Sketchy Path

Small vessel vasculitides. Wegener's/GPA, MPA, Churg, HSP, Cryoglobulinemia, Goodpasture's.

*Organization of sketch/important things to note:* Middle shows characteristics of all small vessel vasculitides. Breaking a golf club on leg. Arthralgia. Red spotted shirt, kidney shaped drink and lung shaped pocket on caddy's bag. Palpable, non-blanching purpura, glomerulonephritic syndromes, lung involvement (with an exception). Rapidly progressive as the slogan for crescent sports also indicates that these can cause RPGN. EMTs running define p-ANCA and c-ANCA and also their other names (MPO and PR3). Their locations are also important. EMTs with the fat guy, antibodies sticking out of belly and the back EMT pouring MPO on the patient. p-ANCA. p stands for perinuclear and this one is also known as antibody to MPO. EMT with the skinny guy and the antibodies in the mounds of sand surrounding him. c-ANCA. c stands for cytoplasmic and this one is also known as antibody to PR3 (proteinase something 3). *Last pieces of general information:* Frayed wire of golf cart EMT. ANCA associated vasculitides present with mono neuritis that manifests as wrist or foot drop. Pauci on the ANCA greens. Glomerulonephritis is common to the ANCA associated vasculitides, but does not cause immune complex deposition in glomeruli ("pouch" immune on microscopy). *Diseases of the sketch:* Wedge. Wegener's granulomatosis a.k.a. Granulomatosis with polyangiitis. Microscopic poly ants crawling on guy. MPA. Churg! sneeze. Churg-Strauss disease. Henoch shoe shine boy. Henoch-Schonlein purpura a.k.a. HSP. Cold older women. Cryoglobulinemia. Guy in shark shirt holding '4' pin flag. Goodpasture's syndrome. *More organization of sketch:* Wedge in bottom left, poly ants in upper left, churg! sneeze in middle, shoe shine boy in bottom right, cold older women in middle right, shark man upper right. EMTs. Keep c-ANCA next to wedge only. Wedge. Wegener's = WeCkner's. C shape on a stick figure. Nasopharyngeal, lung, kidney involvement. Nothing more to be said about microscopic polyangitis. Churg asthma inhaler. Eosinophilia. Floppy failing heart balloon behind. Heart failure. *Closer to p-ANCA EMTs!* Man getting shoe shined with purpura socks. HSP has predilection to form purpura in gravity dependent areas a.k.a. buttocks, thighs, legs. Sneezing young caddy. Most cases of HSP follow an upper airway infection. Complex IgA ball washer. Thought to be due to IgA. Adult with steam coming out of ears and red on his white pants. Adults with HSP typically have worse disease. Severe HTN and hematuria. Telescoping ball retriever. IgA deposition in stomach can cause intussuseption. Sock with dots, boy shining shoes hurting from kneeling so much and kid getting hit in the stomach with the telescoping ball retriever. HSP classic triad: purpura, arthalgias, colicky abdominal pain. 4th triad finding: renal disease. Cold older woman. Cryoglobulinemia. Proteins that precipitate at colder temperatures and cause a small vessel vasculitis. Hep. C hippo next to cold older woman. Strong association between cryoglobulinemia and Hep. C. Shark on the guy's shirt. Collagen. '4' hole pin. Type 4 collagen in goodpasture's syndrome. Linear antibody fence behind him. Linear IF in goodpasture's.

Combined B and T cell disorders. Kids out for summer and hitting up local comic book shop - being bullied by the SCID gang.

*Organization of the sketch: Far right, Wiscott Aldrich and the wasp net outside the pizza shop, middle back is Hyper IgM, far left is Ataxia-telangiectasia, and middle front is SCID and the two most common causes of SCID.* Fallen comic books with archer and knight. B and T cell disorders. Boy receding behind X door from the wasp nest. Wiskott -Aldrich syndrome is X-linked recessive. Wasp stings on the boy's arms and a knocked over trash can in front of him with broken plates. Eczema and thrombocytopenia as 2/3 in the triad defining Wiscott-Aldrich. Red lines on wasp nest. Mutation in that gene means an inability to reorganize actin cytoskeleton resulting in dysfunctional B and T cells. Pizza slices under capsules, virus lanterns and mushrooms on pizzas. Failure of B cells represents difficulty in combating encapsulated bacteria. Failure of T cells results in difficulty dealing with viruses and fungi. Elevated EAt sign and lower GaMes sign on the pizza store with the wasp net on it. Elevated E and A Ig's and lowered G and M Ig's in Wiscott. Kid hiding behind the X door of Hyper CoMics and the kid in front of the Hyper CoMics store holding up only M cards. X-linked recessive Hyper IgM syndrome. Alibaba and the 40 thieves poster in the window of the Hyper CoMics store. Defects in CD40L on T-cells. Crossed out germ sanitizer dispencer. Lack of germinal centers in Hyper IgM syndrome. SCID gang with car bullying the kid with the X bike. Each are hiding behind their vehicle. bADAss on the license of the car and a fat bully hiding behind the car. ADA deficiency leading to SCID is auto recessive. Kid with X bike holding an "11-7" soda. IL-7 defects leading to SCID are X-linked recessive. Crossed out T-3IRD. Lack of CD3, the marker on all T cells in SCID. Run over thyme cookbook. SCID can present with thyme aplasia or hypoplasia. Germ sanitizer bottle. Lack of germinal centers in SCID. ATM machine knocked over with double strand power cord and a camera overlooking the scene that is also unplugged. Failure to repair double strand DNA breaks. Defect in ATM gene. Falling A on the ATM machine. IgA is low. Taking place in front of Alf's Fresh Produce. High AFP.

Primary immunodeficiency disorders at the primary school talent deficiency show. CVID, Bruton's agammaglobulinemia, IgA defiency, DiGeorge.

*Organization of the sketch: far left is CVID, second from left is XLA a.k.a. Bruton's, back bridge is IgA and front and right is DiGeorge syndrome. Front is common features of all primary immunodeficiency disorders.* Kid playing cancer crab chess game in audience. Predisposes to lymphomas. "Y" antibody pattern passed from mother's dress to baby's blanket. Provision of baby with passive immunity for 4-6 months. "A" antibody pattern on mother's chest. Maternal IgA passed through breastfeeding. Provision of baby with more passive immunity. "6" shaped swirl on babies hair. Passive immunity occurs as long as antibodies from mom occur. Until 3rd trimester antibodies are gone and until breast milk IgA antibodies are gone. Typically 6 months. No "live camera footage." Avoid live vaccines. Great Bruton flag. Bruton Disease (X-linked agammaglobulinemia, XLA - B cell primary immunodeficiency). Dropped antibody bullets. In XLA, plasma cells are not created, lack of antibodies. Receding behind X flag pole. X-linked recessive. Tire at the bottom holding the great british flag in place. Mutation in the BTK gene, the Bruton Tyrosine Kinase gene that encodes for a tyrosine kinase. Breakfast underneath capsules (British were attacked during breakfast). Encapsulated bacterias especially give Bruton's disease patients a difficult time. GI dolly beneath viral lantern. XLA increases susceptibility to viral infections (particularly enterovirus, where they infect through the gut). Protozoal hat in gravy puddle. XLA increases susceptibility to Giardia lambia (usually neutralized by IgA) - persistent diarrhea. Infant with giardiasis has XLA until proven otherwise. X-germ hand sanitizer. In XLA, lymphoid tissue lacks germinal centers (normally the site of B cell aggregation). Undersized white crumpets. In XLA, lymphoid tissues are abnormally small (due to absence of germinal centers). T-shaped bayonet lighting canadian soldier on fire. Candida injection given to Bruton's. T-cells respond to candida and the result will be a warm induration (T-cells are working fine, this is an isolated B cell defect). Submit "CV/ID" here. Common variable immunodeficiency (CVID) (heterogenous group of C cell primary immunodeficiency disorders). *Lighter version of Bruton's.* Presents later in life than Bruton's. *MARKSMEN WANTED.* Defect in differentiation. *Plasma cells are the problem*, not B-cells. Calling all men and women. Not X-linked and affects populations equally. IgA bridge burning. IgA deficiency. Thumbs up guy. Frequently asymptomatic. Coughing guy next to giardia puddle. Airway and GI infections. Flag that looks like a draining bag of blood next to a beehive. IgA deficient individuals will produce antibodies against IgA and when they receive a blood transfusion (which contain IgA), their mast cells will degranulate. G. Washington. DiGeorge syndrome. Soldier behind george with a falling mustache and a dropped T bayonet. Isolated T cell maturation defect. Camp with bacteria lanterns, virus lantern and mushrooms growing underneath. Difficulty with intracellular organisms that T-cells are good at fighting. Dropped T3A, thyme, T3A, TE4, and milk (coming from a PthD box). No CD3+ cell markers which are present on all T cells. Failure of the 3rd and 4th pharyngeal pouches to develop leading to absent or hypo plastic thymus, absent parathyroid (hypocalcemia), and cardiac defects (TOF and truncus). American soldier with blue heart and 22, 11 design on trench coat. 22q11 micro deletion and a reminder of the congenital heart defects in DiGeorge syndrome (TOF and truncus). Masks to remind of velocardiofacial syndrome. *Cleft hats, notice these are different than the other people's hats, to remind of cleft palate specifically.*

Ovarian Neoplasms (Germ Cell & Sex Chord-Stromal Tumors).

*The following two bullets are a list of all tumors in this sketch:* *Germ cell:* Cystic teratomas, struma ovarii (cystic teratoma subtype), dysgerminomas, yolk sac tumors. *Sex-cord:* thecoma-fibromas, granulosa-theca, sertoli-leydig. Teeth, multiple layers and bright spot. All layers in a cystic teratoma, bright on radiology due to calcification. Shrooms with a green glow and a bowtie gnome. Struma ovarii secrete thyroid hormone. Hyperthyroidism. A subtype of cystic teratoma. Dys-germinator. Dysgerminoma. Sea-man in the dish washer. Dysgerminoma equivalent to testicular seminoma in males. b-hCG babysitter. b-hCG is a tumor marker for dysgerminoma. Dehydrated milk being put into the dish washer. LDH is a tumor marker for dysgerminoma. Fried egg above the dys-germinator. Fried egg appearance on histology for dysgerminoma. Yolk falling through girl's spoon. Yolk sac tumor. Girl eating egg from Alf's Fresh Produce from the egg chiller. Yolk sac tumor. Usually occur in girls and young women. Malignant. AFP a tumor marker. Schiller-duvall bodies on histology. Egg spots with red centers. Schiller-duvall bodies are papillary structure with a central vessel. Combing through fibers of boy's hair in the sink. Thecoma-fibroma. Perimenopausal women combing the boys hair. Typically occurs in perimenopausal women. Little boy hoarding "MY EGGS." Meigs syndrome. Thecoma-fibromas cause Meigs syndrome: ascites, pleural effusion and an ovarian tumor, generally theca-fibromas. Ascites represented by the yellow tube. Wet shirt represents pleural effusion. Yellow tube of the boy. Ascites and yellow on gross pathology due to theca cells. Granny with the earrings. Granulosa-theca tumors. Low-grade malignant. Any age, usually perimenopausal and produce estrogen. Little girl with make-up on pretending to call her exners while drinking coffee. Granulosa-theca tumors can cause precocious puberty due to estrogen production. Blood on grandma's pant. Bleeding cause estrogen. Granny WAGGING HER FINGER (not smoking) and disapproving of the little girl's behavior. Granny *inhibiting her behavior - INHIBIN* is the tumor marker for granulosa-theca tumors. Call exner. Telephone with cuboidal rotary and pink center. Coffee cup with beans all over. Granulosa-theca tumors have call exner bodies (cuboidal with eosinophilic centers) and coffee bean nuclei (compare to brenner tumors). Yellow chick. Granulosa-theca cells appear yellow on gross pathology due to theca cells. Girl painting ladybugs with a self-painted mustache on herself. Sertoli-leydig. *Leydig = ladybug.* Produce androgens that cause hirsutism.

Paget disease of bone

4 phases of Paget's disease. Kids at the bone box. Osteoclast phase first. Mixed phase and then builders on the right hand side and then completely wiped out on the far right side. Disorganized Paget's skeleton. Paget's problematic parts. The skull, femur, and pelvic bones are most commonly affected in Paget's disease. Builder *with a heart shaped helmet light that has high output* holding a floppy heart balloon. High output heart failure from those with Paget because of the arteriovenous shunts that are developed. Tiny hat skull man. Enlarged skull from bone deposition. Complaints that hat won't fit anymore. Guy listening in to the tiny hat skull man. Bones of the cochlea involved. Hearing loss. Chalk being broken on the board. Chalk box being shown. Chalk stick fractures and elevated alk phos. Crab spear. Small increased risk for osteosarcoma.

1.1 Bumper skulls sketch on epidural hematomas, subdural hematomas and subarachnoid hemorrhage.

AKPD guy passing out balloon. Ehler Danlos (loose screws in the shark with 3 gills in the epidural, subdural, SAH video). *VASCULAR TYPE* of Ehler Danlos is associated with type III collagen - berry aneursyms and SAH. *Do not worry about numbered types of Ehler Danlos. Just know that the classical type is associated with type V collagen and that the vascular type is associated with type III collagen.*

Joan of Amyloid Sketch

Chainmail and beta skirt. Chain mail worn on exterior. Extracellular accumulation. Beta skirt. Beta pleated sheets. Theme of sketch: systemic amyloidosis represented by those wearing full chain mail armor. Localized amyloidosis represented by those wearing just a few chains and then hereditary amyloidosis represented by kids wearing chain mail. *Places amyloid typically deposits and causes problems:* Horse with tongue sticking out. Heart shaped chest cloth on horse. Kidney canteen hanging from Joan. Shoulder pad on Joan. Chain mail glove. Flag with neuron tassels. Tongue, heart (restrictive cardiomyopathy), kidney (causing a nephrotic syndrome), joints, hand (median nerve entrapment), and neurons. Sir myelo from the multiple myeloma sketch above Joan of Amyloid. Notice the light chains on his chain mail. Multiple myeloma is AL amyloid deposition (Ig light chain). Knights reacting to Joan coming into town. Reactive amyloidosis a.k.a. secondary amyloidosis. Knights are holding up two spears that look like A's. Reactive/secondary causes deposition of AA amyloid. In front of RA lanterns. Seen in cases of chronic inflammation. Knight with two beta daggers with shoulder and wrist pads on while he is having his chest tunic washed. Beta-2 microglobulin amyloid deposition in shoulder and wrists as a result of hemodialysis. Family above the AA spears with children in chain mail and flame bandanas. One kid hiding behind mother. Familial Mediterranean Fever inherited in an autosomal recessive manner and producing AA amyloid. Persistently lit pyre. FMF is caused by a mutation in the PYRIN gene, overproduction of cytokines and persistent inflammation. *Theme:* transthyretin produces deposition of ATTR amyloid. Thy transporter. Genetically mutated forms of transthyretin lead to deposition of ATTR amyloid. A heritable amyloidosis. Multiple gold neuronal chain links. Familial amyloidotic polyneuropathies (mutated transthyretin) leads to ATTR deposits in peripheral nerves. Boy with heart hole on the balcony. Familial amyloid cardiomyopathy is deposition of mutated transthyretin. Old man on balcony with chain mail and heart hole. Transthyretin can deposit without mutation and just be due to the fact that you are old. Called senile cardiac amyloidosis.

Crohn's disease and Ulcerative colitis.

Context/anatomy: Recall that rectum is proximal to the anus and rectum is involved in UC and not in Crohn's. Although Crohn's affects the anus and UC does not. Bottom line. Anus = Crohn's. Organization of sketch and memory hooks: Union cannon on the right side. Ulcerative colitis. Conferates on the left. Crohn's. Middle underneath the tent are features common in IBD. Rusty rectal stool. Rust traveling proximally on the cannon in a continuous pattern. Spread proximally from rectum. Lead pipe of cannon. Lead pipe appearance on radiology in UC. First responders with peri-nuclear battle plan. Recall pANCA was represented by peri-abdominal antibodies in the small vessel vasculitides sketch. pANCA vasculitides are microscopic polyangitis and Churg-Strauss. Cannon failing to blast through the wall. Not transmural. Shrapnel in the soldiers left side causing massive bleeding underneath him. Bloody diarrhea and left sided pain to reflect rectal involvement. Toxic mega cannon exploding backwards. Toxic mega colon (inflammation erodes into smooth muscles and causes paralysis) and perforation as complications. 'Don't tread on me' snake flag in the tree on the UC side. Primary sclerosing angitis as an extra intestinal manifestation. Cobblestone path from mouth to anus. In Crohn's, cobblestone 'skip' lesions anywhere from the mouth to the anus. Confederate running away with a sac on a wooden stick. In Crohn's, anti-sac antibodies. (Saccharomyces cerevisiae). Hit in the RLQ. Crohn's present right sided due to location in ileum and cecum. Debris littered puddle spilling from the sac. Fat malabsorption in Crohn's because of inflammation of distal ileum. Cages. Non-caseating granulomas in Crohn's. Wall busted through. Transmural in Crohn's. Doctor using strings to sew up a soldier. String sign on radiology in Crohn's (due to strictures - these can also cause bowel obstruction). Fistula trench in the background on confederate side. Fistula formation due to transmural inflammation between adjacent organs (i.e. bladder, vagina) in Crohn's disease. Pale erosions on mouth arch. Apthous ulcers on mouth in Crohn's. Soldier being examined in the tent. Wraps around joints, skin infections, being examined by a doctor who is wearing red sunglasses and is picking out shrapnel into a kidney shaped pan. Tent has shin pillars with red spots on the legs. Common findings in those with IBD include polyarthritis, skin manifestations (pyoderma gangrenosum), renal calculi (oxalate absorption), and eye disease. 5-pointed american flag. Treatment for IBD is 5-ASA. Sulfasalazine, masalamine.

Large bowel and appendices disorders.

Context/anatomy: two borders to an intestine. Arteries and veins in the mesenteric border (closest attachment to back abdominal wall) and then the free border which holds the intestine. Organization of sketch: Diverticulosis and diverticulitis on right. Appendicitis bottom left. Volvulus top left. Large bowel obstruction in the middle. Donkey with pouches. Diverticulosis (colonic diverticula). False teeth of the old man next to the donkey with pouches. Diverticula in diverticulitis are false diverticulum. 'Welcome to the Nevada Border' sign above the red vines. Colonic diverticula typically arise closest to mesenteric border as opposed to the free border. S snake. Colonic diverticula are typically found in the sigmoid colon. Red drink spilling from man's water-bottle. Diverticulosis causes painless hematochezia. Fire next to the donkey. Diverticulitis. Fire starting on the LLQ. Because most colonic diverticula found in sigmoid colon, this is where the pain will be. Adult next to rock in the river. Child stuck in quicksand with soggy tissues next to him. Causes of appendicitis very by age. In adults, appendicitis is typically caused by a fecal lith. In children, appendicitis is typically caused by lymphoid tissue (post infection). McBurnie's Lookout point. Late appendicitis presents with localized RLQ pain at McBurney's point, which is 2/3 of the way from the umbilicus to the right ASIS. Donkey tying it reins around a cactus with red and blue roots. Volvulus is twisting of bowel around it's mesentery (think corkscrew opening a bottle of wine). Near volvulus donkey, kid with RLQ gun holster, older women being approached by snake. Locations of volvulus vary by age. In adults, they typically occur in the sigmoid colon. In children, they typically occur in the cecum.

Pancreatic cancer and Islet cell tumors.

Context: Glands (ship) vs. endocrine cells (islet of langerhans - diff cell types on the islet). Organization of sketch: Left 1/3 is pancreatic adenocarcinoma. Broccoli. BRCA1 and BRCA2 are causes of familial pancreatic adenocarcinoma. *C*o*D*e boo*K* *N2A*. CDKN2A *HMS* *S*ala*M*an*D*er. Mutations in SMAD4 cause pancreatic adenocarcinoma. Fish heads being dumped over. The majority of pancreatic adenocarcinomas occur in the head of the pancreas. Mass at the head of the pancreas can cause a palpable, non-tender, gallbladder (usually associated with jaundice and called Courvoisier's sign) (in pancreatic adenocarcinoma). Left supraclavicular pigeon. Pancreatic adenocarcinoma may METS to the left supraclavicular node ("virchow's node"). Periumbilical pigeon. A pancreatic adenocarcinoma METS to the periumbilical region can form a periumbilical mass (sister mary joseph nodule). Migrating net with thrombotic seaweed. Pancreatic adenocarcinoma can cause superficial migratory thrombophlebitis (Trousseau's sign) (a paraneoplastic syndrome). Stranded person at sea with a cushion. "Stranded at CEA, *CA*ll 19-9." CA 19-9 and CEA are tumor markers for pancreatic adenocarcinoma. Cushing syndrome as a paraneoplastic syndrome. Severe splotchy sunburn of the guy next to the glucagon case. Cause necrolytic migratory erythema (epidermal necrosis casting migrating erythematous plaques, usually affects extremities and perioral regions). Gas powered raft with intestines that has black holes in it and leaky acid. Gastrinomas. C shaped duodenum. Arise in duodenum and pancreas. Acid spilling out the back. Causes ulcers or Zollinger-Ellison syndrome. Top secret. Secretin test. Positive diagnosis for gastronome if secretin rises after administration. VIP only guy on the toilet. VIPOMA. Causes diarrhea a.k.a. pancreatic cholera. Nearly empty gastric toilet, VIP inhibits gastric acid secretion. Leader wearing P hat, P bowtie, P tattoo. MEN 1. P tattoo stands for pancreatic tumors. Somatostatinomas as the raft in water. Brown pile behind them, gas tank on low, seagull with gallstones and passengers with candy. Somatostatinomas inhibit cholecystokinin which causes increased risk of gallstones and malabsorption. Inhibits gastric acid secretion. Inhibits glucagon more than insulin and causes hyperglycemia.

Reproductive Hormones overview and Polycystic Ovary Syndrome.

Context: Left is review of hormones. Right is PCOS. Flickering GnRH light sign. GnRH in a pulsatile fashion causes release of FSH and LH. Flower stimulating fertilizer. FSH. Light bulbs. LH. Male trowel/shovel. Androgens. Female symbol flower. Thecal matter and light bulb. *Light causes the male shovel to appear.* LH causes androgens to be released from theca cells in the ovarian follicle. Next pot over. FSH granules. *Granules from fertilizer cause flowers to appear from shovels.* Androgens are transformed into estrogen in granulosa cells when FSH acts on them. Woman with female symbol earrings trying to switch off the sign. Normally, estrogen produced causes a negative feedback on the pituitary and hypothalamus. Woman failing to unplug and inadvertently kicking lightbulbs out of the bag. Estrogen suddenly becomes positive feedback and stimulate massive release of LH. LH surge (on last day of follicular phase). Light shines down on single flower. LH surge focuses on single flower and initiates ovulation. Top row of pots: follicular phase. Bottom row of pots: luteal phase. Sunflower down below. Corpus lute secretes progesterone. Raising multiple male trowels. PCOS presents with hyperandrogegism (due to overproduction of androgen production by theca cells of the ovaries). Bushy beard. Male pattern baldness. Deepening of the voice. Increased muscle mass. Granules spilled over. Incorrect functioning of granulosa cells and subsequent estrogen production leads to anovulatory cycles and infertility. Loudspeaker with the caption stating string of pearls. String of pearls pathognomonic for PCOS. Welcome inside and candy hangers. Insulin resistance and obesity. Large female stake with crab in pot. Anovulatory cycles means no luteal phase and no progesterone to balance out the estrogen. Unopposed estrogen that leads to an increased risk of endometrial hyperplasia and cancer.

Cervical neoplasia.

Context: Left side is the endocervix with butterflies. Right side is the exocervix/vaginal canal. Caterpillars represent columnar epithelium and the butterflies represent squamous epithelium. Transformation from columnar caterpillars to squamous butterflies is due to the acidic environment of the vagina. Vagina is acidic because of gram positive lactobacillus that produce lactic acid. These are represented by the purple stamen on the flowers. Sometimes the transformation can become dysplastic and this is due to human papilloma virus. Pill bug killing the butterfly. HPV has an affinity for the immature metaplastic squamous cells at the transformation zone. Kois. Koilocytes. C-INside. CIN. Will have the same thing with vulvar intraepithelial neoplasia (VIN). Dead butterflies accumulating in 3 zones. CIN is divided into 3 distinctions. Zone 1 has lower 1/3, Zone 2 has lower 2/3 and Zone 3 has 2/3+. Scope. Colposcopy is performed if pap smear comes back abnormal. Testing the water white. During colposcopy acetic acid is put on the cervix to turn abnormal areas white.

Lab Evaluation of Liver Injury and Hyperbilirubinemia

Context: Uncollared goats. Unconjugated bilirubin. Organization: Left pen is unconjugated: Newborn jaundice, Gilbert, Criggler-Najjar. Middle is how alcoholic and viral hepatitis relate to bilirubinemia. Right pen is conjugated involving gallstone metabolism: choledocholithiasis, Dubin-Johnson, Rotor syndrome. Slow farmer Gilbert. Gilbert syndrome. Decreased activity of UDP-gluconuride transferase leading to slight unconjugated hyperbilirubinemia. Critter being captured in a jar. Absence of the enzyme in Gilbert syndrome leading to unconjugated hyperbilirubinemia. Corn on fence. Kernicterus. New born baby jaundice, kid on mother's breast. 2 things. Slow activity of UDP causes physiologic jaundice. An enzyme in breast milk also inhibits UDP. Alcohol and bilirubin. XXX moonshine on the fence. Alcoholic hepatitis is a cause mixed bilirubinemia. Gadget knife, toasting his drink and pouring water out onto the collared side. Increase in GGT, AST>ALT, conjugated bilirubin into the serum and eventually into the urine (always abnormal - this also occurs in cholestasis). Hippo above the fence divider. Viral hepatitis causes mixed hyperbilirubinemia. Do not confuse with hepatic enzymes! Elevated malt shake. ALT>AST in viral hepatitis. *Cholelithiasis vs. choledocholithiasis: stones in the gallbladder vs. stones in the common bile duct.* Whitish poops underneath trough. *Context: conjugated bilirubin secreted in bile.* Lack of bile from being static in the gallbladder decreases the amount secreted into intestines. Lower amounts of bile secreted into the intestine means less is transformed into stercobilin. Pale stools. Chalk and gadget. Alk phos and GGT are elevated in conditions that block bile outflow. *Specifically choledocholithiasis. This is repeated in the gallbladder and biliary tract disease.* Garbage bin. Dubin-Johnson syndrome. Mutations in bile duct membrane proteins such that cholestasis occurs. Black trash bags next to a liver shaped trash bag. Bile accumulates in liver because excretion is impaired in Dubin-Johnson syndrome. Black liver found on surgery. Rotor of the windmill. Rotor syndrome. Dubin-Johnson but without the black liver.

Cirrhosis

Copper Kayser-Fleisher rings on the trojan in the back. Wilson disease can cause cirrhosis. Stars in the background. Stellate cells to cirrhosis sketch as the ones that mediate the damage (through secretion of TGF-beta). Falling bones and photo album. Hypoalbuminemia and decreased total serum calcium levels. "I" bone not falling. Ionized calcium still normal despite decreased total serum calcium levels. No effects of hypocalcemia. Spray bottle on the mirror. Ammonia accumulation in cirrhosis due to impaired function of the urea cycle. *The following are manifestations of cirrhosis.* Man clutching his head, swirly eyes, benzene armor. Hepatic encephalopathy, altered mental status, seizures, coma. Increased AAA (unknown how they are elevated) causes excess AAA to enter the brain. Excess AAA causes shunting of these AAA, which normally make regular neurotransmitters, to be shunted into pathways that produce false neurotransmitters. These false neurotransmitters are then packaged into neurons and brain dysfunction ensues. Female sex sign on a trojan with two round shields. Liver is responsible for breaking down estrogen. Elevated estrogen levels in men causes gynecomastia. *Following are consequences of increased estrogen.* Red hands, fallen sword. Palmar erythema. Impotence. Red spider. Telangiectasia. Medusa with a spleen shield getting her head cut off as she lay on a bed of broken plates. Cirrhosis causes splenic dysfunction. Splenic dysfunction causes consumption of platelets. Thrombocytopenia. Inflamed tail around the abdomen. Protein rich fluid in ascites can cause spontaneous bacterial peritonitis. Decreased intravascular volume as a consequence of hypoalbuminemia can cause activation of the RAS system. Inability of the liver to metabolize and shut down aldosterone causes potassium wasting. Hypokalemia. Skeletons with splanchnic and pulmonary snakes. These vessels dilate in severe cirrhosis.

2.2 Idiopathic pulmonary fibrosis.

Cryptogenic organizing pneumonia a.k.a. bronchiolitis obliterans mentioned. Honeycomb as treat for rich people. Honeycomb changes to lungs. RA, wolf and dragon fountain can all cause pulmonary fibrosis.

Acute and Chronic Gastritis and Peptic Ulcer Disease. Ulcers, H. pylori, autoimmune metaplastic atrophic gastritis.

Cushing vs. Curling ulcer. Crushing head with a paint bucket from the Vegas sign. Cushing ulcer from increased ICP and vagal nerve stimulation. H. pylori helicopter next to the distal stomach. Affects antrum first. White mucus knots on columnar fence. Stomach metaplasia. Chronic H. pylori infection causes normal gastric columnar epithelium to develop goblet cell hyperplasia. Pile of lymphoid tissue. Chronic H. pylori infection can cause MALT. Dropped lemons, no intrinsic right, tractor with gas tank pushing protestors out of the way with antibody prongs. Autoimmune metaplastic atrophic gastritis. Antibodies against intrinsic factor and parietal cells, destruction against parietal cells, decreased production of pH, overcompensated production and hyperplasia of G cells. No mushroom blast. Megaloblastic anemia due to B12. Knocked over STOP sign. Chronic H. pylori infection causes destruction of antral delta cells. Gas tanks. Acid lemons at his feet. In chronic gastritis, loss of somatostatin leads to uninhibited gastrin production. Causes overproduction of acid. Guy in stomach area eating lunch with active jackhammer next to him. Gastric ulcer pain does not improve with eating. Guy dragging jackhammer away from scene smiling with lunch. Duodenal ulcer pain improves with eating.

4.2 Malignant melanoma

Different types of melanoma: superficial spreading, nodular, acral-lentiginous, lentigo maligna. Organization of sketch: Old woman on top represents lentigo maligna (and population who gets it), kid climbing stairs on top represents superficial spreading, kid in rocket ship with death symbol is nodular, and black man with melanoma on palm represents acral lentiginous (and population who gets it - individuals with darker skin types a.k.a. asians and african americans). Out of control cycle labeled cycle-DKN. CDK2A mutations lead to unchecked progression through cell cycle (CDK2A = p16). 100 dollar bill. Melanoma cells stain positive for S-100 (expressed by cells with neural crest origin = not specific for melanoma!). Death skull rocket. Nodular melanomas have worst prognosis. Ink stain near laterally moving ink post. Lentigo maligna (displays long period of radial/lateral growth). Older sun-damaged face. Lentigo malignant occurs in elderly with chronically sun-damaged skin. Black guy with ink on his palm (can also be soles). Acral lentiginous melanomas are the most common melanoma subtype among dark-skinned individuals. Death belt buckle. Acral lentiginous have poor prognosis.

3.2 Chronic kidney disease. Only right side of sketch is useful.

Diorama showing volcano overflowing with acid. Bananas high in tree and caveman drowning in water. CKD causes acidosis, hyperkalemia, and edema. Draining red kidney, fossil wall with P's, running PthD next to malaysian T-rex jaw and bone with brown holes in it. Anemia due to EPO underproduction, high phosphate due to kidney dysfunction, low calcium due to inhibition of Vitamin D, high PTH to try and elicit higher calcium levels, osteomalacia, osteitis fibrous cystica "brown tumors." Central stand labeled Jureassic. What uremia does. Baby bird regurgitatation, flapping, eggs forming a heart shape cracking, dinosaur plates cracking, head butting dinosaur with brain cap, little dinosaur itching back. Nausea and vomiting, asterixis, pericarditis, platelet dysfunction, encephalopathy, pruritis.

1.5 Congenital bone disorders: OI, achondroplasia and osteopetrosis.

Domino pattern on white walker and midget. Auto dominant. Whitewalker. Type I OI a.k.a. brittle bone disease. Mother with two babies. Type 2 OI. Next to triple helix that is disrupted. Type 2 is most severe and not compatible with life. Dwarf near the door with shark and bone shield. Endochondral ossification is the problem is achondroplasia. Dwarf near *FriGid FoRtr3ss entry. Pull 4 entry.* FGFR mutation on chromosome 4. Knocker is a tire. Tyrosine kinase receptor. Osteoclast soldiers unable to maintain acid pot. *Acid pot NOT spilling.* In Osteopetrosis, osteoclasts are unable to generate an acidic environment. Unable to dissolve hydroxyapatite. Unable to resorb bone. Pelvis/spine/skull flagpole. Osteopetrosis most commonly affects these bones. Flag of wide bones with bright center. On X-ray, osteopetrosis displays wide bones with concentric rims ("bone-within-bone") and excess growth at the ends ("Erlenmeyer flask deformity"). Empty pan. Pancytopenia (due to bone explain into marrow). Cowhide with liver and spleen. HSM. Wearing broken helmet and hanging from myelinated rope. Osteopetrosis can present with CN nerve compression (vision loss, hearing loss, facial paralysis due to respective CN nerve involvement). Adult protected by domino shield. Mild osteopetrosis is autosomal dominant and presents in adolescence or adulthood. Mother with child next to cowhide and pancytopenia. Infantile malignant osteopetrosis is much more severe and presents with leukemia. Often fatal. Receding behind wall. Auto recessive.

3.3 DVT and PE

French Revolution. Hampton and Westerminque are French soldiers. Virchow's wheelchair in the French barricade.

2.2 RA.

HLAddin's DRied fruit 4 less. HLA-DR4 associated with RA. Citrus stand. MacroCAGE citrus salesman. Peptidylarginine deaminase (expressed in macrophages, pathogens and synovial tissue) converts environmental antigen *arginine residues to citrulline*, antigen present and activation of CD4+ helper T cells. *Development of anti-cyclic citrullinated peptide antibodies (ACPA - specific to RA). Grease fire in pan. Pannus formation in RA. Symmetric red ash ketchum gloves on Aladdin's lover. Proximal joints affected more and symmetrical in RA (contrast to OA where distal are affected and less symmetric). Felty magic carpet with the hourglass on the tip. Felty syndrome. RA, neutropenia, *and splengomegaly.* Kaplan syndrome mentioned.

Vulvar and Vaginal Lesions.

Hanging gardens of Bartholin hotel. Archway is supposed to be lips of vaginas. Air vents on either side of the archway. Bartholin glands. Gunk and pressure building on one of the vents. Bartholin gland cyst. Lichens tree. Lichen sclerosis, planus, simplex chronic. Itching mother. Severe pruritus. Snake with sheded skin (crab design) at the top. Next to a thinned branch. Lichen sclerosis. Smooth white plaques on 'parchment-like' paper. Small risk of progressing to vulvar squamous epithelium. Purple lichen at hole. Lichen planus. Tree-hole with a spider net. Lichen planus can appear as fine net-like white plaques (Wickham striae) in oral mucosa. Purple polygonal papule. Lichen planus can appear as purple polygonal papules. *Picmonic for lichen planus is good. Lichen planus a.k.a. lion plants. Key points: lion with saw teeth. Sawtooth appearance at the dermal epidermal junction. Candle wick ham in the lap of the lion. Wickham striae. Petting his happy tie cat. Associated with chronic hepatitis C virus.* Thick flaking bark. Lichen simplex chronicles. Called this because of chronic itching. Causes thickening of the skin. View INside. Same as CIN. Striated leaves of a raspberry bush in the lobby. Little girl in front eating them. Embryonal rhabdomyosarcoma. Occurs in little girls and presents as a jelly-like cystic mass protruding from the vagina. Translucent cell glass behind the guy in the lobby. Clear cell adenocarcinoma. Columnar desk for the lobby attendant. Vaginal adenosis (when vagina and exocervix develop columnar epithelium rather than squamous). INFO DESK reading INF(female sign) DESk. DES is a synthetic estrogen. Diethylstilbestrol. Women exposed to this in utero have a greater risk of developing Clear cell adenocarcinoma and vaginal adenosis. Gardner in wolf shirt watering plants on the lateral wall. Gardner wall cysts (remnants of the wolffian duct - mesonephric duct) appear on the lateral wall of the vagina.

Autoimmune Disease: Overview and SLE. Do not watch first 9 minutes.

High School of Los Angeles. Dr. David Q on door. SLE associated with HLA DR and HLA DQ. Auto shop window with car jumper cables that are double stranded. Always be specific poster in the background referring to how to place the cables. Anti-dsDNA are specific to SLE. Mr. Smith teaching the course. Anti-smith antibodies are specific to SLE. duRO-LAst battery on the powerpoint. Also called Ro and La and are seen more in *Sjogren's syndrome*. U on the front of the car with "Runs on Natural Petroleum" on the bumper. Anti-URP antibodies are seen more in mixed connective tissue disease. Don't do drugs. You'll be history. Anti-histone antibodies are specific to drug-induced lupus. Kid with antibody fork stabbing red lunch meat. Antibodies against RBCs. Broken plates next to him. Antibodies against platelets. Cytopenias in SLE. Black woman hall monitor with antibody earrings above her phospholipid necklace. Anti-phospholipid antibodies. Trash can behind the black woman hall monitor. Anti-phospholipid syndrome leads to a hypercoaguable state. New sports complex poster and kids high giving. SLE is T3 HSR. Complement required to clear immune complexes. Torn 3-4PM poster. Active SLE presents with decreased C3 and C4. Girl with butterfly rash and dermis epidermis shirt. Malar rash and skin findings. Migrating volleyball player with wraps. Migratory polyarthritis affecting hands and knees. Goth girl with ripped leggings and torn hand gloves with black nail polish. Vasculitis and raynaud's phenomenon. Bag open looking like a heart. Pericarditis. Shark tooth necklace worn by girl wolf. Pericarditis presents with sharp precordial chest pain (worsened with inspiration, relieved by leaning forward). Lunch bag with heart tape on it. Libman-Sach's endocarditis (clusters of bacteria on BOTH sides of the affected valve). 2-cusped plastic bag. Libman-Sacks endocarditis most commonly affects the mitral valve. Brain beanie. CNS involvement.

1.1 COPD and Emphysema.

Hockey guy wearing a paradoxus shirt. Pulsus paradoxus found in emphysema. Other sketches: asthma, pericardium

1.3 Acute MI and Post-MI Timeline.

King on a "4" chair. S4 sound in MIs. King. On his left is a lady with an anterior left sided braid. Occlusion of LAD. She has a wet tunic. With LAD infarctions expect left sided heart failure symptoms a.k.a. flash pulmonary edema and bibasilar crackles. King. On his right side is a man with his arm wrapping around his back, a heart shield with notes on it and a heart stop watch dangling. RCA wraps around the back and supplies the nodes of the heart. With RCA infarctions expect bradycardia or heart block and right sided heart failure symptoms a.k.a. JVD. II, III, aVF triangle on shield, MI with RCA occlusion can present with ST elevations on the inferior leads. 4 clock dongles. Crushed jester with accordion in motion next to him. Ventricular arrhythmia as a complication immediately. Half sun on the jester. Wavy tassels. 12 hours you get wavy fibers. Full sun on the jester gripping over the ledge of the coagulative necrosis catacombs. 3 suns jester falling into the coagulative necrosis pit with a shark tooth necklace and a falling guitar case. 3 days post MI there is extensive coagulative necrosis. Complications include post infarction fibrinous pericarditis. First responders coming to the 3 sun jester's aid. Neutrophils at day 3. Half moon. 3-14 days. Cage and jesters spraying their drinks in front of the half moon soldier. Macrophages, ruptures as complications 3-14 days post MI. Jester with ruptured harp strings getting his drink all over himself wearing a miter hat. Papillary muscle rupture as a complication (RCA fed), mitral regurgitation. Sparying bottle to say that mitral regurgitation is a systolic murmur. 2nd jester holding a tambourine and spraying out his drink. 2nd jester's hat with a slightly longer left side. LAD occlusion complication as interventricular septum rupture. Presents also as a holosystolic murmur. 3rd person in front of half moon with guitar that has hole ripped through the side. Guitar case filled. Free wall rupture as a complication leading to pericardial tamponade. Soldier in armor underneath many moons, holding a guy with a quivering accordion. Contracted scar. Arryhthmias as a complication. Cross dressing jester. Dressler syndrome. Cross dressing jester dragging his guitar case as he is being shot at by antibody arrows. Dressler syndrome as an autoimmune pericarditis complication weeks to months after an MI.

5.1 Alzheimer Disease, Frontotemporal dementia, Lewy body dementia.

King with tau inner robes and beta outer robes. Tau protein/neurofibrilary tangles are intracellular inclusions. Beta plaques are extracellular. Kings alchemist at his side with seahorses on his robes. Loss of cholinergic neurons in the hippocampus. N. basil plant. Area of brain especially prone to low ACh levels. FTD Jester playing the Pick game. Pick disease is a subtype of frontotemporal dementia. Domino pattern on the jester. Autosomal dominant inheritance for FTD. The dancing prankster 43. TDP-43. FTD is caused by an accumulation of TDP-43 RNA. Spinal cord collar with frayed lateral edges. FTD associated with ALS as some ALS cases show TDP-43 inclusions. King lewy in the background with an alpha scepter. Cogwheels on the grave tomb. Lewy body dementia and PD as the alpha-synucleinopathies.

3.5 Acquired and inherited thrombosis syndromes. Anti-phospholipid, lupus anticoagulant, cobalt deficiency, hyper viscosity syndromes (polycythemia vera, sickle, MM, Waldenstrom's macroglobulinemia, Leiden's, protein C and S deficiency, G to A prothrombin gene mutation, ATIII deficiency).

Left are acquired, middle is hyper viscosity syndromes, and right is inherited. Barbed wires with phospholipids and antibodies against it. Antiphospholipid syndrome. The following antibodies can be seen in antiphospholipid syndrome: cardiolipin, beta-2 glycoprotein, lupus anticoagulant. Wolf, wizard hat and RA lantern. Common conditions that cause anti-phospholipid syndrome. PTTTTT sound above the wolf. Lupus anticoagulant shows a prolonged PTTT in the lab, but causes a thrombotic state. Guy being shot in the heart with an antibody arrow while looking through the syphillis telescope. Anticardiolipin antibodies causes a false positive VDRL. Women fleeing with a dropped carriage. Anti-phospholipid syndrome can cause multiple repeated miscarriages. *PATHOMA: antiphospholipid syndrome is a cause of spontaneous abortion and recurrent pregnancy loss. First aid also mentions factor V leiden as a potential cause of recurrent pregnancy loss.* Man firing cobalt rocket. Blast coming out of the rocket. Holding up a homing beacon. Cobalt deficiency causes a megaloblastic anemia and elevated homocysteine levels. Red lilly pads. Polycythemia vera. Sickle held by the soldier. Sickle cell disease. Excessive antibody twigs. MM and Waldenstrom's macroglobulinemia. Soldier crawling in the mud with the helmet and glasses off his face. Hyper-viscosity causes diminished flow to the brain and retinal hemorrhage. Bear trap with roman numeral triangle V as the serrated edge. Factor V leiden. Captain caught in the bear trap and unable to deactivate the factor V trap. Protein C unable to deactivate the mutated Factor V. Domino wall on the inherited side of the sketch. Most inherited thrombosis syndromes are inherited in an autosomal dominant manner.

1.2 Intracranial HTN (ICH) hot air balloon sketch

Left most balloon has pharmacology tie ins. The following increase the risk for developing ICH. Bicycle propeller. Oral contraceptive on bottom of basket. Big A on the hot air balloon. Mountain cap in the background. Tetracyclines, oral contraceptives, all trans retinoic acid (APL treatment), and isotretinoin (accutane) increase the risk for ICH.

Benign Breast Disorders.

List of disorders: mastitis, mammary duct ectasia, fat necrosis, breast cyst (fibrous stromal, fibrocystic change, papillary apocrine), epithelial hyperplasia, sclerosing adenoma, fibroadenoma, phylloides tumor, intraductal papilloma, galactorrhea. Clover end is inside the breast. End of slip and slide is nipple. Mastitis. From breast feeding. May present with purulent discharge. Mammary duct ectasia. Inspissated green discharge. Fat necrosis. Breast cyst (blue dome appearance). Fibrous stromal. Fibrocystic change. Papillary apocrine. Epithelial hyperplasia on the far end. Occurs in cells in terminal ductal or lobular epithelium. Crab. Sclerosing adenomas. Crab. Young woman with flowers. Fibroadenoma. Fibroadenoma affects women 15-35. Wearing estrogen earrings. Sensitive to estrogen. Large pile of leaves. Phylloides tumors. Old woman clutching it and crab at the end of rake. Phylloides tumors display leaf-like papillary projections. Crab. Capable of malignant behavior. Papillary bush at the end of the slip and slide with blood near it. Intraductal papillomas are the most common cause of bloody nipple discharge. Crab. Kid shooting milk out nose. Galactorrhea (breast milk discharge unrelated to breastfeeding). 2 ropes snapping. D2 antagonists release the inhibition that dopamine has on prolactin.

Intestinal ischemia and Angiodysplasia

Lucha Libre with perplexed doctor. Abdominal pain out of proportion to physical exam. Acute mesenteric ischemia. Watershed on right with colon drape. Colonic ischemia caused by watershed infarcts. Elderly clutching left side. Acute colonic ischemia occurs in the elderly and with left sided pain because that is the side with with watershed. *Angiodysplasia* Skeleton on puppet strings. Malformed, tortuous blood vessels that composed only of endothelium. Colonic dress. Most commonly occurs in the colon (particularly the cecum). Pool of blood. Happy appearing person. Painless hematochezia. Aortic stenosis hat. Bleeding of angiodysplasia is associated with aortic stenosis.

4.1 Lung Carcinoma

Metropolitation bus carrying the METS. Crab bra, kidney purse and colon belt. Breast, kidney, colon. Small and Squamous in the center. Centrally located. Sentral and Smoking. Squamous cell has columnar wall design and then a temporary sheet metal with multiple layers. Metaplasia from columnar epithelium to stratified squamous epithelium. Pearl necklace underneath the squamous. Keratin pearls. Raised calcium cup and PthD in the squamous cell. PTH-independent hypercalciemia. (Resident PthD psychiatrist is on the floor and the inmate dresses up as him and escapes). Granite cell of the small cell. Small cell carcinoma has granular ("salt and pepper"), and stains positive for chromogranin (neuroendocrine marker). *Caution: bronchial carcinoid tumor also stains positive for chromogranin.* Radiation window and chemistry set. Small cell responsive to radiation treatment and chemotherapy. *Next to the small cell.* Guard replacing water, guard on cushion eating calcium ice cream and drinking acetyl choline, guard with antibody keys putting on a turban. SIADH, Cushing Syndrome, LEMS, cerebellar degeneration and encephalomyelitis. Dining den. Adenocarcinoma. No smoking sign. Most common lung cancer seen in non-smokers. Leopard print worn by lunch lady. Lepidic growth pattern and more common in females. Clubbed fingers, wrapped joints of the inmate getting lunch. Hypertrophic osteoarthropathy. HOA causes sudden arthopathy of the hands and wrists (less commonly elbows, knees, ankles). Large inmate. Large cell.

Sketches: Princesses (aortic murmurs). Jesters (mitral murmurs minus stenosis). Pie genies (mitral stenosis). Kilt guy (HOCM).

Note

Polymyositis and dermatomyositis

Organization of sketch. Dermatomyositis represented by the dirt on the bike and on the uniform of the biker girl a.k.a. cutaneous involvement. 1 sample only. MHC class I is unregulated in polymyositis. Mesquite hickory chicken. MHC class I. Sausages in a pyramid formation with blue spots. Endomysosial inflammation. Google marks and beat up knuckles. Heliotrope rash and gottron papules. Dirt bike with red brake lines involved. Vascular capillary involvement in dermatomyositis. Dirt bike with pink wheel and blue specks on the tire of the wheel. Perimysial inflammation. Radio with alpha and beta wires. Upregulation of interferon alpha and beta in dermatomyositis. Crab on the uniform of dermatomyositis. Small risk for lung and ovarian adenocarcinoma with dermatomyositis. "Jo's autobody." Anti-jo antibodies in both conditions.

1.4 Malignant Bone Tumors

Organization of sketch. Far left is METS. Left is osteosarcoma. Middle is Ewing sarcoma. Right is chondrosarcoma. All METS to lung. *FURTHER ORGANIZATION TO RECALL: Both osteosarcoma and Ewing have their knees up. Osteosarcoma guy is eating crabs and has a crab on his knee. Ewing guy has a basketball wedged in between his arm and leg.* Crab bra, bow tie, kidney purse, getting hit in the prostate. METS to the bone. Most common tumors in the bones are actually METS from other sites. Page 221 FA: Prostate, breast > lung, thyroid, kidney. Bone and crab party table. Osteosarcoma (most common malignant bone tumor). 2 piles of crab debris. Osteosarcoma has a bimodal age distribution. Root beer. RB. *Root beer in the hand of the osteosarcoma guy, onion rings in the hand of the Ewing sarcoma guy.* Caution tape checkpoint being broken. P53. So many varieties. Li Fraumeni syndrome associated with P53 mutations and includes osteosarcoma. Microwave. Radiation therapy (particularly in children) increases the risk of osteosarcoma. Bony discarded pile. Osteosarcoma in older patients due to Paget's disease of bone. Pools of pink slime. On histology, osteosarcomas display pink-staining osteoid. Whitish mass with bloody spots. Osteosarcomas form a gritty white mass with cystic degeneration and areas of hemorrhage. Bone split open to display marrow. Osteosarcomas often invade the medullary cavity. Crab on the knee. Osteosarcoma is most common near the knee. Jolly roger flag next to sunburst window. Osteosarcoma displays a sunburst pattern. Fish costume. Codman triangle. Raised periosteum that forms a triangle. Not specific for osteosarcoma. Guy wearing 33 jersey. Ewing sarcoma. 11 and 22 translocation that creates EWS-FLI1 fusion protein. 11 + 22 is 33. Patrick Ewing's jersey number. Ecto headband. Ewing sarcoma originates from neuroectodermal tissue. Ball wedged between mid arm and mid leg. Ewing sarcoma is most common in the diaphysis of long bones in the extremities. Ball popping painfully. Ewing sarcoma presents with pain. Inner red bone plate with escaping wings. Starts in medullary cavity. Tan white pile with black spots and BBQ sauce. Appears tan white with spots of necrosis and hemorrhage. Blue ventilation dots on jersey. Small blue cells. Blue-dotted basketball rim. On histology, ewing sarcoma displays circular groups of cells with an area of central clearing (Homer-Wright rosettes). Moth eaten jolly roger. Moth eaten appearance on X-ray. Can also have a conman triangle. Onion ring. Ewing sarcoma periosteal reaction creates onion ring appearance on X-ray. Old guy on the inflatable shark. Chondrosarcomas common in older men >50. Riding shark using hip area. Chondrosarcomas are most common in the hip, pelvis, and proximal femur. *Sattar's principles about cartilage tumors of the bone: all occur in medulla of bones. Benign occur in small bones of hands and feet. Malignant occur centrally (i.e. pelvis, central skeleton).* Lung spots on the old guy. Chondrosarcoma frequently METS to the lungs.

1.3 Benign Bone Tumors

OC surfer dude. Osteochondroma. Most common benign bone tumor. Primarily occurs in males age 20. Metaphyseal bulge of long bone tree. Osteochondromas most commonly grow out of endoconwdral tissue at the metaphysics. Sharp cap. Osteochondroma cells produce cartilage. Tumors are covered with a cartilage cap. Mallet over knee. Osteochondromas most commonly occur over at the distal femur. Crab and meat grill next to OC surfer dude. Small risk of transformation to osteosarcoma. Middle aged mister oste. OSTEOMA (benign bone tumor) (most common in middle aged males). Bulge in cortical rocks. Osteomas are composed of cortical bone. Hit in the face. Osteomas commonly form in the head and neck. *Pathoma: arises on surface of facial bones.* Garden lilipolyps. Osteomas are associated withGARDNER polyposis syndrome (also associated with colonic polyps, supernumerary teeth, desmoid tumors). Omega omega. Osteoid osteoma. Sitting on outer house layer. Osteoid osteomas typically develop in the bone cortex. Sun tan. OOs are composed of well-defined tan tissue. White framed sunglasses. On X-ray, osteoid osteomas display a radiolucency area surround by a bright sclerotic ring of reactive cortical bone. Sunglass case on upper thigh. Osteoid osteomas are most common in the proximal femur. Pain while wearing sleepy cap and the pledge being woken up by the fire extinguisher. OO have pain that is relieved by NSAIDS. (There is prostaglandin production by the OOs). *Fire extinguisher is in the house, IGNORE THE REACTION of the pledge because that would make you think that OOs are not responsive to NSAIDs. ALTERNATIVE: the pledge is REACTING to aspirin. ALTERNATIVE: the pledge is in pain with the NSAID and is located right behind the osteoblastoma.* *Prevailing way to recall the image and that fact: Pledge is in the OO house and is reacting to the NSAID fire extinguisher.* Large tan osteo-builder. Osteoblastomas are also tan. Large >2 cm in size. Swinging back spinal mallet. Osteoblastomas are most common within the posterior spinal column. Back pain. NOT RELIEVED BY NSAIDS. End of the contest. Enchondromas. Enchondromas affect men and women equally (most common in adolescents. Shark shirt. Produce cartilage. Bone stake with medullary line. Enchondromas develop in the medullary cavity (location of bone marrow). Croquet gloves and shoes. Enchondromas are most common in hands and feet. Girl swinging large ball at end of mallet with her knee sticking out. Giant cell tumor. Ball at epiphysis of bone mallet. Giant cell tumor typically involves epiphysis of long bones. *PATHOMA: the ONLY tumor you need to know that arises in the epiphysis.* Large croquet ball. Giant cell tumor of bone. Most common in women between ages 20s-40s. Mallet swinging past knee. Giant cell tumor most commonly occurs near knee (distal femur or proximal tibia). Can be locally aggressive. Histology shows multiple multi-nucleated cells in a stroma.

Hereditary hemochromatosis and Wilson's Disease

Older man lifting weights. Hemochromatosis is diagnosed in men in their 50s. Woman flexing her six pack with a pause button on her bikini as a child cowers behind her. HFE gene that is mutated is on chromosome 6 and the disease is inherited in an autosomal recessive manner. Pause is for postmenopausal women because premenopausal women lose iron in their menses and in breasfeeding. Venice Beac*H*, *LA* *A*merican *A*thletic *A*ssociation. Hemochromatosis associated with the HLA-A3 locus. *The following are places where iron deposits.* Liver stone. Cirrhosis. Bronze skin. Candy weight. Destruction of pancreatic islet cells. Muddy pile. Destruction of exocrine pancreatic function. Punching bag heart. Dilated cardiomyopathy. Guy with heart fishnet t-shirt punching the bag heart. Restrictive cardiomyopathy (although double check if dilated). Wimpy guy getting hit back by the pituitary punching bag. Deposition in the pituitary interferes with sex hormones. Wraps around joints. Blue face paint. Golden granules of hemosiderin stain with prussian blue. Guy transfusing blood in the back. Secondary hemochromatosis can occur with blood transfusions. Poorly assembled hemoglobin weights. Beta-thalassemia can cause iron overload. Pile of copper pennies coming out of the 7B biliary tree vending machine. Wilson's disease caused by a mutation in ATPase 7B, a protein that aids in the excretion of copper into the bile. Without it, copper cannot be excreted from the bile. Dropped cerulean pants and dropped 'serious' flyer about total gym. Pennies freely floating in blood and urine that is coming out from beneath the bathroom. Labs. Low ceruloplasmin (copper transporter in blood - however, copper can also freely float in the blood as well). Low total serum copper (due to ceruloplasmin). Elevated blood and urine copper. Red buckets that are chipped. Free copper in blood causes hemolytic anemia. Stone liver. Also recall the rings held by the trojan in the cirrhosis medusa sketch. Rings were meant to remind of Wilson disease. Cirrhosis Confused man on the monkey bars. Neurodegeneration due to copper deposition in the brain.

4.1 Actinic Keratosis, SCC, BCC, and XP.

Organization of sketch. Actinic keratosis on left hand side. SCC in middle. BCC on right hand side. XP in the back. Facts not easily illustrated: brief, intense sun exposure is associated with BCC. Total sun exposure associated with SCC. Fire pit and stream (stream to represent draining sinus tract). Majorlin's ulcer mentioned. When areas of chronic skin inflammation or scarring develop SCC. Lichen sclerosis snake (vulva disorders sketch) crawling out of water towards SCC castle. Plastic water bottle floating towards SCC castle. Arsenic exposure associated with SCC. Seaweed bow on SCC castle. Bowen disease mentioned. SCC in situ. Pouty lower lip by castle. SCC most commonly develops in sun exposed areas of skin such as the head, neck, hands, and lower lip. Sand base. Basal cell carcinoma. Bad sunburn on the kid digging the base. Brief, intense sun exposure are greater risk factors for BCC than total sun exposure (as in SCC). Cancer fighting ribbon on patchy shorts. Inactivating mutation of the Patched-1 tumor suppressor gene is associated with BCC. Snoic hedgehog shirt. Inactivation of PTCH1 tumor suppressor gene leads to activation of sonic hedgehog regulatory pathway. Unchecked cell proliferation and development of BCC. Eye patch and mustache in sand base. BCC most commonly develops in sun exposed areas such as the lateral cantonal folds and upper lip (opposed to lower lip in SCC). Nodular rocks in dermal sand. Nodular type. Boogie board. Superficial type. Bony driftwood by basal base. BCC rarely METS, but often invades surrounding structures such as cartilage and bone. Little crab beach. Beach regulations saying *no scissors = nucleotide excision repair defect.* UV radiation damage to DNA can cause pyrimidine dimer formation that normally undergoes nucleotide excision repair. Patients with XP are unable to perform nucleotide excision repair. Extensive DNA damage with UV light exposure. Kid hiding behind sign. AR.

2.1 Nephrotic Syndrome

Organization of sketch/symbols. Wall = BM, foot soldiers = podocytes/epithelium, shields in circular arrangements = endothelium, grass on other side = mesangium. Recall that past the epithelium is bowman's space, into the tubule. *Bottom right.* Falling hams with a 3.5 cart. Loss of protein greater than 3.5 g/day. Beaver. ATIII loss causes hypercoaguable state. Pigs. Fatty casts. Loss of family albums. Hypoalbuminemia. *Upper left.* King with puffy body. Edema. Man stabbed in flank and with wormy pant leg. Hypercoaguable state with renal vein thrombosis, if left, varicocele. Bread and butter near the king. Hyperlipidemia. Bottom left of sketch is FSGS. Hugging foot soldiers. Effacement of podocytes. Viral lantern and drugs on the focal and segmental attack plan table. HIV and heroin patients develop a FSGS neuropathy. Minimum list. Minimal change disease. Small soldiers hugging. Woman blowing nose with a moon face shield. Effacement of podocytes, selective loss of albumin, responds well to corticosteroids. *Picmonic addition: the light reveals the whole feet. Thus, effacement is only seen on electron microscopy.* Diabetes and amyloid in the sketch. Top right of sketch. Membranous nephropathy. Man with spike and dome shooting antibody arrows with his wolf. Spike and dome sub epithelial deposits, SLE (more likely to get a diffuse nephritic syndrome, but if they do get a nephropathy, then they will get a membranous nephropathy). Moon shield, cape on the wall and antibodies in the foot soldier shield. Responds to corticosteroids, causes membrane thickening, IF, and antibodies to PLA2 of podocytes.

2.1 Congestive Heart Failure - Pathophysiology.

Organization of sketch/symbols: left side is systolic heart failure, right side is diastolic heart failure. Spraying bottle for systolic. Diamonds for diastolic. Dunce hat is recurring symbol for aortic stenosis (notice the aortic arch and three vessels coming off the ascending aorta). Waiter struggling to carry cake. Cutter and plate shaped like a "40" falling. Decrease contractility and 40% EF in systolic dysfunction heart failure. Guy blowing balloon up. Increase in EDV in systolic dysfunction heart failure. Dilated heart sac. Dilated cardiomyopathy results in systolic dysfunction heart failure. Eel below the left side of the ship. Eccentric hypertrophy (sarcomeres added in series) in systolic dysfunction heart failure. Bridesmaids with diamonds. Diastolic dysfunction heart failure. Failing to blow up balloon. Normal EDV in diastolic dysfunction heart failure. Waiter holding up the cake with "55" on it. 55% EF (preserved) in diastolic dysfunction heart failure. Bridesmaid stomping on compliance on stage. Decreased compliance in diastolic dysfunction heart failure. Conch below the ship on the right side. Concentric (added in layers) hypertrophy in diastolic dysfunction heart failure.

2.4 Sickle cell disease.

Organization of sketch: 3 horsemen overlooking the river sticks represent what causes an increased risk of sickling. 1st boat is disease. 2nd boat is complications. 3rd boat is trait. Bottom right is autosplenectomy and how to treat kids with sickle cell. Hydrotherapy hydroxyurea in the background. Beta chariot with a hemoglobin wheel. Mutation in beta gene on chromosome 11. Kid hiding behind mom on the beta chariot. Autosomal recessive. Guy scared of water. Replacement with valine, non polar. Blue horse, acid horse, and dehydrated horse. Hypoxemia, acidosis, dehydration increase risk of sickling. Hades dog with purple DNA collar. Splenic fatigue eventually increases the number of Howell-Jowel bodies that make it out into circulation (recall usually taken up because of persistent DNA). Hades' dog in sickle cell is *HOWLING* for, *Howel-Jowell* bodies. Represents the fact that Howel-Jowell bodies are seen in patients with low functioning or asplenic. Purple DNA collar. DNA remnants. Spleen damaged shield and man cowering behind. Man riding dog with hole ripped in shirt where spleen should be. Splenic fatigue and eventual autosplenectomy. Man riding dog with vaccine and pencil sword. Kids should receive vaccines for encapsulated organisms and penicillin prophylaxis. Complication boat: blackened femur head, guy ripping on harp with fingers, stabbed in chest and penis. Lungs for sails. Avascular necrosis of the femoral head, dactylitis, acute chest syndrome (#1 cause of death in adults with sickle cell disease), priapism, and pneumonia infiltrate. Skeleton holding the C shaped sickle that "will lyse your body." Hemoglobin C results from mutation involving lysine.

Esophageal dysmotility and cancer.

Organization of sketch: Adenocarcinoma on the left. Nothing new except for CREST underneath the stage causing GERD. SCC (inclusive of achalasia, Plummer-Vinson syndrome, and the foods offered for the stars) on the right. Food on table. N-nitroso compound containing foods (pickled vegetables, smoked foods). Betel nuts (chewable nuts in asia) Hot tea Smoking (also increases risk for adenocarcinoma. Drinking Plumber in white with falling iron tools in the dysphagia sketch. Webs near the pipes and the bulge in the upper third of the pipe. Plummer-Vinson syndrome is a triad of IDA, dysphagia and esophageal webs. Bird man upside down. Achalasia. Loss of LES tone due to deficiency in VIP and Nitric Oxide. Corkscrew shaped rope. Diffuse esophageal spasm. Increases risk for GERD. Physical esophageal locations of each pathology in the sketch: GERD/adenocarcinoma of esophagus is distal 1/3. SCC wiener dog tutu is middle 1/3. Esophageal webs next to the upper bulge in the pipe = esophageal webs occurring in the upper 1/3.

1.2 Asthma and Bronchiectasis.

Organization of sketch: Asthma everywhere but bottom right corner. Bronchiectasis in the bottom right corner. Obstructing exit. Obstructive disorders. Spiral wire leading to telephone can. Kurschman spirals. Jacks. Charcot layden crystals. Paradoxus shirt. Acute asthma spells can produce pulses paradoxus. Also seen in emphysema and pericardium. *Bronchiectasis* Bacterial lanterns, TB lobes, thick mucus, ciliated moss. Recurrent bacterial infections, tuberculosis, CF and primary ciliary dyskinesia as causes of bronchiectasis. Low hanging pomegranates. Bronchiectasis affects lower lobes.

Alcoholic and Non-alcoholic fatty liver disease.

Organization of sketch: Back left is metabolism of alcohol. Left is alcoholic hepatitis, right is non-alcoholic fatty liver disease, far right is Reyes syndrome (only new information is liver enzymes in Reyes). Patrons at the bar drinking NAD+. Cracked beta fish tank. Metabolism of alcohol to acetaldehyde and then to acetate requires NAD+. Heavy alcohol consumption causes NAD+ to be depleted and beta oxidation cannot occur. Fatty acids in the liver pile up. Course III being offered. Zone III of the liver is damaged first in alcoholic hepatitis. Filamentous lace on the the left mallory sister. Alcohol damages intermediate filaments and causes filament clumping. Clumped filaments appear as pink densities in hepatocytes (called mallory bodies). Left mallory sister with a gadget knife and a toasting a glass. GGT and AST>ALT in alcoholic hepatitis. Right mallory sister raising a MALT shake. In NASH/NAFLD ALT>AST. MALT shake being raised by the umpire. Reyes syndrome leads to ALT>AST.

2.3 NHL.

Organization of sketch: Back right burkitt, mantle and follicular sash near the fireplace. Front and middle is follicular (bracelets on the woman and waxing and waning moon). Front and left is diffuse large B-cell. Recall diffuse large-B cell is the most common. Sporadic bat nodes. NHL affects multiple lymph nodes in a non-contiguous distribution (unlike contiguous spread in Hodgkin lymphoma. Scattered chess pieces AWAY from the chess board. NHL commonly involves EXTRA-nodal secondary lymphoid tissues (spleen, tonsils, GI tract, respiratory tract) and non-lymphoid tissues (CNS) (unlike Hodgkin lymphoma). 8 underneath the Burkitt sign. Candle shaped like a "14." Burkitt lymphoma is due to a 8:14 translocation. Mice running above the store's sign. c-myc in Burkitt lymphoma. Guy in front of the store with a starry sky cloak, flight mask with a jaw respirator, and a broomstick that says KI67. Starry sky histology background, endemic (Africa and Papa new guinea - up to 50% of pediatric cancers there are Burkitt) form associated with jaw lymphoma (this is also classic demonstration of the extra nodal involvement typically seen in NHL). KI67 is something that is elevated in Burkitt lymphoma. Epstein's bar across the street. EBV causes Burkitt. Kid or gnome with green flask to his belly. Non-endemic form is abdominal. Falling sash that connects the "14" candle to the "18" design on the fire poker. Follicular lymphoma is a translocation between chromosome 14:18. Woman with double "invincibility BRACelet: in Follicular lymphoma, the t 14:18 translocation results in over expression of the BCL-2 (B-cell lymphoma-2 gene) oncogene (inhibits apoptosis) (also in some Diffuse large B-cell lymphomas). Recall Bcl-2 also seen in CLL. Waxing and waning moon cloth on the table to the right (video view) of the fireplace. Follicular lymphoma presents with generalized waxing and waning lymphadenopathy. Black guy transforming into diffusely large patron. Follicular lymphoma can transform into diffuse large B-cell lymphoma. Archer in far left pointing with "1" finger. Diffuse large B-cell lymphoma is the most common lymphoma in adults. Double and hexagonal bracelet. Diffuse large B-cell can have mutations in Bcl-2 and Bcl-6. Wizard drinking beer. EBV and HIV co-infection can cause diffuse large B-cell lymphoma. White ward hat. In HIV infected patients, lymphoma is an AIDS-defining condition. Hermes statue with "8" staff. HHV-8 and HIV co-infection can cause primary effusion lymphoma (a NHL) (presents in pleura, peritoneum or pericardial spaces). Brain jar. NHL can present as a primary CNS lymphoma (usually diffuse large B-cell type). Mantle with "11" candle and "14" candle with the cell cycle clock. Mantle cell lymphoma a t-11:14 translocation involving the cyclin D1.

Congenital GI Disorders.

Organization of sketch: Bottom left, pyloric stenosis. Front bottom. Meckel's diverticulum. Bottom right. Gastrochisis and ompalocele. Top right. TE fistula. Back center is duodenal atresia. Top left is hirschsprung disease and NEC. Yo-yo kids are malrotation. Muscular babysitter holding a first born male child in front of a calendar. Pyloric stenosis. More common in first born males. Round tip to the bottle. Palpable olive shaped mass. Presents 1 month after birth. Gastrochisis and ompahlocele. Trisomy triplets with chromosome waistbands around the omphalocele kid. Omphalocele has the peritoneal layer covering it. Associated with trisomies 13 and 18. Back to school 'September 4th and 5th.' TE fistulas result from failure of septation that occurs during the 4th and 5th week of development. Double bubble play house. Duodenal atresia presents with double bubble on radiology. Violinist. Vitelline duct. Stomach shaped violin. Meckel's diverticulum exists when the vitelline duct persists. Meckel's is essentially stomach tissue in the intestine and this becomes important for diagnosis. Kids holding 2 signs. Mocker's hecklers. Rule of 2's. 2 of population, exists 2 feet proximal to ileocecal valve, 2 inches in length, 2 years of age, 2:1 male. Technique book in front of the violinist. Diagnosis of Meckel's with technetium-99m. Horse spring. Hirschsprung disease. Tight spring supporting the horse. Loss of nerves causes musculature of the rectum to remain tight. Shield for neural crest cells. Yo-yo kids. Malrotation. Yo-yo in upper right shirt pocket. Cecum in RUQ. Death metal babysitter. Necrotizing enterocolitis.

Acute and Chronic Pancreatitis

Organization of sketch: Causes in front, labs and presentation in the middle. Seagulls next to the pancreas. Gallstones are most common cause of acute pancreatitis. Alcohol drinking chef. Raised trident fork. Mortar and pestle. Medications can cause acute pancreatitis. Seatbelt. Trauma, especially seatbelt trauma can cause acute pancreatitis. Periscope inspecting sponge. ERCP can cause acute pancreatitis. Limbo-ing with back pain. Acute pancreatitis presents with epigastric pain that radiates to the back. Breaking down sugary apple. Serum amylase is elevated in acute pancreatitis. *However, this is not specific because amylase is also secreted by the salivary glands.* Fatty juice. Lipase is elevated in acute pancreatitis and is more specific than amylase. Dropping calcium ice cream. Fats dripping on the bones of the pig. Fatty acids released from the pancreas in times of acute pancreatitis bind calcium. Can present as hypocalcemia. Seagull holding sea sALT rub for the rib roAST. Elevated liver enzymes in pancreatitis caused by gallstone obstruction ALT>AST. Compare different ALT/AST... alcohol in mallory sister sketch, non-alcoholic hepatitis in mallory sister sketch, viral hepatitis in the farm sketch. Big red flowers on the people drinking. Alcohol abuse may cause macrocytosis. Fibrous coconut shell and low tide. Acute pancreatitis can present with a pseudocyst (walled off), and hypovolemia. ARDS shark. Pancreatitis can cause ARDS. Splenic jellyfish obstructed by the hula dancer. Splenic vein thrombosis. Chronic pancreatitis in the back. Alcohol, CF, ADECK, progression to pancreatic adenocarcinoma.

3.4 Pericarditis and Constrictive Pericarditis.

Organization of sketch: Constrictive pericarditis represented by the cowgirl. Guitar case with red lining. Pericarditis. The flaming heart bar in the background. Many of the cause of myocarditis can also cause pericarditis. Wolf on stage. Pericarditis is a common finding in SLE. Broken string on the guitar. MI associated with two forms of pericarditis. Initial form and then an autoimmune form (Dressler's syndrome). Elevated BUN grease. Uremia. Throwing carb picks. METS can cause pericarditis. Flame bandana guy. Fever and tachycardia a common finding. Flame bandana guy leaning forward with shark tooth necklace: the pain of pericarditis is characteristically precordial and sharp; worsened with inspiration and relieved with leaning forward. Friction marks. Friction rub on auscultation. Different than a pleural friction rub. Bunch of elevated street signs. Pericarditis causes a characteristic diffuse ST elevation on ECG. Wet guitar case. Two types of effusion seen in pericarditis. Serous and hemorrhagic. Serous most likely seen in pericarditis (also seen in congestive heart failure). Ketchup packets underneath the girl holding the BUN bun bag. Uremia causes hemorrhagic effusion in the setting of pericarditis. METS guitar picks also cause hemorrhagic effusion. Speed kills. Rate of the volume entering the pericardium, not the volume determines the severity. Beck's triad. Cardiac tamponade presents with muffled heart sounds, hypotension and JVD. Underneath the Beck's triad sign. JVD glass spilling, passed out girl (hypotension), and drummer wearing earmuffs (muffled heart sounds). Pulsus parodoxus shirt worn by the stage diver. 3 people underneath him represent the RV, LV and septum. Security guy is holding is breath (inspiration) and a blood pressure cuff is dropping to the ground. Inspiration can cause a drop in systolic blood pressure >10mmHg (pulsus parodoxus). Y shaped falling glass. Constrictive pericarditis causes a prominent Y descent on the jugular venous waveform (due to rapid atrial emptying). Also seen in the dilated and restrictive cardiomyopathy sketch. Sniffing cookie smell from jug. Inspiration causes an increase in JV in constrictive pericarditis (Kussmaul's sign). Knocking on table. Ventricles expanding against a thickened pericardium in constrictive pericarditis causes a characteristic "pericardial knock" on auscultation. Cavitary TB cactus. Constrictive pericarditis can be caused by TB. Knife in heart steak. Constrictive pericarditis from surgery. Radiation symbol on the cowgirl. Radiation.

Ovarian cysts and epithelial ovarian cancer.

Organization of sketch: Cysts in the top left, general characteristics and risk factors on the left side. Presentation in the back. Back coming forward: serous, mutinous, endometroid, brenner, krukenburg. Follicular and corpus luteal cysts can exist. Ovarian tumors: epithelial, germ cell, and sex-cord (stromal). *Epithelial types:* serous, mucinous, brenner, endometroid, krukenburg. Cuboidal ovarian rim. Normal ovarian histology is cuboidal. Broccoli. BRCA-1 and BRCA-2 increase risk of breast and ovarian epithelial cancer. Inch worm. Lynch syndrome. HNPCC increases risk of endometrial, ovarian, and colon epithelial cancer. Torn basket rim. Repeated damage to the ovarian epithelial surface increases the risk of epithelial ovarian cancer. Eggs falling out. Increased ovulation. Trauma. Opened up eggs. Nulliparity. Increased number of ovulatory cycles. Early bloomer. Evergreen/late deciduous. Early/late menarche increase the risk of epithelial ovarian cancer. Locked OCP. Decrease the risk of epithelial ovarian cancer. CA-125 highway. CA-125 is the tumor marker used for epithelial ovarian cancer. Used to track response to therapy. Girl in puddle holding two wet baskets. Next to columnar fence with cilia and swirly flowers (dog biting a *BONE*). Serous. Most common. Bilateral, benign or malignant. Columnar with cilia. Psammoma bodies. Recall psammoma bodies have calcifications. *PATHOMA INSERT ABOUT PSAMMOMA BODIES: two not included in sketchy path, but mentioned by Sattar (one of these mentioned in FA) = mesothelioma and sporadic endometrial carcinoma a.k.a. serous a.k.a. papillary.* Mucousy dog. Wet abdomen shirt. Mucinous tumors can cause pseudomyxoma peritonei (peritoneal cavity filled with jelly-like mucin). Brown hen. Brenner tumor. Chicks running in front. Transitional something. Coffee beans that the hen is picking at. Coffee bean nuclei. Cooking burgers. Flipping into two baskets. Crab over abdomen. Signet ring. Bilateral METS from gastric carcinoma (recall gastric carcinoma = gastric adenocarcinoma, diffuse or intestinal type. Diffuse type causes krukenburg).

3.1 Dilated and Restrictive Cardiomyopathy.

Organization of sketch: Diagonal line through the sketch. Dilated on the left, restrictive on the right. Systolic spray and slushie. Dilated cardiomyopathy causes systolic dysfunction and an S3 heart sound. Iron sack, Duchenne and Becker sack, alcohol sack, box of rubies and trophy cup full of blueberries. Hemochromatosis, Duchenne and Becker, alcohol, rubicin drugs, wet beriberi as causes of dilated cardiomyopathy. Diamond pouring near the restrictive half. Restricted cardiomyopathy causes diastolic dysfunction. Smelling the cookies in the JVD jar. Kussmaul sign. JVD upon inspiration. *Following as causes of restrictive cardiomyopathy. Iron being tossed. Hemochromatosis (although usually causes dilated) Joan of amyloid. Amyloidosis. Radiation shield. Radiation. Soccer ball. Sarcoid. Dragon flag. Scleroderma. Lysosomal waste truck. Lysosomal storage diseases. *From picmonic:* Loeffler's syndrome. Represented in the restrictive cardiomyopathy picmonic by the loafers on the eosinophilic eagle.

2.2 Nephritic syndrome.

Organization of sketch: IgA and PSGN on the left. Diffuse proliferative in the lupus wire hold. MPGN, dense deposit on the right, rapidly progressive represented by the crescent warriors (immune complex mediated, pauci immune a.k.a. ANCA's and Goodpasture's). High pressure steam and baby genghis khan. Periorbital edema and HTN. Left is IgA nephropathy (Berger disease). Blowing nose. Presents after upper respiratory or GI syndrome. Periodic blood puddles. Episodic hematuria in IgA nephropathy. Shoeshine. Henoch-Schonlein purpura in IgA nephropathy. Proliferating army in the field. Most nephritic syndromes will present with mesangial proliferation. Moon shield next to the IgA dummies. Corticosteroids. Pie being thrown at the foot solider on the hump of his back. Hump that transverses in PSGN. Looped wire around the soldiers and the wolf. SLE diffuse proliferative glomerulonephropathy. Shows "wire looping" of the capillaries due to sub endothelial immune complex deposition. Dropping meat load. MPGN and dense deposit disease can present as both nephrotic and nephritic syndromes. Multi-lobulated shovel. Glomerulus in MPGN shows a multi-lobulated glomerulus. Membranous sash along wall. Membranoproliferative glomerulonephritis causes diffuse GBM thickening. *If membranous in the name, there is thickening of the basement membrane.* Dug into and split into two. Tram tracking in MPGN. Viral, bacteria and immune pattern. Many associations in MPGN. Bombs. Dense deposit disease. 3 friendship bracelets. Dense deposit disease is associated with the formation of the autoantibody, C3 nephritic factor. Deadly crescent weapon. RPGN causes crescents in Crescent warrior #2 shooting arrows. Pauci-immune RPGN. Ankle = ANCA. Crescent warrior #3 on the horse wishing it was on the pasture eating. Goodpasture's syndrome. Linear antibody arrows in front of it. Goodpasture's has linear antibody deposition.

4.1 Mitral Stenosis and RF. Minute 9:15 onward. The Pie Genies.

Organization of sketch: Ignore left 1/3 of the sketch. Acute RF in the background and chronic RF causing mitral stenosis on the right side. Pan of heart cookies. Acute RF affects all layers. Hands off. Histology finding. Aschoff bodies in RF. Caterpillar cupcakes. Anitschkow ("caterpillar") cells (activated macrophages with slender, ribbon-like nuclei) may be seen in the granulomas of acute RF. Oven with heart on fire. Endocarditis. This layer includes the valves. Guy *frosting* a hat over the oven. Acute RF can cause *fibrinoid* necrosis and sterile verrucous on the line of the valve leaflet. Regurgitating bicuspid hat chef. *Acute RF* typically causes mitral regurgitation. New murmur in a kid with heart failure? RF. Regurgitating aortic princess. Diamond on her outfit. Less commonly, acute RF causes aortic regurgitation. Will usually cause mitral regurgitation. Chef squeezing a miter hat in front of the grandfather chronic clock. Chronically, RF/rheumatic heart disease (RHD) causes mitral stenosis. Stenotic princess hat behind the chef squeezing a miter hat. Chronic RHD can sometimes cause aortic stenosis. More commonly RHD causes mitral stenosis. Girl on horse squeezing red pillow. Dilated LA. Consequences of dilated LA: cupcakes on wall (mural thrombi), recurrent reigns (compression of the recurrent laryngeal nerve, leading to a *hoarse* voice), gulping horse (compression of the esophagus). Girl with diamonds, rumbling stomach, and snap. Mitral stenosis presents with a mid-diastolic rumbling murmur. Opening snap. 2 scared sisters. The closer the opening snap is to the S2 heart sound, the greater the severity of mitral stenosis.

3.2 Qualitative Platelet Disorders. Spoof on Sandlot.

Organization of sketch: left is Bernard, right is GT, center is Wiscott. On fence is uremia and diabetes. Uremia BUN bag. Uremia causes platelet dysfunction. Diabetes candy and dirt clods with guitar and a broken string underneath it. Diabetes causes thrombus formation and MI. Bernard dog. Bernard platelet disorder. Kid hiding behind the antenna dish. "Big suckers." Large platelets in Bernard platelet disorder. Autosomal recessive inheritance pattern. Kid with 16 jersey failing to grab the guy's wrist. 1b defect in Bernard. Abnormal ristocetin test in Bernard. Kid on the hood of a GT car. GT platelet disorder. In front of 2 balls and 3 strikes and the guy over the fence grabbing the wrist. GT platelet defect is in IIb/IIIa. Normal ristocetin test. Wasps. Wiscott aldrich syndrome. Covered in bumps, crutches, *chewed up* license plates of all sizes.*

4.3 MAP, Uric Acid, Cystine Stones

Organization of sketch: Left front corner MAP, right front corner uric acid stones, background cystine stones. *Two shared features.* Yellow puddles for cystine and uric acid. Radiolucent jolly roger flag for cystine and uric acid. *Nearly hidden feature.* Stag hiding behind cistern for stag horn calculi in cystine stones. *Revision: the color of the puddles represents the environment that was REQUIRED for growth of the stone. NOT what is used to get rid of the stone. For example, basic blue is required for AMP, and yellow acid is required for uric acid stones.* MAP, stag, coffins, miners spraying blue with blue puddles. Magnesium, ammonium phosphate stones. Coffin shaped under microscope, form in alkaline urine, urease positive organisms. Nun knitting, cracked stained glass window, diamond on church, yellow puddles, blue being poured out. Allopurinol. Uric acid stones, tumor lysis syndrome, diamond shaped under microscope, forms in acidic conditions, alkalization of the urine is treatment. COAL, cistern, crane, hexagon shaped coal, child hiding behind mother, cyanide + nitro prusside with blue fumes, yellow leaking from water tower turning red, crane taking up a stone next to the *mine*. Cystine, ornithine, arginine, lysine. Cystinuria, hexagonal shaped under microscope, autosomal recessive, cyanide + nitro prusside blue test that when urine undergoes test - positive test turns the urine red, pencilamine as a pharm treatment. Stag hiding behind cistern. Cystine stones staghorn.

Hydatidiform Mole and Choriocarcinoma

Organization of sketch: Left is complete mole, right is partial mole. Front left is choriocarcinoma. Trophy case. Synchronized swimming trophies on the outside, cyto-cycling trophies on the inside. Syncytiotrophoblasts on the outside and cytotrophoblasts on the inside. Baby sitter. b-hCG babysitter. Secreted by moles. Nerf with X's. Sperm. Doesn't necessarily have to be X genetic material. Completely stuffed underneath shirt. Complete mole. Empty mirror and nerf football. Complete mole is fertilization of an empty ovum by two sperm. Vase with marbles that look like grapes. "Bunch of grapes" that represent the hydropic cells. Bullhorn and pillow fight with feathers storming about. Ultrasound of a complete mole displays "snow-storm" appearance. Clamp held in the air and crab behind. Preeclampsia. Complete moles pose the risk of transformation to choriocarcinoma. Mole wearing bowtie. Complete moles secrete so much b-hCG that people become hyperthyroid. This is because b-hCG shares a subunit with thyroid stimulating hormone. Partially stuffed mole. Partial mole. Normal uterine size. Two nerf balls being thrown into basket. Basket has XXX, XXY and XYY. 69 chromosomes. Maternal and paternal DNA. Doll in the vase and 57 on term paper. Because partial moles have maternal and paternal DNA there is fetal tissue in the mole. p57 is also a protein expressed by a maternal allele and is present with partial moles and not complete moles. Choriocarcinoma girl with crab held up to her lungs and with chopsticks in her hair. Choriocarcinoma METS to the lungs and the gestational type (not the germ line type) is extremely responsive to chemotherapy a.k.a. methotrexate.

Large and Medium Vessel Vasculitides.

Organization of sketch: Left is giant cell arteritis. Middle is Takayasu arteritis. Upper middle is common characteristics of all (elevated cylindrical wind chimes, ESR, and carpet, CRP). Right upper is Kawasaki, right middle is Polyarteritis nodosa, and bottom right corner is Buerger's disease/thromoangiitis obliterans a.k.a. TO. Glasses strap around the temporal region of the grandma. Giant cell/temporal arteritis. Grandma with wincing HA in scandinavian skirt with old lady glasses and a myalgic walker. Presents as headache. Affects older women of scandinavian descent. Up to half of patients with GCA also have polymyalgia rheumatica. Walker also has a grabber. Dx made by bx. Gargoyle touching finger to jaw. Jaw claudication. Moon face next to her apartment. Corticosteroids as tx. Fire alarm ringing between GCA and Takayasu. Turbulent blood flow through the carotid and aorta/branches can lead to audible bruits. Taco stand. Takayasu arteritis. Middle aged asian women with two different sized hoses. Population it affects. Causes narrowing of vessels and can cause different BPs in arms and even diminished or absent pulses ("pulse-less" disease). Foggy glasses on taco truck driver. Ocular involvement. Stealing sub. Subclavian steal syndrome. Kawasaki ATV. Kawasaki disease. ASA umpire with Ig keys. Aspirin and IVIG are treatment. Little asian boy with fever on back. 5-day fever and population it affects. 2nd passenger with red goggles, red gloves, and a red spotted shirt sticking out his red, strawberry tongue. Guitar flying off with a broken string. Kawasaki presents with conjunctivitis, erythema on hands and feet, red desquamative rash, strawberry tongue. Affects coronary arteries. *Strawberry tongue is also present in Scarlet fever.* Peace ANd Harmony. Polyarteritis nodosa. Hippie van. Hepatitis B association. "Spare the air." No pulmonary involvement. String of beads in a wall formation. Ultrasound of artery shows 'string of beads' appearance. Also *transmural.* Kidney bag. Affects renal arteries. Henna tattoo. Up to a third will have skin involvement. Sometimes, livedo reticularis: a lace-like rash. Pink gunk and skull in dreadlocks. Apparently supposed to represent fibrinoid necrosis (also seen in acute RF - mentioned in pathoma in preeclampsia "may have fibrinoid necrosis in vessels of placenta."). Telephone pole with wires on the van. Sometimes neuronal dysfunction. Bottom right corner. Guys with black gloves and blue fingertips that are smoking near a non-smoking sign. Buerger's disease a.k.a. TO. Raynaud's phenomenon and highly associated with smoking. Quitting smoking is highly curative. Picmonic: Booger disease with a trombone angel and a guy smoking with a booger coming out of his nose. Fingers are auto-amputating because of ischemia and necrosis.

Gestational Disorders.

Organization of sketch: Left side - ectopic pregnancy, gestational diabetes, placenta previa, placenta abruptio, placenta accreta, increta, percreta. Right side - preeclampsia, eclampsia. PID chandelier. PID increases the risk of ectopic pregnancy. Soil overflowing. Endometriosis increases the risk of ectopic pregnancy. Name tag DESk. DES (diethylstilbestrol) exposure increases the risk of ectopic pregnancy. Meat sticks being offered. Methotrexate treats an ectopic pregnancy. Baby holding HPL formula. HPL secreted by syncytiotrophoblasts cause insulin resistance in the mother causing gestational diabetes. HPL is decreased after delivery of the baby. Happy pregnant woman next to the trashcan os shoving a pink plate over it. Placenta previa, when the placenta implants over the cervical os. Painless vaginal bleeding. Angry pregnant woman who had the plate abruptly dropped on her. Placenta abruptio. Painful vaginal bleeding. Background: uterine vessels are exposed after delivery of the baby and muscles of the uterus contract to mechanically clamp down on the vessels and stop the bleeding. Floppy uterine bag. Uterine atony. Most common cause of postpartum hemorrhage. Plates adhered to smooth tile wall. Plates pushed in and plate pushed past. Placenta accreta, increta, percreta. Adherence to the myometrium instead of the endometrium. Increasing in depth with accreta, increta, percreta. Class of 20. Gestational hypertension. Isolated HTN at onset of 20 weeks. Clamp pulled into the placenta outlet in a strange way. Abnormal vessels to the placenta is the cause of preeclampsia. Person clamping hair in bathroom. HTN can cause these end-organ deficits. HA, blurry vision, kidney, proteinaceous hair in puddle (from renal failure). Holding up 1 finger. First pregnancy is a risk factor for preeclampsia. Shaking from clamp complication. Seizures in eclampsia. HELLP on door. Hemolysis, elevated liver enzymes, low platelets. Broken plates on floor, squished tomatoes, AST and ALT falling from a liver bag that is also falling. HELLP mnemonic.

2.1 Extravascular hemolysis: Overview and RBC membrane defects. Hereditary spherocytosis and elliptocytosis. Pyruvate KINASE deficiency.

Organization of sketch: Left side is hereditary spherocytosis, elliptocytosis. Middle is pyruvate KINASE deficiency (zoom in to the burr cell, also called echinocytes, bonnet), right side of the sketch is generally what is seen in extravascular hemolysis. *LDH seen in extravascular hemolysis because macrophages are sloppy and do not pick up everything. DOUBLE CHECK THIS.* Truck with domino flaps and spherical water tank in the truck bed. Hereditary spherocytosis. Autosomal dominant inheritance. Rainbow and anchor pattern. Spectrin and ankyrin mutations. Water spewing out. Osmotic fragility test as diagnosis. *Stack of hemoglobin metal lids. Characteristic increase in MCHC seen in hereditary spherocytosis.* Private property. Pyruvate KINASE deficiency. Doll. Presents as hemolytic anemia in a newborn. Doll with the burr bonnet. ATP deficiency causes membrane dysfunction and burr cells/echinocytes. Ekhinos = greek for sea urchin.

Polyhydramnios and Oligohydramnios

Organization of sketch: Left side is polyhydramnios. Right side is oligohydramnios. Headless baby on the TE-Fistula slide. C-shaped diapers with a bow at the end. Anencephaly, TE-Fistula, duodenal atresia. Candy being thrown and white porcelain girl. Diabetes causes diabetes and polyuria in the infant. Anemia causes high cardiac output and high urine production in the infant. Cystic kidney balloons, two renal balloons popping, ACE card in pocket. Cystic kidneys, bilateral renal agenesis, ACE exposure in utero (causes dysfunction of angiotensin II which are vital to proper kidney development in infants). Bladder with ribbons. Posterior urethral valves. Males only.

4.3 Aortic Stenosis and Regurgitation.

Organization of sketch: Left side of the sketch is aortic stenosis, right side of the sketch is aortic regurgitation. Bicuspid horse mouth next to milk. Bicuspid aortic valves are at risk of early dystrophic calcification. Concentric conch. Chronically increased afterload in aortic stenosis leads to concentric hypertrophy of the left ventricle. Concentric heart walls cause diastolic filling defects. Dilated left wing. Aortic stenosis causes chronically elevated pressures in the left ventricle and atrium. LA dilation and hypertrophy. Pair of vibrating pipes. The murmur of aortic stenosis is best heard at the right sternal border and radiates to the carotid arteries. Stiff wooden chair. Concentric hypertrophy in aortic stenosis leads to left ventricular wall stiffness and an S4 heart sound. "Those who are tardus will be parvus. Severe aortic stenosis presents with a weak, slow-rising pulse ("pulsus parvus et tardus"). Picture to the left of the carotid showing young, ugly cinderella depicting the fact that she is a late bloomer. Crossed out S2 photo. Cresendo peak and diminished or absent S2 indicate more severe stenosis. Squatting cinderella. Maneuvers that increase preload (e.g. straight leg raise or squatting) increase the murmur of aortic stenosis (due to increased stroke volume across the valve). *Contrast this to HOCM, where squatting decreases the murmur of HOCM.* *Mouse* straining to grip tail. Straining (valsalva) and handgrip decrease (makes mouse) the murmur of aortic stenosis. Schistocytes mentioned, not represented. Also not represented is "ejection click", do not confuse with mid-systolic click found in MVP. Princess regurgitating milk. Aortic regurgitation. Inflamed tree base. Vasculitis (giant cell and takayashu) can cause aortic regurgitation. Bark on aortic tree. Aortitis in tertiary syphilis can cause aortic regurgitation. Bamboo spine. Ankylosing spondylitis can cause aortic regurgitation. Martian. Collagen vascular diseases (e.g. Marfan, Ehler-Danlos) can cause aortic regurgitation (due to aortic root dilation). Eccentric myocardial ribbon on aortic regurgitation princess. Sister jumping on the bed bulging up and down. The increased stroke volume in aortic regurgitation causes an increased SBP and decreased DBP, widened pulse pressure (e.g. 160/60). Hammering water. Aortic regurgitation causes the rapid filling and collapse of blood vessels (Corgigan or "water hammer" pulse). Bobbing doll head in the arms of the sister jumping on the bed. Aortic regurgitation can cause a characteristic head bob with each pulsation (de Musset sign). Jumping on a nail bed shaped pillow on the water bed. Pulsations in the lips or nail beds seen in aortic regurgitation (Quincke pulse). Diamonds all over the aortic regurgitation princess. Diastolic. Slushie. S3 sound in aortic regurgitation.

2.4 Plasma Cell Neoplasms

Organization of sketch: MM in far lane. MGUS in second lane and Sir Waldenstrom, the IgM ninja star thrower in the close lane. Mainly features of MM around the scene. Sir Jones sitting on the bench above a puddle of urine with a fan. Bence Jones proteins are free light chain that is excreted in the urine. Fan for MM causing fanconi syndrome. Joan of Amyloid next to Sir Milo. AL amyloid deposition. Sir Milo's arrow retriever with holes in his helmet and in his arrow quiver. Situated below the rank L rank archery class who are being fed milk. Rank-L secretion causes hypercalcemia and punched out lytic lesions in bone (can be found in skull). Stacked targets in the background. Rouleaux formation of red blood cells because secreted substances causes dysfunction of RBC charge. Bacteria in the background. Monoclonal antibodies lack diversity. Protein zone. Protease inhibitors treat MM. Bortezomib. Protein ZONE. BorteZONIB. Ninja star retriever boy being hit in the head and wearing glasses with stockings and gloves. He is standing atop a flow of brown/red. IgM overproduction cause hyper viscosity syndrome known as Waldenstrom Macroglobulinemia. Sluggish blood impairs flow to CNS. Retinal hemorrhage, peripheral neuropathy. *Waldenstrom's is theoretically a cause of cold AIHA.* Ninja star boy straining the ninja stars. Plasmapheresis is treatment.

Colorectal polyps and cancer.

Organization of sketch: Moving left to right: Hamartomatous polyps, Peutz pop, juvenile polyposis (has hamartomatous polyps), hyperplastic (has serrations only at surface, not all the way through), seyssile serrated, and then adenomas. Adenomas are split into two categories. Tubular and villous. Villous closer to the crab beetle. Lower left FAP. Colorectal cancer on the right side of the sketch. A single pulled carrot stalk near the FAP. APC allele mutation. Garner next to the FAP family. Gardner syndrome is a variant of FAP. Gardner has skin rash, the garden is contained within bones, and he has sunglasses on. Gardner syndrome presents with cutaneous lesions, hypertrophy of retinal pigment epithelium, and osteomas. Tooth in the garden. Gardner syndrome has dental abnormalities. Turban worn by the smurf near FAP. Turcot syndrome is a variant of FAP. Brain turban. Turcot syndrome presents with colon adenomas and medulloblastomas. A pulled carrot, rat, broken check point, broken "Don't CCross" sign. APC, KRAS, p53, and DCC mutations in colorectal cancer. DCC stands for deleted in colon cancer. Cauliflower and apple core. Locations of CRC dictate the nature of the tumor. Cauliflower presents right sided lesions and usually cause occult bleeding and are asymptomatic. Apple core with the path obstructed and blood. Left sided tumors present with hematochezia and obstruction. Something about napkin ring. Inch worm. Lynch syndrome. Mismatched colors on a domino. Mismatch repair. Autosomal dominant. Smurf with a crab belt buckle on the inch worm. Endometrial, ovarian, stomach, small bowel, hepatobiliary cancer is also associated with lynch syndrome.

4.3 Neurofibromatosis

Organization of sketch: NF type 1 on left, NF type 2 on right. Dominoes on the signs. Both inherited in an autosomal dominant manner. 2nd waitress still represents NF1. Astral hats represent other CNS tumors that NF can present with. Spresso-100 and $100 cash register. S100 positivity for both (neural crest origin). Von Recklinghausen 17 100% Peruvian beans. Chromosome 17, 100% penetrance. Broken broom sweeping at the active rat. NF1 encodes neurofiBROOMIN, which normally inhibits ras. Mutated neurofibromin allows GTP-Ras to be active. Eye pattern of DeLisch mocha. Lisch nodules on the eye in NF1. Bulge in wires leading to eyeballs. Optic gliomas in NF1. Pink swirls. Optic gliomas are composed of astrocytes with eosinophilic inclusion bodies (Rosenthal fibers). Rainbow frappe. Pheochromocytoma in NF1. Twisted broken broom on NF1 side. Bony abnormalities in NF1. Hat with astral star logo. NF1 can present with other CNS tumors. *Below is NF2* Counter 2, "22" shaped steam and a merlin wizard with a tumor suppressor ribbon. NF2, chromosome 22, encodes for merlin protein which is a tumor suppressor. Kid with headphones in. NF2 presents with bilateral swannomas. Droopy face, trigeminal headband, covered ears and unsuccessfully balanced cups. Facial, trigeminal, cochlear, vestibular nerve involvement can lead to all of these symptoms. Foggy glasses, dura beanie with two poofs. Cataracts, multiple meningiomas. Headphones with *wires that bulge* leading to the iPod in the back pocket. Spinal tumors that lead to motor dysfunction (spinal swanommas, spinal meningiomas, ependymomas). Recall pediatric tumors, adult with pen and white spinal stripe: "In adults and NF type 2, ependymomas occur in the spinal cord." Antoni frappe that is capped with alternating areas of dark and light pink areas. Vestibular schwannomas are encapsulated tumors of neoplastic schwann cells with alternating layers of hypercellularity (Antoni A) and hypocellularity (Antoni B).

2.2 Hodgkin lymphoma

Organization of sketch: Only shows Nodular sclerosis, mixed cellularity and lymphocyte predominant subtypes. Lymphocyte rich and lymphocyte depleted subtype not illustrated. Slytherin poster, Hermoine, and Hagrid respectively. Owls in a row. Contiguous distribution. Contrast NHL which affect multiple lymph nodes in a non-contiguous distribution. Owl with XV and XXX design. RS cells with CD 15 and 30. Owl eyes with blue bird poop in the background. RS cells with inflammatory infiltrate. Epstein bar beer. EBV possibly the culprit. Hermoine mixing chemicals into a global cauldron. Mixed cellularity subtype. More common in developing countries. 2nd most common overall. Dumbledore next to hermoine with an abdominal belt buckle and a spleen pocket. Classic locations for mixed cellularity subtype to arise. Beer on hermoine's table. EBV possibly a culprit. Slytherin poster. Nodular sclerosis subtype is the most common of HL. Light beams next to the poster. Lacunar cells seen in nodular sclerosis subtype of HL. Hagrid is black, has a hippogryph. Lymphocyte predominant subtype. Does not have CD15 and CD30. More prominent in african americans. Hagrid's stitching has XX and XIX. Lymphocyte predominant subtype expresses CD 19 and CD 20.

3.1 Quantitative platelet disorders.

Organization of the sketch: ITP far left. Front and center is HIT. The foul ball poll with the mesh represents MAHA. MAHA consists of HUS (E. coli shiga gorilla) and TTP (touch that plate). Nine inning's reading 150 000 000. Normal platelet count. Nine inning reading 50 000 000. No symptoms until this platelet count. Child with kleenex and a bat in front of a 3 month youth league sign up. ITP in children is thought to be post viral and is typically self-limited with conservative treatment. Woman with IgG bat against a plate. ITP more frequently in women. Three treatments for ITP in the bottom left. Moon facies baseball, keys on a ring, and a spleen trash can being dragged away. Corticosteroids, IVIG, and splenectomy are treatments for ITP. HIT cleats touching the "4" glove and the defensive player with cleats touching the base. *Not well explained.* Right side of sketch are MAHA pathologies. Hussah. HUS. Touch that plate. TTP. Adams jersey being fought over in front of the vonWillebrand sign. ADAMST13 normally cleaves vWF. Crowded vWF in the sketch represents the uncleared vWF seen in TTP. Brain cap falling off in front of the touch that plate. Neurological symptoms in TTP. Mainly women touching that plate. Women are mainly affected by TTP.

Autoimmune biliary tract disorders and cancer.

Organization of sketch: PBC on left, PSC on right, cholangiosarcoma in water. Features of all include general features of cholestasis (gadget knife, alk phos, and collared goat) *including fatigue and pruritus.* Female hunter. PBC in middle aged women. Mitochondrial shield. PBC involves development of antibodies to mitochondria. Collection of yellow feathers and eye black. Xanthomas a.k.a. eyelid xanthelasmas and excess melanin deposition causing hyperpigmentation (unknown reason for melanin deposition). Green biliary vine inside PBC teepee. PBC is intra-hepatic bile duct damage (not a good job done in this sketch about indicating PBC and PSC as affecting intra and extra hepatic bile ducts - *REVISION* there are two men in vine shirts, one inside and one outside that represent PSC). PSC is intra and extra hepatic bile duct damage. Ursa star drawing closest to the PBC tent. Ursodeoxycholic acid as a treatment for PBC *ONLY.* Two men near the other teepee, one inside and one out. PSC is an autoimmune disease that affects both intra and extra hepatic bile ducts. Boy holding the 2 rabbits with a D quiver. HLA-DR, MHC class II. Antibody arrows around the deer. p-ANCA (recall p-ANCA for UC and anti-sac for Crohn's). Onion layers. PSC shows onion layers on histology. Green beads. Imaging in PSC shows beading due to alternating areas of stricture and dilation. Torch ascending biliary tree. PSC can present with ascending cholangitis (due to transient blockage of extra hepatic biliary tree). Recall Charcot's triad. Kid with crab up the tree. PSC risk factor for two cancers. Cholangiosarcoma and HCC. PBC is a risk factor for HCC. Kids with gourds, kid with gourd tripping trying to get at the crab in biliary tree. Choledochal cyst (RUQ mass, abdominal pain, jaundice) increases risk for cholangiosarcoma. Palpable seaGALL held by the man next to cholangiosarcoma. Cholangiosarcoma can present with Courvoisier sign (non-tender palpable gallbladder and jaundice). Thin and sweaty with flame feathers. Cholangiosarcoma can present with weight loss, fever and night sweats.

5.1 Renal Cell Carcinoma, Wilm's/nephroblastoma, angiomyolipoma.

Organization of sketch: RCC on the track, Wilm's/nephroblastoma at Will Call, fan with tube of pringles eating corndog with ketchup representing angiomyolipoma up in the stands. RCC a.k.a. renasccar. 3 VHL on the car. VHL mutations on chromosome 3 for RCC. Red balloons, hat umbrella, PthD chalkboard, ATCHion action clapper. Paraneoplastic syndromes associated with RCC. Polycythemia vera, excess renin production, hypercalcemia, Cushing syndrome. Will call spelled with "11." WT genes on chromosome 11. Wagers on poster that has Denis Dash - Beck Wide - Win. 3 syndromes that Wilm's tumor is associated with. Faded print on Beck Wide part. Tongue sticking out. Macroglossia and other things that make you *wide.* This syndrome associated with genetic imprinting. Denis in full nascar gear looking like "he" has a chest and is a "she." Denys-Drash syndrome. Pseudohermaphroditism. Do not forget about WAGR as the last syndrome associated with Wilms' tumor. *Addition to picmonic:* Willy wonka has strange eyes, a boner, and handing out a read-tarred book. Also holding out "11" wand.

2.2 Intravascular hemolysis: Overview and PNH.

Organization of sketch: Right side useful. Motel with a pig sign on the top and fibrin sticks on the roof. Motel on route 55 and 59. CD 55 and 59 are inhibitors of compliment. Complimentary PIG breakfast. Glucosylphosphatidylinositol synthesis gene. Fibrin sticks on roof. Hepatic, portal and cerebral vein thrombosis is the main cause of death. From picmonic: eco-lizard-mob as pharm treatment.

3.2 HOCM

Organization of sketch: Right upper corner = drugs that treat HOCM. Left side of the sketch = drugs to avoid in HOCM. *Avoid sinkhole* in the left lower corner. Filling problem. Diastolic dysfunction in HOCM. Domino sporran. HOCM is caused by an autosomal mutation in sarcomeres. Beta myosin rope on pips. HOCM is commonly caused by a gain-of-function mutation in sarcomere proteins (e.g. beta-myosin heavy chain myosin-binding protein C troponin T). Athletic sweatband and skeleton in front of the bag piper. Common cause of death in young athletes due to fatal arrthymias (due to disorganized myofibrils) Jester falling forward spraying a can between his miter hat. Mitral valve shifting anteriorly causes problems in HOCM, causing a systolic murmur. Standing and straining bagpiper. Valsalva and standing decrease preload, higher degree of LVOT obstruction, increased murmur intensity. Leg raise and squatting increases preload and left ventricular size. Smaller degree of LVOT obstruction, decreased murmur intensity. Grappling. Handgrip decreases murmur intensity. S4 chair that the central man is standing on. HOCM causes an S4. Non-dairy, muted bugle. Non-DHP and beta blockers treat HOCM. DHP calcium channel blockers, ACE inhibitors, diuretics, nitroglycerin are to be avoided in HOCM. Free Drinks. Friedrich's Ataxia.

6.5 RTA

Organization of sketch: Type 1 RTA on right, Type 2 on left, Type 4 in background. Canoe duct with phosphate stones on the right side. Collecting duct issues and calcium phosphate stones in type 1. Antibody lights and frog on the type 1 side. Autoimmune conditions and amphotericin as causes of type 1 RTAs. Wasted banana peels and broken citrate crate on right side. Hypokalemia and hypo citrate in type 1 RTAs. Blue water on the right side. Basic pH. Liftium over the canoe duct. Lithium as a cause of type 1 RTAs. Yellow pro cart track and car battery on left side. Type 2 RTA acidic urine, proximal tubule problems. Acetazolamide *and fanconi fan* as a cause. Crumbling mineral mountain in the background next to blue water. Type 4 RTA due to hypoaldosteronism and with a basic pH. Bananas high in the trees in the background. Hyperkalemia. NSAIDs, diasweeties, heparin hunter, family of adrenal disorders, cracked ACE cards, sulfa eggs, spiral notebooks and tangerines. Causes of hypoaldosteronism and type 4 RTAs.

2.2 Hydrocephalus

Organization of sketch: anatomy, communicating hydrocephalus on the left, NPH on the right and obstructive/non-communicating in the middle. Colloid buoy with a #3 on it. Colloid cyst arise in the 3rd ventricle. Communicating hydrocephalus due to meningitis (inflammation), fibrous clots, broken arachnoid granulations. Rafting family with phone that has fallen to the ground. Non-communicating hydrocephalus. Pine trees germinating. Pinealoma can cause compression of the cerebral aqueduct. Call us! Accommodations available. Superior colliculus compression due to obstruction of the cerebral aqueduct can lead to parinaud syndrome. Eyes accommodate, but do not react to light. Similar to argyll robertson pupils seen in tertiary syphillis. Setting sun in the accommodations available billboard. Setting sun sign, cannot look upwards, constant downward gaze and view of the sclera above the pupil.

1.2 Unstable angina, NSTEMI, STEMI. Right side of sketch only. Last 8 minutes.

Organization of sketch: farthest stall is UA, 2nd stall is NSTEMI, closest stall is STEMI. ST signs falling in UA and NSTEMI. ST segment depression in each. Differentiated by cardiac enzymes. Ye Olde Grille with the T-bone steak open 24/7. Troponin peaks at 24 hours and remains elevated for 7 days. Chicken and More Biscuits. CK-MB. "Good the next day, try reheated." CK-MB peaks at 24 hours and falls over the next 24 hours. Good for diagnosing reinfarcts. 4 EKG changes to be made aware of. Over the STEMI. "T" weather vane, ST sign elevated, the old man with the Q lasso and then the inverted shadow of the "T" weather vane. Hyperacute T waves immediately following that turn into ST segment elevation, Q waves, inverted T waves.

1.1 Microcytic anemia: Overview and Thalassemias

Organization of sketch: left side is alpha thalassemia, right side is beta thalassemia. 1 alpha deleted is the dog, 2 alpha deleted is the black man and the two asian sisters, 3 genes deleted is Ku bla Khan with the H war-ax, 4 genes deleted is the asian woman without any braids and the gamma design on her robe. Background 16 mongol flag on the left side of the sketch. Alpha alleles on chromosome 16. Background 11 italian flag on the right side of the sketch. Beta alleles on chromosome 11. Dog is one alpha allele knocked out. Two alleles knocked out are represented by two people. Black guy with the trans Africa crossroads is the trans configuration of two genes deleted and is more common in African Americans. The two asian sisters represent the cis configuration of two genes deleted. They are holding a bowl of lychee, because two genes deleted strangely has an increased amount of RBCs. 3 genes deleted. Ku blah khan. His war ax is an H for HbH. Picture of a speedy mongol warrior indicating that HbH goes the fastest and farthest on electrophoresis. Tea bag with <3. Reticulocytes less than 3%. Pathoma: corrected <3% indicates poor marrow response and suggests underproduction. Target cup pads. Target cells in thalassemias. Spices. Splicing defects. Right side black guy behind marco polo. One beta braid knocked out. Two adults and a baby down in the carriage behind him. HbA2 and HbF. Marco polo with two braids knocked off. Two adults with a baby jumping up behind him. Beta major. HbA2 and a significant increase in HbF. Macro polo with a tear drop garb. Beta major has tear cells. Marco polo with a chipmunk face crew cut top helmet. Beta major has chipmunk facies and a crew cut appearance on radiograph. Transfusion bag leading down to marco polo. Constant need for transfusions in beta major leads to secondary hemochromatosis.

4.2 Ca Oxalate and Ca Phosphate stones

Organization of sketch: majority Ca oxalate, back left Ca phosphate. Citrate crate with milk bottles nicely fitting into it. Acid miners taking the citrate crates and using them to place gold in. Citrate crates are flung aside with milk bottles flying everywhere. Citrate binds Ca and prevents stones. Citrate is also used to buffer the blood. In settings of acidosis, citrate is being used up and calcium becomes supersaturated in the urine. Diarrhea. Loss of bicarb causes an acidosis. Meat eater. High protein diet causes increased acid from breakdown. Acidosis. Miner spilling the milk as a stampede of oxalate dives in the tubule. Decreased calcium mechanism. Increased unbound oxalate in your GI tract. This oxalate is resorbed by your body and increased in concentration in your urine. Ox eating plants. Pure vegan diet increases oxalate in diet. Skipped cobblestone path. Crohn's disease cause Ca malabsorption. Acid cylinder. RTA type 1. Ca phosphate. Elevated pH shape on the side of the crevice. Alkaline urine environment promotes calcium phosphate stone formation. Envelopes from ox cart. Ca oxalate stones have envelope shape. Wedge shaped fossil mine car. Ca phosphate crystals have an elongated wedge shape on microscopy. Thigh guy in the front. Thiazide diuretics treat calcium stones.

2.2 Congestive HF.

Organization of sketch: patient left = left side of heart. Sails with branches near the top. Cephalization of vessels when looking at a chest on heart failure. Bourbon street. Kerley B lines on CXR for left sided heart failure. Slushie. S3 more common in systolic heart failure. Diamond bridesmaid on a stiff 4 chair. S4 more common in diastolic heart failure. Jester with a mitral hat and spraying bottle. Left sided heart failure presents with a systolic murmur (mitral regurgitation). *Bottom left of sketch: right heart failure signs and symptoms.* Nutmeg liver, course III. Zone 3 necrosis. *Nutmeg liver also seen in Budd-Chiari syndrome.* Inspiration of cookies through the JVD jar. Kussmaul sign is JVD with inspiration. Inner tube. Ascites. Seal with sad liver spot. Painful hepatomegaly. Coffin with portal that is cracked. Portal hypertension.

3.1 Muscular dystrophies.

Organization of the sketch. Myotonic dystrophy on the left. MacBecker on the far right and DuSeamus in the middle. Duchenne = blonde. *NOTE: distinction between blonde and black hair is not important. All that needs to be noted is the frame. Duchenne frame is slightly off, Duchenne due to a deletion (both D's).* Myotonic dystrophy also in the sketch on the left. Not well illustrated. Brown halos. Brown halos mean staining for dystrophin. If any tiny bit is present there is a brown halo around the cell membrane. If in Duchenne, there is absent dystrophin, there will be no brown halo. Damp rock cottages. DMPK gene in myotonic dystrophy. CTG trinucleotide repeats. *That's my town!* Domino gate to damp rock cottages. Auto dominant. Population 50. Symptoms around 50 repeats. Long drooping face. Temporal wasting and ptosis. Bald spot. Myotonic dystrophy can present with frontal balding. Foggy monocle. Myotonic dystrophy can present with cataracts. Sporran (gaelic for purse). Myotonic dystrophy can present with testicular atrophy.

2.1 ALL, CLL, Hairy cell, Adult T cell leukemia.

Organization of the sketch: Back left is general characteristics of lymphoblasts, i.e. stains PAS, tDt positivity. Then archers vs. knights with CD #'s. Adult T cell in the back right corner on the horse. CLL up front with the king and the lower banister. Hairy cell leukemia in the bear trap picture above the CLL banister. Recall that the lower banister is portraying archers. CLL is a B-cell disorder! From AML video: Hour sundial for Auer rods. Auer rods are MPO aggregates. Downtown plan far left. Acute leukemias are associated with down syndrome. *From pathoma: AML is associated with down syndrome before the age of 5 and ALL is associated with down syndrome AFTER the age of 5. This can be remembered by the fact that ALL primarily affects children and they've already gotten a disease early on, so they must get down syndrome LATER on.* Passing the frisbee. TdT weapon rack. LymphoBLASTs stain for these. *tDt is a DNA polymerase.* *Recall that ALL is subdivided into B-ALL and T-ALL.* *Detecting a lymphoblast: PAS and TdT positivity. Differentiating between a B and T lymphoblast: looking at the CDs. Any CD lower than the number 10 indicates a T cell, i.e. 2, 3, 4, 5, 7, 8. Any CD higher than the number 10 indicates a B cell.* 2, 3, 4, 5, 7, 8 footwook near the boy knight. Pre-T lymphoblasts express CD2, CD3, CD4, CD5, CD7, CD8. 10, 19, 20 archery target. Pre-B lymphoblasts express CD10, CD19, CD20. Helmet and testicles hanging from flag closest to the archers. Pathoma: "Excellent response to chemotherapy, requires prophylaxis to scrotum and CSF." The T knight is practicing 2, 3, 4 footwork while practicing against a dummy with a sack hanging from chest. Pathoma: The T in T-ALL is the mnemonic. T-ALL presents as a thymic mass and in teenagers. Knight with virus helmet raising milk to his face to drink. Adult T-cell leukemia. Virus that infects CD4+ T-cells. Hypercalcemia is a finding. Knocking over tDt. tDt negative. Skin rash and bony legs of horse. Presents with red plaques and papules. Punched out lytic bone lesions. Older king. CLL in older people. King with the smudge on the parchment. Smudge cells in CLL. Lower banister with archer "5" bow. Strangely, the neoplastic B cells in CLL have CD5, which is typically a marker for T-cells. Skeleton with "1" spear and "9" shield. CD19 found in CLL. Not pictured, but also other CD 20's. Small chess board next to the king. Pathoma: Involvement of lymph nodes leads to generalized lymphadenopathy and is called small lymphocytic lymphoma (SLL). Archer that has arrows spilled. Hypogammaglobulinemia. Bacteria underneath the lower banister. Recurrent infections is cause of death in CLL. Antibody toothpicks in food that is in pan. Autoimmune hemolytic anemia.

Anorectal disorders

Organization of the sketch: Front is outside world. Behind is entrance to the rectum (from GI tract). Dentate line in the middle of the water. Innervation given by the power lines, automatic sensors, and guy peddling. Pathology in the sketch: Ship coming out of the canal represents prolapse, inner tube represents anal fissures. Columnar histology above the dentate line. Endoderm. Squamous histology below the dentate line. Ectoderm. Yellow ladder *below the stomach but above the dentate line.* Inferior hypogastric plexus innervates above the dentate line. Automatic sensor. Autonomic innervation above the dentate line. Guy peddling and feeling the pain. Pudendal nerve innervates below the dentate line. Somatic innervation. Boat with a porthole called International Marine Vessel. Inferior mesenteric vein drains to portal vein above the dentate line. Guy peddling in the water. Pudendal veinous drainage below the dentate line. Systemic drainage. Thick tree sap. CF can cause rectal prolapse (due to chronic coughing and straining). Posterior inner tube rider. Majority of anal fissures are posterior. Cobblestone. Crohn's associated with anterior anal fissures. 3 cancers. Squamous (below dentate), basaloid (at the dentate line), rectal adenocarcinoma (above and behaves like colon adenocarcinoma). Men kissing men, HIV hat, pill bug, smoking, crutches. Risk factors for development of squamous cell carcinoma of the anus.

4.2 Mitral Valve Regurgitation and Prolapse. Jester jump club.

Organization of the sketch: Middle 1/3 of the sketch is useful. Characteristics of murmurs only useful part of this sketch. Front half of the sketch is mitral regurgitation. Back half of the sketch is MVP. Jester in the front with the champagne spraying. Mitral valve regurgitation. Jester parachuting with the mixer. Mitral valve prolapse. Parasailing jester with #1 finger. Mitral valve prolapse is the number one cause of mitral regurgitation. Mixer on the parachuter. Myxomatous degeneration. Eccentric myocardial ribbon. Chronically increased preload in chronic mitral regurgitation causes eccentric hypertrophy of the left ventricle. *Jester in armpit. Murmur from systolic spray. The systolic murmur of *mitral regurgitation* is heard best over the cardiac apex with *radiation to the axilla*. *Holographic design on the jester jump.* The murmur of mitral regurgitation is holosystolic. Sloshing Slushi3. Dilation of the left ventricle with chronic mitral regurgitation can cause an S3 heart sound. Wet crotch closing bicuspid hat. Functional mitral regurgitation (due to acute left ventricular volume overload) can be corrected with diuresis (decreased murmur). Martian with mixer. Connective tissue diseases such as Marfan syndrome, osteogenesis imperfect, and Ehler-Danlos can cause mitral valve prolapse (due to myxomatous degeneration). Straining next to S1. Maneuvers that decrease preload (e.g. Valsalva) cause the mid-systolic click in MVP to move closer S1. Elevated heart watch next to S1. Tachycardia (decreases the diastolic filling time and preload) will cause the mid-systolic click in MVP to move closer to S1. Propping legs up next to S2. Maneuvers that increase preload (e.g. straight leg raise) cause the mid-systolic click in MVP to move closer to S2. Squatting next to S2. Maneuvers that increase preload (e.g. squatting) cause the mid-systolic click in MVP to move closer to S2. Sustained grip next to S2. Maneuvers that increase after load (e.g. sustained hand grip) cause the mid-systolic click in MVP to move closer to S2.

Structural Esophageal Disorders and GERD.

Organization of the sketch: Zenker's diverticulum on the left. Mallory-Weiss and Boerhaave in the back left. Hiatal hernias in the front as the hit-a-mouse game. GERD on the right. Zany Zenkers/ Where "kids go for enjoyment". Zenker's diverticulum is due to a weakness of cricopharyngeus muscle in the Killian (an area of the hypopharynx). Zany Zenker sign next to the guy with fake teeth on the pizza. Fake diverticulum. Linear stratches on distal slide. Mallory-Weiss tears consist linear longitudinal lacerations on the mucosa of the distal esophagus and proximal stomach. Wrench and guy drinking behind mallory slide. Alcohol, retching and vomiting increase pressure and cause tears. Bounce house. Boerhaave syndrome. Submarine scope coming out in front of it. Esophageal endoscopy can cause boerhaave syndrome. Air coming out of the bouncy house and chips being stomped on. Subcutaneous emphysema from air as a clinical presentation. Sewer plate with lightning bolt on it. Boerhaave syndrome can present as septic shock. True emergency. Mouse on the 'hit-a-mouse' game up in bed coughing and holding an inhaler. Noctural coughing and nocturnal asthma as big symptoms of GERD! Bears with metal intestines on a column shaped stage with cups on it. Barrett's esophagus as a consequence of GERD. Metal intestines for intestinal metaplasia of esophageal cells. Cups for goblet cells. Transformation from squamous (normal esophagus) to columnar (feature of intestinal cells) with goblet cells. Eos slingshot person shooting a slingshot through the parasol. EOE is eosinophilic esophagitis and should be on the differential for GERD. Resistant to PPIs (end in the suffix -prasol, which are represented by the lady bear's parasol).

5.2 CJD, PD, Huntington's disease.

Organization of the sketch: left side is CJD/PD and right side is Huntington's disease. Hunting town with a cab in front. Loss of GABA neurons. Cargo short hunter. CAG trinucleotide repeat. Cargo pants father. Anticipation happens much more during spermatogenesis than in oogenesis. Cod fish. Caudate atrophy. Dominos. Autosomal dominant. "4" in the broken sign of Hunting Town. Chromosome 4. 7B copper penny machine. Wilson's disease can cause Parkinsonianism. Villain in striped suit with his submachine gun raised in the air. Thalamic control room lady is scared in her room. Striatum disinhibited, subthalamic nucleus activated, thalamus inhibited.

4.1 NTD, holoprosencephaly, chiari malformation and syringomyelia.

Organization/symbols of sketch: NTD's on the right side. Anterior neural tube defects on the right side. Posterior neural tube defects on the left side of tube city. Chiari tonsilar cherries. Fruit with leaf cerebellar vermis. String bean syringomyelia. Holoprosencephaly down below the table. Acetyl cola bottles. Alf's fresh produce. Acetylcholine-esterase and AFP elevated in NTD. Calendar interrupted during the 4th week. Neural tube closes during the 4th week. 3 stages of spina bifida. Occulta farthest away, meningocele in middle, myelomeningocele closest. Two cherries next to myelomeningocele. Myelomeningocele associated with type two chiari. Rodent bathing in own water supply next to anencephaly. Polyhydramnios associated with anencephaly because baby fails to swallow urine produced. One cherry. Chiari type one. Tonsilar herniation. Fruit with leaf protruding through skull. Chiari type 2 malformation. Cerebellar vermis, tonsils and medulla herniation. String bean below one cherry. Syringomyelia associated with type 1 chiari malformations. Kid laughing and adult suffering. Type 1 chiari malformations asymptomatic in childhood and present as adults. Mice and kid with fire cape and white strings in front. Syringomyelia disports the anterior white commissure where pain and temperature signals travel. Loss of upper body pain and temperature at C8-T1 (right where a cape is worn). Tight walkers. Dandy walker syndrome. Triad of cerebellar vermis genesis (leaf on fruit is gone), cystic dilation of 4th ventricle (water in the bowl), enlargement of posterior fossa (largest skull bowl) Sonic hedgehog 13ig, 13all, 13rand (13 supposed to look like a B). Alcohol bottle behind the two mice failing to separate from a hug inside the cyclops ball with a cleft piece hanging off. Shh, Petau syndrome, Fetal alcohol syndrome implicated in holoprosencephaly. Holoprosencephaly associated with cyclopia and cleft lip deformity.

Gallbladder and Biliary Tract Disease.

Organization/useful items: Factors increasing gallstone formation in the back. Acute cholecystitis with the table on fire. Choledocholithiasis in the middle. Ascending cholangitis in front. Chronic cholecystitis in the bottom left. Yellow balls. Cholesterol balls. Black balls with the collared goats. Black pigmented stones contain conjugated bilirubin. Brown balls being kicked by the uncollared goat. Brown pigmented stones contain unconjugated bilirubin. Sign of infection as bacteria unconjugate the bilirubin. Pregnant woman holding TPN bag near the STOP to-go FAST sign. Pregnancy, TPN, somatostatin, fasting cause an increase in gallstone formation (decreased motility). Ball on the table caught fire. Acute cholecystitis. Chef hitting the man as he breathes outward. Murphy's sign. Pain upon palpation when patient inspires. At the acute cholecystitis table. Kid at the table caught on fire hiding from the bocce ball. HIDA scan used to diagnose acute cholecystitis. Woman in the middle of the sketch with the gadget knife, chalk drawing and a collared goat. *Next to the bocce ball further down the court.* Choledocholithiasis. Elevated GGT, elevated alk phos and conjugated hyperbilirubinemia in choledocholithiasis. Repeat from 1.1 (lab eval - billy goats on a farm) and also in 1.3 (autoimmune biliary tract disorders). Ampulla-like vase in bottom right corner being cleaned by a pancreas sponge. If the ampulla of vater is obstructed by a gallstone, pancreatitis ensues. Gallstones are the most common cause of acute pancreatitis. Candle fires. Ascending cholangitis (inflammation of the bile duct). Charcot short shirt on the woman. Charcot's triad of ascending cholangitis: jaundice, fever, RUQ pain. Bocce ball bouncing off the tract to the intestine shaped pathway. Sparking water bottle fizzing and a pathway obstructed sign. Gallstones can erode from the bile duct into the adjacent bowel causing air to be present. Can create a gallstone ileus. Crab on the table next to the chronic clock. Chronic cholecystitis. Gallbladder adenocarcinoma. Spilled milk and porcelain vase. Chronic gallbladder inflammation causes dystrophic calcification of the gallbladder leading to porcelain gallbladder.

1.2 AML and CML

Organization: AML on left with the big blotchy "blast" spray painter. CML on left with the guy in the tire swing painting nice, mature circles. Leukomoid reaction in the back right corner. Both are old guy painters. >50 y/o are typically affected. Chemistry set and benzene ring on the AML rooftop. Prior chemo and benzene exposure are risk factors. Peroxidase paint and a sundial. MPO positive and auer rods in AML. *MPO is analogous to tDt positivity in lymphoblasts. Auer rods are crystalized and visible MPO enzymes* 15 y/o teenager translocating his letter man jacket to the 17 y/o cheerleader. They are rolling dice and playing a make out game. 15:17 translocation involving the vitamin A receptor, DIC is common in AML patients. Treatment is ATRA. 20% satellite. Diagnosis is minimum 20% blasts. Downtown. Increased risk of AML in down syndrome patients. *BEFORE* the age of 5. *PATHOMA REVISION: The AML subtype associated with down syndrome before the age of 5 is acute megkaryoblastic leukemia.* CML painter in the tire swing in front of the philadelphia breakable box. CML has the 9:22 translocation, philadelphia chromosome. *Philadelphia chromosome is always present in CML, but it can be present in other conditions such as B-ALL.* Plates next to the mature painting. Thrombosis in CML. Broken plates next to the painting that is getting more blastic. Thrombocytopenia in blast crises of CML. Cop holding chalk next to the EMTs in the back right corner. Alk phos is elevated in leukomoid reaction. Alk phos is positive in granulocytes in leukomoid reaction, and NOT in CML. Edit the leukomoid reaction. LAP = leukocyte alk phos. *Common to both: air vents that look like radiation. Exposure to radiation as risk factors for the development of both.* *Picmonic addition (not represented in the sketch): basophilia. Memory hook for CML in picmonic is the camel. Basophil addition in picmonic to the right of the camel. Also another reminder that alk phos is low in CML vs. an infection is the elk with down arrows to the left of the camel.*

Abnormal uterine bleeding and Endometriosis

Organization: Fibroids (a.k.a. leiomyoma) with the black woman, gophers are adenomyosis, histology section is endometrial hyperplasia, top right with the infertile tree is endometriosis. PALM COIENS mnemonic for abnormal uterine bleeding. Weak tbh. Black woman with estrogen earrings planting an infertile tree. Fibroids more common in black women, are sensitive to estrogen and can cause infertility. ADDING dirt to the myometrical path. Adenomyosis. The stratum basilis layer of the endometrium grows into the myometrium. *Pathoma revision: Adenomyosis is when endometriosis involves the myometrium.* Histology section on the uterus. Endometrial hyperplasia. OCP lawn mower. OCPs reduce the risk of endometrial hyperplasia (due to correct balance of estrogens and progestins). Estro-grow, trademark (TM). A *fertilizer.* Unopposed estrogen and tamoxifen (a SERM) are risk factors for endometrial hyperplasia. Inch worm. Lynch syndrome is a risk factor endometrial hyperplasia. Unruptured polycystic buds. PCOS is a risk factor for endometrial hyperplasia. Seeds. Early bloomers, evergreens, and seedless. Early/late menarche and nulliparity are risk factors for endometrial hyperplasia. Pile of dirt on ovarian patio. "Chocolate cysts" in endometriosis. Dirt powder spots, pink nodules, and creepers. Endometriosis implants appears as 'powder burn' lesions, flesh colored nodules, and filmy adhesions on serial surfaces. *Notice the fallopian looking pathway to the ovary for endometriosis. Dirt on different places indicate where the endometrial implants can go. For instance, on the tube pathway (fallopian tube - scarring and increase risk for ectopic pregnancy), on the intestine looking part (intestinal serosa), etc. PATHOMA: involvement of the uterine myometrium in endometriosis is called adenomyosis.* Infertile tree. Endometriosis can cause infertility. OCP lawn mover blowing. Oral contraceptives are treatment for endometriosis.

Amenorrhea.

Organization: GnRH deficiency top left (congenital and Kallman syndrome). Ovarian (turner) dysfunction on left. Mullerian agenesis, hymen, excessive exercise/anorexia, hyperprolactinemia, menopause, Asherman syndrome. Maria's Quinceanara. Primary amenorrhea is absence of menses by age 15 or 13 + no secondary sex characteristics. Girl calling her on her cell phone near her nose. Kallman syndrome. GnRH deficiency causing amenorrhea and anosmia (olfactory neurons require GnRH for migration). Turning Turner fan next to the ovarian dysfunction pot. Streaks of fibrous plant in wilting ovarian pot. Streak ovaries/streak gonads in Turners. Woman with FSH and light trying to revive plants. Dysfunctional ovaries unresponsive to FSH and LH. Mule. Mullerian genesis. MRKH syndrome. This normally develops into the upper part of the female reproductive tract. Woman trying to perforate bag. Imperforate hymen. Running on the gardner bag. Excessive running/exercise and anorexia nervosa cause insuffienct calorie intake. Acquired GnRH deficiency. Broken robes and woman squirting milk into the air. Antipsychotics with D2 antagonism properties cause hyperprolactinemia and hyperprolactinemia can cause amenorrhea due to GnRH interplay. Ash on uterus cake. Asherman syndrome. Scarring of uterus causing a secondary amenorrhea. Can be caused by repeated endometrial infection or surgery.

5.2 Right to Left shunts.

Organization: Truncus arteriosus on the right, transposition of great vessels, tricuspid atresia, TOF, TAPVR, Epstein anomaly. 22, 11 design and large V in front of truncus. DiGeorge syndrome, VSD usually associated. Monster trainer with the red hair tuft in front of the blue tuft, the pokemon ball on a string and two separate circuits. Kids throwing candy in the air. Aorta anterior to the pulmonary artery on cardiac echo. Cardiac silhouette looks like an "egg on a string" on CXR. Two seperate circuits. Maternal diabetes is a risk factor for development. Goku reading the atresia magazine. He is being busted through the hole on the front page of the magazine. Tricuspid atresia. Typically associated with an ASD. TOF sailor moon girls. One squatting with a conch. Right ventricular hypertrophy. One being choked with a lung design on her chest. Pulmonary stenosis. One with a large V and a 22, 11 design. VSD. DiGeorge syndrome. One flying overhead with a red ponytail. Overriding aorta. TAPVR game. On the screen is "Right down." Return to the right heart in total anomalous pulmonary return.

5.1 Left to Right shunts.

Organization: Upper left is PDA. Bottom left is VSD. Bottom right is ASD. Eisenmenger. Dr. Strange poster where he is reversing the flow and becoming a cyanotic version of himself. Eisenmenger syndrome is when a left to right shunt eventually develops pulmonary hypertension and the shunt reverses. R to L is EARLY cyanosis and people become cyanotic. Ruby robot machine near the duct. Congenital rubella infections cause PDA. Continuous machine like murmur heard in PDA. VSD. Torn V shirt. Kid getting punched and spraying water. Holographic magazine. Holosystolic murmur heard in VSD. ASD. Spraying arm cannon and the mother separating the two sisters. ASD presents as systolic wide, fixed splitting of S2. Colorful arch. Coarctation of the aorta. Turner X wheel. Turner's syndrome. Biscupid horse puppet. Associated with biscupid aortic valve. Notched rungs of the ladder on the ground. Notched ribs in coarctation of the aorta. Red paint stroke on guy's hat next to a bulging circular vent. Berry aneursyms associated with coarctation of aorta.

Sturge-Weber syndrome

Sketchy path: Left half of the SWS/TSC sketch. Memory hook: Steven Weber on the Southwest train being followed. How SWS should be thought of: malformations at the capillary venous interface that causes neuro/eye angiomas/cutaneous manifestations. Mosaic lamp. Mosaicism. Menu upside down. Mental retardation. coGNAQ wine bottle spilling. GNAQ mutations. Woman and baby with port wine stain. Port wine stain. One face because predilection for V1 and V2 dermatomes. Eye ball tea pot. Glaucoma if angiomas grow in eyeball. Skull accessory on hat. Leptomeningeal angioma. Seizing arm. Seizures if angiomas grow in the leptomeninges. Tram track train with snow outside. Tram track calcifications around the leptomeningeal angiomas on radiology.

Small Bowel Obstruction, Ileus, & Hernias

Organization: small bowel obstruction up top, ileus left most, intussusception bottom left, SMA syndrome with the skateboard middle top, hernias on right. Hernia step up: striated wood board is rectus abdominus, canal is ilioinguinal canal. Shirt only vs. shirt and hoodie is important. Canal entrance on lateral side of the red and blue pipe. Collie on a skateboard with rocks falling down into the tunnel making the noise tink tink tink. Small bowel obstruction presents with colicky abdominal pain and has the bowel sound tink, tink, think (as opposed to ileus which is silent). Broken boombox on the ileus guy. Ileus is silent. Woman skateboarder sliding down the railing compressing it with her pads falling off. Rapid weight loss in SMA syndrome (when SMA and aorta clamp off a portion fo the duodenum). Currant jelly sandwich being held by the telescope person. Currant jelly stool as a sign of intussusception. Pile of tissues next to the telescope. In kids, infection causes hypertrophy of the lymphoid tissue and this serves as a lead point for intussusception to occur. Meckel's hecklers wearing mushrooms near the telescope. Meckel's diverticulum can act as a lead point. Mushrooms represent polyps and tumors. Berry yum landing pad. Barium enema is diagnostic for and treats intussusception. Shirt only with the guy coming through the fence. Direct. Covered only by external spermatic fascia and due to weakness in wall. Hoodie and shirt guy coming through the canal. Indirect (can also think of wearing a hoodie as trying to be indirect). Covered by all three layers of spermatic fascia. Virginia Co Patent. Indirect due to a persistent patent processus vaginalis.

4.2 Sturge Weber and Tuberous Sclerosis. Picmonic.

Picmonic

2.3 G6PD Deficiency and Autoimmune Hemolytic Anemia.

Route 66. The 6 and 6 are supposed to represent G and 6 in G6PD deficiency. Route 66 produce with 3 P's stops. Pentose phosphate pathway (responsible for synthesis of fatty acids and cholesterols; generates NADPH). Organization of sketch: Front sketch is G6PD deficiency. Background is AIHA. Receding behind X. G6PD deficiency is X-linked recessive. Tomatoes in cage. Hemolysis associated with G6PD. Guy in yellow jacket. Jaundice during hemolytic episodes. Stinky sulfa eggs. Trimethoprim sulfamethoxazole can precipitate hemolysis in G6PD deficiency. Sack of beans. Fava beans can precipitate hemolysis. Dapsone deputy. Dapsone can precipitate hemolysis. Bacteria in the back. Bacteria can precipitate hemolysis. Mosquito netting. Protection against malaria. Hot food with the antibody fork and a steak at the end of the fork. *IgG antibody* to the steak. Warm = IgG. Viral kid blowing his nose, man taking his order with a pencil and a wolf at the counter. Viral infections, penicillin and SLE causes of warm AIHA. Coon guy with an *ANTIBODY ON SLEEVE* holding an antibody fork with a steak. Coombs test. Coombs test detects if there are antibodies attached to the cell membrane. Recall that indirect coombs measures antibodies in the serum. Cold drinks with IgM snowflakes. Cold AIHA is with IgM. Snowshoe guy, Epstein's bar and chess table lymphoma in front of Cold AIHA.

Complement system disorders.

Shoe thrown at the kid in the face with the no chatting no kalling sign. C1 esterase inhibitor deficiency results in hereditary angioedema due to unregulated activation of kallikrein. Braided girl in the row with the bullies. Bradykinin increases because kallikrein increases. Holding an ACE cell phone cover. ACE inhibitors contraindicated. 4, 3, 2, 1, showtime next to teen wolf poster. Early complement deficiencies present as lupus like. Encapsulated shaped lamp light. Highlighted 2 on the showtime presents as difficulty with encapsulated bacteria. Noir series on from 5-9. Later complement deficiencies present with recurrent Neiserria infections. Route 55 and 59 "peaceful night hotel." CD55 regulates complement and when deficient results in paroxysmal nocturnal hematuria.

Sjogren's syndrome, systemic sclerosis and mixed connective tissue disease.

Squire book at the feet of the Sjogren's lady. T-cell mediated destruction of glands. *Type 4 HSR.* Lady in front of XeRO LAnds. Anti-Ro and La are serologic markers of Sjogren's syndrome (although they do NOT cause direct damage in the disease - it is T-cell mediated destruction of the glands!) Tent with flags A and B. Anti SSA and SSB, Sjogren's is in the name of these and these will probably not be on the exam. Blue bugs swarming camel's eyes and mouth. Intense lymphocytic infiltrate in the lacrimal and salivary glands in Sjogren's syndrome. Helper boy next to camel. Design on Sjogren warrior garb. Eyes cracked and mouth cracked. Increased risk of dental caries. Dry tattered loincloth. Destruction of Bartholin glands (exocrine glands of the vagina) can lead to dyspareunia (painful intercourse), and increased infections (both upper and lower urinary tract). Chessboard at the camp. Increased risk of non-hodgkin lymphoma. Scaley dragon. Diffuse systemic sclerosis a.k.a. scleroderma. Divide into two types. Diffuse and limited (CREST with limited). Cressandei the lesser. Limited systemic sclerosis (CREST syndrome). Staff with a chromosome and centromere on top of it. Anti-centromere antibodies. Bones buried in sand underneath Cressandei. Nodular subcutaneous calcification (calcinosis cutis) may occur in systemic sclerosis (especially limited sclerosis). Gloves worn by Cressandei. Raynaud's. Slave being choked by GI rope by Cressandei. Esophageal dysmotility. Any part could be affected! Blood red highlights in Cressandei's hair. Telangiectasia. Fibrotic lung tree. Systemic sclerosis can cause lung disease. Dragon on top of endothelial cells. Endothelial cell damage inciting event. Army with shark shields. Collagen deposition and fibrosis. Red dragon tail with black end. Fibrosis of vessels causes ischemia and necrosis of distal extremities. Antibody hair clips and unwinding hair. Anti DNA topoisomerase I (Scl-70) autoantibodies are serologic markers of diffuse systemic sclerosis. Steam coming out of dragon. HTN. Corked heart jug. Cor pulmonale. Mixed fabric outfit sorceress. Mixed connective tissue disease. Lupus wolf next to her and RA lantern. Features of many autoimmune diseases. Pretty much the only thing you have to know with mixed connective tissue disease is the antibody. Crescent moon staff held by the mixed fabric sorceress. Anti-U1 ribonucleoprotein antibodies are the serologic marker for mixed connective tissue disease (though they do NOT cause direct damage).

Phagocytic disorders. Burst is the first step in oxygen dependent killing. Oxygen is converted to superoxide by NADPH oxidase. This is the burst step.

Super granulomata. *Chronic granulomatous disease.* X-shaped ship. CGD is most commonly X-linked recessive. Kid can't open NADPH energy drink. NADPH enzyme is defective. "Super" is cracked on the game. Superoxide cannot be formed. Burst is impaired. Green "Roads of rage" arcade game next to super granulomata. Dihydrorhodamine flow cytometry (presence of superoxide converts dihydrorhodamine to rhodamine, which is a fluorescent green compound). Out of order on roads of rage. Disease shows minimal green fluorescence. Tetraz game out of order. In CGD, the NBT test produces minimal blue dye. Max Power World Fighter. MPO deficiency. Bleach bottle spilled next to the game. Cannot produce bleach. Fighter receding behind wall. MPO deficiency is autosomal recessive. Albicans fighter with more health. Most MPO are asymptomatic, but increased risk for candida infections. GauntLAD. LAD. Knight hiding behind the wall. Autosomal recessive. Scratched out "18+" on the game's controller area. LAD results from deficiency of CD18. Goblin with no teeth and boils. Periodontitis and boils common in LAD. Sparkling clean game screen. In LAD, infections lack purulence. Knight unable to sever cord where the goblin in scaling the wall. Delayed separation fo the umbilical cord. Jobs board stapled with IgE pines. Hyper-IgE (Job) syndrome (primary phagocytic disorder) (impaired neutrophil chemotaxis). Domino board. Torn STAT sign. Mutation in STAT3. 17+ only. Th17 helper T cells are deficient (due to mutations in STAT3). Torn EMT poster. Lack of neutrophil chemotaxis. Abnormally cold air vent that the kid is posted to. Hyper-IgE syndrome presents with cold skin abscesses and absence of fever during systemic infection (lack of neutrophil chemotaxis and absent inflammatory response to infection). Crusty acne and dandruff. Hyper Ig-E syndrome presents with recurrent skin infections (beings in newborns and pruritic papulopustular crusted rash on face and scalp). Hockey mask bully tormenting the kid attached to the jobs board. Hyper Ig-E syndrome can present with coarse facies (broad nasal bridge, deep set eyes). *From picmonic: retained primary teeth.* Staff oreos can get stuck in retainer teeth. Ninja Higashi. Ninja hiding behind wall. Auto recessive. Trash disrupted en route to dumpster. Lyosomes represented by trash. Chediak Higashi syndrome is a defect in lysosomal trafficking. First responders with large blue bombs. In Chediak Higashi syndrome, neutrophils contain giant azuophilic granules. Purely white ninja. Albinism. Zapped by broken wires. Peripheral neuropathy.

Gastric Dysmotility and Cancer

Theme: Asian. Much higher incidence of gastric adenocarcinoma amongst those of Asian descent. Organization: Menetrier disease, both types of gastric carcinoma, GI lymphoma in bottom left, GIST in top left. RaMEN Try it! Menetrier disease. Ramen noodles in the stomach. Hypertrophied rugae. Little asian girl drooling. Excess mucus production. Meat flying out of the ramen bowl. Protein-losing enteropathy. Donburi crab. Gastric adenocarcinoma. Chronic grandfather clock, antibody burner, smoked meats, 15% off with EBV purchase, mushroom family, helicopter fan, smoking and drinking. Chronic gastritis/metaplasia, autoimmune metaplastic atrophic gastritis, smoked meats, EBV infections, familial adenomatous polyposis (not regular old polyps!), chronic H. pylori, smoking and drinking are risk factors for development of gastric adenocarcinoma. Chronic atrophic metaplastic gastritis is the largest risk factor for development of gastric adenocarcinoma. Background: two types of gastric adenocarcinoma. Intestinal and diffuse. Diffuse is worse and has the E-cadherin and linitis plastica ("leather bottle"). *Two women walking in the street represent diffuse only.* Crab claws that have finally broken free of their adhesion. E-cadherin in diffuse gastric adenocarcinoma. Leather stomach purse. Linitis plastica in diffuse. Ring jewelry. Signet rings in diffuse type. Ring lapels on liver, lungs and ovaries. Common places for both types of gastric carcinoma to METS to (when METS to the ovaries it is called a krukenberg tumor). Bottom left. GI lymphoma. Top left. GIST. Arcade hall. C-kit for fixing a machine. Derivation of interstitial cells of cajal. C-kit as the mutation.

Carcinoid tumor and Small bowel Neoplasms (small bowel adenocarcinoma and Peutz-Jeghers syndrome).

Theme: Carcinoid tumors secrete vasoactive substances such as histamine and serotonin. Metabolism of these secrete substances can occur if the carcinoid tumor is located in the GI tract and secreting there. Liver and lungs can metabolize. If METS to liver, then it bypasses metabolism and causes effects of the vasoactive substances. Bees flying in the liver compartment. METS to liver causes bypass of first pass. Top left. Red face. Flushing. Wheezing party blower. Bronchospasm. Sewer pipe coming directly beneath him. Diarrhea. *Triad of carcinoid syndrome: flushing, diarrhea, bronchospasm.* Also top left. Red streamers/ninja turtle headband for telangiectasis (vasodilation from vasoactive factors). Right heart of the heart compartment is diseased, but in the left heart the reptile is eating the bee. Lungs metabolize the vasoactive substances. Left heart is left clean and right heart is diseased. Giant crab. Small bowel adenocarcinoma. Small family of mushrooms, inch worm, cobblestone. Familial adenopolyposis, lynch syndrome, Crohn's disease are risk factors for development of small bowel adenocarcinoma. Peutz pop/popsicle. Lizard with purple mouth, genitals, hands and feet. Peutz-Jegher syndrome. Domino hammer. Syndrome that causes mucocutaneous hyper pigmentation of the mouth, lips, palm, genitalia. Autosomal dominant. Benign hamartous growths primarily in the small bowel.

6.1 Osmolality and Sodium disorders.

To Do

Check FA and see if potassium, calcium, acid/base disorders are worth watching.

To Do

1.2 Rickets

Toddlers tend to develop outward bowing. Older children tend to develop knock knee. Soft plush shark hat. Infants with rickets can develop craniotabes (abnormal soft areas of skull bone) as well as frontal or parietal bossing (protruding skull bone). Non-fused turtle shell. Delayed closure of the fontanelles. Wide, frayed open bone basket. Widening of the epiphyseal growth palate and fraying of the metaphysics are commonly seen on x-ray in rickets. Rachitic rosary necklace. Enlargement of the costochondral junction forms nodules at the ends of ribs that can be seen on CXR or palpated on the anterior chest wall ("rachitic rosary").

Liver tumors and Hepatocellular carcinoma.

Tumors represented in the sketch: FNH (Focal nodular hyperplasia), hepatic adenomas, hepatic hemangiomas, METS to liver (colon and lung). HCC on the left (represented by Frankenstein). Angiosarcoma of the liver represented by Frankenstein's wife. Organization of sketch: FNH as the electrical power thing. Hepatic adenoma represented by the hunchback assistant ADDing to the liver. Hepatic hemangioma as the red glob on the floor. *Despite the hunchback representing hepatic adenoma, the female assistant is there to remind you that those three are most common in women of reproductive age. The hunchback with crazy hair simply means how large the tumors are and how they are filled with glycogen.* Middle is METS to liver. Frankenstein = HCC, Frankenstein's wife = angiosarcoma. Solitary star shape of the electrical power thing. FNH is a solitary area of hepatocyte proliferation (forms a nodular star pattern). Red wire around node. Green wires. Large central artery and bile ducts, arterioles, venules in FNH. Spokewheel at the bottom. Contrast imaging shows a spoke wheel pattern. Estrogen earrings on the female assistant. Stimulate growth of FNH and hepatic adenomas. (Male symbol of Igierke is supposed to represent how anabolic androgens stimulate the growth of hepatic adenomas). *Pathoma: FNH not mentioned. Sattar says that Hepatic adenomas are associated with OCPs and responsive to estrogen. The assistant has estrogen earrings and an OCP plate.* #1 finger as a shadow next to the red glob. Hepatic hemangiomas are the most common benign liver tumor. Bloody grabber of the red glob. Fine needle aspiration of a hemangioma causes profuse bleeding. Igierke working on the liver. Large hunchback. Crazy branched pink hair. Type 1 and 3 glycogen storage diseases can cause hepatic adenomas. Hepatic adenomas can be very large (up to 30 cm) and on histology have glycogen in them. Red sutures on the stitched up hepatic adenoma liver. No bile ducts. All risk factors for HCC are known or are highlighted in other sketches with the exception of azo dyes. Exposure to azo dyes (paints, leather working) increases the risk of HCC. Cork obstructing blue pressurized liquid. HCC can occlude hepatic veins. Frankenstein getting a liver that is spilling blood onto a lung. Most common place for HCC to METS is to the lung. Alf's fresh protein. AFP is a tumor marker for HCC. CD belt and XXI (going vertical) stitching on Frankenstein's wife. Angiosarcomas express CD31. Arsenic bottle (sources include pesticides, herbicides, wood, mining, glass making, etc.) is a risk factor for angiosarcoma. PVC pipe night stand for Frankenstein's wife. PVC pipe exposure. Th bottle. Thorotrast, an early radio contrast dye is a risk factor for angiosarcoma.