Step 1 Review NK

Tibial nerve

"can't stand on TIp toes" Tibial nerve is response for plantarflexion and inversion of the foot. It also innervates the muscles that allow for toe flexion. Provides sensory over the distal palmar surface of the foot.

globus hystericus

"lump in the throuat" commonly triggered by emotions barium swallow and neck exam shows no abnormalities may be a/w GERD

What are the characteristic findings during the maintenance phase of acute tubular necrosis

(24-36hrs after insult, oliguria 1) *muddy brown casts* 2) inability to concentrate urine (urine osm <350) 3) inability to reabsorb Na+ (FeNa>1%) 4) high anion gap metabolic acidosis (retention of H+) 5) hyperkalemia 6) increased ICF

Calculating a half life?

(Volume of distribution * 0.7 )/ clearance

Loading dose calculation?

(Volume of distribution * target plasam conc. at steady state) / bioavailabity

MI stages

*0-4hr*: minimal changes *4-12 hr*: early coagulation necrosis, wavy fibers *12-24hr*: coagulation necrosis, contraction band necrosis *1-5 d*: coagulation necrosis and neutrophils *5-10d*: macrophage phagocytosis of dead cells *10-14d*: granulation tissue, neovascularization *2wks-2mos*: Collagen deposition (type 1), scar forms

Recap female oogenesis (whats arrested in what stage, etc)

*At birth*: primordial follicles containing primary oocytes arrested in prophase I *At puberty*: each month, some mature to primary follicles (containing primary oocyte), then to secondary follicles (finish meosis I and become secondary oocytes; under influence of FSH), and finally to Graffian follicle (secondary oocyte arrested in metaphase II; under FSH influence) *If fertilized*: complete meoisis II

Allelic heterogeneity

*Different alleles at the same gene* locus can cause similar phenotypes eg Becker and Duchenne

Before reaching the wrist, the median nerve courses through which muscles?

*Flexor digitorim superficialis and flexor digitorum profundus* Higher up in the forearm, it courses between the humeral and ulnar *heads of the pronator teres* Higher higher up it courses in the groove b/w the *niceps brachii and the brachialis muscle*

Immunoreactivity of a CNS tumor for GFAP indicates what origin?

*Glial origin* ("gliomas" include astrocytomas, oliogodendromas, ependymomas) GFAP= glial fibrillary acidic protein

47 yo F with hyperglycemia, necrolytic migratory erythema, and anemia

*Glucagonoma* (α cell tumors) rare pancreatic tumors, secrete glucagon; characteristic rash-red blistering crusty usu on lower extremities and around lips Occur most frequently in peri/post menopausal women

Liver "zones" I vs III and susceptibilities

*I* is periportal and closest to blood supply so most susceptible to ingested toxins (eg cocaine). *III* is near the central vein and further from blood supply and contains p450 enzymes so most susceptible to ischemia and metabolic toxins. site of alcoholic hepatitis.

Osteomyelitis in kids vs adults

*Kids* usually hematogenous spread of bacteria and seeds *metaphysis*; in general, osteomyelitis more commonly in kids. *Adults* usually open wound and bacteria seeds *epiphysis* Most common cause overall= S aureus

What type of bacterial make up the majority of the normal vaginal flora?

*Majority= Gram + lactobacilli* Other colonizers are Candida, E Coli, GBS, Cornyebacterium Use of broad-spectrum antibiotics suppresses normal bacterial flora of the vagina, and facilitates Candida overgrowth (yeast infection)

What drugs increase the risk of gout (hyperuricemia)?

*P*yrzainamide, *T*hiazides, *F*urosemide, *N*iacin *C*ylcosporine Painful Tophi and Feet Need Care

Paget Disease of the bone- Path, Epi, Micro

*Path*: Increase in *osteoclastic activity* > osteoblastic *Epi*: White people, older (mean age 70) *Micro*: Too much bone turnover gives it a *woven, mosaic* appearance

Triptans

*Serotonin agonists (5HT1B/1D)* that directly counter the pathophysiologic mechanism of migraine headache by *inhibiting release of vasoactive peptides* (CRGP and Substance P), promoting vasoconstriction, and *blocking pain pathways* in the brainstem. Used as abortive agents in acute migraine

Trendelenburg gait

*Superior* gluteal injury (which innervates the gluteus *medius and minimus*) Non-weak side will drop

What nerves are involved in inversion of the foot?

*Tibial* and deep peroneal assists

Most important mediators of immunity against reinfection with influenza?

*ant-hemagglutinin* IgA and IgG antibodies that increase in circulation after initial exposure.

Subfalcine herniation

*cingulate gyrus* herniates under the falx cerebri → can compress the *ACA*

Bone resorption in hyperparathyroidism is what type of bone?

*cortical bone*, leads to subperiosteal thinning compare with osteoporosis which is loss in *trabecular bone*

What causes a "U" wave on ECG?

*hypo*kalemia, bradycardia

Vigabatrin MOA

*inhibits GABA-T* (Gaba-transaminase) which *normally degrades GABA* that has been re-uptaken by presynaptic neuron → ↑ GABA.

Frameshift mutation

*insertion or deletion* of any # of nucleotides that isn't a multiple of 3 shift in reading frame results in production of different protein or premature stop

Key findings in ARDS

*normal pulmonary capillary wedge pressure* (distinguishes it from cardiogenic pulmonary edema) ↓lung compliance (d/t hyaline membrane formation), ↑work of breathing, V/Q mismatch (↓ventilation d/t alveoli damage and atelectasis), increased capillary permeability (leaky alveolar-capillary membrane)

Missense mutation

*substitution* point mutation that causes codon change, resulting in incorporation of wrong AA into the polypeptide chain

Nonsense mutation

*substitution* point mutation that results in premature stop

anti-Jo1 antibody

+in dermatomyositis/polymyositis

Cori disease

-*Debranching enzyme deficiency* -α-1,6 glucosidic branch points can't be degraded, so small chain *dextrin-like* molecules accumulate with hepatocytes -Affects both liver and muscle cells -baby presents with hepatomegaly, ketoacidosis, hypoglycemia, growth retardation -No fat in the liver

Assuming a normal distribution, how many values fall within -1 SD of the mean? -2 SD of the mean? -3 SD of the mean?

-68% -95% -99.7%

Ovarian ligament

-Connects medial pole of the ovary to the lateral uterus -Contains no structures

Suspensory ligament (of the ovary)

-Connects ovaries to lateral wall -Contains ovarian vessels -Ligate during oophrectomy to avoid bleeding; ureter courses posterior to it so at risk of being injured

Round ligament of the uterus

-Connects the uterine fundus to the labia majora -Contains no structures -Derivative of the gubernaculum

Communicating hydrocephalus- common causes, what do you see on CT?

-Defect in CSF reabsorption through the arachnoid granulations -possible sequelae of meningeal infections, SAH, or IVH (obliterate arachnoid villi) -See ventricles that are symmetrically enlarged

Branches of the splenic artery

-Pancreatic branches -Left gastroepiploic artery -Short gastric branches

Top causes of avascular necrosis?

-Trauma -high dose corticosteroids (mech. unknown) -sickle cell (d/t thrombotic occlusions) -alcoholism (mechanism unknown) -SLE (vasculitis impairs blood flow) -emboli (fat emboli, air emboli)

Small vessel vasculitidies that are granulomatous?

-Wegners -Churg Strauss

HUS triad

-acute renal failure -microangiopathic hemolytic anemia -thrombocytopenia

Resistance to aminoglycosides is achieved by what bacterial alteration?

-altered structure of 30s -bacterial transferase enzymes inactivate drug by acetylation, phosphorylation, adenylation

Thing that will increase K+ excretion

-high extracellular K+ levels, stimulate Na+/K+ ATPase on basolateral, secrete more K+ -increased aldosterone (enhances Na+/K+ pumps; retain more Na and lose K+) -Alkalosis (exchange K+ for H+ to help buffer pH, increase in [K+] in cell leads to loss in urine) -Increased fluid flow through distal tubule ("flushes" away secreted K+)

Small vessel vasculitidies that are not granulomatous?

-microscopic polyangitis -Henoch-Schonlein

Pigment stones

-most in rural Asian populations, women -a/w biliary tract infection→ release of β-glucuronidase by injured hepatocytes and bacteria→ hydrolysis of bilirubin glucuronides→ ↑unconjugated bili -infection with E.Col, Ascaris lumbricoides, O. sinensis ↑risk of brown pigment stones

Isolated diastolic heart failure- what findings?

-normal ejection fraction (myocardial contractility is fine) but have decreased LV compliance -Causes include impaired relaxation, increased LV stiffness (eg amyloid), LV hypertrophy -increased EDP helps maintain near-normal EDV and ejection fraction

Superficial peroneal nerve does what?

-sensory over dorsum of foot -foot eversion

Low ESR is found in what conditions?

-sickle cell -polycythemia -CHF

Type I interferons (α and β)

-synthesized by eukaryotic cells in response to viral infx -suppress viral replication and induce apoptosis of infected cells -act on neighboring cells→produce antiviral proteins that halt protein synthesis in cells surrounding only once/if they become infected

Myotonic dystrophy key points

-trinucleotide repeat (CTG) in DMPK gene, codes of myotonin-protein kinase; AD -classics sxs= difficulty loosening grip after handshake/doorknob grab -Other sxs= frontal balding, cataracts, testicular atrophy

In an X linked recessive disease, what % chance would an affected father have of having affected children?

0%. Daughters will be carries, sons will be normal

Glycogen is depleted after how long of fasting?

1 day

Complete closure of the ductus venous occurs when?

1 week of age

Adult lead poisoning sxs

1) *L*ead lines (bluish pigmentation on gum line) 2) *E*rythrocyte basophil stippling, *E*ncephalopathy 3) *A*bdominal pain, colicky 4) *D*rops- wrist and foot; also treat with *D*imercaprol and E*D*TA (succimer for kids)

PCR basic steps

1) 1st heating= denature DNA 2) Cooling= DNA primers anneal to ssDNA 3) Warming= DNA polymerase replicates DNA

Down Syndrome is associated with a number of other conditions. Name them.

1) Acute leukemias (ALL, AML) 2) Congenital heart disease (endocardial cushion defects, ASD, VSD) 3) GI defects (duodenal atresia, Hirschsprungs) 4) Alzheimers disease (early onset)

Methimazole adverse effects

1) Agranulocytosis 2) Aplastic anemia 3) Teratogen (aplasia cutis congenita)

Diphtheria treatment

1) Antitoxin (passive immunization) 2) Antibiotics (penicillin or erythromycin) 3) DTP vaccine (active immunization)

Causes of pancytopenia without splenomegaly

1) Aplastic anemia 2) Severe b12 deficiency 3) Folic acid deficiency anemia 4) Myelodysplastic syndrome 5) Aleukemic leukemia (low serum WBCs)

Major neuroendocrine derived tumors

1) Carcinoid (gut, ECF cells) 2) Medullary carcinoma of the thyroid 3) Pancreatic islet cell tumor 4) Paraganglioma 5) Pheochromocytoma 6) Small cell carcinoma of the lung 7) Merkel cell carcinoma of the skin 8) Neuroblastoma (adrenal) 9) Ewing sarcoma These will all be chromogranin A+, synaptophysin + Mnemonic: I use google CHROME to surf the NET to search for an all MEN'S CaMPPP

In congenital QT-prolongation syndrome, what other clinical signs/sxs are seen?

1) Congenital sensorineural deafness 2) Syncopal episodes Name of this disease is Jervell and Lange-Neislen Syndrome Mnemonic- Jervell a QT but can't hear worth crap

Tolerance to opiods- which side effects are typically resistance to tolerance (ie persist even after long term use?)

1) Constipation (opiods bind and stimulate mu receptors in the GIT, decrease secretions and motility) 2) Miosis (opiods activate parasympathetics on the pupil, resulting in constriction)

How does therapeutic radiation kill cells?

1) DNA double strand break 2) Free radicals

Major side effects of ACE inhibitors

1) Decreased GFR (so elevated creat) 2) Hyperkalemia 3) Cough

Two main mechanisms by which ESRD causes hypocalceima (and resultant osteodystrophy)

1) Decreased synthesis of 1,25D (calcitriol) → decreased intestinal absorption of Ca⁺⁺→hypocalcemia 2) Decreased clearance of phosphate → ↑phosphate means more Ca²⁺ is bound up → exacerbates the hypocalcemia Hypocalcemia caused by these two mechanisms leads to increased PTH activity (secondary hyperparathyroidism), increased bone turnover and osteodystrophy (osteitis fibrosa cystica)

IL-12 major actions

1) Differentiation of TH1 cells (which then secrete IFN-Ɣ) 2) NK cell stimulation

4 main types of thyroid cancer

1) Follicular 2) Medullary 3) Papillary 4) Anaplastic

Trinucleotide expansion diseases

1) Fredriech Ataxia (GAA) 2) Huntington (CAG) 3) Fragile X (CGG) 4) Myotonic dystrophy (CTG) X-Girlfriend's First Aid Helped Ace My Test

The lesser omentum is made up of?

1) Gastrohepatic ligament 2) Hepatoduodenal ligament

Treatment nephrogenic DI

1) HCTZ (has paradoxic anti-diuretic effect) 2) Indomethacin (↑ water absorption by ↓prostaglandin synthesis- prostaglandins inhibit ADH)

Common precipitating factors of G6PD deficiency anemia

1) Infections 2) Drugs (TMP-SMX, Dapsone, antimalarials) 3) DKA 4) Fava beans

Drugs that cause hyperkalemia?

1) K+ sparing diuretics 2) ACE inhibitors and ARBs (↓aldo) 3) Digoxin (inhibit Na⁺/K⁺ ATPase) 4) Non-selective β blockers (β2 mediates K⁺ uptake into cells) 5) NSAIDs (impaired local prostaglandin synthesis ↓renin and aldo) 6) Succinylcholine (continuous stimulation of end plate- Na+ influx and K+ release)

3 major dopaminergic systems:

1) Mesolimbic-mesocorticol: regulates behavior, abnl in scz 2) Nigrostriatal: regulates voluntary movement, abnl in parkinsons 3) Tuberoinfundibular: controls prolactin secretion

Two most common cardiac abnormalities a/w Marfan?

1) Mitral valve prolapse 2) Cystic medial degeneration of the aorta (predispose to aortic dissection)

Infertility d/t ovulation abnormality- treatment?

1) Modifiable risks (overweight, underweight) 2) Clomiphene citrate is drug off choice for inducing ovulation. It is a SERM that inhibits estrogen's negative feedback on the hypothalmus, so that FSH and LH output are increased. Think of it an inverse birth control 3) Pulsatile GnRH is also an option, but this is more expensive and requires more monitoring

Diseases a/w thymoma

1) Myasthenias gravis 2) Pure RBC aplasia

Growth in bile? 1) Strep pnemo? 2) Group D strep (enterococci, bovis)?

1) NO (bile soluble) 2) YES

How would minimal change look on: 1) Light microscopy 2) Electron microsopy

1) NORMAL 2) diffuse effacement of the foot processes

Causes of acute pancreatitis?

1) Obstruction (Gallstone, alcohol) 2) Direct acinar cell damage (alcohol, trauma, drugs, post ERCP, viruses), hypertriglyceridemia (>1000mg), hypercalcemia

Exotoxin A- found in what two organisms?

1) Pseudomonas- inactivates E2F - inhibit protein synthesis 2) Strep pyogenes- superantigen

Two most important factors for osteoclastic differentiation

1) RANKL 2) M-CSF

Skeletal muscle contraction key steps

1) Release of presynaptic neurotransmitters 2) Binding to post-synaptic receptor, leading to depolarization at motor end plate 3) Depolarization travels, and eventually stimulates voltage-gated dihydropyridine receptor, which is linked with ryanodine receptor which causes Ca++ release from the SR 4) Ca++ binds to Troponin C which moves tropomyosin out of the way (they were blocking mysoin binding sites on actin) 5)Ca++ is taken back up rapidly into SR by Ca++ ATP ase

PTHrP secreted by what neoplasms?

1) Squamous cell carcinoma of the lung 2) Breast cancer 3) Renal cell carcinoma

3 cytogenetic abnormalities that can produce Down Syndrome?

1) Trisomy 21 (95%); d/t meiotic nondisjunction of ch 21usually of maternal origin 2) Unbalanced Robersonian translocation (2-3); 46 chroms but extra arm of 21 attached to another chrom 3) Mosaicism

What are the 3 small vessel vasculitides that DO NOT have immune-complex deposition? Of these, which are granulomatous?

1) Wegner's granulomatosis- granulomatous 2) Microscopic polyangitis- no 3) Churg-Strauss- granulomatous These all have ANCA (anti-neutrophilic cytoplasmic antibodies)

Risk factors for Candida vaginitis?

1) antibiotic use (suppress normal bacterial flora) 2) Contraceptive use (esp high estrogen) 3) Systemic corticosteroids 4) Uncontrolled DM 5) Immunosuppression (HIV)

2 major drugs a/w buffalo hump?

1) glucocorticoids 2) HIV protease inhibitors Both cause medication-induced body fat redistribution syndrome

Risk factors for avascular necrosis?

1) high dose corticosteroids 2) trauma 3) alcoholism 4) sickle cell

Two most common causes of eugonadotropic amenorrhea (absent menses but secondary sexual characteristics are normal)

1) incomplete recanalization of the vaginal plate (results in imperforate hymen) 2) mullerian duct anomalies

PTH action on the kidney

1) increase 1α hydroxylase acticity 2) increase Ca²⁺ reabsorption in the distal tubule 3) inhibits phosphate reabsorption in proximal tubule (increases urinary cAMP excretion)

Side effects of protease inhibitors?

1) lipodystrophy 2) hyperglycemia 3) inhibition of p450

Adverse effects of succinylcholine

1) malignant hypertermia (esp w/ halothane) 2) Severe hyperkalemia (pts with burns/crush injuries) 3) Bradycardia or tachycardia

Clinical manifestations of neuroleptic malignant syndrome

1) mental status changes- agitated delirium, confusion, coma, mutism 2) *extreme muscle rigidity* 3) Hyperthermia 4) autonomic instability (tachycardia, HTN, tachypnea, diaphoresis) Must differentiate from serotonin syndrome (similar, but hyperreflexia, myoclonus, n/v/d and no rigidity)

What are the causes of renal hyaline arteriolosclerosis?

1) nonmalignant HTN 2) Diabetes mellitus

Benzos are eliminated more slowly by elderly people why?

1) old people have less total body water, less total body mass and more fat -- high volume of distribution 2) old people have reduced liver size and hepatic blood flow --slower elimination

α1AT deficiency will increase risk for?

1) panacinar emphysema 2) Liver cirrhosis 3) hepatocellular carcinoma

(4) major conditions a/w renal papillary necrosis

1) sickle cell trait/disease 2) diabetes mellitus 3) acute pyelo/urinary tract obstruction 4) chronic phenacetin use (acetominophen=phenacetin derivative)

CD8 cytotoxic cells defend against?

1) virus infected cells 2) neoplastic cells 3)donor graft cells induce apoptosis

Effects of poor glucose control in pregnancy

1) β cell hyperplasia in baby → hypoglycemia 2) Macrosomia (big ol baby) → d/t hyperinsulinemia (↑fat deposition and fetal growth)

Schizophreniform

1-6mo of schizophrenia sxs (delusions, hallucinations, disorganized speech, negative sxs)

Number needed to treat

1/ARR ARR=absolute relative risk=event rate in the placebo group-event rate in the treatment group

Number needed to harm

1/attributable risk AR= (a/(a+b)) - (c/(c+d))

What is a normal A-a gradient?

10-15mmHg

NF-2 penetrance

100%

NF-1 penetrance

100% if there are no affected relative, it must be d/t germline mutation (not decreased penetrance)

High risk strains of HPV- what are they and why are they high risk?

16, 18, 31, 33 Unlike low risk strains, these guys integrate themselves into human cell genome, leading to overexpression of viral proteins E6 and E7. E6 binds and degrades p53 and E7 binds Rb. This results is loss of cell cycle regulation and uncontrolled growth → cervical cancer

Branchial cleft derivatives

1= external auditory meatus 2-4= temporarily form cervical sinuses but then are obliterated by 2nd arch mesenchyme (if persistant cervical sinus, branchial cleft cyst)

How many half lives does it take to clearance 75% of a drug? (assuming 1st order elimination?)

2

Combines words to form almost understandable sentences, builds tower of 9 blocks, rides a tricycle- what age?

3

What part of the tRNA molecule carries the amino acid?

3' CCA is the amino acid acceptor side

what component of viral replication is inhibited by NRTIs?

3'→5'phosphodiester bond formation NRTIs incorporate as nucleotide analogs but they do not have the normal 3' OH group so new nucleotides can add on

Which nerves enter the orbit though the superior orbital fissure?

3,4,5(1),6

At what point in the MI timeline do you expect to see wavy fibers, edema, hemorrhage, and early coagulation necrosis?

4-12hr

During continuous infusion of a drug metabolized by 1st order kinetics, how many half-lives does it take to reach steady state concentration?

4-5

At what point in the MI timeline do you expect to see macrophage phagocytosis of dead cells

5-10d

-steride (eg finasteride, dutasteride)

5α reductase inhibitor (block testosterone →DHT) Used for reduction in prostate size in BPH (not as effect though for actual sx relief in BPH- use α1 antagonists)

Major Depressive Disorder

6-12 months Atleast 5 of the 9 sxs for 2+ weeks Sleep disturbance Interest (loss of) Guilt or feelings of worthlessness Energy loss and fatigue Concentration problems Appetite changes Psychomotor retardation Suicidal ideation

Rate limiting enzyme for bile acid synthesis?

7 α hydroxylase (cholesterol → bile acid)

Vit D metabolism (start with sun)

7-dehydrocholesterol is a present in the skin and when irradiated, is converted to vitamin D3 (cholecalciferol). In the liver, it is converted to 25-hydroxycholecalciferol. Finally, in the kidneys, it is converted to the active 1,25 dihydroxycholecalciferol aka calcitriol

The end result of single nephron GFR after nephrectomy- what percent of baseline GFR can these pts acheieve with one kidney?

80% should reach this by 6 weeks or so

Where do most VIPomas originate?

80-90% of VIPomas are pancreatic Rest due to VIP-secreting pheochromocytomas, intestinal carcinoids, and rarely ganglioneuromas

Conduct disorder

<18 yo repetitive behavior that violates the basic rights of other After 18=antisocial

Leucovorin/Folinic acid

=N⁵Formyl-THF Does not require dihydrofolate reductase before it can function Use to "rescue" normal cells from MTX toxicity Also helps amplify 5-FU's actions (5-FU binds thymidylate synthase in to cells high in THF more strongly)

What does a high "blood-gas partitioning coefficient" mean

=gas is highly soluble in the blood

PTSD

A disorder in which a person has lingering memories, flashbacks, nightmares, and other symptoms for weeks after a severely threatening, uncontrollable event. Sleep and concentration suffer. Loss of interest and social detachment common.

Pleiotrophy

A single genetic mutation causes multiple different phenotypic manifestions (Examples include PKU, homocysteinuria)

Correlation coefficient

A statistic, r, that expresses the strength and direction (positive or negative) of the relationship between two variables. The closer the absolute value is to 1, the stronger the linear correlation +r = +correlation -r= -correlation

Berkson's bias

A type of selection bias that involves selecting hospitalized patients

Treatment of Hodgkin lymphoma

ABVD regimen Adriamycin (doxorubicin), Bleomycin, Vincristine, Dacarbazine (alkylating)

What drug is most appropriate for slowing progression of diabetic nephropathy?

ACE inhibitor +/- ARB

Lynch syndrome- inheritance?

AD

Name the class III antiarrthymics?

AIDS Amiodarone, Ibulitide, Dofetilide, Sotalol

Gas gangene

AKA myonecrosis. C perfringens infection. Rapidly progressive, a/w penetrating injury by soil-contaminated objects α toxin lecithinase does the damage

Lead poisoning inhibits what enzymes?

ALAD and ferrochelatase (heme synthesis)

TdT+ leukemia?

ALL (acute lymphoblastic) TdT is a marker for pre-T and pre-B cells

Upper and Lower motor neuron signs without sensory loss. Early sign is atrophy and weakness of the hands. What is it and what do you use to slow progression?

ALS Treat (slow) with rilouzole

Peroxidase+ leukemia?

AML, M3 Auer rods are myeloperoxidase +

t(15;17), what disease and what is the fusion gene product?

AML, M3 type; abnormal retinoic acid receptor (PML/RARα fusion gene which is unable to signal for myeloid cellular differentiation as a normal RAR would)

How would a pt with a lipoprotein lipase deficiency most likely present?

Abdominal pain d/t pancreatitis Recall that acute pancreatitis is most often d/t alcohol, trauma, hypertriglyceridemia (>1000mg/dL), or hypercalcemia. These pts have high triglycerides because they can't unload them off of chylomicrons in the blood after a fatty meal

Pt presents in 1yr of life with malabsorption, fatty stools, poor growth, mental retardation. Labs show acanthocytes and low plasma triglycerides and cholesterol

Abetalipoproteinemia d/t AR mutation in MTP gene (needed for proper folding of ApoB and for transfer of lipids on chylomicrons and VLDL

Persistent colonization of Pseudomonas in CF pts is due to what?

Ability for Pseudomonas to produce a biofilm Pseudomonas can convert to a "mucoid" phenotype. This conversion typically happens only really in CF pts. Once this conversion happens, its really hard to eradicate it.

Imperforate anus- definition and key associations

Abnormal development of the anorectal structures Imperforate anus is most commonly a/w *genitourinary tract abnormalities* (renal agenisis, hypo/epispadias, bladder extrophy). other congenital malformations are also a/w it (VACTERL) but these are less common than urogenital abnormalities.

Key features of epidural hematoma

Accumulation of blood between the dura mater and skull Typically due to temporal bone fracture, rupturing the middle meningeal artery Clinical: lucid interval (followed by rapid decline); biconvex (len-shaped) hematoma on CT

Pseudogout

Accumulation of calcium pyrophosphate crystals in the synovial fluid Typically affects large joints, esp knee Rhomboid crystals, positive birefringence under polarized light, blue when parallel with slow ray of the compensator Contrast with gout which typically gets 1st MTP, uric acid, negative birefringence, yellow when parallel with slow ray

Acetylation and methylation- what does each do to transcriptional activity?

Acetylation of histones and DNA- makes them ACtive Methylation of histones DNA- make them Mute (inactive)

Reflex nerve roots

Achilles- S1, S2 Patellar- L3-L4 Biceps- C5-C6 Triceps- C7-C8 Cremasteric- L1-L2 Anal ;) S3-S4 1,2 buckle my shoe 3,4 kick the door 5,6 pick up sticks 7,8 lay them straight

Antiphospholipid Syndrome (APS)

Acquired thrombophilic disorder in which patients have vascular thrombosis and/or pregnancy complications (attributable to placental insufficiency) + lab evidence of antiphospholipid antibodies (including lupus anticoagulant) in blood. May or may not be a/w SLE. Labs show increased PTT and thrombocytopenia (despite being hypercoagulable). False positive VDRL

how do adenosine and Ach work on cardiac myocytes?

Act on phase 4 (spontaneous depolarization, consisting of slow Na+ influx through funny currents, Ca++ influx, and K+ slow efflux). They increase K+ efflux by activating K channels, block L-type Ca++ channels. ACh also block Na+ influx. Net result of all of this is the slow the time it takes to reach phase 0 spontaneous depolarization.

In a sarcomere, where are actin and myosin filaments attached, respectively?

Actin filaments (in the I bind) bind to the Z line Myosin filaments (in the H band) bind to the M line An Interesting Zoo Must Have Mammals

Small red-brown lesions with a sand-paper like texture, in sun-exposed areas of the body?

Actinic keratosis

What is the defect in achondroplasia?

Activating mutation in FGFR3 → receptor turned on → inhibits growth of cartilage AD or sporadic (?)

Most common defect in achondroplasia?

Activating mutation in fibroblast growth factor 3 (FGF-3) at the epiphyseal growth plate- inhibits growth, and resulting in disproportionately short, thick limbs and usually normal spine length (vs GH/IGF-1 deficiency in which short stature is proportional in limbs and axial skeleton)

Presentation of acute GVHD vs acute transplant rejection

Acute GVHD- grafted immunocompetent tissue (bone marrow, organs rich in lymphocytes like the liver, or transfusion of non-irradiated blood). Present with maculopapular rash, diarrhea, jaundice w/in week Acute transplant rejection- CTLs of pt against donor MHC. Present with *vasculitis of graft vessels*, dense lymphocytic infiltrate

p450 inhibitors

Acute alcohol Gemfibrozil Ciprofloxacin Isoniazid Grapefruit juice Quinidine Amiodarone Ketoconazole Macrolides Sulfonamides Cimetidine Ritonavir Gemmy and Ami Quietly Cip on Grapefruit juice + booze; Mac, Rigatoni and Ketchup Cimmering InSide.

2yr presents with swollen gums with ulcerative lesions, tender cervical LAD, fever and irritability. Oral lesion scrapings show intracellular inclusions

Acute gingivostomatitis caused by HSV-1 Typically ages 1-3

Acute stress disorder vs PTSD?

Acute stress= same as PTSD but duration of sxs <4wks PTSD= same sxs just distinguish by time frame (>4wks)

Delirium

Acute-onset, confusional state characterized by *fluctuating levels of consciousness*, memory and attention deficits, deficits in executive function. Contrast with dementia, which is gradual onset, irreversible and does not feature fluctuations in consciousness.

Drug of choice for PSVT and side effects of this drug

Adenosine flushing, chest burning (d/t bronchospasm), HoTN, AV block

Major tissues GLUT4 is found on ?

Adipose tissue and skeletal muscle. Insulin-dependent tissues.

Administration of what will worsen sxs in pt with Wernicke? Why?

Administration of glucose without giving thiamine with it will worsen sxs and can precipitate encephalopathy. This is b/c B1 is needed in glucose metabolism (eg pyruvate dehydrogenase).

Carcinoid heart disease- complications

Affects R heart Fibrosis and restrictive cardiomyopathy Also can lead to pulmonary stenosis

Marcus Gunn Pupil

Afferent defect in pupillary reflex. Decreased bilateral pupillary contraction when affected side is illuminated (looks like its dilating). Normal bilateral contraction, when healthy side is illuminated. "swinging flashlight test". Seen in damage to optic nerve or retina.

Corneal reflex- afferent and efferent limbs?

Afferent- nasocilliary branch of the trigeminal nerve (CNV1) Efferent- Temporal branch of the facial nerve (orbiculais oculi)

afferent and efferent limb of the cough reflex?

Afferent: CNX (superior laryngeal nerve, internal branch- can damage it by things stuck in the piriform recess) Efferent: CN X (superior laryngeal nerve)

Gag reflex- afferent and efferent limbs

Afferent: Glossopharyngeal (CNIX) Efferent: Vagus (CNX)

CNX (Vagus) lesion?

Ahhhh and uvula deviates away from lesion

At FRC, what is the airway pressure and what is the intrapleural pressure?

Airway pressure is 0 (no tendency for air to move in or out) Intrapleural pressure rests at -5 (keeps lungs open)

High Yield CYP450 inducers

Alcohol Modafinil Phenytoin Phenobarbital Rifampin Griseofulvin Carbamazaepine

Major risk factors for development of *squamous cell* carcinoma of the esophagus?

Alcohol consumption and tobacco smoking are the biggest factors, esp in the Western world and increasingly in Asia. Consumption of N-nitroso containing foods is an important factor to take into account with Asians esp Japanese food Consumption of hot beverages contributes but less-so

Alcohol steatosis- pathogenesis

Alcoholics have ↑NADH/NAD+ ratio (due to EtOH metabolism enzymes) ↑NADH signifies high energy state...↓TCA, ↓ β oxidation of hepatic fatty acids and increases lipogenesis (chronic alcoholic upregulates lipogenic enzymes, including acetyl-CoA carboxylase)

Osteoblasts require what sort of environment?

Alkaline (this is why theres a high ALP when osteoblasts are active)

Labs in a pt with osteoporesis (Ca++, ALP, Phos, PTH)

All are normal

Superficial inguinal nodes drain what structures?

All the skin from the umbilicus down, including the anus (below dentate line) and external genitalia, excluding the posterior calf (goes to popliteal nodes)

N-acetylglutamate (NAG)

Allosteric activator of CPSI, which is the rate limiting step of the urea cycle Takes CO2+NH3+2ATP → Carbamoyl phosphate (which then is added to ornithine to make citrulline, via OTC)

Cystic hygroma is a/w what condition?

Although not exclusively, for board purposes it is seen in Turner syndrome as a posterior neck mass causes by defection lymphatic outflow. Histo shows a mass composed of cystic spaces separated by connective tissue rich in lymphoid aggregates. Transilluminates.

Defense mechanisms: Sublimation vs Altruism

Altruism is when the pt takes their negative/guilty emotions and channels them towards something to help others Sublimatio is when they take those negative emotions or impulses and channel them towards something productive (like a hobby, but to an activity that is aimed to benefit others)

How to prevent cisplatin nephrotoxicity

Amifostine (free radical scavenger)

Treatment of a neonate with meningitis with ceftriaxone. What should you add for Listeria coverage?

Ampicillin Ceftriaxone covers all of the major causes of meningitis (N. meningitidis, S. pneumo, GBS, Hib). Listeria however is not susceptible to cephalosporins.

How many ATP do you make with anaerobic vs aerobic glucose metabolism?

Anaerobic= 2 ATP Aerobic= 38 ATP

Treatment of hirsuitism in a PCOS pt?

Anti-androgens 1) Spironolactone 2) Ketoconazole 3) Flutamide 4) Finasteride

Drugs that can give you Parkinson-like syndrome? How do you treat Parkinson-like syndrome?

Anti-psychotics (1st gen), Resperdine (VMAT inhibitor, antipsychotic and anti-HTNive), Metoclompramide (D2 antagonist + mixed 5HT-3/4 antagonist, lead to increased gut motility and anti-emetic)

Why can an infection with Mycoplasma pneumoniae cause anemia?

Antigenic similarity between cell membrane of Mycoplasma pneumoniae and cell membrane of RBCs When immune system launches response against the bacteria, also can destroy some RBCs, resulting in a mild anemia ("Cold-agglutinins").

Head bobbing and bounding pulses?

Aortic regurgitation

Direct factor Xa inhibitors

Apixaban (Eliquis), rivaroxaban Inhibit Xa directly Use for rx and prophylaxis for DVT/PE; stroke prophylaxis in pts with Afib

Direct thrombin inhibitors: Name them, and what they are used for

Argatroban, bivalirudin, dabigatran (oral) Inhibit thrombin (IIa) directly Use instead of heparin in pts with HIT

Phrenic nerve (location,innervation, sxs if knocked out)

Arise from C3-C5 segments of the spinal cord Innervates ipisilateral hemidiaphragm Irritation or palsy may be due to intrathoracic spread of lung cancer Phrenic nerve irritation sxs: Shoulder pain, persistent hiccups, dyspnea Phrenic nerve palsy sxs: elevated of affected hemidiaphragm, diminished breath sounds on affected side, respiratory distress

Pt with h/o TB presents with cough and occasional hemoptysis. Methenamine stain shows "broom-like" conidiophores with outbranching phialides.

Aspergillus -> fungus balls in old TB cavities

Female oogenensis arrest points?

At birth, arrested in prophase of meiosis I At puberty, complete meoisis I and then arrests in metaphase of meoisis II until fertilzation

"apple peel atresia"

Atresia distal to the duodenum, due to vascular occlusions in utero Diminished perfusion = ischemia of segment of the bowel with obliteration of the lumen

ANP

Atrial natriuretic peptide. Release by the atria in response to increased volume. Inhibits aldosterone (so decreases Na+ absorption). Works against renin-angiotensin system.

Projection

Attributing ones own feelings to somebody else. Immature defense. Example: A student who dislikes the teacher says: "She never liked me."

Disproportionate loss to followed up between exposed and unexposed groups may lead to what type of bias?

Attrition bias (which is a form of selection bias)

17yo boy with sore throat, fever, cervical and axillary LAD. Peripheral smear shows lypmphocytes with abundant blue cytoplasm with a basophillic rim and they are indented by surrounding RBCs. What is the dx and how do you distinguish, based on the smear, from a hematologic malignancy?

Atypical lymphocytes of EBV (T cells directed against infected B cells). Distinguishing features that differentiate reactive lymphocytes from immature blast cells of hematologic malignancy are 1) the abdundant cytoplasm and 2) the lack of bizarre nuclear changes

EBV infected persons blood smear shows atypical cells- what are they?

Atypical lymphocytes seen on peripheral blood smear are NOT infected B cells! They are cytotoxic T cells (reactive lymphocytes aka Downey cells) These are also seen in CMV

Hungtinton disease inheritance

Autosomal dominant

MEN inheritance?

Autosomal dominant

Inheritance pattern of Achondroplasia?

Autosomal dominant (with 100% penetrance)

Fall on outstretched hand. Now has R shoulder pain, flattening of the deltoid, and diminished sensation over the deltoid. What nerve is affected and what injury is most likely?

Axillary nerve, injured by an anterior shoulder dislocation Glenohumeral joint injuries often d/t forceful external rotation and abduction of the arm at the shoulder. See flattening of deltoid, protrusion of the acromion, and anterior axillary fullness

Localized deposition of amyloid in alzheimers disease- what is depositing?

Aβ amyloid, which is derived from β-amyloid precursor protein on chromosome 21

present with serum-like sickness (fever, fatigue, joint pain, urticaria, LAD)- Hep B or C?

B

Apolipoprotein B-100 vs B-48

B-100: ligand for LDL receptors; required for assembly of VLDL B-48: does not bind LDL receptors; required for the assembly of chylocmicrons

Axonal degeneration involving the posterior columns and the lateral corticospinal tracts. Likely cause?

B12 or Vit E deficiency

Uterine relaxation- stimulation of what receptors?

B2 adrenergic receptors eg terbutaline (reduces premature uterine contractions)

Major actions of cortisol

BIG FIB ↑BP (↑α₁ receptors on arterioles) ↑insulin resistance ↑gluconeogenesis, lipolysis, proteolysis ↓Fibroblast activity (causes striae) ↓Inflammatory/Immune response ↓Bone formation (↓osteoblast activity)

Nesiritide

BNP analog used in pts with decompensated LV dysfunction/CHF BNP activates GC, increases intracellular cGMP → dilate veins and arteries; also causes diuresis/natriuresis Lower BP

Which tissues are insulin independent?

BRICK-LP Brain, RBCs, Intestines, Cornea, Kidneys, Liver, Pancreas

Major risk factors for development of *adenocarcinoma* of the esophagus?

Barrets esophagus, GERD, obesity, tobacco smoking

Pink, pearly nodules with telangietasias and rolled borders with central crusting found on sun-exposed areas. What is and and would would histo show?

Basal cell carcinoma Histo shows palisading nuclei

Why are ACE inhibitors contraindicated in pts with bilateral renal stenosis/renovascular disease?

Because in these pts, ACE is needed to produced ATII action the efferent arteriole (constriction, maintains GFR)

Reaction Formation

Behaving in a way that's exactly the opposite of one's true feelings. Immature defense mechanism. Example: recovering heroin addict who still has strong desires to use heroin speaks publicly about how all heroin users should be avoided in society

Flumazenil is used for?

Benzo overdose (Competitive antagonist at the GABA benzo receptor)

Immediate treatment for status epiplepticus?

Benzodiazepines (eg Lorazepam)

Glomerulonephritis that occurs 2-3 days after URI

Berger Disease (IgA nephropathy)

How do bile acid resins work as a lipid lowering agent?

Bile acids prevent recycling/reabsorption of bile acids from the gut Liver has to *use more cholesterol* to make bile acids By "depriving" liver of cholesterol, it also *upregulates LDL receptors*, decreasing circulting LDL

Protamine sulfate

Binds to heparin and forms a complex that has no anticoagulant activity Use to reverse heparin's effects. Not effective at reversing effects of LMWH

"holiday heart syndrome"

Binge alcohol consumption can precipitate isolated episodes of Afib Other precipitating factors include ↑cardiac sympathetic tone and pericarditis

Pulmonary fibrosis is a adverse effect of what drugs?

Bleomycin, Busulfan, Amidoarone, Methotrexate

Ethosuximide MOA

Blocks T-type Ca++ channels in thalamic neurons, causing hyperpolarization Treatment of absence seizures

Strawberry vs. Cherry hemangioma

Both are benign capillary hemangiomas Strawberry= infancy, regresses around 5-8yo Cherry=adults, does not regress Mnemonic: Think about Strawberry shortcake doll- for kids

Janeway lesions and subungual splinter hemorrhages

Both are signs of microemboli, typically a/w bacterial endocarditis. Janeway lesions are nontender erythematous/hemorrhagic papules on palms and soles. Other signs include Osler nodes (painful nodules on finger/toepads), and Roth spots (white spots on retina surrounded by hemorrhage)

Development of a cleft lip vs a cleft palate

Both occur at wk 6 in development. Although they often occur together, they have separate causes Cleft lip: d/t failure of the maxillary prominance to fuse with the medial nasal prominence; L>R Cleft palate: d/t failure of the palatine shelves (which come off tof the maxillary prominence) to fuse to the primary palate

Pulmonary V/Q and different areas of the lung

Both ventilation and perfusion are higher at the base than the apex, but perfusion (Q) increases much more than ventilation (V), so V/Q at base < V/Q at apex

What tissues are insulin independent?

Brain, RBCs, small intestine, cornea, kidney, liver, pancreatic β cells

Tender loving care for nancy enzymes (Enzymes that require Thiamiane phosphate, Lipoate, Co-A, FAD, NAD)

Branched chain α ketoacid dehydrogenase Pyruvate dehydrogenase α-ketoglutarate dehydrogenase (and then transketolase only need thiamine)

Brocas area/Brocas aphasia

Brochas area is located in the inferior frontal gyrus in the dominant (left) hemisphere; supplied by the MCA Brochas aphasia is expressive aphasia, meaning that they can understand but cannot speak or write

Abdominal pain, ascites, hepatomegaly; a/w hypercoagulable state

Budd Chiari

Young female with bilaterally enlarged parotid glands, irregular menses, and eroded tooth enamel

Bulimia nervosa

Alternative to SSRI in pts experiencing sexual side effects

Buproprion

Side effect of an anti-epileptic: seizures in a pt with h/o bulimia?

Buproprion

Long thoracic nerve orginiates from?

C5, C6, C7

What hormone is produced by I duodenal/jejunal I cells in response to fatty foods coming down into duodenum?

CCK (stimulates pancreatic secretions by acinar cells, gallbladder contraction, and decreased gastric emptying)

CD40 and CD40L - where is each found?

CD-40L is on CD4 T cells CD-40 is on APC

In Fragile X syndrome, what exactly leads to gene inactivation?

CGG repeats cause hypermethylation of the FMR1 gene on Chromosome X, inactivating the gene

What nerves pass through the jugular foramen?

CN IX, X, XI

Methylphenidate

CNS stimulant (ritalin). Increased catecholamines at synaptic cleft used for Rx of ADHD and narcolepsy Also appetite suppressant

Phentermine

CNS stimulant (similar to amphetamine) Used as an appetite suppressant for short term treatment of obesity works by increasing catecholamines in the synapse (esp NE and DA)

PaO2 normal, %sat decreased, O2 content decreased

CO poisoning

Injury to the neck of the fibula would likely injure what nerve? What symptoms would you see?

COMMON peroneal would be injured Common peroneal is a branch off the sciatic, and it splits into superficial and deep after coursing around neck of fibula. Superficial provides sensation over dorsum of the foot, and innervates muscles of the lateral compartment of the lower leg (eversion). Deep innervates anterior compartment muscles (dorsiflexion) and provides sensation to web space between 1st and 2nd toes

Entacapone

COMT inhibitor used for parkinsons. May be added to pts in which levadopa/carbadopa is not sufficient. Recall that DOPA can be converted peripherally to Dopamine through either DOPA decarboxylase (which carbadopa inhibits) OR by COMT. Inhibiting COMT will allow for even more DOPA (levadopa) to reach the CNS. Other COMTi are tolcapone (which also decreases central degradation of dopamine by COMT)

Cadherins

Ca2++ dependent adhesion molecules involved in cell-cell adhesion in epithelial and muscles cells Examples of cadherins include desmogleins, E-cadherin, etc Removal of Ca++ from environment of cell = loss of cadherin mediated cell cell adhesion

Pancreatic Pseudocyst

Can appear 4+ wks after acute pancreatitis episode encapsulated collection of fluid that is typically found OUTSIDE of the pancreas (MC is lesser sac) "pseudo" because walls consist of fibrous and granulation tissue (not epithelial cells) Occurs b/c release of proteolytic enzymes in acute pancreatitis leaks out and can damage surrounding structures

Drugs a/w development of aplastic anemia?

Can't Make New Blood Cells Properly Chloramphenicol, Methimazole, NSAIDs, Benzene, Carbamazepine, PTU

carbadopa MOA

Carbadopa is a Dopa Decarboxylase inhibitor (DDI) that prevents peripheral breakdown of DOPA into dopamine. It is frequently administered with Levodopa, increasing the amt of Levodopa that reaches the brain

Adverse drug reactions: SIADH

Carbamazapine, Cyclophosphamide, SSRIs,

1st line treatment for partial seizures (both simple and complex?

Carbamazepine

Side effects of what anti-epileptic drug= SIADH and agranulocytosis?

Carbamazepine

First line treatment for trigeminal neuralgia?

Carbamazepine (Na+ channel blocker, excitatory neurons)

Fibrous intimal thickening with endocardial plaques limited to the R heart

Carcinoid heart disease (a/w carcinoid syndrome) limited to the R heart because the lungs have MAO which can can inactivate serotonin and bradykinin

Carcinoid tumor vs neuroendocrine tumor?

Carcinoid tumor is a neuroendocrine tumor, but this term is used to describe neuroendocrine tumors that arise in the gut Both are derived from neuroendocrine cells, can secrete stuff (hormones, vasoactive substances), and are chromogranin A+, synaptophysin +

Pt presents with R nasal hemianopsia. What is the most common cause?

Carotid artery atherosclerosis on the side compresses the uncrosses chiasmal retinal fibers (#4) Distinguish from a lesion that would affect the retinal artery more distally, which would result only in a central scotoma (#1)

Carotid massage for PSVT

Carotid massage stimulates baroreceptors, resulting in increased parasympathetic outflow. Acting on the heart, this slows conduction through the AV node, slowing HR, and abolishes re-entry tachycardias.

Carotid sinus vs Aortic arch baroreceptors: responds to what and signals through what nerve?

Carotid: responds to BOTH ↑ and ↓ in blood pressure signals through glossopharyngeal Aortic arch: responds to only ↑ in blood pressure and signals though vagus Mnemonic: Be CAReful with your lip GLOSS- apply it to both ↑ and ↓ lips.

Transport of glucose into most cells occurs by what type of transport?

Carrier mediated (facilitated) transport

Red Safarin O stains what red?

Cartilage, mucin, and mast cells also used as a counterstain in Gram staining (so stains gram - pink)

Drug that slows progression of heart failure and reduces long term mortality in pts with CHF?

Carvedilol (blocks β1, β2, and α1)

Red man syndrome- sxs and prevention?

Cause: rapid infusion of vancomycin Sxs: flushing, erythema, pruritis usu UPex, HoTN Prevention: pretreat with diphenhydramine (may also add cimetidine-H2)

What causes vitiligo?

Caused by partial or complete *loss of epidermal melanocytes* Pathogenesis is unclear- leading theory is autoimmune

Acute hemolytic transfusion reaction

Caused by the immune-mediated destruction of ABO-incompatible transfused blood (w/in minutes because preformed antibodies) Type II HSR (anti-ABO Ab bind antigens on donor RBCs and fix complement) Present with fever, HoTN, DIC, hemeglobinuria

DQ2/DQ8 associated with?

Celiac

Tonsillar herniation

Cerebellar tonisils herniate down through the foramen magnum → can compress the medulla

Intracranial schwannomas are typically located where? and affect which cranial nerves?

Cerebellopontine angle Affect CNVII (facial), CNVIII (oculomotor), CNV (trigem) See tinnitus, sensorineural hearing loss, vertigo, paralysis of facial expression, loss of taste to anterior 2/3 tongue, loss of corneal reflex, etc.

Axonal reaction

Changes seen in the neuronal body after the axon is severed (12-24h after injury) 1) Cellular edema 2) Nucleus displaced to the periphery 4) Nissl substance becomes fine, granular and dispersed throughout the cytoplasm (central chomatolysis) Changes reflect increased protein synthesis in efforts to repair the cell

A drug with a low volume of distribution (3-5L) has what properties?

Charged, Large, bound to albumin

Low potency typical antipsychotics

Cheating Thieves are low Chlorpromazine, Thioridazine

Child presents with white hair, pale skin, light eyes, and prominent red pupils. She has h/o multiple bacterial infections. What disease do you suspect, and what would you expect to see on peripheral smear?

Chediak-Higashi This is a disorder in lysosomal trafficking. Results in failured of the phagosome-lysosome to fuse (can't fight infections) also also a failure of melanocytes to transfer their pigment containing melanosomes to the keratinocytes (oculocutanous albinism) Peripheral smear shows giant granules in neutrophils.

Expansitile glistening mass within the medullary cavity of pelvic bone of a 45yo M

Chondrosarcoma

Ciliary muscle actions

Ciliary muscle is what does accomodation and regulates flow of aqueous humor into Sclemms canal. Changes the shape of the lens within the eye not the pupil size. Activated by M3

Treatment of choice for intermittent claudication?

Cilostazol- phosphediesterase (PDE3) inhibitor that works as both an anti-platelet and a direct arterial vasodilator (↑cAMP, prevent myosin light chain from being phosphorylated, smooth muscle relaxation and vasodilation).

Triple therapy- what is it and why?

Clarithromycin, Amoxicillin, PPI Give PPI for sxs. Give antibiotics to kill H pylori and prevent *recurrence*

Sotalol

Class III antiarrythmatic; only one with β blocking effects blocks K+ channels → ↓K+ efflux so longer time to repolarize and increases QT

Management of exertional chest pain- for pts who can't take aspirin, what is the best alternative?

Clopidegrol irreversibly blocks the platelet ADP receptors- can't aggregate Clopidegrol and aspirin are equally efficacious for prevention of thromboembolic disease and have a synergistic effect

Which antibiotic blocks peptidyltransferase at the 50S subunit?

Cloramphenicol

HER2/neu codes what for what gene product?

Codes for a transmembrane glycoprotein that has intracellular tyrosine kinase activity It is a member of the family of epidermal growth factors receptors, and plays a role in epidermal growth and differentiation

Pt being treated for acute gout develops diarrhea. what medication was used?

Colchicine

Loss of eversion, Loss of sensation over dorsum of the foot, loss of dorsiflexion. What injury?

Common peroneal, likely a neck of the fibula fracture Eversion and dorsum sensation comes from superficial Dorsiflexion comes from deep

Meningiomas

Common, and typically benign Arises from cells of the arachnoid villi Slow growing, and sxs typically reflect compression of the frontal lobe (personality changes, new onset of seizure in adult) Key histo: psamomma bodies (round, eiosinophillic, laminar structures with a core of dense calcification and surrounding collagen fiber bundles) If you see a tumor in the CNS with psammoma bodies, think meningioma!

A pt with COPD develops cor pulmonale (indicated by an echo that shows RV dilation) but he does not yet exhibit peripheral edema. Why is this, and when would clinically apparent edema appear?

Compensation for moderate ↑in capillary fluid pressure can be offset by ↑tissue lymphatic drainage. Clinically apparent edema is seen when the net plasma filtration pressure can risen enough to overwhelm resorptive capacity of the tissue lymphatics

CO inhibits what part of the electron transport chain?

Complex IV, specifically the transfer of electrons to O₂ Note that cyanide also inhibits complex IV

Tabes dorsalis

Complication of tertiary syphillis Degeneration (demyelination) of the dorsal columns and roots→ ataxia, impaired propropception A/w Argyll-Robinson pupils, +Romberg, absent DTRs

Cardiac tamponade

Compression of the heart by fluid (blood, effusion) Present with Beck's triad (distended JVD, distant heart sounds, HoTN)

Superior Mesenteric Artery Syndrome

Compression of the transverse duodenum by the SMA Most common cause is significant wt loss, leading to loss of mesenteric fat pad. Common in severe debilitating disease in which there is a lot of wt loss (cancers, AIDs, trauma, burns) or severe lordosis

Weber test that lateralizes to affected ear- what is the type of hearing loss?

Conductive

Baby with prolonged jaundice, feeding problems, hypotonia, enlarged tongue, and umbilical hernia.

Congenital hypothyroidism

2-6wk old male with nonbillious projectile vomiting, olive mass in the epigastric region, increased peristalsis?

Congenital pyloric stenosis

Cord factor

Cord factor is a *mycoside* (composed of 2 my colic acids bound to disaccharide trehalose) Presence of cord factor correlates with *virulence* of mycobacteria tuberculosis (strains that do not have cord factor cannot cause disease) Specifically, cord factor is responsible for *inactivating neutrophils, damaging mitochondria, and inducing release of TNF*

Child presents with a brain lesion that is cystic and filled with cholesterol crystals

Craniopharyngioma Most common childhood supratentorial timor Can cause bitemporal hemianopsia Derived from Rathke's pouch; calcification is commmon

Sensory innervation of the anterior thigh

Cutaneous branch of the femoral

Nitroprusside toxcity-what is it and rx?

Cyanide poisoning To treat this, give *sodium thiosulfate* (donates *sulfur* to liver rhondase and enhance conversion of cyanide to thiocyanate). Can also give nitrites (induce methemoglobinemia), or hydroxycobalamin

What would you culture Cornyebacteria diphtheria on?

Cysteine-tellurite (Tinsdale) agar Could also use, Loffler's medium I TELL U what, your CORNEY joke made me LOFF!

Cardiogenic Pulmonary Edema

D/t increased left heart volume or decompensated heart failure. Edema in the lungs. Can cause relatively rapid onset of shortness of breath. **

Acute mania dx

DIG FAST Distractibility, irresponsibility, grandiosity, flight of ideas, ↑activity/ agitation, ↓sleep, talkativeness

Pancreatic Islet amyloid deposition vs islet leukocytic infiltration

DM Type II= amyloid deposition DM Type I = leukocytic infiltrate

DR3/DR4 associated with

DMI

What enzyme and cofactor are needed for the production of dopamine (most directly?)

DOPA decarboxylase, B6

Osmotic fragility of sickle cells: increased or decreased?

Decreased

What is the cause of narcolepsy?

Decreased production of orexin (hypocretin) by the lateral hypothalamus, normally involved in maintaining wakefulness

What artery is likely to be injured with a mid-shaft humeral fx (along with radial nerve)?

Deep branchial artery

Sensory innervation of skin between 1st and 2nd toe

Deep peroneal nerve Get all deep and "personal" between the 1st and 2nd toe

Sideroblastic anemia- what is the defect, and what causes?

Defect in protoporphyrin synthesis Causes: Hereditary defect in ALAS Myelodysplastic syndromes Alcohol, Lead, Vit B₆ deficiency, isoniazid

Acute Intermittent Porphyria

Deficiency in porphobillinogen deaminase (PBG→ HMG) step in heme synthesis. Result in accumulation of PBG and ALA which are toxic. Sxs include abd pain, neuropsych manifestations, and urine color that changes on standing. Worsened by alcohol, barbituates, hypoxia, improved by glucose or heme administration.

Intermittent Claudication- what is it and what it the usual cause?

Defined as muscle pain that is triggered by exercise and relieved by rest. Almost all cases are caused by atherosclerosis of the large arteries (fixed atheromas cause obstruction of flow, stenosis of the lumen, and poor flow to the muscles)

Shared delusion disorder

Delusion that develops in the context of a close relationship with another person who already have that delusion

Langerhan's cell is what type of cell?

Dendritic cell (APC), normally found in the skin and mucosa. They are derived from the myeloid lineage

What structure lies posterior to the esophagus (mid esophagus)

Descending aorta

Immunohistochemical stain for a rhabdomyosarcoma

Desmin

Most common cause of death in SLE?

Diffuse Proliferative Glomerulonephritis

Where are lipids primarily digested and absorbed?

Digested in the duodenum Absorbed in the jejunum

Class of anti-hypertensive that can cause edema and flushing?

Dihydropyridine Ca2+ channel blockers, specifically Amlodipine and Nifedipine

Common cause of death in Duchenne?

Dilated cardiomyopathy

What causes a direct inguinal hernia?

Direct hernias are protrusions through Hesselbach's triangle. The floor is formed by the *tranvseralis fascia*, so *weakness* in this fascia leads to hernia

Argatroban, Bivalirudin, Dabigatran- MOA and use

Direct thrombin (IIa) inhibitors Use for anticoagulation in pts with HIT

Uric acid stones typically precipitate in what part of the nephron, and why?

Distal tubules and collecting ducts lowest pH is found there- uric acid is not soluble anymore.

What drugs are a/w drug-induced interstitial nephritis?

Diuretics, β-lactam antibiotics, sulfa drugs, rifampin, NSAID Dying, Suffering Renals Need Betta'-Lovin'

6th aortic arch gives rise to?

Ductus arteriosus and pulmonary arteries

IL2's antitumor effects?

Due to *increased activity of T cells and NK cells* Aldesleukin used for RCC and metastatic melanoma

Isolated systolic hypertension- what is it and what is the treatment of choice?

Due to age-related decrease in compliance (increased stiffness) of the aorta and its major branches. Results in increase in systolic BP (>160), with diastolic remaining in normal range 1st line rx in nondiabetcs; thiazide diurectics and dihydopyridine Ca²⁺ channel blockers 1st line in diabetics: ACE and ARBs

Double bubble sign?

Duodenal atresia (stomach and duodenum with pyloric sphincter between). DDX annular pancreas

Enteropeptidase (enterokinase)

Duodenal brush-bprder enzyme that activates trypsinogen to trypsin

Alport syndrome- what are the major organs affected?

Ears, eyes, kidneys (Type IV collagen mutation)

Small mouth, low set ears, prominent occiput, "clenched hands" (flexed fingers with the index finger overlapping the third finger and the fifth finger overlapping the fourth), Meckel's diverticulum

Edwards syndrome (trisomy 18)

Effect modification

Effect of the main exposure on the outcome is modified by the level of another variable. NOT A BIAS and not due poor study design! Distinguish from confounding variable bias, in which stratified analysis does not show significant difference in risk b/w the groups. Two classic examples: 1) the effect of estrogens on the risk of venous thrombosis is modified by smoking 2) the risk of lung cancer in people exposed to asbestos greatly depends on smoking status, etc.

Which connective tissue pathology is due to impaired extracellular protein cleavage, preventing proper collagen cross-linking?

Ehler-Danlos syndrome

What causes polyhydramnios? (broadly, and specific examples)

Either d/t decreased fetal swallowing or increased urination ↓swallowing: duodenal atresia, anencephaly (missing swallowing center) ↑urination: high CO d/t anemia, twin-twin transfusion syndrome

Branchial cleft cyst

Embryologic defect, failure of closure of a branchial cleft, most commonly the 2nd branchial cleft. External opening is located along anterior border of the sternocleidomastoid. Internal opening is usually at the level of the tonsillar fossa. Present as lesion on the lateral neck, may enlarge with respiratory infxs

Epithelial lining of the cervix?

Endo= simple columnar Exo= stratified squamous

Major culprits in aseptic meningitis?

Enteroviruses (belong to picornoviridae) (Coxsackie, echo, polio)

Temporal arteritis

Epi: Typically elderly F>M Sxs: unilateral headache, jaw pain in the middle of meals, scalp tenderness, sudden onset of blindness. 50% also report polymyalgia rheumatica (muscle pain and morning stiffness) Labs: High ESR, temporal artery bx to confirm (T lymphocytes, macrophages, giant multinucleated cells) Treatment (prevent blindess): Corticosteroids

Epinephrine vs NE: which receptor does each primarily act on?

Epi: β>α, except at high doses α predominates NE: α₁>α₂>β₁

Bromocriptine

Ergot dopamine agonist Used for Parkinsons, prolactinoma, neuroleptic malignant syndrome

Local anesthetics- two classes?

Esters: Procaine, Tetracaine, Cocaine Amides: Lidocaine, Mepivacaine, bupivacaine (amides all have two I's in their name) If pt is allergie to one class, give the other MOA: block Na+ channels

Effect of estrogen on thyroid hormones?

Estrogen increases thyroid binding globulin levels (by decreasing its breakdown) Increased TBG= increase in total T4 (bound+free) and total T3 Level of free thyroid hormone doesn't change, so TSH is normal

Why is there an increased incidence of cholelithiasis in women who are preggers or on oral contraceptives?

Estrogen upregulates hepatic HMG-CoA reductase activity= ↑cholesterol in bile Progesterone reduces bile acid secretion and slows gallbladder emptying (hypomotility)

Absolute Risk Reduction

Event Rate in the control group - event rate in the treatment group 1/ARR= number needed to treat

Zollinger-Ellison syndrome

Excessive gastrin production by tumor cells (usu in the pancreas, can also be small intestine) causes both increased H+ secretion by parietal cells AND has a trophic effect on parietal cells (so proliferation and hyperplasia of these cells)

Myasthenias gravis- pulmonary function tests?

Expect to see ↓VC, ↓TV, ↓ERV Normal RV Other labs reflect respiratory acidosis (↓pH, ↑pCO2)

Damage to the superior thyroid artery during thyroidectomy- what nerve is likely to be injured?

External branch of the superior laryngeal nerve lies just beneath the superior thyroid artery. It branches off the vagus, and it innervates the crycothyroid. Note that all other laryngeal muscles are supplied by the recurreny laryngeal, which is also a branch off the vagus

Growth hormone receptor: intrinsic tyrosine kinase or extrinsin tyrosine kinase associated?

Extrinsic Others include prolactin, cytokines, IL-2

Calculating false positives expected in a population given the disease prevalance

FP rate tells how many healthy people will test positive for a disease. Disease prevalence tells you how many people (x/population) have the disease. So to calculate false positive in a population, take hte FP rate and multiply by the number of *healthy* people (population-x)

Confirming menopause- what lab do you order?

FSH Expect to see elevated FSH d/t drop in estrogen since ovaries are less active Note that LH will also rise, but it typically happens later

Kallmann syndrome

Failure of GnRH-secreting neurons to migrate from the olfactory placode to their normal position in the hypothalamus. KAL-1 mutation Pts have central hypogonadaism (delayed puberty) and anosmia (can't smell)

Fatty acid oxidation inhibitors for treatment of angina

Fatty acid oxidation is the main source for energy production in the myocytes, despite the large O2 use compared with use of glucose/glycolysis. If you inhibit FA oxidation, you can use less O2 per one ATP synthesized. Decreased O2 demand will help in pts that have a decreased O2 delivery ability to start with.

Most common site avascular necrosis?

Femoral head, due to insufficiency of medial circumflex artery

Drug used in hypertensive emergencies that especially cause renal artery dilation and ↑natruresis

Fenoldopam D1 agonist Only IV agent that improves renal perfusion Causes arteriolar dilation, natriuresis, decreased BP

Which form of iron has high affinity for cyanide?

Ferric (Fe3+) this is why you can give nitrites for cyanide poisoning oxidizes ferrous Fe2+ to Fe3+ which avidly binds cyanide

Iron toxicity- what is the basis of the damage it causes?

Ferric iron (Fe3+) is toxic to a number of cellular processes. The primary mechanism for iron-induced tissue damage is free radical production and lipid peroxidation

Goal= lower triglycerides. What pharm agent is most appropriate?

Fibrates If still high, may add niacin (B3)

management of status epilepicus?

First line: Benzo (lorazepam) Administer with phenytoin (doesn't work as fast, but prevents recurrence) If seizure does not stop, phenobarbital is indicated

Intestinal biopsy of a pt with Celiac disease will show?

Flattening of the mucosa with loss of villi and chronic inflammatory infiltrate of the lamina propria; most pronounced in the duodenum and prox jejunum

Blowout fracture

Floor of the orbit is weak. Direct trauma on or around the eye can cause fracture, with subsequent bleeding into the maxillary sinus

Name the 4 major SSRIs

Fluoxetine, Paroxetine, Citalpram, Sertraline (Prozac, Paxil, Celexa, Zoloft)

Adult with waxing and waning lymphadenopathy, indolent, relatively common

Follicular cell lymphoma most common indolent non-Hodgkin lymphoma in adults B cell derived, t(14;18) bcl-2

What's the point of a conjugated vaccine?

For organisms with a polysaccharide antigen (Hib for example), APCs can't recognize them (only recognize peptides), so they will trigger a T-independent response (B cells recognize them but only can produce IgM). In infants and young children, the T independent response is poor. If you conjugate the polysaccharide antigen with a protein component (diphtheria for ex), it will now elicit a T-dependent response. This will produce antibodies that can class switch to IgG and memory B cells and ultimately increased immunogenicity.

What foramen do the middle meningeal artery and vein traverse?

Foramen spinosum

Dermatitis herpetiformis- pathogenesis and key associations

Formation of IgA and IgG antibodies against gliadin. These antibodies cross react with reticulin, and deposit at the tips of the dermal papillae→ formation of tiny itchy vesicles a/w Celiac disease

Treating HSV strain that does not have thymidine kinase- what should you use?

Foscarnet or cidofovir

Apocrine glands

Found in dermis and SubQ fat of breast areolae, axilla, genital area. Secrete membrane bound vessicles (sweat) into the hair follicles. Initally odorless but smell secondary to bacterial decomposition on skin surface. Compare with eccrine (merocrine) sweat glands which just secrete odorless fluid. The smelly stuff comes from apocrine though.

Liver cells that have a high concentration of Fructose 2,6-BPG will have a low conversion rate of?

Fructose 1,6 BP→ Fructose 6P Fructose 2,6 is ⊕ regulator of glycolysis and a ⊖ regulator of gluconeogenesis- exhibits control though PFK-1 and Fructose 1,6 bispohosphatase respectively

MOA of morphine

Full mu opiod agonist. On presynaptic, close Ca++ channels (decrease NT release). On postsynaptic, increase K+ efflux (hyperpolarize membrane)

Uses for metronidazole?

GET GAP on the Metro Giardia, Entamoeba, Trichomonas, Gardnerella, Anaerobes, Pylori

Major side effects of metformin

GI upset *Lactic acidosis Metformin increases intestinal production of lactate by anaerobic glycolysis. This excess lactate can't be converted to glucose in the liver (b/c metformin blocks gluconeogenesis). Lactic acidosis is mainly a risk in pts with renal failure or hepatic dysfunction because they can't effectively clear the lactate. Monitor creatinine in pts taking metformin.

Duodenal ulcer on the posterio wall of the duodenum can cause hemorrhage d/t ulceration into what artery?

Gastroduodenal

High Yield CYP450 inhibitors

Gemfibrozil Ciprofloxacin Isoniazid Quinidine Amiodarone Ketoconazole Macrolides Sulfonamides Cimetidine Ritonavir

Post-partum woman (normal pregnancy) develops hemoptysis and abnormal vaginal bleeding.

Gestational choriocarcinoma Expect to see high hCG, proliferation of both syncytio and cytotrophoblasts on endometrial curettage. No chorionic villi. *Hematogenous spread to the lungs is common*

Epiphyseal tumor that arises in a 30yo with knee pain.

Giant cell tumor only one (for our purposes) that arises in the epiphysis)

How would you correct a TCA overdose?

Give NaHCO₃ (can correct QRS prolongation, reverse HoTN, and treat ventricular dysrhythmias)

Treatment of drug-induced parkinsons

Give anticholinergics (benztropine, diphenhydramine) This is b/c the drug is decreased D2 action (eg haloperidol) resulting in a relative ACh excess. Dont want to give D2 (the very thing causing their disease) so curb the ACh excess

Antidote for B blocker poisoning?

Glucagon increases intracellular cAMP and cardiac contractility

Polyol pathway- what are the steps

Glucose → Sorbitol → Fructose (aldose reductase, NADH) (Sorbitol dehydrogease, NAD+)

Von Gierke

Glycogen-6-phosphatase deficiency Can't break down glycogen or do gluconeogenesis Hypoglycemia, lactic acidosis, hyperuricemia, hepatic steatosis Only affects liver and kidneys (not muscle)

Leuprolide

GnRH analog Used in pulsatile fashion for infertility Used continuously for prostate cancer or precocious puberty

Neisseria gonorrhea- Micro and virulence factors

Gram negative diplococci, no capsule, often intracellular (w/in neutrophils) Pilli: attach to mucosal surface, antigenic variation IgA protease: mucosal adhesion LOS (lipooligosaccharide): functions as endotoxin

H1 and H2 receptors are found where?

H1= vascular endothelium and bronchial smooth muscle (stimulation increases nasal and bronchial secretions, vascular permeability, bronchoconstriction, pruritis) H2= parietal cells (stimulation increases H+ secretion)

What are the functions of HA and NA?

HA: binds sialic acid, promotes viral infection a cell NA: cleaves sialic acid, promotes viral progeny release and spread of the virus

Target cells are seen in?

HALT HbC disease, Asplenia, Liver disease, Thalassemia

What causes focal or diffuse hepatic necrosis?

HAVAc Halothane Amanitin mushroom Valproate Acetominophen

Transmission of HBV vs HCV

HBV is sexual transmission or parenteral *HCV is classically d/t IV drug use* B for bone

HBV vs HCV histology?

HBV= cells with "ground glass" appearance HCV=periportal lymphocytic infiltrate

Drugs a/w development of SLE-like syndrome

HIPPES Hydralazine, Isoniazid, Procainamide, Phenytoin, Entanercept, Sulfa drugs

Temporal lobe encephalitis- what microorganism is likely the cause?

HSV-1 Has predilection for temporal lobe

Single most important risk factor for aortic dissection?

HTN → development of intimal tears

Thiazides- side effects

HYPER problems: -uricemia -calcemia -glycemia -lipidemia HYPO problems -kalemia -tension

The active form of Rb protein at the G1→S checkpoint is what- hypo or hyperphosphorylated Rb?

HYPOphosphorylated. An active Rb stops the cell cycle

TRAP+ leukemia?

Hairy cell Tartrate-resistant acid phosphatase.

Tuberous sclerosis key features

Hamaratomas (CNS and skin), Angiofibromas (eg BILATERA renal angiomyolipomas, facial angiofibromas), Mitral regurg, Ash-leaf spots, Cardiac rhabdomyomas, Mental retardation, renal angiomyolipoma, Seizures, Shagreen patches Increased incidence of subependymal astrocytomas Autosomal dominant

Intense mononuculear infiltration of the thyroid with lymphocytes and plasma cells, several well-developed germinal centers, and Hürthle cellls

Hashimoto thyroiditis Hürthle cells are large, highly eiosinophilic cells with abdundant granular cytoplasm; d/t metaplastic changes of thyroid follicular cells and they line residual thyroid follicles

Antimicrosomal antibodies

Hashimoto. Synonymous with anti-TPO antibodies. Also see anti-thyroglobulin antibodies.

HbH vs Hb Barts

HbH is a type of α thalassemia in which there is 3 allele deletions. HbH= tetramer of β globin, damages RBCs Hb Barts is a type of α thalassemia in which there are 4 allele deletins. Hb Barts = tetramer of Ɣ globin, hydrops fetalis

alveolar cells containing golden cytoplasmic granules that turn dark blue with Prussian blue staining

Heart failure cells (hemosiderin-containing alveolar macrophages)

HELLP syndrome

Hemolysis, Elevated Liver enzymes, Low Platelets Occurs typically in 3rd trimester. Present with abdominal pain, n/v, HTN (although not necessarily r/t preeclampsia), elevated ALT/LDH, TTP midepigastrum/RUQ. Serious complications include: DIC, abruptio placenta, ARF, need for transfusion

What viral family's DNA is partially DS and circular. Hint- they also have a reverse transcriptase?

Hepadnavirus

DVT treatment in pregnancy?

Heparin In regular people, warfarin is drug of choice but its a teratogen

Which virus acquires its envelope from the host cell nuclear membrane?

Herpesviruses

35yo Female with fatigue, fever, wt loss, weak upper extremity pulses with claudication, carotic bruits, and lightheadedness. PE shows unequal BP in each arm. What Labs do you expect to see?

High ESR This is Takayasu arterities, which is when there is granulomatous thickening and narrowing of aorta and its aortic arch branches, leading to "pulseless disease". Clinical manifestations include vascular sxs as well as constitutional sxs. Most common in Asian females

What part of the inner ear responds to high vs low frequency sounds?

High frequency= base of the basilar membrane Low frequency= apex of the basilar membrane, near to helicotrema

Na+, K+, and glucose levels in the serum in DKA

High glucose High K+ (in SERUM..drawn out of cells) Low Na+ (osmotic diuresis from high glucose)

What prevents lactation in gestation, despite high levels of prolactin?

High levels of gestational progesterone and estrogen prevent lactogenesis. After placental separation, drop in these two allow for prolactin to stimulate milk production

First area of the brain damaged during global cerebral ischemia?

Hippocampus- most vulnerable to ischemia Other vulnerable areas: pyramidal cells of the neocortex, purkinje cells of the cerebellum, watershed areas

Leptin

Hormone produced in adipocytes that is normally active in suppressing food intake (Decreases production of neuropeptide Y, an appetite stimulant, and stimulates POMC production; α MSH derivative of POMC inhibit food intake) Human obesity may be a/w mutations in leptin signaling or more commonly, a/w constantly high leptin levels and leptin desensitization

Atrophy of the caudate nuclei is associated with what disease? What is the path of this disease?

Hungtington's Due to increased CAG repeats in the HD gene results in abnormal huntingtin protein product that contains expanded poly-glu tracts. This protein can aggregate and inhibit transcription of other genes as well (thru hypermethylation of histones). Results in selective loss of caudate, decreased levels of GABA and ACh in the brain, and uncontrolled/uncoordinated movements

Degenerative disease that makes the lateral ventricles appear very large?

Hungtintons (d/t atrophy of the caudate nucleus)

Howell-Jolly bodies: See in what conditions?

Hypo or asplenia this includes sickle cell anemia (autosplenectomy)

intrinsic muscles of the tongue are innervated by?

Hypoglossal (CNXII)

Chiari I vs II

I: dx'd in adolescents and young adults, no meningomylocele present, syringomyelia in 30-70% cases, sxs include HA, neck pain, dysphagia, cerebellar sxs...may be asymptotic II: dx'd at birth, meningomyelocele ALWAYS presents, syringomyelia common, hydrocephalus common, sxs include brainstem dysfx (swallowing, feeding issues, apnea), extremity wkness

RPGN types

I= anti-GBM antibodies (Goodpasture) II= immune complex mediated (post-strep, SLE, IgA) III= pauci-immune (Wegner, Churg Strauss)

For class I anti-arrhythmics, what is the order of strength of Na⁺-channel binding?

IC>IA>IB

PEG-IFN : Use, MOA, SE

IFN-α has direct antiviral activity against HCV and HBV. Pegylated interferons are INF-alpha conjugated to polyethylene glycol, thus increasing the molecular weight of the molecule, decreasing its renal clearance, and *increasing its serum half-life*. Major side effects= depression, somnolence, myalgias

Name the collage type: 1) granulation tissue 2) vitreous humor 3) scar tissue

III, II, I

What mediates the osteolytic lesions in multiple myeloma?

IL-1 (also known as osteoclast activating factor) and TNF

What does ESR increase with infection?

IL-1, IL-6, and TNF-alpha mediate inflammatory response, and stimulate hepatic secretion of acute phase proteins, including *fibrinogen*. High levels of fibrinogen correlate with increased ESR.

Plummer-Vinson: Iron or B12 deficiency??

IRONNNN! Mnemonic: Plummers deal with pipes..iron pipes?

Pt presents with IgG4 serum antibodies to the PLA2R (phospholipase A2 receptor) on podocytes. She has peripheral edema and proteinuria/

Idiopathic membranous nephropathy PLA2R is thought to be the major antigen in the path of idiopathic membranous nephropathy.

Body's major immune defense against Giardia?

IgA It attaches to duodenal and jejunal mucosa by adhering to the intestinal brush border and release inflammatory stuff. Secretory IgA impairs adherance

Major muscles for hip flexion

Iliopsaos, rectus femoris, tensor fascia lata

Cilastatin is always adminstered with what drug and what?

Imipenem (broad spectrum B lactamase resistant carbapenem). Cilastatin is an inhibitor of renal dehydropeptidase I, which would inactivate imipenem if taken alone.

Presentation of cryptococcus neoformans

In HIV+ or immunocompromised, most common presentation is meningitis (HA, n/v, confusion). Although lung infection typically occurs first, it is usually asymptomatic.

What is the pathogenesis of pulmonary HTN in pt with LV failure (vs COPD)

In LV failure, there is pulmonary venous congestion, leading to increased hydrostatic P in the lungs, edema, and subsequent alveolar collapse. This results in decreased ventilation and reactive vasoconstriction due to hypoxemia In COPD, the reactive vasoconstriction is is response to hypoxia

The rate of glycogen breakdown increases greatly after onset of muscle contraction- why?

In addition to binding tropinin C and and activating muscle contraction, Ca++binds to and activates phosphorylase kinase, which activates glycogen phosphorylase

Cirrhosis- pathogenesis of infertility

In cirrhosis, there is increased peripheral conversion of androgens to estrogens. Low testosterone in the blood is what causes the infertility

Relative Risk

In cohort studies, used to determine how strongly a risk factor is associated with disease RR= (a/(a+b))/(c/(c+d)) RR=1 is no link RR>1 means increased disease if have risk factor/exposure RR<1 means decreased disease if have risk factor/exposure

How to distinguish primary (psychogenic) DI from nephrogenic?

In nephrogenic, urine osm after dehydration will be lower, ADH will cause b/w 10-50% increase in urine osm, and serum sodium will be high (>142) in psychogenic, urine osm after dehydration will be higher, only slight (<10%) increase after ADH, and serum sodium is normal or low

Central venous catheter insertion- highest and lowest risk of catheter associated infection?

In order from highest to lowest risk Femoral→Internal Jugular→Subclavian

Woman with bilateral renal masses composed of fat, smooth muscle, blood vessels. What other findings may you expect to see?

In pts with bilat renal angiomyolipomas, they have tuberous sclerosis in 80-90% of cases Other findings- ash leaf spots, subependymal hamaratomas, angiofibromas on face, cardiac rhabdomyomas.

Acute chest syndrome

In sickle cell anemia pts, *vaso-occlusive* crisis localized to the pulmonary vasculature. Commonly precipitated by pulmonary infection. Same vaso-occlusive crises also cause splenic infarction → autosplenectomy

IgA in the serum vs IgA in secretions?

In the serum, IgA exists in its monomer form. In secretions (mucus, tears, saliva, colostrum), it exists in dimer form. It contains a secretory component that is made by epithelial cells and facilitates its movement though mucosal membranes

Labs you would expect to see in a pt with secondary hyperaldosteronism?

In these pts, there is ↑renin and ↑aldosterone. Other labs will be similar to Conn syndrome (↓K+, ↓H+) Causes: CHF, renal artery stenosis, cirrhosis, nephrotic syndrome (body senses low volume)

Passive leg raising will augment what types of murmurs?

Increase venous return Increase preload Increase flow through stenotic valves

Sustained handgrip will exaggerate what types of murmurs?

Increased afterload Will enhance L-sided regurgitant murmurs

Fibrates- Indication, MOA, and adverse effects?

Indication- high triglycerides MOA: enhance lipoprotein lipase, which increases triglyceride clearance; also activates PPAR-α to induce HDL synthesis Adverse effects: myopathy (esp if used with statins), hepatotoxicity, *cholesterol stones*

Derivatives of the 3rd pharyngeal pouch?

Inferior parathyroids Thymus

What is a pannus?

Inflamed granulation tissue In RA, it forms in the joints d/t synovitis. It can destroy the articular cartilage and deform the joints.

Infliximab vs Entanercept

Infliximab is a *monoclonal antibody against TNF-alpha* Entanercept is a *decoy TNF receptor* (recombinant TNF-receptor fusion protein)

What viral illness predisposed a person to subsequent bacterial pneumonia (in otherwise healthy person)

Influenza virus (segmented, ss, enveloped, RNA virus)

Cisplatin MOA and major toxicities?

Inhibits DNA synthesis by the formation of *DNA cross-links* Ototoxicity and nephrotoxicity

Anemia of chronic disease What are the labs and why are they like that?

Initially normocytic then becomes microcytic, hypochromic Chronic inflammation= release of acute phase protein, hepcidin Hepcidin keeps iron hidden away (senses infection and wants to keep Fe away from the pathogen that needs it). Inhibits enterocytes absorption (ferroportin) and macrophage release of iron. Also suppresses EPO Labs shows high hepcidin, high ferritin, low TIBC, low Fe in the serum

In mediating cell adhesion, integrins interact with who?

Interact with the extraceullar matrix by binding to collagen, fibronectin, laminin

Lymph from the prostate drain where?

Internal iliac nodes primarily but also to the external iliac and sacral nodes

Most common initiating condition for AAA

Intimal streak →*Athersclerosis is the major cause of AAA.* (Eventually weaken the underlying media of the aortic wall) While conditions that involve cystic medial degeneration also can cause AAA, this is less common

Growth factors (PDGF, EGF, etc): intrinsic tyrosine kinase or extrinsic tyrosine kinase associated?

Intrinsic Others include insulin

3 ways Aspergillus can presents (3 'forms')

Invasive aspergillosis- in immunocompromised pts. primary lung involvement. Cough, hepoptysis, CP, fever Colonizing aspergillosis - "fungus ball", occurs in old lung cavities. may be asymptomatic, or cough and hemoptysis. ON XR shift when person changes position Allergic bronopulmonary aspergillosis- occurs in pts with asthma. wheezing, fever, migratory pulm infiltrates

Hemiballism

Involuntary violent flinging or jerking of a limb(s) in an uncoordinated manner, caused by a lesion of the contralateral subthalamus A/w pts who have had lacunar strokes (h/o HTN)

TAP (Transporter associated with antigen processing)

Involved in MHCI expression Allows in internal peptide antigen to enter the RER and bind with MHCI, which will eventually be expressed on the surface

Presentation and labs a/w Paget disease of the bone

Involvment of axial skelton and prox femur in 80% cases; chalk-stick fractions, bone pain Also see enlargement of the head (incr hat size), hearing loss (narrowing of auditoty foramen), lion-like facies Labs show *isolated elevated ALP* (Ca++, PTH, etc normal), imaging shows large thick bones, chalk stick fractures

Red swollen tongue, spoon-shaped nails, weak. What is it and describe what you would see on CBC?

Iron deficiency anemia This is a microcytic hypochromic anemia so you would see low MCV. Also low Hb.

Resistance to what drug is achieved by bacteria decreasing their catalase-peroxidase activity through KatG mutations?

Isoniazid Bacterial catalase-peroxidase is needed to convert isoniazid to its active metabolite Bacterial catalase-peroxidase is encoded by KatG

Why does Isoniazid cause a B6 deficiency

Isoniazid is chemically similar to B6 and compete with it in the synthesis of neurotransmitter (ex, GABA), resulting in defect end products. This usually manifests as peripheral neuropathy. Isoniazid also increases urinary excretion of B6

β selective agonists

Isoproterenol (β₁=β₂) Albuterol, salmeterol, terbutaline (β₂>β₁)

Locked in syndrome

Issue in the *ventral pons*- Common causes include stroke of the ventral pons, which is supplied with the basilar artery, or central pontine myelinolysis They are completely awake and cognitively intact but cant move extremities or face and usually can only blink and move eye vertically (this is a function of the rostral midbrain)

How does leuprolide work for treatment of BPH?

It is a GnRH analog, but when given continuously, it has antagonist action. Decreases anterior pituitary release of LH which in turn decreases testosterone production

tuberculoid vs lepratomous leprosy

Its a spectrum so can have a range of severity Most severe form= lepromatous. occurs in pts with wk Th1 immune response Less severe form= tuberculoid. occurs in pts with normal immune response. mild skin plaques

Chronic myeloproliferative disorders are a/w what mutation?

JAK2 mutation- results in cytokine-independent activation of JAK-STAT pathway These disorders include polycythemia vera, essential thrombocytosis, and myelofibrosis

What is K-ras? (eg transcription factor, tyrosine kinase, GTPase, etc)

K-ras is a *GTPase* that participates in cell signaling. Implicated in colon, pancreatic, and lung cancers.

Ketamine and opiod tolerance

Ketamine is a *noncompetitive NMDA receptor antagonist* that blocks the actions of glutamate thereby blocking morphine tolerance (Stimulation of NMDA by glutamate causes increased phosphorylation of opioid receptors and increased NO levels- these things are implicated in opioid tolerance )

Should test what before initiating metformin treatment?

Kidney function (probably liver fx too) Metformin increases gut lactate production by anaerobic glycolysis. *Need good liver and kidneys to clear the lactic acid* contraindicated in pts with CHF, alcoholism, sepsis b/c of ↑ risk lactic acidosis

Trace the L gastroepiploic back to the aorta?

L gastroepiploic, splenic artery, celiac trunk, aorta

2 major watershed areas of the intestines

L splenic flexure (SMA and IMA) and distal sigmoid colon (IMA and hypogastric)

Spinal level at which SMA leaves aorta?

L1

At that spinal level can the SMA compress the transverse duodenum

L3

What must be monitored in pts taking TZDs (Thiazolidinediones) for DM?

LFTs Other adverse effects of TZDs: fluid retention, fluid weight gain, precipitation of CHF.

Woman being treated for infertility is administered short course of menotropins followed by single injection of hCG. What is the hCG simulating?

LH surge The menotropin acts like FSH and allows for follicular maturation. The hCG simulates LH surge and induces ovulation

Extraocular eye movements

LR6SO4R3 Lateral Rectus= CN6 Superior Oblique= CN4 Everything else (Medial rectus, inferior oblique, inferior rectus, superior rectus)=CN3

During DNA replications, the daughter strand that is contructed 3' → 5' is which strand (leading or lagging?)

Lagging Both are synthesized 5'→3' but the lagging strand is formed in pieces, and are constructed towards the replication form 3'→5' The leading strand is sythesized continuously towards the replication fork 5'→3'

Proximal muscle weakness, impotence, dry mouth

Lambert Eaton

Tennis elbow

Lateral epicondylitis d/t overuse of the superficial extensor muscles of the forearm and wrist (eg extensor carpi radialis)

Ethylene glycol- what does it do to the kidney?

Leads to acute renal failure d/t *precipitation of calcium oxalate crystals* (Enveloped shaped) in the tubules. Signs of acute renal failure (oliguria, flank pain, anorexia) within 24-72hr of ingestion Glomeruli appear normal but proximal tubules especially show signs of tubular epithelial damage (ballooning, vacuolar degeneration)

Which part of the heart lies adjacent to the esophagus?

Left atrium

Visualized with silver stain. Grown on charcoal yeast supplemented with cysteine (BCYE)

Legionella

Sandfly- a/w?

Leishmania donavani Visceral leishmaniasis, spiking fevers, hepatosplenomegaly, pancytopenia, macrophages containing amastigotes

hepatosplenomegaly, pancytopenia, macrophages containing amastigotes

Leismania donavani

Name the derm pathology and what you'd expect on histo: Polygonal, planar, pruritic, purplish plaques with finely reticulated scale, a/w chronic Hep C, involves wrists, elbows, oral mucosa

Lichen planus Histo shows sawtooth infiltrate at dermal epidermal junction

Use of what antibiotic is linked to serotonin syndrome?

Linezolid has weak MAO inhibitor effects, so if administered in pt on SSRI, serotonin syndrome

Dystrophin

Links intracellular actin to transmembrane proteins (α and β dystrophiglycans) which are linked to the ECM. Loss of dystrophin= myonecrosis Duchenne- X-linked defect in dystrophin gene

Best insulin type to use for postprandial hyperglycemia?

Lispro, Aspart, or Glutisine (peak quickly, short acting)

Granulomatosis infantiseptica a/w what infection

Listeria monocytogenes

Name 3 mood stabilizers

Lithium Valproate (Depakote) Carbamazepine (Tegretol)

Rubella vaccine is what kind of vaccine?

Live attenutated (MMR)

Major tissues GLUT2 is found on?

Liver, pancreas, kidney, small intestine. Insulin-independent tissues. Bidirectional.

Senile cardiac amyloidosis

Localized amyloidosis Deposition of non-mutated serum *transthyretin* in the heart asymptomatic, seen in the elderly

Where does osteosarcoma usually occur?

Long bone, classically distal femur or prox tibia around knee), METAPHYSIS

2nd generation anti-histaminics: name them

Lorat*adine* Fexofen*adine* Deslorat*adine* Cetirizine

Cranial Nerve III Palsy

Lose innervation to the Superior/Inferior Rectus, Inferior Oblique, Medial Rectus, and Levator palpebrae superioris Eye is "down and out" with pupil dilated, ptosis, loss of accomodation, diagonal diplopia Most dreaded cause is enlarging intracranial aneurysm

What would a Quad screen that indicates and Down syndrome baby look like?

Low AFP Low free estriol High hCG High Inhibin A Would confirm with amniocentesis

An inhaled anesthetic that has a low AV concentration gradient will have what other characteristics (peripheral tissue solubility, onset of action)?

Low AV gradient means not much is taken up by peripheral tissues. Less anesthetic is required to saturate the blood, and the concentrations in the brain will equilibrate faster.

Primary indication for use of niacin (lipid-lowering agent)

Low HDL Of all the lipid lowering agents, this has the greatest effect on increasing HDL

Dopamine's actions at low vs high dose?

Low dose: stimulates D1 = renal vascular smooth muscle relaxation Higher dose: stimulates β1 on heart= ↑SBP Very high dose: stimulates α1 on systemic vasculature = ↑ afterload = ↓cardiac output

Describe the murmur you would here hear with a VSD?

Low pitched holosystolic murmur best heard at the L sternal border, accentuated by hand grip (increase L →R shunt through VSD)

Hyperventilation will more significantly increase the speed of induction of an inhaled anesthetic with high or low blood solubility?

Low solubility increased ventilation = greater increase in arterial tension for a substance with high solubility (like NO)

Why do pts with crytorchidism have low sperm count, but have normal testosterone levels?

Low sperm count is d/t heat-induced damaged of the *seminiferous tubules* (from being up in abdomen) seminiferous tubules contain *sertoli cells* Damage of these cells = poor spermatogenesis. inhibin will be low and FSH high Hormonal function of Leydig cells NOT imparied (so normal secondary sexual development)

correcting serum sodium too fast? (low to high vs high to low?)

Low to high, the pons will die (central pontine myelinosis) High to low, the brain will blow (cerebral edema/herniation)

Panacinar emphysema r/t ATA1 deficiency most severely affects what area of the lungs?

Lower lobes because they receive relatively greater perfusion, so greater degree of neutrophil infiltration down there →↑elastase activity Centriacinar emphysema typically affecter upper lobes Mnemonic- you Pee down

Ixodes tick- a/w?

Lyme disease, Erlichlosis, and babesiosis

Histones are rich in what amino acids?

Lysine and arginine + charged, interact with neg charged phosphate groups on DNA

Basic amino acids?

Lysine, Arginine, Histidine

Stages of Paget disease

Lytic (Osteclastic) Mixed (Osteoclasts and osteoblasts) Sclerotic (Osteoblastic) Quiescent (minimal activity of both)

M1 M2 and M3 receptors are found where respectively?

M1- brain (Gq) M2- heart (Gi- decr HR) M3- everywhere else (Gq- bronchoconstriction, detrusor contractor, pupillary sphinter and ciliary muscles, GI movement, sweat)

Fever, wt loss, diarrhea in AIDs pt + hepatosplenomegaly, anemia, ↑ALP and ↑lactate dehydrogenase. Acid fast and optimal growth at 41ºC. What is it and what should have the prophylaxis been?

MAC, azithromycin

MAOis and tyramine containing foods?

MAOi prevent degradation of tyramine in the gut. Tyramine is a sympathomimetics and can travel in the blood, enhance adrenergic activity, and cause HTN. Hypertensive crisis can ensue (HA, tremor, blurred vision) Wine, cheese, sausage. Classically person eats of pizza

Should wait at least 2 weeks after discontinuing an MAOi before starting an SSRI- Why?

MAOi's bind monoamine oxidase and inhibit their action in breaking down serotonin, NE, and dopamine. If you start an SSRI right away, you will now have HIGH serotonin but a lack of functioning enzymes to metabolize it. Need to allow time for more, unbound, functioning MAO to be regenerated to avoid serotonin syndrome.

Hypoglycemia after prolonged fasting with inappropriately low ketones?

MCAD deficiency (impaired β oxidation of fatty acids) (MCAD= medium chain acyl-CoA dehydrogenase)

"unhappy triad" knee injury

MCL, ACL, medial meniscus is the classic triad, although lateral meniscus is actually much much more common

What GI sxs would you expect to see with MEN 1?

MEN1= parathyroid, pituitary, and *endocrine pancreatic tumors, commonly Zollinger-Ellison Syndrome*. ZE is a gastrin-secreting tumor of the pancreas and can cause recurrent ulcers, abd pain, diarrhea

Distinguish key presentating signs of myasthenias gravis and Lambert eaton

MG--> FEMALE, presents with ptosis and extraocular eye weakness Lambert Eaton --> MALE presents with bilateral proximal muscle weakness esp in lower extremities. May have h/o smoking

Most common cause of death in pts with diabetes?

MI

Phenytoin

MOA: Na+ channel blocker (decrease firing of presynaptic neuron) Use: status epilepticus (with benzo), generalized sz SE: gingival hyperplasia, teratogenic, generalized LAD, hirsuitism, SLE-like syndrome, megaloblastic anemia, peripheral neuropathy

Foscarnet

MOA: Pyrophosphate analog; Binds to pyrophosphate binding site of viral DNA polymerase and inhibits it. No activation by viral kinase required Use: CMV retinitis in immunocompromised whe ganciclovir fails, acyclovir resistant HSV AE: nephrtoxic

Bupivacine- MOA and toxicity?

MOA: amide anesthetic, blocks intracellular portion of voltage-gated Na⁺ channels→ prevents depolarization→ no initiation or conduction of a pain signal Adverse effects: *severe cardiotoxicity*

Cylcosporine- MOA, use, SE

MOA: calcineurin inhibitor, binds cyclophilin and blocks T cell activation by preventing IL-2 transcription Use: transplant rejection prophylaxis, psoriasis, RA SE: nephrotoxicity is major one

Flucytosine: MOA and Use

MOA: inhibits DNA and RNA synthesis by conversion to 5-FU (by cytosine deaminase); 5-FU inhibits thymidylate synthase (dUMP --> dTMP) Use: Crytococcal meningitis (+AmphoB)

Tetrabenazine- MOA, Use

MOA: inhibits vesicular monoamine transporter (VMAT)- limit DA packaging and release Use: Hungtingtons

Cidofovir

MOA: inhibits viral DNA polymerase. no activation by viral kinase required Use: acylvoir-resistant HSV or CMV retinitis in immunocompromised pt AE: Nephrotoxic (coadminister with probenecid and IV saline)

Rapamycin (sirolimus)- MOA

MOA: mTOR inhibitor blocks T cell activation and B cell differentiation by blocking IL-2 signaling NON-NEPHROTOXIC.

Varenicline- MOA

MOA: partial agonist of α₄β₂-nicotinic Ach receptor (implicated in development of dependence) → competes with nicotine at this receptor. Since partial agonist, helps reduce sxs of nicotine withdrawal but causes less downstream feel goodies than nicotine.

MPS I vs MPS II

MPSI= Hurler. α-L-iduronidase deficiency, leading to accumulated heparin and dermatan sulfate. Present with developmental delay, coarse facial features, corneal clouding, hepatosplenomegaly, dwarfism, frequent infx. AR MPSII= Hunter. Iduronate sulfatase deficiency, leading to accumulated heparan sulfate and dermatan sulfate. Present with *Mild Hurler*, aggressive behavior and *NO CORNEAL CLOUDING*. Xlinked recessive

Increased anion-gap metabolic acidosis- causes

MUDPILES Methanol Uremia DKA Propylene glycol Iron tablets or isoniazid Lactic acidosis Ethylene glycol Salicylates

Osteoclasts differentiate from?

Macrophages/monocytes

calculating a maintanence dose?

Maintenance dose= [(target plasma concentration at steady state) * (Clearance) * (time b/w doses)] / oral bioavailability oral bioavailability will be 1 if given IV

Sensation to the medial forearm?

Medial cutaneous branch of the ulnar nerve

Lateral vs Medial lesions of the cerebellum?

Medial lesions: midline involved in motor execution, rapid and slow eye movements so tends to produce gait ataxia and imbalance, truncal ataxia, nystagmus Lateral: hemispheres are involved more in coordination so tend to see dysdiadochokinesis, dysmetria, limb ataxia, intention tremor, and scanning speech

Findings in a transtenorial (uncal) herniation

Medial temporal lobe hernaties down through the space between the crus cerebri and the tentorium. MCC is a ipsilateral mass lesion. Presenting signs relate to compression of CNIII (present with fixed, dilated pupil with paralysis of oculomotor muscles) and compression of ipsilateral PCA (contralateral hemianopsia w/ macular sparing. Other possible complications include hemiparesis, brainstem hemorrhages

Which hernia is medial to epigastric vessels? Lateral?

Medial- direct Lateral- indirect

Atrophy of the thenar eminence- what nerve lesion?

Median nerve

What brain tumor has psamomma bodies, and what is this tumor derived from?

Meningioma Derived from arachnoid cells

High activity of what enzyme would increase risk of plaque rupture?

Metalloproteinases, which are released by activated macrophages This is why ongoing intimal inflammation is bad (because ↑activated macrophages=↑metalloproteinase relase = plaque instability)

Most common malignant hepatic lesion

Metastasis to the liver NOT HCC

BRAF protein kinase mutation is present is a pt with a brain tumor. what type of tumor do you suspect?

Metastatic melanoma

methanamine stain ID's what fungi? mucicarmine stain ID's what fungi?

Methanamine = pneumocystis jirovecii (will show disc/condom shaped yeast forms; extracellular) Mucicarmine= crytococcus neoformans (will stain capsule red; extracellular)

Fracture of the pterion would cause damage to what artery?

Middle meningeal Which is a branch of the maxillary (which is a branch off the external carotid)

Injury to the radial nerve mid-humerus vs at the radial head?

Midhumerus- have weakness in the posterior compartment + sensory deficits (affects both the deep and superficial branches) Radial head- only get the deep branch; weakness in extensors but sensation is intact

minute ventilation vs alveolar ventilation

Minute ventilation (VE)- volume of air that enters or leaves the lungs and airways per min; accounts for all air (even dead space) Alveolar ventilation (VA)- volume of air participating in gas exchange per minute (doesn't include dead space)

MELAS

Mitochondrial Encephalopathy with Stroke-Like Episodes and Lactic Acidosis Mitochondrial Disease, so only female can pass it on. Will see *heteroplasmy*, meaning that there will be inherited a lot of different mtDNA, and so the severity will vary depending on how much mutated mtDNA is present. Clinical: "red ragged fibers", muscle fibers with "blotchy red appearance" on Gomori trichome stain, abnormal mit accumulate. seizures trigged by starle, muscle weakness

Treatment of narcolepsy

Modafinil: non-amphetamine stimulant, MOA not well known but thought to enhance dopaminergic signaling First line for treatment b/c effective and less side effects and less abuse potential than amphetamines

CD14

Monocyte-macrophage lineage

How do you treat the manic phase of bipolar?

Mood stabilizer + atypical antipsychotic Mood stabilizers may also be used as a monotherapy, and are effect as such in 60% of pts MS: lithium**, valproate*, carbamazepine AA: Olanzapine, risperidone, aripipirazole

Of all the mood stabilizing agents, which ones also have anti-convulsant activity?

Mood stabilizers: Lithium, Carbamazepine, Valproate Also anti-convulsants: Carbamazepine, Valproate

Femoral hernia

More common in women Protrude through the femoral ring- lateral to the pubic tubercle and lacunar ligament and medial to the femoral vessels.

Primary CNS Lymphoma

Most common CNS tumor in immunocompromised pts! A/w *EBV* Most are *B cell origin*, with diffuse large B cell being most common subtype Poor prognosis

9yo boy with fever, throat pain, and worsening dysphagia. Peripheral blood smear show blasts.

Most common peds malignancy is acute lymphoblastic leukemia. T-all is more likely to present with anterior mediastinal mass (can compress great vessels and the esophagus). T-ALL is most commonly in males. Mnemonic: T-ALL, T-cells, thymus infiltration, testes (can spread there and think males)

Essential tremor

Most commonly dx'd movement disorder Autosomal dominant Worsens while particular posture is being maintained Sxs improve with alcohol Treat with propranolol (nonselective β blocker)

Musculocutaneous nerve

Motor: flexors (biceps brachii, coracobrachialis, brachialis) Sensory: Lateral forearm (lateral cutaneous branch of the forearm)

Shaken baby syndrome

Movement of immature brain in relation to the skull leads to tearing of bridging veins and a subdural hematoma Other signs include bilateral retinal hemorrhages

What defines a gastric erosion?

Mucosal defect that does not extend fully through the muscularis mucosa (limited to the mucosal layer) Distinguish from ulcers, which penetrate through the mucosa and extend into the submucosal layer

Elevated AFP in pregnant mom- what are the causes?

Multiple gestation Neural tube defects Abdominal wall defects Dating errors

GTOs are sensitive to?

Muscle *tension* (not passive stretch or changes in length)

Major side effects of statins?

Myopathy Hepatotoxicity

Difficulty loosening grip after handshake or after grabbing doorknob, testicular atrophy, long narrow face with high arched palate

Myotonic dystrophy (DM1)

Prevention of NE extravasation (during IV NE drip)

NE extravasation is a complication of NE infusion-- local necrosis of tissue caused be leak of NE and α1 vasoconstriction Prevent with local injection of *phentolamine* which is a reversible α1 blocker

Aminoglycosides adverse effects

NNOT Nephrotoxicity (acute tubular necrosis), neuromuscular blockade, ototoxicty, teratogen

Secondary TB- involvement of mediastinal nodes or no?

NO

Treatment of *acute* gouty arthritis?

NSAIDs are first line for acute gout attack *Prevention* with allopurinol/uricosuric agents

Glucocorticoids can cause what sort of electrolyte imbalance?

Na+ retention and K+ loss d/t cross reactivity with mineralocorticoid receptors

Who has IgA protease and how does it work?

Neisseria gonorrhea and meningitidis Mucosal surfaces release secretory IgA, which binds and inhibits actions of pilli, fimbriae, and other cell surface components that normally help mediate mucosal adherence. IgA protease cleaves this secretory IgA, facilitating mucosal penetration

Medullary thyroid cancer- histo

Nests of polygonal cells w/ Congo red+ amyloid deposits Derived from parafollicular C cells

Amniocentesis shows high AFP and high AChE- what is likely dx?

Neural tube defect

Ewing sarcoma is derived from?

Neuroectoderm

Immunoreactivity of a CNS tumor for synaptophysin indicates what origin?

Neuronal origin These compose less that 1% of all CNS tumors (majority are if glial orgin, with meningiomas and pituitary adenomas being next most common)

Major tissues GLUT-3 is found on?

Neurons

What cell types are most susceptible to increased oxidation in Vit E deficiency?

Neurons with long axons and erythrocytes

Hypocretins (orexins)

Neuropeptides produced in the lateral hypothalamus that promote wakefulness, inhibit REM sleep ↓ hypocretin in the CSF is a/w narcolepsy w/ cataplexy (loss of motor tone triggered by emotion)

Isoniazid toxicity

Neurotoxicity Mild hepatotoxicity (may prevent as just fever, anorexia, nausea; occurs within 4-6mo of treatment) Mnemonic- Isoniazid (INH)= Injures Neurons and Hepatocytes

Isoniazid toxicities

Neurotoxicity (peripheral neuropathy, B6 def), hepatotoxicity, SLE

Tetrodotoxin

Neurotoxin found in pufferfish, a Japanese delicacy binds voltage gated Na+ channels in nerve and cardiac tissue, prevent sodium influx and depolarization Sxs: dizziness, weakness, loss of reflexes, paresthesias, n/v/d; if high dose, HoTN, paralysis, death from resp failure

Goal= raise HDL. What pharm agent is most appropriate?

Niacin (B3)

What lipid-lowering agent is a/w development of gout?

Niacin (B3) MOA: reduces hepatic synthesis of VLDL and triglycerides, increases HDL, inhibits lipolysis in adipose tissue Other adverse effects: hyperglycemia (can cause acanthosis nigricans), cutaneous vasodilation (prevent with aspirin prior to administration), hepatitis

What adjustments may need to be made in a pt started on Niacin who are already being treated for HTN and DM

Niacin may potentiate effects of anti-HTNives because of their vasodilatory effects- so decreased this med Niacin promotes hyperglycemia so increase this med

Rabies virus can bind to what cellular receptors?

Nicotinic ACh receptors

Nitroglycerin vs Nitroprusside

Nitroprusside: used in hypertensive emergency. Causes direct release of NO, ↑cGMP, and SM relaxation. Works on both arteries and veins Nitroglycerin: Used for acute coronary syndrome, causes ↑NO, ↑cGMP, and SM relaxation. Dilates veins >>> arteries so ↓preload

In Barrett's esophagus, nonkeratinized stratified squamous epithelium in the esophagus is replaced by?

Nonciliated columnar epithelium with goblet cells (intestinal epithelium)

Pilocarpine

Nonselective muscarinic receptor agonist Use for open angle glaucoma (contracts ciliary muscle of the eye), closed angle glaucoma (contracts pupillary sphincter). Resistant to AChE

How do TNF-α, glucocorticoids, catecholamines, and glucagon all increase insulin resistance?

Normally, insulin binds to its receptor on tissues, and initiates downstream signaling that eventually results in insertion of GLUT-4 receptors, thereby decreasing blood glucose. These things listed all work by activating cellular serine kinases, causing *serine phosphorylation of IRS-1* (which is part of the signaling pathway). This inhibits downstream signaling and induces insulin resistance. Note that high FFA also contribute to insulin resistance.

Acute effects of corticosteroid administration on CBC?

Notably, corticosteroid administration results in INCREASED neutrophil count, due to "demargination" of leukocytes that were attached to the vessel wall. According to FA, corticosteroids also decrease activation of neutrophil adhesion molecules. Otherwise, see low everything else (low lymphocytes, eiosiniophils, monocytes, basophils because corticosteroids are immunosuppresants,

Adverse effects of furosemide?

OH DANG Ototoxicity, hypokalemia, dehydration, Allery (sulfa), nepritis (interstitial), Gout

Collagen Synthesis- key steps and locations

Occurs in fibroblasts, osteoblasts, and chondroblasts. 1) N-terminal signal sequence direct polypetide chain to the RER (this is a pre-pro-α chain) 2) in RER, cleave signal sequence, leaving pro-α chain 3) in RER, post-translational modifications help stabilize the chain. Includes hydroxylation of proline and lysine residues and glycosylation of hydroxylysine residues. 4) Form procollagen triple helix, which is then exported to the Golgi 5) In the Golgi, package procollagen for secretion into the extracellular space 6) In extracellular space, cleave the C and N propeptides to convert procollagen to tropocollagen 7) Tropocollagen assesble with each other to form fibrils. Lysyl oxidase cross links these fibrils to increase strength

Pygmalion effect

Occurs when a researcher's belief in the efficacy of a treatment changes the outcome of that treatment (observer-expectancy bias)

Why use octreotide to treat esophageal varices?

Octreotide is a somatostain analog Somatostain promotes splanchnic vasoconstiction indirectly by inhibiting secretion of vasoactive peptides (VIP, glucagon). Does not cause any system vasoconstriction.

Risk analysis using 2x2?

Odds Ratio- use for case-control studies (retrospective, observatonal; look at group with and without disease, and look for prior exposure) Relative Risk- (pro or retrospective, observational) use for cohort studies (look at group with and without exposure/risk factror and see if it incr likelihood of disease) Attributable risk- difference in risk between the exposed and unexposed groups (proportion of disease occurance that are attributable to the risk factor)

If treatment of severe allergic asthma with β agonists and corticosteroids are not effective enough, what can you add?

Omalizumab monoclonal antibody against IgE

Only DNA virus to replicate in the cytoplasm, and only RNA virus to replicate in the nucleas?

Only DNA to replicate in the cytoplasm: pox Only RNA to replication in the nucleus: retro

Most notable adverse effect of ethambutol?

Optic neuritis Clinically, manifests as central scotoma, decreased visual acuity, or color blindness Should periodically monitor visual acuity in pts taking it Reversal with discontinuation of the drug

Recurrent nosebleeds and spider-like lesions on oral and nasal mucosa, face, and arms

Osler-Weber-Rendu (aka hereditary hemorrhagic telangiecta) Autosomal dominant inheritance of congenital telangiectasias on skin and mucosal membranes; rupture of these can lead to nose bleeds, GI bleeds, and hematuria

Metastatic prostate cancer- osteolytic or osteoblastic lesions?

Osteoblastic

Osteosarcoma is a malignant proliferation of?

Osteoblasts

Which connective tissue pathology is due to impaired collagen triple helix synthesis?

Osteogeneis imperfecta

Multiple myeloma- osteolytic or osteoblastic lesoins?

Osteolytic

Pancytopenia, recurrent fractures, vision and hearing impairment, renal tubular acidosis?

Osteopetrosis (d/t CAII mutation)

Pertussis toxin mechanism

Overactivates AC → ↑cAMP by disabling Gi → impair phagocytosis

MPO and NADPH oxidase...what does what?

O₂ → O₂∙¯ via NADPH oxidase O₂∙¯ → H₂O₂ via superoxide dismutase H₂O₂ → H₂0 via catalase H₂O₂ → HOCl ("hydroxy-halide radical") via MPO

45yo woman with h/o fatigue and pruritus develops pale stools and xanthelasma

PBC

Antimitochondrial antibodies?

PBC

Drug of abuse that is most likely to induce violent behavior

PCP

Most common presenting infection in SCID infants.

PCP In general, will have recurrent infections caused by bacteria, viruses, fungi, and protozoa occur in early infancy (3 months of age). Indicative of both T and B cell dysfunction.

PDE3 vs PDE5

PDE3= breaks down cAMP (inhibited by cilastozol, methyxanthines) PDE5= breaks down cGMP (inhibited by sildenafil)

Catalase + organisms

PLACESS Pseudomonas, Listeria, Aspergillus, Candida, E. Coli, S. aures, Serratia.

As disease prevalence increases, what epidemiological factor also increases?

PPV Similarly, as prevalance increases, NPV decreases

Onion skin fibrosis of the bile duct?

PSC

Factor VII deficiency would affect what lab value(s)?

PT EXTRINSIC PATHWAY

PTH action on the bone

PTH activates osteoblasts, stimulating expression of RANKL and OPG. RANKL can interact with RANK on preosteoclasts, promoting differentiation/maturation (break down bone and release Ca++ and Phos). RANKL also interacts with OPG, a decoy receptor that prevents osteoclast maturation (counteract its own effects)

In zone 2 of the lungs, what drives blood flow?

Pa>PA>Pv difference between arterial pressure and alveolar pressure drives blood flow

What determines PaO2? what about O2 content?

PaO2 is a measure of how well O2 can diffuse from the alveoli to the blood. It is only decreased in cases where theres and A-a gradient, or when PAO2 is low (high altitude, hypoventilation) O2 content is a measure of O2 concentration in the blood. and is decreased in when Hb is low (anemia) or unavailable (CO)

Thyroid cancer: Orphan annie eye nuclei?

Papaillary cancer of the thyroid

Psammoma bodies are seen in what thyroid cancer?

Papillary carcinoma of the thyroid

Thryroid cancer: psammoma bodies?

Papillary carcinoma of the thyroid

Pathogenesis of Lambert Eaton as a paraneoplastic syndrome of small cell lung cancer?

Paraneoplastic syndromes often are a results of autoimmune reactions secondary to the neoplasm producing crap. In Lambert Eaton, there is development of autoantibodies directed against presynaptic voltage gated Ca++ channels, preventing release of neurotransmitter.

Invariant chain and MHC

Part of MHCII molecule. Helps hold the heterodimer together as it tracels up through the RER/Golgi, then is cleaved/digested by macrophages and replaced by antigen which came into phagolysosome.

Platelet activating factor

Part of inflammtory response (produced by several inflam. cells including neutrophils, endothelial cells, platelets, macrophages) Promotes platelet activation and aggregation, mediates leukocyte functions, bronchoconstriction, vasoconstriction Signal through Gq

What is the smallest DNA virus?

Parvovirus This is also ss

Most common viral cause of aplastic crisis in a sickle cell patient?

Parvovirus B19

Holoprosencephaly, cleft lip and/or palate, microophthalmia, polydactyly, omphalocele, rocker bottom feet

Patau syndrom (trisomy 13)

Lung abscess causes by aspiration is most likely to contain what species?

Peptostreptococcus Fusobacterium Bacteriodes These are all anaerobes usually found in the oral cavity Risk factors for aspiration= sz, alcoholics, dementa, CVA

Where do lung adenocarcinomas arise typically in the lung?

Peripherally These are the most common types of lung cancer in smokers and overall

QRS corresponds to what "phase" on the ventricular myocyte action potential?

Phase 0 (Na+ influx= depolarization)

α1 selective agonists

Phenylephrine, methoxamine

Drugs that cause folic acid deficiency?

Phenytoin, Methotrexate, Sulfonamides

GFAP+ part cystic part solid brain tumor in a kid. Histo shows eiosinophillic, corkscrew fibers

Pilocytic astrocytoma The histo is showing Rosenthal fibers

Cerebellar tumor in a child- what is top on your differential?

Pilocytic astrocytoma (benign) Medulloblastoma (malignant)

Which beta blockers also have partial agonist activity?

Pindolol and Acebutolol

Pt with sxs of Cushing syndrome, borderline elevated ACTH, serum cortisol is suppressed by high dose by not low dose dexamethasone.

Pituitary adenoma distinguish from an ectopic ACTH secreter (eg small cell) in which neither high nor low dose would suppress

What is the defect in osteopetrosis?

Poor osteoclast function; multiple genetic variants. high yield one is CAII mutation, which normally helps create an acidic environments that helps remove Ca++ from bone.

Enzyme deficient in acute intermittent porphyria?

Porphobillogen deaminase Aka Uroprophyrinogen synthase I compare with porphyria cutanea tarda which is a deficiency in Uroprophyrinogen synthase III and lead poisoning which inhibits ALAD

Where do positive and negative selection of T cells occur in the thymus?

Positive selection in the thymic cortex, negative in the medulla

Post-strep glomerulonephritis follows which form(s) of GAS infection? What about rheumatic fever?

Post-strep glomerulonephritis can follow either GAS impetigo or pharyngitis. Rheumatic fever can only follow pharyngitis

Spina bifida is a failure of closure of what?

Posterior vertebral arch

Serotonin Syndrome

Potential adverse effect of any drug that increases serotonin DAMN Fuucking Serotonin Diarrhea, AMS, Motor (hyperreflexia, myoclonus), Nausea, Flushing, Sweating Others- tachycardia, CV collapse Treatment: Cyproheptadine (5HT2 receptor antagonist)

What is the largest DNA virus?

Poxvirus

α₁ selective antagonists

Prazosin, terasozin, doxazosin, tamsolosin

Precision, Reliability, and Accuracy

Precision=Reliability= consistency Accurate=is it right/close to actual value

Retinopathy of prematurity

Premees commonly have surfactant deficiencies and they are treated with supplemental O2 at high concentrations. Local hyperoxia in the retina induces changes that cause ↑VEGF → retinal proliferation (neovascularization and possible retinal detachment w/ blindness

What finding in MS supports the theory that is may be autoimmune?

Presence of IgG in the CSF, detected as oligoclonal bands on electrophoresis Note that this is a theory, and there are other factors

Best indicator of severity in mitral regurgitation

Presence of audible S3

How/where does cocaine work?

Prevents reuptake of neurotransmitters (similar to TCAs and amphetamines). + psychological effect d/t DA. Stimulant

Most common CNS tumor is immunocompromised

Primary CNS Lymphoma Derived from B cells and EBV infection Poor prognosis

Addison's Disease

Primary adrenal insufficiency (d/t adrenal atrophy, autoimmune, TB, etc) Clincal signs: hyperpigmentation (increase POMC to get more ACTH, result in also increase in MSH), hypotension, hyperkalemia, normal anion gap metabolic acidosis. Spares medulla

Autoimmine destruction of intrahepatic bile ducts and cholestasis. See granulomatous inflammation.

Primary biliary cirrhosis

How would you distinguish primary from seconary adrenal insufficieny

Primary: destruction of the adrenal cortex. Result in increased ACTH, hyperpigmentation (incr MSH), hyperkalemia (d/t low aldo) Secondary: Low ACTH. No hyperpigmentation and no hyperkalemia (aldo is stimulated by renin-angiotensin, not ACTH)

episodic and transient anginal chest pain, occuring during nighttime hours. Transient ST elevations noted on holter monitor.

Prinzmetal angina coronary artery vasospasm typically occurs with rest and usu occurs near sites of atherosclerosis Ergonovine test can provoke it (ergot alkaloid that constricts smooth muscle by stimulating α1 and 5HT receptors)

Thromboxane A2

Pro-aggregation factor that is produced within and released by platelets. Membrane phospholipids are converted to TXA₂ though the arachodonic acid/COX pathway.

Positive Predictive Value (PPV)

Probability of true positives within the positive test results. =TP/(TP+FP) =a/(a+b)

Production and catabolism of GABA

Produced from glutamate within neurons, use glutamate carboxylase and B6 cofactor Breakdown by transamination by GABA transaminase and B6 cofactor

Calcineurin

Protein phosphatase, upregulates NFAT which activates of IL-2 transcription→ T cell proliferation

Changes in cell type as you move down the respiratory tree?

Pseudostratified ciliated columnar cells= Trachea, bronchi Simple colunmar/cuboidal= bronchioles Simple cuboidal= Respiratory bronchioles, alveolar ducts Simple sqaumous= alveolar sacs

Man presents with bilat lesions over the elbows. Bx shows very thin strarum granulosum and prominent parakeratotic stratum corneum with occasional foci of neutrophils

Psoriasis

What key histo finding do you expect to see in glioblastoma multiforme?

Psuedopalisading necrosis (central foci of necrosis surrounded by columns of tumor cells) New capillaries may be seen at the periphery

Prolactin-induced hypogonadism

Pts with prolactinomas will have excessive negative feedback on the hypothalamus, resulting in decreased release of GnRH As a result, they may experience amennorhea, anovulation, low estrogen (leading to increased risk for bone fractures and vaginal dryness)

Cardiac tissue conduction velocity (fastest to slowest?)

Purkinje system Atrial muscle Ventricular muscle AV node

Trace the R gastric artery back to the aorta?

R gastric, proper hepatic, common hepatic, celiac trunk, aorta

Trace the R gastroepiploic back to the aorta?

R gastroepiploic, gastroduodenal, common hepatic, celiac trunk, aorta

anti-cyclic citrillinated peptide (anti-CCP) antibodies --> highly specific for what disease?

RA

Major tissues GLUT-1 is found on?

RBCs, cornea, brain (endothelial cells of BBB). Insulin independent.

Calculating RBF

RBF= RPF / (1-Hct) RBF= (PAH clearance)/(1-Hct)

SA and AV nodal arteries arise from what coronary artery in most people?

RCA

Neuron with shrunken nuclei, no detectable Nissl substance, and intensley eiosinophillic cytoplasm?

RED NEURON irreversible injury

What are your killed vaccines?

RIP Always Rabies, Influenza, Poli (Salk), Hep A

Calculating renal plasma flow given PAH?

RPF= (urine [PAH] * urine flow rate) / (plasma [PAH]) RPF= PAH clearance

Red man syndrome is d/t to what exactly?

Rapid infusion of vancomycin causes non-specific mass cell degranulation, leading to widespread histamine release NOT IgE MEDIATED.

Caudal regression syndrome

Rare birth defect in which there is incomplete development of the caudal region. Babies are born with sacral and sometimes lumbar agenesis, flaccid paralysis of legs, dorsiflexed ft, urinary incontinence. A/w poorly controlled maternal diabetes

Stewart-Treves Syndrome

Rare complication of chronic lymphedema Formation of cutaneous angiosarcomas Classically r/t woman who underwent radial mastectomy and has had chronic lymphedema in ipsilateral arm. Present many years later with multiple, firm, violaceous nodules on ipsilateral upper arm Poor prognosis

Carotid paraganglioma

Rare neuroendocrine tumor Most common of the head and neck paragangliomas Related to pheochromocytomas Presents as painless mass in the neck Readily metastasizes

Reid Index

Ratio of thickness of the mucous gland layer of the bronchial wall to the thickness of the wall from epithelium to cartilage (but not including cartilage). Should be 0.4 or less. If greater, correlates with duration and severity of chronic bronchitis b/(a+b+c+d)

Top bugs causing reactive arthritis vs septic arthritis

Reactive (Reiter's syndrome) - Chlamydia, GI bugs (Shigella, Salmonella, Yersinia, Campylobacter) Septic- Gonorrhea

Most common presentation of cerebral amyloid angiopathy?

Recurrent hemorrhagic stroke compare with HTNive hemorrhages which are typically more severe.

Termination of the effect of an IV anesthetic is achieved how?

Redistribution to primarily the fat and skeletal muscle (less-perfused, inactive tissues) This is why most drugs used have similar duration of action despite differences in their metabolism

Best insulin type to use for DKA

Regular insulin

Major basic protein

Released by eiosinophils It is anti-parasitic cytotoxin that attaches to and disrupts the outer membrane of helminths. It is also thought to contribute to bronchial epithelial damage in atopic asthma.

In a renal transplant, what is the major blood source for the upper ureter?

Renal artery In a transplant, the prox 1/3 of the ureter comes from the donor and is supplied by branches of the donor renal artery (which is anastomosed with the recipient external iliac) The distal part of the ureter gets is blood from branches off the aorta, iliacs, gonadal a, and vesical a)

Derivative of the renal parenchyma vs caliceal system and ureters?

Renal parenchyma is derived from the metonephric mesoderm (blastema) The collecting system is dervied from the ureteric bud, which is a dorsal outgrowth of the mesonephric duct (also called the metanephric diverticulum)

For pts with stiff lungs, work of breathing is minimized when?

Resp rate is high and tidal volume is low → prefer rapid shallow breaths

For pts with obstructive lung disease, when is work of breathing minimized?

Resp rate that is slow and tidal volume that is high (slow deep breaths) Pursed lip breathing exercises in COPD help to promote this deep breathing

Goodpasture syndrome causes what sort of lung disease?

Restrictive

Person with sjrogen's comes in with joint pain. What is most likely the cause?

Rheumatoid arthritis Sjrogens is a/w other autoimmune diseases, with rheumatoid being one of them

Ribbon-like hyphae branching at 90 degrees

Rhizopus/Mucor cause rhinocerebral infections in diabetics

Beading along the anterolateral aspects of the chest in a kid

Rickets (d/t abnormal mineralization and deposition of osteoid at the costochondral junction) Other findings include "soft bones", bowing of the legs, pigeon breast deformity, frontal bossing

Chemoprophylaxis for close contacts of pts with meningococcal disease?

Rifampin Note that there is a vaccine, but this is typically used as a prophylactic strategy for large populations at risk (military, healthcare workers).

Coronary sinus drains into?

Right atrium

R and L recurrent laryngeals loop under what structures respectively?

Right loops under the R subclavian Left loops under the arch of the aorta

Amenorrhea in pt taking risperidone- why?

Risperidone can cause hyperprolactinemia (b/c anti-dopaminergic effects). Prolactin feeds back on hypothalamus and prevents release of GnRH.

What are Lewy bodies?

Round intracellular eiosinophilic bodies composed of α-synuclein (accumulates in Parkinson's), found within surviving neurons

DNA replication occurs during what phase of the cell cycle?

S

What bug is a/w food poisoning from mayonnaise, meats, custards?

S aureus

S3 and S4 heart sounds

S3= rapid filling of ventricle, volume overload S4= atrial kick against a stiff ventricle

Retroperitoneal structures

SAD PUCKER Supra-renal glands, Aorta and IVC, Duodenum (2nd thru 4th parts), Pancreas (except tail), Ureters, Colon (ascending and descending), Kidneys, Esophagus (lower 2/3), Rectum

CNXI (accessory) lesion- how to see on physical exam?

SCM weakness (can't turn head to the opposite side of the lesion), can't shrug shoulder against resistance

Raloxifene

SERM. Binds to estrogen receptors and exhibits tissue specific behavior that can imitate OR antagonize estrogens natural effects. Has agonist on bone, antagonist on breast and uterus

infant botulism- what do they ingest (spore or neurotoxin?)

SPORE in adult botulism, they ingest the preformed toxin

Viruses that encode for viral proteases that cleave large polyprotein products into several small functioning proteins?

SS, positive sense, nonsegmented, linear, RNA viruses eg picornovirus, hepeviris, calicivirus, togavirus, coronavirus, retrovirus, flavi

What structure is derived from the common cardinal veins?

SVC

Phenotypic heterogeneity

Same mutation causes different phenotypes

What two wrist bones articulate with the radius?

Scaphoid and Lunate (with scaphoid being situated more radially)

Schizoid personality vs Avoidant personality

Schizoid= voluntary social withdrawal, limited emotional expression, content with social isolation Avoidant= hypersensitivity to rejection, socially inhibited, feelings of inadequacy, desires relationships with others Mnemonic- schizoid people couldn't give 2 schits, avoidant people care but avoid.

Intracranial mass that is composed of elogated cells with regular, oval nuclei. Demonstates areas of high and low cellularity

Schwannoma S-100+ The high cellular areas are called Antoni A The low cellular areas are called Antoni B

Brain tumor that is S-100+ is most likely found where?

Schwannoma (acoustic neuroma) most likely found at the cerebropontine angle

Protocol for GBS prevention in neonates?

Screen mom at wk 35-37 for GBS (vaginal and rectal culutres) If + cultures or prior infant with GBS, give intrapartum prophylaxis with penicillin (first line) or ampicillin

What is a ringed sideroblast?

Seen in sideroblastic anemia Erythrocytes with iron-laiden mitochondria surrounding the nucleus d/t defect in protoporphyrin synthesis- iron enters mit to join with proto but not there and gets trapped

Major adverse effects of high dose imipenem

Seizures

Thayer Martin medium vs MacConkey agar....which one is selective and which one is differential?

Selective= TM (use abx to kill off everything but neisseria Differential=Mac (differentiate based on metabolic/biochem properties- in this case, fermenting lactose)

Intraventricular hemorrhage

Serious complication of prematurity, within 5d of birth. Bleeding is typically from the germinal matrix, which in premees is more prominent than full term infants. *Germinal matrix* contains thin-walled vessels lacking glial fiber support→ vulnerable to hemodynamic instability since premees have impaired autoregulation of cerebral flow Clinical: *bulging anterior fontanelle*, HoTN, hypotonia, altered level of consciousness, seizures, coma, *blood in the lateral ventricles*

Abdominal pain and distention, fever, diarrhea, ↓BP, ↑HR in a pt with ulcerative colitis.

Should r/o toxic megacolon (complication of IBD, UC>Crohns). See colonic dilation of more than 6 cm on flat plain XR. DO NOT dod colonoscopy or barium contrast, as it increases risk of perforation

Eplerenone

Similar to spironolactone but fewer side effects competitive inhibitor of aldosterone receptors Use for hyperaldosteronism

Epithelial lining of the fallopian tubes?

Simple columnar

Epithelial lining of the ovaries?

Simple cuboidal ("germina")

Epithelial lining of the uterus?

Simple pseudostratifed columnar

Cricothyrotomy- incision will go through what layers?

Skin Superficial cervical fascia Investing and pretrachial layers of deep cervical fascia Cricothyroid membrane

Name the layers you pass through when doing an LP?

Skin, superficial fascia, deep fascia, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, dura, arachnoid, subarachnoid space.

Inhalation of an anesthetic with a high solubility in the blood will result in a slow or fast onset of action?

Slow Example is halothane- high solubility in the blood=longer to saturate blood and enter the brain

Slow twitch (type I) vs fast twitch muscles (type II)

Slow twitch ("red muscle fibers")- perform actions required *low-level sustained force* (eg postural maintenance). Have *high myoglobin* (O2 store) and *many mitochondria (aerobic met.)* Fast twitch- specialized for generating *rapid forceful* pulses of movement. Type IIb get ATP energy from *anaerobic metabolism* Type IIa though aerobic metabolism.

Elimination of an inhaled anesthetic that is highly soluble in the blood will be faster or slower? Where/how is elimination achieved?

Slower (eg halothane) Elimination is achieved primarily by ventilation, not metabolism.

Lacunar infarct. What is it and how is it different from Charcot Bouchard

Small cavities located in the deep structures of the brain (eg basal ganglia), caused by lipohyalinosis and microatheromas of small penetrating arteries. HTN and DM are predisposing factors. Distinguish from Charcot Bouchard Aneurysms - occur in the same location and with same risk factors, but instead of fatty, occluded vessels they are weakened and ballooned out. -CT would likely appear normal in symptomatic lacunar infart with lipohyalinosis but would not for symptomatic Charcot in which you would see bleeding in that area.

For which lung cancer subtype, even when localized, is inoperable?

Small cell carcinoma- this is treated up front with chemo Non-small call are treated with surgery

A drug with a medium volume of distribution has what properties?

Small, hydrophilic

A drug with a high volume of distribution has what properties?

Small, lipophilic

Conductive hearing loss

Some obstruction or issue in the outer or middle ear (wax, infection); most medically treatable Weber (tuning fork on top of head in the middle)→ sound localizes to the affected ear Rinne is abnormal (bone>air)

How do K+ sparing diuretics work?

Spironlactone and eplerenone= competitive inhibitors of aldosterone receptors Amiloride and triamterene= inhibit Na+ influx though ENac channels in cortical collecting tubule (don't create Na gradient that is needed to dump K+ out)

What are your K+ sparing diuretics?

Spironolactone Triamterene Amiloride

Primary histo finding in pts with eczema?

Spongiosis (epidermal accumulation of edematous fluid in intracellular spaces)

How is Klebsiella spread in the hospital setting?

Spread through person-to-person contact (contaminated hands is the big one). Not spread through the air. Prevent with thorough handwashing, gowns, and gloves

Lung cancer with keratin pearls and intercellular bridges

Squamous cell carcinoma

MEN2A

Square medullary thyroid cancer + parathyroids and pheos

What types of murmurs would squatting enhance?

Squatting increases venous return Will increase R and L preload. Will increase flow though stenotic valves Sitting and lying supine will do the same

Treatment of malaria

Start with chloroquine (mefloquine if resistant)- gets the erythrocyte form Add primaquine if vivax or ovale (gets the form in the liver) If life threatening, give quinidine IV

Type I error (α error)

Stating there is an effect or difference when there is not (null is incorrectly rejected) b/(b+d)

Type II error (β error)

Stating there was not an effect or difference when one truly exists (null is not rejected when it should be) Related to statistical power. Increasing power will decreased β errors (increase power by increasing sample size) c/(a+c)

Goal= lower LDL. What pharm agent is most appropriate?

Statins If still high, may add ezetimibe or bile acid binding resins

Primary indication for use of fibrates vs statins?

Statins main action is lowering of LDL Fibrates main action is increasing clearance of triglycerides

Secretin

Stimulates pancreas to secrete bicarb-rich fluid. main stimulus for secretin to fire is low duodenal pH

That type of epitheiim lines the true vocal cords?

Stratified squamous epithelium (In the airway, only found in the oropharynx, laryngopharynx, anterior epiglottis, upper half of posterior epiglottis, and true vocal cords)

Callus formation- involves what layer(s) of the skin

Stratum cornem

Most common cause of bacterial meningitis in adults of all ages

Strep pneumo

Bisphosphonates

Structural analogs of pyroposphate, which is an impt component of hydroxyapatite Make hydroxyapatite more insoluble and also interfere with osteoclasts bone resorption Careful in pts with renal failure

Pt with tender thyroid- most likely

Subacute (de Quervain) thyroidiitis -s/p flu-like sxs -granulomatous -incr ESR -tender thyroid

Crossover study

Subjects randomly allocated to a sequence of 2 or more treatments given consecutively, washout period added btw treatment intervals to limit confounding; each subject acts as both experimental subject and control

Innervation of the salivary glands

Sublingual and submandibular = facial nerve (CNVII) Parotid gland = glossopharygeal (CNIX)

What step of TCA creates GTP?

Succinyl CoA --> Succinate

Conversion disorder

Sudden loss of certain neurologic functions often following an acute stressor. Workup is completely normal. F>M. Sxs include blindess, weakness, paralysis etc. Distinguish from somatization disorder in which there are typically numerous body systems involved and they have be seeking medical care for many years for their problems

Sensory innervation to the most of the dorsum of the foot

Superficial peroneal

injection in the superiomedial quadrant of the butt can damage what nerves?

Superior gluteal (causing weakness in the glut medius and minimus) and sciatic nerve

Derivatives of the 4th pharyngeal pouch?

Superior parathyroids Ultimobranchial body

Suppression vs Repression

Suppression is a mature defense. Conscious withholding of an idea/feeling (choosing not to worry about a big game) Repression is an immature defense. Involuntary withholding of an idea/feeling (repressing a traumatic event)

Bilateral loss of pain and temperature sensation but sparing of fine touch and position in the upper extremities

Syringomyelia

Primary amyloidosis

Systemic deposition of AL amyloid derived from Ig light chain a/w plasma cell dyscrasias (eg multiple myeloma)

Lateral horns containing the sympathetic preganglionic neurons is present at what spinal cord levels?

T1-L2

Mechanism by which death occurs in pts with TCA overdose?

TCAs act on the heart and *inhibit fast sodium channels* on myocytes. Result in decreased contractility and can lead to arrhythmias and/or cardiogenic shock. NOT d/t accumulation of 5HT or NE in the cleft.

Th1 cells- what do they secrete and what is their major function?

TH1 cell is a type if CD4+ cell. It secretes 1) IL-2 → autocrine proliferation of TH1 cells 2) IFN-Ɣ → activates macrophages.

Define: TIBC Ferritin Transferrin Hepcidin

TIBC is a measure of unbound transferrin in the blood Transferrin is what carries Iron in the blood Ferritin is what iron is attached to when stores. Ferritin and TIBC are always opposite! Hepcidin is the "master regulator" of iron metabolism. It is an acute phase protein from the liver, and decreases absorption of iron in the gut and release of iron from macrophages.

Etanercept

TNFα inhibitor that is used in addition to MTX for treatment of RA (when MTX alone is not enough). It is a fusion protein (links soluble TNFα receptor and Fc component of IgG1. It acts as a decoy receptor for TNF

Rate limiting step of heme synthesis

Take glycine and succinyl-CoA and using ALA synthase and cofactor B6, go to ALA. This step is upregulated by alcohol, barbituates, and hypoxia. It is inhibited by glucose and heme. Recall that the majority of heme synthesis takes place in the erythroid cells of the bone marrow for production of hemeglobin. Small percentage occurs in the liver for production of the detox 450 enzymes

Reactive arthritis

Tends to affect *HLA-B27 +* people Typically folllow *GI infections* (Shigella, Salmonella, Yersinia, Campylocbacter) or *Chlamydia* infections. Presents as asymmetric arthritis of the large joints, but joint aspirates are *sterile* Classic traid typically seen in a/w chlamydial infections: *arthritis, conjunctivitis, urethritis*

Struma ovarii

Teratoma that contains functional thryoid tissue causes hyperthyroidism

Why do pts with Crohn's have a higher risk of developing gallstones?

Terminal ileum is impt is bile acid reabsorption ↓bile acid resorption = ↑cholesterol to bile acid ratio in bile = precipitation of cholesterol stones

Which antibiotic prevents attachment of amino-acyl tRNA to the A site

Tetracyclines (binds 30S and does this)

Tetracycline- effect on baby if used by pregnant mom?

Tetracyclines cross the placenta Retard skeletal development (growth) Cause discoloration of the teeth Can cause these symptoms in kids under 8 so should no give tetracycline to this age group

What type of stroke would cause pure sensory deficits?

Thalamic syndrome Damage to thalamic VPL and VPM = contralateral sensory loss (VPL gets fibers from dorsal columns and anterolateral, VPM from the trigem and gustatory pathways) Note that while it is purely sensory, they tend to have proprioceptive defects as well so may see difficulty ambulating but there are no true motor deficits

H pylori usually colonizes where specically in the stomach?

The atrum and prepyloric areas

How does lactulose help in pts with hepatic encephalopathy?

The bacterial degradation of lactulose resulting in an acidic pH inhibits the diffusion of NH3(ammonia) into the blood by causing the conversion of NH3 to NH4+ → reduces blood ammonia concentration reduces the degree of portal systemic encephalopathy

Why is the pO2 in the left atrium slightly less than that in the pulmonary capillaries?

The bronchial veins carrying deoxy blood drain into the pulmonary veins

Osteoblasts are derived from what cells?

The differentiate from mesenchymal stem cells in the periosteum

Adnexal mass + endometrial hyperplasia .. what are you thinking?

The endometrial hyperplasia is likely produced about a hyperestrogenic state. So mass is most likely a Granulosa cell tumor which produces estrogen

What is there an increased NADH/NAD+ ratio in alcoholics?

The primary hepatic metabolism of ethanol requires two enzymes, both of which convert NAD→NADH.

Negative predictive value (NPV)

The probability that a person who is disease free tests negative =b/(b+d)

PCOS Pathogenesis

The root of the problem is thought to be high LH ↑LH = ↑stimulation of the theca cells to produce androgens. Androgens are peripherally converted to estrione which then suppress FSH. Without FSH, follicles don't develop and degenerate, forming cysts.

HCM pt has a harsh systolic murmur. What is causing it and what would enhance this murmur?

These pts have a thickened IV septum, and a dynamic LV outflow obstruction, causing the systolic murmur. The obstruction is enhanced when there is less LV volume. So rapid standing or valsalva which both decrease venous return will accentuate it.

MOA of typical anti-psychotics?

They *block D2 receptors* D2 is Gi linked, so blocking this will inhibit inhibition of AC, and result in increased cAMP

What are "P-bodies"?

They are cytoplasmic proteins that are involved in mRNA regulation and storage.

Methotrexate vs Trimethoprim vs Pyrimethamine?

They inhibit dihydrofolate reductase (DHF→THF) in humans, bacteria, and protozoa respectively. Can't make dTMP.

Respiratory Tree- How far down do cilia go?

They persist up to the end of the respiratory bronchioles.

2 yo with abdominal mass and non-rhythmic conjugate eye movements a/w brief muscles twitches?

This describes opsoclonus-myoclonus, which is a paraneoplastic syndrome a/w neuroblastoma (adrenal mass in kids a/w N-myc overexpression)

30yo M with exertional calf pain that improves with rest. He demonstrates hypersensitivity with intradermal injection of tobacco.

This is Buerger disease Typically in heavy smokers, YOUNG, asians more common Results from direct endothelial damage from the tobacco and/or hypersensitivity to them. Causes segmental vasculititis of the tibial and radial arteries, with possible involvement of associated nerves and veins.

40yo male, high IgE, eiosinophilia, asthma, sinusitis, palpable purpura, peripheral neuropathy. This pt is at risk for what kidney pathology?

This is Churg-Strauss. They are at risk for pauci-immune rapidly progressive glomerulonephritis

6yo boy with palpable purpura, polyarthralgias, colicky abdominal pain. What type of renal involvement may you expect to see

This is Henoch-Schönlein, a small vessel vasculitis characterized by IgA immune complex deposition. Most often develops in relation to recent URI. Renal involvement- IgA nephropathy (Berger disease). Will see episodic hematuria with RBC casts

Person taking haloperidol develops fever, AMS, rigidty, myoglobinuria, autonomic instability. What should you treat with?

This is Neuroleptic Malignant Syndrome Treat with dantrolene or D2 agonists (bromocriptine)

7yo boy with multiloculated, cystic, suprasellar lesion, bulging into the 3rd ventricle and base of brain. Calcifications are present. What is it and what is most common clinical presentation?

This is a craniopharyngioma Derived from remnants of Rathke's pouch Presents most commonly as growth failure. Visual sxs are also frequent.

Immature squamous cell with dense, irregularly staining cytoplasm and perinuclear clearing. Has enlarged pyknotic nucleus with undulating nuclear membrane. What disease is this characteristic of?

This is a koilocyte, HPV

What is cystic medial degeneration, who has it, and what disease(s) are associated with it?

This is also known as "myxomatous change". It refers to fragmentation of elastic tissue (giving a basket weave appearance) and separation of the elastic and fibromuscular components of the tunica media by amorphous ECM. Seen in Marfans Increased risk of aortic dissection and aortic aneursym

Pt give ceftriaxone and then develops lightheadedness, HoTN, maculopapular rash. What treatment?

This is anaphylactic shock → treat with epinephrine stimulates α₁ receptors → counteract vasodilation stimulates β₁ → improve contractility and increase CO stimulates β₂ → bronchodilaton

Increased intestinal iron absorption, micro nodular cirrhosis, diabetes mellitus, and skin pigmentation. What labs do you expect to see?

This is hemachromatosis Increased iron absorption so high Fe, high transferrin, high ferritin, low TIBC

Ulcerative red lesions with frequent scale, on face, lower lip. Histo shows?

This is squamous cell carcinoma Histo shows keratin pearls

Treatment of acute promyelocytic leukemia?

This is the M3 type of AML. D/t abnormal retinoic acid receptor. Treat with all-trans retinoic acid (ATRA) to stimulate differentiation of myeloblasts

Lorazepam MOA

This is your classic benzo Mechanism of action= allosteric binding of the GABA receptor, increases FREQUENCY of opening of the Cl- channel. Increased influx of Cl- hyperpolarizes (inhibitory)

Healing of fracture- what cell type in the bone is important?

To build bone, you need osteoblasts. Osteoblasts differentiate from mesenchymal cells in the *periosteum* After a fracture, progenitor cells develop into osteoblasts and chondroblasts, which are essential to the healing process.

Lymph drainage from the sigmoid colon?

To the inferior mesenteric nodes

Aside from skin cancers, what are the top 3 most common cancers in woman? What is the most fatal?

Top 3 are breast, lung, colon Top mortatility lung, breast, colon (2011 stats)

Side effects of what anti-epileptic drug= kidney stones

Topiramate (weakly inhibits carbonic anhydrase, leading to acidosis in the renal tubules)

Calculating renal excretion rate of a substance?

Total filtration rate - total tubular reabsorption = (inulin clearance or GFR)(plasma concentration) - tubular reabsorption

Transference vs displacement

Transference- unconscious shifting of emotions a/w one person to another (eg psychiatrist seen as parent) Displacement- unacceptable feelings are unconsciously expressive toward a different "safer" object or person (mom yells at her kid because husband yelled at her)

Aorta that lies anterior to and to the R of the pulmonary artery- what what the embryologic issue?

Transposition of the great vessels, d/t failure of the aorticopulmonary septum to spiral

Pleural effusion: exudative vs transudate

Transudate: hypocellular, low protein, low LDH compared with plasma Exudate: cellular, protein rich, high LDH compared to plasma (>0.6 ratio)

List the 4 main MAOi's

Tranylcypromine Phenelzine Isocarboxazid Selegiline (selective MAO-B) MAO Takes Pride In Shanghai

Noise induced hearing loss is due to damage to what structure(s) of the ear? What is lost first- high or low frequency?

Trauma to the stereocilliated hair cells of the organ of Corti. High frequency is lost first

Acute pulmonary hypertension- treatment and adverse effects

Treatment is nitric oxide (NO) NO= ↑guanylate cyclase activity = ↑cGMP ↑cGMP = ↓Ca²⁺ and ↑myosin-light-chain phosphatase activity (dephosphorylate myosin light chain)=relaxation of endothelial smooth muscle = vasodilation Adverse effect: Can induce methemoglobinemia because NO (nitrite) can oxidize Fe⁺⁺ to Fe⁺⁺⁺, which does not as readily bind O2

Demeclocycline

Treatment of SIADH member of the tetracycline family, works as an *ADH antagonist* Toxicity includes diabetes insipidus

Treatment and complications of Paget disease of the bone

Treatment: Calcitonin (opposes PTH), and bisphosphonates Complications: increased risk osteosarcoma, high output cardiac failure

Treatment of Toxoplasmosis vs prophylaxis?

Treatment= Sulfadiazine and pyrimethamine Prophylaxis= TMX-SMP

Major toxicity of TCAs

Tri-Cs Convulstions, Coma, Cardiotoxicity (arrythmias, because *block sodium channels in the myocytes*, slow depolarization) Also has atropine-like effects

Samter's triad- what is it and why does it happen?

Triad of asthma, aspirin hypersensitivity, and nasal polyps Occurs in 10% of asthmatics taking aspirin d/t overproduction of LTEs that occur since aspirin blocks COX (shunt AA pathway to lipoxygenase)

MEN2B

Triangle with long legs medullary thyroid cancer + oral involvement pheos marfanoid

High potency typical antipsychotics?

Try to Fly High Trifluoperazine, Fluphenazine, Haloperidol

Reduviid bug- a/w?

Trypanosoma cruzi (DCM, megacolon, megaesophagus)

Wilm's tumor (nephroblastoma)

Tumor arising from persistent embryonic tissues. Most common renal malignancy in kids <10. Presents as palpable smooth abdominal mass +/- pain, hematuria, hypertension.

Why are eyes blue in OI?

Type I collagen defect → thin sclera→ exposure of the underlying choroidal veins

MG is what type of HSR?

Type II HSR Autoantibodies bind to cell surface antigens or ECM components In MG, bind to and destroy nicotinic ACh receptors at the NMJ

Serum Sickness

Type III HSR. Immune complexes deposit in membranes, fix complement, lead to tissue damage. Typically caused by drugs (eg SULFA) now. Takes 5-10 days after exposure. Fever, Urticaria, Arthralgias, proteinuria, lymphadenopathy, vasculitis with fibrinoid necrosis. Labs shows decreased C3 levels (hypocomplementemia, since lots of complement fixation going on)

Xanthalasma

Type of xanthoma (yellowish macules/papules) found on the medial eyelids They are dermal accumulations of macrophages that are filled with cholesterol, phospholipids, and triglycerides r/t condition of 1º or 2º hyperlipidemia (dyslipidemia w/ or w/out underlying DM, obstructive biliary lesions, PBC)

Sxs assocaited with iron deficiency anemia

Typical sxs of anemia (eg fatigue, weakness, HA) + reduced taste sensation, burning sensation in the mouth, lip dryness, tongue atrophy, alopecia, pica can also be totally asymptomatic

Herniated disc between C5 and C6 is likely to compress what nerve?

Typically, herniation of the nucelous pulposus extends poseteriolaterally, and there will compress the spinal nerve root. In the C-spine, the nerve root exits above its corresponding vertebrae (so between C5 and C6, C6 will exit), and cervical disc herniations affect nerves this nerve, at the level of the issue. In the lumbar spine however, the spinal nerve exits below its corresponding vertebrae (so if herniation between L4-L5, nerve root in that space is L4) BUT disc herniation elsewhere tends to get the nerve 1 below anyway (so you will compress L5)

Atrophy of the hypothenar eminence- what nerve lesion?

Ulnar nerve

Ureters pathway

Under the bridge, over the hill, and through the valley (Under gonadal vessels, over the external iliac, between the external and internal iliacs)

Distinguishing features between neuroleptic malignant syndrome and serotonin syndrome?

Unlike serotonin syndrome, NMS *does not* have hyperreflexia, myoclonus, shivering, ataxia. N/v/d is also rarely seen in NMS

Borderline personality disorder

Unstable mood and interpersonal rlnships Self-mutilation Impusiveness Boredom and sense of emptiness Splitting is a hallmark of borderline personality (people are all good or all bad)

Fasting...how does the body maintain plasma glucose?

Up to 12 hours= glycogenolysis 12-36 hours= gluconeogenesis After 3 days= break down fat stores- ketones

Muscles involved in shoulder abduction (degrees)

Up to 15º = supraspinatus and deltoid From 15º to 90º= deltoid Past 90º (overhead)= long thoracic

Secondary TB- lower or upper lungs?

Upper

Lymph drainage of the bladder

Upper bladder= external iliac nodes Lower bladder = internal iliac nodes

Treatment of hepatic encephalopthy

Use Lactulose to acidify the GI tract and trap ammonia as NH4 for excretion low protein diet

Treatment of premature labor?

Use a B2 agonist Uterine relaxation Ex Terbulaline, ritodrine

Absolute risk reduction

Use for *cohort studies* How much do you reduce risk in a population that is given a treatment vs not? Risk in placebo group - risk in treatment group 1/ARR will be #needed to treat

Relative risk

Use for *cohort studies* What is the relative risk that a certain exposure imparts? look at risk in exposed / risk in unexposed (a/a+b) / (c/c+d)

How do TZDs work?

Use for treatment of diabetes (eg piogliatazone) Bind PPAR-Ɣ, which a nuclear receptor and initiates trascription of genes involved in glucose and lipid metabolism. One of the most impt gene transcribed is adiponectin. Adiponectin in low in type 2 diabetics, and increase in it increases insulin sensitivity

Aminocaproic acid

Use to reverse action of thrombolytics (inhibits fibrinolysis)

Mannitol- Use, MOA, SE

Use: Treatment of cerebral edema and glaucoma MOA: osmotic diuretic (increases plasma/tubular fluid osm, move water from interstitial space into vascular or tubular lumen). In kidneys, diuresis. In brain, water pulled out of tissues. AE: hypernatremia, excessive volume depletion, pulmonary edema (increased hydrostatic P in the lungs)

Mifepristone- Use and MOA

Use: abortifacient often used in combo with misoprostol (prostaglandin analog) MOA: Competitive inhibition of progesterone receptor. Since progesterone is needed for maintenance of pregnancy, blockade results in decidual necrosis and expulsion of products of conception. Also stimulate endogenous release of prostaglandins

Phenoxybenzamine

Use: pheochromocytoma (pre-op) to prevent catecholamine crisis MOA: irreversible nonselective alpha-blockers

Cladribine (2-CDA)

Use: treatment of hairy cell leukemia MOA: adenosine analog, resistant to adenosine deaminase degradation

Metyrapone testing

Used to determine the integrity of the HPA axis. Administration should block cortisol synthesis, and increase ACTH Intact: Labs show incr ACTH, increased 11-deoxycortisol and 17-OH corticosteroid in the urine

Ribavirin

Uses: Hep C and RSV MOA: multifactorial; nucleoside antimetabolite, interferes with duplication of viral genetic material. Inhibits IMP dehydrogenase (deplete GTP). Causes hypermutation of viral RNA. SE: hemolytic anemia, severe teratogen

What ovarian ligament contains the Uterine vessels? What about the ovarian vessels?

Uterine vessels= Cardinal ligament (connects the cervix to the side of pelvic wall; ligate during hysterectomy) Ovarian vessels= suspensory ligament (connects ovaries to the lateral pelvic wall)

Angiogenesis is driven by what 2 growth factors?

VEGF FGF

What is VLDL?

VLDL is a lipoprotein attached to B100 produced by the liver and rich is trigylcerides and cholesterol esters. They travel out in the blood, and unload TGs into the adipose tissues for storage (with help of LPL). VLDL then becomes IDL. IDL will be enriched with more cholesterol esters from HDL, which converts IDL to LDL. LDL if not taken up by hepatic receptors can be oxidized, releasing cholesterol, and creating fatty streaks in the vessels.

1st line treatment for myoclonic seizures?

Valproate

What types of mutations typically cause β-thalassemia?

Variety of mutations that affect transcription, processing, and translation of *β globin mRNA* Most commonly, *aberrant splicing of pre-mRNA* or early chain termination in mRNA translation. Unlike α-thalessmias which are d/t gene deletions, these are *point mutations*.

VIP

Vasoactive Intestinal Peptide Produced by the *pancreatic islet cells* and the neurons in the gut mucosa Causes 1) relaxation of GI smooth muscle and sphincters 2) Increased intestinal water and electrolyte secretion 3) decreased H+ secretion VIPoma can cause WDHA syndrome (watery diarrhea hypokalemia achlorhydria)

Name the 2 major SNRIs?

Venlafaxine, duloxetine

Development of the pancreas- what gives rise to what?

Ventral bud= main pancreatic duct, head, uncinate process Dorsal bud= everything else (tail, body, isthmus, accessory pancreatic duct)

Key sign of trochlear nerve palsy?

Vertical diplopia Pt complains of double vision when walking down stairs or reading newspaper CN4 innervates the Superior Oblique

Pathogenesis of liver injury in α1AT deficiency

Very different from that in the lung! In the lung, it is the destruction of elastin by elastases. In the liver, it is the accumulated of α1AT molecules within the hepatocytes rather than b/c of proteolysis. See PAS+ inclusions within hepatocytes. Thought to be d/t abnormal folding and decreased degradation of α1AT molecules in certain genotypes of the disease (Pi*ZZ individuals)

Gram negative, oxidase positive comma shaped organisms that can survive on alkaline media?

Vibrio cholera Distinguish from campylobacter which is also gram- Ox+ but cannot survive on alkaline media

Vincristine vs Paclitaxel

Vincristine INHIBITS β tubulin polymerization into mucrotubules (M phase arrest) Paclitaxel HYPERSTABILIIZES microtubules in M phase so can't break down (and move on to anaphase)

Frequently the first sign of gastric cancer?

Virchow node (involvement of the L supraclavicular node- metastasis from the stomach)

Topical treatment of psoriasis that activates nuclear transcription factors?

Vitamin D analogs (Calci-) Bind to and activate vit D receptor --> inhibit keratinocyte proliferation and differentiation

5yo boy with retinal angiomas and elevated hemeglobin?

Von Hippel Lindau Retinal angiomas may be only visible manifestaton of VHL Pts have retinal angiomas, bilat renal cell carcinomas, capillary hemangioblastomas (cerebellum), angiomas/cystic lesions of several organs. High hemoglobin because hemangioblastomas can produce EPO and lead to polycythemia

What to use for long term anticoagulation to prevent VTE?

Warfarin (*Acute* management of venous thrombosis- heparin)

Triad of confusion, ophthalmoplegia, and ataxia?

Wernicke encephalopathy (B1 deficiency in alcoholics). May progress to Korsakoff syndrome (permanent memory loss, confabulation, inability to form new memories)

Genetic heterogeneity

When *more than one gene mutation* causes similar phenotypes

Post-SAH vasospasm- when, where, why?

When: 4-12d after SAH Where: vessels surrounding ruptured aneurysm Why: impaired brain autoregulation, toxic substances released from injury

Pt presents with abd pain and malabsorption, polyarthritis. Histo shows foamy macrophages and PAS+ granules in the lamina propria of the small intestine

Whipple Disease

Efferent arteriole vasoconstriction does what to the filtration fraction?

Will INCREASE GFR and DECREASE RBF, so net effect is to increase FF (FF=gfr/rpf)

Cystic degeneration of the basal ganglia

Wilson disease Defect in copper excretion

Major actions of glucagon

Works primarily on the *liver*, less-so on adipocytes 1) Glycogenolysis 2) Gluconeogenesis 3) Lipolyisis (use substrates for gluconeo) 4) Urea production (AA used for gluconeogenesis)

Young boy presents with recurrent bacterial and enteroviral infections. Underdeveloped tonsils, absence of CD19+ cells

X-linked (Bruton) Agammaglobulinemia

What type of mutation is typically seen in Duchenne Muscular Dystrophy?

X-linked *frameshift* mutation Compare with less severe point mutation that causes Becker

Fabry disease

X-linked lysosomal storage disorder Defective α-galactosidase A enzyme, can't convert trihexose ceramide to glucocerebroside Clinical: present with peripheral neuropathy, angiokeratomas, renal and CV disease

Wiscott-Aldrich: inheritance

X-linked recessive

Why do you see flushing with use of anti-cholinergics?

You block eccrine sweat gland secretions Without sweat cooling mechanism, there is compensatory cutaneous vasodilation to increase heat loss, resulting in flushing

Negri bodies

a/w Rabies infection round, eiosinophillic inclusions seen in the cytoplasm of pyramidal neurons of the hippocampus and cerebellar purkinje cells. Contain rabies virus.

Pott disease

a/w TB Hematogenous seeding in the vertebrae from the lungs

On jugular venous waveform, what does each hump indicate?

a=atrial contraction c= bulging of tricupsid back during vent contraction x= right atrial relaxation v= right atrial filling y= passive emptying of RA after tricuspid opens

6-MP is activated by what enzyme and inactivated by what enzyme?

activated by HGPRT primarily inactivated by XO Careful in pts taking allopurinol!

Dextromethorphan

active ingredient in NyQuil, Robutussin, etc Non-opiod anti-tussive. Does not cause constipation, not addictive, and low potential for abuse. Was developed as an alternative for codeine which is an opiate and is addictive. The stuff we hear about in the news about kids and cough syrup abuse is due to its hallucinogenic effects at high doses

Morphine MOA

acts on mu opiod receptors *Increase K+ efflux* on post-synaptic neuron (post-synaptic neuron hyperpolarization)

Serious adverse effect of both PTU and methimazole?

agranulocytosis should get WBC with diff for any pt in these meds who present with a fever

Pseudohypoparathyroidism

aka Albright hereditary osteodystrophy AD; *kidney is unresponsive to PTH* Pts have hypocalcemia, short stature, shortened 4th and 5th digits d/t defective Gs protein (α subunit)

Cyclobenzaprine

aka Flexeril Centrally acting muscle relaxant Structurally similar to TCAs and have similar side effect profile (anticholinergic sxs- dry mouth, drowsiness, tachycardia, urinary retention, abd cramps)

Councilman bodies

aka apoptotic bodies round acidophilic apoptotic hepatocytes (on H&E) a/w viral hepatitis

Leiomyoma

aka fibroids; benign Comprised of uterine smooth muscle ("whorled pattern") some asymptomatic, some cause pelvic pain, *menorrhagia*, reproductive difficulties most common in *black women* 30s-40s are estrogen sensitive (size increase with pregnancy, decreased with menopause)

Prostacyclin

aka prostaglandin I2 Produced from prostaglandin H2 by prostacyclin synthase in vascular endothelial cells Vasodilates, inhibits plt aggregation, incr vascular permeability (oppose TXA2)

Major causes of acquired sideroblastic anemia?

alcoholism lead poisoning (ALAD, ferrochel) B6 deficiency, isoniazid (ALAS) myelodysplastic syndrome

long term SE of Vit A overdose

alopecia, dry skin, papilledema, hepatotoxicity, hepatosplenomegaly, visual defects

Unmyelinated nerve fibers

also known as C fibers include afferent neurons that conduct heat, afferent neurons that conduct slow-onset dull, burning, or visceral pain, autonomic post-ganglionic nerves, and bipolar sensory neurons of olfaction

ototoxicty drugs

aminoglycosides, furosemide, vancomycin, cisplastin

PaO2 normal, %sat normal, O2 content low

anemia

macula adherens

another name for desmosome

Innervation of the psoas major muscle?

anterior rami of L1-L4 and femoral nerve

What is rheumatoid factor

anti-IgG antibody found in RA, absent in seronegative spondyloarthropathies note that anti-citrullinated peptide antibody is more specific

Benztropine

anticholinergic used for treatment of cholinergic excess in Parkinsons and for drug-induced parkinsons Side effects include anti-cholinergic sxs (dry mouth, slow gut motility, fever, etc)

DNA laddering

appearance of DNA fragments in multiples of 180bp on gel electrophoresis --> *sensitive indicator of apoptosis* d/t action of endonucleases during *karyorrhexis* that cleave DNA at internucleosomal linker regions (occur at 180 bp intervals)

Most common cause of death in pts with antidepressant intoxication?

arrhythmias, due to *blockage of fast sodium channels* (eg TCAs)

Vomiting, rice-water stools, garlic breath

arsenic poisioning treat with dimercaprol or succimer

Structures perforating the diaphragm

at T8= IVC at T10= esophagus, CNX at T12= aorta, thoracic duct, azygos vein

Schizoaffective disorder

at least 2 weeks of stable mood with psychotic sxs + major depressive, manic, ot both (bipolar and depressive subtypes)

Clozapine

atypical antipsychotic block D4 receptors; less likely than typicals to cause EPS Major adverse effect= agranulocytosis**, seizures need to monitor CBC weekly in these pts

Von Hippel Lindau

autosomal dominant disorder characterized by cerebellar/retinal/brainstem hemangioblastomas, bilat renal clear cell carcinomas, and pheochromocytomas. All patients have a deletion of VHL gene on Chromosome 3, which results in activation of HIF and angiogenic growth factors

Injury to the surgical neck of the humerus would involve what nerve? What sxs?

axillary would have weakness of the deltoid and teres minor + loss of sensation of the lateral upper arm

what cholesterol if used as a monotherapy can cause hypertriglyceridemia?

bile acid-binding resins

Colchicine MOA

binds intracellular tubulin and inhibits its polymerization into microtubules

Fick Principle

calculate CO by determining how much blood must flow through the pulmonary or systemic circulation to account for the difference in O₂ content b/w artery and vein CO= O₂ consumption/ AV O₂ difference

Most common malignancy in the small intestine?

carcinoid tumor note: will not cause sxs unless it metastasizes (eg to the liver). This is b/c serotonin produced by the tumor will be metabolized by MAO in the liver to 5-HIAA and just excreted in the urine. Lung also has MAO.

The majority of deaths in CF pts is due to what?

cardiorespiratory complications (pneumonia, bronchiectasis, cor pulmonale, etc)

In a case-control study, who serves as the "case" and who is the "control"?

case-control studies are looking at people with a certain disease and trying to figure out if an exposure is related to having the disease The "case" is all the people (with and without exposure) who have the disease. The "control" is all the people with and without exposure who do not have the disease

Decreased activity of cholesterol 7α hydroxylase would have what effects?

cholesterol 7α hydroxylase is the rate limiting of bile acid synthesis; takes cholesterol to bile acid. Decreases activity of this enzyme (eg suppression by fibrates) would result in ↓bile acids and ↑concentration of cholesterol in the bile, leading to precipitation of cholesterol stones

Ankylosing spondylitis

chronic inflammatory disease of the axial skeleton manifested by back pain and progressive stiffness of the spine, due to fusion of joints HLA-B27 association. A/w IBD. "Bamboo spine" on XR

Phenotypic mixing

co-infection of a host cell by two viral strains, resulting in progeny that contains nucleocapsid proteins from one strain and genome from the other. Since there is no transfer of underlying viral genome, the next generation of virions will revert to their normal phenotypes.

Toxic megacolon

complication of IBD (UC>Crohns) Cessation of neuromuscular activity in the intestinal wall → distention of the colon → thinning of the wall, prone to rupture

16S rRNA in prokaryotic ribosomes have what function?

contains sequence complimentary to the shine-delgarno sequence on mRNA- binding of these 2 is needed for initiation

Adverse effects of triptans?

coronary vasospasm, ↑BP contraindicated in people w/ CAD or Prinzmetal angina

L1 L2 reflex

cremasteric reflex

Differential cyanosis

cyanosis in the LOEx but not upper body result of reduced arterial O2 sat in distal aorta vs proximal aorta most likely d/t PDA with late onset reversal of shunt flow (R to L) note that coarctation can decrease LOEx exercise tolerance but does not cause cyanosis.

Treatment for serotonin syndrome

cyproheptadine

when chemical pro-carcinogens enter the body, how are they converted to active metabolites?

cyt450 oxidase system (specifically p450 monooxygenase, which is an enzyme present in hepatic microsomes) People in whom these enzymes are overactive have increased risk of developing certain cancers (eg benzo induced lung cancer)

How does capsaicin reduce pain?

decrease levels of Substance P in the PNS

What sort of esophageal issues do CREST pts have?

decreased peristalsis decreased LES tone This is called sclerodermal esophageal dysmotility, and can cause severe acid reflux and dysphagia in CREST pts

Valsalva maneuver does what to the preload?

decreases it (decreases venous return)

Most common defect in hyper IgM syndrome?

defective CD40L on CD4 Th2 cells

Codman triangle

destructive lesion growing within the bone drags periosteum off the bone, creating the codman angle or triangle.

Sensitivity

detecting a disease when its actually there Screening tests should have high sensitivity a/(a+c)

MEN1

diamond pituitary adenoma, parathyroids, pancreas (ZE)

1st generation anti-histaminics: name them

diphenhydramine chloropheniramine promethazine dimenhydrinate

How do integrase inhibitors work?

disrupt the ability for ds HIV DNA to integrate into the host cell genome, thereby inhibiting production of HIV mRNA by host cell machinery.

Treatment of lyme disease

doxycycline or penillcin-type antibiotics (ceftriaxone)

GI ulcer that typically improves with food intake?

duodenal ulcer

Absorption of iron occurs where?

duodenum

Tensilon test in pt already being treated for myasthenias gravis?

edrophonium= a short acting AChE inhibitor. Both under and over-treatment of MG with an AChEi can cause muscle weakness in pt. If they are undertreated, not enough ACh in NMJ (myasthenias crisis), and the Tensilon test improves their sxs. If they are overtreated, edrophonium adminstration will not improve sxs, and their sxs are due to cholinergic crisis, in which NMJ becomes insensitive to ACh

HIV structural genes

env- gp120 (attachement) gp41 (invasion) gag- p24 and p7 (nuclear capsid) pol- reverse transcriptase, integrase, protease

Describe appearance of eczematous dermatitis?

erythematous, papulovesicular, weeping, encrusted lesions, may have yellow crust and may have development of thickened plaques

α toxin lecithinase

exotoxin a/w C perfringens (gas gangrene) disruptes cell membrane integrity

Cross-sectional study

exposure and outcomes are measured simultaneously at a particular pt in time (Snapshot study)

Clinical presentation of imperforate anus?

failure to pass meconium or passing it through the urethra/vaginal (may have fistula) Often have other congenital abnormalities, with urogenital abnormalities being most common (hypo/epispadias, bladder extrophy, renal agenesis)

Source of estrogen in the 2nd and 3rd trimester?

fetal adrenal glands (makes DHEA), fetal liver (hydroxylates DHEA), and fetal placenta (aromatized to estrogen)

12 days after MI- what would light microscopy of the myocardium show?

fibrovascular *granulation tissue* with neovascularization

Enfuviritde

fusion inhibitor, binds gp41 prevents HIV genome ENTRY into CD4 T cell recall that its gp120 that does attachement, g41 does entry

How to treat pt who has overdosed on β blocker?

give IV glucagon increases HR and contractility independent of adrenergic receptors. Binds GPCR on cardiac myocyte, activates AC, increases cAMP. Release intracellular Ca+ and increase SA node firing.

Hawthorne effect

groups that know they are being studied behave differently that they would otherwise

Dystrophic calcification

hallmark of cell injury and death occurs focally in necrotic tissue most common sites are aged/damaged cardiac valves amd atheromatous plaques pts are normocalemic

Dilated pupils, yawning, lacrimation (which withdrawal?)

heroin

hyperacusis

hypersensitivity to sound. Caused by paralysis of the stapes muscles (wider oscillation of the stapes as a result). CNVII innervates it (stapedius nerve is a branch of the facial)

Pulmonary embolism- what arterial blood gas values would you expect to see?

hypoxemia (low O2) compensatory hyperventilation (low CO2) respiratory alkalosis (pH high) bicarb slightly low

Hypoglycemia unawareness

if pt who who is diabetic is taking a *nonselective beta blocker*, the beta blocker can block the sympathetic surge that allows pt to recognize hypoglycemia coming on.

Most common site of intestinal atresia

ileum

Cushing ulcer

increased ICP, increased vagal activity release of ACh onto parietal cells, H+ produced

inhaled fluorinated anesthetics do what to cerebral blood flow?

increased cerebral blood flow this can increase ICP

In restrictive lung disease, what causes the relatively high expiratory flow rates?

increased elastic recoil pressure and increased radial traction on the conducting airways by the fibrotic pulmonary interstitium

Influenza vaccine prevents reinfection how?

increases host circulating antibodies against *hemagglutinin* of the selected viral strains These antibodies interfere with binding of the HA to sialic acid and prevent viral cells from entering cells.

Hydralazine- MOA

increases production of cGMP = smooth muscle relaxation, arterioles > veins

which rotator cuff muscle(s) laterally rotate the arm?

infraspinatus and teres minor

MOA of -azoles?

inhibit ergosterol synthesis by inhibiting p450 envy,e that converts lanosterol to ergosterol (14-α-demethulase). Can't make fungal cell membrane.

Tiagabine MOA

inhibits GAT-1 (GABA reuptake) by presynaptic neuron → more GABA in synapse → ↑inhibitory effect

ARDS- what is being damaged?

injury to *endothelial cells* lining the pulmonary capillaries adjacent to the alveoli --> results in leakage of fluid into the alveoli ("exudative stage)

PCP prophylaxis in AIDs pts with sulfa allergy?

instead of TMP-SMX, give aerosolized pentamidine

Innervation of the gluteus maximus muscle

interior gluteal

T-tubules: function

invaginations of the muscle cell membrane (sarcolemma). *Transmit depolarization from the sarcolemma to the SR* in a rapid uniform manner - necessary for *coordination of muscle contraction*.

Almost all TCAs end in..?

iptyline or ipramine Amytriptyline, nortriptyline, imipramine, clomipramine, desipramine

Dexrazoxane

iron-chelating agent that can help prevent *anthracycline-induced (eg doxorubicin) cardiotoxicity*

Pt with a CNV (trigem) motor lesion. When you ask them to open their jaw, what happens?

jaw deviates toward side of the lesion (V3 lesion)

Best auscultatory indicator of the severity of mitral stenosis?

length of the intervial between S2 and the opening snap (the shorter the interval, the worse the stenosis)

Major cause of hepatic adenoma? How do they present?

long h/o oral contraceptive use Present with RUQ pain, or sudden collapse from rupture and intra-adominal bleeding

Winged scapula- what nerve and what muscle

long thoracic, serratus anterior

Transtentorial herniation (uncal)- what is it an what sxs may you expect to see?

medial temporal lobe herniates through the gap b/w the crus cerebri and the tentorium → can compress CNIII (ptosis, down and out, fixed dilated), ipsilateral PCA (hemonimous hemianopsia with macular sparing), and ipsi or contralateral corticospinal tracts (hemiparesis)

Major site of airway resistance

medium sized bronchi

Why do you see lipiduria in pts with minimal change disease?

minimal change is characterized by selective loss of albumin to compensate for ↓plasma albumin concentration, liver increased synthesis of proteins to "beef up" the blood, including lipoproteins. ↑lipoproteins contributes to lipiduria

Rituximab

monoclonal antibody against CD20 Use for non-Hodgkin's lymphoma, RA (+MTX), ITP

Denusomab

monoclonal antibody against RANKL Binds RANKL so it can't bind to RANK in pre-osteoclasts Kind of just like an exogenous OPG

Acute hemorrhagic cystistitis

most common viral cause: *Adenovirus*, typically male children Pts present with UTI w/ dysuria and hematuria

Piperacillin-tazobactam is effective against?

most gram- enteric rods this includes *pseudomonas* AND *bacteriodes*

Pseudomonas- motile or nonmotile?

motile!

Pt with organophosphate overdose is given atropine and sxs improve. They are still at risk for what though?

muscle paralysis atropine only blocks muscarinic receptors not nicotinic this is why you also should give pralidoxime, which regenerates AChE and will also work at nicotinic receptors

Germline mutation

mutation in the germ cells early on in development such that some sperm or some eggs have this mutation. parent is unaffected but can pass on disease to kids. example is OI.

NF1

neurofibromatosis 1 aka von recklinghausen AD disorder in NF1 on ch 17, 100% penetrance with variable expression Tumors of *Schwann cells (neural crest origin)* Cafe-au-lait macules, cutaneous neurofibromas ("rubbery", skin colored lesions that "buttonhole" down when pressed), Lisch nodules (pigmented iris hamartomas)

A correlation coefficient of 0 indicates what?

no correlation

Pramiprexole

non-ergot dopamine agonist used for treatment of Parkinson's disease

The vast majority of Down syndrome cases arise due to (be specific)

nondisjunction of maternal Ch 21 during meiosis 1

Case fatality rate

number of fatal cases/total number of cases (both fatal and non)

Pentazocine

opiod with *partial agonist* and *weak antagonist* activity at mu receptors When used in combo with full agonists, can cause withdrawal sxs

In the US, the majority of overdose death are related to what drugs?

opioid analgesics

Treatment of opiod withdrawl in neonates

opium solution ("tincture of opium") Sxs are pupillary dilation, rhinorrhea, sneezing, tremors, seizures

most common benign tumor of the both

osteochondroma lateral projection from the growth plate- mature bone with cartilaginous cap. Continuous with the bone from which its growing

Churg-Strauss

p-ANCA (MPO-ANCA). Same as microscopic polyangitis. Asthma, eiosinophils, vasculitis

Parinaud syndrome

paralysis of upward gaze aka dorsal midbrain syndrome; lie above the superior colliculi May be a/w pineal germinomas, in which there is precocious puberty, Parinaud syndrome, and obstructive hydrocephalus

Butorphanol

partial mu opiod agonist Can cause opoid withdrawal sxs if pt is also taking full agonist

Individuals predisposed to drug-induced lupus?

people who are "slow acetylators" are at greater risk for developing lupus-like syndrome after taking procainamide, isoniazid, or hydralazine (which are all metabolized by N-acetylation in the liver)

anti-epileptic a/w generalized LAD?

phenytoin

Phenytoin can lead to megaloblastic anemia- why?

phenytoin in an anti-folate

A dislocated knee or fracture distal femur is most likely to injure what structure?

popliteal artery, b/c of its deep position adjacent to the femus and the knee joint capsule *traction force*- will hurt artery but not the also nearby tibial nerve.

Sturge Weber syndrome

port wine stains on face, ipsilateral leptomeningeal angioma, sz/epilepsy, intellectual disability, episcleral hemangiomas, early onset glaucome Sporadic, activating mutation in GNAQ gene resulting in developmental abnormalities of neural crest derivatives; affects small blood vessels

ADH acts on which cells of the kidney

principal cells of the collecting duct

Medullary carcinoma of the thyroid

proliferation of parafollicular C cells, causing increased calcitonin release and deposition as amyloid Histo: malignant tumor cells w/in a congo red + amyloid stroma A/w RET mutations, MEN2A/2B

Heberden nodules

prominent osteophytes at the DIPs, seen in osteoarthritis

CNXII (hypoglossal) lesion?

protrusion of tongue→ tongue deviates to the side of lesion. This is because muscles are weak on this side, and other side dominates "lick your wounds"

basophilic rhomboid crystals in the joint space

pseudogout (calcium pyrophosphate) occurs in large joints esp knee

What nerve do you block for providing anesthesia during childbirth?

pudendal

Sensation to the posterior arm and forearm - what nerve?

radial

Malignant hyperthermia

rare hereditary condition in which *inhaled anesthetics (except NO) and succinylcholine* induce fever and severe muscle contractions, dysautonomia. more fulminant than NMS Treat with dantrolene

Rasburicase

recombinant version of urate oxidase, which is present in a lot of mammals but not humans and catalyzes uric acid → allantoin (soluble and pee it out) Use to prevent and treat hyperuricemia (eg in tumor lysis syndrome)

Gottron papules

red/violaceous flat topped papules w/ a light salce most common over MCP, PIP, and DIP joints a/w dermatomyositis

Von Hippel Lindau shares gene mutation with what other high yield pathology?

renal cell carcinoma VHL gene on chromosome 3

D1 receptors are found where?

renal vascular smooth muscle (relaxes it)

Attributable Risk Percent (ARP)

represents the excess risk in a population that can be explained by exposure to a risk factor ARP= (RR-1)/(RR)= (risk in exposed-risk in unexposed)/(risk in exposed)

HGPRT (the enzyme defective in Lesch-Nyhan) does what?

salvages guanosine and hypoxanthine (converts guanosine back to GMP and hypoxanthine back to IMP)

Pts with familial retinoblastoma have increase risk for development of?

sarcomas, esp osteosarcomes Rb mutations in both

pedunculated mass attached to the L atrium. If its a myxoma, what will it look on histo?

scattered cells within a mucopolysaccharide (myxoid) stroma, abnormal blood vessels (myxomas produce VEGF), and hemorrhaging

Chief cells of the thyroid- function

secrete PTH small pale cells with round nuclei

Human Placental Lactogen (hPL)

secreted by the syncytiotrophoblast increases maternal insulin resistance (so mom takes up and uses glucose less, increase glucose in the blood for baby) Also increases maternal lipolysis and and proteolysis (mom uses FFA and ketones, leave for glucose for baby) Levels rise with gestational age

Light microscopy of peripheral nerves in a Guillain Barre pt shows?

segmental demyelination and endoneural inflammatory infiltrate

acute theophylline toxicity

seizures, tachyarrhythmias, abd pain, v/d Treat with β-blocker for theophylline induced arrhythmias

Scopolamine

selective muscarinic cholinergic receptor antagonist use for treatment of sxs r/t cholinesterase inhibitor use in MG. Also use for motion sickness.

HSV-1 goes latent where

sensory neurons (trigeminal, sacral, etc)

silent mutation

single base *substitution* that does not change AA coded for. No effect on protein.

What are Heinz bodies?

small aggregates of *denatured hemoglobin* seen in G6PD deficiency

Sensorineural hearing loss

sounds passes properly through the outer and middle but is distorted by a defect in the inner ear (damage to the cochlea's receptor cells or to the auditory nerves) Weber: lateralizes to normal ear Rinne: Air>bone (normal)

Most likely outcome for pt acutely infected with HCV?

stable chronic hepatitis

which rotator cuff muscle(s) medially rotate the arm?

subscapularis

physiologic stimuli for oxytocin secretion?

suckling and cervix dilation

What does urticaria look like on histo?

superficial dermal edema and lymphatic channel dilation no epidermal changes are present

Secondary amyloidosis

systemic deposition of AA amyloid, which is derived from a protein called SAA SAA is an acute phase reactant that is up in chronic inflammatory states, malignancy

Ewing Sarcoma

t(11;22) Boys <15 Commonly diaphysis of long bones (femur) Small blue malignant cells, onion skin appearance on nome Aggressive but responds well to chemo

half life equation

t1/2=(0.7xVd / CL)

Pathophys of hyperthyroidism in male with testicular tumor

teratoma produces hCG hCG has similar structure to TSH, LH, and FSH. Can bind to TSH receptors and stimulate them

5α reductase deficiency

testosterone needed for development of internal male genitalia, DHT needed for development of external genitalia and enhances testosterones effects Low DHT= improperly developed external genitalia (hypospadias, small penis, ambiguous) at pubertu. high testosteroe will then result in masculinization

Specificity

the ability for a test to indicate no disease when it is not there d/(b+d)

Why are Down syndrome pts predisposed to developing alzheimers?

they have an extra copy of *amyloid precursor protein* (APP) on Ch 21

enlarged RBC that appears blue on Wright-Giema stain

this is a reticulocyte the bluish color is d/t basophilic reticular network of residual rRNA

What type of bone is lost in osteoporosis?

trabecular (spongy) bone

What is n-myc? (eg transcription factor, tyrosine kinase, GTPase, etc)

transcription factor binds DNA implicated in neuroblastoma

CFTR is what type of channel?

transmembrane ATP-gated Cl- channel

MDR1 gene codes for P-glycoprotein. What is P-glycoprotein?

transmembrane protein that functions as an *ATP-dependent* efflux pump

Blowing, holosystolic murmur that increases with inspiration

tricuspid regurg likely an IV drug user

Elevated levels of what ENZYME is a marker of mast cell degranulation?

tryptase along with histamine, it is released when mast cells degranulated. Histamine is the major cause of the sxs (acutely, with leukotrienes taking over in delayed response) but tryptase is a useful serum marker.

Fomepizole

txt of methanol or ethylene glycol intoxication inhibits alcohol dehydrogenase

Finding of dermatomyositis suggests what?

underlying carcinoma, particularly gastric carcinoma

What type of stone is radiolucent?

uric acid stone

Probenecid

urocosuric drug treatment of hyperuricemia and gout

odds ratio

used in case-control studies (retrospective, observational) to see what the odds were that the group with a disease was exposed to a risk factor vs the group without the disease was exposed OR= (a/c)/(b/d) = ad/bc

Flumazenil

used to treat benzodiazepine overdose Competitive antagonist at GABA benzo receptor

most common cause of e coli bacteremia

uti

What are clue cells?

vaginal squamous epithelial cells covered in small dark particles (G. vaginalis organisms) (bottom cell in pic)

Standard error

variability around the mean; the larger the sample size the smaller the standard error measured as (standard deviation/square root of n)

Virulence factor of aspergillus that allows disease progression throughout the body?

vascular invasion THey can disseminate to distant organs by hematogenous spread

Sulfatides

virulence factor of TB *inhibits phagolysosome fusion*, allowing for mycobacteria to persist within phagocytes

What do you use for long term anticoagulation in pt with mechanical heart valve?

warfarin

Micro appearance of cryptococcus neoformans?

yeast form only- round or oval encapsulated cells with *narrow-based buds* (india ink shows round/oval budding yeasts in CSF; use mucimarine for stain in tissues)

Lipofuscin

yellow-brown, finely granular, perinuclear pigment that is a product of free radical injury and lipid peroxidation

Miglitol MOA

α-glucosidase inhibitor (along with acarbose). Prevent disaccharidase action in the brush border by competitive inhibition. Less absorption of carbs

Pupillary dilation is achieved through stimulation of what receptors?

α1

where are α, β, and M3 receptors found in the eye?

α1= dilator M3= ciliary muscle, pupillary sphincter β= ciliary epithelium (produces aqueous humor)

alpha vs beta adrenergic actions on the pancreas (insulin release?)

α2 = ↓insulin release β2= ↑insulin release

-osin (eg prazosin, terazosin)

α₁ antagonist used for urinary outflow obstruction (eg in BPH); other uses include hypertension (except tamsulosin) (α₁ = ↑vascular smooth muscle contraction, ↑pupillary dilation, ↑intestinal and bladder sphincter muscle contraction)

Treatment of MS

β-interferon, immunosuppression, natalizumab and then symptomatic treatment

Lab values you would expect to see in a pt with Conn syndrome

↑aldosterone ↓renin ↓K+ metabolic alkalosis Normal Na⁺ (aldosterone escape- end up absorbing more sodium but also bring back water with it. Also increase in GFR and RBF increases Na+ excretion)

Renal osteodystrophy- labs?

↓calcitriol (1,25D), ↓Ca++ (can't reabsorb), ↑PTH, ↑phosphate (renal damage, can't get rid of it)

Pulsus peridoxicus

↓in amplitude of systolic blood pressure by greater than 10mmHg during inspiration Occurs in tamponade because heart is being constricted, and when you inspire and try and bring blood in, instead of the R heart expanding to accepIUt it, the R heart just pushes into the L. this lowers LV diastolic volume (which lowers SV and systolic P)

Resistance to tetracylcines is achieved by what bacterial mechanism?

↓uptake or ↑efflux out of bacterial cells by plasmid-encoded transport pumps

Thoracentesis-technique

●Insert needle 1-2 interspaces below the level at which breath sounds decrease or disappear on auscultation, percussion becomes dull, and fremitus disappears ●Above the ninth rib, to avoid subdiaphragmatic puncture ●Midway between the spine and the posterior axillary line, because the ribs are easily palpated in this location. ●Always insert ABOVE the rib rather than below to avoid damage to the neurovascular bundle