UWORLD/COMBANK (non-OMM) 1 liner

iron deficiency sequence seen with lab testing:

1. decreased bone marrow iron stores (ferritin and hemosiderin) 2. decreased serum ferritin 3. increased serum TIBC, reflecing icnreasing transferrin 4. decreased serum iron concetration 5. decreased hemoglobin 6. microcytic, hypochromic RBC

male patient has a mitochondrial disorder (muscle biopsy shows muscle fibers with blotchy red apperance) what is probability that his offspring inherit disease?

0%

normal v/q at base of the lung

0.6

what are the chances of a child having cystic fibrosis when: Father has disease. Mother's brother has disease, but she does not.

1/3 Chance mother passes allele to child is 1/3. Chance Dad passes allele to child is 1. 1/3 * 1 = 1/3

normal anion gap

10-14

what part of the tRNA molecule is associated with amino acid binding?

3' CCA site T loop = binding to ribosomes Anticodon loop = complementary to mRNA codon; binds to mRNA codon and assures placement of proper amino acid in growing chain D loop = facilitates correct tRNA recognition by the proper aminoacyl tRNA synthetase 5' terminal phosphate has no amino acid or mRNA binding

HCV's genome changes frequetny due to lack of

3'-5' exonuclease activity many errors are made during replication

dna pol III

5'-3' polymerase 3'-5' exonuclease

dna pol I

5'-3' polymerase and exonuclease removes RNA primer

resistance is reduced by a factor of 16. what percentage has the radius of the lumen been reduced?

50% radius is to the 4th power

Infant is 46, XY. Phenotypically male but has hypospadias and small phallus. Testes are in the inguinal area. Normal BP. Serum Testosterone is within normal limits. What enzyme?

5a-reductase internal genitalia develop normally under influence of testosterone, but external genitalia do not develop properly due to lack of DHT cause male pseudohermaphroditism

ANA vs. anti-dsDNA antibodies in SLE

ANA is found in virtaully all SLE patients but in other connective tissue disorders; test is *sensitive for SLE* anti-dsDNA are *specific* - only 60% of SLE patients have anti-dsDNA titers, thus absence of anti-dsDNA does not rule out diagnosis

febrile neutroepnia and what organisms are there increaesd ifnectiosn with?

ANC<500 with high temp increased gram-negative organisms

fixed, wide splitting of S2...

ASD - allows equalization of L/R atrial pressures, thus minimizing the respirotary variation in L/R ventricular blood flow

common causes of spotenous intracranial hemorrahge in young adults

AV malforation ruptured cerbeal anerusym abuse of sympathomimetic drugs (cocaine)

what is the most common cause of intracranial hemorrhage in chidlren?

AV malformation

CD4 count is 122. Testing for HLAB*57:01 is positive. This finding is considered relevant for what drug?

Abacavir - NRTI a engaitve test for the allele has a 100% negaitve predictive value for AHR

upper GI series for malortation and volvulus and shows normal rotation but constriction of duodenum. Abdominal CT reveals pancreatic tissue encircling the duodenum. What is causing this condition?

Abnormal migration of ventral pancreatic bud - Annualr pancreas Ventral prancteic bud is foregut derivatve that apepars by 5th week of gestation and rotates behind duodenum during 7th week of fetal development ventral bud moves twoards midline where it fuses with dorsal pancreatic bud during 8th week ventral bud gives rise to uncincate process and main pancreatic duct abnormal mgiration of ventral pancreatic bud can be cause dby adherence to either the dorsal bud or duodenum before the rotation begins This abrnomal mgiration leads to annular pancreas, a rare congenital anomaly in which pancreatic tissue surrounds second part of duodenum

Patient has vitilgo. What happens to the melanocytes?

Absence of melanocytes in skin and complete absence of melanin pigment

early penicllin treatment for group A strep prevents what?

Acute rheumatic fever has NO effect on PSGN

acute stress disorder vs. Past traumatic stress diroser

Acute stress disorder = *3 days - 1 month* PTSD = *>1month*

what characteristic of acute post-strep glomerulonephritis is associated with poor long term prognosis?

Adult onset

mitral stenosis patient - when is the opening snap heard?

After the mitral valve opens during diastole

lissencephaly

Agyria - congenital absence of gyri severe mental retardation and seizures brain has smooth appearance

type IV collagen disease in kidney

Alport syndrome a nephritic syndrome

60 y/o man is given a drug that is known to rpolong QT interval. however, the drug is assocaited with lower incdience of torsade de points than other QT prolonging agents. What medication?

Amidoraone drugs the prolong cardiac action potential (class IA and III) will cause porlongation of QT - proongation increases risk for torsades Amiodarone has very little risk of inducing torasades

22 y/o with acute intermittent porphyira. patient receives IV infusio of heme rpep that results in rapid resolution of symptoms. Treatment induced down regulation of what enzyme?

Aminolevulinate synthase

what is drug of choice for Lymes disease in patient under 8 years old?

Amoxicllin adults = doxycylcine

paraventricular nucleus of hypothalamus

ADH CRH oxytocin TRH

acute mitral regurgitation Afterload: preload: LV-EF:

AF: decrease (low resistance reguritant flow pathway for blood into lA) PL: increase (reguritant blood + normal pulmonary venous return) LV-EF: increase (increased preload and decreased afterload increase ejection fraction); however much of SV is lost to reurgitation into LA, thus reduced cardiac output (hypotension, cardiogenic shock)

64 y/o with flank discmfort and red urine. PMH - HTN, T2DM. Three months ago, patinet had ischemic stroke and mild residual R sided weakness. Serum Cr 0.9, and serum lactate dehydrogenase is elevated. Urine has RBC. Cause?

Atrial fibrillation flank pain, heamturia, elevated lactate dehy (cell necrosis) and wedge shaped kidney lesion = *renal infarction* msot common cause of renal infarction is systmeic *thromboembolism* systemic thromboembolism commonly occurs with *atrial firbillation* small number of colalterals between segmental renal arteries (end organ blood supply) means that blood flow interruptions can lead to *coagulative* infarcts Macro - *pale wedges*

differenitating between aortic stenosis and mitral insufficiency. Handgrip

Aortic stenosis = decreases intensity mitral regurgitation = increses

what are the first tests to order when Giant Cell Arteritis is suspected?

CRP ESR althoguh nonspecific, they are highly sensitive and almost always ignifcantly elevated in GCA

a case control study is designed to evaluate the department officials claim that exposure to chemical wast eis associated with AML in childhood. Which population should be selected as the control group?

Children who do *not* hvae AML, *regardless* of exposure status to chemical waste Case control studies compare a group of people with dsiease to a group without disease Looks to see if odds of prior exposure or risk factor differs by disease state

44 y/o undergoes cholecystectomy without any complications. Two days after admission - anxiety, tremulosness and agitation (alcohol withdrawal). NKDA, FH insignficant. PE - hand tremors bilatearlly. Most appropriate treatment?

Chlordiazepoxide Benzodiazpines are 1st line for pyschomotor agitation assoociated with alcohol withdrawal and to prevent prgoression to seizures and delirium Long-acting benzos are preferred (Dizepam, Chlordiazepoxide) due to self tapering effects resulting in smoother control of withdrawl

65 y/o is diven diazepam for muscle spasticity. What other drug should be used in caution?

Chlorpheniramine - first generation antihistamines Diphenhydramine promethazine hydroxyzine

30 y/o with Adult Polycystic kidney disease presents to ED with sudden onset headache and onfusion. No meningeal signs of focal signs. Ct shows blood in subarahcnoid space. 5th day after admission, patient has weakness in right and leg. What could have prevented this

Calcium channel blocker - patient has vasospasm *Nimodipine* prevents vasospasm

most common cardiac malformation in patient with Turner syndrome?

Bicuspid aortic valve - early systolic, high frequency clock heard over 2nd R-ICS

Three weeks after laceration, actin contianing fibroblasts and increased MMP activity at injury. Related to?

Contracture

Woman was in MVA. Restrained and denies hitting head, but has abdominal pain and nausea. BP 115/55, P96 PE - ecchymosis over seat belt area CT - retrpoeritneal hematoma Injury?

Conutsion of body of pancreas - *retroperitoneal hematoma*

what injury is common in newborn during shoulder dystocia when force is applied to shoulder/arm to free shoulder from pubis?

Erb-Duchenne palsy head is stuck against pubis, causing traction injury to superior rbachial pelxus

best drug for absence seizures? best drug for absence + tonic-clonic seizures?

Ethosuximide Valproate

flat, yellow, hexagonal kidney stones

Cystinuria autosomal recessive disorder affecting the high affinity, sodium independent dibasic amino acid transporter found on the apical membrane of intestinal and proximal renal tubular epithelial cells this prevents dibasic amino acid (cystine, orntinthine, lysine, arginine) from being reabsorbed in proximal renal tubules, leading to urine supersaturation with cystine and formation of cystine stones sodium cyanide-nitroprusside test is qualitative screening test that detects the presence of urinary cystine tx = urinary alkalization (e.g., acetazolamine)

activation/inactivation of 6-mercaptopurine and 6-thioguanine

Cytotoxic purine analogs that inhibit de novo purine synthesis Activated by HGPRT inactivated by XO and TPMT (thiopurine methyltransferase) effect of XO on 6MP metabolism is so significant that chemotherapy doses must be reduced by 75% if patients are on XO inhibitor allupurinol

29 y/o with fever, skin rash. Just returned from Brazill. Symptoms began 5 days ago with headache, retro-orbital pain, high fever, joint/muscle ackles. Shes had 1 episode of epistaxis. Skin rash all over her body - maculopapular and scattered petechiae. Labs show thrombocytopenia.

Dengue Fever - virus transmitted by Aedes aegypti mosiquto prevalent in tropical and subtropical regions DF presents as acute febrile illness with headache, retro-orbital pain, and joint nad muscle pain Other findings can include hemorrahge, thrombocytopenia, leukopenia and hemocontration Aedes mosquite also transmits the virus causing Chikungunya Febrile illness with flulike symptoms, prominent polyarthralgia/athritis and diffuse macular rash

how does the body fight off Listeria (narrow beta hemolytic, tumbling motlity at 22C, cultured at 4C)?

Facultative intracellular - cell mediated immunity Listeria is able to lyse the vacuolar membrane through action of listeriolysin O, a pore fomring toxin that is selectively activated within acidified phagosomes in healthy individuals, listeria stimulates production of cytokines (IFNy, TNFb, IL12) that induce cell mediated immune response elading to macrophage activation and killing of intacellular Listeria people with impaired cell mediated immunity (pregnant, elderly, neonates, immunocrompised) are more vulnerable

In healthy individals, sorbital is normally metabolized into what substance before being excreted from most cells?

Fructose In process of logn standing hyperglycemia, sorbitol accumulates in tissues with lwoer sorbital dehdyrogenase acitivty, such as reinta, lens, kidney and peripheral nerves sorbital accumulation causes *osmotic and oxidative stres* and contirbutes to pathognesis of diabetic reitnopathy, neuropathy and nephropathy

what are the GFR, RPF, FF in hemodynamic shock

GFR = decreased RPF = decrased more FF = increased

ras is active when bound to?

GTP

where do splicesomes cleave?

GU = 5' splice site AG = 3' splice site

hepatitis B complete recovery serology

HBcAb IgG + HBsAb +

hepatitis B chronic carrier serology

HBcAb IgG+ HBsAg+ HBeAg+

innervation of partoid gland

IX

mechanism of Latanoprost in glaucoma

Increase outflow of aqueous humor SE - increased pigmentation in iris and eyelashes

Breslow depth

Distance from epidermal granular cell layer to depest visible melanoma cells *most important prognostic indicator in malignant melanoma*

arcuate nucleus of hypothalamus

Dopamine GHRH GnRH

Beriberi

Dry = polynerutiis, symmetrical muscle wasting wet = dry + highoutput cardiac failure (dilated cardiomyopathy) + Edema

patient with Paget disease of breast will have underling....

Ductal carcinoma in situ if nonpalpable mass invasive cancer with palpable mass

One patient receives IM vaccine, other receives live attenuated oral vaccine. One month after vaccination, levels of what antibodies would differ?

Duodenal luminal IgA

55 y/o malaise, cough 2 months. Yellow sputum with streaks of blood. Alcohol abuse wth prior binge drinking. Exam - poor dentition, dental caries, gingivitis, enarlged submandibualr nodes. Coarse rhonci in right lung. CT - right lung consoldiative process with air bronchograms.

Colonize mouth, colon, vagina and can be found in dental caries and amrgins of gums in poor denittion. Most commonly develops cervicofacial abscess but can go systemic when mucosa is disrupted *pulmonary* actinomycosis develops by *aspiration* leading to lower lobe consolidation - alcoholics increased risk Diagnosis is by *filamentoud branching with sulfur granules* which are formed by calcified mycelial fragments sulfur granules are yelow but on H&E they can appear basophilic (purple/blue) tx - penicllin

Murmur - midsystolic click that is followed by short late-systolic murmur at cardiac apex. Disappears with squatting. Related to abnoramlity involving what tissue?

Connective tissue Mitral valve prolpase with mitral regurgitation primary MVP is most commonly sporadic and cahracerized by myxomatous degenraiton (*pathologic deterioration of connective tissue*)

4 y/o boy with difficulty breathing and productive cough. PMH of recurrent sinusitis and otitis media. Cardivascular exam shows cardiac point of maximal impulse that is on the RIGHT 5th ICS. what is dysfunction in this patient?

Dynein arms Kartagener syndrome

distinguishing feature between E coli and Enterobacter in UTI?

E coli is indole positive

Congenital hydrocephalus

Etiology -congenital obstruciton (stenosis, chiaris malformation) -acquired obstruction (infeciton, posthemorrhagic) symptoms -macrocephaly -bulging fontanelle -poor feeding -developmental delay -spasticity AND hyperreflexia treatment -cerebral shunting

what will be electrolyte and fluid status in a patient with chronic SIADH from small cell lung carcinoma?

Euvolemic hyponatremia

LA - enarlged LV mass - increased LV thickness - increased underlying condition?

Long standing HTN - *cocnetric left ventricular hypertorphy*

17 y/o with seasonal allergies should be treated with?

Loratadine (Claritin) 2nd generaiton antihsitamine that does not cross the BBB and therefore does not cuase much sedation as first generaiton drugs Other 2nd gen = Fexofenadine, Desloratadine, Cetrizine

iron deficinecy anemia: MCV: Fe: TIBC:

MCV: low Fe: low TIBC: high

anemia of chronic disease: MCV: Fe: TIBC:

MCV: normal Fe: low TIBC: low

68 y/o with back pain. Thinks she pulled a muscle while getting out her car. no leg numbness or weakness, btu reports maliase and fatigue. patient has HTN, T2DM and was treated several weeks ago for staphlyococcal abcteremia associated with dialysis catheter. T100.4. Tenderness over upper lumbar vertebare without skin cahnges. Straight leg test is negative. Next step in amangement?

MRI of spine localized back pain, low grade fever, recent staph ifneciton = *vertebral osteomyelitis* *Bacteremia* due to intravascualr devisions (eg. hemodialysis catheters) increases risk of helath care realted vertebral osteomyelitis Vertebral osteomltisis should be suspected in patients with new or worsening back pain, and recent endocarditis or abcteremia (espeically S. aureus) inital evaluation inlucdes *blood cultures and MRI* of spine

45 y/o man with suicide ideation. Past month he has been depressed, withdrawn and restless. Has lost 10lbs, difficulty falling and staying asleep. During this time he said he is responsible for evil in world and heard a voice telling him he does not deserve to live. Diagnosis?

Major depressive disorder with psychotic features the diagnosis is differentiated from psychotic disorders in that the psychotic symptoms are present only during episodes of major depression

Pityriasis versicolor

Malassezia species infeciton confined to stratum corneum of skin KOH prep - *spaghetti and meatballs*

64 y/o with persistent back pain, constpiation, and easy fatigability for last several months. BP 115/75, P88. Dry mucus membranes. Renal biopsy - atrophic tubules, many with large, obstructing, intesnely eosinophilic cats. Diagnosis?

Multiple myeloma fatigue - anemia constpiation - hypercalcemia bone pain - bone lysis via osteoclast activaitng actor elevated serum protein - monoclonal proteins renail failure

bacterial fail to stain with hydrochloric acid and alcohol after stianing carbolfushin. what cell wall component is missing?

Mycolic acid

Eaton agar

Mycoplasma pneumonia

40 year old female presents of progressive muscle weakness with myotonia. PMH is diabetes type 2, cataracts. Patient takes long time to release grip of handshake. Disease and mechanism

Myotonic dystrophy type 1 Trinucleotide (CTG) repeat characterized by skeletal muscle weakness and myotonia Cardiac conduction abnormalities, cataracts, testicular failure, excessive daytime sleepiness, hypogammglobulinemia, impaired sleep, insulin resistance In myotonic dystrophy, anticipation occurs due to instability during maternal meiosis, meaning that it will occur when inherited from mother

under hypoxic conditiosn what inhibits pydruvate dehydrogenase?

NADH shunts pyruvate down to lactate to regenrate NAD+

locus ceruleus

NE-secreting neurons Dorsal pons

receptor affected by PCP

NMDA-ANTAGONISM

do patients with Asherman syndrome experience progesterone withdrawal bleeding?

No

K waves and sleep spindles are associated with what stage of sleep?

Non-REM Stage 2 sleep

bilateral pontine hemorrhage, what pigmented neurons are involved?

Norepinephrine neurons in locus cereleus Lateral floor of 4th ventricle Posterior rostral pons

how many monomers does myoglobin have and what does its curve look like?

One hyperbolic

48 y/o woman with weakness. Worsened over 3 motnhs. Difficulty climbing stairs, getting up from chair, placing dishes overhead. 10lbs weight loss, subjective fever, abdominal discomfort. PE - weak shoulders and hips. Image shows Gottron's papules. Whatis the condition underlying?

Ovarian adenocarcinoma Dermatomysotis is systemic autoimmune dsiease characterized by proximal muscle weaknes, resembling polymyositis, but with additional features involving skin - heliotrope rash of peri-orbital and Gottron's papules (raised eryhematous plaques over joint and prominences of hands) muscle biopsy will show perimysial infilitrates, perifasciular atrophy and patchy necrosis dermatomysoitis can occur alone or as PARANEOPLASTIC (ovarian, lung, colorectal, non-Hodgkins)

Estimation of patient renal blood flow

PAH clearance / 1 - HCT

oculomotor nerve. Where is parasympathetics vs. motor innervation?

Parasymapthetics = outer portion of nerve motor = inner portion of nerve thus motor is more affected by diabetic ischmiea

25 y/o with symmetrical swelling and pain in PIP, wrist, knee joints. 5 y/o son saw pediatrician last week for facial rash and fever. Patient returns 4 weeks later without symptoms. Cause?

Parovirus B19 infeciton children - *erythema infectiosum* adults - *acute symmetric arthropathy*

transvaginal US shows interuterine gestational sac without fetal cardiac activity, adn a dialtion and curettage is performed. Pathology shows fetal itssue, focal trophoblastic hyperplasia, and some enarlged villi intersperedw with normal villi.. Diagnosis?

Partial mole

First dose hypotension is likely to occur in what patient when starting ACE inhibitor?

Patient who is volume dpleted (eg. from diruetic use) or heart failure

what is the most common cranial nerve lesion associated with sarcoidosis?

Peripheral 7th nerve palsy (Bell's palsy)

STK-11 gene

Peutiz-Jeghers syndrome AD - 3rd decade Multiple hamartomatous polyps of GI tract

location of AV node

RA near septal cusp of tricuspid

76 y/o with severe insomnia for several months. In addition to non pharmacologic internvetions for insomnia, short term pharmacologic therapy is being consisdered with?

Remlelton - melatonin agonist few side effects, and no dose adjustment for elderly

what female reproductive ligament needs to be ligated during oophorectomy?

Infudiublopelvic (suspensory ligament of ovary)

What HLA class II component is digested by macorphages during antigen processing?

Invariant chain

what type of receptor does GH use?

JAK/STAT --> increaesd IGF1

erythropoietin receptor is....

Janus kinase 2 (JAK)2 - *cytoplasmic (non-receptor( tyrosine kinase*

What is different between the two strands being synthesized from a replciation fork?

Joining of DNA fragments by ligase one strand is continously synthesized wheras the other is pieced together in Okazaki fragments by DNA ligase Okazaki fragemnts are short stretches of newly synthesized DNA that are separted by RNA primers

serum abnomalirites in DKA K: Na: glucose:

K: increased Na: decreased Glucose: increased

On PE patient cant feel dermatome on left at L5. 0/5 muscle strength in right lower extremity. Absent right sided patellar and achielles reflexes. Where is the lesion?

L3 Brown-Sequard syndrome Loss of ipsilateral UMN function below level of lesion Loss of posterior columns ipsilateral to lesion Loss of contralateral pain and temperature 2-3 levels below lesion

Neuro exam: Dysarthria loss of pain/temp from R face loss of pain/temp from L body artery?

Right Posterior inferior cerebellar artery - Wallenberg syndrome

Man with severe left leg pain after minor laceration to leg 2 days earlier. Temp is 103, BP 85/45. PE - left leg is swollen and firm with eryhtema of overlying skin. Small wound drianing blood tinged exudate on his left calf. Gram stain = gram+ cocci, wie zone of hemolysis. Coagulase and catalse are negative, PYR is positive. Organism?

Streptotoccus pyogenes necrotizing fasciitis C. perfreinges = double zone of beta hemolysis

what side colon cancers are slow growing, bulky masses that protrude the colonic lumen and more likely to bleed causing iron deficiency anemia?

Right sided colon cancer

Man with 8 months of SOB. Xray - nodular desnities in both lungs prominent in apical regions. Calcificaiton of hilar lymph nodes is seen. bronchoscopy of calcified node is performed and shows birefrignent particles surrounded by dense collagen. Exposure ot what?

Silica

Anti Ro (Anti-SSA)

Sjogrens syndrome

what is best auscultatory finding for severe Mitral regurgitation?

presence of an S3 gallop in cases of severe MR, the left ventricular S3 gallop reflect an increased rate of LV filling due to large volume of regurgitant flow re-entering the ventricle during mid diastole incorrect = intensity of MR murmur; regurgitant volumes are associated with larger regurgitant orifices - these larger orifces decrease the systolic transvalvular pressure gradient and cause the regurgitant jet to move at a slower velocity, reducing murmur intensity

6 y/o boy with hemophilia presents with bleeding. Currenlty, hemostasis in this patient can eb achieved by administration of?

Thrombin in absence of factors VIII or IX, activaiton of factor X and subseuqnet conversion of prothrombin into thrombin do not occur administering thrombin, will make up for deficiency and lead to blood clotting

Receptor proteins are isolated and purified from a homogenized tissue sample. Detailed structural analysis shows that one of the proteins contains a 30-amino acid motif coordinating a zinc molecule. Receptor of what hormone would contain this?

Thyroid hormone zinc-finger structure represents the most commonly identified DNA-binding domain in humans Intracellular receptors located in cytoplasm or nucleus can act directly as transcription factors Once bound to their ligand, these receptors bind directly to DNA via zinc fingers to regulate gene expression Examples: -steroid: estrogen, aldosterone, cortisol -thyroid -fat soluble vitamin

single bolus of propofol provides adeqaute sedation for procedure, and he becomes clinically alert several minutes after administration. What explains rapid recovery from anesthesia?

Tissue redistrubtuion of drug

mechanism of C diff toxins

Toxin A (enterotoxin) and toxin B (cytotoxin) Both act synergistically in colitis pathogenesis, although toxin B is more virulent Toxins bind receptors on intestinal mucosal cells and are internalized, allowing them to exert their effects bot toxins INACTIVE RHO-REGULATORY proteins involved in signal transudction and ACTIN CYTOSKELETAL STRUCTURE maintenance as a result toxins cause disruption of intercellular tight junctions leading to cell rounding/retraction and increased paracellular intestinal fluid secretion

pelvic exam shows severe cervical inflammation and a foul-smelling, thick, green, frothy discharge in the vaginal vault

Trichomonas vaginalis Motile protozoan most common STI worldwide Tx = metrinidazole - forms free radicals that damage DNA

common side effects of methotrexate:

Ulcerations - oral, GI mucosa Alopecia Pancytopenia hepatotoxicty pulmonary fibrosis affects rapidly turning over cells

15 y/o boy with 3 months of periodic, sudden onset jerking movements in both arms. Occur in early morning, soon after awakening and aggravated by sleep deprivation. FH = seizure disorder in uncle best initial treatment?

Valproic acid patient has myoclonic seizures due to juvenile myoclonic epilepsy, form of idiopathic GENERALZIED epilepsy that may be familial Because juvenile myoclonic epilepsy if rom of generalized epilepsy, treatment should include a broad spectrum agent such as VALPROIC ACID

5 y/o boy cant stop eating. His pediatrician is concerned of possible CNS involvement. What lesion in hypothalamus

Ventromedial

Polycythemia multiple cysts in pancreas in kidney hypertension

Von-Hippel Lindau disease

synovial fluid in rheumatoid arthritis

WBC moderately elevated RBC count is fairly low glucose level is low

conjuagtion

process in which DNA is passed from one bacterium to another by direct cell-cell interaction

step viridans virulence mechanism

produces insoluble extracellular polysacchairdes (dectrans) using sucrose as substrate Allows the bacteria to adhere to tooth enamel and fibrin-platelet aggregates on damaged heart valves

epoprostenol

prostacylin angol used in in pulmonary HTN

killin vaccines

rabies influenza polio hepatitis A

brainstem cranial nerves

remember to look exactly where the arrows are going

cotton wool spots

retinal ischemia foci

IL-3 function

secreted by T cells support growth and differentiation of bone marrow stem cells

cryptochordism increased risk in what tumor?

seminoma

what lab test should be run before starting a patient on *amiodarone*

serum TSH 40% iodine by weight - am*iod*arone

what should be routinel monitored in patient taking amphotericin b?

serum potassium and magnesium levels *renal toxicity*

what stage of sleep do night terros occur

stage N3

gram positive cocci in clusters

staphyloccocus

stafford disaster relief and emergency plan

state must implement action and admit that they need federal help to correct the problem

superior displcaement of medial clavicle after fracture is cause dby what muscle?

sternocleidomastoid m.

sublimination vs. displacement

sublimination - mature defense mechanism - channels unaccetapble, angry impulses into socially acceptable action displacement - feelings associated with one situation/person are inappropriately shifted to another

angioedema

sudden swelling of dermis, subcutenous tissue, mucosa, and submucosa if severe, may lead to airway obstruction

normal pressure in the right ventricle

systolic = 15-30 diastolic = 1-6 RA = 1-6

dorsal pancreatic bud

tail body head (most) small accessory duct

lymph from: testes scrotum glans penis

testes: para aortic scrotum: superifical inguinal glans penis: deep inguinal

what section of the sarcomere lengthens with increased preload?

the "I" band - thin filaments both I band and H band lengthen as sarcomere relaxes

what is a low HCO3 in DKA from?

the acid combines with HCO3 decreasing its concentration it is *not* from increased HCO3 excretion by the kidney

Exam - L2 F RL SL what point should be stabilized prior to performing seated articulatory treatment?

the vertebrae below dysfunctional segment must be stabilized to allow physiican to take the joint in question through full ROM using torso as level dysfunctional vertebrae = L2 So *L3* should be stabilized at spinous process if you wre doing lateral recombant then L2 would be stabilzied to move L3 through full ROM to treat L2 segment

what blood type has increased gastric tumors?

tpye A

since all human cells posses the entire genome, how do different tissues express different genes?

transcirptino factors

midrodrine MOA

a1 receptor agonist

Hepatitis B and C virus mechanism of increased HCC

active hepatitis caues chronic liver cell injury and *regenerative hyperplasia* which results in increased number of hepatocyte cell divisions This increases chance for genetic mutations taht can induce malignant transformation HBV = DNA HCV = RNA

what is *positive pressure ventilation* used to treat

acute respiraotry distress syndrome

patient on ventilator treated for sepsis. suddenly has decreased oxygen levels and increased CO2 levels. What happened?

acute respiratory distress syndrome - increased dead space ventilation

what cancer is someone with porcelain gallbladder at increased risk for?

adenocaricnoma of the gallbladder

best way to prevent acyclovir induced nephropathy

adeqaute hydration

how to prevent contrast induced nephropathy?

adequate hydration

bronchoalveolar lavage fluid from healthy person has elastase. Where is this enzyme from?

alveolar macrophages inactivated by tissue inhibitors of metalloproteinases (TIMPs)

what antidepressant can be used for migraine prophylaxis?

amitriptyline

what is the treatment for intractable and ditressing tourette syndrome

antipsychotics - D2 receptor antagonism risperdal

what could cause falsely low HbA1c levels

any disease that has increased RBC turnover (e.g., B-thalassemia)

branches of common iliac

as aorta courses through lower abdomen, it divides into common iliac arteries, which branch into internal and external iliac arteries inferior epigastric a. is 1 of 2 branches of external iliac artery and takes off immediately proximal to inguinal ligament (external iliac becomes common femoral once it passes the inguinal ligament) as inferior epigastric runs SUPERIORLY and medially up the abdomen, it provides blood to lower anterior abdominal wall other main branch off external iliac is deep circumflex iliac a., which branches more laterally but also supplies lower abdominal wall

how do sympathetic fibers reach the eye?

ascend with internalc artoid artery through the carotid foramen joint with opthalmic division of V1 and procedes through the *superior orbital fissue*

transduction

bacterio-phase mediated transfer of genetic informaiton

characteristic findings of acid reflux

basal zone hyperplasia elongation of lamina propria ppaillae scattered eosinophils

colorectal carcinoma in setting of uclerative colitis compared to sporaid colorectal caricnoma will exhibit what feature?

be multifocal in nature colitis associated caricnoma is more likely to: affect younger patients progress from flat and non polypoid dysplasia appear mucinous and/or ahve signet ring morphology develop eraly p53 mutations and alte APC gene mutations (opposite of sporaidc) proximal colon (espeiclaly Crohns disease or concurrent PSC) be multifocal in nature tend to be higher grade with more anaplasia

45 y/o woman has on nodule palpated on right lobe of thyroid gland. Painless. No other symptoms. Most likely?

benign adenoma

treatment for persistent night terrors

benzodiazepine

what do you give someone with drug induced parkinsonism?

benztropine, trihexyphenidyl Centrally acting anti-muscarinic

midbrain ptosis...

bilatearl both levator palpebrae are innervated by single nucleus

vitamin K deficiency

bleeding diathroses

loss of sensation in perineal area indcates....

cauda equina syndrome epidural cord comrpession from malignancy patients develop urianry retention late in course of disease, usually associated with fecal incontince

trochlear nucleus

caudal midbrain nerve exits at dorsl midbrain just below inferior colliculus (below red nuclues)

contact inhibition

cells on a growth plate normally stop growing when they cover the surface of the plate malignant cells will begin to pile up on top of each other

an overdose of acetaminophen is most likely to result in which of the following changes to the liver?

centrilobular necrosis toxic levels deplete glutahione stores and allow accumulation of free radicals damage to hepatocytes by these free radicals causes centrilobular as well as diffuse necrosis in the liver

gray pseudomembrane on bak of throat

corynebacterium diphtheria

public health service act

coverage for major disasters

CT associated with subdural hematoma

crescent shaped area of bleeding on head CT

mechanism of Zenker diverticulum

cricopharyngeal motor dysfunction

What is a regular activities recommended for type 2 diabetics?

daily foot sinepction

what do you give someone in neuroleptic malignant syndrome?

dantrolene

what is the treatment for neuroleptic malignants yndrome (patient overdosed on rispeidrone - atypical antipyschotic)

dantrolene

fetal growth restriction how was prenatal testing

decreased estriol

what is the mechanism that causes lactase deficiency later in life?

decreased gene expression

patient in septic shock with lactic acidosis. what is most likely cause of increased anion gap?

decreased oxidative phosphorylation

72 y/o man with long standing aortic stenosis. ECG shows new onset afib without ST elevation. Patient has pulmonary edema what hemodynamic change is most likely?

decreased preload patients with aortic stenosis rely on the atrial kick to have sufficient preload due to the decreased compliance of the LV When patient goes into Afib there is a buildup of fluid in the atria causing the pulmoanry edema

mechanism of action of carbidopa

decreases plasma dopamine levels by inhibiting DOPA decarboxylase increases the bioavailability of levodopa for the brain carbidopa reduces amount of levodopa required to produce a given response by 75% increases both half life and plasma levels of levodopa and decreases plasma and urinary dopamine levels

diffusion capacity in severe emphysema - increased or decreased?

decresed

test to assess toxicity of magneisum sulfate

deep tendon reflexes increased mg decreases impulse transmission acrross NMJ, producing S/S of neuromuscular toxicty Becuase loss of DTRs always apepars before respiratory arrest and coma, it is of the utmost important to continually test for them Reversal of toxicity = calcium gluconate

where are the stem cells of the gut

deepest portiosn of crypts of Liberkheun

refsum disease

defect in peroxisomal alpha oxidation neurologic disturbance in response to accumulation of phytanic acid in body Tx = strict avoidance of chlorophyll in the diet

allergic reaction is associated with what change in skin?

dermal edema

what is mechanism of tetrology of fallot?

deviation of infundibular septum abnormal neural crest cell migration leads to anterior and cephalad deviation of infundibular septum during development, resulting in maligned VSD and overriding aorta

characteristics of learning disorder

difficulty with learning key academic skills problems manifest at school age when these skills are being acquired and performance is well below average for age many children display anxiety, inattention or hyperactivity when under stress to perform in an area of weakness teased in school --> school avoidance

sensory loss of obturator nerve injury

distal medial thigh

what is the mechanism of antiseptic of isopronaol

disurption of cell memrbanes, denature proteins chlorhexidine - disrupt cell memrbanes, coagulation of cytoplasm used in surgical and percutenous procedures; contraindcated in neuro, otologic and opthalmologic due to neurotoxity Hydrogren peroxide - free radicals that oxidze cell components (sporicidal) used for skin clensine and wound debridement Iodine - halogenation of proteins and nucleisc acids (sporicidal)

differing features of E coli O157:H7 from other E coli strains

does not ferment sorbitol does not produce glucuronidase EHEC elaborates a Shiga-like toxin - inactivate the 60s ribosomal subunit in human cells, leading to an inhbition of protein synthesis and evenutal cell death

substantia nigra

dopaminergic neurons

12 y/o patient bitten by stray cat. has cellulitis. allergic to sulfa drugs and penicllin. what do you give?

doxycycline - Pasteurella multicodia infection dont give ceftriaxone due to 10% cross reactivity dont give flouroqinolones to young children due to tendon reupture

superficial inguinal lymph ndoes

drain nearly all cutenaous lymph from umbilicus to feet - icnluding external genitalia and anus (up to dentate line) *exceptions*: testis - para-aortic glans penis - deep inguinal cutenous portion of posterior calf - deep inguinal

treatment of xerosis

dry skin (winter itch) moisturize directly after bathing

where is iron absorbed?

duodenum

difference between dysplasia and carcinoma

dysplasia is *reversible*

how is cardiac output maintained in aortic regurgitation?

eccentric hypertrophy of LV gradual increase in LV chamber size increases stroke volume and maintains cardiac output acute AR - small LV cavity, cannot increase stroke volume --> decline in cardiac output, rapid increase in LVEDP --> acute pulmonary edema

how are most efflux pumps in bacteria energeized

efllux pmping is an active, energgy requiring process most antibiotic efflux pumps are pwoered by moving proteins (hydrogen ions) along their concetration gradient out of the cell coupled with simulatenously expelling the anbiotic against its concetrationg radient

what patients are at risked for developing reactivaiton of varicella?

elderly immunocompromised = HIV

lab diagnosis of digoxin toxicity

elevated potassium

Bosentan

endothelin receptor antaognist that blcoks effects of endothelin (potent vasoconstrictor taht also stimualtes enodthelial proliferaiton) bosentan decreaes pulmonary arterial pressure and lessens progression of vascular and RV hypertrophy

gram positive cocci in chains

enteroccocus -*gamma hemolytic* - no hemolysis

gemma hemolytic (no hemolysis) oragnisms

enterococci - saline and bile s. bovis - bile

what E coli associated with: bloody diarrhe w/ WBC and fever that ferments sorbitol

enteroinvasive EHEC is not correct ebcause it doesnt invade, so there is no fever or WBC in stool

activation of phosphorylase kinase (enzyme for phosphorylation of glycogen phosphorylase) in the liver

epinephrine and glucagon bind to Gs receptor increase cAMP phosphorylation of PK

viral recombination

exchange of genes between 2 chromosomes via crossing over within homologous regions resulting progeny can have recombined genomes with traits from both parent viruses

cervical biopsy shows high grade cervical intrapeithelial neoplasia. What is the histopathology?

expansion of immature basal cells to epithelial cells to epithelial surface

31 y/o man with tonic-clonic seizure. Grew up in Guatemala, immigrated 3 years ago. Works as architect and owns a cat. Afebrile and no focal deficits. HIV and IFN-y assay are negative. Chest x-ray is normal MRI of brain = 2.5cm cyst within left sylvian fissure that has minimal enhancement and no edema. how did get this?

exposure to infected stool neurocysticercosis Taenia solium (pork tapework) eggs excreted in feces of human carries Common in Central and South America Prolonged incubation (years) Seizures CT/MRI - cysts, scolex Eoosinopholia Tx = albendazole

what gives elastin its rubber like properties

extracellular cross linking

where does *protelytic processing* and *cross linking of lysine-hydoxylysine* for collagen occur?

extracellular space

patient complains of increased noise from everyday sounds.. what nerve?

facial n - stapedius m.

increased Acetylcholinesterase in amniotic fluid suggest?

failure of fusion of edges of neural plate

compartment syndrome

fascia is inelastic and limits outward expansion of contracting muscles if the pressure in a compartment increases, the circulation within it can be compromised, leading to severe pain and eventual tissue ischemia Etiology - long bone fractures, crush injury, thermal injury or nontraumatic causes (bleeding disorder, vascular disease) Tx = early diagnosis and surgical decompression (fasciotomy) of involvement compartments are necessary to prevent permanent disabling injury (myonecrosis, nerve damage, amputation) most common site = anterior compartment which includes the foot extensor muscles, ANTERIOR TIBIAL a., DEEP PERONEAL n. deep posterior compartment has posterior tibial a., peroneal a., tibial n. lateral compartment = superficial peroneal n. and proximal part of deep peroneal n.

patient is put on Olanazpine. At her 3 month check up what should her labs be?

fasting glucose and lipid panel

what is immediately lateral to a femoral hernia?

femoral vein superior = inguinal ligament medial = pubic tubercle

foam stability index is used for?

fetal lung maturity amniotic fluid is placed in a containing with ethanaol and shuken is a *foam ring* appears, lungs are mature

what lines a pancreatic pseudocyst?

fibrous and granulation tissue fibrosis, thickening and orangization of walls over time formation of firm fibrotic pseudocyst walls takes about 4-6 weeks following episode of acute pancreatitis

35 y/o woman with severe heartburn refractory to antacids. Scattered telangiectasias on face, severl ulcers at tips of fingers and small calcium deposits in soft tissues of ahnds and elbows. cause of heartburn?

fibrous replacement of muscularis in lwoer esophagus

what drug and prevent androgenic alopecia?

finasteride

child who can not copy a circle or stick figure at age 3

fine motor delay

fasting and glucongeosis times

first 12 hours = glycogenolysis after 12-18 hours = gluconeogensis

stages of pCR

first heating = denature cooling = primers attach rewarmed = heat stable *taq* DNA pol synthesizes new complementary DNA strand

prognosis of hemangioma

first increase in size and then regress

what part of the dudoenum has glands that secrete HCO3?

first part of dueonum - *submucosal Brunner glands*

where are the reactions for de novo pyrimidine/purine synthesis?

first reaciton of pyridmine is in cytosol and then rest is in nucleus purine synthesis is in the cytosol

patient started on androgen derpivation therapy for adnvaced prostate cancer. what drug?

flutamide

tissue distribution of highly lipophilic drugs propofol exmaple

following bolus infusion, propofol si rapidly cleared from plasma and *preferenitally distributed* to oragns receiving *high blood flow* This inital distbrution accounts for rapid onset of sedation seen with administraiton over time propfol is *redistributed* to organs receiving less blood flow (fat, muscle)

distrbution of drugs in body due to blodo flow

follwoing IV administration, a highly lipophilic drug will eb rapidly disitrbuted to organs with high blood flow - brain, liver, kidneys, lungs the drug is then redistirbuted to tissues with realitvely lower blood flow - skeletal muscle, fat, bone

vertebral arteries enter through...

foramen magnum

cholesterol granulomas in middle ear

form after hemorrahge bluish black gelatinous material behind tympanic membrane

pseudomonas in cystic fibrosis

forms biofilms

mechanism of biliary slude

gallbladder functions to actively absorb water from bile conditions that cause gallbladder hypomotlity result in excessive dehydraiton of bile this promotes precipitation and accumulation of particualte material in bile, forming viscous *biliary slude*

how to treat decreased testosterone levels in mumps infection

give testosterone

patients with medically intractable symptoms of Parkinsons may benefit from high frequency sitmulation of...

globus pallidus itnernus subthalamic nucleus high frequency stimulations *inhibits firing of these nuclei* this causes increased activity in downstream nuclei, resulting in *thalamo-corticla disinhibition* with imrpoved mobility

skin disease of of smooth shiny papules or plaques arranged in ring or cluster

granuloma annulare cluster of T cells below the skin can be see in healthy people or associated with diabetes, thyroid, lupus and other autoimmune diseases the lesions are often asymptomatic or can be pruritic

spread of psoas abscess by direct conitnuation can lead to abscess formation where?

groin psoas does not enter true pelvis decesncdes from T12 to insert on lesser trochanter of fermur

what is the etiolgoy of dystrophic calcficaiton?

hallmark of cell injury and death occuring in all types of *necrosis* in the setting of *normal calcium levels*

when does aortic regurgitation increase in sound?

handgrip - increased afterload

what is the reasoning that heparin is better than warfarin in pregnancy?

heparin has incrased water solubility and cant cross the placenta

BMPR2

hereditary pulmonary HTN BMPR2 normally inhibits vascular smooth muscle proliferation

what infection in eryhtema mulitform most commonly associated with?

herpes simplex virus EM is a systemic IMMUNE response to a localized infection - it DOES NOT represent disseminated ifnection

salivary gland excretion high vs. low flow

high = resemble plasma low = loweer NaCl, higher K more contact time with the ductal epithelail cells

what is the first area damaged during global cerebral ischemia?

hippocampus

in huntingtons, loss of huntingin causes increased...

histone de-acetylation --> DECREASED gene expression

what to ask a patient who all of a sudden feels extremely energized after starting Sertaline (SSRI) within first couple of doses?

history of mania rapid response to SSRI is suggestive of treatment emergent mania (antidepressants typically take 2 weeks to take effect)

what type of gland is the sebaceous gland in acne

holocrine - cell lysis and relases all of its contents

lens disaplcement: homocysinuria marfans

homocystinuria - downward marfans - upward

arcuate line

horizontal line lcoated below umbilicus that demarcates lower limit of posterior rectus sheath above = recutus abdomnisis surrounded by anterior and posterior sheaths below = muscle only covered by anterior sheath

patient is hypovolemic what types of casts will be in the urine

hyaline casts

the conversion of alpha helices to beta sheets involves the breaking and reforming of ____________________

hydrogen bones - prinicpal stabilizing force for seondary structure of proteins

narcolepsy is associated with a decrease in:

hypocretin (orexin)

hypomanic vs. manic time frame

hypomanix = 4d-1w manic = >1w interfering with life 1

risk factors of sleep apnea

hypothyroidism large neck circumference obesity male gender narrowed airway use of alcohol or sedative family history

patient has Na of 129 Supine 120/80 Seated 118/75 Standing 97/72 physiologic state?

hypovolemic hypotonic hyponatremia

promyelocytes

immature myeloid cells

psoas CT

immediately lateral to vertebral bodies

what causes the symptoms in Reactive arthritis?

immune complxes ivolving bacteiral atngeins

pathogenesis of diffuse esophageal spasm

impaired inhibitory neurotransmission

how does elevated FFA contribute to insulin resistance

impairs insulin dependent glucose uptake increases hepatic gluconeogenesis

what are the adlosterone elvels in a patient with use of a loop diuretic?

increased

what is the result of transcription from NF-kB

increased *cytokine production* disrupted in Corhn's and UC

lab values associated with PCOS estrogens in patient are most likely elevated from the?

increased LH Increased DHEA Decreased FSH increased Insulin adipose tissue by aromatase

lab testing in warfarin overdose

increased PT increased PTT normal bleeding time (platelets arent affected)

pathogenesis of gallstones in Crohn's dsiease?

increased bile acid wasting when mucosa of terminal ileum is inflamed, *bile acids are lost in the feces*

urge incontenince

increased contractions of detrusor muscle within bladder wall present with hx of involuntray urine loss wehther or not the bladder is fully, creating *random* pattern of occurences throughout the day

patient with nrphoetic syndrome. secondary changes?

increased liver lipoprotein synthesis to comepnsate for decreased plasma albumin, liver icnreaes syntehsis of proteins, including lipoproteins this increase in lipoprotien produciton, along with decreased lipid catabolism due to low plasma levels of lipoportein lipase and abdnormal transport of circulating lipid particles, conitrbuets to icnreased cholesterol, triglyceride, VLDL and LDL, apoprotein concentraitons in nephrotic syndrome

54 y/o with chronic hepatitis C is brough to ED after episodes of vomiting bright red blood. he has hepatic encephalopathy. What happened to cause this?

increased load of nitrogenous substances absorbed by the gut GI bleeding causes increased nitrogen delviery t gut in form of hemoglobin, which is converted to ammonia and asborebd into bloodstream ammonia enter liver via protal vein and detoxified to urea in chronic liver failure -- hepatocyte dysfunction and shutning through prtosystemic colaltears impairs detoxification leads to accumulation of ammonia and other neurotoxins (GABA, gluatamta, catecholamines)

thymoma CT

increased myasthenia gravis - antibodies against a NT receptor

what is the direct effect of morphine on spinal cord neurons?

increased potassium efflux out of the cells on postsynpatic membrane reduced calcium influx, decreased exitatory NT release from presnyaptic terminal

when does aortic stenosis increase in sound?

increased preload

AV shunt cardiac loop

increased preload from increased blodo entering venous system - elongation of diastolic filling segment (botomon line) and higher end diastolic volume because AV shunts allow blood to bypass arterioles, total peripheral reistance is reudced, decreasing afterload as well

consequences of acute pyelonephritis in pregnancy

increased risk of premature labor because bacterial toxins can cause early contractions Tx = ceftriaxone or cefepime or aztreonam or Ampicillin + Gentamcin

two stains used for cryptococcus

india ink (unstained) mucicarmine (stains red)

Ehrichosis

infection of WBC that divded into human monocytic ehrlichiosis and human granulocytic anaplasmosis HME is transmitted by the lone star tick, Amblyomma Americanum Infective organism is Ehrlichia chaffeensis, an obligate intracellular gram neagative bacterium HGA is transmitted by the deer tick, Ixodes scapularis and is a coinfection with Lyme disease most have history of tick bite, fever, headaches, malaise, myalgias, and rigors HME = eastern and central US HGA = eastern US, California, oregon, washington

what does a positive urease test signify?

infection with H. pylori ulceration and cancer diagnosis require biopsy

osler nodes

infective endocarditis *tender*, violaceous nodules located in pulp of fingers and toes pathogensis of Osler ndoes is immune complex deposition in skin

horizontal transection of rectus abdominis can affect what artery?

inferior epigastric arteries epigastric artery ascends the posterior sruface of rectus abdominis m. and enters latearl aspect of mucle at arcuate line because there is *no supporting posterior sheath*, ttrauma to *inferior epigastric a.* below the aruate line can cause significant hemorrhage

where does the horsehoe kidney get stuck?

inferior mesenteric artery

distal clavicle fracture. lateral side will be pulled inferolateral by: medial side will be pulled superomedial by:

inferolateral: deltoid superoemdial: sternocledimastoid

mechanism of oxalate kidney stones in Crohn's disease

inflamed ileocecum decreased absorption of bile acids loss of bile acids = impaired fat abosrption excess lipids in bowel bind to calcium forming soap complexes soap complexes excreted in feces normal bowel - calcium binds to oxalate and produce insoluble calcium oxalate salts that promtoe oxalate excretion in crohn's - decreased calcium, means increased oxalate absorption, promoting formation of oxalate kidney stones (enteric oxaluria)

left shoulder abduction is normal, but external rotation against resistance is weak and painful. what muscle?

infraspiantus

what ligament are the ovarian vessels contained in?

infudinbulopelvic ligament (susepnosry ligament of the ovary) rotation of voary around the IP ligament results in ovarian torsion present with sudden onset unilatearl pelvic pain diagnosis via pelvic ultrasound cardinal ligament = uterine vessels

patient has severe hepatotoxicty after anesthesia.. what drug?

inhalaed anesthstics centrilobular hepatic necrosis that is indistguishable from viral hepatitis

NSAID and acetaminophen effect on CYP450

inhibit

where are *fibrates* associated with increased gallstones

inhibit *7a hydroxylase* thus decreaseing cholesterol incorporation into bile - *decreased choelsterol solubility*

amiodarone affect on warfarin metbaolism?

inhibit metabolism of warfarin --> increased PT/INR and bleeding risk

mechanism of death in TCA overdose

inhibition of fast Na channels on cardiac cells leading to arrhythmia

purpose of using paclitaxel in coronary stening

inhibits intimal hyperplasia

preload in muscles

initial muscle fiber length prior to contraction - refers to amount of stretch placed on fiber before contraction occurs increasing prelaod increases contractile veolcity up to a max value at preload levels beyond its max, actin/myosin overlap becomes inefficient (decrased) and contractile veolicty will decrease

patient has been having coffee ground emesis. what will be increased in his smooth muscle cells?

inositol triphosphate patient will have increaseed sympathetic tone alpha 1 receptors work via Gq receptors --. increased PLC --> increases IP3, DAG IP3 liberates calcium stored in ER and DAG activates PKC Leads to *smooth muscle contraction*

laryngomalcia

inspiratory stridor during infancy due to collapse of supraglottic structures during inspiration worse in supine improves with uprgiht

elevated basline insulin levels are highly suggestive of...

insulin resistance

insular cortex

integrating body states with emotions (limbic system) autonomic nervous system control conscious experience of visceral sensations

inferior margin of rib during thoracentesis can injure

intercostal n.

histo of wilms tumor

cluster of cells containg epithelial, blastemal, and stromal elemnts

sputum with spherule spores 20-60 micrometers in diameter

cocciodiodiomycosis

patient has hyperhidrosis in the axilla region.. what is the treatment surgically?

interupttion of thoracic sympathetic trunk at T2 stellate ganglion = hyperhidrosis of hands and Raynaud phenomenon

phosphorylation of serine residues on the inusline receptor leads to?

inuslin resistance conducted by TNFa, glucagon, epinpherine, catecholamines

jugular v. exits through

jugular foramen

location of SA node

junction of RA and SVC

where is the SVC on CT?

just lateral to ascending aorta

densely staining cells adjacent t the glomerulus? waht do they produce?

juxtaglomerulus cells - renin

PAX6

key regulatory gene for *eye* and *brain* development mutations are associted with ocular defects such as *aniridia*

what drug is given to treat cocaine voerdose

labetolol - a1, b1, b2 antagonism

molluscum bodies

large eosinophilic cytoplasmic inclusions made of virus particles

nitroglycerin chemical pic - what is most suceptibel to this?

large veins

mechanism of basophilic stippling in lead poisoning

lead denatures ribonuclease ribosomes do not get degraded --> ribosomes persist and form cytoplasmic inclusions

most appropriate therapy for pre-HTN?

life-style modifcations preHTN Systolic 120-139 Diatolic 80-89

jaundice in first 24 hours of life

likely to be non-physiologic (eg. enzyme deficiency, breast milk)

what infections is a patient with hemocrhoamtosis increased for:

listeria vibirio vulnificus yersinia enterocolitica

histopathology of mesothelioma

long slender micovilli and abundant tonofilaments

murmur associated with VSD?

loud holosystolic murmur, LSB, 3rd or 4th ICS

biopsy of liver with hepatitis C

lymphoid aggregates within portal trats and focal areas of macrovesicular steatosis

23 y/o from Greece with mild anemia. Slightly elevated HBA2. Microcytic anemia. Target cells on smear. What process is initial step in pathogenesis of this patients disorder?

mRNA formation Beta thalassemia minor - Mediterranean heritage most common mutations cause aberrant precursor mRNA splicing or premature chain termination during mRNA translation

76 y/o with Enterococus mitral valve vegetation. Shes given an antibiotic. Several days later, she develops tinnitus and hearing loss attributed t this antibiotic. What durg mechanism?

mRNA genetic code reading - *Aminoglycosides* - *ototoxicity, nephrotoxicity* AG's bind to *bacterial 30s* causing *genetic code misreading* and bacteiral protein synthesis inhibition AG's also impact *translocation*, whereby an aminoacyl tRNA is shifted from ribsoomal A site (after inital binding) to the P site (after AA incorporation into the peptide chain during elongation) to the E site (after AA cleaving from its tRNA)

Ricin toxicity

made from castor plant strips ribosomes of purines causes vascular leak syndrome first step is intubation and airway maintenance

composition of struvite stones

magnesium ammonium phosphate - Coffine lid increased with infections by urease positive organisms Proteus Pseudomonas Klebsiella

alcohol effect on body temperature

makes you feel warm but lowers core temperature

chondrosarcoma

malignant cartilage tumor men aged 30-60 pelvis, spine, scapula, humerus, tibia, femur moderate cellularity with small, round nuclei and occasionally binucleate abundant hyaline cartilage matrix

Bipolar I + psychotic features

manic episodes + hallucinations that only occur during the manic episode

mitral stenosis gets less intense with..

manuvers that decrase preload (standing, valsalva)

protease nihibits prevent...

maturaiton of new virsues - HIV protease cleaves polypetide products of HIV mRNA into functional parts

linaer skull fracture at junction of frontal, parietal, tempral, and spehnoid bones on CT scan. branch of what artery?

maxillary

transtentorial (uncal) herniation

medial temporal lobe herniates through gap between crus cerebri and tentorium what can be compressed: *ipsilateral oculomotor nerve* - fixed and dialted pupil on side of compression; paralysis of oculomotor muscles occurs later and leads to ptosis and down and out *ipsilateral PCA* - contralateral homnoymous heminaospia with macular sparing *contralateral cerebral peduncle against tentorium* - contralatearl corticospinal tract --> ipsialtearl hemiparesis *brainstem hemorrahge* (*duret hemorrhage*) - can occur in pons and midbrain due to stretching and rupture of basilar artery --> *fatal*

apocrine glands

membrane bound vesciles mammary glands

what are microglia derived from?

mesoderm

trichomonas vaginalis

metronidazole

colchicine mechanism of action and its downstream effects

microtubular polymeraization - disrupts cytoskeletal dependent functions such as chemotaxis, phagocytosis and degranulation also reduces formation of LTB4

aspirin causes what changes in liver in children

microvesicular steatosis - presence of small fat vacuoles in hepatocytes

chest tube placement

midaxillary line at fourth intercostal sapce

im emboyrnic development, both melanocytes and germ cells undergo what?

migration

findings on PE exam of someone overdosing on opioids

miosis bradycardia hypotension decreased respiratory rate

CD14

monocyte-macrophage cell lineage

where does the suatachian tube lead into

nasopharynx obstruction can lead to otitis media

what is main source of protection against influenza?

natibodies against *hemagglutinin*

ovarian hyperstimulation syndrome (OHSS)

nausea vomiting ascites hypercoagulability acute respiratory distress syndrome pulmonary emboli acute renal failure

synovial fluid in gout

needle shaped crystals that demonstrate negative birefringence moderate elevation in WBC count glucose is within normal range

mechanism of radiocontrast hypersentivity

non-IgE mediated direct mast cell activation, activation of the coagulation, kinin, and/or complement cascades inhibitino of platelet aggregtion

diarrhe cuaes what acid/base disturbance

non-anion gap metabolic acidosis as HCO3 is lost in stool - the engative charge is replaced by increased chloride

somatic symptom disorder

non-neurlogic symptoms that are not associated with a stressor patient is usually not satisifed with false findings

x-ray in asthma exacerbation

normal

where dos pioglitazone target in the cell?

nuclear receptor

where are ribosomal RNA made?

nucleolus

xeroderma pigmentosum is defect in...

nucleotide excision repair

what needs to be known in PCR for amplifiation part of analysis?

nucleotide sequence of reigons flanking target exon - *primers*

h pylori treatment

omeprazole, clarithromycin, amoxicillin

mechanism of diphenoxylate

opioid anti-diarrheal binds to mu opiate receptors and slows motlity

contralatearl homonoymous heminaopsia lesion location

optic tract damage

candida histology

oval budding yeast with pseudohyphae

paician vs. ruffini

paician = rapidly adapting rufifni = slowly adapting

common complications of varicose veins

painful thromboses stasis dermatitis skin uclerations poor wound healing superifical infections

histology of Paget cells

pale, ovoid nucleus, large nucleolus and large amount of pale staining cytoplasm Halo cells

what is the most common cause of death in acute rheumatic fever?

pancarditis

what is relaesed from the pacnreas in response to Secretin?

pancreatic HCO3 chlrodie content of pancreatic secretions decrees in proprotion to bicrbonate contration increases

Sheehan syndrome

panhypopituitarism - failure of lactation, central hypothroidism, adrenal insuffciiency ischemic necrosis of pituatiry gland during pregancy, pitutiary enalrges due to estrogen indcues hyperplasia of lactotrohs; however blood supply does not increase proportionately As a result - enlarged pitutiary is vulnerable to ischemia in case of systemic hypotension due to peripartum hemorrahge

secretin in gastrinoma

paradoxically increases gastrin reelase

hemophiliacs will have prolonged....

partial thromboplastin time

6 y/o immigrant comes in with Corynebacterium diptheriae infection. (neck swelling, palatal paralysis, gray pharnygeal exudate). What is most likely to imrpvoe prognosis?

passive immunization diptheria exotoxin specific of neural and cardiac tissue can cause CNS and cardiac sequelae in some treatment in order of importance: -diptheria antitoxin -penicllin or eryhtromycin -DPT vaccine

patient bit by dog. wound culture grow gram negative coccobacilli. culture has MOUSE like odor.

pasteurella multocida indole positive species

definition of treatment resistant shizphrenia and what medication would you give?

patient is considered treatment reistant as he has had poor response to >2 trials of antipsychotics and continues to expiernece multiple delusions and disorganized speech and behavior Give CLOZAPINE

ristocetin testing in von willebrand disease

patients serum + ristocetin = no platelet binding fresh plasma with vWF + patients serum + ristocetin = normal aggregation

ST elevation on ECG after missing dialysis

pericarditis

copd patient given oxygen, respiraotry dirve stops. what is cause?

peripheral chemoreceptor COPD patients have very low oxygen to begin with giving them O2 will cause decrased stimulation of the peripheral receptors central chemoreceptors dont respond to oxygen

right paracolic gutter

peritoneal recess found between ascneding colon and abdominal wall fluid (bile, pus, blood) typically accumualtes here from pathology involving GI organs, particuarly appendix and gall bladder

what zones of prostate cause BPH?

periurethral (lateral and middle) lobes Both stroma and glandular elements

myeloblast histo and what is positive in these cells?

peroxidase large cells with abundant basophilic cytoplasm myeloblast nuclei are often folded or bilobed, containing multiple nucleoli Myeloblasts have large number of coarse rod shaped intracytoplasmic granules (Auer rods) that stain for PEROXIDASE auer rods indicate myeloid differenitation

3 week old infant with staw colored discharge from umbilicus and eryhema around the area. Postnatal course was uncomplicated, with shriveling of the cord around 14 days of life. Normal white count and differnetial

persistence of allantois remnant wasnt LAD because the umbilical cord separates over 1 month after bith and child would have leukocytosis.

patient has shingles. what is likely to happen in next 6 months?

persistent pain

when pig epithelial cells, which contain both types of sialic acid are ifnected with combo of avian and human influenza A virus, some of new avian infleunza viral particles become capble to attach to human cells. However, the progency of this new strain of avian infleunza virus cant attach to human epithelial cells. What phenomema best describes change in avain infleuzna during expirment?

phenotypic mixing there is no change in underlying viral genomes, subsequent progency will revert to having only avain influenza type surface proteins

effect of phenytoin on vitamin D levels

phenyoin can undce hepatic P450 enzymes to accelerate the catabolism of vitamin D can mask as osteomalacia in the adult

what drugs have zero order elimination

phenytoin ethanol aspirin

what nerve passes between anterior and midle scalene?

phrenic n.

what is the most common brain tumor in children? How does it appear on MRI?

pilocytic astrocytoma - appear as mass and cystic components on MRI

adult male with scortal mass. Painless mass that he thinks is getting larger. Left sided mass that is plapble when he stands, disapepars when he lies down. Does *not* transluminate Diagnosis?

Testicular Varicocele dilatedv eins in pampiniform plexues due to increased venous pressure; usually on L sid ebecause of increased resitance to flow from left gonadal vein drainage into left renal vein *bag of worms* on palpation*

what cell in Crohn's disease is responsible for formation of the granulomas?

Th1 - secrete IL2 and IFNy and activate macrophages to synthesize TNF

vaginal bleeding in pregnacy

placenta previa = painless aburptio placentae = painful

in knee dislocation what vaculature is at high risk?

poplitearl artery - deep within popltiearl fossa, closure to articular surfaces of joint tightly fixed proximal and distal to poplitearl fossa by adductor magnus and soleus muscles, respecteily, making it susceptible to tearing by traction forces tibial nerve courses through poplitearl fossa superficially to popltiearl a/v it is nost subject to traction forces like the poplitearl a., althought its vulenrable to penetrating trauma to popliteral fossa

patient presenting with portal HTN but has normal liver biopsy. what is cuase?

portal vein thrombosis.

dobutamine effect on heart

positive inotopic positive chronotopic (weak) increased oxygen consmpution

64 y/o male loses consciousness. Physician palpates pulse along inner side of SCM muscle. Vessel palapted is derivative of what arch?

Third

how does tertiary syphilis BEGIN

vasa vasorum endarteritis

cord factor in TB

virulence inactivates ntruphils induces formation fo TNFa damages mitcochondria

haldane effect

when deoxygernated blood neters the alveolar capillaries of the lung, the rise in pO2 increase the binding of oxygen to hemoglobin and casues the release of H+ cand Co2 from heoglobin as bicarbonate shifts back into RBC in exchange for chloride, carbonic anhydrase converts H+ and HCO3 back into CO2 and water The CO2 is excreted through lungs increase Po2 --> unloading of CO2 + H+

what part of the sarcomere do actin filaments bind to?

z-line

3'-->5' exonuclease activity

DNA pol III

Bloom syndrome

*helicase dysfunction* growth retardation facial anomalies (microcephaly) photosensitive rash immunodeficiency (recurrent ifnections)

25 year old with fever and cough. Works on cattle farm. Bilateral patchy segmental opacities. Obligate intracellular organism

Coxiella burnetti

patient taking estrogen supplmenets, how is their thyroid hormone levels affected?

*increased TBG* --> increased T4 pool patient remails euthyroid

lisch nodules

*iris* hamartomas in NF1

hypertensive encephalopathy

*progressive* headache and N/V followed by *nonlocalizing* neurologic symptoms (e.g., confusion)

what arch is the ductus arteriosus derived from?

6th

what muscle takes up majority of greater sciatic foramen and what is its action?

Priformis externally rotate thigh when extended abduct thigh when flexed

conidophores

Aspergillus - commonly seen in this form in a fungal ball in an old TB cavity

medication used in multiple sclerosis related spasticity?

Baclofen (GABA-B receptor agonist) Tizanidine (alpha 2 agonist) also effective and commonly used

what are the main cells involved in type 4 hypersensitivty?

CD4 helper T cells CD8 cytotoxic T cells Macrophages

what cell si the primary mediator in urishiol induced contact dermatitis

CD8

what yeast infection is associated with catheters?

Candida

HIV esophagitis types

Candida (most common) CMV = linear ulcers HSV

most common cause of death in SLE

Cardiovascular disease

what anti-inflammatory agent does not impair platelet aggregation and can be used in a patient with pain, fever and heamturia?

Celecoxib - spaires COX1 which allows TXA2 to remain - no platelet affects

Biopsy shows accumulation of lipid laden macrophages. analysis suggests lack of ApoE3 and ApoE4. What is impaired in this patient?

Chylomicron remnant uptake by liver cells Familial-dysbetalipoproteinemia Premature atherosclerosis Tuboeruptive and palmar xanthomas

what should be used in a patient with stable agina with aspirin allergy?

Clopidogrel

22 y/o with severe headache and comiting. Patient dies. Autopsy - subarachnoid hemorrhage. Associated with what congenital heart defect?

Coarcation of aorta berry anerusyms are prone to rurpute when associated with coarctation, becuase of HTN in branches of aortic arch proximal to coarct

macrocytic anemia in alcoholics is because of...

Folic acid deifiency = within months vitamin b12 deficiency = within years

pacemaker atrioventricular groove

Coronary sinus lead is in the AV groove

5'-->3' exonuclease activity

DNA pol I

how do antianginal relieve pain so quickly

Decrease preload (venodilation) = nitrates Increase coronary perfusion = nondihydropyridine, dihydropyridine, nitrates (mild) decrease HR = Beta blockers, Nondihydropyridines (verapamil, dilitzam) arterial dilation (dec. afterload) = dihydropyridines (amlodipine, nifedipine)

why does Acyclovir work for HSV and VZV but has limited effect in EBV and CMV?

EBV and EMV do not produce the same thyrmidine kinase as HSV and VZV As a result, EBV- or CMV-infected cells cannot eaisly covert acyclovir into its pharmacologically active form

what is the initial test for a postmenopausal woman with abnormal uterine bleeding?

Endometrial biopsy because of its high sensitivity, low complication rate and low cost If structural abnormalities such as polyps are suspected, transvaginal ultrasound can be acceptable initial test Endometrial biopsy is required if the endometrial lining is thicker than 4mm, endometrium shows diffuse or local echogenecitiy or the woman has persistent bleeding

gamma hemolytic (no hemolysis) catalase negative organisms

Eneterocci - can grow in hypertonic (6.5% NaCl) and bile S. bovis - can grow in bile but not 6.5% NaCl S. bovis bacteremia is associated with colon cancer

fucntion of IkB and NF-kB in inflammation

Extracellular signal (ex, binding of TLR) causes activaiton of *IkB kinase* - results in *ubinquination* and destruction of IkB with release of free NF-kB once free, NF-kB enters nucleus and promoters the synthesis fo a number of *inflammatory proteins* such as cytokines, acute phase reactant, cells adhesion molecules, leukocyte related growth factors inflammatory cascade is self limiting as NF-kB also sitmualtes transcirption of more IkB - rebinding freed NF-kB

Filtration fraction equation

FF = GFR/RPF = GFR/(RBF/[1-Hct])

Zika virus

Flavivirus - positive ssRNA Causes conjunctivitis, low grade pyrexia, and itchy rash Can lead to congenital microcephaly or miscarriages if transmitted in utero sexual/vertical transmission is possible outbreaks more common in tropical and subtropical climates Tx= supportive, no definitive treatment Dx = RT-PCR

Urine cultures grow Enterococcus. Further analysis shows that the isolated organism produces an enzmye that is involved in acetyl group transfer to exogenous substances and is located on surface of cytoplasmis membrane. The bacteria are most likely resistant to what?

Gentamicin (aminoglycosides) this resistance is acquired by plasmids or transposons

HLA-B8

Graves disease

measurement of osteoclast activity

Hydroxyproline, Deoxypyridine

21 year old male with no significant past medical history presents to the hospital with chief complain of blood in the urine and low grade fever. he reports a recent upper respiratory infection.

IgA neprhopathy (Berger's disease) autoimmune characterized by globular deposits of IgA immunoglobulins in the mesangium of kidney tissue patients present with hematuria thats recurrent and follows URI type 3 hypersensitivity reaction and most common cause of glomerular hematuria

Graves disease antibody

IgG

Patient has ER+, PR+, HER2+ breast cancer. Treated with monoclonal antibody. What is target?

Tyrosine kinase receptor - Trastuzumab

elderly man with progressive dyspnea. lung biopsy shows macrophages with golden cytoplasmic granules that stain dark on prussian staining. what condition?

LV dysfunction - heart failure

presence of S4 heart sound (extra low frequency at end of diastole just before S1) can be indicative of what pathology?

LV hypetrophy 4th heart sound is often heard in older adults due to age realted decrease in LV compliance, and in usch cases is a relaitvely benign finding the louder the sound, the more likely it is due to a pathologically stiff left ventricle - resitrctive cardiomyoatphy, LV hyetrophy (HTN)

patient has mild hypercalcemia. patient's parathyroid hormone level is broderline high and urianry calcium is low. mutation in what receptor is likely responsible?

Membrane bound receptor coupled to Gprotein - Familial hypocalciruic hpercalcemia Defective G-coupled Ca2+-sending receptors in multiple tissues higher than normal Ca2+ levels required to suppress PTH Excessive renal Ca2+ reuptake --> mild hypercalcemia and hypocalciuria with normal to increased PTH levels

serum has IgG4 antibodies to phospholipase A2 receptor in setting of peripheral edema.

Membranous nephropathy (idiopathic)

2 day old girl in nursey with persistent crying, tremors, tachypnea, sneezing, diarrhea. Born to mother with poorly controlled schizophrenia and did not receive prenatal care. Patients mother had psoitive hepatitis C antibody. PE - baby has increased tone. Irritable unless when swaddled. Normal lung fields. Drug to treat this?

Methadone - *neonatal abstinence snydrome* at risk newborns include those born to mothers with poor mental health, no prenatal care and hepaitis C infection clinically: neuro - irraibility, hypertonia, jittery, seizures (rare) GI - diarrhea, vomting, feeding intolerance autonomic - sweating, sneezing, pupilalry dilation tx = morphine or methadone and patient is weaned off over several weeks

two options for treating Gardnerella

Metronidazole Clindamycin

Patient with lead poisining. What are his symptoms. What is seen on peripheral smear vs. bone marrow

Microcytic aenmia, conspitation, mental status changes in setting of construction work, abtteries, allos, ammunition Peripheral smearl = basophilic stippling Bone marrow = ringed sideroblasts

4 y/o with acute onset ab pain, vomiting, loose stoole during vacation. Treated supportive care, felt better. Few days late,r she has urianted only once in past 10 hours and urine was red. Hb=7.8 Platelets = 80,000 Creatinine 1.7 mechanism?

Microthrombi in small blood vessels = Hemolytic uremic syndrome - major casue of acute renal failure in young children

recurrent pyogenic infections periperal neuroapthy parital alinism neurodegeneraiton what is mechanism?

Microtubule dysfunction in phagosome-lysoome fusion Chediak-Higashi

most commonly site of drainage in oropahryngeal bacteria sinusitis

Middle meatus sinusitis begins when mucosal edema, due to viral infection or allergic process, causes obstruction of paranasal sinus ostia impaired drainage and inflammation of sinus lining then lead to accumulation of mucus and transudative or purulent fluid small percentage develop secondary infection with oropharyngeal bacteria (acute bacterial rhinosintusit) the maxilalry sinuses are most commonly affectes as their path of drinage (semilunar hiatus in middle nasal meatus) is located superior to floor of sinus, impairing drinaage while upright

what paremter best correlates with potency of inhaled anesthetic?

Minimal alveolar concetration since anesthetics concentraiton in brain tissue is directly proprotional to its partial pressure, its possible to use stady state alveolar partial pressure of inhaled agent as measure of anesthetic potency

what is the number of melanocytes in albinism?

NORMAL - it is the production of melanin that is impaired

first line treatment for acute goutry arhtirtis

NSAIDs

2 y/o caucasian boy has spontenous bursts of non-rhytmic ocnjugate eye movements in various directions. Also has hypotnia and myoclonus. Exam reveals abdominal mass. Diagnosis?

Neuroblastoma - *most common extracrnial childhood cancer* N-myc amplifcation better if patient <1 y/o Opsoclonus-myoclnous syndrome - nonrhythmic conjugate eye movements associted with myoclonus

major adverse effect of *ganciclovir*

Neutropenia Naemia Thrombocytoepnia imapired renal function

where do the acl and pcl attach

PCL attaches to *posterior* intercondylar area of tibia and *anterolatearl* surface od *medial condyle* of femur ACL attaches to *anterior* itnercondylar area of tibia and *posterior medial* side of *latearl femoral* condyle

genital exam shows multiple, painful shallow uclers with eryhemtaous base on labia. bilatearl tender inguinal lymphadenopathy. diagnostic test?

PCR for viral DNA HSV - mutliple painful genital ulcers, dysuria, tender lymphadenoapthy, systemic symptoms characteristic vesicles are often ABSENT diagnosis: PCR direct fluoresence antibody viral culture Tzanck smear

affected enzymes secreted from pancreas in cystic fibrosis

Pancreatic amylase Lipase Colipase Phospholipases

Fine needle aspiration of thyroid nodule: Clusters of overlapping cells with large nuclei contianing sparse, finely dispered chromatin. Nuemrous intranuclear cinlusion bodies and grooves are seen. Diagnosis?

Papillary carcinoma large with overlapping nuclei containing *finely dispered chromatin* giving them a group glasss appearence (*orpha annie eye*) numerous intranuclear icnlusions and grooves can be seen due to invagination of nuclear membrane *Psammoma bodies* are also found

Serpentine pattern of growth (mycobacteria in parallel chains). Bacterial growth pattern correlates with:

Presnce of ropelike cords (*cord factor*) of mycobacterial organisms in a twisted, serpentine apttern is consisntent with cord factor Cord factor is a mycoside - correlates with *virulence* - myobacteria that dont have cord factor cant cause disease cord factor inactivate neutrophils, damages mitochondira, inducing release of TNFa

HEV

RNA hepevirus incubation = short clinical = fulminant hepatitis in pregnant women prognosis = high mortality in pregnant women HCC risk = no liver biopsy = patchy necrosis Enteric, epidemic, no carrier state

RNA in nucleoli

RNA pol 1 = rRNA; basophilic in the nucleus RNA pol 2 = transcribes mRNA, snRNA, miRNA RNA pol 3 = occurs in cytoplasm making tRNA

supracondylar fracture resulting in anterolateral displacement of proximal fracture cause what nerve injury?

Radial if it said anteromedial it would've been median nerve

Colonoscopy of C. difficle

Raised, yellowish-white, 2-10mm plaques overlying eryhtematous, edematous mucosa = pseudomembranes Biopsy = inflammatory exudate composed of mucinous debris, fibrin, necrotic epithelial cells and polymorphonuclear cells

immediate complications of a women/fetus with maculopapular rash that spreads to face/chest and trunk and extremities. PE shows postaurical lymphadenoapthy.

Rubella (deciphered from the lymphadenopathy) most adult women with rubella develop polyarthritis and polyarthraglia Fetal infection with rubella virus in 1st trimester can cause: Sensorineural deafness cataracts Patent ductus arteriosus

asplenic patient frmo sickle cell. increased infection from S. pneumonia or S. pyogenes

S pneumonia

organism that is Pyrrolidonyl arylamidase positive causing glomerulonephritis

S. pyogenes

wire looping light micrscopy

SLE - diffuse prolfierative gleomrulonpehritis

ST elevation vs. prominent Q wave

ST elevation = acute prominent Q wave = chronic

equations of cardiac output - 2 questions on this ƒ

SV x HR [EDV-ESV] x HR MAP/TPR rate of O2 consumption/[arterial O2-venousO2] stroke volume can be determined if given EF and EDV by the equation SV = EDVxEF therefore: CO = HRxEDVxEF

stool shows non-lactose fermenting, hydrogen sulfide producing bacteria

Salmonella

HLA-DR3

T1DM

administering T3 to a patient with hypothroidism: TSH: T3: Reverse T3: T4:

TSH: decrase T3: increase Reverase T3: decrease T4: decrease reverse T3 is an inactve form that is generated almost entirely from peripheral conversion of T4 Exogenous T3 suppresses TSH, which decrease T4 rT3 would decrease because less T4 would be available for conversion (T3 cannot be converted into rT3)

what cadriac structure is most often implicated in Digeorge sydrnome?

Truncus arteriosus

Cytomegalovirus retinitis

Tx = ganciclovir AIDS patients with CD <50 Most common complication is: Retinal detachment due to tearing of thin, atrophic scar tissue that forms in areas of prior inflammation

Patient has injured lung tissue. One month later shows partial recovery. This regenerated tissue is most likely derived from what cell type?

Type 2 pneumocytes 95% of surface of alveolis is covered by type 1 pneumocytes the remaining 5% is covered by interspersed cuboidal type II pneumocytes that make up 60% of total number of alveolar cells type II pneumocytes are source of PULMONARY SURFACTANT and have ability to PROLIFERATE in response to injury others: club cells are nonciliated secretory cells in terminal bronchioles - they can regenerate ciliated cells in bronchioles

Impaired oxidation of Very Long chain fatty acids

Zellweger syndrome Autosomal recessive failure to thrive seizures nystagmus death by age 1

phenytoin metabolism

Zero order elimination - hepatoc hydroxylation of phenytoin is dose depdnent Inducer of P450 oxidase

duodenal ulcers distal to bulb...

Zollinger Ellison syndrome

location of Ghon complex

upper lower lobe, lower upper lobe = primary TB

where is the most common site of obstruction causing hydronephrosis in a newborn?

ureteropelvic junction

true appendix - true/false diverticulum?

true other true diverticulum = meckles

what is niacin derived from?

tryptophan

where is a Meckel diverticulum

two feet proximal to ileocecal valve

45 y/o with 1d history if severe dyspnea on exertion. Worsens throughout day, and occuring with shorter distances. 20 pack year history. PaO2 = 54, PaCO2 = 26. Cause?

Alveolar hyperventilation assuming normal rate of metabolic CO2 production, *hypocapnia* implies *alveolar hyperventilation* can result form V/Q mismatch that causes decreased O2 and Co2 exchange (penumoina, PE) resultant hypoxemia stimualtes periphearl chemoreceptors and increases respiratory drive above normal levels --> excessive CO2 excretion by lungs --> hypocapnia HOWEVER, *hypoxemia will persist* since blood flowing through highly oxygenated lung cannot absorb extra O2 to compensate for the hypoxemic blood returning from poorly oxygenated regions this caues *increased alveolar-arterial oxyen gratient* which can be treated with OXYGEN and correcting underlying disease process

75 y/o with fever, neck stiffness, mental status changes. Lumbar puncture shows herpes simplex virus. While recovering patient acts inappropriately on sexual urges, eat inappropriate objects and is unable to recognize familial objects or people. What area is involved?

Amygdala - involved in emotional behavior, aggression, memory, hunger and sexual urges bilateral involvement of amygdala (Kluver-Bucy syndrome)

5 week old boy with hyperdynamic precordium, mid diastolic rumble at LSB, and 3/6 holosystolic murmur in apex taht radiates to left axilla. Echo shows defects in lwoer part of interatrial septum and interventricular septum. Patients condition is associated with what genetic condition?

Autosomal trisomy Echo showed *complete AV canal defect*, the most common cardiac defect in *Down syndrome* failure o endocardial cushion fusion results in ostium prinium atrial septal defect; a ventricular sepatl defect; and a single AV valve

anterior horn cells of spinal cord demonstrating cell body rounding, peripheral dispclaement of nculei and sieprsion of nissl substance to peripheral of cells Findings described as:

Axonal reaction cahnges in neuronal body after axon is severed in Wallerian degenration is the *axonal reaction*

common variable immunodeficiency B cell count: Immunoglobulin count:

B cell count: normal Immunoglobulin count: decreased across the boards

mechanism of decreased transcription of other genes in Huntingtons?

CAG repeats leads to GOF huntington protein Huntington protein causes increased histone deactelyation which leads to decreased transcription of proteins needed for neuronal survival

treatment of Salmonella osteomyelitis

Ciprofloxacin or another floruoquinolone in addition to coverage against Staph aureus (nafcillin/oxacillin, cefezolin or vancomycin)

p57 staining

Complete moles are *p57 negative* due to absence of maternal genome

high dose IL2 is started and there is reduction in his tumor burden. What is mechanism for this regression?

Enhanced activity of natural killer cells and T cells IL2 (aldesleukin) is used as immunotherapy for metastatic melanoma and renal cell carcinoma

24 y/o pregnant woman with DVT. what do you give her?

Enoxaparin Heparin doesnt corss placenta other LMWH = dalteparin, Fondaparinux (primarily Xa)

Nonmaleficience

First, do no harm weighing risks vs. benefits

beta blocker overdose is treated with ________ which binds to what receptor?

Glucagon - Gs

what reaction is catalyzed by G6PD?

Glucose6P --> 6 phosphogluconate --> Ribulose 5P

the CaSR is what type of receptor

Gs receptor

HbF HbA1 HbA2

HbF = a2y2 HbA1 = a1b2 HbA2 = a2d2

several days later the bruise becomes greenish in color. This change in color is best explained by activity of which of the following enzymes?

Heme oxygenase - degardes heme into *biliverdin*, CO, Fe while consuming oxygen and eletrons proivded by NADH and NADPH biliverdin is *gren* in color and further reduced (by *biliverdin reductase*) to yellow pigment bilirubin, which is then transported to liver bound to albumin

what is an essential finding in the diagnosis of thrombotic thrombocytopenic purpura?

Hemolytic anemia Thrombocytopenia

in absence of red flags,w hat is best management of low back pain?

NSAIDs and follow up

granuloma inguinale (donovanosis)

Organism = klebsiella granulomatois features of primary lesion: -extensive, progressive ulcerative lesions without lymphadenopathy -base may have granulation tissue -deeply staining gram-engative intracytoplasmic cysts (Donovan bodies) painful? *no* if donovanosis is left untreated, scarring and stritures can lead to severe lymphatic obsutrction and lymphedema (elephantiasis)

First step in management of somatic symptoms disorder?

Schedule regular visits with the Same provider

what two growth factors increase angiogenesis

VEGF FGF

most common cranial nerve dysfunction in pseudotumor cerebri?

abducens nerve

where is CSF absorbed?

arachnoid granulation and enters venous sinuses

scurvy

bleeding gums gingivitis perifollicular hemorrhages

Red safranin O stain

cartilage mast clel granules mucin

imaging of choice in DVT

compression ultrasonography

how doe herpes viruses get into cell?

contact with glycosaminoglycans on cell surface

what does the phrenic a. supply

diaphargm suprarenal glands

methotrexate casues accumulation of...

dihydrofolate

what is the major component of surfactant

dipalmitolphosphatidylcholine from type II pneumocytes

mechanism of argatroban

direclt inhibits activity of free and clot associated trhombin

Legg-Calve-Perthes disease

disease of young children isolated idiopathic osteonecrosis of hip

internuclear opathalmoplegia

disorder of heavily myelinated MLF MLF is paired nuearl tract mediates ocmmunication between CNIII and CNVI for cooridnate dhorizontal eye movements conjugate horizontal eye movement is intiaed with activation of frontal eye field in cerebral cortex frontal eye field projects to cotnralatearl apremdian pontine reticular formation, which then sends efferen tsto the ipsilatearl CNVI nucleus at level of facial colliculus in *dorsal pons* subsequnetly, the CNVI nucleus projects to ipsilatearl rectus muscle (abducts the eye) and contralateral medial retus sbunucelus of CNIII (adducts the eye) via the MLF lesions of *left dorsal pons* can disrupt the left MLF, resulting in *impaired adduction* of ipsialteral eye during right *conjugate horizontal gaze* patients may develop diplopia and horizontal nystagmus of abducting eye (right) *convergency and pupillary light reflex* are generally *preserved*

2 mechanisms of hydrocephalus from intereerbal neoplasm

disruption of BBB leads to *vasogenic edema* disruptin of CSF fow can elad to *non communicating hydrocephalus*

left vs. right temproal lobe injury

dominant (left sided) = verbal memory, word recognition nondominat (right sided) = nonverbal memory, including musical ability

what enzyme is responsibel for activating trypsin?

enteropeptidase a small intestine brush boarder enzyme trypsin then goes on to activate other pancreatic enzymes and degrade dietary proteins

components of glutathione

glutamate cystine glycine

metabolic effects of thiazides

hyponatremia - decreased Na absorption hypokalemia - increased renin alkalosis - increased renin hyperuricemia - increased urea absorption from decreased urine flow hypercalcemia - increased absorption in distal tubule Hypoglycemia - decreased inuslin INCREASED LDL

mechanism of Bordetella pertussis toxin

inactivates inhibitory G proteins, leading to activation of adenylate cyclase, thus impairing the phagocytic mechanism and allowing microbes to survive This allows water secretion into the trachea increased cAMP production, leads to increased insulin production, lymphocyte and neutrophil dysfunction and INCREASED SENSITIVITY TO HISTAMINE

St John's wort on CYP

inducer

do small alveoli have higher or lower collapsing pressure?

larger collapsing pressure P = 2T/r T= surface tension P = collapsing pressure R = radius P:R are ivnersely proprotional

what are the phosphatidycholine levels when there are multiple glasstones

lower

1 week post stroke. Lipid staining cells in on histology.

microglia

patient has achalasia. Dgeneration of inhibitory neurons located in....

muscularis externa - myentric (Auerbach) plexus

radiogrph - exapnsile, obliterative mass within the metaphysis with spiculated periosteal formation circumcribing the tumor

osteosarcoma this describes the 'sunburst' pattern

strep pneumoniae culture

partial (a) hemolysis bile soluble optochin senstive

patient exposed to nitrites. PE - cyanosis that is not improved with oxygen facemask. What is going to be normal in his arterial gasses?

partial pressure of oxygen in arterial blood iron bound to heme is normally in Fe2+ state Nitrites cause poisoning by inducing the conversion to Fe3+ state, leading to formation of methemoglobin which can not bind oxygen (additionally, affinity increases of residual Fe2+ so leftward shift) However, the partial pressure of oxygen in blood, which represents amount of oxygen dissolved in plasma is unchanged bound oxygen will DECREASE oxygen carrying capacity will DECREASE oxygen content will DECREASE oxygen delivery will DECREASE

beta-lactamase anaerobic infection... give?

pipercillen-tazobactm others: metrondizaole clidnamycin carbapenems

transmural inflammation with fibrinoid necrosis

polyarteritis nodosa young adults intermittent episodes of: -abdominal pain -peripheral neuroapthy -renal insufficiency -severe HTN

what is the only statin not metabolized by CYP3A4

pravastatin

cromyln sodium

prevents mass cell degranulation (asthma prophylaxis)

polycistronic mRNA

prokaryotes can synthesize multiple proteins from singular mRNA ex - lac operon in e. coli

sural nerve

pure sensory nerve that innervates posterolateral leg and lateral foot

what is first line medication for N/V in pregnancy?

pyridoxine (B6)

recombination vs. reassortment in virus

recombination = non-segmented viruses reassortment = segmented virsues

patient exhibits symptoms of mania, but also has history of delusiosn and hallucinations occuring in abence of major mood episode

schizoaffective

what is the histology of Buerger disease (thromboangitis obliterans)

segemental vasculitis extending into contiogus veins and nerves

mechanism of milrinone

selective PDE3 inhibitor cardiomyocytes = increased inotropy and chronotrophy Vascular smooth muscle = general vasodilation Short term use in acute decompensated HF

16 y/o who is anxious. Worried about going to a party for weeks and ended up not going at all. Girl is very shy and afraid of being embarssaed or looking stupid. During interview she doesnt make eye contact and gives brief answers. diagnosis

social anxiety disorder

fate of proinsulin

stored in secretroy granules endopeptidases in secretroy granules cleave prosinulin into insulin and C-peptide, which are stored within granules until they are secreted via exocytosis

sleep hygeine

teaching about imporatnce of regular sleep schedule and the effects of environmental stimuli - caffiene, alochol, etc.

muscle fiber type of the paraspinal muscles

type 1

the scar tissue from a myocardial infarction is what type of collagen?

type 1

what type of collagen is cartilage?

type 2

pacnreas of a 22 y/o Caucasian male with recurrent pulmoanry ifnections and finger clubbing shows extensive exocirine gland atrophy and fibrosis. pancreatic ducts are lined with squamous epithelium with areas of keratinization. Finding of squamous metaplasia in pancreatic ducts is realted to?

vitamin a deficiency patient have cystic fibrosis avitaminosis can contirbute to squamous metaplasia of epithelial lning of pancreatic exocrine ducts, which are already injured and prediposed to squamous metaplasia by inspissated mucus normal levels of vitamin A (and retinoic acid its metabolite) are required to maintain ordlerly differenitaiton of specialized epithelia, including mmucus secreting columnar epithelium

Lung biopsy reveals fine carbon particles within patient's respiratory bronchioles and alveolar ducts. Which defense mechanism is directl responsible for clearing particles from this portion of the respiratory tract?

*Phagocytosis* Finest particles (<2um) reach respiratory bronchioles and aleveoli where they are phagocytoized be alveolar macrophages engulfment causes *macrophage activation* and release of cytoiens that induce pulmoanry inflammation (GF, PDGF, ILGF) --> fibroblasts to proliferate and produce collagen --> *progressive interstitial lung fibrosis* *mucociliary transport* - primary means of elminating mdedium particles that lodge in bronchi and proximal bronchioles

psychodynamic psychotherapy

developing insight into unresolved conflicts that began in childhood

angiogram in polyarteritis nodosa

diffuse, small, saccular aneurysms

what drugs can cause a mobitz type I

digoxin CCB beta blocker

what substrate builds up when methotrexate is used?

dihydrofolate

atelectasis

diminished air volume in part of lung and most commonly occurs due to obstruction of corresponding bronchus or bronchiole

what is the most common cuase of painless rectal bleeding in the elderly with no visible findings on physical exam couplied with an unremarkable anscopy?

diverticulosis anoscopy = rectum + anus scope

prognosis of cherry hemagioma

do not regress spontenously often increase in number with age

mechanism of the salmonella infectivity

does not produce enterotxin elicits a direct immune response that leads to increased intracellular cAMP levels - this accounts for the diarrhea associated with salmonellosis

treatment of restless leg syndrome

dopamine agonist (ropinrole, pramipexole) Iron deficiency is common in RLS and low iron concentrations have been found in substatntia nigra of patients with RLS RLS vs. akathisia RLS has discomfort that is relived by moving Akasthia is not associated with discomfort (use propranol)

spinal tracts involved in vitamin b12 deficiency

dorsal columns lateral corticospinal spinocerebellar

what nucleus provides parasymthapethics for vagus?

dorsal motor nucleus

facial nucleus

dorsolatearl aspect of cadual pons and nerve exits at ventrolatearl pontomedulalry juction (below middle cerebellar peduncles)

inpatient community acquired pneumonia treatment

doxycycline levofloxacin ceftraixone

mechanism of hypervntilation to decease ICP

drop in PaCO2 due to hyperventilation casues *vasoconstriction* resulting reduction in cerebral blood volume leads to *decrased ICP*

key to diagnosis of beta thalassemia on hemoglobin electrophoresis...

elevation in HbA2 HbF can be seen but does not confirm the diagnosis of thalassemia as it is non-specific HbF can be seen in hereditary fetal hemoglobin, sickle cell, HbC disease

deficiency of C1 complement causes increased suscpetibility to...

encapsulated bacteria predisposition to SLE

coronary perfusion pressure

end diastolic aortic pressure - lV EDP

in the absence of ADH where is renal tubular fluid most concentrated?

end of descending loop of henle

location of AV node

endocardial surface of RA, near insertion of septal leaflet of tricuspid valve and the orifice of the coronary sinus site of radial ablation in Afib

nucleotide exicsion reapir

endonuclease removes bases DNA pol ligase connects

what is the inital step in coronary artery disease?

endothelial cell dysfunction increased permeambilit y--> monocyte, lymphocyte adhesion and mgiration endothelial denudaiton and exposure of subendothelial collagen - platelet adhesion fibrous cap = syntheizzed by smooth muscle cells taht have migrated to and prolfierated in intimal layer in which plaque forms

most common cause of aseptic meningitis

enterovirus -coxsackievirus -echovirus -poliovirus

most common cause of viral menigitis?

enteroviruses - picornavirdae

where does Creutzfeldt Jakob disease degeneration occur?

entire cerebrum - gross pathology shows spongiform encephalopathy of entire cortex

negri bodies

eosinophilic inlcusion bodies in hippocampus

patient undergoes radiacl prostatectomy can cause whatnerve injury sequlae?

erectile dysfunction prostatic plexus lies in fascia of prostate and origiantes from inferior hypogastric plexus the lesser and greater cavernous nerves arise from prostatic plexus and pass beneath the pubic arch to innervate the coprora cavernosa of the penis and urethra cavernous nerves carry post ganglionic parasympathetic that facilitate penil erection prostatectomy or injury to prsotatic plexus can cause erectile dysfunction

CT of the heart

esophagus is closest to LA allowing LA, atrial septum and mitral valve to be viewed well on TEE Descending aorta is posterior to esophagus so can be easily seen on TEE

esophagus ct

esophagus is lcoated between trachea nd vertebral bodies in superior thorax it is typically collapsed with no visible lumn on CT images of the chest

Flank pain, gross hematuria, oliguria and high anion grap metbaolic acidsois. cause?

ethylene glycol poisoning ethylene glycol is metabolized to glycolate - cytotoxic to renal tubules and casues acute tubular necrosis glycolate is further metbaolized to oxalate, which contributes to oliguri renal failure by preciptating in kidneys and causing tubular obstruction urine microscopy will show *envelope or dumbell shaped* calcium oxalate crytals that are positive birefrigent

merocrine glands

exocytosis apocrine sweat glands salivary glands

paratid gland tumors that progress can cause what?

facial droop extracranial portion of CNVII carries motor innervation to muscles of facial expression most parotid gland tumors causing facial nerve paralysis are malignant neoplasm no sensory problems because sensory of face is through CNV

cleft lift pathogensis

failure of maxillary prominsence and intermaxillary segment

patient in hypertensive emergency. patient is started on IV medication that causes arteriolar dilation, improves renal perfusion, and increases natriruesis. what drug?

fenoldopam Contraindicated = hydralazine - results in reflex sympathetic activation, resulting in increased HR and contractility with Na/fluid retention

Ghon complex

forms during *primary tuberuclosis* infection and consists of Ghon focus and hilar lmyphadenopathy

what accumulates when patient has fructose intolerance? Consequence?

fructose 1P Decreased Glyceraldehyde 3P, normally made from glyceraldehdyde and DHAP without this essential molecule, metabolism is impaired, causing hypoglycemia whenever fructose is ingested

what substance would have the quickest effect in glycolysis and what enzyme does it bypass?

fuctose-1-phosphate made from fructokinase then ternyed into Glyceraldehyde 3P by aldose B PFK1

what is increased in pernivious anemia?

gastrin levels

mechanism of paraneoplastic hyperthroidism in a tesicular tumor?

germ cell tumors can secrete *hCG* which has the same alpha subunit as TSH - thus hCG can bind to TSH receptor (lower affinity than TSH)

candida

germ tube formation

where does isotype switching occur

germinal matrix in lymph nod

what is seen on light microscopy in glomerular basement membrane disease

glomerular crescents composed of proliferating parietal cells with an infiltration of monocytes and macrophages

treatment of hypersentivity pneumonitis

glucocorticoids pathogenesis: two hits 1 - genetic and/or enviornmental exposure 2 = atigen exposure from inhaled antigens which are second hit leading to either type III or type IV hypersensitivty reaction

patient diagnosed with diabetes at very young age. not insulin depednent. has high post-prandial glucose level. what is mutated?

glucokinase - this enzyme phosphorylates glucsoe when it enter beta cell, increaseing the ATp levels and cusing insulin release in its asbence, there is decreased insulin release

what amino acid needs to be metbaolzied to increase acid secretion in the kindeys

glutamine puts ammonia in the urine - traps H+ HCO3 can go back into blood to buffer the increaesd acid

asbestos bodies

golden brown, fusiform or beaded rods that consist of asbestos fibers coated in proteinaceous material containing iron

what is medial to the putamen

golubus pallidus

murmur heard in tetraology of fallot?

harsh and systolic due to pulmonic stenosis

to be eligible for home hospice under meidcare guidelines, the patient must

have a life expectancy equal to or less than 6 months

Polycthemia vera mutation of V617F in the JAK2 gene results in...

hematopoietic cells being more sensitive to grwoth factors such as EPO and thrombopoietin

HLA-A3

hemochromatosis

9 y/o girl with 3 minute generalized seizure. On PE - disoriented and difficulty staying awake. Speech is inappropraite word choice. Patient beomes unresponsive and dies. Bilateral, hemorrhagic necrosis of ifnerior and medial tempraol lobes. Infeciton?

herpes simplex virus - most common cause of fatal sporadic encaphlitis or inflammation of brain parenchyma HSV1 results from *primary oropharyngeal infection* that travels via olfactory tract or from *reactivation of latent virus* in trigeminal ganglion with spread into cerebral vault post-mortem macroscopic brain exam will show *edema and hemorrhaci necrosis of temporal lobe* - unilateral involvement is most common

PAS staining

histochemical stianing that the periodic acid oxidzed carbon-carbon bones, fomring aldehydes that produce magenta color upon reacting with fuchsin-sulfurous acid as a result, PAS stain is effective at highlying: -polysaccharides of fungal cell wall -mucosubstances secreted by epithelia -basement membranes Diastase can be used in conjunction with PAS to demonstrate glyocgen, which is found in skin, liver, parathyroid, and skeletal/cardiac muscle Diastsase works by digesting glycogen to form maltose and glucose, two sugards at are easily washed from sections during processing Glycoprotein in cells of *Tropheryma whippelii* apepars emgenta with PAS and is diastase resitant

obstruction of the MCA just out of the circle of willis will cause what type of visual field defect?

homonymous heminaopsia

extracellular domain of receptor composition

hydrophilic amino acids

components of alpha helices in G-proteins

hydrophobic amino acids to interact with hydrophobic tails of the membrane

disorder associated with *increased resorption of cortical bones resulting in subperiosteal thinning*

hyper-parathyroidism

crescendo/decrescendo systolic murmur that increases with valsalva

hypertrophic cardiomyopathy hypertrophic cardiomyopathy is almost always associated with mitral regurgitation secondary to impaired mital valve closure

electrolyes in primary adrenal inssuficiency

hyponatremia hyperkalemia hyperchloremia decreased bicarb non-anion gap metbaolic acidosis

what is a contraindication to morphine administration in heart disease

hypotension

2 month old with progressive floppiness and poor feeding. Born in Eastern Europe. Stools have decreased to every other day and are small and pellet-like. PE - hyptonic infant with large anterior fontanelle, large tongue, reducible umbilical hernia. Low tone and unable to hold head erect on own. cause?

hypothyroidism etiology - thyroid dysgensis (most common) or iodine deficiency (Europe) cogenital hypothroidism is one of most common causes of preventable intellectual disability initally no symptoms from maternal T4 from transplacental transfer as materan T4 wanes, metabolism is impaired and marked slowing of activity accumulation of matrix substances cutenously and internalyl results in nonpitting edema (puffy face), umbilical hernia, protruding tongue and large anterior fontanella

45 y/o smoker with THN and DM, has St elevaiton MI. Patient goes to cardiac cath and cardiac ICU. While in unit, develops cardiogenic shock requring vasopressors. patient dies from Vfib in hospital. Autopsy - bilatearl wedged shaped strips of necrosis are seen over cerebral convexity, prallel to and a fe centimeters latearl to longintudal cerebral fissue. What is this described as?

hypxoic-ishcemic encephalopathy *watershed necrosis* - located at borders between reas perfused by anterior, middle and posterior ceberal arteries.

what is the only way to distinguish precusor B-ALL from precusor T-ALL?

immunophenotyping B-ALL = TdT, CD10, CD19 T-ALL = TdT, CD1a, CD2, CD3, CD4, CD5, CD7, CD8

5 week old boy with cystic fibrosis. CT shows right sided intracranial hemorrhage. Cause of presentation?

impaired gamma carboxylation neonatal vitamin K deficiency Cystic fibrosis - decreased pancreatic enzymes and decreased fat absorption --> decreased vitamin K on top of neonates already having low vitamin K reserves

canitine deficincy

impaired transport of FA from cytosol into mitochondria skeletal muscles cant use FA for ATP liver cant make ketone bodies (decreased acetoacetate)

how do you treat a 3rd degree AV block?

implantation of a pacemarker

inital vs. secondary asthma

in extrinsic asthma, inital alelrgen stimulation causes induciton of CD4 Th2 cells to release IL4 and IL5 second antigen stimulation casues IgE cross linking on mass cells, which relases histamine

distinguishing feature between somatic symptom disorder and illness anxiety disorder?

in somatic symptom disorder there are true complaints instaed of just worry

orotic aciduria

inability to convert orotic acid to UMP (de novo prymidine synthesis pathway) because of defect in UMP synthase AR failure to thrive, development delay MEGALOBLASTIC ANEMIA refractory to folate and B12 no hyperammonemia (vs. ornithin transcarbmylase deficiency) increased orotic acid in urine tx = uridine monophosphate to bypass mutated enzyme

irregular menses can cause what discrepancy in maternal serum proteins?

inaccurate dating causing wrong prenatal testing time frame

what would have prevneted rabies in someone who has it?

inactivated vaccine- virus travels retrograde via periphearl nreves to dorsal root ganglia and to brain, where replciatino occurs its not a toxoid vaccine becuase rabies is a virus and doesnt release toxins

child with down syndrome has an abdominal protrusion that is more pronouced when he cries. the protrusion is covered by skin. the umbilical stump is at the center of the protrusion. what is the likely cause of the finding?

incomplete closure of the umbilical ring umbilical hernias are due to defect at linea alba covered by skin reducible bulge at umbilicus, notably with increased abominal pressure (crying, passing bowel ovmenet) associated with - Down syndrome, hypothroidism, Beckwith-Wiedmann syndrome)

cause of on/off phenomonon in Parkinson

incrased nigrostrial degredation thus making the on/off symptoms *unpredictable*

patient with cystic fibrosis. results show baselines transepithelial potenital difference that is more engative than normal This patients nasal mucosa is most likely to demonstate which of the following during the test?

increaesd sodium asborption daignosis of CF based on elevated sweat chloride concentrations, characteristic findings and/or positive family history in respiratory and intestinal epithelial - CFTR hydtaes mucus by *secreting* chloride ions into lumen; increaesd mucus chloride concentration in turn decreaes Na/H2O reabsorption trough ENac swet glands - CFTR is reserved compared with repsiratory and itensitnal galnds; CFTR reduces the salt content of sweat by *absorbing* luminal chloride; leads to increased sodium absorption from lumen into cells via ENaC CFTR mutations result in production of sweat with high chloride and sodium content patients with CF have increed sodium abosprtion via ENaC (due to impaired CFTR0 in nasal mucosa, sodium will be absorbed intracelluarly but chloride will be retained in the lumen *More negative test than normal*

what finding is suggestive of combined mitral stenosis + aortic valve deformity?

increase LV end diastolic pressure

mechanism of praziquanetel

increase calcium permeability of the tegument Casues paralysis and death

how to retinoids affect acne

increase cell turnover normalize keratinocyte differneiation decrease sebum production

maternal insulin resistance results from:

increase hPL (made from synctiotrophoblast) increased CRH progesterone increased placental secretion of growth hormone

compenstaory physiologic changes that conitebute to long term high alittude acclimzatization

increased 2,3 DPG increase Hb production increased pulmonary diffuse capcity vEGF angiogensis increased mitochondria

genes upregulate connexin 43 and oxytocin receptor.. what molecular cahnges?

increased gap junction Gap junction = connexins tight junction = claudins, occludin adherens junction = cadherin desmosomes = cadherines hemidesmosomes = integrins

how does gemfibrozil (and other fibrates) affect triglycerides and total cholesterol

increases LPL which hydroylzes FA's from VLDL promotes uptake of FA by adipose and increases conversion into triglycerides these triglycerides stay in adipose tissue and dont circulate in bloodstream

mechanism of erythromycin in gastroporesis

increases intestinal motility

70 y/o with PMH of mycardial infarction and CHF with a low ejection fraction has recently been repscribed verapamil. Most appropraite statement regarding this drug is that...

increases mortality in patients with congestive heart failure patients with HF and a low ejection fraction have increased moratlit when given CCB with a negative inotropic effect such as verapamil.

how does breat cancer induce hypercalcemia

induce osteoclats to secrete PTHrP, which leads production of RANKL - increased osteoclast differneiation osteocalts dmeinarlize bone, causing release of growth factors such as bone morphogenic proteins all of which support cancer cell proliferation and induce further release of PTHrP

how does thiamine deficiency modulate damage?

induced mitochondrial dysfunction - results in accumulation of intracellular free radicals

nerve injured in orbital fracture

infraorbital n. runs along the inferior aspect of the orbit along the maxillary sinus patient will have numbness/paresthesia of upper cheek, upper lip, upper gingiva

patient complains of slight blue tint to visual field. Fundoscopic shows nothing. He takes medications for diabetes mellitus, HTN, peripheral vascular disease, erectile dysfunction, and catartcs. Cause of visual?

inhibition of phopshodiesterase - Sildenafil blocks PDE5 increasing blood in corpus cavernosum Sildenafil weakly inhibits PDE6 which is required for transformation of light into electrical singals - blue vision

Ranolazine

inhibits late phase of Na current thereby reducing diastolic wall tension and oxygen consumptions does *not* affect HR or contractility clinically - used for angina refractory to other medical therapies Adverse - conspitation, dizziness, ehadache, nausea, QT prolongation

action of protein M in steptococcus pyogenes

inhibits phagocytosis and activation of complement M protein is also cytotoxic for neutrophils in the serum and a meditaory of bacteiral attachment

how does pobenecid affect penicllin levels

inhibits the secretion of penicllin in renal tubular cells --> increased concentration of penicllin in serum

ribavirin MOA

inhibits viral RNA polymerase activity and RNA fragment initation and elongation, lading to viral protein synthesis inhibition used in chronic hepaitis C and some cases of RSV

Kozak consenses vs. Shine-Dalgarno sequnce

initaite translation Kozak = eukaryotes Shine-Dalgarno = prokaryotes

Patient has MRSA. Treated with a drug that elevated creatinine phosphokinase level. MOA of drug?

interfere with maintenace of membrnae potential - *Daptomycin* disrupts bacterial membrane by creatine *transmembrane channels* that cuase intracellular ion leakage resulting cell membrane depolarization and macromolecular synthesis inhibition ultaimtely lead to cell death daptomycin is associated with *increased creatine phosphokinase levels* and increased icndence of myopathy

Superior mesenteric artery syndrome

intermittent intesinal obstruction symptoms (postprandial pain) when transverse (third) portion of duodneum is compressed between SMA and aorta occurs in conidtions with diminished *mesenteric fat* (e.g., low body weight, malnutrition)

what nerve supplies innervation to supraglottic region

internal branch of superior laryngeal n.

what nevrve innervates anal sphincter, external urethral sphincter, perineum, external genitalia?

internal pudendal n.

studying during cells during apoptosis. Activated caspases degrade severeal proteins including tranlsation initation factors - elF4 iniates translation by recognizing and binding 5' cap of mRNA. Although cells under investigation are dying, they continue to synthesize proteins required for apoptosis. Best explanined by what feature of mRNA?

internal ribosome entry site IRES are usually located in 5'l untralanted region, the segment of mRNA lcoated upstream from start codon

transient myocardial iscemia causes myocardial cells to increse in size. What is causing this?

intracellular Ca2+ accumulation anaerobic metabolism cant maintain proper intracellular ATP levels without ATP, the Na/K-ATPase and sarcopalsmic reticulum Ca-ATPases fail, leading to increased intracellular Na and Ca and increased intramitchondiral Ca concentrations these attract free water --> cellular and mitochondrial swelling

most common cause of palpable mass causing bloody and/or serous discharge from nipple

intraductal papiloma

germinal matrix hemorrhage

intravenultricular hemorrhage that is common complication of prematurity Results from impaired autoregulation of cerebral blood flow Germinal matrix is subventricular zone that is highly vascularized from which neurons and glial cells migrate out during brain development Hemorrhage occurs within first 5 days postnatal Can be clinically silent or present with altered consciousness, hyptonia and decreased spontaneous movements

lankmarks for pudenal nerve blcok

ischial spines - bony protusions lcoated posterolatearl to vaignal sidewalls sacrospinous ligament - firm band that runs medially and posteriorly from ischial spine to sacrum S2-S4 sensory to perineum and genitals motor to sphincter urethrae and external anal sphincter

lung harmatoma

islands of mature hyaline cartilage, fat, smooth muscle and clefts lined by repsiratory epithelium

what drug for TB would make the bacteria lose their "acid-fastness"

isoniazid - inhibit mycolic acid synthesis

what drug will decrease vascular resistance but increase cardiac contractility?

isoproterenol

site of radial ablation for atrial flutter

isthmus between IVC and tricuspid annulus

why cant the liver use ketone bodies?

it lacks the enzyme succinyl CoA-acteoacetate cotransferase (thiophorase) required to convert acetoacetate into acetoacetyl-CoA

modification of an amino acid already bound to its amino-acyl tRNA by the aminoacyl-tRNA synthetase. what is its fate?

it will be incorporated at the site of its original amino acid. examples: Erythrocyte radiolabed cysteine residues are attached to appropriate tRNA by enzyme aminoacyl-tRNA synthetase The bound cysteine residues are then chemically modified to form alanine The end product of this reaction is a tRNA molecule that contains cystine anticodon but is mischarged with alanine. What is most likely to occur to this alanine residue during polypeptide synthesis of alpha-hemoglobin? incorporated into polypeptide chain at site required cystine

where is the trigeminal nerve on brainstem?

latearl aspect of mid pons at level of middle cerebellar peduncles the sensory nuclei run from midbrain to upper cervical spine and receive afferent signals for facial sensation via all 3 nerve branches motor nucleus is located in latearl mid pons and sends efferent signals to muscles of mastication

dermatome from musculocutenous nerve

lateral forearm medial forearm = medial cutenous n. of forearm posterior arm and forearm = posterior cutenous branches of radial n thenar eminence = palmar cutenous branch of median n. (arises proximal to carpal tunnel)

what is cuase of paradically split S2

left bundle branch block aortic stenosis

fracture of Left 12th rib injures...

left kidney

what neve wraps around the aortic arch?

left recurrent laryngeal anerusymal dilation of aortic arch can comrpess L recurrent nreve results in *hoarseness* due to pralysis of intrinsic laryngeal muscles on that side (except cricothyroid)

what foramen does obturator internus go through?

lesser sciatic foramen

what is the biopsy of bullous pemphigoid

linear deposite of IgG and C3 located at dermo-epidermal junction

yellow subcutenous mass in thin fibrous capsule. mature univacuolated adipocytes

lipoma - benign neoplasm of fat cells most common benign soft tissue neoplasm

benefit of methadone therapy?

long half life mu-opioid full agonist half life >24 hours = suppresses cravings and withdrawal symptoms SE: -QT prolongation -respiratory depression with lethality in voerdose

what is the leukocyte alkaline phsophtase in CML?

low normal/eelvated in leukoemoid reaction

epinephrine effect on blood pressure by dose (low v. high)

low dose epinephrine = B2 receptors = vasodilation, decreased diastolic BP high dose epinephrine = a1 receptors = vasoconstriction, increased diastolic BP Systolic BP increases at any dose via b1 and a1 stimulation

risk factors for nephrolithiasis

low fluid low calcium high oxalate high protein high sodium high fructose Primary hyperparathroidism --> hypercalciuria Crohns disease --> hyperoxaluria Distal renal tubular acidosis --> hypocitraturia Gout --> hyperuricosuria

murmur associated with biphasic P wave in V1

low pitched decrescendo murmur with opening snap Mitral stenosis

location of pneumonia that obscures the diaphragm

lower lobe of lung

what will accenuate S3 heart sound?

lsitening at end expiration

radiograph of carpals

lunate is more medial o two bones that articulate with radius scaphoid is more lateral

52 y/o woman with fatgiue, pruritis. Patients sister has Sjogrens. PE shows skin excoriations and mild hepatomegaly. Labs: elevated ALT, AST, Anti-mitochondiral antibody. What is her biopsy of liver? and what other disease looks like this?

lymphocitic infiltirate +/- granulomas (Primary biliary cirrhosis) other disease = Graft vs. host disease graft T cells recognize host MHC and infilirtate and when Liver is involved --> destruction of small intrahpeatic bile ducts

causes of vitamin A deficiency

malabsorption from biliary obsturciton exocrine pancreatic isnufficiency small bowel resection

hypoglossal nucleus

medailly on floor of 4th ventricle at level of medulla nerve exits at rostal end of preolviar suluc

psammoma bodies meningioma

meningioma arachnoid cell origin spindle cells concentrically aranged in whorled pattern PSammoma bodies (laminated calcifcation)

what germ layer is notochord derived from?

mesoderm

manifestations of methylmlonyl-CoA mutase deficiency?

metabolic acidosis (increased methylmonyl acid) Hypoglycemia (decreased TCA cycle, so increased glycolysis) Ketones (decreased ATP, increaesd ketone production) hyperammonia (urea cycle inhibited by organic acids) lethargy, vomiting, tachypnea

patient with mallory weis tear will hvae what acid/base disturbance?

metabolic alkalosis

cancer in multiple brain lesions that have a BRAF mutations?

metastatic melanoma tx = Vermurafenib is potentent inhibitor of BRAF

recurrent vomiting leads to what acid/base disturbance

metbaolic alkalosis

Formic acid accumulation

methanol ingestion tx = ethanol or fomepizole - bothave higher affinity for aclhol dehydrogenase

purpose of metyhlation of in prokaryotic DNA

methlaytion of adenine and cysoine helps the cell distinguish its DNA from froiegn DNA unmethylated foreign DNA is destroyed as part of cellular defense mechanism Adenine resiudes may also be methylated shortly after DNA replication, allowing mismatch repair enzymes to distinguish between old and new strands

patient has anaerobic bacteria causing sinusitis. what do you give?

metrinidazole or clindamycin

double stranded RNA molecule in eukoaryotic cells?

miRNA functions to degrade mRNA if it is complementary leads to decreased mRNA translation

what is indicative of nephropathy in diabetic patients?

micro-albuminuria (30-300 mg/d) which can not be detected on urine dipstick (only >300mg/d can be = macroalbuminuria) to prevent worsening give ACE inhibitor or ARB

Williams syndrome

microdeletion on chromosome 7 - including elastin gene Elfin face mental developmental delay well developed verbal skills high calcium due to increased vit D sensitivty extreme friendliness with strangers

44 y/o HIV+ is brought to clinic for progressive cognitive decline. Last few years has had worsening memory and difficulty carrying out simple tasks. Patient has difficulty with delayed recall and executive function tasks. What would be found on biopsy?

microglial nodules HIV infected monocytes cross BBB to become perviascular macrophages activated macrophages and microglial cells form groups (microglial nodules) around small areas of necrosis and amy fuse to form multinucelated giant cells neuronal damage is believed to occur from inflammatory cytokine release by macrophages/microglial cells and direct toxic effects of HIV derived proteins

enzyme associated with increasing conversion of procarcinogens into carcinogens

microsomal monooxygenase CYP450 metabolizes many products in the body, but can convert some procarcinogens into potent carcinogens

appropriate treatment for tension pneumothorax in unstable patient

midcalvcular needle isnertion into second intercostal sapce chest tube placement is gold standard but is not firs tline due to time consuming methods

signs of reversible injury

mitchondiral swelling myofibril relaxation diaggregation of polysomes disaggregaiton of granular and fibrillary elements of nucleus triglyceride droplet accumulation glycogen loss

what cell change is associated with irrversible injury?

mitochondiral vacuolization - implies a permanent inability to generate further ATP via oxidative phosphorylation

mature erythrocytes are found that are unable to synthesize heme even though they contain detectable levels of cytoplasmic enzymes involved in heme synthesis. Lack of what organelle explains this?

mitochondria mitochondria are needed for first and final 3 steps of MITOCHONDRIA -----Glycine + succinyl Coa ---> Aminovulinic acid---->CYTOSOL---> Aminovlulenic acid --> prophobiningen-->hydroxymethylbilane-->uroporphyringen-->coproporhypringeon ----- MITOCHONDRIA ---- protoporphyrin --> HENE erythrocytes precursors divide many times before losing their nuclei and mitochondria and forming mature RBC that survive for 120 days When erythrocytes lose their mitochondria, they lose ability to generate heme and hemoglobin

histo of subacute granuloamtous thyroiditis

mixed, cellular infilitration with occsaional multinucleated giant cells

glomus tumors are derived from?

modified smooth muscle cells of the *thermoreguloatry glomus body* role of glomus body is to shunt blood away from skin surface in cold temperatures in order to prevent heat loss, and to direct blood flow to skin surface in hot envinroments to facilitate dissipation of ehat

denosumab

monoclonal antibody postmenopausal osteoprosis binds RANKL and blocks its interactio wtih RANK recetpor

what is consistent with malignancy in a lymph node?

monoclonal proliferation

Strawberry Hemangioma

most common benign vascular tumor in children superifical hemangiomas are bright red compressible plaques with sharply demarcated borders and referred to as strawberry hemangiomas appear during first first days or weeks after bith and grow rapidly during first 1-2 years majority of these regress by 5-8 years of age micro - thin walled blood vessels with narrow lumens filled with blood and separated by connective tissue these veseels are lined by endohtelium that rapidly proliferes during growth phase of tumor

post streptococcal glomerulonephritis mechanism

most common form of acute nephritis in children Type III hypersensitivity during infection, Antibodies form against antigen expressed by neprhitgenic strains of group B hemolytic streptococci These anti-strep antibodies combine with streptococcal antigens to form immune complexes that are deposited along glomerular basement membrane

where does most of the blood from the bronchial arteries go and waht is this conseuqnce?

most of bronchial arteries returns to left heart via pulmonary veins this causes slight mixing of deoxygenated blood causing slightly less partial pressure of oxygen

alpha 1 antitrypsin deficiency

most with AAT deficiency develop severe *panacinar emphysema* due to unchecked destructio of alveolar walls liver ivnolvement is of greater concern during first 2 decades of life lvier disease develops due to *intrahepatocyte accumulation* of polymerized AAT moelcule and can progress to *cirrhosis* intracellular granules of unsecreted AAT are seen wtihin peripheral hepatocytes of afflicted people globules stain red-pink with PAS reaction and resist digestion by diastase

treatment of cataplexy

muscarinic antagonists

mechanism of oxybutinim for bladder relaxation

muscarinic receptor antagonist decrease production of IP3 and release of calcium, leading to smooth muscle relaxation (M3 receptor)

mechanism of increased potassium in a patient with quadriplegia treated with succinylcholine?

nAChR is a nonselective cation channel - allows Na influx, K efflux Exaggerated hyperkalemia and life threatening arrythmias can occur in pateints with curhs or burn injuries, denervating injuries or diseases (quadriplegia, Guillain-Barre), These pathologic states cause upregualtion of muscle nAChRs and/or rhabdomyolysis - result in release of large amounts of potassium when succinylcholine is adminsetered use non-depolarizing agents in tehse patients

synaptophysin positive biopsy in intracranial mass... what are the cells derived from?

neruons neruoectrodermal neurodendocrine

conversion disorder

neurologic symptoms that have engative workup preceded by acute stroessor

inactivated influenza vaccine (the normal one) will cause what type of response when patient is exposed to antigen later on

neutralizing antibodies will prevent attachment of virion into cells

what cells are responsible for intesnse inflammatory response in gout?

neutrophils

what lipid lowering agent is associated with gout attacks

niacin - decreased uric acid excretion

function of DNa pol1

nick repair removal of RNA primer

are *autonomic postganglionic nerves* myelinated ?

no other unyemalinted neruons (group C nerve fibers): -afferent neurons that conduct heat sensation -affernt neurons that tarnsmit slow onset dull, burning or visceral pain -first order bipolar olfaction sensory neruons

Will mycoplasma hominis be affected by a drug that affectes D-ala-Dala cross linking?

no - it has no cell wall

mechanism and indication for rifaximin

nonabsorbable antibiotic that alters GI flora to decrease intestinal production and absorption of ammonia Hepatic encephalopathy sometimes used in travelers diarrhea as it inhibits bacterial RNA synthesis via binding with DNA-dependent RNA polymerase

what brainstem nucleus proives motor innervation to the pharynx, larynx, and elevates the palate?

nucleus ambiguus

characteristic histology of lymphoid tissue containing RS cell

numerous lmyphocytes (small cells with drak, round nuclei and small rim of cytoplasm) two mirror image nuclei of RS (owl eyes)

22 y/o works at pet store. Mild eryhtema and cobblestonning of posterior oropharynx without tonsillar hypertrophy or exudate. She has a headache, cough, fevers and chills for last three days. headache is bilateral and throbbing and worsened by bright lights. Right sided chest pain when she coughs. Macular rash on face, no rash or lesion anywhere else. Organism?

obligate intracellular gram-negative bacteirum = Chlamydia pstassci increased incidence in people handling birds on exam - lobar pneumonia, facial rash (Horder spots), splenomegaly and a fever without a commensurate increase in HR

42 y/o with daytime sleepiness. Doesnt feel refershed when waking and has occasional morning headaches. No abnormal dreams or hallucinations. BMI 32. Cardiopulmoanry normal. BP 148/100. diagnosis?

obstructive sleep apnea daytomine smnolence, nonrestrative sleep and elevated BP in setting of underlying obestiy OSA is caused by closure of upper airway due to relaxation of pharyngeal muscle tone during sleep additional contirbuting factors - obestity, tonsilalry hypertrophy and hypothrodism S/S - daytime sleepiness, morning headaches, depression most have loud snoring due to partial closure of airway chronic OSA can lead to pulmonary HTN and RHF

most common cause of acute appendicits

obsutrction of appendicular lumen - faclith

most common cause of iron deficiency in western world

occult blood loss Premenopause = menstraul bleeding Postmenopause = GI malignancy

Dumping syndrome

occurs after gastric bypass or damage to pyloric sphincter empyting of hyperosmolar chyme into small itnesine caues a rapid shift of fluid from serum to intesine, resulting in postprandial GI and vasomotor symptoms

nummular eczema

occurs in setting of xerosis use of harsh soaps and exposure to irritants can exacerbate condution pruritic, coin-shaped, erythematous patches

what can be used to treat acute manic episode

olanazapine - atypical antipsychotic

on/off phenomenon in levodopa therapy prognosis and do drug holidays help?

on/off phenomenon is a consequence of progressive nigrostriatial neurodegeneraiton leading to decreased therapeutic window for levodopa drug response will become more unpredictable as disease progresses and will become unrelated to dose because the therapeutic window decreases drug holidays do not help in preventing motor fluctuations in PD

increased IFNa and IFNb in viral cells

once secreted, alpha and beta IFN binds to type I IFN receptors of infected cells results in trasncriptin of antiviral enzymes capable of *halting protein synthesis* such as RNAse (endonuclease degrades cell RNA in cells) and protein kinase R (inactivates elf2) only active in presnce of DS-RNA -- selectivity of viral infected cells

etiology of marcus gunn pupil

optic nerve damage optic tract - contralateral eye because the nasal portion contributes more to the pretectal area eye will appear to constrict less (dilate) when swung to contralateral to lesion side Afferent pupillary defect - due to optic n. damage or severe retinal injury Decreased bilateral pupillary constriction when light is shone in affected eye relative to unaffected eye Tested with 'swinging flashlight test'

protective measures of ovarian cancer

oral contraceptives multiparity breast feeding

emergency contraception within 5 days

oral ulipristal inhibits ovulation

young female with bilatearl conductive hearing loss and family history...

otosclerosis overgrowth of middle ear bones, msot comonly the stapes, which itnerferes with sound conduction when stapes is involved, it becomes fixed to oval window and can no longer be pulled away bt the stapedius muscle in response to loud sounds *loss of stapedial relex*

what microbial component of N. meningitidis is associated with morbidity and mortality

outer membrane lipo-olgiosaccharide analogous to LPS of enteric gram negative rods, btu lacks the repeating O antigen of enteric LPS N. meningitidis LOS acts as an *endotoxin* - correcaltes with disease manifeations and outcomes High levels --> septic shock and death LOS causes sepsis by inducing systemic inflammatory response characterized by production of TNFa, IL1b, IL6, IL8 the *capsular* polysaccharide of N meningitidis is important virluence factor that assists bacteirum in resisting phagocytosis - but does not induce system inflammaory response

cryptococcus histology

oval budding yeast with thick capsule india ink stain

where is the most common site of endometriosis

ovaries

what portion of the female reproductive tract has *cuboidal epithelium*

ovary - simple uboidal cells divide and prolfierate rapidly to repair ovarian surface defects from ovulation

histoplasma

ovoid bodies in a macrophage

44 y/o homeless man with h/of alcohol abuse, unresponsive. He responds to pain; dry mucus memrbanes. renal biopsy shows marked ballooning and vacuolar degeneration of proximal renal tubules; multiple oxalte crystals are osberved in tubular lumne. pathogenesis?

oxalate crystals --> *ethylene gylcolar poisnonig*

urine chemistry pattern in diabteic ketoacidosis pH: HCO3: H2PO4:

pH - decrease HCO3 - decrease H2PO4 - increase (butffer that traps H+ in tubule)

Pulmonary embolism: pH: pCO2: pO2:

pH: elevated PaCO2:decreased PaO2: decreased hyperventilation lwoers CO2 but is unable to comepnsate fully for hypoxemia from the V/Q mismatch Blood normally becomes completely saturday with oxygen as it traverses the pulmoanry capillaries; tehrefore, a further increase in ventilation does not result in increased oxygen absorption this prevents well ventilated lung regions from being able to compensate for poorly ventilated regions with regard to oxygen aborption however, because CO2 is not entirely removed from blood durign traversal through lungs, highly ventilatied regions can excrete more CO2 to compensate for poorly ventilated regions hyperventilation results in hypocapnia with *respriatory alkaosis* without signifcant imrpovement in hypoxemia

pathogenesis of acute calculous cholecystis

persistent outflow obsutrction promotes hydroylsis of luminal lacithins to lysolecithines - disrupt protective mucus layer luminal epithelim is then exposed to detergent action of bile salts, resulting in chemical irritation and prostaglandin release inflammation of mucsoa and deeper tissue causes gallbladder hypomotility increasing distention and itnernal pressure iwthin gallbladder result in ischemia finally bacteria invdae injured and necrotic gallbladder --> infection

bleeding AFTER the placenta is removed via manual extraction

placental accreta scar tissue from prior surgery (C-section) can result in malformed or absent decidual layer between palcenta and myometrium allwoing for direct myometrial attachment

bilatearl amygdala lesions (Kluver-Bucy syndrome)

placidity with asbence of moetions, loss of facial animation, marked icnrease in sexual drive and libido, as well as hyperoality

likelihood of plaque rupture leading to acute coronary syndrome is related to...

plaque stiablity rather than size or degree of luminal occlusion plaque stiablity depends on strength of fibrous cap - thin cap = unstable and more vulnerable to rupture balance of collagens yntehsis and degrdation detemriens mechanical strength of cap *Thin cap fibroatheromas* have large necrotic core covered by a thin firbous cap activated amcropahges infiltriating atheroma contribute to breakdown of extracellular matrix proteins (collagen) by secreting *metalloproteinases* ongoing intimal inflammation can destablize the mechnical integirty of the plaque through release of these *MMPs*, resulting in plaque rutpre and conseuqnet caute coronary syndrome

what would be found in the kidney of someone suffering from TTP-HUS?

platelet rich thrombi in glomeruli and arterioles

pleural plaques

pleural thickening with calcification of posterolateral midlung zones and diaphragm, likely has *asbestos-realted plerual dsiease* *calcified lesions* are one of the hallmarks of asbestos exposure and usually affect paietal pleura, especially between 6th and 9th ribs

pneumonia vs. pneumonitis

pneumonia = oral contents, days after pneumonitis = gastric acid, hours after

mechanism of inheritency of androgenetic alopecia (male pattern baldness)

polygenic inheritence most common hair loss in male and females = androgenetic alopecia hair los occurs primarily at temporal areas and vertex and progresses through life severity/pattern depend on both hormonal (circulating androgens) and genetic factors and vary between males and females polygenic with variable expressivity

muscle biopsy shows endomysial inflammatin with CD8 T cells

polymyositis

difference between streptococcal pneumoniae vaccines: polysaccharide vs. conjugate

polysacchraide = wider range of serotypes but in children is not immunogenic; this vaccine protects for about 5 years and is recommended for adults >65 and thsoe 2-64 with certain medical conidtions conjugate = nontoxic diptheria protein conjugated to polysaccharides that bosst the immune response through T cell recruitment --> development of memory B cells this is part of routine childhood vaccines

Internal capsule

posterior limb separates globus pallidus and putamen from thalamus and carries corticospinal motor and somatic sensory fibers as well as visual and auditory fibers the genu of the internal capsule lies between anterior and posterior branches and carries corticobulbar fibers anterior limb of internal capsule separates caudate nucleus from globus pallidus and putamen and carries portion of the thalamocortical fibers

late complication of sepsis and ARDS?

potential late finding is progressive interstitial fibrosis 3 stages: Exudative phase - alveolar macrophages release cytokines, attracting neutrophils to cause capillary damage; this damage allows protein exudate producing hyaline membranes; decreased Po2/FiO2 indicates reduced arterial oxygen content relative to inhaled gas, indicating failure of lung to transport oxygen to blood Proliferative phase - type II pneumocytes and fibroblasts proliferate in the area, eventually leading to: Fibrotic phase - collagen is produced and deposited in lung, causing fibrosis and decreased tissue compliance

acute retinal hemorrhage

predisposing *hypertension* painless, unilatearl visual distburances, ranging from mild obscuration without loss of visual acuity to permanent blindness severe HTN in retinal precapillary arterioles causes endothelial disruption, leakage of plasma into arteriolar wall, and *fibrinous necrosis* - necrotic vessels bleed into nerve fiber layers, cusing dot- and flame-shaped hemorrahges

what burse is involved in housemaids knee

prepatellar

preproinsulin prosinulin insulin

preproinsulin is transcribed with an N'terminal sequence, which directs the protein the the RER At the RER, the N-terminal is cleaved forming prosinulin proinsulin undergoes conromational change with 3 dislfide bonds and secreted from RER and sotres in secretroy granules endopeptidases in granules cleave prosinulin into insulin and C-peptide for secretion

acute salicylate intoxication

presents with N/V, confusion, *tinnitus*, *fever*, *tachypnea* within several hours *respiratory alkalosis* occurs first as salicylates directly stimualte medulalry respiratory center, resulting in increaed ventilation and loss of CO2 in expired air *anion grap metabolic acidosis* begins to develop 12 hours later as high conetrations of slicylates increase lipolysis, uncouple oxidative phosphorylation and inhibit acid cycle results in accumulation of organic acids in blood, which bind bicarbonate increaed the anion gap PaCO2 = 1.5[HCO3} + 8 +/- 2

45 y/o male in MVA. Unable to void and has full bladder. Foley cath is aborted once resitance is encoutered and patient has pain. CT shows left hemothorax and pelvic fracture. Injury where?

presnce of pelvic fracture and inability to void despite full bladder = urethral injury other signs = presence of blood at urethral meatus and high riding boggy prostate (hematoma below gland) Foley is contraindicated Membranous urtethra is unsupported by adjacent tissues and wekaest point of posterior urethra trauma to pelvis can cause disurption of posterior urethra at bulbomembranous junction bulbous urethral segment is reifnorced by corpus spongiosum and suceptible to curshing injuries when perineum is struck forcefully (straddle injury) penile urethra is injured from instrumentation

mechanism of albdeazole

prevents microtubule dependent uptake of glucose by worms

what anti-malarial drug is approved to treat hypnozoites?

primaquine

50 year old female with history of inflammatory arthropathy presents with jaundice

primary biliary cirrhosis

what condition is associated with lipid laden macrophages in the upper eyelid?

primary biliary cirrhosis xanthelasma and other forms of xanthoma (tuberous, eruptive, tendinous) are associated with primary or secondary hyperlipidemia chronic cholestatic processes including obstructive biliary lesions and primary biliary cirrhosis result in subsequent hypercholesterolemia, leading to formation of xanthelasmas

48 y/o who died in MVA found to have small fibrotic focus in ower lobe of right lung and calcified lymph nod ein right lung hilus. Most consistent with?

primary exposure to TB lower lobe lung lesion (Ghon focus0 accompanied by ipsialteral hilar adenopathy = Ghon compelx Ghon complex occurs during inital infection with TB

40 year old man with jaundice has an ERCP demonstrating narrowing and dilation of the bile ducts

primary sclerosing cholangitis

transformation

process by which abcteria take up anked DNA from envionrment

action of mifepristone in pregnancy termination

progesterone antagonist - results in apoptosis and necrosis of uterine deciuda and prevents further development of first trimester pregnancy misoprostol = PGE1 agonist (cervical softening and expulsion of pregnancy) mifepristone = progesterone antagonist, glucocorticoid antaognist methotrexate = folic acid antagonist

PD1

programmed death receptor is on T cells it binds to its ligand PD1-R on cells which causes down-regulation of the immune response cancer cells use PD1R to escape from being destroyed

what happens to the endometrium when progesterone is withdrawn?

prostaglandin production increases leading to vasoconstriction of spiral arteries progesterone withdrawal also increases MMP by endometrial stromal cells --> degradation of ECM and APOPTOSIS of endometrail epithelium

development of anterior vs. posterior piutiatry

prosutrion of roof of mouth forms anterior pituatiry posterior pituatiry forms from outpouching of diecenphalon (neuroectoderm)

what degrades viral proteins for expression on MHC class I molecules for recognition by T lymphocytes?

proteasome

Good Samaritan law

protecting those who help someone in danger from any liability

volunteer protection act

protecting volunteers from any liability Ex - volunteers in large scale disaster relief

warfarin induced skin necrosis

protein C and S have shorter half lives and disappear quicker than 2, 7, 9 10 transient hypercoaguable state

emergency medical treatment and active labor act

provide a screening when requested provide stabilization care provide care to a woman in labor if the hospital is unable to perform stabilization, they should transfer the patient

morphologic changes associated with BPH

prsotate = ruberry bladder = hypertrophy ureters, renal pelvis, calyces dialte and deform, leading to hydronephrosis Renal parenchyma becomes *atrophic* and scarred due to reflux of urine and damage of renal tissue

granulation tissue with otitis externa

pseudomona

causes of ereticle dysfucntion

psychogenic stressors (acute onset of ED) performance anxiety or depression medications (SSRI, sympathetic blockers) vascular or neuologic impariment genitourianry trauma (e.g., postatectomy)

what nerve innervates external anal and urethral sphinceters

pudendal n.

what is the one artery that polyarteritis nodosa doesnt involve?

pulmonary

associated finding with sleep apnea in an obese patient?

pulmonary hypertension when the patient becomes hypoxic there will be vasoconsitrciton in the lung, causing there to be increased resistance and pulmonary HTN other findings = cardiovascular, systemic HTN, CHF, CAD, increased insulin reistance, cardiac arrhyhtmias and increased stroke and myocardial infarction

nitrogen isotpes are transfered to oxaloacetate, forming aspartate in the process. which of the following substances is most likely involved in this reaciton?

pyridoxine B6 is necessary for transmaination and decarboxylation of amino acids,f or gluconeogensis and for other essential biochemical processes transamination reactions occur between an amino acid and a keto acid amino group is tranferred to a-keto acid from amino acid, and the a-keto acid thereby becomes an amino acid ex: Glutamate (amino acid) reacts with oxaloacetate (a-keto caid) to form aspartate (resulting amino acid) and a-ketoglutarate (resulting a-keto acid) transmaniases (aminotransferases) are enzymes that catalyze trnasmaination reactiona nd B6 is essential cofactor

What has a similar structure to bisphosphonates

pyrophosphate

what space is the axillary nerve in?

quadrangular superior = teres minor latearl = humerus medial = long head of triceps inferiorly = teres major

what is the most important risk factor for primary thyroid malignancy?

raidation exposure

where are serotenergic neurons found?

raphe nucleus of brainstem raphe nuclei are in midbrain, pons, and medulla, and axons from these cell bodies project widely throughout CNS to synpase on cortex, thalamus, hypothalamus, cerebllum, hippocampus, spinal cord play role in sleep-wake, anxiety, mood, psychosis, sexuality, eating, impulsiity

Reid index

ratio of thickness of mucous gland layer in bronchial wall submucosa to thickness of bronchial wall between respiratory epithelium and bronchial cartilage (DOES NOT INCLUDE CARTILAGE)

Mother never wanted children due to unhappy childhood and resents having to care for her husbadns 5 y/o son. In waiting room, woman seems excessively concerned when boy trips and is uinjured. During visit, she tells physician that she adores child and describes her elaborate prep for his birthday party. Defense mechanism?

reaction foramtion - transforms unacceptable feelings or impulses into their etreme opposites displacement - woman yellated dog instead of child projection - woman accused husband of disliking the child rationalization - woman explaiend that hse is much too old for caring for a young child suppresssion - aware of resentment but chose to put it aside

72 y/o man with mild abdominal pain and bloody diarrhea fater undergoing uregent cholecystectomy. Surgery complicated by eisode of hypotension. Treated with bolus IV fluids. PMH - HTN, hyperlpidemia, T2DM, myocardial infarction. SH - smoked for 40 years, quit after MI Colonscopy would show pathology of what portion of large bowel?

rectosigmoid junction = *ischemic colitis* colon receives blood from marginal a. of colon (a. of drummond), an anasotmitc system of arteries that is in turn supplied by SMA and IMA distal colon recesivs from itnernal iliac in low flow state, as may be seen in severe hypotension, *nonocclusive ischemia* may occur at margins of the anastomatic distrbutions these *watershed* areas are priarmily in left colon at *splenic flexure* and *rectosigmoid junction*

what nerve travels with the inferior thyroid artery

recurrent laryngeal n. superior thyroid a. = superior laryngeal n. (sensation to supraglottis)

what happens to the spleen in pyruvate kinase deiciency?

red pulp hyperplasia - reitculoendoethlail cells in spleen are in the red pulp and undergo hyperplasia

atrophy cellular level

reduction in mitochondria and rough ER

breathing in obstructive sleep apnea

reductions or cessation of airflow during sleep due to upper airway obstruction despite adequate respiratory effort HOWEVER, ventilation remains nearly constant during the non-apneic periods with minimal cyclical variation in tidal volume

what forms nodules in cirrhosis?

regenerating *hepatocytes*

serum creatinine vs. glomerular filtration rate

relationship btween serum Cr and GFR is non lienar a person's serum creatinine can be essentially normal even after 50% loss of kidney function serum creatinine elvels begin to rise signficantly as gFR declines to <60 ml/m as GFR continues t decline the slope of the creatinine-GFR curve steepens when GFR is signifcantly decresed, small decrements in GFR produce large changes in serum Creatinine serum creatinine is therefore an insensitive indcator for decreasing GFR when creatinine levels are normal

what artery supplies the proximal ureter?

renal artery distal ureter = superior vesiclar a. in kidney transplant, native kidney left in palce and donor kidney palced in retroperitoneal right iliac fossa blood supply eastblished by anasotmosing donor renal a. with recipients external iliac a. proximal 1/3 of donor ureter is presreved and used to establish continuirty from colelcting system of kidney to recipients bladder distal transplanted ureter is suceptible to ischemia distral ureteral ischemia is complication of renal transplant cand causes lekade of urine 5-10d after transplant

what part of the kidney is affected most from ischemic injury?

renal medulla - low blood supply even under normal conditions straight portion of proximal tubule and thick ascending limb are suceptible to hypoxia, as they particpate in active transport of ions and ahve high oxygen demand

renal artery stenosis CT

renal size discerpancy is abrnomal and cahracteristic of unilateral RAS in unilateral RAS, chronic ischemia causes *atrophy of affected kidney* while the *contralatearl kidney becomes enlarged* due to comepnstaory hypertrophy

17a hdyoxylase deficienc renin: cortisol LH:

renin: increased cortisol: increased LH: increased

equlibrium potenitals

resting membrane is negative - indicating that at rest, the membrane is pemrable to an ion with a negative equilibrium potential opening of ligant gated ion channels in response to a neurotransmitter cuases an increase in membrane potenteial to above zero this indicates that the membrane as become more permeable with a *positive equlibrium potential* opening of voltage gated channels in response to change in membrane potenial causes a drop in membrane potential, indicated that the membrane becomes permaeabl to an ion with a *negative equilibrium potenital*

what is biopsy of pemphigus vulgaris

reticular pattern of IgG lcoated around the cells of the epidermis

an external stimulus applied to cell increases activity of several enzymes, icnluding dihydrofolate reductase and DNA polymerase. Which of following immediately precedes the osberved effect?

retinoblastoma protein phosphorylation Rb is regulatory of G1-S phase transition Active: hypophosphorylated Inactive: hyperphosphoryalted Hyperphosphorylated Rb relases E2F transcirption factor, which allows the cell to progress through the G1-S checkpoint

calcium pyrophosphate

rhomboid shaped calium pyrophosphate crystals is diagnostic postively birefirgnent under polarized light meaning the color pattern is opposite that seen in gout

what is at risk of being injured during a thoracentesis along upper border of 10th rib at right midaxilalry line?

right hepatic lobe visceral pleus covers surface of lung parietal pleura lines inner surface of chest well and diaphragm - extends 2 ribs below viscearal pleura and ifnerior margin of lung Potential space at reflection of costal pleura onto diaphgramtatic pleura is called - costodiaphragmatic recess - wehre pleural exudate accumulates when body is erect thoracentesis should be perofmed between: 6th-8th ribs along MCL 8-10th rib along midaxillary line 10th-12th along paravertenral line Any higher = lung injury insertion of needly at these levels still risks penetrating abdominal structures

location of pneumonia that obscures the cardiac silhouette

right middle lobe

oculomotor nucleus

rostral midbrain at level of superior colliculus and rednucleus nerve exits at interpeduncular fossa

blastomyces dermatitidis

round yeast with broad-based budding

renal cell carcinoma histology

rounded and polygonal cells with abundant clear cytoplasm cytoplasm appears clear due to high glycogen and lipid content of the tumor for the same reason, this neoplasm is often golden yellow on macroscopic exam hematuria, palpable mass, secondary polycythemia, flank pain, fever weight loss invades renal vein and metastasizes to lung and bone

Left ventricular free wall rupture

rupture appear as slit like tear in infarcted mycaordium, with preference for LV due to higher systolic pressures abrupt rupture of LV leads to hemopericardium and cardiac tamponade and presents with suddent onset of chest pain and profound shock, followed by rapid progression to electromechanical dissociation and death

cerebral palsy gait

scissoring gait is narrow based and spastic, and circumduction of hip helps with toe clearance

major cause of mortalirty in theophylline overdose?

seizures tachyarrhyhtmias are a concern but usually do not cause QT prolongation Tx = activated charcoal --> decrease GI absorption Tx = beta blocks --> cardiac tachyarryhtmias Tx = benzos/barbituates --> seizures

Hepatitis B replication in host cells

semi-double-stranded DNA --> RNA+ strand template --> DNA double strand progeny uses reverse transcirptase

ANA in SLE

sensitive

metyrapone stimulation test

sensitive indicator of HPA axis integrity metyrapone blocks cortisol synthesis by inhibiting 11b-hydroxylase, which converts 11-deoxycortisol to cortisol in zona fasiculata because 11deoxycortisol lacks glucocorticoid activity it does NOT inhibit ACTh secretion as a result, reduction in cortisol levels following metryapone administration cause an increase in pituitary ACTH secretion this leads to increased production of 11-deoxycortisol which is further metabolized by liver to 17-hydroxycorticosteroids that accumulate in urine serum 11-deoxycortisol and urianry 17-hydroxycorticosteroid levels normally rise in response to metrypaone, indicated intact HPA failure of these steroid levels to increase implies primary or secondary adrenal insufficiency, which can be distinguished based on plasma ACTH levels

Fever + Nuchal rigidity

septic bacterial meningitis

what cell is responsible for secreting a substance rthat maintains the tubule testosterone levels?

sertoli cells - androgen binding protein

Kidney biopsy LM - cell proliferaiton, focal necrosis, crescent formation of most goemruli. IM - no immuglobulin or complement. Adidtional finding?

serum ANCA

periportal pipestem fibrosis

shistosomasosis

nitroprusside pressure volume

short acting venous and arterial vasodilator decreaes LV preload and afterload allwoign adeqaute cardiac output to be delivered to aw loer LVEDP

obstetric conjugate

shortest diameter fetal head must get through sacral promontaory to pubic symphysis

signs of irreversible neuron injury

shrinkage of neuronal body deep eosinophilia of cytoplasm pyknosis of nucleus lsos of Nissl substance

Parvovirus replication in host cells

single stranded DNA --> DS DNA template --> SS DNA progeny

why do CCB have no effect on skeletal muscle?

skeletal muscle doesnt rely on xtracellular calcium to contract

cricothryotemy goes through

skin superficial cervical fascia investing deep pretrachel fascia cricothyroid mebrane

what does drug induced Lupus have a prediclection for

slow acetylators

chrondromas

slow growing, locally aggressive neoplasm of bone arise from remnants of notochord most common primarily malignant spinal tumor in adults >50 sphenooccipital region of skull and sacrum composed of lobules that contain epitheloid cells arranged in clusters and have vesicular nuclei with abundant vacuolated soap bubble like cytoplasm - *physaliphorus cells* that contain glycogen or mucin

histoplasma capsulatum

small oval yeast forms within macrophages

where is glucose 6 phsophatase found

smooth endoplasmic reticulum

lesions in vitligo

smooth or slightly raised to surrounding skin and Wood's lamp positive (hypopigemneted areas will fluoresce in a dark room under Woods lam) increased incidence in patients with throid disease

what artery traveses the superior portion of the pancreas? what artery supplies the blood to the pancreas?

splenic a. gastroduodenal supplies blood to pancreas

intermittent ear discharge for 2 years in 48 y/o. Decrased hearing in right ear. Small perforaiton in right tympanic membrane and pearly mass behind membrane. Conduction hearing loss ntoed in right ear. cause?

squamous cell debris - *Cholesteatomas* can occur congenitally or develop in adults as acquired primary lesion or secondary to infeciton, trauma, or surgery of middle ear primary cholestatomes are result of chornic negative pressure in middle ear causing retraction pockets in tympanic membrane taht become cystic; as *squamous cell debris accumulation* a cholesteatome is formed secondary cholesteatomas ocur after squamous epithelium migrates to or is implante din middle ear *do not contain cholesterol*

Myocardial hibernation

state of chronic myocardial ischemia in which both myocardial metabolism and function are reduced to match a concomitant reduction in coronary blood flow (due to moderate/severe flow limiting stenosis) this prevents myocardial necrosis chronically hibernating myocardium shows decreased expression and disorganization of contractile and cytoskeletal proteins, altered adrenergic control, reduced calcium response these changes lead to decreased contractility and LV systolic dysfunction coronary revasculirization and restoration of blow flow improves contractility and LV function

Subclavian steal syndrome

stenosis of subclavian a proximal to vertebral a. Retrograde flow from contralateral vertebral a. to ipsilateral vertebral a. Asymptomatic Some present with extremity ischemia

leishmania

stibogluconate sodium amphotericin

what layer of skin is increased in a *skin callus*

stratum conruem

Liver synthesis large quantities of glucose from source molecules such as alanine, lactate and glycerol. As part of this process, phosphoenolpyruvate is formed from oxaloacetate in a reaction that requires specific nucleoside triphosphate cofactor. What reaction synthesizes this cofactor?

substrate level phosphorylation Succinyl-CoA synthetase coverts succinyl-COA to succinate and uses the high energy thioester present in succinyl CoA to drive GTP synthesis This GTP can than be used to transphorphorylate ADP to ATP, or it may be utilized by specific GTP hydrolyzing enzymes, such as phosphoenolpyruvate carboxykinase (converts oxaloacteate to phosphoenolpyruvate during gluconeogenesis)

what supplies blood to ductus deferences

superior vesical a.

where is a superior gluteal nerve lesion likely to occur?

superomedial quadrant of buttock superolateral quadrant is safest place for dorsogluteal injections but gluteal and sciatic n. can still have injury here. most itnragluteal injections should target anterogluteal area (von Hochstetter triangle)

where does repaglinide bind?

surface ion channel of Beta cell

electrolytes in Cystic fibrosis

sweat with high sodium and high chloride patients can develop hyponatremia due to excessive salt wasting risk factors - breast or formula feeding prior to introduction of sodium rich, solid foods High temperature exercise

27 y/o with severe knee pain and welling for two days. Temperature is 101. Knee is sollwen, eryhtematous, warm and tender with resitrcted range of action and passive motion. next step?

synovial fluid fluid analysis synovitis = acute joint pain, swelling, erythema with restricted ROM acute undiagnosed synovitis, when accompanied by fever or luekocytosis, reprsents an emergency delayed diagnosis of spetic arthrtis may lead to loss of joint and long term diability, and can be fatal

M3 receptor stimulation on endothelial cells

synthesis of Nitric oxide, an endothelium derived relaxaing factor NO diffuse into vascular smooth muscle cells --> increased cGMP --> myosin light chain phosphatase --> dephopshorylates myosin and prevents interaction of myosin head with actin Results in smooth muscle RELAXATION and VASODILATION no muscarinic receptors actually on peripheral blood vessels

mechanism of infection after VP shunt punt in, from a coagulase negative staph

synthesis of extracellular polysaccharide matrix S. epidermidis foriegn bodies are covered with granulation and fibrin poducts, which serve as the reservoir for S. epidemridis to bind to these bugs encase themselfs in an extracellular polysaccharide matrix

follicular lymphoma

t14;18 - overexpression of *BCL2*

coccidioides immitis

thick walled spherules packed with endospores

work of breathing...

tidal volume increases force against elasticity work against arifrlow resistance is increased with increased rate stiff lungs = work is minimized with high respiraotry rate, low tidal volume obstructive lesion = work minimzied with high tidal volume

latent period and incubation period

time elapsed from initial exposure or pathogenic insult to clinical manifestation of disease Incubation = infectious disease latent = noncommunicable chronic disease exposure to risk modifiers sometimes occurs well before the exposure's effect on the disease process is evident (e.g., mesothelioma developing decades after asbestos exposure)

what decreases in peak stress exercise?

total systemic resistance

diagnosis of patient with abdominal pain/distention, blodoy diarrhea, fever and signs of shock in setting of untreated ulcerative colitis

toxic megacolon

42 y/o with episode of seizure. No prior seizure, but has had headaches for several weeks. Works in construction. No travel out of US, no pets. PE shows postictal state, oral thrus and several enlarged cervical and inguinal lmyph nodes. MRI shows multiple ring enhancing lesions

toxoplasmosis patient probably has HIV given his thrus (<200), cervical and inguinal lmyphadenopathy and brain lesions Headache, seizures, multiple ring enhacning lesion = toxoplasmosis cat exposure is not needed becuase toxoplasmosis can be throug contaminated foods

TATA boxes....

transcription initiation RNA pol II attaches to one of the promoter regions in a process that requires general transcription factors

how do strep pneumo acquire ability to produce capsules?

transformation

Child born to a women with poorly controlled type 1 diabetes will have:

transient hypolgycemia after birth, neonate no longer exposed to mothers high blood glucose, but a hyperinsulinemic state persists for several days, predipsoing neoante to hypolgycemia resolves within 3-7 days

deficient in PECAM-1, what neutrophil funciton is affected?

transmigration Rolling = L selectin (leukocyte), E-selecitn/P-selectin (endothelial cells) Tight adhesion and crawling = CD18 beta 2 integrins (Mac1 and LFA1) to intercellular dhesion molecule 1 (ICAM1) transmigration = PECAM1 migration = C5a, IL8, LTB4m kalikrein, PAF

noise induced hearing loss

trauma to sterociliated hair cells of organ of corti prolonged noise exposure can cause distortion or fracture of sterecilia due to shearing forces against tectorial membrane high frequency hearing is lost first regardles of the frequency of the sound causing the damage

holosystolic murmur that increases with inspiration

tricuspid regurgitation

glycerol kinase

triglyceride stored in adipose tissue are emtabolzied to FFE and glycerol by HSL in response to low insulin and high catecholamine levels adipocytes cant metabolzie glycerol so its secreted into circulation and transproted to iver, where it it is phoryphorylted to glycerol 3-P by glycerol kinase Glycerol3P is converted by glycerol3 phosphate deydrogerase to dihydroxyacetone phosphate (DHAP) which can be used to produe glucose through gluconeogensis

what is the only cranial nerve to decussate in brainstem and exit dorsally?

trochlear

patient gets double vision when walking down stairs. what nerve?

trochlear symptoms often improve when chin is tucked and head is tilted away rom affected eye as this comepnsates for hypertropia and extorsion

Giardia histo

trophozoite is bilatearlly symmetric, *pear shaped* orgnism with multiple flagella and *2 nuclei* cysts are oval and contain up to 4 nuclei Diagnosis confirmed by *stool micro for ova and parasites* major immune mechanism is *secretory IgA production* and CD4 T cells

Meiliodosis

tropical disease caused by *Burkholderia pseudomallei* motile gram-negative rod with bipolar 'safety pin' appearance frequently progresses to sepsis, causing disseminated microabscesses in the skin, ievr and spleen

patient is having eye exam. Solution causes pupils to dilate and patient to have poor near vision. whwat was given?

tropicamide - anti-muscarinic pupillary muscle has M3 receptors and a1 the cilairy muscle ONLY HAS MUSACARINIC

straitified squamous cell epithelium - false or true vocal cords

true vocal cords false - psuedostratified, ciliated culumnar

symptoms of acute hemorrhage in cerebellar vermis without mass effect or midline shift

truncal ataxia - wide based, unsteady gait patients may also have vertigo and nystagmus due to involvement of inferior vermis and flocculonodular lobe with modulate balance and ocular movements via connections with vestibular nuclei and medial longitudinal fasiclus

what is the precursor amino acid for serotonin? What do you give to treat serotonin syndrome?

tryptophan Cyproheptadine (first generation histamine antagonist with nonspecfiic 5HT1 and 5-HT2 receptor antagonism)

hypersensitivity reaction of rheumatic fever

type II cytotoxic

hypersensitivity reaction of poststreptococcal glomerulonephritis

type III

what blood type has increased peptice ulcers?

type O

what amino acid needs to be replaced in phenylalanine hydroxylase deficiency?

tyrosine

what reaction is impaired in alkaptonuria

tyrosine to fumarate

Viral proteins are degraded and attached to MHCI and expressed on cell surface for CD8 cells. What enzyme is involved in this process?

ubiquitin ligase enzymes that recognize specific protein substrates and ctalyze ubiquitin attachment role of UPP in immune response is realted to ability to degrade foreign intracellular ptoeins such as viral particles

44 y/o with long standing GERD. Recently less responsive to OTC antacids. Has substernal pain on swallowing. No fod stickin in chest, coughing or choking. HIV-negative. BMI 32. whats causing recent symptoms?

ulceration - *erosive esophagitis*

loss of abduction and adduciton of fingers is what nerve

ulnar - interossei muscles - PAD/DAB

ventral pancreatic bud

uncinate process head (some) proximal main duct

Rickets is characterized by

unmineralized osteoid matrix prior to ambulation - frontal bossing, cranioabes, costochondral junction widening from cartilage overgrowth (rachitic rosary) are apparent once weight bearing - pateints have lateral femoral and tibial bowing (genu varum) radiographs of growht plates - epiphyseal plate widening and cupping

paitent has riodlucent kidney stones that are in shape of rhomboids. She has a colestomy bag and noticed increased fluid in the bad over past few days. Mechanism of stones?

uric acid stones - riodulenct, rhomboid chornic diarrhea --> increased HCO3 excretion Kidneys try to compensate by increased H+ excretion --> acidic urine increasing conversion of soluble salts into insoluble uric acid

most useful test for diagnosing metabolic alkalosis?

urine chloride vomiting/suctioning - loss of H and Cl in gastric sections causes net gain of alkali in body --> metabolic alkalosis; loss of Cl impairs HCO3 excretion in kidney, worsening alkalosis Tx = volume and Cl repletion with isotonic saline Thiazine/loop diuretic - increased Na delivery to distal kidney increases K and H urinary loss causing metabolic alkalosis; these patients have high urine Cl Tx = volume and NaCl repletion minearrlocroticoid excess - HTN and high urine Cl; the alkalosis cannot be corrected with isotonic saline due to mineralocorticoid activity

3 day old girl with persitent bilous vomting. Dehydrated. No blood in emesis. Normal duodneum, absence of alrge segment of jejunum and ileum, and remainder of distal ileum winding around a thin vascular stalk. What is responsible?

vascular occlusion = distal atresia diminished intesitnal perfusion leads to icshemia of segment of bowel, with narrowing (stenosis) or obliteration (atresia) of the lumen result is a proximal segment ending in blind pouch followed by area of absent small bowel and associated dorsal mesenery finally, distal segment of ileum that assumes SPIRAL configuaration around an ileocolic vessel (apple peel sign)

what forms the firbous cap in athersclerotic leions?

vascular smooth muscle cells

mechanism of pulmonary hypertension in hypertensive heat disease

vasoconstriction due to pulmonary venous congestion 1. increased diastolic filling pressure 2. increased LA pressure 3. pulmoanry venous congestion 4. increased pulmonary arterial pressure 5. vasoconstriction 6. intimal thickening and medial hypertrophy

villous adenoma

veillous adneomas can secrete large amounts of watery mucus --> *secretory diarrhea*, hypovoelmia, electrolyte abnroamlities

oral thrus interstitial pneumonia severe lymphocytoepnia in first year of life

vertical transmission of HIV *zidouvidine* is used in pregnancy

cellulitis on hands of salt water shellfish handlers

vibrio vulnificus

on colon biopsy, what has the highest risk of malignancy?

villous adenoma - large and flatter with velvety, califlower like apperance sessile polyps with broad based attachments are more likely to become malignant than pedunculated polyps attached to a stem

HIV protein becomes glycolsylated before being rptoelytically cleaved into smalelr proteins in th ER and golgi. What is the fucntion of these 2 protines?

virion attachment to target cells Env forms gp160 --> gp120, gp41 gp120 medaites viral attachment by binding to CD4 (blocked by Maraviroc) gp 41 anchors gp120 through noncovlent interactions, mediating fusion process (blocked by Efnluvirnide)

why does hepatitis C evade the immune system so well?

virion encoded *RNA-dependent RNA polymerase has no proofreading* in the 3'-->5" exonuclease activity, which results in many errors during replcaition most are ifnected with single genotype, the high mtuation rates leads to development of distinct equasispecies within infected individuals over time these variant strains differ primarily at *hypervariable genomic regins* such as those coding for *envelope glycoproteins*

an HIV itnegrase inhibitor prevents downstream development of..

virus mRNA inhibits the integration of viral genome into the host

Visal pathway

visal perception being with light form nasal visual fields striking temporal side of each retine and light from temporal visual fields stirking the nasal sie of each retina information from retina is transmitted by optic nerves to optic chiasm at the optic chiasm, optic nerve fibers from nasal half of each retina cross and project into contralateral optic tarct in contrast, nerve fibers from temproal parts pass into ipsialtearl optic tract the optic trac thus contains nerve fibers from temporal part of ipsilateral retina and nasal part of contralatearl retina optic tract proejcts mainly to lateal genicular nucleus (LGN); but also superior colliculus (reflex gaze), pretectal area (light reflex) and suprachiasmatic nulcues (circadian rhyhtms) axons from LGN project to primary visual cortex are known as optic radiation (or greniculocalcarine tract) Lower fibers of optic radiation carry infomration from lower retina (upper contralatearl visual field) and take route anterior into *temporal lobe* (Meyers loop) before reaching lingual gyrus o striate cortex Upperf ibers of optic radiation carry ifnormation from upper retina (lower contralatearl visual field) and pass more directly form LGN through *parietal low* to reach cuneus gyrus of striate cortex

patient with weird eating habits, alopecia, dry skin, hepatic toxicity, joint pain, papilledema

vitamin A chronic toxicity papilledema = pseudotumor cerebri (tx = mannitol) acute toxicity = N/V, vertigo, blurred vision

what vitaminers/minerals are overporudced in small bacterial voergrowth?

vitamin K folate

newborn at birth receives no medicines. has brain bleed 3 weeks alter. cuase?

vitamin K deficiency normally newborns get a vitamin K shot after birth

eccentric and concentric cardiac hypertrophy

wall thickness = concentric cavity size = eccentric

what stype of casts are seen in end stage renal disease?

waxy casts

pneumothorax

white visceral pleural line on pateints riht side - indicated separtion of lung parenchyma from parietal pleura by pocket of air *pulmoanry vessels are not visible beyond the visceral pleural boundary* herat and trachea are sometimes shifted away form affected side, especially when pleural pressure exceeds atmspheric pressure (tension pneumothorax) Treatment = *chest tube placement*

rhizopus histology

wide shaped branching fungus can present like aspergillus but histology separates it

inheritence pattern of chronic granulomatous dsiease

x linked

patient has elevated ALP, what should be ordered next?

y-gluatmyl transpeptidase - presnt in hepatocytes and bilairy epithelia GGTP is not present to signifcant extent in bone - useful in detemrining whetehr and elevated alkaline phosphatase is of heaptic or bone origin

mrophology of cryptococcsu

yeast only narrow budding yeast

Are fluoxteine and dulexotine safe to use in pregnancy?

yes

what chromosome is beta globulin on?

11

what is increased in 11b-hydroxylase deficiency?

11-deoxycortisol and Deoxycorticosterone

Duodenum course

1st part - emergees from pylorus and is horizontal over L1; only part of dueondm that is not retroporeitneal 2nd part - courses inferior from L1-L3, close relation to head of pancreas and has ampulla of Vater (pancreatic and common bile duct secretions) 3rd part - horizontal over L3, abdominal aorta, and IVC; close association with uncinate process of pancreas ans SMA; if a tumor were to anteriorly invade here it could comrpomise SMA 4th part - courses superiorly and to left of L2 and L3 becoming jejunum at ligament of Treitz

leucine zipper

2 alpha helical domains that form a dimer with repeated leucine derivatives at every 7th position *transcirption factor* - the basic charged allows for the moelcule to bind to the engatively charged DNA

what would be appropriate respiratory compensation for a HCO3 of 10

21-25 1.5*10+8 +/- 2

a cross sectional study measured cholesterol levels in a population of 100 patients with type II diabetes. The values followed a normal distribution curve, with a mean of 250 mg/dL and a standard deviation of 10 mg/dl. What is the mode?

250 mg/dL in a normal distribution, the mean, median and mode are all equal. Since the mean is given as 250, the mode and median are also 250.

when is anti-Rh normally given?

28 weeks intrapartrum immediate postpartum

what is considered the most restful stage of sleep?

3

normal v/q at apex of lung

3.0

what weeks does the heart begin to beat

4

child born with protrudign tongue, excessive skin at nape of neck and upslanting palpebral fissues. startle reflex is symmetric and weak. cardaic ausc - harsh, III/VI systolic murmur at LSB. Normal female genitalia. echo - VSD karyotype?

46, XX t(14;21) Roberstonian translcoations occur between 2 acrocentric, nonhomolgous chromosomes resulstnat translcoated chromsomes are fusion of 2 long arms (14q and 21q) and fusion of 2 short arms (14p, 21p)

where is a chest tube placed?

4th or 5th ICS @ mid-axillary line

5'---ACG-CUA-CCA-*UUG*-UAA-CAA-GUU-AGC-UAG----3' what is anticodon for last amino cacid?

5' CAA 3' translation of mRNA template proceeds in 5'-3' direction the codon before the stop codon is 5' UUG 3' and this amino acid will be carried by the 5' CAA 3' anticodn (caodon-anticodon binding occurs in opposite directions)

how long does it take for depletion of ATP in critical cellular areas and accumulation of toxins resulting in loss of contractility myocardial infarction?

60 seconds when ischemia is less than 30 minutes, loss of contractile function is reversible upon restoration of blood flow, full contractility is not immedateily restored; there is porlonged dysfunction of the myocardium, with contractility returning over next horus to days

when does progesterone peak in the menstrual cycle?

7 days prior to menses This is equal to halfway through the luteal phase

if fertilziation and implantation occur during a cycle, when will B-hCG be detectable in the serum?

8 days after fertilization the blastocyst implants 6 days after fertilization and the outer cell mass (trophoblast) differentiates into cytotrophoblast and synctiotrophoblast the syncytiotrophoblast invades endometrial connective tissue 6-7 days after fertilization and starts secreting b-hCG accordingly, b-hcg may appear in maternal serum 6 days after fertilization at the earliest and may require additional time (typically 8 days) b-hcg can be detectable in serum at <5 IU/L - most sensitive method of detecting pregnancy a urine pregnancy test is less sensitive than a serum test - becomes positive when b-hCG reaches 20 IU/L which is 14 days after fertilization

serum ascietes-albumin gradient

>1.1 = protal HTN <1.1 = other (e.g., decreased albumin)

compound is a pentapeptide with strong affinity to delta and mu receptors. What substance is most likely to have common molecular origin with the pentapeptide above?

ACTH beta-endorphin is one endogenous opioid peptide that is derived from POMC POMC is polypeptide precursor that goes through enzymatic cleavage and modification to produce not only beta-endoprhins, but also ACTh and MSH The fact that beta-endoprhin and ACTH are derived from same precursor suggests there may be close physiological relationship between the stress axis and opioid system

when treating congenital adrenal hyperplasia, what is the target of drug therapy?

ACTH tx = administering low (physiologic) doses of exogenous corticosteroids to suppress ACTH secretion by removing excessive ACTh stimulation, exogenous corticosteroids can decrase androgen production by adrenal cortex

diagnosis the cause of cushing syndrome

ACTH suppressed = adrenal adenoma, adrenal malignancy, exogenous glucocorticoids High dose dexamethasone suppresses ACTH = pituitary adenoma high dose dexamtheasone unchanged ACTH = ectopic ACTH production Cushing disease = pituitary adenoma secreting ACTH

patient as acute intermittent prophyria. She is given glucose and heme. What is enzyme is inhibited to help her symptoms?

ALA synthase

intermittent respiraotry symptoms (dyspnea, cough) in setting of *normal chest xray*, sputum *eosinophils* and reduced FEV1...

ASTHMA reversible obstructive pulonary disease characterized by bronchial hyperreapsoniveness to vairous triggers - exercise, cold air, infection, *inhaled allergens* common aeroallergens - dust mites, cockraoches, pet dnader, mold, pollen allergens promote bronchospasm and inflammation by interacting with IgE bound to pulmonary mast cells mast cell activation results in release of inflamamtory mediatores and recruiemnt of inflammatory cells - *eosinophils*

in vitra studies dmeonrate that tumor cells can become resistant after exposure to various anticancer agents. These cells express a specific sruface glycoprotein that has which of following funcitons?

ATP-dependent tansporter Human multidurg resistance (MDR1) gene - prototype product of this gene is P-glycoprotein, a transmembrane proiten that functions as an ATp dependent efflux pump P glycoprotein is normally expressed in intesinal and renal tubular epithelial cells and functiosn to eliminate foreign compounds from the body Also in capilalry endothelium of vessels that form BBB in tumor cells, ATP powered trnasmembrane pump protein actively removes chemotherapy agents, particuarly hydrophic agents like anthryacyclines

Wolf-Parkinson-White

AV conduction tract bypassing AV node (bundle of Kent) *WPW triad* Short PR interval Widening of QRS interval Slurred and broad upstroke of QRS complex = *delta wave* can be asscoiated wtih arrhyhtmia (AV reentrant tachycardia) due to retentry of electrical impulses through aberrant conduciton pathway

5 month old with poor weight gain since birth. bulky greasy stools. Jejunal biopsy shown - enterocytes have clear or foamny cytoplasm due to accumulation of lipids in asborptive cells

Abetalipoproteinemia - disease caused by impaired ormation of apoB-containg liporteins Chlymocirons, VLDL, LDL are absent infants - fat malbasorption, steatrrhea, failure to thrive Later - retinitis pigmentosea, spinocerebellar gedneraiotn due to vitamin E deficiency, ataxia, *acanthocytosis* - spurr cells

1 month old brought to ED due to difficutly awakening. Mother says ifnant was left alone for a fwe minutes this morning and rolled of a bed. Since then, he has been sleepy and less active than usual. PE - lethargic with large, full anterior ontanella. Bilateral retinal hemorrhages on funduscopic exam. What is suspected?

Absuve head trauma (Shaken baby syndrome) - intracranial injury due to blunt force trauma or vigorous shaking ina to and from fashion infants have larger heads, enalrged subarahcnoid sapces, higher brain water content and ecreased cervical muscle tone compared to older children These factors lead to increased mvoement of immature brain --> *tearing of bridging veins* and subdural hemorrhages Becuase AHT can occur repatedly - acute on chornic subdural hemorrahges are often seen Shaking motion results in *retinal hemorrahges* due to rupture of congested reitnal veins - *retinal hemorrahges are highly suggestive of AHT*

Maintenance of blood glucose levels is facilitated by hepatic conversion of pyruvate into glucose. What substance directly stimulates first enzyme involved in process?

Acetyl-CoA - increases pyruvate carboxylase during gluconeogenesis, substances like lactate and alanine are converted to pyruvate pyruvate cant be converted to phoshopenolpyruvate directly as pyruvate kinase is unidrectional to convert pyruvate to phosphoenolpyruvate, pyruvate undergoes bioetin-dependent carboxylation to oxaloacetate in the mitochondira - this reaction is catalizyed by PYRUVATE CARBOXYLASE (incresed by ACETYL CoA) this crticial regulatory step diverts pyruvate to pyruvate dehydrogenase when acetyl-CoA levels are too low, preventing the cell from becoming energy starved when acteyl coA levels are high (as increased beta oxidation of FA during fasting), pyruvate carboxylase can operate at full capcity and convert most of pyruvate into oxaloacetate for use in gluconeogesis

28 y/o woman with acute onset abdominal pain and confusion. No PMH. CT shows nothing. Urine = reddish in color and darkens on standing for 24 hours. What diagnosis? Treatment and mechanism

Acute intermittent prophyria Enzyme = porphobilinogen demainase Accumulated = porphobilinogen, ALA Treatment = glucose and heme Inhibition of AlA synthase Dextrose inhibits Peroxisome Proliferator-activated receptor-gamma, a TF that induces synthesis of ALA synthase.

8 year old boy. No food for 24 hours on hiking trip. On exam he is listless. Glucose = 30 Acetoacetate = not detected Elevated liver enzymes. what enzyme?

Acyl-CoA dehydroegnase Decrease ability to break down fatty caids into acetyl-CoA --> accumulation of Fatty acyl carnitines in the blood with HYPOKETOTIC HYPOLGYCEMIA causes vomiting, lethargy, seizures, coma, liver dysfunction Can lead to sudden death in infants or children carnitine deficiency presents similarly because FA's cant get int the mitochondria for breakdown

62 y/o with cough + dyspnea. Copious amounts of pale tan colored fluid. Xray shows pulmonary infiltrate that is biopsied. Columnar mucin secreting cells that line the alveolar spaces without invading the stroma or vessels

Adenocarcinoma in situ = malignant neoplasm

patient wtih SVT given a drug that causes flushing, chest burning (bronchospasm), hypotenion

Adenosine

Risk factors for a cancer that causes an enlarged nontedner gallbladder, progressive weight los, jaudnice and anroexia for 3 months.

Adneocarcinoma at head of pancreas compressing common bile duct Age = 65-75 Smoking = most imporatnt envirnomental risk factor Diabetes Chronic pancreatitis = 20 years of chronic pancreatitis Genetic = hereditary, MEN, Lynch, familail adenomatous polyposis

46 y/o dies in hospital from respiraotry failure after porlonged illness. Multiple comorbidities, icnludcing advanced renal disease. Autopsy - small, nondestrcutive masses attached to edges of mitral valve leaflet. Microscopy - masses are platelet rich thrombi, but no bacterial growth. What disease associated with condition?

Advaced malignancy - *mucinous adenocarinomas* also seen in: SLE antiphospholipid syndrome endothelial injury caused by cytokines, tirggers platelet depositio in presence of hypercoaguable state

hippocampus ct

Advanced Alzheimrs dsiease is associated with diffuse braina trophy Atrophy is most pronouced in temporopariteal lobes and hippocampus hippocampal atrophy is evident even in early stages of dsiease and can be detected by brain MRI

when will carcinoid tumors begin to present? Murmur associated?

After metastasis to liver and beyond because the liver is a main site of metabolism As serotonin concentration rises, it begins to stenose the tricuspid valve and eventually may lead to tricuspid insufficiency tx = octreotide

Brocas area involvement will result in what type of speech? Primary motor cortex ivnolvement will result in what type of speech?

Agrammatism - slow speech consisting primarily of nounds and verbs Expressive (motor) aphasia Slurred speech due to paresis/paralysis of skeletal muscle involved in movements of mouth, tongue, larynx

45 y/o man has new diabetes. Recommended treatment with medication that alters glucose metabolism within liver by increasing concentration of: FRUCTOSE-2,6-BISPHOSPHATE within hepatocytes. which of following conversions will be inhibited by high intracellular concentrations of this?

Alanine --> Glucose Fructose 2,6 bisphosphate helps control balance b/w gluconeogenesis and glycolysis through inverse regulation of PFK1 and fructose-1,6-bisphosphatase Fructose 2,6-bisphosphate activates PFK1, the main regulatory enzyme involved in glycolysis, which converts fructose 6 phosphate to fructose 1,6-bisphosphate the opposite reaction occurs in gluconeogenesis and is catalyzed by fructose-1,6-bisphosphatase (inhibited by fructose 2,6-bisphosphate) the interconversion of fructose 6 pshophate and fructose 2,6-bisphosphate is achieved by a bifunctional enzyme complex composed of PFK2 Increases fructose 2,6-bisphosphate) and fructose 2,6-bisphosphatease (decreases fructose 2,-6bisphophate) insulin activates PFK2, increased fructose 2,6-bisphosphate levels and augmented glycolysis high concentrations of fructose 2,6-bisphosphate inhibit gluconeogenesis leading to decreased conversion of alanine and other gluconegic substrates to glucose conversion of Fructose 6P to fructose 1,6P would be increasied because increased fructose 2,6BP alloesterically increase PFK

mechanism of hypoglycemia in hereditary fructose intolerance

Aldose B deficiency Hypogycemia results from intracellular *accumulation of fructose-1-phosphate* and depletion of inorganic phosphate, which inhibit glycogenolysis and gluconegesis Primary manifestations = vomiting and hypoglycemia 30 minutes after fructose ingestion tx = elimination of dietary fructose

patient moved from Kazakhstan as a child. she owns a dog. now she is 37 and has had progressive right sided abdominal discomfort. PE - hepatomegaly. US - large liver mass with cystic lesion. During resection of mass, patient suffers procedural complication and dies. Cause of death?

Anaphylaxis Echinioccous granulosus is most common cause of hydatid cysts Most occur in endemic regions or those residing in SW-US with sheep and dog exposure initial infection is asymptomatic, which subsequent manifestations depending on cyst location and size when infection occurs, echinoccocal larvae implant into capillaries triggering inflammatory reaction involving monocytes and eosinophils Some larvae encyst Micro exam - encapsulated and calcified (eggshell calcficiation) containing fluid and budding cells that will become daughter cells The outer wall has THICK FIBROUS CAPSULE Cyst manipulation should be performed with caution as spilling of cyst contents can cause anaphylactic shock

54 y/o woman with multiple firm violaceous nodules on her right upper arm. Diagnosed with R sided breast caricnoma 12 years ago and treated with radical mastectomy. Extensive axilalry lymph node disseciton at the time showed no lymph node metastases. Post-operatively, patient developed chronic lymphedema in R arm. What is etiology?

Angiosarcoma chronic lymphedema is a risk factor for devleopment of cutenous angiosarcoma (Stewart-Treves syndrome) histo - infilitration of dermis with slit like abnormal vascular spaces prognosis is poor due to delay in diagnosis

23 y/o with back pain from a fall in a gym. She is a vegan to lose weight. LMP 3 months ago. 110lbs, 5'7". PE - fine, soft hair on her lower extmreities and enlarged partoid glands. X-ray - veretbral compression fracture and reduced heart size.

Anorexia nervosa Amenorrhea, reduced heart size, osteoperosis and low bdoy weight Binge eating/purging = self induced vomiting, misuse of laxative, diuretics partoid galdn hypertrophy, dental caries, halitosis, caluses on dorsum of hands differs from Bulimia Nervosa in that in Bulimia they maintain their body weight, in anorexia you dont

Patient undergoes ultrasound duided mdline suprapubic cystostomy. besides bladder awll, what structure is likely to be penetrated by the trocar and cannula during proceudre?

Anterior abdominal aponeurosis the bladder is *extraperitoneal* - as baldder fills and bulges upward, it comes into direct contact with anterior abdominal wall anteroinferior to peritoneal space in *suprapubic cystostomy*, the trocar/cannula pierces the *aponeurosis* of abdominal wall uscles, along with layers of superifical fascia, transversalis fascia, and extrapertinoeal fat the peritoneum is not entered becuase of the bladder being extraperintoeal

20 year old with flattening of deltoid and insensitvity to voerlying skin to pinprick. Acute R shoulder pain. One hour ago, he sustained a blow arm when tackled mid-throw during football game.

Anterior dislocation of humerus most common GH dislocation; classically follow a blow to externally rotated and abducted arm (throwing a football) when head of humerus is displaced anteriorly, there if: Flattening of deltoid prominence protrusion of acromion anterior axillary fullness (due to humeral heads movement into this location) axillary n. is most commonly injured by anterior shoulder dislocations

country hostpial has outbreak of MRSA wound infections. Where would you expect most commonly MRSA populated site in staff members?

Anterior nares huamns are natural resevoir for S. aureus asymptomatic colonization of nasopharynx is most common nasal carriage increases risk of ifnection following surgery, peritoneal dialysis and hemodialysis

structures palpated on digital rectal exam

Anterior: bladder (if full), perineal body, bulb of penis/uterine cervix, prostate Lateral: ischiorectal fossa posterior: sacrum, coccyx

patient with treatment resistant asthma (beta agonists, corticosteroids) should have what additional medication added on?

Anti-IgE monoclonal antibodies (Omalizumab) binds mostly unbound serum IgE and blocks binding to FceRI Used in allergic asthma with increased IgE levels resistant to inhaled steroids and long acting b2 agonists

patient has an infection with Shistosome eggs. Elevated eosinophil count. How does elevated eosinophils against shistosomiasis?

Antibody dependent cell mediated cytotoxicity - *parasitic defense* eosinophil proliferation and activation during parasitic infeciton is stimulated by *IL5* poduced by Th2 and mast cells when parasite invades the mucsao or enter bloodstream, it is coated by IgG and igE antibodies that bind the Fc receptors lcoated on the eosinophil cell surface this tirggers eosinophil degranulation and release of cytooc proteins (*major basic protein* and reactive oxygen itnermediates, substances taht damage and destroy antibody bound parasites this is an example of *antibody dependent cell mediated cyotoxicity*

Man who has been HIV ositive for over 5 years presnts to clinic. Signficant increase in pol gene mutations over last year. What is osberved finding realted to?

Antiretroviral chemotherapy Pol gene mtuations are responsible for emergency of HIV protease variants that are resistant to standard prtoease inhibotrs the pol gene mutations are also responsible for structural changes in HIV1 reverse transcriptase that render enzyme resitant to standrad nculeoside and non-nculeoisde reverse transirptae inhibitors

44 y/o with idiopathic membranouns nephropathy. Left flank pain, gross hemarturia, varicocele. Serum lactate dehydrogenase is elevated. Urinary loss of what is predispoed to acute conidtion?

Antithrombin III patient has renal vein thrombosis

what side effect of levodopa will still be presentw hen cabidopa is added?

Anxiety and agitaiton - central efects of doapmine

40 y/o with persistent anxiety and insomnia over 6 months. Really worrier something is wrong. She has lost 5 pounds without trying. No medications. BP 130/90, P106/m. Patient is restless and has warm, moist skin and mild hand tremor bilaterally. Diagnosis?

Anxiety due t general medical condition new onset anxiety with no prior psychiatric history and prominent physical findings suggests that anxiety is more likely due to medical condition than a primary anxiety disorder She has symptoms of hyperthyroidism other medical conditions presenting with anxiety: hypoglycemia pheochromocytoma hypercortisolism cardiac arrhythmia

IV drug used. Liver biopsy - acidophilic bodies, swelling, mononuclear cells. Acidophilic bodies is result of:

Apoptosis

ACh infusion during coronary angiography results in dilation of epicardial coronary vessels. Reaction involving what amino acid is responsible?

Arginine

what amino acid should be supplemented in disorders of the urea cycle?

Arginine when patients with urea cycle disorders develop hyerammonemia, arginine is administered for production of downstream water soluble intermediates (ornithine, citrulline) that lead to nitrogen disposal and decreased plasma ammonia levels

Biopsy seen in Acute rheumatic fever

Aschoff body is pathognomnic for ARF-related mycoarditis endocardial involvement resulting in valvular dysfunction (specifically acute mitral valve regurgitation) will cause holosystolic murmur Over years, Aschoff bodies are replaced by fibrous scar tissue causing chronic mitral valve stenosis Most serious manifestation of ARF is pancarditis

V-shaped narrow branching fungus in the paranasal sinuses of a patient receiving chemotherapy for acute myelegenous leukemia

Aspergillus

34 y/o with PMH of asthma with recurrentr transient pulmoanry infiltriates. CBC shows eosinophilia and CT scan shows proximal bronchiectasis

Aspergillus fumigatus - Alelrgic bronchopulmonary aspergillosis patients with asthma or cystic fibrosis may develop and alelrgic hypersentivity reaction to the fungus result is alelrgic bronchopulmonary asperigllosis (ABPA) patients with ABPA have very high levels of IgE, eosinophilia and IgE plus IgG serum antibodies to Aspergillus repeated exacerbations may produce transient pulmonary infiltriates and proxima bronchiectasis

56 y/o man comes to ED with chest palpitations. he hosted a party last night and had a large amount of alcohol, he normally only drinks 2-3 times per year. He has no chest pain, SOB or dizziness. What is to be seen on ECG?

Atrial firbilattion = absence of P waves, , irreguarly irregular rhyhtmn with varying R-R intervals AF is most common tachyarryhtmias and often precipated by acute systemic illness or increased sympathetic tone; it can be see occsaionlly in patients after excessive alochol conumspion

16 y/o in ED with progressive confusion and agitation for past several hours. Friend reports he started acting 'bizarre' after chewing some plant seeds. Patient said bugs were crawling on skin, and he was talking to people who werent there. He is very thirsty. Overdose of what is similar to this?

Atropine

bilaterally enlarged, cystic fetal kidneys and oligohdydramnios are consistent with what? How would the baby present after delivery?

Autosomal recessive polycystic kidney disease in respiratory distress

45 y/o suffers inability to walk. Spinal cord shows symmetric myelin layer vacuolization and axonal degenrtion of posterior columns and lateral corticospinal tracts. Cause?

B12 deficiency dorsal columns latearl cortcospinal tracts axonal degeneraiton of peripheral nerves

what is required after a gastrectomy?

B12 injections pepsin and HCl are helpful, but not required for protein digestion

paitnet has high leukocyte alkaline phosphatase. What will be seen on blood smear?

Basophilic oval inclusions in mature neutrophils - *Dohle bodies* other findings of sstemic inflammation: increased bands toxic granulation cytoplasmic vacuoles

patient with phobia of riding in the elevator. what treatment?

Behavioral therapy - involving systematic, repeated exposure to the phobic stimulus, is the treatment of choice for a specific phobia

5 y/o in status epilpeticus. What is the first drug to give?

Benzodizepine - enhanced postsynaptic chloride influx Phenytoin (presynaptic votlage gated sodium channels) is given to decrease the recurrence but it is not the first drug to give

34 y/o with months of hearing loss and ringing in ear. Hearing is dminished on left side. Neuro exam shows L sided facial numbess, an asymmetric smile and decreased afferent/efferent corneal reflex respones in L eye Diagnosis is ceebellopontine angle with acoustic schwannoma. Where is the mass located?

Betwen cerebellum and lateral pons Schwannomas in this location arise from CNVIII CNVII and CNV are in close proximity to CNVIII and may be affected

52 y/o with chronic cough for 3 weeks - no phlegm, but sometimes blood. Smaked 2 ppd for 30 years. PE = right sided face and arm swelling and enorgement of subcutenous veins on same side of neck. What vein is obsutrcted?

Brachiocephalic Right bachiocephalic is formed by union of R subclavian vein and right Internal jugular vein Right external jugular vein drains into right subclavian, so obstruciton of right brahciocephalic vein will also cause venous congestion of structures darined by extenral jugular vein important - right brahciocepahlic vin also drains the right lmyphatic duct, which drains lmyph from right UE, R face and neck, R hemithorax and RUQ of badomen

21 y/o recurrent self limited, colickly abdominal pain. peisode of facial swelling that resolved spontnosuly. Eval shows that her complement protein C1, even when not attached to Ag-Ab complex, is excelssively lceaving C2 and C4. What is increased in patient?

Bradykinin *C1 inhibitor deficiency* (C1INH) - C1INH prevents C1 mediated cleavage of C2 and C4, thereby limiting activation of complement cascade it also blocks kallikrein induced conversion of kinogen to *bradykinin* a potent vasodilator that increased vascular pemrability acquired or hereditary *C1INH deficiency* can lead to elevated elvels of bardykinin and pateints can develop *bradykinin assocaited angioedema* facial swelling w/o urticaria; laryngeal edema, GI manifesations

Masses in the kidney composed of fat, smooth muscle, and blood vessels. Patient is most likely to have/

Brain hamartomas and ash leaf skin patches Renal angiomyolipoma - blood vessels, smooth muscle, fat Associated with *tuberous sclerosis*

65 y/o with multiple medical problems. 20 pack year history, drinks daily. Exam of fingers *clubbing* shown. Diases?

Bronchiectasis fingers with drumstick appearance, *flattening of nail folds* and shininess of nail and distal protion o finger pressing on nails produces spongy fluctuant sensation caused bys oftening of anil beds

legionella pneumonia agar

Buffer charcoal yeast extract weakly gram negative rod

bacterial toxin mediated axonal damage

C. diphtheriae synthezied potent exotoxin associated with cardiac and neural toxicity

hows does C. diptheriae obtain its virulence exotoxin?

C. diptheriae acquires virulence via bacteriophage mediated infection with Tox gene, which codes for the diptheria AB exotoxin LYOGENIZATION: whereby a bacteriophage infects a host bacteirum and integrates its genome into the hosts bacteirum's genome

65 y/o man with long history of smoking, nonproductive cough over last several months. He has left shoulder pain, persistent hicups, dyspnea. PE shows decreased breath sounds on left side. Xray shows large left lung mass. Compression of nerve arising from which location is cuasing his recent symptoms?

C3-C5 = phrenic n. phrenic n. irritation can cause dyspnea, hiccups and referred pain to shoulder phrenic n. palsy is associated with respiratory distress and decrased breath sounds on affected side, with elevation of affected hemidaphragm on xray upward movement of affected hemidaphragm with inspriation is seen on fluroscopy

CAAT box

CAAT box is highly conserved sequence that functions as promoter of transcription in the eukaryotic genome usually 80 bases upstream from transcription start site TATA box is second promoter region that is 25 bases upstream from transcription start state both CAAT box and TATA box promote initiation of transcription by acting at binding sites for general transcription factors and RNA polymerase II

a specific RNA has high amounts of modified abses such as *dihydrouridine, pseudouridine, ribothymidine* and its secondary structure arises from base pairing within. What is the composition of 3' end of this molecule?

CCA - *tRNA* the CCA tail hands off the 3' end, with the amino acid bound to the 3' temrinal hydroxyl group CCA tail is added to 3' end of tRNA as poasttranscirptional modifcation in eukorytoes and most prokaryotes D loops has numerous dihydrouridine residues T loop as the TWV sequence needed to bind to ribosomes - ribothymidine, pseudouridine, cytidine residues

what is the mechanism of liver injury in Hepatitis B

CD8 T cells response to viral antigens on cell surface resulting in hepatocyte damage HBV has no direct cytotoxic effect

clearance equation

CL = .693xVd / t(1/2)

CLL + elevated reticulocyte count + positive coombs test + decreased haptoglobin... what happened?

CLL has an autoimmune hemolytic anemia 10% of the time Blood smear will show SPHEROCYTES

Progeny virus demonstrates that the phospholipid composition of viral particle is similar to that of cell nuclear membrane. patient is infected with?

CMV all the other choices were uneveloped or RNA or: HCV = budding through plasma membrane Mumps = plasma membrane

53 y/o man on immunosuppressants (lung transplant 4 years ago) and TMP/SMX develops progressive SOB, nonproductive cough, low grade fever. No recent sick contacts. X-ray diffuse interstitial infiltirates. Biopsy shows owl eye inclusions.

CMV pneumonia - particuarly common in lung tranplsnats CMV is enveloped DS-DNA

organ susceptibility to infarction (greatest to least)

CNS myocardium kidney spleen liver (collateral blood supply)

Constrictive pericarditis

CT image shows thickening and calcification of the pericardium suggestive of constrictive pericarditis patients typically have slowly progrsesive dyspnea, chornic edema and ascietes rapid y-descent that becomes both deeper and steeper during inspiration is observed on jugular venous pressure etiology -radiation to chest -cardiac surgery -tuberuclosis

Patient has psorasis. Treatment is initaited with mediaction that activates a nuclear transcirption factor. what drug?

Calcipotriene - topical vitamin D analog another vitamin D analogs: calcitriol tacalcitol these factors bind vitamin D receptor, a nucelar transcirption factor that cuauses inhibition of kertinocyte prolfeiration and stimulation of keratinocyte differentiation

Fungal cultures grow a species of Candida with utation in gene coding an enzyme responsible for synthezing a fungal cell wall polysaccharide. Oragnism is most likely resistant to what antifungal?

Capsofungin

patient exposed to carbon monoxide, what are his levels of: Carboxyhemoglobin: PaO2: methemoglobin:

Carboxyhemoglobin: elevated PaO2: normal Methemoglobin: normal

Wet keratin

Carniopharngioma derived from *rathkes pouch*

56 y/o Patient is 2 ppd smoker since 18. When oxygen is put on, his RR decreases. What is causing this?

Carotid bodies - *reduced peripheral chemoreceptor stimulation* Chemoreceptors *periphearl* - carotid and aortic bodies are sitmulated by decreased Po2, increase PCO2, and incraease pH of blood *central* - stimulated by changes in pH and PCO2 of brain intersitial fluid, which are ifnluenced by areterial CO2 *do not directly respond to PO2*

68 y/o with rpgoressive exertional dyspna nad lower extremity edema. BP 126/76, P 88. Bibasilar lung cracnkes, 1+ lower extremity edema. Echo - biventricular dilation and LV ejection fraction of 35%. Stress myo perfusion scan negative for inducible ichemia. Long term use of what will imrpvoe surviival?

Carvediol patient has *decompensated systolic heart failure* *after inital stabilization*, long term use of *beta blockers* has been shown to imrpove survival in patients with HF due to LV systolic dysfunction beta blocks decrease myocardial work/oxygen demand lowers pierpheral resistance (afterload) by decreasing ciruclating levels of vasoconstriting hormones (renin, endothelin)

Biopsy of brain lesion - 1.5cm mass composed of engorged purplish clusters; micro - numerous dilated capillaries with an endothelial lining separated by a thing layer of fibrous connective tissue. Diagnosis

Cavernous hemangioma abnromally dilated capillaries seprated by thing connective tissue septa lack of structural support gives them a tendency to bleed

medicaiton given to patient selectively bind to an IL1 inducible enzyme that is highly expressed by inflammatory cells and undetectable in surrounding normal tissue. what drug?

Celecoxib *COX2* is an *inducible* enzyme that is undetectable in most tissues under normal conditions during *inflammation*, infiltirating cells secrete cyotkines (*IL1, TNFa*) that cause COX2 upegualtion in inflamed tissue

nucleus basalis of Meynert

Cell bodies of CHOLINERGIC neurons - located at base of forebrain and widely projects to neocortex decreased in Alzheimer disease

gram positive organism is treated with __________, after being put in a hyptonic solution it bursts. what is ________?

Cell wall inhibitor

75 y/o man with vision problems and R sided hemisensory loss of 1 hour. CT should multiple small LOBAR hemorrhages of varying ages in OCCIPITAL and PARIETAL areas with medium acute bleed in L PARIETO-OCCIPITAL LOBE. CT shows old FRONTAL lobe hemorrhage. Diagnosis?

Cerebral amyloid angiopathy deposition of beta amyloid in small/medium arteries in cerebrum vessel weakening and rupture amyloid angiopathy is most common cause of spontaneous lobar hemorrhage especially in those over 65 Occipital - homonoymous hemionpsia Parietal - contralateral hemisensory Frontal - contralateral hemiparesis

45 y/o with groin pain and swelling. 1 month ago had ulcer that was not painful on penis, disappeared in 1 week. Several days ago, has painful swelling in inguinal region, with inflammation of skin and draining ulcer. Cell scrapings show cytoplasmic inclusion bodies: organism?

Chlamydia trachoamtis Serotype L1-L3

commonly reported sexually transmitted diseases to CDC

Chlamydia trachomatis Gonorrhea hepatitis B, acute hepatitis B, chronic hepatitis B, perinatal infection hepatitis C, acute hepatitis C, past or present HIV infection

most common STI in sexually active adults

Chlamydia trachomatis tx - azithromycine or doxycycline

73 y/o with unstable agine. Undergoes coroanry angio via femoral appraoch. Stent placed, and discahrged. Returns to ED 2 days later with blue discolartion of right toe. Pain, tingling in toe. PMH - Hyperlipidemia, CAD. PE - right toe cyanotic, and thre is *livedo reticularis* affecting right thigh. Peripheral pulses are palpable bilaterially. Serum Cr is 2.8 (pre-op 1.0). Pathology in kidney?

Cholesterol clefts in arterial lumen signs of embolism (blue toe, livedo reticularis with normal pulses), following an invasive procedure, is suspciious for *atheroembolic disease* , in which cholesterol contaning debris get dislodged from larger arteries (arota during cardiac cath) and lodges in smaller vessels *acute kidney injury* is msot common presneting symptom of postporecudre atheroembolism and seen in elderly with preexisting renal atherosclerois Frank ifnarction and hematuria doesnt occur as choelsterol emboli are small Cholesterol is dissovled during tissue prep for mico eval, leaving *needle shaped clefts* taht obstruct arcuate or intralobular arteries

22 y/o that is 16 weeks pregnant. Diagnosed with CMV infection. Patient unborn infant is greatest risk for what eye condition?

Chorioretinitis CMV related complications observed in infants exposed to virus *in utero* include: chorioretinitis (most common eye realted problem) sensorineural deafness seizures jaundice hepatomegaly splenomegaly microcaphly

PMH - HTN, osteoarthritis. Smoked cigatted for 40 years. Patient has pulsating, central abdominal mass on PE. What is pathologic conditions is udnerlying cause of abonrmal finding.

Chornic transmural inflammation AAA is associated with several risk factors (age >60, smoking, HTN, male sex) that lead to oxidative stress, vascular smooth muscle apoptosis and *chronic transmural infalmmation* of the aorta Macropahges release MMPs that degarde extracellar matrix leading to weakening and *progressive expansion* of aortic wall

Newborn. PE shows orbital hypertelorism, submucous cleft palate, bifid uvula. Echo shows RV hypertrophy, pulmonary stenosis with VSD, overriding aorta. Patients diagnosis is confirmed by FISH.

Chromsome microdeletion. Velocardiofacial syndrome - cleft palate, cardiac anomalies, dysmorphic facies defective neural crest migration into 3rd/4th pharyngeal pouches results in malddeelopment of the thymus and parathyroid as well as T cell deficiency and hypocalcemia. Cardiac defects include interrupted aortic arch and tetrology of Fallot Dysmoprhic facial features - orbital hypertelorism, short palpebral fissures and short philtrum, cleft palate, bifid uvula FISH is gold standard for diagnosis Lack of signal = microdeletion

What is a drug for varicella that does not need to be phosphorylated by the virus?

Cidofovir - braod spectrum antiviral *nucleotide* analgoue of cytidine monophosphate Can be actiated solely by cell kinases, thus its efficay doesnt depend on presnce of virally encoded kinase

What drug provides symptomatic improvement due to direct dilation of arteries and inhibition of platelet aggregation?

Cilostazol reduces platelet activaiton by inhibiting phosphodiesterase, the enzyme responsible for breakdown of caMP also acts as direct arterial vasodilator net effect is a decrase in caludcation symptoms and increase in pain free walking distances in patients with *peripheral arterial disease*

what chemotherapy drug is associated with wrist drop and ringing in ears?

Cisplastin

Patient experiencing hypocalcemia after receiving multiple blood transfusions.

Clacium chelation by substance in transfued blood prior to storage, whole blood (for transufions) is mixed with solutiosn containg citrate anticoagulant packed cells derived from these whole blood collections also contain citrate infused citrate can chelate calcium, causing hypocalcemia

how does IgA protease help certain bacteria (N. gonorrheae, N. meningitidis, S. pneumonia, H. infleunze) produce disease?

Cleavage of IgA at its hinge region decreaeses its effectivess this faciltiates bacterial adherence to mucosa

18 y/o with fever and generalized aches and pains. Fever for 3 days with a period of resolution for two days. Fever started again earlier today. PE shows no rash, but a tick is found attached to his scalp. Dermacentor andersoni tic.

Colorado tick fever (reovirdae = dsRNA) 50% can have saddleback fever which consists of cycles with a fever of 2-3 days followed by absence of fever for 2-3 days second most common arbovirus in the US diagnosis is made off of presence of antibodies

63 y/o man with abnormal nighttime breathing. Cheyne-stokes breathing. What is wrong?

Congestive heart failure CSB is cyclic breathing pattern in which apnea is followed by gradually increasing then decreasing tidal volumes until next apneic periods patient with CHF have chronic hyperventilation with hypocapnia, which induces apnea during sleep when partial pressure of CO2 falls below a certain level (apneic threshold) apnea causes excessive buildup of CO2 (hypercapnia) - this stimulates a ventilatory response that overshoots (hypernea), causing the PaCO2 to again fall below apneic threshold This cycle of apnea and hyperventilation is further perpetuated by prolonged circulation time between lungs and brain resulting in discrepancy between PaCO2 levels senses by central chemoreceptors and paCO2 contraction in alveoli

Kerley B lines

Congestive heart failure - short linear pulmonary opacities seen at lung periphery; represent edema of the interlobular septa

34 y/o man with difficulty swallowing, dry mouth and blurred vision. PMH = major depression. PE - mydriasis, poorly reactive pupils. Electo - normal nerve conduciton veolcity but decreased compound muscle action potenital (CAMP). Rapid, reptitive nerve stimulation leads to faciltaition of CMAP. What would be present in his history?

Consumption of home canned food Combo of nicotinic + muscarinic blockade = Clostridium botulinium toxin Highly portent preformed neurotxin that inhibits acetylcholine release from presynpatic nerve terminals at NMJ, preventing nmuscular contraction High repetive nerve sitmulation improves the deficit as rapid depolarization rate increases calcium concetration in presynpatic nerve terminal, helping mobilize additional acetylcholine vesicles the toxin is readily destroyed by heat; but can remain if food is not cooked properly 3Ds within 12-36h = Diplopia, Dysphagia, Dysphonia TCA overdose would have *no* effect on the NMJ

what treatment is associated with decrased recurrence o Herpes?

Continous daily valacyclvoir the antiviral is not active againat lent virus form,s they can suppress further multiplication as soon as reactivation occurs acyclovir at priamry infection reduces duration but does not alter reucrrence rate

4 y/o boy of Chinese descent. Brought to doctor with fever of 5 days duration. No prior medical problems. Received all vaccines. Temp = 102. PE = bilateral conjunctival injection with no exudate. Tongue is bright red and lips are cracked. Non pitting edema on hands and feet. Major complication of disease?

Coronary artery aneurysm Kawasaki disease

herpangina

Coxsacki A virus vesicles are discrete lesions occurring on erythematous base that may ulcerate and create an erythematous halo patients present with fever, sore throat, and cervical lymphadenopathy herpangina occurs in children during summer

28 y/o with vague ab pain, diarrhea - treated with antibitocs without improvement. Several weeks after symptom onset, patietn develops skin lesion over abdomen. Bowel contents appear to be draining to surface of skin in RLQ. Diagnosis?

Crohn disease transmural inflammation of bowel may result in formation of fistulas and fibrotic strictures, causing bowel obstrction fistuals can form between: 2 adjacent loops of bowel bowel and another organ between bowel and skin of abdominal wall

57 y/o man with new onset endocarditis. Blood cultures = gram+ cocci, catalase negative, grow in hypertonic (6.5%) and bile. Medical history has what?

Cystoscopy - enterococci The GU tract is most common portal of entry Enterococci can cause UTI (most common), intrabaodminal and pelvis infections, and wound ifnections, and endocarditis (elderly men) Gamma hemolytic Catalase negative Pyrrolidonyl arylamidase positive Hypertonic saline and bile you picked dental extraction (viridans group strep - dont grow on hypertonic saline and bile insoluble)

60 y/o woman with SOB and productive cough. 30 pack year smoking history. 88% on room air. PE - using accessory respiratory muscles. Expiratory wheezes are heard throguhout lungs. Patient started on high flow oxygen. She becomes lethargic and confused. Patients clinical decline is most likely attributable to increase in?

Dead space ventilation Oxygen induced hypercapnia occurs via 3 mechanisms: 1. hypxoia normally casues vasoconstriciton of pulmonary arterioles, which shunts blood toward alveoli with the highest oxygen content, minimizing physiologic dead spcae. Hyperoxia reverses pulmonary vasoconstriaciton, *increasing physiolgoic dead space*, as poorly ventilated alveoli are perfusion (*ventilation perfusion mismatch*) 2. increased PaO2 decreaes hemoglobins affinity for CO2, resulting in dissociation of bound CO2 form hemoglobin and increased blood pCO2 levels (Haldane effect) 3. peripheral chemoreceptors in carotid and aortic bodies sense arterial PaO2 and are normalyl stimulated by hypoxmia. High flow oxygen reduces chemoreceptor stimulation, resulting in decreased respiratory rate and minute ventilation.

defect in BTK tyrosine kinase gene has what conseuqnces?

Decreased B cell maturaiton of all types

Woman is having panic attack. Severe anxiety as well as dizziness, weakness and blurred vision. What is cause of patients symptoms?

Decreased arterial partial CO2 tension hypernvetilation --> decreased CO2 --> decreased cerebral blood flow

Lab values associated with CO poisoning

Decreased oxyhemoglobin Increased carboxyhemoglobin Decreased bicarbonate cannot screen via pulse ox because it cant differenitate cboxyhemoglobin from oxyhemoglobin

when viral antigen injected inhelathy volunteers, researchers find that certain patients with HLA haplotypes can noto form a IgG response, but are able to form IgM response. Reasoning?

Defective antigen rpesentation likely that these patients have MHCII molecules that can not present the viral protein - thus can not have class switching causing an IgG response hwoever, B cells can still mount the IgM response that is T cell indepdnent

What is deficient causing: hyperphenyalaninemia + hyperprolactinemia?

Deficient dihydrobiotinreductase

what are the nonnucleoside reverse transcirptase inhibitors and mechanism?

Dela*vir*dine Efa*vir*enz Ne*vir*aprine Do *not* need activation via itnracellular phospholryation

what do you give to prevent antrhacycline induced dilated cardiomyopathy?

Dexrazoxane swelling of sacroplasmic reticulum is morphologic sign of an early staged doxorubicin associated cardiomyopathy

65 year old female presents with L shoulder pain. PMH - HTN, uncontrolled diabetes, hypothroidism. PE shows decreased active and passive ROM in L shoulder with associated pain. What is associated with patients condition?

Diabetes Frozen shoulder - high risk for adhesive capsulitis include diabetics, females and patients with hypotheirsm Adhesive capsulitis typically follows some type of insult to joint resulting in inflammation, the local inflammation results in thickening and adhesion in fascial layers of the joint capsule resulting in pain and decreased ROM Tx = spencer's technique

renal biopsy performed. light microscopy of tissue sample shows widepsread narrowing of renal arterioles with deposition of homogenous, glassy material in subendothelial space that stains pink with periodic acid-Schiff stain. underlying conidtion?

Diabetes mellitus eosinophilic hyaline materail in the intima and medial of small arteries and arterioles is characteristic of hyaline arteriolesclerosis chornic endothelial injury cuased by hemodnyamic stress in HTN or hyperglcemia causes leakage of plasma conistuents across vascular endothelium and stimulates smooth muscle cell porlfieration and excssive extracellular matrix productio

25 y/o with signs of heart failure. Had episode of fever, runny nose and myalgias resolved several days ago. Has both left and right heart failure signs. What would bes een on echo?

Dialted ventriles with abrnoaml systolic ventricular function Progessive onset of heart failure in setting of recent viral ifnection shoudl raise suspciious for *dialted cardiomyoapthy caused by viral myocarditis* - direct viral injury as well as autoimmune reaction to virally altered myocytes myocardial inflammation leads to dilation and enlargement of heart changes (*eccentric hypertrophy*) with decreased ventricular contraction (*systolic dysfunction*)

A-a gradient

Difference between partial pressure of oxygen in alveoli and arteriole blood *healthy individuals: A-a = 5-15mmHg* Hypoxemia with normal A-a gradient indicates high atitude or poor ventilation

Patient with Prinzmetal angina. What drug can induce coronary vasospasm in her?

Dihydroergotamine - ergot alkaloid used to treat acute mgiraine headache constricts vascular smooth muscle via alpha and serotnergic receptors other triggers: -cigarette smoking -cocaine/amphetamine -triptans

Phenytoin affects on fetus

Dilantin (hydantoin) syndrome abnoramlities of skull and face hypoplasia of fingernails and toenails

constipation new onset 2nd degree AV block syncope medication given for Afib

Dilitiazam and Veramapil Nondihydropyridine CCBs

medication that prolongs activated PT and PTT in dose dependent manner but has no effect on thrombin time?

Direct factor Xa inhibitor - apixaban, rivaroxabam

13 y/o with post strep glomerulonephritis. What is seen on biopsy?

Discrete subepithelial humps on EM Starry sky granular apeparnce (lumpy bumpy) on IF hypercellular on LM

haemophilus decreyi

Disease = chancroid features of primary lesion: -multiple, deep ulcers -base has gray to yellow exudate -organisms clump into long parallel strands (school of fish) painful? *yes*

Tubular fluid sample shows osmolarity of 110 mOsm/L after 12 hours of water deprivation. Where is this taken from?

Distal tubule in proximal tubule, water is reabsorbed along with electrolytes - tbular fluid remains isonotic with plasma (300 mOsm/L) descending loop of Henle, free water is drawn out of tubules into renal interstitium and tubular fluid becomes hpertonis (>300, typically 1200 mOsm/L when ADH is high) electrolyes, but not water is reabsrobed in ascending loop of Henle, and tubular fluid becomes hypotonic (<300 mOsm/L) distal convoluted tubular is relatively impermeable to water, so the tubular fluid remains hypotonic. reabsorption of solutes continues to occur; thus, fluid in distal tubules is most dilue (lowest osmolarity, 100 mOsm/l) in repsnce of ADH, collecting duct is highly permeable to water water leaves tubular fluid driven by high osmolarity of medullary interstitium and hpertonic urine is formed (up to 1200 mOSM/l)

colonization of gastric antrum with H. pylori with decreased number of somatostatin producing antral cells. Depletion of these cells from gastric antrum is most likely to cause which of the following?

Duodneal ulceration Chronic antral inflammation --> decreased number of somatostatin producing cells (delta cells) Somatostatin inhibits gastrin release; in its absence, high gastrin acts to increase hyodgen ion secretion by parietal cells Reults in gastric fluid with ver low pH that is not adequately neutralized by duondeal HCO3 production causing *duodenal ulceration* and duodeanl gastric metaplasia

aortic regurgitation severity correlation?

Duration of diastolic murmur More advances cases producing a holodiastolic murmur and mild cases leading to only an early diastolic murmur REMEMBER = Aortic regurgitation is heard at Left sternal border If it is caused from aortic root dilation (RIGHT sternal border) - developed countries

newborn with classic galactosemia is at increased risk for what infection?

E. coli (gram-negative rod) sepsis

27 y/o presenting with fatigue, dyspnea, palpitations. PE - cyanotic, trace bilateral low extremity pitting edema, fingernail clubbing. As a child, he was told he had a congenital heart defect, and it was not result of drug toxicity in utero. Diagnosis?

Eisenmenger syndrome - cyanosis, pulmonary HTN, reversal of intracardial flow due to uncorrected VSD, ASD or PDA complications - arrhythmia, infective endocarditis, heart failure

Diagnostic criteria of premature ejaculation

Ejaculation in less than 1 minute for over 6 months Often associated with anxiety Medical conditions - prostatitis, thyroid disease

Acquired QT prolongation

Electrolytes - hypokalemia, hypomagnesemia Pharmacologic antiarrhyhtmics (Class IA, III) antibiotics (macrolides, fluroquinolones) methadone antipsychotics (heloperidol)

Patient has new onset T2DM. What is associated with this?

Elevated FFA levels early T2DM --> increase inuslin and decreased sensitvity of target organs to effects of insulin insulin resistance in adipose cells hinders the antilipolytic effects of insulin, leading to lipolysis and release of FFA Chronically eelvated FFA levels contribute to insulin resistance by impairing insulin-dependent glucsoe uptake and increasing hepatic gluconeogenesis other factors contributing = obseity, sedentary lifestyle C peptide levels increase, but dont cause insulin resistance

46 y/o with painful rash in groin and elgs. Diangoised with diabtes 6 months ago, no other problems except some loose stools. PE - coalescing eryhtematous plaques with cursting and scaling at the broders and central areas of brownish induraiton. Biopsy - superifical necrolysis. Abnormlaity?

Elevated glucagon *necrolytic migratory eyhtema* *glucagonoma* - alpha cell tumor patient has hyperglycemia or over diabetes mellitus necrolytic migraory eythema, an elevated painful and pruritic rash trypically affecting the face, groin, extremities over time, papules coalesce to form large, indurated plaques with central clearing that often appear brown or bronze colored

long term complication of Coxiella burnetti?

Endocarditis coxiella brunetti is most commonly contracted through handling of sheep placenta in chronic form, C. burnetti multiplies in macrophages and produced an extended bacteremia that produces high level of antibodies, immune complexes, and autoantibodies (particularly of smooth muscle and cardiac muscle) endocarditis, primarily of the aortic and mitral valves is most common manifestation of chronic Q fever

gram positive cocci in chains causing a UTI

Enterococi gamma hemolytic grow in bile and 6.5% NaCl PYR-positive

25 y/o withnew diangosed seizures develops fever and skin rash. Started phenytoin 4 weeks ago. Temp 102. Diffuse confluent erythema ivnolving 60% of body,palpable general lymphadenopathy, symmetrical facial swelling. Labs?

Eosinophilia - *DRESS syndrome* rare life threatening drug reaction occurin 2-8 weeks after drug exposure asscoiated drugs involve: anticonvsulants - phenytoin, carbmazepine allopurnol suflonamides antibitiocs - minocycline, vancomycin Drug induced herpesvirus reactions followed by cloncal expansion of T cells that cross react with the drug patients develop *fever, geneal lymphadenoapthy, facial edema, diffuse morbilliform skin rash* that can progress to confluent erythema with follicular accentuation Liver - hepatomegaly, jaundice kidney - acute itnerstitial nephritis lung - cough,d yspnea labs - *eosinophilia*, atypical lymphocytosis, elevated serum alanine transmaniase

51 y/o male, 20 year history of alcoholism presnts to ED with decreased apeitite, abdominal pain and fever for 24 hours. He consumed 12 beers and a bottle of vodka 2 days ago. AST>ALT What is associated with this?

Eosinophilic hyaline inclusion bodies (Mallory bodies) Biopsy shows swollen hepatocytes (ballooning necrosis), inflammation and mallory bodies. Injury is more prominent in centrilobular areas. Alcoholic cirrosis = micronodular

30 y/o history of IV drug use and HIV comes to ED with abdominal distention and anorexia. CT - ascites and alrge mass surrounding small itnesinse Biopsy - unform, round, medium-sized tumor cells with basophilic cytoplasm and prolfieration fractor of >99% What infecitous agent?

Epstein barr virus - *Burkitt lmyphoma* - infection is in 40% of immunodeficiency associated Burkitt lmyphoma t(8:14) - increased *cMYC*

Difference between ulcer and erosion

Erosion = mucosal defect that doesnt extend through muscularis mucoas (ie. limited to ucosal layer) - tend to be acute process Ulcer = penetrate through mucosal layer and etend into submucosal layers and muscularis propria (inner cirucmferential and outer longitinudal smooth muscle layers)

13 y/o girl with hematologic mutation. Hemoglobin mutatio that changes partial pressure of oxygen at which hemoglbin is 50% saturated to 20 mmHg. Normal hemoglobin becomes 50% satruated with oxygen at 26 mmHg. What is likely to develo?

Eryhthrocytosis A p50 shift from 26 to 20 indicates taht affinity of hemoglobin for oxygen is icnreased - meaning that there is a reudced ability of hemoglboin to release oxygen within peripheral tissues low oxygen levels stimualte kidneys to increase erythropoietin synthesis, which results in *compensatory erythrocytosis* that helps maintain normal oxygen delviery

what test should be ordered for and adult patient with frequent black 'tarry' stools over past week. SH: smokes 20 pack year history and heavy drinker.

Esophagogastroduenoscopy This patient has MELENA = upper GI bleed colonoscopy would be ordered secondarily, but is more important for hematochezie

25 y/o primigravida has gallstones at 38 weeks of pregnancy. What is pathogenesis

Estrogen induced cholesterol hypersecretion (increased HMG-CoA reducaase) progesterone induced gallbladder hypomotlity

Test is round superior to scrotom, medial to right mid-inguinal point. Orchipexy, reaplcement and fixation of testis into scrotum, is reommended. During procedure, the malpositione dtestis will be puled through physiological oepning in what structure?

External oblique muscle aponeurosis between 8 weeks and full term, tests slowly descend into scrotum by passing from abdomen through *deep inguinal ring* to enter inguinal canal the deep inguinal ring is a physiolgic oepning in *transversalis fascia* bounded by transversus abdominins muscle altearlly and ifnerior epigastric vessels medially the testes then passes anteromedially to exit the canal via the *superficial inguinal ring*, which is formed by an opening in the *external oblique muscle aponeurosis* above and medial to pubic tuebrcle once it has passed through superficial inguinal ring, the testis enters the scortum in this case, the patient's undescended testicle is lodge in inginal canal and must be mobilized through superifical inguinal ring

how to calculate oral bioavailability from a plot of oral/IV doses

F = (area under oral curve x IV dose) / (area under IV curve x oral dose)

Fatty Acyl-Coa Synthetase

FA must first be acitvated by acyl-CoA synthetase in cytoplasm in order to undergo beta-oxidation in mtochondira resulting acetyl-CoA is used for energy and ketone body formation

extremely obese person of recent onset FEV1 FEV FRC RV TLC

FEV1: decreased FEV: decreased FRC: decreased RV: unchanged TLC: decreased *obesity related restrictive lung disease*

PE of girl after bith - head in 90th perecntile circumerece, mid face hypoplasia, humeral and femoral shortening. Hans have shortened digits and space between 3rd and 4th digits. Cause?

FGFR3 gene mutation

what factor causes the lognest delay in warfarin efficacy?

Factor II = 3 days

23 y/o evaltued for 10 days of nonproductive cough, low grade fever, malaise. Lung exam - scattered rales. Xray - patchy areas of consolidation. Mild anemia, elevated serum lactate dehydrogenase. Treated for Mycoplasma with azithromycin. Two months later symptoms and anemia ahve resolved. Explination?

Fading of immune response M. pneumonia can lead to comlement mediated, intravascular *hemolytic anemia* due to simlarity bween antigens of cell membrane and cell membrane of erythrocytes (I antigen) - *cold agglutinins*

what diagnostic test is most specific for acute cholecystitis?

Failed gallbladder visualization on radionuclide biliary scan radiotracrer is given IV and taken up by hepatocytes and excreted in bile images of tracer as it mvoes thrgouh hepatobiliary system and itnesine are obstained for several hours after injection in patient with patent cystic duct, the gallbladder will be seen as radiotracer accumulates and conetrates within in acute or chonic cholecystic - radiotracer will be taken up by liver with progressive excretion into common bile duct and proximal small bowel, but the *gallbladder will not be seen* due to obstruction

inherited deficiency in cross links

Fanconi anemia - AR aplastic anemia short stature absent thumbs increased malignancy

patient is HIV+, has CMV colitis. Therapy is started with IV agent that doesnt require intracellular activation and is known to bind in vitro with viral encoded enzymes such as DNA polymerase, RNA polymerase, and reverse transcriptase. Agent?

Fascarnet - pyrophosphate analgod that does *not* require intracellular activation Directly inhibits DNA pol in Herpesvirus and reverse transcirptiase in HIV treats ganciclovir resistant CMV and acyclovir resistant herpesvirus

50 y/o man with bilateral crackles, increased JVP, hepatomegaly, ascities and pitting edema. Scattered ecchymoses on each extremity. Increased PT. Given IM vit K, and 2 days later nothing change. What is cause of lab abnoramlity?

Favtor VII deficiency Clotting factors II, VII, IX, X are produced initally by the liver in an inactive form and then activated by vitamin K carboxylation Factor VII (extrinsic pathway) has shortest half life of all coauglation pathways PT assesses extrinsic and common pathways and is first to become abnromal in liver disease Edema and ascites are from hypoalbuminemia in the patient

42 year old male presents with bulge in upper thigh next to his groin. he is otherwise asymptomatic; however, he notes he has occasional abdominal pain, nausea, vomiting.

Femoral hernia

management of fever in child? management of heat stroke in child?

Fever (febrile seizures - benign) = acetaminophen for comfort [decreased PGE2] heat stroke (end organ damage) = rapid external cooling Above 108F, oxidative phosphorylation ceases and ATP is depleted

Gross exam of mitral valve shows large friable masses with extesnive destruciton of cuspal tissue. (valvular inflammation and scarring --> infective endocarditis) Blood cultures grow Streptococcus. What is most likely initiating step in pathogenesis?

Fibrin deposition inital process in IE is dirsuption of normal endocardial surface this occurs most commonly at areas of max turbulence to blood flow in preexisting valvular lesions, typically the atrial surface of incompetent AV valves or ventricualr surface of incompetent semilunar valves Followed by focal adherence of fibrin and platelets, fomring STERILE FIBRIN PLATELET NIDUS myxomatous degenreaiton can predispose to endocadritis, however, endocarditis vegetations tehmselves are not formed through myoxmatous degneraiton

25 y/o annual checkup. Healthy, no PMH. Monogamous relationship, uses condoms for birth control. No abnormal paps. Breast tenderness preceding each menses and some lumps. Symptoms resolve following menses. PE - breast tissue has diffuse nodulairty

Fibrocystic changes clues were the diffuse and tender, without forming a well defined mass tx - birth control, progesterone

malignant cells have decreased integrin experession. these cells most likely exhibit poor adhesion to what ocmponent of ECM?

Fibronectin integrins bind to collagen, fibronectin and laminin

Patient has C diff. Allergic to penicllin. Oral macrocyclic antibiotic that inhibits the sigma subunit of RNA polymerase. What drug?

Fidaxomicin other ways to treat C diff: Metronidazole - disrupts DNA structure and causes strand breakage Oral Vancomycin - bacterioSTATIC against C diff

recent travel to Africa. Hypotensive, tachycardia, febrile. What virus?

Filovirdae (ebola) negative ssRNA non-segmented

Evaluiation shows aortiv valve endocarditis with an intracardiac abscess and small fistula formation between aortic root and right ventricle. Doppler would show waht flow pattern?

Flow from aortic root to right ventricle continuously Central aortic pressure = 120/80 Right ventricular pressure = 25/5 the lowest central pressure is greater than the highest RV pressure thus the flow is continous

what would be the initial treatment for patient with CSF: WBC = 50 WBC = 55% lymphocytes Glucose = low protein = high opening pressure = elevated

Fluconazole patient has fungal meningitis

what is given to reverse MTX toxicity?

Folinic acid (leucovorin) reduced form of folic acid that does not require DHF to be converted to THF and is unaffected by MTX Leucovorin can *potentiate* cytotoxic action of 5FU (by binding thymidylate synthetase)

type of mutations associated with Duchenne muscular dystrophy and examples of codons that would be present?

Frameshift or nonsense (stop codon) Ex: UCA --> UGA UAA-->UAG does not work because both of these are stop codons, so there would be no change

Patient has a bite from a dermacentor tic. Contains Gram negative pleomrphic bacteria that grew on buffered charcoal yeast extract. Pulse-temperature dissociation. What is it?

Francisella tulrenesis Ricketsseia Ricketsseia is *incorrect* because it is intracellular and would not have shown on gram stain

What proteins are syntheiszed on free ribosomes? Attached ribosomes?

Free ribosomes = proteins found in cytosol, nucleosol, peroxisome matrix and nuclear encoded mitochorndiral proteins Attached ribosomes = secretory proteins, integral membrane proteins of nucleus and cell membrane and proteins within the ER, Golgi and lysosomes Ribosomes attach to RER via the translocon (binds the 60s subunit)

patient ingests rat poison. what should be given immediately?

Fresh frozen plasma most rodenticides contain braodifacum (superwarfarin) by ignesting rodenticide patient deplets vitamin K clotting factors causing an acquird coagulopathy leading to bleeding

Patient wast old he had problem metbaoizing sugar. Has no dietary restriction and eats vegetables, fruits, meats and processed foods. urine sample shows positive copper reduction test, but glucose oxidate dipstick is negative. What is deficient?

Fructokinase asymptoamtic patient with inborne error of sugar metabolism = essential fructosuria fructose is a reducing sugar and can be detected by copper reduction test (other reducing sugars = glucose, galactose)

GH acts on liver to increase what substance via what receptor

GH acts on JAK-STAT GH increases IGF-1

genes upregulated by Thiazolideniones

GLUT4 adiponectin (cytokine secreted by fat tissue that increases the number of insulin-responsive adipocytes and regulates fatty acid oxidation) Pioglitazome Rosiglitazone

6 y/o boy with fatigue, abdominal distention. Brusies easily, apepars pale, subconjuctival pallor. Nontender massive splenomegaly and moderate hepatomegaly. Hemoglobin = 8, leukocyte count is 3,800, platelets 90,000. Bone marrow aspirate shows crumpled tissue paper macrophages

Gaucher disease - most prevalent genetic disorder among Ashkenazi jewish B-glucocerebrosidase defiincy --> accumulation of glucocerebroside (glycolipid of luekocyte and erythrocyte membranes) bone pain due to bone marrow invasion/inflammation abdoimnal distention due to hepatosplenomegaly easy brusing, pallpar and fatigue due to pancytoepnia

Rett syndrome

Girls normal development until 5-18 months loss of motor and language skills sterotpic hand movements deceleration of head growth mutation: X linked MECP2 gene

patient presents to ED with panic attack. what do you do?

Give benzodiazepine you wouldnt give SSRI/SNRI because they take weeks to beign working

Pseudopalisading necrosis

Gliobastoma multiforme Astrocyte origin GFAP+ Pseudopalisading plemorphic tumor cells border *central areas of necrosis and hemorrahge*

65 y/o man multiple episodes of lightheaded while buttoning tight shirt collar; hes passed out breifly without injuries. BP was 70/40 and pulse 45/m during one of the episodes. Stimulation of afferent sensory fibers in which following nerves is most likely?

Glossopharyngeal carotid sinus hypersensitivty triggered by pressure on carotid sinus by a tight shirt collar cartoid sinus use arteria wall stretch as indicator of systemic blood pressure carotid sinus is a dilation of internal cartoid artery just above bifurcation of common carotid artery Affernt limb (glossopharyngeal) = barorecptors in sinus traveling to medulalry centers via hering nerve Efferent limb (vagus) = parasymptahetic fibers result is decreased BP (peripheral vasodilation), decreased cardiac output (decreased contractility/stroke volume and HR)

44 y/o woman with weight loss, diarrhea and pruritic painful rash. PE - eryhtematous papules and plaques with central clearing that involve face and extremities. Diagnosis?

Glucagonoma

patient in adrenal crisis. what is inital drug to give?

Glucocorticoid supplemtnation with hydrocortisone or dexamethaseone

if patient has gestational hyperglycemia is genetically predipsosed, she most likely has decreased activity of what enzyme?

Glucokinase heterozygous mtuatoins of glucokinase gene cause a decrease in beta cell metabolism of glucose, less ATP formation, and diminshed insulin secreiton this prdouces a type of *maturity onset diabetes of the young* - cahracterized by mild, nonprogressive hyperglycemia that often worsens with prengancy indcued inuslin reistance

68 y/o man with ab pain and Nausea for 2 days. PMH: atherosclerotic CV disease and underwent coronary a. bypass 2 years ago. BP: 106/65, HR 120 irregular. Abdominal ex: mild diffuse tenderness, decreased bowel sounds. Arterial gasses: acidotic, low CO2, increased lactic acid. ECG: atrial fib CT: colonic wall thickening and no enhancement with IV contract Urinalysis: acidic urine Renal metabolism of which of following amino acids is most important for maxing acid excretion?

Glutamate patient has acute ischemic colitis from embolism of atrial fibrillation Ischemic bowel --> lactate accumulation Acidosis stimulates renal ammoniagenesis, a process by which renal epithelial cells metabolize GLUTAMINE, generating ammonium and HCO3 Ammonium ions are transported into tubular fluid and excreted in urine while peritublar capillaries absorb HCO3 which buffers acids in blood normally, 50% of acid secreted in urine is in form of ammonium, and remainder is titrable acids, particularly inorganic phosphate However, increased ammonium production is almost entirely responsible for increase in renal acid excretion seen in chronic acidosis

Hepatic encephalopathy. What is elevated in astrocytes?

Glutamine when *excess ammonia* is present in blood, it crosses BBB and taken up by astrocytes, *increasing glutamine production* presence of excess glutamine within atrocytes leads to increased intracellular osmolarity, casuign astrocyte swelling and impaired glutamine release hyperammonemia decrease amount of glutamine avaialble for conversin to glutamate in neurons --> *disruption of excitatory neurotransmission*

45 year old type 2 diabetic presents with sweating, dizziness, heart palpitations and tremor 30 minutes after taking her medicine. She states her appetite has increased. On exam - diaphoretic, tachycardia, paravertberal hypertonicity T6-10. Drug causing these symptoms?

Glyburide patient is presenting with hypoglycemia Diabetic drugs causing hypoglycemia are: -2nd generation sulfonylureas - glybride, glimepiride, glipizide

out of the second generation sulfonylureas which are the most likely to cause hypoglycemia?

Glyburide and Glimepiride Glipizide is short acting and has much lower incidence of hypoglycemia

what is the most abundant amino acid in collagen?

Glycine Gly-X-Y

mechanism of base excision repair

Glycolyase removes altered base Endocnulcease celaves 5' Lyase cleaves 3' Polyermase fills gap ligase seals it

5 month female brought to pediatrician for poor feeding and chronic diarrhea. The mother is concerned about small bulge at infants umbilicus that becomes prominent with crying. PE shows macrocephaly with bulging frontal bones, coarse facies, hepatosplenomegaly. Ophthalmic exam shows complete corneal opacification. Pathophysiology?

Glycosaminoglycan accumulation in lysosomes Hurler's syndrome Absent L-iduronidase Chronic diarrhea, poor feeding, facial changes (macrocephaly, bulging frontal bones, depression of nasal bridge, enlarged lips, and/or protruding eyeballs) many infants with hurler's are born with umbilical or inguinal hernias or develop them during the first few months of life Hepatomegaly, valvular heart disease (aortic valve thickening causing aortic regurg), obstructive airway disease (enlarged tonsils, adenoids, tongue), developmental delay, hearing loss Corneal ground glass appearance that can lead to blindness

leuprolide in prostate cancer

GnRH analog - agonist when used in pulsatile, antagonist when used continously Evenutal suppresssion of LH release from ptuitary and reduced production of testosterone by Leydig cells As T falls, DHT will fall Beginning treatment will have acute rise in LH and T/DHT

lab values in a male with a prolactinoma GnRH: LH: FSH:

GnRH: low LH: low FSH: low

alpha 3 chain of type IV collagen

Goodpasture syndrome

increased activity of PRPP synthetase can increase the risk of what disease?

Gout PRPP synthetease increases the coversion of ribose-5-poshphate into IMP Therefore increased purines --> increased purine breakdown Which will be broken down into uric acid and predispose to gout

43 y/o had 4 week history of cough. Initally bad cold that lasted 10 days. Sneezing, runny nose, muscle aches improve,d but cough as worsened. Patient has brusts of coughing for several minutes and feels like he cant celar mucus. Recevied childhood vaccinations but hasnt seen pyhsician in many years. organism?

Gram-negative coccobacillus - Pertussis diagnosis should be conisdered in any adult with acute trachebronchitis who has not had vaccination boosters

Patient had pulmonary infection. Alveoli filled with exudate contianing neutrophils, fibrin and *fragmented* red blood cells. What phase of disease?

Gray hepatization

DNAase

Group A step degrades DNA in pus to facilitate bacterial spread

what type of receptor does Glucagon bind to?

Gs - adenylate cyclase second mesenger system incrases cAMP --> increased *PKA*

35 y/o with vulvar lesion. Diastolic murmur with proimnent second heart sound. Painless indurated nodule on her vulva. VDRL is positive. Chest x-ray shows calcifications at level of ascneidng aortic arch. CSF is positive for VDRL What describes vulvar lesion?

Gumma patient with neurosyphilis likely has cardiovascular syphilis = tertiary syphilis making her vulvar lesion a gumma chancre = priamry syphilis condylomata lata = secondary syphilis

sarcomere

H = thick (myosin) filaments A = thick with overlapping thin Z line = distinctly darker than remainder of sarcomere; thin filaments (actin, tropomyosin, troponin) anchor at Z line I band = section of thin filaments that don't overlap with thick filaments during muscle contraction, both I band and H band decrease in length

window period of HBV infection

HBsAg has disappeared but HBsAb has not yet appeared

34 y/o with CD4 of 280. Several months of pain and itching in perirectal area. Intermitten bleeding. On exam, a single, hard mass with superifical ulceration is ntoed in anal canal. No hemorrhoids. No palpable lmyphaaenoapthy. Organism?

HPV - squamous cell caricnoma given duraiton of pain, itching and rectal bleeding in addition to visible ulcerative mass (anal cancers are uclerate in >50%) HPV 16,18 = cervix, vulva, penis, anus

patient given nitro: HR: EDV of LV:

HR: increased - reflex tachycardia EDV of LV = decreased

Hormone sensitive lipase vs. lipoprotein lipase

HSL releases FFA and glycerol from adipose tissue during times of stress LPL is on endothelial cells that degrades triglycerides found in chlymocrions and VLDL; works in bloodstream to form FFA that are then transported into adipocytes storage or used by tissues (heat/skeletal muscle) for energy

83 y/o brought to ED for eval of mental status chages. Baseline - mild memory impariment. Over past 24 hours, she is combative and agitated and stays up all night. Neuro exa is normal but patient is unable to attend to conversation, mildly disoriented, and cannots tate days of week ackbards. Labs - UTI. in addition to antibitocs what med should be given?

Haloperidol Delririm is acute onset confusional state - waxing and waning mental status changes and impaired attention Delirium occurs secondarily to underlying medical condition, such as UTI and therefore a priamriy management in treating underlying cause *High potency 1st generation antipsychotics* and some 2nd generaiton antipsychotics be used for *acute treatment of agitation and psychosis* assocaited with delirium in low doses haloperidol is well toelrated with minimal sedaiton, anticholinergic, hypotensive and extrapyrimadal

HOXA13 mutations

Hand-foot-genital syndrome - dominantly inhreited malformations of distal limbs - hypoplasitc first digits Mullerian fusion abnoramlities (uterus didelphys) - miscarriages

electrophersis in testing for sickle cell

HbA = goes furtherest due to negative charge HbS = mutation is to a neutral amino acid, so less far HbC = mutation to lysine (positive) amino acid so goes the least far Alpha thalassemia (Hemoglobin H) = would go further than HbA

15 y/o boy with eryhtrocytosis. His father and sister have elevated red cell levels. Genetics of B-globin gene= single base subtition at amino acid position 82 that repalces normal lysine residue with methionine This amino acid repalcement impairs ionic interaction between B-subunit and 2,3-bisphosphoglycerate. The patients hemoglobin will be similar to which of the following hemoglobin types?

Hemoglobin F Familial erythrocytosis Mtuation resulting in reduced binding of 2,3 bisphophoglycerate 2,3BPH is synthesized from glycolytic intermidates and binds strongly to deoxyhemoglobin in a pocket formed between 2 bets chains this binding decreaes oxygen affinity of hemoglobin, allowing more oxygen to diffuse into peripheral tissues mutations that decrease positive charge of the binding site decrease 2,3BPG binding and increase hemoglobin oxygen affinity fetal hemoglobins gamma chains dont binds to 2,3BPG due to reaplcement of histidine with serine HbF thus has higher oxygen affinity than adult hemoglobin A

32 y/o man with several months of fatigue and weight loss. no PMH. Used ilicit drugs in past. Sexually active with girlfriend. Liver biopsy obtained and light micrsocopy shows *large heaptocytes filled with finely granular, homogenous, pale pink cytoplasm*. What is diagnosis?

Hepatitis B infection one of most common caues of hpeatic injury in US is frequently transmitted sexually or via percutenous inoculation distinct histopathologic manifestion of *chronic* Hepatitis B is accumulation of hepaitis B *surface antigen* within infected hepatocytes - this results in appearance of finely granular, *diffusely homogenous, pale eosinophilic* cytoplasm (*gound glass hepatocytes*)

halothane inhaled anesthetic hepatotoxicity what lab values?

Hepatocellular pattern of liver injury Extensive hepatocellular damage causes the liver to rapidly atrophy and appear shrunken Centrilobular necrosis and inflammation fo portal tracts elevated serum aminotransferase prolonged prothrombin time leukocytosis eosinophilia Acutely, albumin is normal (half life of 20 days)

mature B lymphocytes exposd to specific virus in vitro acquire ability to prolfierate indefinitely while maintaing capcity to secrete immunoglobulins. What test is used to diagnose an in vivo infection with this virus?

Heterophile antibodies - EBV circulating surface antigen=HBV cryoglobulins=HCV Hemadsorption=influenza,paralinfluenza

what enzyme is upregulated in fuctokinase deficiency?

Hexokinase Converts dietary fructose into fructose-6-pshophate

58 patient with fasting glucose of 160 mg/dl without diagnosis of diabetes yet. Serum TG are elevated and HDL is low. What finding would be most suggestive of increased insulin resistance?

High waist circumference increased BMI and excess visceral fat correlates with insulin resistance LDL levels do not increase with insulin resistance

what is the autoantibody in polymyositis directed againt?

Histidyl-tRNA synthetase = anti-Jo1

what histone protein is outside of the core?

Histone H1 normal nucleosome: (H2A, H2B, H3, H4)x2

25 y/o with susepcted tetanus. Most important in making diagnosis?

History and Physical exam there is *no* serum toxin assay available for teatnospasmin there is *no* antibody test avialable for tetanus

what is correlated to a diagnosis of dermatitis herpetiformis?

History of abdominal pain, diarrhea and steatorrhea

40 y/o to ED with involutnary movements, ataxia, tremor. Started 2 weeks ago and have worsened acutely over past 2 days. Has bipolar and recently diagnosed hypertension. She takes lithium for many years and new BP med started 2 months ago for HTN. Neuro - resting tremor and difficutly with balance. ECG - sinus and nonspecfic T wave abnroamlties Patients HTN drug?

Hydrochlorothiaizde patient has *lithium toxicity* - very narrow theraeutic index Acute - GI upset; later develop neurologic findings as drug epentrates CNS Chronic - gradual onset of neuro symptoms, such as this pateints worsening involutnray movements, ataxia and trmeor Lithium is simlar to sodium in its properites and exclusviely exrete dby kidneys any decrease in GFR can icnrease proximal Na/lithium reasborption and icnreased lithium retention *Thiazide diruetics* limit Na reabsorption in distal tubule, causing mild volume depletion (and potenital hyponatremia) taht stimaultes proximal tubualar Na/lithium reabsorption, leading lithium toxicity over time ACE-I and NSAIDs can also impair lithium clerance

what is the mechanism by which CTG repreates in Fragile X syndrome cause diease?

Hypermethylation

58 y/o with sudden right sided weakness. No sensory loss, problems spearkign/swalloing, or difficulty with balance. Patient previously told had high BP, btu didnt follow up. Exam shows itnact cranial enrves and sensory function. Patient has decreased strenght on right side. Inital CT showed nothing. Four weeks - 9mm, fluid filled cavitary lesion in left ienrnal capsule. Conditions is cuased by?

Hypertensive arteriolar sclerosis small cavitary lersion in internal capsule --> pure motor hemiparesis from *lacunar infarct* which is a form of sichemic stroke ivnolving *small penetrating arteiroles* that supply deep brain strctures and subcortical white matter lacunar ifnacrcts are cause dby chronic HTN, which promotes liphyalinosis, microatheroma formation and hardening/thickening of vessel wall - *hypertensive arteriolar sclerosis* Leads to progressive narrowing of arteriolar lumen and prdipsoses to thrombotic vessel occlusion pure motor hemiparesis - posterior limb of internal capsule or basal pons pure sensory - VPL, VPM Ataxia-hemiplegia - posterior limb of itnernal capsule or basal pons Dyarthria-clumsy hand syndrome - genu of itnernal capsule or basal pons in acute setting, CT may not show expected hypodesnity dueto small infarct size after several weeks, necrotic lesions turn into cavitary spaces with CSF and surrounded by scar tissue called *lacunas*

homeless man is unresponsive to verbral and tacile stimuli. Partial pressure of oxygen in arterial blood is 60. Partial pressure of oxygen in his alveoli is 71. What is cause of symptoms?

Hypoventilation partial pressure of oxygen in alveoli is normally 104. blood pO2 normally reaches PAO2 by time it passes through first third of alveolar capillary due to high O2 diffusion through membrane pO2 dops to 100 by time it gets to systemic from: -addition of deoxygenated bronchial circulation -intrapulmonary AV anastomeses -Thebesian vieins of heart This difference is the A-a gradient (normally between 5-15) this patient has a NORMAL A-a gradient (71-60 = 11) - this indcates that his low paO2 is directly due to his low PAO2 and not caused by V/Q mismatch or O2 diffusion imapirment causes of hypoxemia with normal A-a gradient: -alveolar hypoventilation -high alittiude

chiari I is associated with... chiari II is associated with...

I = syingomelia II = meningomyelocele

3 year old male with deteriorating vision and decreased ROM. PE - clouded cornea, coarse facial features. Labs - elevated plasma level of lysosomal enzymes. Diagnosis?

I cell disease Failure of golgi apparatus to add mannose-6-phosphate to lysosomal proteins and as a result proteins are erroneously secreted outside the cell instead of to lysosome

what interluekin causes class witching to IgE?

IL 4

what immunological factor is assocaited with severity in Giant Cell Arteritis?

IL-6 Tx = Tocilizumab (monoclonal against IL6) inflammatory infiltrate in affected vessels is composed of lmyphocytes (CD4+) and amcrophages and frequently contains multnucleated giant cells

A researcher studies components of immune response. Which of following cytokines is produced exclusively by lmyphocytes?

IL2 - produced exclusively by antigen-stimualted T lmyphocytes Functions to stimulate growth and differenitation of T cells, B cells, NK cells and macrophages

patient is unconscious with hypoglycemia. what do you do?

IM glucagon glucagon corrects hypoglycemia by icnreasing hepatic glyocgenolysis and glucoengesis, and will cause return to consciousness within 10-15 minutes of administration if glucagon is not avaible, buccal or sublingual glucose may be attmpted, btu asborption of glucsoe from oral mucosa is slow and erratic and may be ineffective

surgeon occludes hepatoduodenal ligament, but patient continues to hemorrhage. What structure is most likely sourc eof patient's bleeding

IVC heaptoduodneal ligament = portal traid (hepatic a., commbon bile duct, portal vein)

31 y/o woman with transient visual changes (loss of vision for a minute) that are precipitated by bending forward or lifting objects. Has had persistent headaches over last 3 months that she thinks are migraines. What will be seen on fundoscopic and mechanism?

Idiopathic intracranial HTN (pseudotumor cerebri) This is presents in young obese women with DAILY headaches, bilaterally symmetric papilledema and transient visual disturbances related to impaired cerebral venous outflow and elevated intracranial pressure Symptoms worsen during Valsalva increased intracranial pressure is transmitted through CSF int the subarachanoid space which is continuous with optic nerve sheath This buildup of pressure compress the optic nerves externally, which impairs AXOPLASMIC FLOW within the optic nerves causing bilateral optic disc EDEMA (PAPILLEDEMA)

Patient is given IV morphine sulfate for pain relief. 15 minutes later, she develops diffuse itching ivnolving the arms, legs and back. Which of following is most likely mechanism causing this patient's adverse reaction?

IgE-*independent* mast cell degranulation Opioids, radiocontrast agents and some antibiotics (vancomycin) can induce mast cel degranulation by activation of PKA and PI3K Results in increase in several mediators - histamine, bradykinin, heparin and number of enzymes and chemotactic factors common symptoms - diffsue itching/pain, bronchospasm, localized swelling

what type of antibody is the anti-RH(D) immune globulin?

IgG anti-D given at 28 weeks gestation and immedaite postpartum period once given, anti-Rh antibodies bind to Rh postiive fetal eryhtrocytes that enter maternal circulation prevneting their itneraction with maternal immune system via sequestration and elimination by spleen

patient has patella fracture. What is additional exam finding in patient?

Inability to extend knee against gravity patella is large sesamoid bone that improves knee extension, protects direct injury and improves nourishment of distal femur articular cartilage patients have: acute swelling, tednerness inability to *extend* knee against gravity palpable gap in extensor mechanism

2 y/o African American body presents with malaise and abdominal pain of 1 day. Recent measles infection, which was treated conservatively. PE - yellowing of sclera and mucous membranes. Abdominal exam shows mild diffuse tenderness without mass or hepatosplenomegaly. Cause of symptoms?

Inability to generate reduced glutathione G6PD deficiency most common cause of flare is infection

cardiac and vascular function curve fistula

Increased cardiac output (increased height of cardiac function curve) decreased TPR (increased slope of both cardiac function curve and venous return curve) increased mean systemic pressure (rightward shift of venous return curve along x-axis) SNS and kidneys compensate for chronic fistula by increasing cardiacc contractility, vascular tone and circulating blood volume

15 y/o attempts suicide by ingesting acetaminophen after drinking an entire bottle of wine. He takes daily phenytoin. He has never had alcohol or acetaminophen prior to this incident. His risk for heaptoxicity in this setting..

Increased due to acute alcohol consumption following dose, acetaminophen is converted to nonotixc metabolites via phase II conjugation and small portion oxidized by P450 into intermediary metabolite NAPQI (normally detoxified by conjugation with glutathione to form cystine) hepatotoxicity results from high levels of NAPQI depleting hepatic glutathione and directly damaging its cells, causing liver failure primary acute effects of ethanol consumption are the result of the altered NADH/NAD+ ratio from both ADH and ALDH catalyzed reaction other acute effects = oxygen deficits in liver, formation of ROS that damage cell metabolism of ethanol via CYP results in increased ROS which are regulated by different antioxidant compounds (glutathione) risk factors for toxicity include anything that may deplete hepatic glutathione reserves acute alcohol increases availability of phenytoin; phenytoin is an inducer of P450 enzymes, which (at high levels) increase his risk of hepatotoxicity by elevated NAPQI levels from administration with ethanol, increased ROS and net reduced glutathione

alcoholic pancreatitis without gallstones. What additional finding would you see?

Increased mean corpuscular volume Assume because patient is alcoholic he has poor nutrition and resulted in macrocytosis even in absence of anemia due to poor nutrition and/or alcohol toxicity on marrow Other answer choices: Low calcium = any pancreatitis, not just alcoholic pancreatitis hyperglycemia = nonspecific finding; dysfunction of pancreatic islets with decreased secretion of insulin Hypernatremia = severe acute pancreatitis due to large third space fluid loss and decreased water intake, causing subsequent hypovolemia and renal sodium retention. Non specific.

42 y/o with type 1 DM comes to office with *frequent involuntray loss of urine*. Diffictuly starting and maintaining stream. last 3 weeks - 2 episodes of nocturnal enuresis and multiple daytime episodes of uncontrolled voiding without sensation of full bladder. Other problems - chronic kidney disease, gsatroparesis. Additional finding?

Increased postvoid residual volume - *overflow inconence* patients overflow incontinence is most likely due to diabetic autonomic neuropathy affecting detrusor muscle innervation - *common in T1DM* patients initally have infequent urinary due to *loss of autnomic afferent innervation and inability to sense a full bladder* involvement of *efferent fiebrs* to bladder causes *incomplete emptying* patients can develop recurrent UTI and overflow incontinence with poor urianry stream and dribbling pelvic floor relaxation at night combined with full bladder can lead to nocturnal enuresis

53 y/o with progressive exeritional dyspnea. Smoked 2 packs per day for 35 years. PE - increased AP diameter of chest. Auscultation shows decreased breath sounds and scattered wheezes thrgouhout. Echo - moderate dilation of RV and increased CVP. Absence of peripheral edema is expalined by what?

Increased tissue lymphatic drainage Moderate increaes in capilalry transudation can e offset by a compenstaory increase in tissue lymphatic drainage that occurs due to incrased interstitial fluid Clinically apaprent edema appears only when net plasma filtration has rsien sufficiently to overhwlem the resorptive capcity of tissue lymphatics

21 y/o in stuporous condition. Returned from mexico 2 weeks ago. One week ago, high grade fever, headache, severe mylagias and joint apins. Had similar symptoms following trip to Mexico 5 years ago, but at the time symptoms did not progress and resolved spontenously. T101, BP 80/50, P128. Exam - diffuse maculopapular rash, multiple purpuric lesions, hepatomegaly. Labs - thrombocytopenia, leukopenia, elevated liver aminotransferases. Mechanism of severe illness?

Infection with different viral serotype patients presentation after recent travel to endmic area suggests *dengue hemorrhagic fever* - Aedes mosquito and ssRNA virus with 4 serotype Primary infection can be asymtptoamtic of self limited disease in most adults Symptomatic disease can cause: high grade fever, ehadache, retro-orbital pain, bleeding (petechiae/purpura), diffuse macular rash, muscle and joint pain (*break bone fever*), leukopenia, thrombocytoepnia, elevated liver enzymes primary infeciton can cause lead to life long immunity, but individuals can be ifnected with different serotype Seconday infection with *different viral serotype* can cause a *more severe* illness, prossibly due to antibody dependnet enahncement of ifnection, enhanced immune complex formation, and/or accelerated T response DH, which can be a serious manifestation of secondary infection, is due to increased capillary permeability and manfiested by marked thrombocytoepnia, rpolonged fever, respiraotry/circulatory failure and shock patients dvelop more significant hemorrhagic tendencies (petechiae with tourniquet application) and spoatenous bleeding

Janeway lesions mechanism

Infective endocarditis nontender, macular, eryhematous lesions lcoated on plams and sloes result of *setpic embolization from valvualr vegations* and composed of bacteria, neutrophils, necrotic material, subcutenous hemorrhaie

patient has thymoma. what other organ is derived from same embrologic?

Inferior parathyroid glands 3rd pouch

imaging shows complete tear of quadriceps tendon. surgical repair planned. Lidocaine injection at what site is likely to provide anesthesia for procedure?

Inguinal crease fremoal nerve (L2-L4) is largest branch of lumbar plexus Nerve emerges between psoas and ilacus and psses under inguinal ligament (lateral to femoral a.) into thigh before branching in femoral traingle into anterior/posterior divisions optimal site for Femoral N. Block is inguinal crease at lateral border of femoral a. injecting at this site anesthetizes skin and muscle of anterior thigh, femur and knee block also anesthetizes spahenous nerve (terminal extension of femoral n.) - decreased senation in medial leg below knee

68 year old woman. Lower extremity weakness - progressive bilateral leg weakness and difficulty walking. Temp 101. Patient is confused and has morbiliform rash on trunk and arms. Neuro exam - coarse hand tremor and falccid paralysis of bilatearl lower extrmeities. Lumbar puncture shows viral RNA. mode of transmission?

Insect bite - West Nile Virus Febrile with rash and neurologic manifestations associated with flaccid paralysis syndrome WNV is +SS-RNA flavivirus

after trnsaciprtion, extensive processing of precurosr RNA occurs to form final mRNA. The finalizd mRNA exits nucleus and undergoes translation by ribosome complexes before being degraded. Which step occurs within cytoplasm?

Interaction with Po bodies

lack of sertoli cells normally functioning Leydig cells

Internal = female + male External = male

Bilateral ligation of what arteries is needed to control uterine bleeding and preserve fertility?

Internal iliac pelvic organs are mainly supplied by internal iliac arteries uterine arteries, the major blood supply to uterus, are branches of internal iliac arteries bilatearl ligation of internal iliac as. should stop uterine blood flow and hemorrhage, thereby preventing need for hysterectomy uterus has colalteral blood flow from ovarian arteries, which maintains uterine funciton after inernal iliac ligation

within the true pelvis, a surgeon can most likely palpate the righter ureter immediately anterior to which of the following structures?

Internal iliac artery

45 y/o woman with CREST. She has an accenuated second heart sound over upper left sternal border. What is the cause of this?

Intimal thickening of pulmonary arterioles the heart sound = cor pulmonale collagen deposition is triggere dby increased prolfieration and accumulation of monoclonal T ells in affected tissues that secrete varietry of cytoekines (TGF-b), which increases production of collagen and fibroblast dervied proteins

27 y/o medical student is coughed on by patient who has active pulmonary TB. Studen has never beene xposd to TB before. What would most likely happen in first week after exposure?

Intracellular bacterial proliferation pulmonary TB is established after gravity assisted entry of small, organism laden droplets into lower lung fields mycobacteria are phagocyosed by alveolar macrophages and the sulfatide viurlence factor expressed by TB allows for itnracellular bacterial proliferation Continued prolfieration evenutally kilsl macrophage and causes cell lysis, allowing TB o be phagocytozied and infect more amcropahges virulence factors promote recruitment of additional antive, inactivated macrophages and udnermine immunologic itnracellualr siganling between antigen presneting cells and helpter T cells eventually, antigen carrying macropahges or dendritic cells migrate to the lmyph ndoes and induce a helper T cell response this occurs 2-4 weeks after inital infection killing of TB is dependnet on cell mediated Th1 response because immunoglobulins are unable to reach the organism while it is within macrophages

activation of of phosphorylase kinase (enzyme for phosphorylation of glycogen phosphorylase) in muscle

Intracellular calcium release of sarcoplasmic calcium stores following neuromuscular ACh stimulation allows for synchronization of skeletal muscle contraction and glycogen breakdown

62 y/o woman with signs of anemia. Dysphagia especially with large chunks of food. PE - mucosal pallor, tongue smooth and red. Pic in the question shows koilonychia (spoon shaped nails) what should be supplemented?

Iron - *plummer vinson syndrome*

CSF shows mycobacterium tuberculosis with decreased activity of intracellular catalase peroxidase. what agent will not work?

Isoniazid INH must be processed by mycobacterial catalase peroxidase for drug to be activated within bacteria

patient with anorexia, fever, malaise, abdominal pain. Recently diagnosed with latent TB. What is the cause?

Isoniazid induced *hepatoxoticity*

23 y/o patient has chest discomfort with exercise, goes away in 5-10 minutes. FH - uncle died suddenyl at age 35 Soft crescendo-decresecendo systolic murmur at apex and LSB while supine that becomes quite prounced when stands up What medication should be avoided?

Isosrbide dinatrate medications taht should be avoided in HCM: -Vasodilators (CCB, nitro, ACE-I) decrease SVR leading to dec. afterload and lower LV volumes -Diruetics decrease LV venous filling and result in greater outflow obsutrction Dynamic LV outflow tract obstruction worsens with decreased LV volume Negative inotropic agents (Beta blockers, verapamil, disopyramide) reduce LVOT obsutrction and helpful patient has Hypertrophic cardiomyopathy Valsalva, abrupt standing, nitro all decrease preload --> increase murmur Sustained hand grip (dec. afterload); squatting (inc. afterload, inc. prelaod); passive leg raise (inc. preload) --> decrease murmur

what medication selectively decreases HR but has no effect on myocardial contractility or relaxation?

Ivabradine slows rate of SA node firing by selective inhibition of funny sodium channels, thereby prolonging the slow depolarization phase wrong answers: CCB - inhibit L Ca channels (phase 2 and phase 0); slow sinus rate, prolong conduction through AV node, depress contractility Class I antiarrhyhtmic - block Na channels and inhibit phase 0 depolarization; slow action potential velocity but dont affect HR Class III antiarrhytmic block K channels including delayed rectifier K channels, thereby prolong repolarization, action potenital duration and refractory period; they have no role in management of congestive HF

54 y/o man going over coroanry artery bypass grafting. Portion of his great saphenous v. is removed and grafted to one of dsieases coronary arteries to bypass its athersclerotic narrowing. The veins used as a graft is accessed at which following sites?

Just inferolateral to pubic tubercle great saphenous v. is lcoated superfically in leg and is longest vein in body courses superiorly from medial foot, anterior to medial malleolus and up medial aspect of leg and thigh in the proximal anterior thigh, 3-4cm inferoaltearl to pubic tubercle, the great sapehnous v. dives deep through cribiform fascia of sapehnous opening to joint femoral vein surgeons access great sapehnous v. in medial leg, or, less commonly, near its point of termination in femoral triangle of upper thigh

Patient has weakness and headaches for 2 months. BP 190/120, P68. Potassium is low. Renin is high, aldosterone is high. 24h urine shows increeased K excreiton. Cause?

Juxtaglomerular cell tumor

mutation associated with Gastrointestinal stromal tumor

KIT Sx = early satiety and bloating, and generally go unreported until they lead to GI bleeding or obstruction 80% of GIST tumors show spindle shaped morphology

systemic mastocytosis

KIT (CD117) mutations excess histamine from degranulation of mast cells mediates many symptoms of disease Syncope Flushing Hypotension Pruritis Urticaria Histamine induces gastric acid secretion --> gastric ulcers Excess acid --> inactivates pancreatic and intestinal enzymes, causing diarrhea

Multiple hemorrhagic polypoidal lesions. biopsy of colon - spindle shaped tumor cells with small vessel proliferation. CD4 count of 50.

Kaposi sarcoma

65 y/o man with exertional dyspnea and fatigabulity. Smokes a pack a day, drinks 10 alcoholic beverages a week. BP 170/90, pulse 80/m. PE reveals bilatearl lung crackles. What sets of diagnostic findings would be most consistent with isolated diastolic heart failure?

LV-EDP = increased LV-EDV = normal LV-EF = normal diastolic dysfunction can be caused by conditions that decrease LV compliance - impaired myocardial relaxation (ischemia) or increased intrinsic ventricular wall stiffness (amyloid deposition) this patient most likely has long standing HTN leading to LV wall hypertrophy, which can impair myocardial relaxation and increase intrinsic wall stiffness LV diastolic pressure is determined by blood volume in LV cavity and compliance of the left ventricle conditions that reduce ventricular compliance lead to increased LVEDP at same LVED volumes this causes upward shift on pressure volume curve as diastolic dysfunction worsens, LVEDP continues to rise as heart attempts to maintain near normal stroke volume and cardiac output decompensation occurs when increased LVEDP (transmitted to LA and pulmonary veins) causes pulmonary edema and dyspnea

Patient si infused with nitro: LVEDP: Peripheal venous capacitance SVR:

LVEDP: decrease Peripheral capcaitance: incrase SVR: decrease

first line treatment of gestational HTN

Labetolol or Hydralazine Nifedipine and methyldopa are also acceptable

polyethelene glycol administration in similar to what disorder?

Lactase deficiency osmotic laxatives are nonabsorbable or poorly absorbable substances that attract water into intesintal lumen, thus distending the isnteinal wall and increasing peristalsis undigested lactose is a nonabsorbable osmotic substance and its accumulation in small intestine leads to increase in secretion of water and electrolytes into lumen

left vs. right frontal lobe lesions

Left = apathy and dpression right = disinhibited behavior

patient with rheumatic heart disease is presenting with dysphagia, what part of the heart is causing this?

Left Atrium RHD is causing mitral stenosis and increased size of LA, which is impeding on the esophagus

what does the Pulmonary capillary wedge pressure represent? what would cause elevated PCWP with normal LVEDP?

Left atrial pressure Left ventricular EDP Mitral stenosis --> increased LA pressure If LA pressure increases enough, it can overcome the resistance between LA and LV and LV filling may not be significantly affected, causing normal LVEDP Cardiac tampondae = LVEDP and PCWP are both elevated to same degree

patient has left dominant circulation. AV nodal infarct. what artery?

Left cirucmflex

a TEE shows dissection flap in descending aorta but no evidence of dissection in ascneding aorta. Dissection flap originates where what point?

Left subclavian artery Type B dissections involving the descbding aorta typically originate close to origin of left subclavian artery Type A(involve ascending aorta) originate in sinotubular junction

56 y/o woman 2d history of Fever (104F), headache, DRY cough. Smoked for 20 years. Chest x-ray bilateral lower lobe infiltrates. Recently returned from cruise to Hawaii. organism?

Legionella Clinically: fever >102 headache, confusion watery diarrhea Labs: hyponatremia sputum with many neutrophils with few or no organisms diagnosis: Urine antigen test Buffered charcol yeast extract

group of people sick after buying vegetables from the same store that had infected water

Legionella pneumophilia Dx = urine sample facultative intracellular organism

what value is associated with mitral stenosis severity?

Length of time between S2 (A2 component, caused by aortic valve closure) and the opening snap (OS) OS occurs due to abrupt tensing of valve leaflets as mitral valve reaches its max diameter during forceful opening As MS worsens, LA pressure increase due to impaired movement of blood into LV Higher pressure causes the valve to open more forcefully; as a result, the A2-OS interval becomes shorter as LA pressure increases

2 y/o with recurrent infections. Labs shows absent CD18 antigens on surface of luekocytes. Patient at risk for?

Leukocyte Adhesion Deficiency type 1 Persistent leukocytosis Delayed umbilical cord separation (>21d) recurrent skin and mucosal bacterial infections - no pus, poor wound healing CD18 is needed for formation of integrins

17 y/o comes in skin rash thats been presnt for 1 day. One week ago, he had sore throat that imrpoved with oral penicllin therapy. Skin exam show severeal violaceous, raised, non blanchable lesions distrbuted over bilatearl extrmeities. histo shown. Diagnosis?

Leukocytoclastic vasculitis - *cuteanous small vessel vasculitis* only affects skin and arises due to drug or pathogen exposure Penicllins cephalosporins, sulfonamides, phenyotin, allopurinol Nonblanching, palpable purpura is present on lower extmreites Lesions hsitologically have markedly inflamed small blood vessels with firbinoid necrosis in first 24 hours, perivascular inflammaotry cell population consists of *neutrophils* and fragmented neutrphilic nuclei *leukocytoclastic vasculitis*

52 y/o postmenopausal women. Has urine drops with coughing and sneezing. Pe shows mild cystocele. What muscle should pelvic floor exercises be for?

Levator ani muscle women who are obese or have prolonged second stage of labor, multiple deliveries or previous pelvis surgery are at increased risk for pelvic floor injury pelvic floor is composed of levator ani muscles and forms a U shaped sling around pelvic viscera Levator ani muscles hold bladder and urethra in appropriate anatomic position injury to these results in urethral hypermobility and/or pelvic organ prolapse (cystocele) urethral hypermobility results in incomplete closure of urethra and bladder neck against anterior vaginal wall --> stress urinary incontience

treatment of a bacteria that grows on buffered charcoal yeast extract agar that is supplemented with iron and cysteine

Levofloxacin Legionella pneumophilia

patient (meds = metofrmin, lisinopril, paroxetine, multivitamin) presents in serotonin syndrome after treatment of cellulitis. what antibiotic?

Linezolid serotonin syndrome triad of: Autonomic instability - hyperthermia, hypertension, tachycardia Altered mental status - agitaiton, confusion Neuromuscular hyperactivity - tremor, hyperreflexia, myoclonus Serotonin effect is increased when a *monoamine oxidase inhibitor* is combined with a *serotonergic antidpressant*, SNRI or TCA Linezolid has *MAOI activity* and can preciptiate serotoning syndrome

purpose of aminocentesis test: Lipid: AFP: Bilirubin: 17-hydroxyprogesterone:

Lipid - fetal lung maturity AFP - neural tube defect Bilirubin - ertyhroblatosis fetalis 17phydroxyprogesterone - congenital adreal hyperplasia

CSF shows bacterial meningitis. Empiric *Cefotaxmine* is started. no clinical improvement. What oragnism?

Listeria monocytogenes (tx - ampicllin) other cephalopsorin resistant organisms: -MRSA -Enterococci -Atypicals (mycoplasma, chlamydia)

36 y/o with mood swings and sleep problems. New onset constipation, dry skin and hair loss, weight gain despite diet. If current symptoms are from medication side effect, what drug?

Lithium hypothroidism and goieter are most common thyroid abnormalities in lithium treated patients long term lithium is associated with nephrogenic diabetes insipidus

prolonged glucocorticoids will increase protein synthesis in what organ?

Liver stimulate gluconeogenesis and urpegulate key gluconeogenic enzymes (phosphoenolpyruvate carboxykinase, glucose6P)

3 y/o boy brought in with high fever and maliase for 4 days. Began liming yesterday and doesnt want to use right leg. No travel or exposure. Temp is 103. passive ROM doesnt elicit pain, no joint effusion. Where is lesion?

Long bone metaphysis - hematogenous osteomyelitis

Patient desired medication for short term control of anxiety and insomnia without causing excessive daytime fatigue and impaired judgement?

Lorazepam *intermediate action benzo* - alprazolam, lorazepam, temazepam Zolpidem was incorrect becuase yes it does treat insomnia, but it is less anxiolytic

Status epilepticus treatment (2 drugs)

Lorazepam - rapid onset; inhibitory GABA action Phenyoin - long acting, given concurrently to prevent recurrence of seizure activity, regardless of patients response to lorazepam Inhibits Na channels

43 y/o women with prolactinoma (microadenoma). She doesn't want it removed. what is she at risk for developing?

Loss of bone mass prolactin inhibits GnRH secretion --> decreased estrogen low estrogen increases IL, TNF--> increased NF-kB (RANKL) and increased osteoclasts microadenomas dont carry risk of rapid growth that macroadenomas do

diagnosis of thiamine deficiency

Low baseline eryhtrocyte transketolase activity but increases after addition of thiamine pyrophosphate

what vascular areas are the MOST susceptible to atherosclerosis?

Lower abdominal aorta Coronary arteries atherosclerotic lesions occur in these vessels as early as 2nd decade

what tissue in the body has the feature of *decreased vascualar resistance with increased tissue oxygen*

Lungs *hypoxic vasoconstriction* - pulmoanry circulation so that blood flow is diverted away from underventnilated reigons of lung and twoard better ventilated areas where gas exchange occurs more effiicently (thereby decreasing physiological shunting) this relationship is reveresed in systemic circulation, esnuring that hypoxic tissues receive increased blood flow

33 y/o with 3 days of SOB, fatigue chills. History of IV drug use. BP 75/40, P122, RR 40. Lung autopsy is hown:

Lungs have dual blood supply so infarcts tend to be hemorrhagic patient with recent IV drug use and acute presentation with spetich shock most likely developed spetic emboli from tricuspid valve endocarditis

pyruvate dehydrogenase enzyme activity decreased. what should be increased in diet to help?

Lysine Leucine High fat ketogenic diet - high fat, low carb, moderate protein - forces production of ketone bodies from fat and amino acid catabolism to fuel body in plsm of glucose near absence of glucsoe in diet decrease amount of pyruvate generated, decreasing lactate levels ketogenic amino acids geenrate keton body precusor acetyl-CoA and cannot be metabolzied to pyruvate

What anti-depressant should be prescribed for a patient treatment resistant depression and Atypical Depression?

MAO inhibiter Atypical depression: Mood reactivity - feeling better in response to positive events Leaden paralysis - arms and legs feel heavy rejection sensitivity - sensitive to slight criticism Reversed vegetative signs - increased sleep and appetite

B2 microglobulin is associated with which MHC?

MHC-I

what to give for strep pyogenes in a penicllin allergy patient?

Macrolides

35 y/o w/ insomnia and fatigue 1 month. Increasingly depresed, irritable and hopeless since being let go from job. Week prior to her LMP was difficult and she stayed in bed most of day. Patient lost 8lbs and felt unmotivated an unable to concetrate on looking for new work. Diagnosis?

Major depressive disorder *depressed mood, low energy, loss of interest, insomnia, weight loss, poor concentration* meet crteria for *major depressive disorder* - must be present most of day, almost every day for *>2 weeks*

high carb, high protein diet. Beta oxidation of FA is inhibited within these cells as a result of diet. Increase in what is responsible for effect?

Malonyl CoA increased ATP --> inhibits isocitrate dehdyrogenase (TCA) --> increased citrate Citrate is taken from mitochondrial matrix into cytoplasm via citrate shuttle Citrate --> Acetyl-CoA via ATP citrate lyase Acetyl-CoA --> malonyl-CoA via Acetyl-CoA carboxylase Malonyl CoA goes on to form Fatty acids Malonyl CoA inhibits the carnite acetyltransferase that brings FA-CoA into mitochondria for beta oxidation

cellular extract containing purified nucleic acids is incubated along with short sequences of repeated deoxythymidine residues fixed to latex beads. the solution is washed several times to remove unbound molecules. what type of nucleic acid is most likely to bind strongest to latex beads in this experiment?

Mature mRNA the poly-A-tail on mature mRNA is most likely to bind the latex beads because the adenine residues in this tail would form complementary base pairs with repeated deoxythymine residues Mature mRNA has: -5' capping -Polyadenylation (poly-A tail) -Splicing

29 y/o w/ left hip pain. She has bony defomrities of lower extmreities, mobility is limited. PMH - hyperthyroidism, managed with radioiodine therapy. Menarche at age 7, regular cycles PE - large, hyperpigemnted macules with irregular borders located on L shoulder, L side of neck, L buttock. Diagnosis?

McCune-Albright syndrome Mosaic somatic mutation in GNAS gene (stimuatlory alpha subunit of G protein) constitutive activation of adenylate cyclase leads to overproduction of several hormones cafe-au-lait spots - persistent Gs in melanocytes --> macules endocrine abnoramlities (precocious puberty) --> menarche before age 8, hyperthyroidism firbous dysplasia (increased prolfieration of fibrobalt like cells, increased IL6, activation of osteoclasts) --> pathologic fractures

what feature of wernicke encephalopathy is not reversible?

Memory loss - damage to *anterior and dorsomedial thalamic nuclei*

42 y/o woman with dizziness. 6 month history of episodic spinning sensation with nausea and ringing in her ear. She feels fine between episodes.

Meniere disease Increased pressure of volume of endolymph Recurrent vertigo ear fullness/pain Unilateral HEARING LOSS and TINNITUS

common causes of vertigo

Meniere disease - increased pressure and volume of endolymph recurrent vertigo ear fullness/pain unilateral HEARING LOSS AND TINNITUS BPPV - otoliths (otoconia) in semicirular canals brief episodes brought on by HEAD MOVEMENT no auditory symptoms Vestibular neuritis (labyrinthitis) - inflammation of vestibular nerve (viral or postviral) SINGLE EPISODE that can last days severe vertigo but no hearing loss

VACTERL

Mesodermal defects vertebral anal atresia cardiac defects TE fistula renal defects (atresia, dysplasia, duplications) limb defects

24 y/o man with abdominal pain, vomiting, severe watery diarrhea. He reutrned from camping trip where he ate wild mushorroms. He is ill and jaundiced. his liver edge is soft, tender and palpable 4cm below right costal margin. Elevated liver enzymes and biliriubin. Synthesis of what is inhibited by this toxin?

Messenger RNA amatoxins are found in varitery of poisonous mushrooms and responsible for majority of mushroom fatalities ingestion of >1 amatoxin mushroom is life-threatening After ingestions by GI tract, amatoxins are transporterd to lvie via portal circulation where active transport by organic anion transporting polypeptide and sodium taurochloate co-transporter (NTCP) concetrates the toxin within liver cells Here, amaxtoins bind to DNA-dependent RNA poly II and ahlt mRNA synthesis, resulting in apoptosis Other systems affected = GI and proximal convulted tubules due to rapid cell turnover symptoms start 6-24 hours after ingestion urine testing for a-amanitin can confirm suspected amtoxin poisoining

trimethoprim is analgous to what drug used in humans?

Methotrexate - prevent reduciton of THF by inhibiting *dihydrofolate reductase* pyrimethamine - *parasitic* DHFR

26 y/o with comedonal and inflammatory nodular eruption on face, chest and back. he is a minor leage baseball palyer and pratices outdoors for long hours. What is cause of skin findings?

Methyltestoterone patient has nodular and comedonal acne in his 20s, an age when most patients have otugrown acne assocaited with pubertal andrgeon surge becuase he is aspiring profession athelete, anabolic steroid use must be considered anabolic steroids (methyltestosterone) are andrgeons four major elements underlie pathophysiology of acne: 1. follicular epidermal hyperproliferation 2. excessive sebum rpoduciton 3. inflammation 4. Propionibacteirum acnes after conversion to dihydrotestosterone, androgens promote both follicular epidermal hyperporlieration and excessive sebum production excessive persipiration EXACERBATES but does NOT cause acne

5 y/o boy with general edema after mild URI. BP and HR are normal. Cr is normal. Urinalysis = proteinuria without hematuria. Urine protein is principally of albumin with only trace amounts of IgG and a2-macroglobulin. Pathologic change?

Minimal change disease - Loss of glomerular basement membrane anions Immune dysfunction leads to overproduction of glomerular permeability factor - cytokine that directly damages podocytes and decreases the anionic properties of the GMB Loss of negative change leads to selective loss of albumin in urine (selective albuminuria) EM - diffuse podocyte foot process effacement and fusion tx = corticosteroids resulting in rapid resolution and long term prognosis is excellent

Patient has rheuamtic fever. Diastolic high frequency sound and rumbling diastolic mrumur heard best in left 5th ICS at MCL. When is the high frequency sound heard during cardiac auscultation?

Mitral stenosis - loud first heart sound (S1), early diastolci high frequency opening snap after second heart sound (S2), and low pitched diastolci rumble Best heard at cardiac apex using bell when patient in left side in expiration LV pressure falsl rapidly during isovolumetric relaxation the opening snap is casued by sudden opening of mitral valve leaflets when left ventricular diastolic pressure falls below LA pressure at beginning of diastole as mitral stenosis becomes more severe, the opening snap occurs earlier after S2

sectional anatomy of spinal cord

Moving Rostrally, the amount of *white matter* steadily *increases* and the sections become more *ovoid* (paritcuarly in upper thoracic and cervical regions) ventral horns of lower cervical and lumbosacral regions are more prominent as these areas innervate the muscles o arms and legs thoracics have lateral horn (intermediolateral cell column) Gracile and cuneate fasiculi are presnt above T7

what medication can be given to reduce the cravings for alcohol?

Mu-opoid receptor blockage Naltrexone blocks the rewarding and reinforcing effects of alcohol

30 y/o found unconscious in home. Labs = pH 7.1, +ketones mucous membreanes are very dry Patient develops fever, headache and eye pain. nasal cavity has black necrotic escahrd adherent to inferior tubrinate. What procedure would show pathogen responsible for fever, facial pain and eschar?

Mucosal biopsy facial pain, headache and nasal escahar in patient with DKA = mucormycosis infection ascends form nasal passage and sometime to brain histologic exam is necessary for diagnosis fungi are braod ribbon nonseptate hyphae with right angle branching

patient swtiched from a low to high dose typical antipsychotic. Increased what type of side effects?

Muscular rigidity

47 y/o with weakness, fatigue, bleeding gums. PE - widespread eptechial rash on trunk, etrmeities and soft palate. BP - 87/54, HR 117, RR 24, T102.4 CBC - normochromic, normocytic anemia, leukopenia, neutropenia, thrombocytopenia. Bone marrow biopsy shows?

Myeloblasts with pink rod like granules - Acute promyelocytic leukemia patient is presenting in acute DIC

myoclonus vs. dystonia

Myoclonus - sudden, brief, sometimes severe muscle contraction Ex - hiccups, hypnic jerks (occur when fallowing asleep); epilepsy; Creutz-feldt Jakob disease Dystonia - neurological movement disorder characterized by sustained, involuntary muscle contractions, which force certain parts of the body into abnormal, sometimes painful, movements or postures Ex - spasmodic torticollis, blepharospasm, writer's cramp

What is produced in the reaction catalyzed by Glucose 6PD and what is it used for

NADPH - PPP is the main source of NADPH pathway is primarily active in: -cells experincing high oxidative stress (RBC) in which NADPH is used to regenrate reduced glutathione, an antioxidate that helps maintain cell integrity -organs such as the liver and adrenal cortex that are involved in reductive biosynthesis (synthesis of FA [the answer], cholesterol, steroids) and cytochrome -450 metabolism -phagocytic cells generative a respiartory brust via NADPH oxidase *NADH is used in oxidative phosphorylation not NADPH*

Are cricothyrotomy and intubation allowed in DNR?

NO patient on nasal canulla going into respiratory distress --> non-invasive Positive Pressure Ventilation

experinemtn for presence of b-hCG in the urine. serum containing anti-bhCG. woman adds urine. nothing happens. Women adds latex particles containg bHCG and there is aggluniation. Is she pregnant??

NO! the aglguniation is from the latex particles having the bHCG

do varicose veins increase the risk for pulmonary embolism?

NO! these are superficial veins they increased risk of superficial thrombophlebitis

what drug can cause toxic levels of lithium ?

NSAIDs - decreaesd afferent arteriole dilation kidneys in reaciton to decrease in blood flow, incrase absorption of sodium and electrolytes to incrase volume and maintain perfusion pressure in proximal tubule, lithium is handled similarly to sodium and would be reabsrobed just avidly if kidneys were attempting to retain fluid

Micoelectrodes are placed into cardiac muscle cells detect rapid decrease in cytoplasmic calcium level immediately preceding relaxation. What protein is likely responsible for observed changes?

Na/Ca exchanger

Patient has Renin producing tumor. What will the lab values be: Na: K: HCO3:

Na: normal K: low HCO3: high *aldosterone escape* - icnreased vascular volume causes increased RBF w/ pressure natriuresis and relase of ANP limits net sodium retention and prevents development of overload and signifcant hypernatremia

6 y/o who picks his nose a lot has persistent nasal bleeding. Parents say they have been pinching nose for 30 minutes while boy leans forward. No known family history. Silver nitrate cautery is performed and bleeding stops. Where was the cautery?

Nasal septum anterior nosebleeds are by far the most common, and the vast majority occur within the vascular watershed area of the *nasal septum* (anteroinferior part of nasal septal mucosa) known as *Kiesselbach plexus* management is directed at stopping bleeding form Kiesselbach pelxus, preferably by *direct compression of nasal alae* Cautery of area surrounding bleeding site may be necessary for peristent bleeding

3 week old girl with ab distention, vomiting, blood streaked stools. Previously toelrated formula feeds and ahd normal stool and urine. Bron at 27 weeks. Pregnancy was complicated by premature rupture of membranes. Xray - *curvilinear areas of lucency that parallel the bowel wall lumen* Diagnosis?

Necrotizing enterocolitis - once of most frequent GI emeregncies affecting newborns preterm ifnants upon intiation of enteral feeding, bacteria are introduced into bowel where they rpolfierate excessively due to compromised immune clearnce imapired mucsoal barrier allows abcteria to invade bowel wall -- infalmmation and *ischemic necroissis* of temrinal ileum and colon as disease progresses, bwoel becomes congested and gangrenous with formation of (intramural gas collections*

55 y/o man with intermittend abdoimnal pain. Ulcer in DISTAL duodneum. Fasting gastrin is at upper limit of normal and rises in response to IV secretin. Condition?

Neoplasm - Zollinger Ellision syndrome Ulcers found *beyond the duodnal bulb* suggest ZES secretin normally increases pancreatic HCO3 secretion and inhibits release of gastrin However, secretin paradoxically *stimulates gastin release from gastinomas* due to abnoraml cAMP activation

nasal mucosal uclrations and gloermulonpehritis will have antibodies against what?

Neutrophils - *granulomatosis with polyangiits*

when a patient cannot communicate and has no written documentation of his wishes who is responsible for making medical decisions?

Next in kin Next of kin is determined by proximity of relationship and age of majority In most cases, the order is the spouse, adult chidlren, parents, and adult siblings

Patient with carcinoid syndrome. Increased risk for deficiency in? What additional Physical exam finding is commonly seen in carcinoid syndrome?

Niacin Tryptophan is being shunted to produce serotonin causing a niacin deficiency Right sided valvular heart disease (tricuspid regurgitation, pulmonic stenosis)

When experimental drug is applied to cells experssing receptor X, there is immdiate change in transmembrane Ca, Na, K flow secondary to opening of receptor channel. What type of receptor is X?

Nicotonic cholinergic receptor - *ligand gated ion channel receptor - ionotropic receptor* other answer choices: a1 = Gq B1 = Gs B2 = Gs M1 = Gq M3 = Gq

management of adenocarcinoma in situ of the cervix?

No desire to remain fertile = hysterectomy Maintain fertility = no margins involved, use conservative management if there is involvement of margins, or endo-cervical curettage is positive for cellular abnormality, repeated LEEP and evaluation at 6 months is standard

HCV differs from when it was first inoculated. What is responsible for this differing genome?

No proofreading in 3'-->5' exonuclease eactivity built into the virion encoded RNA polymerase

are small VSD present at birth?

No!!! the murmur is not usually detectable at birth, but becomes audible around ages 4-10 days as pulmonary vascular resistance continues to decline, permitting *L-R shunting* most self resolve

47 y/o HIV+ has dyspnea and productive cough for 2 months. PE shows T101, late inspiratory crackles, dullness of chest. CD4 count = 43. Acid fast stain of sputum is seen. Organism and medication?

Nocardia asteroides (Tx = TMP/SMX) Can cause pulmonary disease in immunocompromised patients Nocardia has high predilection for hematogenous spread to CNS or skin This can lead to necrotizing cutaneous infections and formation of brain abscesses the culture shows BRANCHING in acid fast

78 y/o with decreased LV cavity size and sigmoid shaped vencitrcular septum. LM - increased collagen content in ventricualr wall. Myocardial cells have brownish perinuclear cytoplasmic inclusions. Consistent with?

Normal aging brown *lipofuscin pigment* - result of indigestible byproducts of subcellular membrane lipid oxidation

what is the most common cause of viral gastroenteritis in developed countries?

Norovirus - ssRNA acute onset; resolves in 2-3 days VOmiting and/or diarrhea (no blood or mucus) fecal oral spread and results in *outbraeks* in croweded settings (schools, hospital, cruise ship, ursing ome) *Rotavirus is unlikely in developed countries due to routine vaccination*

best form of diagnosis for T. vaginalis

Nucleuc acid amplification tests (NAATs) Most commonly, however, a wet mount microscope exam Media = Kupferberg's STS and Diamond's medium

E coli is plated on glucose containg media. One group has trace amount of B-galactosidase. mutant colonia have a lot of B-galactosiade. Analysis shows variant strain contains mutation that inhibits binding of certain protein to regulatory sequence. Where did this mutation occur?

Operator locus lac operan is regulated by 2 mecahnisms 1. negatively binding of reprossor to oeprator locus 2. positively by cAMP-CAP binding upstream from promoter mutations impairing binding of reprssor protein to its binding site at oeprator region will prevent repression of genes of lac operon in absence of lactose results in increase transcirption of genes of lac operon in lactose-deficient media, although presnce of glucose will prevent max transcirption

2 year old boy multiple illnesses of vomiting and sleepiness Increased blood ammonia, markedly increased orotic acid in urine PE - tachypneic what enzyme?

Ornithine transcarbamylase excess carbomoyl phosphate is coverted to orotic acid (part of pyrimidine synthesis pathway) NO megaloblastic anemia (orotic aciduria)

23 y/o with recurrent severe nosebleeds has pink spider like lesions on oral and nasal mucosa, face and arms. Patient has?

Osler-Weber-Rendu syndrome (hereditray hemorrhagic talngeictasia)

what are the hemodynamic parameters associated with exercise?

Overall decreased SVR from arteriolar vasodilation in active skeletal muscles mediated by local release of adenosine, potassium ions, ATP, CO2, lactate There is contraction of arterioles in all tissues EXCEPT workig muscles, shunting blood towards the musle This increases systolic BP, however, the rise in mean arterial pressure is much lower due to overall decreased SVR Increased HR, SV, CO at higher levels of exercise, HR is responsible for most of the increase in CO LV-EDV and pressure both rise during exercise due to an increase in LV filling (increased venous return) by peripheral vasoconstriction and pumping actions of actively contracting muscles

aloprostadil

PGE1 analog used to maintain a patent ductus arteriousus

lab values in multiple myeloma PTH: Urinary Ca: 1,25-dihydroxyvitamin D PTH-rP

PTH - decreased urinry calcium - increased 1,25-dihydroxyvitamin D - decreased PTH-rP normal Hypercalcemia in MM is result of sotelysis induced by tumor cells, which release osteoclast activating factors With the PTH-Ca axis intact, elevation in serum Ca *inhibits PTH production* Low level of PTh cause increased urianry loss of Ca - *hypercalciuria* Hypercalcemia and light chain case nephropathy cause progressive renal failure - loss of 1a-hydroxylase - suppression of its activity rseulting in *low 1,25-dihydroxyvitamin D*

Bleeding labs and diseases

PTT = VIII, IX, XI, XII PT = VII, tissue factor common pathway = X, V, thrombin, fibrinogen

bHCG in different types of moles

Partial mole = moderately elevated Complete mole = significantly elevated (>100,000)

cellulitis following bite/scratch of dog or cat

Pasteurella multocida Fastidious, gram-negative facultative anaerobe

10 y/o immigrant with heart defect. PE shows toe ctanosis and clubbing but no finger abnroamlities. Diagnosis?

Patent ductus arteriosus typical consequnces include: Heart failure - SOB, fatigability cyanosis - Eisenmenger syndrome cyanosis + clubbing in lower extmreities because PDA delviers unxoygenated blood distal to left subclavian artery.

patient has severe throbbin right sided orbito frontal headache and double vision. There is anisocoria with the right pupil dilated and non reactive to both light and accommodation. Evidence of vertical and horizontal binocular diploopia. Right eye is down and out with ipsilateral ptosis.

Patient has berry aneursym causing a CNIII palsy Compressive aneurysm arising from junction of posterior communicating artery with internal carotid a. unruotured berry aneursyms are usually asympatotmic, but patients may experince headache and cranial neuropathies due to mass effec CNIII courses between posterior cerebral and superior cerebellar arteries as it exits midbrain in the interpeduncular space since general somatic efferent is on the interior and the general vsiceral efferent are on sruface - early symptoms will be mydriasis

BP cuff is inflated to 140 mm Hg and pressure is released slowly. At 120 mmHg, intermitternt Korotkoff soudns are heard only during expiration. At 100 mmHg, Korotkoff sounds are heard throughout respiratory cycle. PE finding is assoacted with what condition?

Pericardial disease in conidtions that impair expansion into pericardial space, the increased RV volume occuring with inspriation leads to bowing of interventricular septum twoard the left ventricle This elads to decrease in LV-EDV and SV, with resultant decrease in systolic pressure during inspiration Asthma and COPD are most frequent causes of pulsus paraoxus in absence of sirngifcant pericardial dsiease

During 2nd stage, as patient is pushing, fetus has nonreassuring HR. Midline episiotomy is performed to expedite dlviery. Vertical, midline cinsion is made at posterior vaginal oepning through vaginal and subvaginal mucosa. What structure is invovled in incision?

Perineal body - tendinous center point of the perineum separates the urogenital and anal triangles Following structures are anchored to perineal body: -bulbospongiosus muscle external anal sphincter superifical and deep transverse perineal muscles fibers from external urterhal sphincte,r levator ani and muscular coat of the rectum midline episiotomy - vertical incision from psoterior vaginal oepning to perineal body; transects the vaginal lining and submucsoal tissue but not the external anal sphincter or rectal mucosa

Patient has right facial droop and right sided hemiaperesis. MRI shows acute subcoritcal infarct in left inernal capsule. 6 months later which of following findings is most likely to be observed in affected pyramidal tracts of patient?

Persistent myelin debris wallerian degeneration refers to process that occurs when axon is damaged, resulting in axonal degenraiton and breakdown of myelin sheath distal to site of injury in CNS, phagocytic macrophages/microglia are recruited slow beacuse of blood brain barrier myelin producing oligodendrocytes become inactive or undergo apoptosis and dont assist with phagocytosis this slows removal of myelin debris, which can persist for years in the degenrating tracts and suppress axonal growth via myelin-associated inhibitory factors astrocytes release inhibtory molecules and prolfierative inw eeks-months, forming glial scar that act as barrier to axon regneraiton you put calcification - more common in neoplasms (oligodendrolgioma), ifnection (neurocysticercosis),, and vascular malromfarions

mechanism by which N. meningitids gets into the meningdes? give other examples...

Pharynx --> blood --> choroid plexus --> meninges H. influenzae = pharynx, lymphatics, meninges S. pneumonia = middle ear, contiguous tissues, meninges S. aureus = traumatic wound, leaking CSF, meninges TB or S. pneumonia = lung focus, blood, meninges

3 y/o boy immigrated to US brought to doctor because he hasnt begun to walk or speak. Dies 6 months later reractory seizures resulting in respiratory failure. Autopsy shows pallor of substantia ngira, locus cereleus, and vagal nucleus dorsalis. undlerying condition is caused by deficiency in?

Phenylalanine hydroxylase

Drug that: Increases PVR Increases SBP Decreases PP Decreases RR

Phenylephrine alpha 1 agonist --> markd atrial vasoconstriciton increased PVR --> increased SBP induced BP increase --> barorectpor vagal increase --> decreased SV and HR pulse pressur (SBP-DBP) is decreased by phenylephrine because of reflex decrease in SV and icnreased afterload

Experimental rats undego resection of pitutiary gland. Decreased proudction of epinephrine by adrenal medulla. Decreased activity of what enzyme?

Phenylthanolamine-N-methyltransferase expression of PNMT is adrenal medulla is upregualted by cortisol venous drainage of adrenal cortex passes through adrenal medulla, cortisol can be very high in the medulla and PNMT expressed at high level in pituairy resection, ACTh and cortisol production are low --> decreased PNMT and reduced conversion of NE to Epi

what can be injured in an interscalene nerve block

Phrenic N. passes through itnerscalene sheath the block is between anterior and middle scalenes in the posterior neck other answer choices: omohyoid - C1-C3 nerve roots platysma - Cervical branch of facial n. Sternocleidomastoid - CNXI Trapezius - CNXI

21 y/o at 16 weeks gestation. Patient has little appeitite and consumption has decreased. however, she craves ice and consumes it throughout the day. Meds include dialy prenatal vitamins. Patient rpescibed iron for anemia, btu doesnt take it. Diagnosis?

Pica

studying effects on a *denervated eye*. Pupillary constriction. What drug?

Pilocarpine - musacrinic agonist you can *not* use an AChE-I becuase without the nerve, there is no ACh in the temrinal

Treatment for b-lactamase-producing Bacteroides species

Pipercillin-tazobactam Vancomyci is gram+ only

50 y/o man with sudden, severe headache. Mild headaches and decreased libido over last few months. PE - loss of temporal visual fiels and impaired extraocular eye mvoements. He becomes hypotnesive and loses consciounss. Cause?

Pitutiary apoplexy - most often occurs in patients with preexisting pitutiary adenoma typically chronic symptoms realted to pitutiary tumor are present for months before the actual hemorrage event bleeding presents acutely with *severe headache and visual disturbance* differenitated form subarachnoid hemorrhage frmo the *bitemporal heminaopsia* patients with pitautriy apoplexy can dvelop *cardiovascular collpase* due to ACTH deficiency and adrenocortical insufficiency tx = emergent *glucocorticoids*

2 day old with ab distention. Rectum as no stool and rectal tone is NORMAL. Infant has dark green emesis. Small bowel dilation on films. Laparotmy - inspissated, green fecal mass obsturcting distal ileum. How will this patient die?

Pneumonia Cystic fibrosis - current problem is meconium ileus abnormalities in Cl, Na and H2O transport by ductal epithelium of itnesinal mucous glands cause isontoic dehydration of lumen conents results in abnormally viscous mucus into small bowel

58 y/o male - fever, fatigue, body aches, weakness, tender erythematous rash on legs. Abdominal pain, 8lbs weight loss in last 4 weeks, decreased sensation in L foot. Lacy, cyanotic rash with central clearing covering bilateral lower extrmeities, as well as bilateral diffuse eryhemtous nodules on LE with some edema. Moderate diffuse weakness in both upper and lower extremities in addition to non-dermatomal decrease in sensation in L foot.

Polyarteritis nodosa

what is the capsule of H. infleunza made of?

Polyribosylribitol phosphate PRP capsule protects against phagocytosis and complement mediated lysis by binding Factor H (circulating control protien that prevents complement deposition on host cells) vaccine = PRP conjugated to tetanus toxoid

30 y/o with acute SOB. Tracheal O2 = 150 Alveolar O2 = 145 Alveolar CO2 = 5 Cause of gas analysis?

Poor alveolar perfusion normal avelolar pO2 is 104,w hich lies between tacheal (150) and venous blood (40) pO2 concentrations normal avelolar pCO2 is 40, between tracheal (0) and venous (45) under normal resting conditions, diffusion of both O2 and CO2 across alveolar membrane is quic, with venous blood only needing to traverse about 1/3 of total capilalry length to completely equilibrate if complete equilibration occurs before venous blood exits capilalry,t hen equilibration is *perfusion limited* patient is suffering from very poor alveolar perfusion evidenced by failure of alveolar gas to reach normal equilibrium

MI causes posteromedial papilalry muscle rupture. What artery was compromised?

Posterior descending

where is the most likely location of aspiration when patient is supine?

Posterior segment of right upper lower

39 y/o nulliparous woman. Pelvic pressure. Constipation. Easier to defecate while pushing vaginal canal with her fingers to get stool out. Exam shows irregulary enlarged uterus and normal rectal tone. Etiology of constipation?

Posterior subersoral uterine leiomyoma Fibroids in posterior uterus can put pressure on colon causing constipation you put Rectocele (pelvic organ prolapse) but there is no pelvic pressure and she has no risk factors (post-menopause, obese, multiparious)

Hypercellular glomerulus + hematuria + proteinuria + urine RBC casts.... Most likely?

Poststreptococcal glomerulonephritis

patient undergoes nephrectomy. PMH is insignifcant. GFR compared to baseline: Postsurgery: 6 weeks after surgery:

Postsurgery: 50% 6 weeks after surgery: 80%

resting membrane potenial for isolated muscle is -70mV. resting membrane potentials: Na = +60 K = -90 Cl = -75 Ca = +125 Mg = 0 what ions would flow out if channels opened?

Potassium only normally intracellular = K+ is high Extracellulary = Na and Cl is high, K is low within the cell, the positive cahrge of K+ ions is normally neutralized by the engative charge of itnracellular anions (phospahtes, proteins) that are trapped in the cell chloride would want to flow in sodium would want to flow in

24 year old male presents with multiple, small, umbilicated, glistening pink papules and vesicles on his penile shaft. They have been present since shortly after he became sexually active 1 year ago. on further exam, the patient has roughly 35 additional lesions of same type on abdomen and back. it is determined that he has an underlying disease which is causing his symptoms to be worse. which of following tests would be most likely to screen for the underlying disease?

Poxvirus (Malluscum contagiosum) Characterized by flesh colored papules and/or vesicles that may or may not be umbilicated Molluscum contagiosum is not considered a sexually transmitted infection because it it is simply transmitted by body to body contact underlying disease = HIV/AIDS Screening is done with Enzyme linked immunosorbent assay and confirmatory western blot

woman has genital warts (verrucous, skin colored lesions over labia majora). Where else can HPV infect?

Predilection for stratified squamous epithelium found in anal canal, vagina and cervix In respiratory tract the TRUE VOCAL CORDS are only area with stratified squamous epithelium infants can get respiratory papillomatosis via passage through birth canal of mothers infected with the virus warty growth on true vocal cord = weak cry, hoarseness, stridor

Patient returns from India. Contracted malaria. Treated with chloroquine and primaquine. Purpose of primaquine?

Prevent disease relapse Organisms are first inoculated into human by Anopheles mosquito and travel to liver, where they ifnect hepatocytes and replicate Lysis of hepatocytes releases MEROZOITES into bloodstream Merozoites go on to infect erythrocytes and it is the resultant erythrocyte lysis taht causes relapsing fevers and sweating P. vivax and P. ovale can establish latent hepatic infection in form of HYPNZOITES, responsible for RELAPSES Chloroquine is effective against chloroquine sensitive plasmoida in blood stream but no effect against latent hepatic ifnections Primaquine can eradicate the HYPNOZOITES Primaquine has no effect against chlorouqine-reistant strains (managed with mefloquine or quinine)

patient has seizures. initial symptoms are persistent right arm tingling and numbness. Progresses to paresthesias along entire right side of body, and then develops right sided convulsions followed by generalized tonic-clonic seizure. Where did the seizures originate?

Primary somatosensory cortex (postcentral gyrus) the progression was then to the primary motor strip (precentral gyrus)

after giving an integrase inhibitor, her viral HIV load decreaes a lot. What step of viral replication is most likely inhbited as a result of patients treatment?

Production of viral mRNA Raltegravis is an integrase inhibitor that disrupts the ability of ds HIV DNA to integrate into the host cells chromosomes in absence of integration, the *viral genome cannot be transribd by host cellular machinery* and is eventually degraded by nucelases

Patient had MI that had eelvation in V2-C5. Dies 5 days later. what happened?

Profound hypotension - *free wall rupture* anterior wall myocardial infraction - 5-14d later free wall rupture is catastrophic mechanical complication abrupt rupture of LV leads to *hemopericardium* and *cardiac tamponade* patients have sudden onset of chest pain and *profound hypotension and shock*, with rapid progression to pulseless electrical activity and death

Boys parents are going through divorce. So he refuses to speak to either of them anymore even though he acknowledges that they have never expressed angery towards him. Defense mechanism?

Projection - attirbuting an unacceptable internal impulse to an extenral soruce

patient with sarcoidosis has visual field defects, headache, hypercalcemia. MRI shows soft tissue mass involving hypothalmaus and piutairy stalk. What pituatiry hormone is elevated?

Prolactin hypercalcemia = sarcoidsis effect Prolactin is inhibited by hypothalamic descending infleunces --> mass effect decreaes inhibition --> increased proalctin

malaria

Prophylaxis in chloroquine resistnat area = Mefloquine IV artesunate (severe malarial infections) P. vivax, P. ovale, P. malaria = chloroquine P. falciparum = cloroquine resistance is a problme; use artemisins which are often used with atovaquine and proguanil

what do you give to treat akathisia and benign essential tremor?

Propranolol

what is treatment for someone who has tremor when maintaining posture?

Propranolol essetnial tremor

What mediates the kin flushing/warmth after taking naicin?

Prostaglandins

what HIV drugs is associated with hyperglycemia?

Protease inhibitors - atazanavir, darunavir, indainavir, lopinavir, ritonavir other SE: lipdystrophic - fat deposition on back abd abdomen and decreased adipose on face, extremties and buttocks inhibition of p450

function of protein A in staph aureus (gram positive cocci in clusters)

Protein A binds wih the Fc protion of igG antibodies at the complement bidning site, prenveitng complement activation results in decreased production of C3b, leading to impaired opsonization and phagocytosis

bacteria associated with struvite stones

Proteus Klebsiella urease proudcing organisms

blood supply to ureter: proximal: distal:

Proximal - renal a. middle - highly anastomstic between common and internal iliac, uterine, aorta, gonadal distal - superior vesical a.

Ecthyma gangrenosum

Pseudomonas aeruginosa pervicasualr abcterial invasion of arteries and veins in dermis and subcutenous tissue with release of exotoxins destructive to human tissue Leads to *skin pathces* exhibiting *necrosis and ulceration* as a result of insufficient blood flow Viruelnce factors that may contirbute to EG include: exotoxin A - protein synthesis inhibtion elastase - degrades elastin: important for blood vessel destruction phospholipase C - degrades cell membranes pyocyanin - generates ROS

34 y/o women with fatigue and progressive exertional dyspnea. Father died of myocardial infarction at 72. Lung asucutlation normal. Echo - enarlged coronary sinus. What would eb observed?

Pulmoanry HTN becuase the coronary sinus communicates freely with right atrium - it will become dialted by any factor that causes dilation of RA most common cause of coroanry sinus dilation evident on echo is *elevated right sided heart pressure* secondary to *pulmonary HTN*

patient goes into acute respiratory distress snydrome from pancreatitis... what will be normal?

Pulmonary capillary wedge pressure ARDS from acute pancreatitis resutls in noncardiogenic pulmonary edema with normal PCWP an elevated PCWP would be suggestive of cardiogenic pulmoanry edema (decompensated LV failure)

What type of diverticuli is in colon diverticulosis

Pulsion - increased itnraluminal pressure during strained bowel movements increased pressure causes mucosa and submucosa to herniate through areas of focal weakness in the muscularis (flase diverticula)

5 y/o boy. Cant see the board at school. Marfanoid habitus. Bilateral lens sublaxation. 4 years later boy dies of massive cerebrovascular accident. Autopsy shows middle cerebral artery thrombosis and old renal infarcts. Which would be helpful supplementation for this patient?

Pyridoxine Homocystinuria Most commonly form cystathionine synthase deficiency Treatment is increase B6, increase cysteine, decrease methionine Patients with Homocystinuria have increased risk of thromboembolic occlusion of both large and small vessels, especially brain, heart kidneys

4 enzymes that use thiamine (b1) as cofactor

Pyruvate dehydrogensase - converts pyruvate into acetyl-CoA a-Ketoglutarate dehydrogenase - TCA Branched chain a-keotcaid dehydrogenease - essential for catabolism of BCAA (leucine, isoleucine, valine) Transketolase - pentophopshate pathway that helps convert 5-P (derived from glucose) to glycolysis intermediates (glyceraldehyde 3P)

49 y/o returns from Congo. AMS, fever, chills, HA. Temp 103, BP 79/51, HR 137. Diaphoretic, pale, diffuse erythematous non pruritic maculopapular rash over trunk. Fecal occult blood test is grossly positive. When an IV is inserted, the patient has oozing from site. First step in treatment?

Quarantine and FFP Suspicion for ebola

cardiac silhouette

RA composes most of right side of cardiac silhouette IVC is most inferior edge of irght border of cardiac silhoutte RV forms anterior wall of herat and best seen on lateral chest xray SVC is formed behind first costal cartilage by confluence of R and L brachiocephalic veins On PA chest xray it is the flattened opacity parallel to vertebral column taht terminates inferiorly at RA

glycolysis in red blood cell

RBC use glycolysis as major pathway of energy during normal glycolysis ATP is generated when 1,3-BPG is converted to 3-PG by phosphoglycerate kinase howver, RBC can bypass this part using *bisphophoglycerate mutase*, and enzyme that converts 1,3-BPG to *2,3-BPG* that prdouces *noATP* This step is increased in *hypoxia* and chornic anemia 2,3-BPG allosterically decreases hemoglobins affinity for oxygen - increased oxygen delviery in peripheral tissues

what types of reactions does riboflavin particiapte in?

Redox where FMN and FAD are reduced to energy carrying states (FMNH2, FADH2) through acceptance of electrons FMN severs as component of complex I of ETC, whereas FAD functions as component of *succinate dehydrogenase* (complex II) In the TCA cycle Succinate dehydrogenase converts succinate to fumarate and transfers electrons to coenzyme Q

12 y/o with HTN. Several episodes of fever and abdominal pain. No family history of HTN. Renal ultrasound = dilated calyces with overlying cortical atrophy bilaterally, mostly in upper and lower poles.

Reflux nephropathy Ureter enters bladder wall at a more perpendicular angle Ongoing injury leads to renal scarring in upper and lower poles of kidney If uncorrected, VUR can lead to loss of nephrons and secondary HTN

36 y/o with acute right side weakness, speech difficulty. Last 3 weeks - progressive fatigue, malaise, low grade fever. Neve been ill or hospitalized. Receptionst, never traeled out of US. No drugs. Admitted to hospital, but dies 2 hours later. Autopsy - large, friable, irregular masses attached to atrial surface o a valve. Underlying conditin?

Regurgitant mitral valve prolpase most common underlying valvualr disease preidosping to developmen of IE in *developed countries*

24 y/o AA woman with feevr, malaise and intense pain over right thigh. Long history of painful crises. Usually treated with O2 and narcotics. However, today, she is febrile (103F) with pain over thigh. Blood cultures = nonlactose-fermenting, oxidase-negative, motile organisms. What virulence mechanism is contirbuting?

Resistance to opsonization - Salmonella osteomyelitis Patient has sickle cell Salmonella is a nonlactose fermenting, oxidase negative, motile gram negative organism with a special CAPSULE called the Vi antigen that protects it form opsonization and phagocytosis sickling in intestinal vasculature leads to areas of necrosis with transient mucosal breakdown and bacterial seeding in pateints with sickle cell E-coli = lactose fermenting Shigella = nonmotile Toxin in salmonella = thyrpid fever, not osteomyltitis

23 y/o with progressive weakness and confusion. Roommate says hes been drinking water all of the time and using bathroom constantly since he got sick with cold 2 days ago. T 100, BP 96/58, P112. PE - dry mucous membranes and urine has strong fruit odor. Bicarb = 14, Glucose = 498, pH 7.17, PaCO2 40

Respiratory failure metabolic acidosis from diabetic ketoacidsois - high anion gap in compenstation, PaCO2 = 1.5[HCO3] +8 +/- 1.5[14]+8 = 29 +/- 2.. and hes at 40 = *respiratory failure* patient's low serum bicarb concentration (due to ketoacidosis0 reduces amount of HCO3 filtered by kidney in addition, his acidosis causes a compenstaory increase in renal tubular H+ secretion by a-intercalated cells in collecting duct, which rpomotes bicarbonate production and increased activity of basoaltearl HCO3/Cl exchanger - these changes decrase urianry bicarb loss

Winter morning. 6 month old abby with 100.7F fever and respiratory distress. Xray = hyperinflated lungs. RR = 66/m, wheezing. Diagnosis?

Respiratory synctial virus (negative ssRNA - paroxymyovirus) common cause of cough, feevr, and distress in infants during winter months. Causes more severe symptoms in infants because of the smaller bronchiole size in infants where inflammation can lead to distress tx = ribavirin

Pecutenaous coronary intervention via femoral a. penettrated superior to right inguinal ligament. Excessive pressure is used to slow bleeding from puncture. Soon after procedure patient is cold, clammy, hypotensive. PE - ecchmyosis around femoral puncture site. Internal bleed suspected. Where is blood collecting?

Retroperitoneal space cardiac cath is typically obtained from common femoral a. or radial a. common femoral a. is continuation of external iliac a. as it crosses inguinal ligament arterial puncture above the inguinal ligament increases risk for RETROPERITONEAL HEMORRHAGE, as this portion of vessel lies directly inferior to peritoneum accidental puncture of posterior wall can cause blood to track along loose connective tissue surrounding vessel and accumulate within interfascial planes of retroperitneum

extensive fat inside hepatocytes from drug

Reyes syndrome = aspirin in chidlren panlobular microvesicular steatosis encephalopathy of Reye syndrome is due to toxic effect of hyperammonemia of CNS leading to cerebral edema

neonate at 24 hours with scleral icterus and yellow pigmentation Labs = elevated indirect bilirubin, reitculocytosis

Rh disease Half of affected wont require treatment, have mild anemia and hyeprbilirubinemia at birth and survive normally 25% will become severe jaundiced with up to 90% dying or becoming affected by kernicterus 25% are affected in utero and develop hydrops fetalis which is an accumulation of edema leading to ascites, pleural effusions

what is most suggestive of *Stongyloides stercoralis* infection?

Rhabditiform larvae in the stool on contact, larvae *penetatre skin* and mgirate via blood to lungs - enter alveoli adnt ravel up bronchial tree to pahrynx - and swallowed when larvae get to insteine, they develop into adults that lay eggs in intesinal mucosa hatch into *rhabditirom (noninfctious) larvae* taht mgirate into itnesinal lumen to be excreted ins tool some larvae caan form into filaifrom larva in itnesine and re-finect cycle of *autofinection* can result in massive increase in worm bruden, leading to widespared dissemination of parasties throughout the body - *hyperinfection*

red blood cells that appear blue on Wright-Giemsa stain

Ribosomal RNA reticulocytes are immature RBC that is larger and bluer than mature RBC Cells lacks a nucleus but retains a basophilic, reticular network of residual ribsoomal RNA

aortic stenosis murmur

Right 2nd ICS mid-systolic click

ischemia of the inferior surface of the heart is from blockage of what artery

Right Coronary artery RCA gives off the posterior descending/interventricular artery which supplies the posterior 1/3 of the septum, posterior 2/3 of walls of ventricles and posteromedial papillary muscle

55 y/o with weakness on L side of body. PE shows loss of pain and vibratory sense on L side of body. MRI shows brainstem lesion localized to right caudal pons. What is associated?

Right facial paralysis The forehead is not spared in lesions of facial motor nucleus or in lower motor neuron pathologies effecting the entire facial nerve distribution This particular patient will have L sided weakness with loss of pain/vibratory sensation because the associated tracts have not et decussated

65 y/o with history of smoking comes in with SOB, chronic mild cough. Symptoms progressed over last week and have suddnely become worse. normal vitals, ecept pulse ox 86%, decreased breath sounds over right chest. Chest xray shown. Cuase?

Right maisntem bronchus obstruction patients decreased breath sounds, hemithorac opacificaiton on right and deviation of trachea toward opaciefied side are suggestive of *collapsed lung due to bronchial obsutrciton* Complete collapse usually occurs folowing obsutrction of *mainstem bronchus* As air trapped in lung gradually gets absorbed into blood, there is loss of lung volume due to *alveolar collpase (atelectasis)* which cases the trachea to deviate *toward* affected side Other meidatinal structures may shit Loss of radiolucent air, combined with shifting of orangs, apepars as *completely opaciied hemithorax* in pnuemothorax or plerual effusion; trachea deviates *away*

penetrating wound to left SB, 4th ICS will pass through what part of circulatory system?

Right ventricle skin/subcuti pectoaris major external inetercostal membrane internal intercostal muscle itnernal thoracic a/v transversus thoracic m. parietal pleura pericardium right ventricular myocardium

23 year old with blood covering white portion of eye. No pain and has never happened before. Physician says it will disappear on its own.

Rupture of subconjuctival vasculature associated with idiopathic and valsalva maneuvers (most common) Trauma bleeding disorders Tx = reassurance that this blood will recede on its won and that there will be no residual complications affecting eye

what enzmye does lead inhibit

S-aminolevulinate dehydratase and Ferrochelatase because protophoryin IX cannot combine with iron to form heme due to ferrochelatase inhibition, it isntead incorprates a zinc ion, leading to *elevated zinc protoporhyin levels* in addition, ALA levels are increased

what enzyme is decreased in sideroblastic anemia caused by isonazid treatment?

S-aminovulinate synthase isoniazid directly inhibits the enzyme pyridoxine phosphokinase, which normally converts pyridoxine (B6) to its active form which is the cofactor for S-aminovulinic avid synthase

marker associated with Schwannomas

S100+ due to neural crest origin other S100 tumor = melanoma

Disatolic sound heard when patient lies in left lateral decubitus position in setting of dyspnea and orthopnea

S3 = bset heard at end expiration - decreases lung volume and brings hear clsoer to chest wall straining phase of Valsalve and abrupt standing decrase venous return and LV volume - reduce S3 intesnity

mechanism of S3 in heart failure

S3 is from blood flowing into an overfilled ventricle with increased end systolic volume

what is the best way to diagnose the ifnection thin, green vaginal discharge with burning?

Saline microscopy (wet mount) is best diagnostic test for trichomonads

60 y/o school teacher. Rash on writs arms axillae. Difficulty sleeping because of intense itching. Skin exam shows small erythematous papules on palms with excoriations, scattered vesicles, and pustules on finger webs, palms and wrist creases. Similar lesions are in the axillae.

Sarcoptes scabeie rapidly spreading, pruritic rash with erythematous papules and excoriations on extremities Scabies mites burrow into skin and spread by direct contact presents with intensly pruritic rash in flexor surfaces of wrist, lateral fingers and finger webs Rash is often worse at night and due to delayed type IV hypersensitivity reaction to the mite, mite feces and mite eggs Skin exam shows excoriations with small, crusted papules scattered around the region patients can also have small vesicles, pustules or wheals Linear burrows are most specific finding in scabies

19 y/o returns from trip to Africa. 5 weeks of fever, headache, itchy hives and cough that began after swimming in a river. States the itching at the time to be worst itch hes ever had. PE shows palpable inguinal lymphadenopathy and mild hepatosplenomegaly. Stool shows small eggs

Schistosomaisis Patient had swimmers tich dermatitis occuring with inital skin pentration by the free swimming cercariae S. mansoni adult worms infecting the potral vein of the liver and causing blodoy dirrhea while S. haematobium adult worms infect the venous plexus of the bladder causing hematuria and in chronic cases, bladder cancer Tx - praziquantel

what are patients with cluster A personality disorders at increased risk for developing?

Schizophrenia cluster A disorders - paranoid, shizoid, shizotypal

Labs show impaird tetrahydrobiopterin synthesis. What is deficient in patient?

Serotonin Phenyalanine accumualtes

26 y/o with hirsuitism. PE - clitoremegaly, large adnexal mass. Diagnosis?

Sertoli-leydig tumor

what is the most sensitive marker for daignosis of hypothroidism?

Serum TSH TSH levels rise before T4 levels fall below normal, TSH is a more *sensitive* screening test

45 y/o man with chronic fatigability and mild weight gain. On PE - localized lump rises from surface of skeletal muscle following percussion of muscle with reflex hammer. Labs show elevated CK level What test woul be most useful for elucidating cause of patient's elevated creatine kinase?

Serum TSH level Fatgiability + weight gain + myodema (focal mounding of muscle following percussion) = Hypothroidism myoedema is found in hypothroid myopathy secondary to slow reabsorption of calcium by sarcoplasmic reticulum serum CK elevation can precede development of overt hypothroidism by several years therefore, hypothroidsm should be excluded with measurement of TSH levels in all with unexplained CK elevaiotion

1 y/o African Aermican boy - 3h history of severe swelling and tenderness of hands and feet. No reent sick contacts or illness. Family history is older borther died of pneumonoccal sepsis at age 6. PE - bilatearl, severe swelling hands and feet. What is abnormal in this patient?

Serum haptoglobin - *sickle cell disease* - most common autosomal recessive disease in African Americans Hemolysis - decreased haptoglobin Vasoocclusive - dactylitis Infection - encapsulated oragnisms because of repeated splenic infarcts cause funcitonal asplenia

main virulence for a non-lactose fermenting, gram negative rod, does not generate hydrogen sulfide.

Shigella - mucosal invasion mucosal invasion is essential pathogenic mechanism for Shigella Shigella invades GI mucosa, particuarly via M cells taht overlie Peyer's patches After cell entry, Shigella can lyse its contaimnet vacuole and enter cytosoic comparment it can induce apoptosis of host cel and spread to adjacent vells via protrustions through host cell actin-polymerziation some shigella have Shiga toxin, but Shiga toxin play minor, nonessential role in disease process, as nontoxigenic strains also cause shigellosis

28 y/o in street drinking urine. A year ago broke up with GF, quit job and became isolated. He doesnt care about things that used to interest him. In past month disconnected his phone and slept in garden shed with his dog. Patient swtiches among unrealted topics and when asks where he lives he says in holy buffet of diplomancy. Diagnosis?

Shizophrenia

CT shows mass extending from greater curvature of stomach, impnging on splenic a. Tissues supplied by what artery will be affected?

Short gastric Short gastric arteries have poor nastomses, and tissue supplied by them is vulnerable to ischemic injury following splenic artery block in contrast, tissues supplid by left gastroepiploic a. can be supplemented by its storng anastomatic connection with right gastroepiploic a.

50 y/o with mild myopia for decades. Begins eating organically grown food without preservatives and feels healthier than ever. She no longer has nearsightedness and doesnt use reading glasses. What conidtion has simlar etiology?

Skin wrinkles - aging process although the patient attributes it to her diet, its most likely *age related changes* normally, in *accommodation*, when focusing on near objects, cilirary muscle contraction relaxes the zonular fibers, allowing lens to become more convex so image focuses on retine starting around age 50, most develop inability to focus on near objects - *presbyopia* - progressive dneaturaiton of lens proteins and cahnges in lens curvature cause lens to become less elastic and lose accommodating power - image *behind retina* conversely, in myopia (increased eye axial elnght), the image focsues *in front of the retina* therefore, presbyopia can *compensate* for myopia by dispacing image backward, so it focuses on retina

drug induced lupus has a predileciton for...

Slow acetylators - *procainamide, hydrlaine, isoanizid* are all metbaolized via phase II *acetylation* in lvier procainamide hyrdalazine isonaizd minocycline TNFa inhibitors

IV anesthetic has large AV concentration shortly after beginning inhalation. What is another property?

Slow onset of action higher solubility = more anesthetic must be absorbed by the blood before it can be effectively transferred to other tissues

Patient has lung transplant. What would be damaged in chronic rejeciton?

Small airways acute rejection - perviascular and peribronchial lymphocytic infilaitres; dyspnea, dry cough, low grade fever tx - immunosupressants chronic - inflammation of small bronchioles (*bronchiolitis obliterans*) inflammation and fibrosis of bronchiolar walls leads to narrowing and obstruction of affected bronchioli dyspnea, nonproductive cough, wheezing *This mechanism contrasts to chronic rejection seen in renal transplntation (vascular obliteration)*

50 y/o acute abdominal pain and distention. Pain began suddenly, and is sharp with cramping quality 6/10. Spasms make it 10/10 every few minutes. PMH: surgical appendectomy, an exploratory laparoscopy and multiple C-sections. PE = abdomen is moderately distended, tympanic percussion. Bowels sound hyperactive. Diffuse tenderness in all four quadrants.

Small bowel obstruction most common from adhesions formed as a result of past surgeries; next most common sign is incarcerated hernia, then tumor x-ray shows multiple dilated loops of bowel and air fluid levels pain signals in bowel are generated in response to stretch in bowel obstruction, intraluminal pressure builds proximally to the transition point, which stretches the bowel wall and generates pain additionally, bowel peristalsis will continue to attempt to advance luminal contents part transition point, bringing increased tension to bowel wall and increase in symptoms NO peritoneal signs since bowel obstruction is a mechanical problem, the best and most important treatment is a mechanical one - decompression of the bowel accomplished by placing NG tube into stomach and hooking it up to suction on LOW INTERMITTENT suction This removes air and fluid from bowel lumen proximal to obstruction, reliving pressure on wall and reducing risk of perforation - reducing pain patient is then held with NPO for 48 hours if it doesnt resolve then surgical intervention is indicated

what to give an individual in TCA overdose with QRS prolongation and frequent premature ventricular beats?

Sodium bicarbonate symptoms of overdose are caused by blockage of cardiac fast Na channels and inhibition of muscarinic ACh, histamine and alpha1 receptors widened QRS interval and ventricular arryhtmias are an indication for sodium bicarbonate therapy NaHCO3 increases serum pH, which favors the non-ionized form of the drug, making it less accessible to bind to sodium channels NaHCO3 also increases extracellular sodium concentration which helps overcome competitive, rapid sodium channel block induced by TCAs

Anti-dsDNA in SLE

Specific

26 y/o in MVA. BP 90/60, P115. Left shoulder pain. Bruise on left lower chest wall with tendnerness to palpation along area. Normal heart sounds, equal breath sides. Rigid and tedner abdomen. Diagnosis?

Splenic lacerations - rigid abdomen, left shoulder pain, hypotension, tachycardia *Kehr sign* - shoulder pain likely represented referred apin due to peritoneal irritation phenic originates from C3-C5 ans passes between lung and heart to provide motor to diaphragm phrenic provides sensory to pericardium, mediastinal pleura and diaphragmatic peritoneum supracalvicular nerves originate from C3-C4 and innervate SC joint, local muscles, and skin of upper and posterior shoulder any abdominal process irritating the snseory fibers around diaphragm can casue *referred pain* via phrenic n. to C3-C5 shoulder region

53 y/o with skin rash. For last 3 weeks has had pruritc rash with worsening severity involving posterior thighs. Recently began exercise program and applies topical anlgesic cream to thighs and buttocks after workouts. On PE - eryhtematous rashw tih blisters, ulcesr and weeping drainage involving posterior thighs. What seen in skin biopsy?

Spongiosis acute eczematous dermatitis is characterized by spongisis, accumulatio of edema fluid in itnercellular spaces of epidermis

Ejection fraction shows 30%. What diruetic would imrpove survival if added to patients current regimen?

Spronolactone - antagonist block deleteirous effect of aldosterone on herat, causing regression of myocardial fibrosis and *improvement in ventricualr remodeling*

73 y/o man with postpraindial epigastric pain. PMH of HTN, hyperlipiedemia, coroanry artery bypass and right sided carotid enarteretomy. Smoekd 1 ppd for 32 years. Upper GI endcoopsy shows nothing. Underlying pathophysiolgoy of this disease is most similar to?

Stable agina patient has chronic mesenteric ischemia - intestinal hypoperfusion can be very painful especially within an hour after meals when more blood is needed for digestion/absorption of nutrients analogous to stable cardiac agina - chest pain occurs when physical exertion due to increaed myocardial oxygen demand

19 y/o with pelvic pain, fever, chills began last night. LMP 12 weeks ago, had surgical abortion 2 days ago. Speculum exam - open cervical os, with foul smelling tissue in vaginal canal. Cause?

Staph aureus septic aborption risk factors - pregnancy termination with reatined proudcts of coneption micro - Staph aureus, gram neg bacilli (E coli), group B strep tx = broad-spectrum antibitoics and prompt surgical evacuation to remove nidus of infection and rpevent severe complications such as sepsis, mutli-organ failure and death

two organisms that cause impetigo

Staph aureus Group *A* strep

57 y/o woman with high grade fever (104), chills, RUQ pain. PE shows rebound tenderness Labs - elevated alkaline phosphatase Imagine - fluid filled cavity in right lobe of liver. organism/route?

Staphylococcus aureus by hematogenous route Liver abscess underdeveloped country = Parasite infection Developed country = bacterial infection Pyogenic bacteria gain access via: Biliary tract infection portal vein pyemia hepatic artery penetration Entamoeba histolytica is transmitted through foodborne exposure and poor sanitation (travels to liver via portal venous system)

5 year old with fever and painful skin rash on arms/trunk. Skin is erythematous with large blisters and serous fluid exudate that contains organisms. There is splitting of the epidermis at the stratum garnulosum. Organism?

Staphylococus aureus bullous impetigo - exfoliative toxin producived by some staph aureus skin splits at superifical granulosum layer of epidermis, resulting in painful blisters that easily erupt and extrude serous fluid containing many bacteria

what medication is recommended for prevention in all patients with known atherosclerotic CV disease, REGARDLESS of baseline lipid levels?

Statins - inhibit HMG-CoA reductase patient in the question had low HDL - giving niacin can help to raise HDL but does not reduce the risk of CV disease and is associated with adverse side effects

necrotic keratinocytes in epidermis

Steven Johnson syndrome severe reaction occurring 1-3 weeks after infection (CMV, mycoplasma) or drug exposure patients have high fever, skin pain, mucosal erosions and skin detachment does not usually involve palms and soles

patient started on lamotrigine. main side effect?

Steven-Johnson syndrome blocks voltage gated Na channels treats partial and generalized seizures and also effective for bipolar disorder SJS incolves <10% of body surface, TEN (toxic epidermal necrolysis) involves >30% histo - epidermal necrosis and subepidermal bulale other anticonvulsants associted with SJS = carbmazepine, phenytoin, phenobarbital

38 y/o with abdominal discomfort and loose stools for year. Lost 22lbs despite normal appeitite. Ha sbalnced diet. No travel, works as office manger, no sick contacts. Drinks socially, doesnt smoke. All labs normal. Next step in assesing for impaired nutrient absorption in patient?

Stool microscopy with Sudan III stain dietary lipids are maconutrient with most complex digestive pathway fats are the earliest and most severely affected in genrealized malabsorption, adn *testing for fat* is the *most sensitive* strategy for screening

65 y/o with normal pressure hydrocephalus. What is cuase of urinary incontinence in this patient?

Stretching of descending cortical fibers micturition reflex: sacral micturition center (S2-S4) - bladder contraction pontin micturition center (pontine reticular formation) - relxation of external uretheral sphincter with bladder contraction cerebral cortex - inhibits sacral micturtion cente r in normal pressure hydrocephalus, expanded ventirucli place traction on cortical efferent and afferent fibers (*corona radiata*) - this traction disrupts the periventricular pathways that ransmit impulses from cortex to sacral micturition center patinet has no sensation of full bldder and no control over bladder function voluntary relaxation of urethral sphincter remains intact

where are hepatitis B and C endemic?

Sub-Saharan Africa Chronic sequale = hepatocellular carcinoma

superior vs inferior devision of left MCA occlusion...

Sueprior = broca's area inferior = wernicke's area

Patient has continous nitroprusside infsion. Next mroning, confused adn lethargic. Nitroprusside infsion is higher than recommended. Medication that acts as donot of which element is likely to help reverse conidtion?

Sulfur *cyanide toxicity* nitrprusside = short ating; increases cGMP via direct release of NO can cause cyanide toxicity (releases cyanide) induced methemoglobinemia can be used to treated cyanide poisoning methomgeloblin has increased affinity for cyanide induced via Nitriets and thiosulfate

defense against candida Superficial: Systemic:

Superficial - T cells Systemic - neutrophils

A central line is palced to access a structure embyonically derived form the common cardinal veins. What structure?

Superior Vena Cava - right common cardinal vein and right anterior carinal vein Central lines are usually placed either into internal jugular vein or subclavian vein and catheter tip enters SVC On CT imaging of upper thorax, SVC can be identified to right of heart, posterolatearl to ascending aorta, anterior to right pulmonary artery, and just below level of carina

patient has vision problems. imaging shows solitary mass within right temproal lobe. What defect?

Superior quadrantopia other s/s -aphasia (dominant hemipshere lesion) -memory deficit -seizures (complex partial, tonic-clonic) -hallucinations (auditory, olfactory, visual)

two months later, the patient reports of positive OTC pregnancy test. The tissue which produces the hormone measured in this test is the?

Syncytiotrophoblast of the placenta

Patient had VP shunt punt in. Develops meningitis with coagulaase negative Staphlyococcus. Virulence?

Synthesis of extracellular polysaccharide matrix - *S. epidermidis*

16 y/o with: Loss of upper extremity pain/temp Upper extremity weakness/hyporeflexia Lower extremity weakness/hyperreflexia kyphosscoilsis

Syringomelia - central cystic dialation slowly enlarges, causing damage to *ventral white commissure* and *anterior horns*

8 y/o with fever and thraot pain, has severe dyspnea, tachypnea and inspriatory striode. Dysphgia with solid foods. Labs - blasts in smear. What is tihis?

T-ALL mediastinal compression is indicative of T-ALL

diaphgramatic structures

T8 = IVC, right phrenic n. T10 = esophagus, vagus n. T12 = aorta, thoracic duct, azygos v.

trehalose dimycolate

TB cell wall compnent and virulence factor protects form being killed by macropahges and stimualtes granuloma formation

pure hemisensory loss stroke location

THALAMUS VPL = spinothalamic, dorsal columns VPM = trigeminal

65 y/o with stool positive for occult blood. Colonoscopy shows 2 polyps. Pathology report shows advanced adenomatous changes in one poly and adenocarcinoma in the other. Mutation in which gene is responsible for transformation from advanced adenoma to adenocarcinoma?

TP53 Normal colon -APC- hyperproliferative epithelium -KRAS- adenoma -p53- Carcinoma

Patient has Hashimotos. What are the levels of: TSH: Free T4: Total T3:

TSH: increased Free T4: decreased Total T3: normal because T 3 have short half life and conversion of T4 to T3 in peripheral tissues can be vairable, T3 lvels fluctuate signifcanlty as a result,s erum T3 levels often remain *normal* until late stage hypothroidism

65 year old man with advanced prostate cancer and bone metastases. Treated with gonadotropin releasing hormone agonist for 4 months. PE shows bilateral, mildly tender enlargement of breast tissue behind the nipple alveolar complex. What medication could have prevented this if initiated early?

Tamoxifen - selective estrogen receptor modulator inhibits effects of estrogen on breast tissue and effective for prevention and treatment of gynecomastia in patients on ADT gynecomastic is common men receiving androgen deprivation therapy for prostate cancer Patient has GYNECOMASTIA - conditions that cause an increased estrogen to androgen ratio may lead to gynecomastia characterized by ductal epithelial hyperplasia surrounded by dense stromal fibrosis common pathologic causes of gynecomastia: obesity = increased aromatase conversion of testosterone to estrogen hyperthryoidsm = increased LH secretion and estrogen production cirrhosis = increased aromatase activity, decreased estrogen clearance chronic kidney disease = decreased testosterone production

Shizophrenic patient presenting with repetitive, rhythmic, involuntary movements of fingers tongue lips fingers

Tardive Dyskinesia side effect of antipsychotic medications

SIRS criteria for sepsis

Temperature >38 or <36 RR >20 or arterial CO2 <32 HR >90/m WBC >12,000 or <4,000 or 10% immature forms

surgical landmark for appendicitis surgical procedure?

Teniae coli - continuous layer of longtinudla muscle that surrounds the rectum just below the serosa at rectosigmoid junction, this layer condenses to form 3 distinct longitudinal bands that track on outside of entire colon before converging at the root of the vermiform appendix

resistance in the airway

The upper respiratory tract (nasal passages, mouth, pharynx, larynx) accound for 50% of total airway resistance remainder derives from lower respiratory tract which begins at trachea and consits of 23 generations of airways although resistance within trachea and mainsteam bronchi is realtively high, it increases in medium sized bronchi becuase of highly turbulent airwflow Resistance is maximal between bronchial generations 2-5 btu drops in subequent generations (small bronchi, bronchioles) because the summated cross sectional area massiavely increases this slows velocity allowing low resistance laminar airflow to predominate in airways <2mm in diameter

what amino acid should be supplemented in maple syrup urine disease?

Thiamine Branched chain a-ketocaid dehydrogenase complex deficiency

Patient presents with s/s of anemia. Bone marrow - absence of eryhtroid precursors but rpserved myeloid and emgakaryocytic elements. Further workup?

Thymic tumor - *pure red cell aplasia*

What substance needs to be added to primary folate deficiency to prevent apoptosis and permit prolfieration of proeryhtroblasts

Thymidine Eznyme thymidylate synthase is responsible for converted dUMP --> dTMP although most enzymes involved in one carbon metbaolism maintain folate in its active THF form, thrmidylate synthase is unqiue in that it oxidzes 5,10-methyleneTHF to DHF This makes de novo thymidine synthesis susceptible to folate deficient conditions as THF must be continously regenrated by DHFR

10 year old boy. Unusual classroom behavior, usually quiet but has sudden sniffling and repetitive throat clearing. Boy distracts other students and the behaviors worsen when he is tired, stressed, or excited. PE shows frequent eye blinking and shoulder shrugging but is otherwise normal.

Tourette syndrome Both motor AND vocal tics Onset <18 y/o Exacerbated by stress and fatigue Tx = antipsychotics, alpha 2 adrenergic receptor agonists, behavioral therapy

5 year old female presents with fever and abdominal pain. Has been going to dog park daily with their golden retriever. PE shows RUQ tenderness and hives on extremities and trunk. Suspect zoonotic infection.

Toxocara canis most commonly will see EOSINOPHILIA T canis can affect liver, heart, lung, muscle eye, brain eggs are ingested and penetrate bowel wall and migrate through vessels of human body Covert toxocariasis - children; mild, febrile illness accompanied by cough or abdominal pain, headaches, behavioral problems pruritic urticaria like cutaneous lesions (hives) are also common)

mechanism of infection in baby presenting with: white-yellow chorioretinal lesions in both eyes Head CT = enlarged ventricles, scattered intracranial calcifications

Toxoplasmosis Triad = hydrocephalus, intracranial calcifcations, chorioretinitis Transmission = in-utero

patient has been doing psychotherapy for depression and conflicts with his boss. during sessions finds out his dad wasnt there for him as a child. During recent confrontation, patient told father "I am angry that you were never there for me". The following week, the psychiatrist cancels a session to attend an emergency. At next appointment, the patient says "I feel as if you are not interested in listening to me, like I am not your priority"

Transference patient projects feelings about formative or other important persons onto physician (e.g., psychiatrist is seen as parent) your answer = displacement in displacement, a person expresses unacceptable feelings meant for someone in their present life towards a different, 'safer' person (e.g., if a resident belittled by an attending on rounds later displaces his anger toward the attending by berating a medical student)

an isolate of S. pneumoniae from patient with menigitis incuabted with low dose radiolabel *ceftrixaone* and subjected to protein eletropheresis. 5 distinct bands are detected. bands represent cefriaxone bound to ?

Transpeptidases penicllins and cephaloposrins *irreversibly* bind to pencillin binding protiens; transpeptidases are one form of PBP that funciton to cross link peptidoglycan in bacterial cell wall *vancomycin binds glycoproteins not transpeptidases*

Patient has difficutly with overhead activties such as combing hair. Exam - left shoulder droop with left arm abduction above horiztonal position. Muscle?

Trapezius - *drooping of shoulder*, imapired abudction of arm *above horizontal* (due to weakness in rotating genoid upward) seratus anterior was incorrect becuase it wouldnt cause the shoulder droop

Diastolic HF in a 72 y/o man. Non smoker. What is cause?

Trasthyretin deposition - amyloid deposition causing restrctive/infilitrative cardiomyopathy

6 month old with skin rash. Bouts of diarrhea. Childs skin reddens after exposure to sunlight. Upon PE notes dry, scaly, well marginated eruptions of skin of forehead, cheeks, and back of hands. Deficiency in absorption of essential amino acid is suspected. What is it?

Tryptophan - hartnup disease Tryptophan is precursor to nicotinamide and nicotinate (two forms of niacin) Therefore, tryptophan deficiency leads to deficiency in niacin, which is called pellegra - Dermatitis, Diarrhea, Dementia, Death

mechanism of skin wrinkles

UVA produces reactive oxygen species which icnrease inflammatory receptors and transcirption factors leads to *decreased collagen fibril production* and upregualtion of MMPs that degrade type I, type III collagen and elastin there is *incresed crosslinking* of collagen, with depostion of collagenbreakdown products

where is the blood oxygen saturation highest in a fetus?

Umbilical v > Ductus venosus > Inferior vena cava

what part of the action potenital does a toxin from a classic japenese dish work on?

Upstroke - Pufferfish binds fast voltage gated na channels in cardiac/nerve tissue, preventing depolarization N/V, parasthesias, weakness, dizziness, loss of rlexes

patient was normal in first year of life. past 2 years has progressive leg stiffness and involuntary movements. congnitive and motor delayed. hight, weight and head circumference are 3rd percentile. Labs = elevated arignine elvels. Deficient enzyme is involved in?

Urea cycle - arginase tx = low protein diet unlike other urea cycle disordres, patients with arignase deficiency have *mild or no hyperammonemia*

Patient has hysterecteomy to have a fibroid removed that was lcoated in lower aspect of uterus at level of caridnal ligaments, compressing bladder anteriorly. Postoperative she has fever and right sided back pain. She uriantes without difficulty. What is the structure involved?

Ureter ureter is retroperitoneal arising from renal perlvis and enters trigone at psoterior aspect of urianry bladder, with equal proprotions in abdomen and pelvis Pelvic portion starts at pelvic brim level and courses medially and anteriorly to bifurcation of common iliac arteries Then, the ureter passes along latearl pelvic sidewall posterior to ovarian vessels to dive under uterine vessels Finally, runs along anterolatearl surface of cervix at level of internal os to enter the bladder trigone Patient was at increased risk for injury secondary to large fibrid close to course of distal ureter Ureter is most vulernable to injury during a hysterectomy, where damage can occur at point of lgiation of uterine vessels and closure of latearl aspects of vaginal cuff ureteral obstruciton injury with a suture leads to flank pain due to distention of proximal ureter with urine a transection injury of ureter cuases localzied leakge of urine as well as flank pain since the second ureter is unijured,patients are able to void normally

Fetal ultrasound shows unilatearl hydronephrosis. male external genitalia is visble. If fetal hyrdonephrosis is caused by osbutrction, which of following is most likely site?

Ureteropelvic junction most common cause of unilatearl fetal hydronephrosis is narrowing or kinking of proximal ureter at ureteropelvic junction newborns not diagnosed prenatally may present with palpable abdominal mass reflecting an enlarged kidney the UPJ is last segment of fetal ureter to canalize pathogenesis of UPJ obstruction may involve failure of this canalization through abnormal development of circulate muscle and/or collagen fibers

what part of the kidney do uric acid stones occur?

Uric acid precipitates in acidic environment the lowest along the nephron is found in distal tubules and collecting ducts tx = urine alkalization and hydration these are commonly seen in tumor lysis syndrome

14 month old. Failure to thrive, developmental delay. At 12 months cant lift head and cant sit unspported. Has not started babbling. 10th percentile for height and weight. Macrocytic anemia. Normal ammonia. Urine has orotic acid crystals. Treatment?

Uridine Orotic aciduria - inability to convert orotic acid t UMP because of defect in UMP synthase present as failure to thrive, development delay and megalobalstic anemia refractory to folate and b12 NO hyperammonemia tx = uriine monopshophate to bypass mutated enzyme

innervation of submandibular and sublingual

VII

prevention of neonatal tetanus

Vaccinating women who are pregnant or may become pregnant with an inactivated tetanus toxin (tetanus toxoid) Appropriately vaccinated women provide transplacental IgG to fetus, which decreases incidence of neonatal tetanus by 95%

what nerve is implicated in a patient expericing syncope after otoscope exam?

Vagus - decreased HR and blood pressure Posterior part of external auditory canal is innervated by vagus n.

how does the HbS mutation interfere with normal functioning?

Valine is hydrophobic and allows for hydrophobic interactions between the two beta strands Leads to sickling, membrane damage and permanent damage to red blood cells

what medication is most helpful in treating both acute seizure disorder and bipolar over long term?

Valproate *generalized tonic clonic seizures* *bipolar with rapid cyclinc (>4 episodes a year)* and episodes with mixed manic-depressive features other optiosn: *carbamazepine* but is a CYP450 induced and can lwoer levels of other medicatiosn *Lamotrigine* but is associated with Steven's Johnson syndrome

10 y/o boy restless and involuntray jerking. No meds, vaccinations up to date. Sore thraot 3 months ago. on exam - rapid irregular jerking mvoements involving hsi face, arms, legs. Greatest risk for?

Valvular heart disease - *acute rheuamtic fever* patient has *Sydenham chorea* - hyperkientic extrpayrindal mvoement disorer that is most common acquired chorea of chlidhood caused by delayed onset autoimmune reaction involving anti-strep antibodies that cross react with *basal ganglia*

patient undergoes mitral valve repalcement. cultures show gram positive in clusters, catalase positive, coagulase negative. empiric treatment?

Vancomycin - S. epidermidis

patient treated with HTN drug that caused him to bcome dizzy. BP 100/70, HR 38/m. Medicaiton?

Verapamil, diliizam Beta-blocker digoxin amiodarone sotalol chloingergic agonists

patient with long standing RA. She needs to be intubated. 2 horus alter, she has developed areflexic, flaccid paralysis of all extrmeities. what isc ause?

Vertebral sublaxation long standing RA frequently involves the *cervical spine* and caues joint destruction with vertebral malalignment *sublaxation* endotracheal intubation can acutely worsen the sublaxation and cause compression of spinal cord and/or vertberal arteries acute spinal cord injury results in falccid paralysis with decreased or absent relfexes below elvel of compression due to spinal shock

how do cancers of the pelvis (including prostate) spread to lumbosacral spine?

Vertebral venous plexus (VVP) VVP communicates with many venous networks, including the prostatic venous plexus which receives venous supply from prostate, penis and bladder it runs up entire spinal column and connects with venous supply of brain via a valveless system, which allows for bidirectional flow and regulation of intracranial pressure increased metastases to brain

55 y/o with abdominal pain and black stool. Fever, weight loss, muscle pain. Smoked for 30 years and abused IV drugs on multiple occasions. Muscle biopsy - transmural inflammation of mid-sized arteries with areas of amorphous, eosin-staining arterial wall necrosis. Areas of internal elastic lamina dirsuption are rpesent. Predisposition for condition?

Viral hepaitis - *polyarteritis nodosa* Bx - transmura inflamattion, fibinoid necrosis

what are two supplements children need even with adeqaute breastfeeding?

Vitamin D Vitamin K

16 y/o with progressive gait instability, dysmetira, dysathria for past several years. PE - bilateral motor weakness and loss of DTR, joint positing and vibration sense. MRI - degenreaiton of posterior columns and spinocerebellar tracts. What syndrome closely mimics this disease?

Vitamin E deficiency and Friedreich ataxia lateral cortcopsinal tract - spastic weakness dosral colums, dosral ganglion - loss of proprio/2pt spinocerebellar - ataxia

patient has Graves disease. Takes anti-thyroid medication. Develops eryhtehmatous pharynx. First step in management?

WBC and diff Propylthiouracial and methimazole are associated with *agranulocytosis, asplastic anemia*

22 y/o with fever and sore throat. PMH = Graves disease. She takes antithyroid medication PE - eryhtemous pharynx but otherwise insigifncant. NExt step?

WBC w/ diff Fever + sore thraot in pt being treated for hyperthroidism should raise concern for *thionamide-induced agranulocytosis* If this is suspected - propylthiourcail should be discnotniued immediately and WBC count w/ wiff should be obtained to confirm diagnosis

40 y/o weight loss, abdominal cramps, flatus, diarrhea for 1 month. Joint pain in knees and wrists that comes and goes. Areas of skin hyperpigemntation Small bowel biopsy shows macrophages with PAS positive staining

Whipples dsiease - Tropheryma whipplei additionally whipples disease can affect the heart and cause arthralgia, fevers and neurologic symptoms Diagnosis is with PAS positive staining macrophages

34 y/o from South asia, heart palpitations at night. With moderate exertion, he has hound pounding accompanied by involuntray head bobbing. He has a murmur but doesnt remember the type and never had treatment. You suspect?

Widening of pulse pressure - aortic regurgitation

what reaction in the TCA cycle would be impaired in an alcoholic?

a-ketoglutarate + NAD+ --> Sunccinyl-CoA + NADH via A-ketoglutagrate dehydrogenase complex (thiamine dependent) Thiamine is cofactor for: pyruvate dehydrogenase a-ketoglutara dehydrogenase transketolase metabolism of ethanol by alcohol dehydrogenaes and aldhehde dehydrogenase consumes NAD+ and increases NADH:NAD ratio this skewed ratio inhibits all pathways requiring NAD, as a result the entire TCA is inhibited

benefit of alpha 1 blockers over nonselective alpha blockers

a1 block causes vasodilation which will lead to reflex tachycardia which is an appropraite response a2 block will disinhibit the reelase of catecholamines thereofre, a1 + a2 = vasodilation with large reflex tachycardic response

what drug blocks the aggregation of platelets

abciximab eptifibatide tirofibran

Globus sensation

abnormal sensation of *foreign body, tightness, or fullness in the throat* worse when swallowing saliva and may be alleviated with food or liquid globus is a *functional disorder* of the eosphagus and by definition is *not* due to a structural abnormality or motility disorder frequently associated with anxiety or other underlying psychological distress

brain tumors associated with: above sellar diaphragm = between cerebellum and lateral pons = dorsal midbrain = lateral cerebral convexity = parasagittal cerebral convexity = posterior fossa =

above sellar diaphragm = craniopharyngiomas between cerebellum and lateral pons = schwannomas dorsal midbrain = germ cell tumors lateral cerebral convexity = meningioma parasagittal cerebral convexity = meningioma posterior fossa = medulloblastoma

what is first sign of magnesium toxicity?

absence of deep tendon reflexes Mg inhibit Ca entry through voltage gated calcium channels

primary ovarian failure mechanism

accelerated atresia menopause before age 40

the atypical cells in EBV are what?

activated CD8 T cells - clonally expand in response to EBV ifnected B lymphocytes in an effort to destroy virally infectedc ells

how does TNFa induce insulin resistance?

activation of *serine kinases* - phosphoryate serine resiudes on beta subunits of IR and IRS1 inhibits tyrosine phosphorylation of IRS1 by IR and subsequently hinders downstream singling, resulting in resistnace to normal actions of insulin phosphorylation of threonine has similar effects

where is the 1-a-hydroxylase expression in sarcoidosis?

actived macorpahges

cadherins

adhesion molecules that bind epithelial cells together within tissues transmembrane proteins that ienract intracelluarly with itnermediate proteins, which facilitate binding to intermediate filaments or microfinlaments within cytoplasm cadherin molecules on epithelial cells bind to cadherin molecules on adjacent cells to form *adherens junctions* and *desmosomes* interactions between extracellular domains of adjacent cadherins are *calcium dependent* - removing calcium from extracellular fluid will cause dissociation of cadherin-mediate juncitons - *loss of cell cell adhesion*

nonmodifiable risk factors for osteoporotic fractures

advancing age female sex White, Hispanic, Asian Hx of fracture

isolated skeletal muscle. Decreasing which of following would increase contraction velocity?

afterload afterload refers to force against which the muscle fiber must contract when a skeletal muscle fiber contracts, its max velcotiy of shortening is indirectly proprotionate to the afterload attached to the fiber

most signifcant risk factor for osteoarthritis?

age

supportive psychotherapy

aimed at bolstering adapative psychological defenses to help individuals cope with acute crises or chronic psychaitrc illness

allergic triad

allergic rhinitis asthma atopic dermatitis

before alanine is converted to glucose, its amino group is transferred to what substance?

alpha ketoglutarate during protein catabolism, the amino group from alanine is transferred to alpha ketoglutarate to form glutamate. glutamate is then processed in the liver to form urea the excretory form of nitrogen for the body Glutamate is processed by glutamate dehydrogenase which releases urea and regenerates alpha ketogluatarate

46 y/o with confusion, fever. Anticholinergic toxicity. She has a PMH of psychiatric problems and attempted overdose on medication in past. PE - skin flushed, oral mucosa dry, and pupils are dilated.

amitriptyline

77 y/o man new onset BP. treated with a BP drug. 3 weeks later returns with bilateral leg swelling with no other symptoms. Serum Cr 0.8. urinalysis negative for protein. what drug?

amlodipine major SE of CCB: headache flushing dizziness peripheral edema edema is from preferential dilation of precapillary vessels (arteriolar dilation) leading to increased capillary hydrostatic pressure and fluid extravasation into interstiium patients given RAAS blockers cause postcapillary venodilation and can normalize increased hydrostatic pressure reducing risk of edema in CCB

volume of distribution

amount given / plasma concentration Vd of 3-5 = low = remains in plasma Vd of 14-16L = plasma plus interstitial volume Vd = 41 = high = inside tissues

most common place of ectopic pregnancy?

ampulla of uterine tube

suppurative parotitis has elevated....

amylase without evidence of pacnreatitis (elevated lipase as well)

what are the amyloid deposits in medullary thryoid cancer derived from?

amyloid deposits are derived from *calcitonin* secreted form the neoplastic C cells and stain with congo red

g protein has abudnace of alpha helices of valine, alanine, isolcueine. what is their purpose?

anchor the receptor into the membrane

edema of deep dermis and subcutenous tissue

angioedema

liver tumor associated with PVC, thorotrast, aresenic

angiosarcoma

HLA-B27

ankylosing spondylarthropathy inflammatory bowel disease reiter syndrome

side effects of clomiphene

antagonist at estrogen receptors in hypothalamus due to ovarian hyperstimulation, multiple follicles are stimulated and multiple simultaneous gestations can result in women others: ovarian enlargement hot flashes/vasomotor flushing abdominal discomfort

temperature regulation by hypothalamus

anterior = cooling posterior = heating

where is the facial motor nucleus

anterior and lateral to fourth verntricle in midt pons

urinary incontinence could result from ischemia of the urianry bladder caused by atheromatous occlusion of

anterior internal iliac artery inferior vesicular artery supplies fundus of bladder and branches of umbilical artery supply rest of the musculature occlusion of internal iliac a. can lead to urinary inctontinency due to decreased blood supply to walls of the bladder

what is the outflow tract obsutrction in hypertrophic cardiomyopathy?

anterior mitral valve lealet and interventricular spetum murmur - crescendo-decresnedo systolic murmur at apex of left lower sternal broder, which changes in intesnity with pyhsiologic maneuvers

what titer is specific for dermatomyositis

anti Jo1 perimysial inflamamtion

myxomatous degeneration with pooling of proteoglycans in media layer is observed in arteries. associated with pathogenesis of?

aortic aneurysm myxotmatous changes (weakening of connective tissue) in media of large arteries are found in cystic medial degeneration medial degeneration is characterized by the fragmentation of elastic tissue and separation of elastic and fibromuscular components of tunica media by small, clef life spaces that become filled with amorphous extracellular matrix Marfans is associated with this pathogenesis

most common location of tramtic aortic rupture

aortic isthmus - proximal descending aorta just ditsal to origin of left subclavian artery

high peaking systolic pressure Loss of dicrotic notch low diastolic pressure

aortic regurgitation

weakness severe dyspnea WIDE PULSE PRESSURE

aortic regurgitation tx = decrease afterload hydralazine + captopril

pancytopenia WITHOUT splenomegaly

aplastic anemia others: -B12, folic acid deficiency acute leukemias myelodysplastic syndrome

DNA laddering

appearnce of DNA fragments in multiples of 180 base pairs on gel electrophresis

prognosis for esophageal squamous cell carcinoma

areas of keratinization (keratin pearls) Intercellular bridges prognosis is generally poor as many present with incurable locally advanced or metastatic disease

what is the funciton of anastrozole?

aromatase inhibiter used in ER+ breast cancer in postmenopausal women

what is the oxygen in altitude sickness

around 55 decreased oxygen content in the air normal %, just decreased total amount

Patient consumed 2 bottles of insecticide. N/V/D/pain. Garlic order on breath. what is antidote?

arsenic poisoning = Dimercaprol, DMSA aresnic binds to sulfhydryl groups, impairing cellular respiraotion via inhibition of pyruvate dehdyrogenase and disruption of gluconeogenesis and glutathione metbaolism dimercaprol inreases urianry excretion of heavy metals by forming stbale, nontoxic soluble chelates narrow therapeutic index, and serious side effects of nephrotoxicity, HTN, fever

64 y/o with 3 months of crmpaing pain in right calf. Pain worse as he walks and at night. PMH - diabetes. PE - thinning of skin at right food, small ulcer at tip of right second toe. Cause?

arterial atherosclerosis - peripheral artery disease the answer is arterial because o the extertional component you put oxidative injury from chronic hyperglycemia - but the exertional symptoms are mroe consisntw ith arterial disease

what would be increased in a patient with CHF?

arteriolar resistance decreased renal perfusion --> increased RAAS --> sympathetics --> arteriolar constriction lung compliance is decreased increased pressure in pulmonary circulation results in transudation of fluid into lung interstitium and air sapces

disseminated gonorrhea infection S/S

arthralgia tenosynovitis ulcerative rash

obstructive shock mechanism in tension pneumothorax

as air building up in the the thoracic cavity, pressure builds up on the RV which means that it cannot get blood to the LV causing OBSTRUCTIVE SHOCK - low preload, low cardiac output, high SVR

immunosuppressed, fungal ball, neutropenia

aspergillus

mechanism of aspirin induced asthma

asthma inhibits COX but has no affect on the leukotrienes by blocking COX pathway, more arachidonic acid is shunted to the leukotriene pathway that can result in asthmatic response

which way does trachea go: atelectasis: pneumothorax:

atelectasis - towards pneumothorax - away

presence of an S4

atrial gallop before S1, heard immediately after atrial contraciton phase as blood is forced into a stiff ventricle sign of diastolic dysfunction S4 may be present in any conidtion that causes reduced ventricular compliance left sided S4 is best haerd with bell of stethoscopy over cardiac apex with patient in left lateral decubits position it intensifies during expiration due to increased blood flow from lungs to left atrium

conseuqnce of long term topical corticosteroid usage

atrophy of dermis - loss of dermal colalgen, drying, cracking, and/or tighetning of skin telangeictasias, echymsoes from mild trauma, and atrophic striae may also be found

anti-smooth muscle antibodies

autoimmune hepatitis - middle aged women as chronic progressive hepaitits

Behcet syndrome

autoimmune vasculitis that can involve immune complex mediated inflammation classically manfiests in patients wtih recurrent oral apthous ulcers, genital ulcers and uveitis can also presnt with erythema nodosum (bilatearl tender, eryhemous pretibial nodules)

compression of what structure leads to horners syndrome when associated with arm pain?

autonomic ganglia b/c unilateral arm pain and weakness are suggestive of lesion affecting brachial plexus/sympathetic ganglia

myotonic distrophy is what inheritance pattern

autosomal dominant

neurofibromas cafe au lait spots lisch nodules pseudoathrosis

autosomal dominant

outpatient community acquired pneumonia treatment

azithromycin

what enzyme is upregulated in brown (unconjugated bilirubin) gall stones?

beta-glucourinadase upregulated from infection and dead hepatocytes, coverts bilirubin into unconjugated bilirubin --> pigmented stones

52 y/o postmenopausal woman with ab pain. Ultrasound shows small, non-osbtructing gallstone. Patient prefers nonoeprative managment. what could treat this?

bile acid supplementation normally, bile acids and phospholpids solublize cholesterol to prevent sone formation decreased amoutns of blie acids and phospholipids can cause bile to become supersaturated with cholesterol, allowing it crystallize and form cholesterol gallstones administering hydrophilic bile acids reduces cholesterol secretion and increaess biliary bile acid concentration this improves cholesterol solubility and promoees gallstone dissolution high rate of gallstone recurrence

acetyl CoA carboxylase

biotin dependent enzyme rpesent in both liver and adipose tissue catalyzes first committed step in FA synthesis, the conversion of acetyl-CoA to malonyl CoA

virus with sand like (grainy) appearance under the microscope

bipartite single sense RNA genome Arenavirdae - Lassa fever (returning from Africa) AST > ALT pancytopenia viral hemorrhagic fever

drug for major depressive disorder mechanism

blockade of serotonin transporter you read it as blocking the release of 5HT, but it means blocking the reuptake of serotonin

where does VDJ recombination occur

bone marrow

Zidovuidine toxicity

bone marrow - anemia in 40% of patients

measurement of osteblasts activity

bone specific ALP

Mucormycosis

branches at 90 degres diabetic ketoacidosis, underlying immunosuppression (organ transplant, hematoligc malignancies, glucocorticoid therapy) patients complain of focial and periorbital pain, HA, purulent nasal discharge

Hernia that is medial to inferior epigastric vessels in a 62 year old construction worker. Cause?

breakdown of transversalis fascia direct inguinal hernias protrude through Hesselbach's triangle Inferior = inguinal ligament Lateral = inferior epigastric vessels medial = rectus abdominus Floor = transversalis fascia failure of trasnveraslis fascia is msot often due to acquired connective tissue abnormalities or chornic abdoimnal wall injury

light microscopy of CSF in cryptococcus meningitis

buddying yeast

mu receptor partial agaonist

buprenophine can precipitate withdrawal in opioid tolerant patients with chronic pain

ANCA associated with granulomatosis with polyangiits

cANCA

what ion is required for presynpatic vesicles wto move and fuse with the synpatic membrane

calcium

what drug classes can cause relaxation of the LES?

calcium channel blockers - failure of myogenic response Nitrates

inital drug to for cardiac protection in hyperkalemia

calcium glucaonate other drugs: b agonist insulin sodium polystyrene sulfonate

cryptococcus

can mimic Candida species but does not form hyphae or pseudohyphea India ink stain shows wide clear zone around nucleus corresponding to capsule

first line treatment for trigeminal neuralgia

carbamazepine SE of carbmazepine: Bone marrow suppression SIADH

reactions catalyized by B7

carboxylation enzymes (add 1 carbon group) - deficiencies occur secondary to poorr deit, excessive raw egg white consupmtion (biotin binding avidin in egg whites) Pyruvate carboxylase: pyruvate --> oxaloacetate Acetyl CoA carboxylase: acetyl-CoA --> malonyl CoA Proponyl CoA carboxylase: propionyl-CoA --> methylmalonyl CoA

valve has fibrous plaques in setting of malignancy

carcinoid tumor

pulse becomes undetectable during inspriation. JVD. clear lungs. Diagnosis?

cardiac tamponade = hypotnesion, JVD, pulusus paradoxus

propionic acidemia

catabolism of several essential amino acids (valine, isoleuceine, methionine, threonine) along with odd chain fatty acids results in propinoyl-CoA Propionyl-CoA is converted to methylmalonyl-CoA in reaction catalyized by biotin dependent propionyl CoA carboxylase Isomerization of methylmalonyl-CoA generates succinyl-CoA which enter TCA AR deficiency in propionyl-CoA carboxylase causes prpionyl CoA to accumulation Severe metabolic acidosis Presents 1-2 weeks after birth with lethargy, poor feeding, vomiting and hypotonia Tx = low protein diet, with minimal valine, isolecuine, methionine, threonine (BCAA)

most common benign liver tumor

cavernous hemagioma prognosis is excellent, with surgical resection an option for those who are smypatomic

treatment of community acquired pneumonia and bacterial meningitis

ceftriaxone

patient is treated with infusion of boronic acid containing dipeptide that has high affinity for the pteoasome catalytic site. This treatment results in what?

cell apoptosis patient had multiple myeloma - increased monoclonal immunoglobulin or IgG fragments as a result of increased protein proudciotn, plasma cells are susceptible to effects or PROTEASOME INHIBITORS such as bortezomib, a boronic-acid containing dipeptide prteoasome inhibition results in accumulation of toxic intracellular proteins inhibition leads to excess proapoptotic proteins

inside to outside what comes first cell well or cell membrane

cell wall

cerebellar functions

cerebellar hemispheres are primary responsible for motor planning and coordination of *ipsilatearl extrmeities* via conenctions with latearl descending motor systems Lesions of elft cerebellar hemisphere = LEFT dysdiadochokinesia (impaired rapid alternating movements) Limb dysmetria (overshoot/undershoot during targeted movement) intention tremor - tremor targete movement cerebellar vermis modules axial/truncal posture and coorindation via connections with medial descending motor systems - ataxia flocculonodular - vertigo, nystagmus

chickenpox vs. small pox lesions

chickenpox = different stages of healing smallpox = same level of healing

malaria treatment

chloroquine-sensitive = chloroquine chloroquine resistant = Mefloquine atovaquone-proguanil artemisinins Primaquine must be added for P. vivax and P. ovale (dormant liver forms [hypnozoites] that require additional therapy)

pathogensis of cholesterol gallstones: cholesterol: bile acids: phosphatidylcholine:

cholesterol: increased bile acids: decreased phosphatidylcholine: decrease bile becomes supersaturated with cholesterol

obesity hypoventilation syndrome

chornic fatigue dyspnea difficulty concentrating increased partial pressure of carbon dioixde *in the setting of obesity*

patient with paroxysmal nocturnal hemoglobinuria can have what changes in kidey?

chornic hemolysis with breakdown of iron containing erythrocytes can also lead to *iron deposition* in kidney (hemosiderosis) can lead to an interference proximal tubule function and cause itnerstitial scarring and cortical infarcts

what chromosome is associated with dysplastic nevus syndrome and what is histology?

chorosome *9* irregular nuclaer contours, hyperhcormasia, psindle shaped or round

neuroendocrine markers

chromgrannin symptophysin neuron specific enolase neural cell adhesion molecule (CD56)

messenger rna containing both BCR and ABL exons

chronic myolgenous leukemia PCR technique

patient with nonproducive cough and worsening SOB with exertion. PMH of pulmonary HTN and transplant 8 months ago. has not missed any doses of transplant medications. FEV1 is 67^ of her posttransplant FEV1. Biopsy = total fibrotic osbturction of terminal bronchioles. cause?

chronic transplant rejection cough, dyspnea, obsturctive findings on spirometry and fibrotic destriction = chronic transplant rejection Spirometry shows *airflow limitation* with a drop in FEV1 and the FEV1/FVC ratio initally - lmyphocit inflammation and destruction of epithelium of small airways subseuqnelty, fibrinopurlent exudate and granulation tissue are found in lumen of brochioli, which results in fibrosis, scarring, and progressive obliteratio of small airways

what helps clear small particles ldoged in terminal bronchioles

ciliated cells *distal to terminal bronchioles = phagocytosis by alveolar amcropahges

why do patients with *hypo*citraturia have kidney stones

citrate normally binds free calcium in it absence calcium can precipitate

28 y/o acute severe depression and sucidial dieation. Thrown out of mothers home for stealing money to drug use. Patient reports taigue and vivid, disturbing dreams. Patient is irritable, withdrawn, hypersomnlent, hyperphagic. Patient has extensive shitory of abuse, and been hosptialized for alcohol detox. PE shows old injuries but no other abnoramlities. He is letheragic and ysophic. what is the condition?

cocaine withdrawl stimulant withdrawl symptosm: -increased apeptite -hypersomnia -sevre depression -intense psychomotor retardation

emergency contraception within 72 hours

combined ethinyl estradiol + progesterone oral

chornic mitral regurgitation

compensatory LA enarlgement allows LA to receive reguritant volume at lower filling pressure, prenveting pulmonary edema from developing chornic volume overload causes LV to undergo enlargement due to eccentric hypertrophy early on, the larger ventricular volumes help maintain forward stroke volume even in setting of substantial regurgitant flow however, with prolonged hemodynamic overload, progressive eccentric remodeling the LV become maladaptive, resulting in voerhwleming increase in wall stress with eventual contractile dysfunction in decompensated state, imapired ocntractility reduces forward stroke volume and increaes left sided filling pressures causing decreaed cardiac output and pulmonary edema

what is most common heart defect in down syndrome

complete AV defect

distnigushing feature between compelte and partial mole

complete mole is engatively staining for p57

why does the Weber test localize to the affected ear in conductive hearing loss?

conductive hearing loss causes lateralization to affected ear as the conduction deficit masks the mabient noise in the room, allowing the vibration to be better heard

choanal atresia

congenital obstruction of posterior nasal passages infants with bilateral choanal atresia can present with upper airway obstruction and cyanosis with feeding, but NO drooling inability to pass nasogastric tube through nares is suggestive of diagnosis

how are genes for antibiotic resistance transmitted?

conjugation

tradive dyskinesia patho

continual blockage of dopamine receptors with antipsychotics causes upregulation of receptors and comepnsatory supersentivity to these receptors

asparagine synthase activity

converts asparatate into asparagine essential for tumor cells that cannot create enough asapragine on their own

ATP citrate lyase

converts citrate back into acetyl CoA that can be used for FA chain elongation in the cytosol

emergency contraception up to 7d

copper IUD

where is the copper accumulation in wilson disease

cornea - deschmet membrane

What mechanism of drug is associated with coroanry steal phenomenon?

coronary arteriolar dilation (adenosine, dipyridamole) when ischemia is present, these drugs cause a redistrubtion of blood flow through collatearl microvessels and coronary arterioles that can reudce collateral blood flow arterioles within icshemic areas are already amximally dilated prior to drug adminitration use of these agents cause vasodilation of coronary arterioles in nonischemic regions this leads to decreased perfusion pressure within collateral microvessels supplying the ischemic myocardium, diverting blood from ischemic areas to nonischemic areas

what is the most common cause of death in diabetes?

coronary artery dsiease

a study was done determining oxygen content of aorta nd other vessels measured at rest. Greatest difference in aorta and what?

coronary sinus heart muscle is perfused during diastole myocardial oxygen extraction if very high - capillary density far exceeding that of skeletal muscle; myocardium extracts 75% of xoygen from blood (higher than any other organ in body) myocardial oxygen demand and coronary blood flow are tightly coupled

infarct of anterior pons

corticospinal tract corticobulbar tract corticopontine fibers - contraltearl dysmteira and dysdiaochokinesia

patient has fish bone lodged in left piriform recess. during an attempt to retreive the bone, a nerve is injured deep to mucosa overlying the recess. what is most likely to be impaired?

cough reflex a thin layer of mucosa overlying pirifrom recess is all that protects the superfically coursing internal laryngeal n. (branch of superior laryngeal n. - CNX) internal laryngeal n. mediates afferent limb of cough reflex by carrying sensation from mucosa superior to vocal cords.

cricothryotomy vs. tracheotomy

cricothyrotomy = emergency situation, outside of ER, emergent airway needed tracheotomy = surgical procedure in hospital

cause of syndeham chorea in rheumatic fever

cross reaction with basal ganglia

pseudobulbar palsy

cuased by neurological conidtions such as multiple sclerosis characterized by: dysarthria dysphagia dysphonia impairmed movement of tongue and faicla muscles

old cerebral infarct

cystic cavity surrounded by gliosis crotex and subcrtical matter ajdacent to cyst are destroyed decreased blood --> irreversible ischemic cahnges in neurons *release of lyosomal enzymes from these ischemic neurons results in degradation of tissue in ischemic region* phagocytic cells migrate into area and remove the necrotic tissue leaving a cavity astrocytes prolfierate around the necrotic area with foramtion of scar (lgiosis) complete digestion of encrotic tissue with formation of cavity = *liquefactive necrosis*

where does glycogen syntehsis and degrdation take place?

cytosol

preprosinuslin has signal sequence at N-terminal consisting of hydrophobia amino acids Deletions in this sequence would cause accumulation of hormonal precursors where?

cytosol N-terminal signal is recognize dby cytosolic ribosomes as a transport to the ER - where the signal is then cleaved and the polypetide being fed into RER through membrane pore Deltion of this hydrophobic signal sequnce would casue failure of SRP binding and inappropraite protein accumulation in the cytosol

what is the treatment for malignant hyperthermia?

dantrolene susceptibility to malignant hyperhtermia is inherited as an autosomal dominant trait abrnomal ryanoidine receptors release large amounts of Ca after exposure to anesthetic excess free Ca in cytoplasm of muscle fibers stimulates its ATP dependent reuptake by sarcoplasmic reticulum excessive consumption of ATP generates heat loss of ATP along with high temperature induces muscle damage

dopamine beta hydoxylase deficiency leads to

decreaed NE and epi

glucocorticoids on eye in graves

decrease inflammatory infiltriation that improve opthalmopathy

how does narcolepsy affect REM?

decreased REM latency (also seen in pateints with depression)

how are PPI's associated with osteoperosis

decreased calcium absorption

mechanism of wrinkles

decreased colalgen fibril production

consequence of 7-alpha-hydroxylase deficiency

decreased conversion of cholesterol into bile increased cholesterol gallstones

most common mutation in CFTR?

deltaF508 --> impaired post translational processing of CFTR, which is detected in the ER drugs (lumacaftor) can partially correct this and lead to expression of functional CFTR

where is the fluid accumulation in allergic reaction?

dermal edema