak TH1 cell-mediated immune response

Angiotensin II Receptor Blockers (ARBs)

work by blocking Ang II type 1 receptors, inhibiting the effects of ang II. Results in arterial vasodilation and decreased aldosterone secretion. The resulting fall in BP increases renin, angiotensin I, and ang II levels. ARBs do not affect the activity of ACE and therefore do not affect bradykinin degradation and DO NOT CAUSE COUGH

Low molecular weight heparin (LMWH)

works by binding antithrombin III which inactivates factor Xa. In contrast to unfractionated heparin, dosage is weight based and does not require monitoring with lab work except in special circumstances (morbid obesity, pregnancy, renal insufficiency). Although protamine sulfate readily reverses unfractionated heparin, it has minimal effect on LMWH.

Middle cerebral artery occlusion

would affect motor control of the hand (gripping), face/mouth (whistling), and throat (swallowing) out of proportion to the leg. Can also result in Broca aphasia (due to damage to the dominant frontal lobe), anosognosia (deficit in self awareness) and spatial neglect of the C/L (due to damage of the nondominant parietal lobe), conjugate gaze deviation toward the side of the stroke, and C/L homonymous hemianopsia (damage to the optic radiations in the subcortical temporoparietal lobe).

Fabry disease

x-linked recessive lipid storage disorder: alpha-galactosidase A def. this enzyme breaks down globotriasosylceramide (Gb3), a sphingolipid aka ceramide treihexoside. sx: neuropathic pain, angiokeratomas, telangiectasias, glomerular dz (proteinuria, renal failure) , cerebrovascular dz (TIA, stroke), Cardiac dz (LV hypertrophy)

Duchenne muscular dystrophy

x-linked recessive, affects BOYS Dystophin structural protein of muscle fibers; in Duchenne's dystrophin gene is deleted causing muscle fiber destruction (myonecrosis) Dz onset is age 2-5. Muscles of the proximal LE, back, and pelic and shoulder girdles are affected first. Sx: clumsy, slow, waddling gait, cant keep up with peers, Gower sign: progressive weakness in proximal musclulature: using hands to support WT and standing, calf pseudohypertrophy: calf muscles hypertrophy initially in response to proximal muscle weakness and later replaced by fat and CT, asymmetric weakening of the paraspinal muscles leading to khyphoscoliosis wheel chair bound by age 12.

Bubonic Plague

zoonotic infection that causes febrile illness with regional inflammatory lymphadenopathy (buboes). The pathogen is Yersinia pestis, gram (-) coccobacillus that exhibits bipolar staining (resembles a closed safety pin). Major reservoir is rodents, transmission usually via rodent flea bite.

Gaucher disease

• AR lysosomal storage d/o • Ashenazic Jews • Glucocerebrosidase (β-glucosidase) deficiency • Glucocerebroside accumulates • Most common. • Type I - no CNS, • Hepatosplenomegaly, pancytopenia (due to marrow infiltration & hypersplenism), aseptic necrosis of femur, bone crises, *Gaucher cells (fibrillar appearing lipid-laden macrophages resembling crumpled tissue paper)*: macrophages that are distended and filled with accumulated Glucocerebroside • Tx - recombinant glucocerebrosidase.

Bicep tendonitis and tendonopathy

• Affects the long head of the biceps tendon as it passes through the bicipital groove • Repetitive overhead motions (eg., painting) Positive Testing: • Positive Speed Test • Positive Yergason Test

acromioclavicular joint

• Often from shoulder injury or trauma, as well as degeneration in older patients • Crepitus, step-off deformity of AC joint • Positive adduction portion of Apley test • Positive cross arm test

Rotator cuff tear

• Pain over lateral deltoid • Weakness with overhead movements Note: Rotator cuff tendinitis presents with pain only Positive Testing: • Empty can test • Active painful arc test • Weakness with external rotation • Positive MRI findings

Subacromial impingement and subacromial bursitis

• Rotator cuff muscle inflammation as muscles transverse subacromial space • Pain with overhead movements Positive Testing: • Positive Neer test • Positive Hawkins Kennedy test

Pyruvate kinase deficiency

↓ ATP; RBCs dehydrated; ↑ 2,3-BPG (right-shifted OBC) presentation: extreme fatigue, and scleral icterus causes hemolytic anemia due to failure of glycolysis and resultant failure to generate sufficient ATP to maintain RBC structure. In this case, splenic hyperplasia results from increased work of the splenic parenchyma, which must remove these deformed RBCs from the circulation