Uworld random sara

a 13 yr old girl is undergoing hematologic evaluation. found to have hemoglobin mutation that changes partial pressure of oxygen at which 50% of hemoglobin is saturated to 20 mm HG comapred to normal is 26. What will the patient develop?

This is a left shif tin the oxygen dissociation curve mutations that cause production of hemoglobin with high oxygen affininity (hemoglobins Chesapeake and kempsey) reduce the ability of hemoglobin to release oxygen within the peripheral tissues low oxygen levls stimulate the kidney to inc EPO synthesis which results in compensatory erythrocytosis to help maintain normal oxygen delivery

what is used ot test for astham

Asthma is airway inflammation and hyperreactivity with variable airflow obstruction that improves with bronchodilator medications see cough, sob, wheeze chornic reduction in FEV1/FVC <70;normal is 80 due to inc FEV1 bronchial challenge testing is highly sensitive with high negative predictive value used to asses bronchial hyperactivity and exclude astham use methacholine - a muscarinic agonost - to induce bronchoconstriction

26 yr old woman, joint pain of elbows knees and ankle for month, experienced dry couhg and mild sob over 6 months, sexualy active takes ocps, 99F, 120/70, 84/min, 16/min. lungs clear mild swelling and tenderness of elbows, knees and ankles lower extremities are tender to palpitation and have scattered erythematous nodles. Xray shows hilar fullness Large epitheliod cells, occasional giant cells, and no areas of necrosis What meds?

Has sarcoidosis.. give oral glucocorticoids (prednisone) arthralgias, dyspnea, cough, erythema nodosum (tendernes, subcutaneous, lower extremity nodules), hilar adenopathym pulmonary infiltrates (nodules, interstital lung disease) skin (erythema nodosum) and ocular (anterior uveitis) involvement, polyrarthritis and fatigue and weight loss

72 yr old woman with bloody bowel movements, 1 hr ago sudden urge to deficate and passed large anount of bright red blood mixed with stool. Several minutes later, another episode of small amount, pateint has no nausea, vomiting, abdominal pain, diarrhea or fever and never had symp before. Hospitalized with no further bleeding. PE shows DRE is unremarkable.

Hematochezia had colonoscopy show outpouching of the colonic mucosa-- colonic diverticulosis. inc with age >60. risk - low fiber diet, high fat diet, obesty and physical inactivity Diverticula form where intraluminal colon lack structural integrity, these weak points are located where the vasa recta (terminal vessels derived from superior and infereior mesenteric arteries ) penetrate thru smooth muscle layer of the colon. as they enlarge, vessels weaken and ulcerate and rupture, leading to intraluminal hemorrahge and painless hematochezia.. often self limiting.

55 yr old right handed man, peristent right arm tinging and numbness for past several hours, no headache, muscle weakness, slurred speech or difficulty ambulating, history of htn, paroxysmal afib, and ischemic stroke, anticoagulation stopped 2 month ago after gi hemorrhage. bp is 150/90, pulse 92/min, reg has right arm paresthesia spread to entire right side of body and develop right sided convusions followed by bilateral tonic-clonic seizure. Where is the mostly likely sight of seizures?

Most likely suffering from embolic stroke complicated by seizure Stroke is a common cause of seizure, which occurs due to release of excitotoxic NT in the ischemic brain region Primary somatosensory cortex - processing of all somatic sensory input from the contralateral side of body, so seizure would lead to contralateral sensory distrubance. paitent intial right arm numbess and parasthesia caused by focal onset seizure originating in the left primary somatosensory cortex (postcentral gyrus)

what is seen with SLE

SLE is excessive autoantibody production due to loss of self tolerance, anti-nuclear lead to formation of immune complexes deposit in various organs and cause complement activation so after -- reduced serum complement levevels

44 yr old man confusion, has meningitis , bacterial, gram stian would reveal what?

inc opening pressure, inc neutrophils, dec glucose, and elevated protein --> bacterial meningitis. Strep pneumo is most common bacterial meningitis in adults of all ages. -- lancet shaped gram + cocci found in pairs norm follos pulmonary infection or mild URTI. alcoholics, sickle cell anemia, asplenic individuals and those in generally poor health at a higher risk 2nd most common: bean shaped gram negative cocci -- neisseria meningitiids - <60 yr old, occur in close quarters. Listeria monocytogenes -faculatitve intracellular, motile, gram + rod. 3rd most common in neonates after group b strep and e coli. can also see in elderly and immunocompromised.

62 yr old man omes to office due to chest pain over last 6 months, pressure like pain in substernal area when walking fast or climbing stairs that subsides when stops, nonsomoker, PE - mild systolic murmur at upper sternum and slow rising carotid pulse, cardiac catherization -> 30% stenosis of mid-left LAD, 50 mmHG pressure gradient when catheter is passed across the aortic valve. What is the msot important contributing factor ?

slow rising carotid pulses, midsystolic murmur, and large pressure gradient --> aortic stenosis can be asymptomatic for long period of time but eventually develop classic symptoms dyspnea is normally the first manifestation following by angina and syncope and overt heart failure AS symptom norm occur with exertion, as capacity to inc SV and CO is limited due to fixed left ventrical outflow obstruction.. leads to inc pressures and inc wall stress during systole and diastole. rise in systolic wall stress inc. MO demand while reducing coronary perfusion pressure gradient, leading to dec Myocardial oxygen demand and angiona

what is the most common site of thrombus formaton in afib?

the left atrial appendage- small sackllike structure in the LA. the clot systemically embolize and lead to stroke, acute limb ischemia and acute mesenteric ischemia

36 yr old construction worker falls 3 meters from ladder. broke his fall with left wrist, left wrist is swollen with no laceration strong radial pulse is present and the fingers are well profused. There is a palpable mass just proximal to the left palm. Xray show lunate dislocation without evidence of distal radius fracture, The greatest risk for impairment of what is seen?

thumb abduction High energy fall onto the outstretched hand now has a volar lunate dislocation, with displaced lunate now palpable in patient proximal palm and visualized on lateral xray ("spilled tea cup sign") Lunate dislocation - high energy required cuz several ligaments (scapholunate, captiolunate, lunotriquental) stabilize the lunate. normally in floor of carpel tunnel but can move and compress the median nerve can lead to sensory and motor loss. palmar digital branches - numbness, pain or paresthesia in the palmar surface of the first 3.5 digits weakness of 1 and 2 lumbricals (interphalengeal joint extension) - recurrent branch of median nrve -> thenar muscle --> weakness of abductor pollicis brevis (thumb abduction) - flecor pollicus brevis (thumb flexion) -opponens pollicis (thumb opposition)

what is bartonella henselae called in immunocompromised?

Bacillary angiomatosis - red purple papular skin lesions, can also be seen on viscera, can be fatal

47 yr old man in car accident, restrained driver and read ended slow moving car, has chest pain, abdominal pain and difficulty breathing, PMH of htn, ashtma and DM. BP is 98/54 pulse 121. 30 min later is unresponsibve and pulse no longer detected, has sinus tachycardia, Autopsy would show injury in what part of thoracic aorta?

Blunt aortic injury - traumatic aortic rupture - sudden decleration that results in extreme streching and torsional forces affecting the heart and aorta. Injury occurs most in aortic ismus , which is tethered by ligamentum arteriosum and is fixed and immoble compared to adacent descending aorta >80% of patients die from aortic rupture before reaching the hospital. can see a widened mediastinum on the chest xray

34 yr old man with sob, episodic cough and chest tightness for 4 months, 2 week vaca from arizona and report no symp. but started when he go thome, no pmg, smoked week when younger, temp is 98, bp 120/80, pulse 76, resp 18. PE expiration is midly prolonged and there are scattered wheezes, FEV1/FVX are 82% and no chest abnormalies What is involved in pathogenesis? Dx?

Dyspnea, cough and intermittent chest tightness - asthma correlation of symptom onset and relief on vacation -- occupational astham OA - airway inflammation, bronchial hyperactivity, variable airflow obstruction triggerd by workplace exposure. can be immuno or non - immunologic - similar to athopic astham, exposure to allergen induce th2 -> stimulate igE and eosinophilic activation. there is a latent period.. cereals, latex, chemicals non-immno - aero-irritant induce denudation of airway mucosa, persisent airway inflammation, loss of epithelial relacation factors, and mast cell degranualtion. chem spill, sudden and severe, chlorine and ammonia.

74 yr old with htn, bp is 160-165/85-90. right carotid endarterectomy for recurrent TIA, mi 2yr ago, coronary artery bypass for unstable angina 1 yr ago. Takes metoprolol, clopidogrel, amlodipine, rosuvastatin. Ramipril is added, 1 week later serum creatinine is 2.1 compared to baseline of 1.1 What is expected?

His persistent hypertension despite meds --> renal artery stenosis due to atherosclerotic disase in renal arteries. this reduces BF and dec GFR due to reduced hydrostatic pressure. this + renin , leading to angioetensin 2. Angiotensin 2 causes systemic vasoconstriction with a resultant rise in bp, thereby inc renal perfusion in kidney, angiotensin 2 constrict the efferent arteriole, inc GFR. blockage of response by ACE inhibitors or arbs causes filtration pressure to fall and dec GFR. in unilateral RAS, normal kidney compensate for dec GFR, and overall creatinine is maintained in bilateral RAS, get a rise in creatinine due to ACE inhibitors becuz glomeruli and renal tubules are normal, urinalysis is unremarkable. (no hematuria, proteinuria or casts )

64 yr old woman, lung cancer, persitent chest pain, squamous cell carcinoma of the right upper lobe that invaded the pleura and 4th and 5th rib, severe right sided chest pain that is exacerbated by movement or couhg, given opoid but couldnt take it Pe - tenderness to palpation on right chest wall, nerve blockplanned to control the pain by injected local anesthetic in the vicinity of the involved neural structure. What is treatment target?

Intercostal nerves. sensation form the parietal plura, ribs, and overlying skin is mediated by throacic intercostal nerves that derive from the ventral rami of the throacic spinal nerves. the nerve, vein, and artery lie in the subcostal groove along the lower border of the rub

30 y rold man with erratic behavior, progressive right sided weakness and difficulty walking for last month, had HIV years ago and noncompliant, PE shows cachetic and dishelved. motor strength in right upper and lower extremities is decreased, his gait is ataxic. Brain shows demyelination in the subcortical and periventricular white matter with no surrounding edema or mass effect CD4 count is 30. Reactivation of what pathogen most likely responsible for patient current symptoms?

JC virus polyomavirua - acquired in childhood -- life long, latent infection of kidney and lymphoid organs most adults remain asymptomatic in adv aids, risk for reactivation with spread to the brain virus attacks oligodendrocytes - cells that produce myelin --? severe demylineated progressive multifocal leukoencephalopathy. PML - slowly worsening confusion, ataxia, motor deficits and seizure MRI shows white matter demyelination with no mass effect or enhancement

20 yr old man is evaluated in the clinic for the right arm weakness and numbness, he is a competitive baseball pitcher and says he played more innings the last week, difficulty using right arm, when lifting objects, PE - diminished strength on right elbow flexion and absent biceps reflex. Most likely has sensory loss over what area?

Musculocutaneous nerve injury in setting of trauma (shoulder dislocation) and strenous upper extremity activity (baseball pitching) from C5-C7 - lateral cord of brachial plexus innervates forearm flexors (biceps brachii, brachialis) and coracobrachialis (flexes and adducts the arm) After innervating these muscles, remaining fibers become the lateral cutaneous nerve of the forearm and provide sensory innervation to the skin of the lateral forearm

42 yr old man with inc abdominal girth with 20 lb weight gain over month, drinks 1 L of vodka daily, BP is 110/70, abdomen is moderately distended, fluid wave is elicited. multiple sider angiomas are present. labs show thrombocytopenia, hypoalbuminemia, normal sodium level, elevated PT. upper endoscopy shows no abnormalities. What should be inhibited in patient?

Patient has abdominal distension and fluid wave has ascites. Heavy alcohol use and evidence sugget chronic liver disease (spider angiomas, thrombocytopenia, hypoalbuminemia, elevated PT) -> alcoholic cirrhosis in cirrhosis ...portal htn leadsing to splanchnic vasoldialtion, dec effective arterial vol and lower BP. renal perfusion is reduced, laeding to activation of RAAS, promotes vasoconstrction (due to angiotension) and fluid and sodium retention by kidneys (due to aldosterone). leads to third spacing fluid with edema and ascites. Spironolactone, an aldosterone antagonist is used, natural natruiesis without blockig the critical vasoconstrictive effects of angiotnesin, used to furosemide (loop diuretic) to inc the efficacy of naturesis and prevent electrolyte disturbances.

69 yr old man with abdominla pain, gi shows single shallow 1cm ulcer in duodenal bulb and mild gastric erythema. no H pylori, What is his history for risk of current condition

Peptic ulcers = most common due to H pylori or NSAID use Duodenal- H pylori NSAIDS (ibuprofen, naproxen, aspirin) effect both forms of COX. in GI COX-1 responsible for synthesis of prostaglandins needed for maintanece of intenstional mucosa. inhibition of COX1 --> inc gastric acid formation, dec mucosal bicarb produciton and dec mucosal blood flow-- inc risk for gastritis and peptic ulcer formation

42 yr old man, syncope, standing, felt palpitations for 4 seconds, then was on the floor. has had intermittent palpations all week, associated with lightheadness, no significant medical history other than chronic back pain after fell from a ladder 3 years ago. fractured several vertebrae and takes methaone with inc dosage in lst year. has a history of IV herione abuse but hasnt used for 20 years, bp 120/70 supine and 125/75 standing, PE is unremarkable, What is the ECG findings?

QT interval prongation - AE of methadone. due to delayed ventricular repolarization which occurs during impairment of the voltage gates K channels that control the delayed rectifier potassium cirrent, can trigger torsade de pointes. Methadone. - inhibit the delayed rectifier potassium current to prolong the QT interval and predispose to torsades. methaone undergoes slow and variable hepatic clearance, making consistent avoidance of toxic blood levels challenging,

what drug treat OCD?

SSRi

54 yr old progressive fatigue and weakeness for 2 months, predominately in lower extremities, cant rise from chair, persisent cough and 15 lnb weight loss, used to smoke, PE shows dec strength in proximal muscles of lower extremities with normal bulk and tone, reflex are diminished bilaterally xray show hilar mass - small cells that stain + with chromogranin and synaptophysin What is the cuase of muscle weakness?

Small cell lung cancer - small cells with neuroendocrine differentiation has proximal muscle weakness and diminished reflexes in lower extremities suggestive of paraneoplastic lambert eaton myasthenic syndrome. autoimmune disorder - antibodies aganist the presynpatic voltage gated calcium channels. at the NMJ normally respond to ca open in response to presynaptic AP, leading to influx of Ca ions that cause synaptic vesicle fusion and ach release. LEM inhibit the ca influx, resulting in reduced ACH relase and failure to promote muscle contraction involved proximal muscles, lower limbs before upper, dtrs are diminished or absent. both strength and reflexes improve with isometric muscle contraction in a phenomenom known as postexercise faciliation likely due to buildup of intracellular ca with repeitice stimuli. 50% of people also have small cell lung cancer

5 week old boy, brought to ER after tonic clonic movement of left upper and lower extremities that lasted 3 minutes. born at 38 weeks, patient + for CF but confirmation is pending. The patient is postictal and no longer seizing, CT shows right sided intracranial hemorrhage. What is teh cause of patient condition?

Vitamin K, a fat soluble vitamin, is essential cofactor for gamma-glutamul carboxylase, an enzyme that carboxylates coagulation factors 2, 7, 9, 10 Infants are born with low Vit K due to poor transplacental transfer additional risk facots - refusal of Vit K prophylaxis at birth and exclusive breastfeeding. patients with CF are at risk for Vit K def due to malabsorption of fat soluble vitamins. Vit K def -> life threatening bleeding diathesis -> intracranial hemorrage, profuse Gi, umbilicus and surgical site bleeding. Prevented by intramuscular supplementation at birth

13 yr old boy brought to the office by parents after involved in fight with another student at school, grades have been declining, is irritable and moody, stays in room for hours at atime, no longer invites friends over, patient says "The wall people warned me that he was trying to poison my lunch". no pmh. fam history of bipolar in aunt, tmep is 99, bp 130/80, pulse is 98, resp 14. Pe shows postural tremor on extension of arms and broad based gait, MSE shows slurred speech, sad mood, distractability, elevated serum transaminases. Dx?

Wilson disaese AR - copper accumulation Hepatic or neurlogical manifestation can be mistaken for normal adolescence or primary psychiatric illness

4 yr old boy for heart murmur, no fatigue, sob, or exercise intolerance, no cyanosis or clibbing. 2/6 holosystolic murmur heard at left lower sternal border. no rubs or gallops. 2+ pulses, compared to unaffect what would the oxygen sat be in all chambers and system circualtion

a harsh, holosytolic murmur along the left sternal border : VSD. L-R shunt lead to inc RV oxygen sat, other chambers are unchanged and patients remain asymptomatic most often

What medications can cause osteoporosis?

common cause of fragility fractures which occur in absence of significant trauma, chronic or recurrent use of glucocorticoids (prednisone) promote osteoporosis and in crisk of fractures. fragility fracture - fracture due to force significantly less than required to fracture a normal bone. suggests an underly bone pathology often due to metastatic malignancy or intrinsic bone disease glucocorticoids - inc osteoclast activity, dec osteoblast precursor cells, supress intestin ca absorption and renal calcium reabsorption

22 yr old man with neck mass, small nodule in his lower neck 6 month ago gotten large, no change in weight feels fine, no allergies, no meds, PE shows 2cm nodule of right lobe of thyroid, has 4-8mm soft papules on his lips and tongue. arm span exceeds height and patient has long fingers. serum calcitonin levels are elevated. What is most likely to develop?What is dx?

enlarging thyrpid with elevated calcitonin lvel --> Medullary thyroid carcinoma. - malignancy arising from thyrioid C (parafollicular) cells. Mucosal neuromas and marfanoid habitus (arm span> height, long fingers and joint laxity) suggest MEN 2B due to mutation in RET proto oncogene Pheochromocytoma develop in roughly half of patients in MEN2 and cause paroxysmal htn and tachy due to intermittent release of catecholamines. leads to episodic headaches, diaphoresis tremor chest pain

What does epinephrine do at low and high doses?

epi inc systolic BP (alpha 2 and Beta 1) and either inc or dec diastolic bp depending on the dose (either alpha 1 or b2 predominates) Pretreatment with propanolol elimnates the B2 effect (vasodilation and tachycardia), elacing only the alpha effect (vasoconstriction)

Obtaining informed consent

explantion of medical condition dec of recommended treatment and alternatives risk and benefit patient to ask question should be by attneding orperson performing but can be by a team member if they have a thorough undertsanding of the procedure

illness anxiety disorder

preoccupied with fears of having a serious, undiagonsed illness and rarely reassured by negative finding on PE or lab, fear of illness becomes dominant feature of lives and lead to high health care utilization (dr hsopping, request for repeat testing) have catstrophic interpretations of normal physical sensations IAD is differentiated from somatic symptom disorder as patients with IAD have minimal or no somatic symptoms. but people with somatic - have prominent and typically multiple somatic symptoms

What is the MOA of zolpidem?

short acting nonbenzodiazepine hyponotic agent. also zaleplon and eszopiclone. Bind to GABAa at benzo site same as GABAa agonist they are more specific for receptor subtype.. they are primarly hyponotics and do not product anxiolytic, muscle relaxant or anticonvuslant effects like benzo similar side effects as benzo - next day somnolene, cognitive dysfunction, inc risk of falls in older adults reveresed by flumazepil

37 yr old owmen with right sided abdominal discomfort over weeks, immigrant from rural Kazakhstan. has a dog, hepatomegaly no fever, US shows large cystic liver mass, during resection, dies from procedure complication What is the cause?

the tapeworm echinococcus granulosus -- most common hydatid cysts... endemic region - eastern mediterrean, middle east, SA, sub saharan africa, former SU, western china, or SW US with sheep and dog initial infection asymptomatic with subsequent manifestation dependent on cyst location and size. mostly the liver but can go to lungs Unilocular - E granulosus but can be multiple via E multicoularis Echinoccocal larvae implant in capillaries trigger inflamm reaction involving monocyte and eosinophils, some larvae encyst Microscop - encapsulated and calcified (egg shell calcification) with fluid and budding cells. outer wall is gelatinous sheets surrounded by thick fibrous capsule Give albendazole. but removal of cyst can lead to anaphylaxis which occured in this patient.

How to handle low literacy?

use visual resources to improve understanding

73 yr old man, never prego, cant breathe and inc abdominal girth, dec appetite and constipation that worsened progressively for the last 6 months, PE abdomen is distended and nontender with right adnexal fullness, Microscopy shows anaplasia of epithelial cells with invasion into the stroma and multiple papillary formations with cellular atypia. What is most like elevated in patient?

CA-125 Ovarian cancer -- 3 histo types 1. epithelial 2. germ cell 3. sex cord stroma Epithelial most common and associted with inc CA-125 CA-125 protein expressed by epithelial cells in reproductive tract (ovary, fallopian tubes) and the peritoneum is a tumor marker but endometriosis can inc CA-125 so cant be used for cancer screening but useful for diagnosis and treatment foll up Ovarian cancer - pelvic mass, ascites, peritoneal metasis that results in dec appetite, abdominal distension, bowel and bladder changes (constipation, urinary frequency) nulliparous women are at ic risk for ovarian due to frequent ovulation, result in continued disruption and repair of ovarian epithelium Histo: anaplasia of epithelial cells with invasion in the stroma, multiple papillary formations with cellular atypia and occasional psammoma bodies

34 yr old with difficulty swallowing, dry mouth, blurred vsion, has major depression, mydriasis and poorly reactive pupils, electrodiagnostic studies show nerve conduction velocity is normal but dec compound muscle action potential Rapid, repetitive nerve stimulation leads to facilitation of CMAP. What did they consume?

Clostridium botulinum toxin, highly potent preformed neurotoxin combo of nicotinic (diplopia, dysphagia) and musacarinic blockage (dry mouth) -- food poisoning with botox. toxin inhibits acetocholine release from presynaptic nerve terminals at NMJ preventing muscle contraction. can be shown as a dec in compound muscle action potenial (CMAP, or electrical response of muscle). following stimulate high rate, repitive nerve stimulation improve deficit as rapid depol inc calcium con in presynaptic nerve terminal.. mobilizing addiitional ach vesicles. canned food - anaerobic environment can have spores. the toxin is not actively secreted, is released via intracellular autolysis. is destroyed by heat, but can cause diplopia, dysphagia, dysphonia (3 Ds) w/i 12-36 hrs of consumption

64 yr old woman with RA, has symmetrical joint pain, swelling and morning stiffness. has had remote peptic ulcer disase and was treated for H Pylori, follow up stool test was negative. Patient started methrotrexate and high does ibuprofen therapy and daily lansoprazole. Three month later, joints were good, stopped ibuprofen and lansorpazole. 2 weeks later got heartburn after meals What is the most likely cause of patients new GI symptoms?

Gastrin mediated rebound hypersecretion Gastrin is releasd from G cells in gastric antrum, stimilated by dietary protein intake, gastrin releasing peptide (in response to vagal stimuli) and inc gastric pH. Gastrin induces acid production by binding parietal cells and indirectly by binding enterchromaffin like cells and inducing histamine release PPIs - omerprazole and lansoprazole.. inhibit the H/K ATPase pump, decrease hydrochloric acid production regardlss of stimuli The resultant inc in gastric pH leads to inc gastrin which induced hypertrophy of the ECL and parietal cells.Withdrawal of a PPI leads to overstimulation of the parietal cells with hyperfunctioning of the unblocked H/K ATPase, leading to rebound gastric acid hypersecretion and reflux. should stop PPIs slowl.y

58 yr old healthy women, left lower abdominal pain and fever, acute diverticulitis with microperferation. hospitalized, flood and liquid withhled to promote bowel rest, and isotonic saline infusion is admin for hydration. 2 days 0- fever and pain go away gave 5L of sodium chloride, compared to preadmission, what is occured ph, bicarb, chloride, urine sodium >

Nonanion gap metabolic acidosis - due to infusion of excess normal saline excess nacl inc serum cl to cause hypercholremia. inc Cl in serum causes intracellular shifting of Hco3- to maintain electronegative balance. the "loss" of bicarb (reduced serum bicarb) dec blood ph. infusion of excess normal saline also inc intravascular vol which the kidney respond by increasing sodium excretion, resultin in increased urine Na. other NAGMAcidosis - renal tubular acidosis or severe diarrhea

Group of researchers evaluating pharmacologic properties of a drug they give increasing doses to healthy individuals and look at PharmaKinetics profile and metabolites incidence of adverse events recorded for various dosages a total of 20 healthy male and female volunteers participate which of the following describes this type of study?

Phase 1 - first step in humans, data collected on pharmokinetic profile, metabolism and pharmacodynamic response (how it affects the body) Different treatment routes (orally, IV) can be investigated Human safety and Ae and Max dose tolerated. Phase 1 - small number of healthy individuals phase 2 - efficacy in affected individuals Phase 3 - safety and effectiveness of new preatment compared to standard or placebo. >/= 2 groups of affected subjects phase 4 - AE over time by new treatmetn after approved and on the market.

21 yr old woman comes to office with burning and inc urinary freq for 2 days, she has no hematuria, discharge or irritation, temp is 98.6, PE shows mild suprapubic tenderness on deep palpation. no CVA tenderness. urine dipstick is + for leukocyte esterase and nitrites. She is started on trimethoprim, leads to rapid resolution of symptoms What other drug has same intracellular target as the drug used to treat this patient?

Trimethoprim (bacteria) methotrexate (human) Primethamine (some protozoa) all prevent THF by inhibiting dihydrofolate reductase (DHFR) Trimethoprim restrict bacterial growth and works well with sulfoanmides - which inhibit an earlier step in bacterial folic acid pathway. methotrexate - folate antimetabolite that target rapidly proliferating human cells by halting DNA syntehsis through binding of DHFR. cell cycle S specific as prvent synthesis pf purine and thymidylic acid (pyrimidine syn) Pyrimethamine - malaria and toxoplasmosis because inhibit parasitic DHFR.

26 yr man at ER after developing a fever and skin rash. patient was discharged from hospital 10 days ago after treatmetn for copperhead snake bite to his left leg. received multiple doses of polyvalent Fab antivenom therapy, patients bite pain, swelling and bruising has resolved. but has developed fever, pain in multiple extremity joints and pruritic rash over past 2 days. temp is 101.3, bp is 128/70, pulse is 98, resp are 17. PE shows diffuse urticarial rash. Tenderness to palpitation of the bilateral metacarophalangeal joints, wrists and ankles with no redness or swelling. Blood cell counts, serum chemistry and coagulation are normal What is the underlying mechanism of condition?

Tissue deposition of host antibodies and antivenom complexes Antivenom contaains foreign proteins, exposure triggers the adaptive immune resposne to form high-affinity igG ab aganist the foreign components of the antievnom... takes 1-2 weeks, due to lag time of antigen processing, presentation and CD 4 T/B cell activation/differentiation once formed, igG binds to free circulating antivenom which creates immune complexes. the Fc of IgG triggers clearnce by activating classical complement system and by directly binding ot he Fc receptor on mononuclear phagocytes in the reticuloendothelial system. Since multiple injecitions, can overwhelm the phagocytic system, leading to the aggregation of IC in blood stream. Aggregated IC deposit in tissue (skin and joints) activate complement cascade, and cause type 3 HS called serum sickness presents with fever, urticarial rash and arthralgia 1-2 weeks after exposure of antivenom, antitoxins, mabs or vaccinations will resolve in some days

52 yr old man with painless mass in right groin, saw weeks ago but has progressed, HIV, takes meds, no new sex partenres, Several enlarged, hard lymph nodes are palpated in right inguinal area inferior to the inguinal ligament, histo shows malignant cells. The malignant cells most likely originated from wher?

patient has superficial inguinal lymph nodes that are palpable. these are over femoral nerve, artery, vein in the femoral triangle, a region bound by inguinal ligament, sartoius muscle and adduct longus superficial inguinal nodes drain most cutaneous lymph from the umbilicus down, including external genitial and anus(below pectinate line) so metasis from malignancy of anal canal. exceptations: glands penia and skin of posterior calf (popiteal lymph nodes) bypass superficial lymph and go straight to deep inguinal lymph nodes.

11 yr old boy, has lower left sternal border murmur which intensifies with the hand grip exercise. Dx?

VSD Large defect result in high volume shunting of blood across the VSD, leading to a low interventricular pressure gradient and soft or absent murmur. Excess blood flow can produce HF in infancy (difficult feeding, tachypnea, failure to thrive) Small defect - allow only a small amount of bloow - asymptomatic but have loud mumurs. a harsh, holosystolic murmur at the left sternal border == small vsd rIght - louder with Inspiration lEft - louder with Expiration most murmurs INC with preload, except, MVP and HCM with INC w/ a DEC in preload

Acute calculous cholecystitis

acute inflammation of the gallbladder initiated by gallstone obstruction of the cytic duct. subsequent steps in include mucosal disruption by lysolecithins, bile salt irritation of the luminal epithelium, prostaglandin release with transmural inflammation, gallblader hypomotility, inc intralumnial pressure causing ischemia and bacterial invasion

Next of kin surrogate decision maker

if patient in unable to communicate his wishes regarding his care, and does not have an advanced directive or designated surrogate decision maker (durable power of attorney), the next to kin becomes default. order - spouse, adult children, parents and adult siblings sequentially need to make decisions based on what they think the patient would want (substiuted judgemetn) and the patient best interest. Basic life support - rescue breathing, chest compressions, advanced cardiac life support, mechanical ventilation, defibrillation. so in case of ventricular fibrillation - would not be resusciated.

what is tertiary hyperparathryroidism

in longstand CKD, PTH release may become independent of Ca levels due to chronic parathyroid cell stimulation. PTH remains elevated despite 1,25 dihydroxyvitamin D and Ca supplementation usally only seen in end stage- on dialysis

Transference

the shifting of emotions or desired associated with a person from the past to another person in the present. originate from early significant figures, particularly parents. can be positive or negative and frequently affect doctor-patient relationships (both psych and nonpsych) Positive plays a roll in trusting their physicans as many paitents have positive expectation that doctors are compassionate caregivers (similar to parents) Patients who were abused as children have difficulty seekking care or complying with the care they receive due to negative expectations of being taken adv of or being harmed by caregiving feature.

What does polyhydraminos cause?

uterine enlargement out of proportion to gestation age can lead to preterm laber, placental abruption, urterine atony due to overdistention. inc risk of maternal respiratory compromise as teh abdominal cavity impairs lungs ability to expand. can be due to dec fetal swallowing or inc fetal urinalition - gastrointestinal obstruction - duodenal, esophageal, intestinal atresia -anencephaly - defect of cranial nerual tube. increased fetal urination - high cardiac output due to anemia or twin to twin transfusion syndome materal DM and multiple gestations tend to cause milder polyhydraminos compared to major fetal abnormalities Patient prenatal use of anti-epileptic therapy 0 risk for NT defect - anacephly

54 yr old man in ER with worsening sob in last.3 days, initially with exertion, couldnt sleep at night suffocating cough when lay down, fam history has htn and asthma. bp 162/86 pulse 92 resp 26 Diagnis?

Acute decompensated heart failure Progressive dyspnea, orthopnea (cough when laying down) along with xray showing prominent pulmonary vessels, patchy bilateral airspace opacities, blunting of costophrenic angel (pleural effusion) and fissure sign (created by fluid trapped between the right upper and middle lobe) chronic HTN -> ADHF -- concentric lv hypertrophy and resulting diastolic dysfunction leading to cardiogenic pulmonary edmea Kerley B limes = short, hortizontal lines perpendicular to the pleural space that represent edema in interlobular septa Cardiomegaly -- cardiac to thoracic width ratio >50%

What is neurokinin 1 receptor antagonist used for?

Acute phase CINV <24 hrs after chemo - mediated target is serotonin from intestinal enterchromafin cells that have been damaged due to the chemo. this stimulates 5-Ht3 in the bowel wall, which project to the brainstem and stimulate the vomiting reflex. serotonin receptor antagonist (ondansteron) can be used delayphase phage 1-5 days after chemo -- primarily mediated by inc levels of substance P in brainsteam due to chemo associated emetic stimuli in csf and bloodstream substance P binds to and activates neurokinin 1 (NK1) in brainstem to mediate vomiting (nucleus tractus solitarius, area postrema) Therefore, NK 1 receptor antagonist (aprepitant, fosaparepitant) are used. AE - neutropenia cisplastic has high risk of vomiting.

81 yr old woman undergoes aortic valve implantation through femoral access. diagnosed with severe calcific AS 2 month ago after sob with mild exertion, vascular access is gained without complication and transcather valve is deployed diastolic bp before is 76, after 44 lvedp before 12 after 25 What is teh complication?

Aortic regurgitation Severe aortic stenosis inc with age, hard bcuz old people have other things going on, so poor candidate for open surgical valve replacement. transcatheter aortic value implanatation (TAVI) is alternative , adanced thru the aorta to the aortic valve where a biprosthetic valve is placed over the native aortic valve leaflets the patients intraoperative pressure reading of decreased diastolic bp and inc lvedp ---aortic regurgiation, a common complication of TAVI-- leading to paravalvular leak (Blood leakage around the valve) other complications - stroke and mi

16 yr old girl altered mental status, was fine 6 hrs ago, temp is 100.9, 120/70, 104/min, resp 30/min. pulse ox 97, girl is disoriented and drowsy. PE shows normal reactive pupils and clear lungs, has high anion gap and inc lactic acid with normal glucose. What is the cause

Aspirin intoxication (salicylate intoxication) aspirin, wintergreen oil In a couple hours - tinnitus -hyperventtaiton --primary respiratory alkalosis - nausea and vomiting - activation of chemo trigger zone in medulla from direct gastric irritation (epigastric tenderness) as a result of dec prostaglandin syn - uncoupling of oxidative phosphorylation leads to hyperthermia and inc anaerobic metabolsum, result in inc in lactic acid leading to primary metabolic acidosis with elevated anion gap. -altered mental status - due to neuroglycopenia (cerebral glycolysis inc due to oxidative phosphorylation inpairment)

4 yr old girl brought to clinic for 2nd dose of measles vaccine, what is the igM and igG trends expected after initial and subsequent measles vaccines?

B cells are primary players in inducing a vaccine response, T cells play a role in enabling high affinity antibodies and immunological memory. Most vaccinations use peptide antigens or nonpeptide bonded to peptides (conjugate vaccine) so the antigen can be displayed on MHC class 2 on APC -- lead to much stronger T cell mediated immune response Primary: - foreign antigen bind and activate B lymphocytes with compatible antigen receptors, leading to clonal B cell expansion and differentiation into short lived plasma cells that secrete low affinity igM. early igM w/i few days of immunization.. APC also ingest the peptide and travel to regional lymph nodes where they stimulate CD4 T cells to interact with activated B cells. this leads to calss switching from igM to other IgG, IgA and stimulate B cell differentiation into memory B cells PLasma cells secrete high affintiy igG and levels peak a few weeks after immunization (after igM peaks) before slowing waning secondary response: second does, get igM like teh fist done but stimulation of antigen specific naive B cells. previous memory B cells quickly differentiate into long lasting plasma cells to produce rapid and sustained iG response that peak around the same time igM response but of greater magnitude.

what is RA?

chronic, symmetric, deforming arthritis consistent with advanced RA, exam shows classic features joint enlargement, ulnar devation at the metacarpophalangeal joints and swan neck deformities (hyperextension at the proximal interphalangela joints with flexiin at the distal interphalangeal joints. RA is initiated by CD4 T helper cells and characterized by synovial hyperplasia and inflammatory infiltrates. the joint space often becomes replaced by synovial pannus, invasive mass composed of fibroblast like synovial cells, granulation tissue and inflammatory cells. Release of proteinases (matrix metallopeptidase 13) causes destruction of articular cartilaginous matrix, faciliating erosion of the surrounding articular cartilage and underlying bone. ossification of the pannus can lead to fusion of the bones across the affect joint (bony ankylosis).

54 yr old man come to Er with fever, shaking, chils and cough of copous sputum, fever, cough, sharp chest pain began 10 days ago and was prescribed oral antibiotics by pcp after saw right lower lobe infiltrate. patient did not take meds are prescribed, symptoms got worse. fever is 102.2, np 114/62 and pulse 116 PE shows crackles in the right lower lung. repeat chest xray a round density with an airfluid level in the lower lobe of the right lung. What is the most important contributor to the obsered lung lesion?

Lysosoma lcontent release by neutrophils lung abscess - necrotic infection of pulmonary parenchyma that present sever days of fever, copious sputum, x ray with cavitation with airfluid level must are due to aspiration of anerobic bacteria from the oropharyna but lunch can develop in untreated pneumonia neutrophils important for lung abcess, they are recurited by chemokines and subsequently activated by microbial molecules (LPS, peptidoglycan, bacterial DNA) and opsonizing factors (iGG, complement) to phagocytize and destroy pathogenic bacteria activatd neutrophils release cytotoxic granules (lysosomes) containing MPO to destroy extracellular bacteria and recruit. but enzymes also damage pulmonary parenchyma and result in liquifying necrosis of lung tissue.

75 yr old man with 2 yr history of slowly worsening vision in both eyes, symptoms worse at night and stopped driving, can see fine during the day, has loss red reflex and poor visualization of retinal detail, acuity testing shows 20/100 vision in both eyes, What is most likely etilogic factor?

Catarcts - progressive opacification of the lense with chronic loss of visual acuity scattering of light within th elens leads to glare and halos around bright lights at night exam show cloudiness in lens, dec detail in retina, and loss of red reflex (shine light in eyes, and reflex red back) Transparency of lens requires an ordered epithelial cell structure and maintanance of intracellular crystallins. agin and environmental stresses can disrupt transparency and contribute to cataract formation via: - nuclear sclerosis - new layer of epithelia form on cortex of lens -photooxidative damage - and cross linking of crystallins cause brown/yellow pigmentary changes - osmotic injury - development of hydrotropic lens fibers that degenerate cumulative photooxidative stress is worse with heavy UV exposure (outdoor joB), smoking, ionizing radiation. same as osmotic damage in DM, or dec glutathione

64 yr old man acut eonset RUQ pain, nausea, vomiting, had small bowel resection due to bowel ischemia a year ago, on parenteral nutrition since, has afib and htn. has moderate leukocytosis with normal hepatic transaminanse, amylase, and lipase levels. US - gallstones and edema of gallblader wall What is most likely responsible for gallstones in this patient?

Cholesterol secreted in bile, solubilized to bile salts and phosophatidylcholine, if excess then insoluble crystals form leading to formation of gallstones. risk - obesity, rapid weight loss, female, glucose intolerance, hypomobility of gallbladder (prego, prolonged fasting) prolonged course of total parenteral nutrtion - complication of gallstones, in normal - enternal passage of fat and aa into duodenum trigger release of CCK, leading to contraction of gallbalder in absence, CCK decrese and get bilary statsis, also with extensice resection of the ileum can disrupt normal enterohepatic circulation of bile acids, leading to inadequat solubization of biliary cholesterol and formation of cholesterol crystals.

4 yr old dies in hosptial of overwhelming infection, bone shows deformities and hepatosplenomegaly, clumps of erythroids precursor found in liver and spleen. Presnece of these precursors is realted to what?

Chronic hemolysis Prensence of erythroid precursor in liver and spleen -> extramedullary hematopoiesis, seen in severe chronic hemolytic anemais, such as B-thalassemia Can cause skeletal deformatities, expanding mass of progenitor cells in the bone marrow thins the bony cortex and impairs bone growth. Pathologic fractures seen in children. maxillary overgrowth and frontal bossing are associated with "chipmunk facies" in pediatric population

40 yr old female with depression and htn, found obtunded, is hypotensive and bradycardic, IV glucagon is given and she gets better What is the intracellular change that helped condiiton

Patient overdose on B-blockers leading to diffuse nonselective blockage of peripheral beta adrenergic receptors, causing depression of myocardial contractility, bradycardia, and varying degrees of AB blcock.. lead to low CO glucagon - doc for BBlocker OD act on G protein - inc intra cellular cAMP and inc Ca during muscle contraction...inc Hr and CO

28 yr old man w/ vague abdominal pain, low grade fever, diarrhea is treated with antibiotics without improvement. patitnts develops a skin leson over abdomen. temp is 100 F bp is 120/70 and pulse is 88. pn PE abdomen is mildly distended and tender to palpation. Bowel contents appear to be draining on the surface of the skin in the right lower abdominal quadrant, patient suffers from what?

Crohns disease prolonged diarrhea and abdominal pain, diarrhea can be bloody if the colon is involved. Constitutionaly symptoms - low grade fever, fatigue, malabsorption, weight loss are common Transmural inflammation of bowel can result in formation of fistulas and fibrotic strictures, causing bowel obstruction. Fistuals can form between 2 adjacent loops of bowel (enteroenteric fistula) between the bowel and another organ (bladder, vagina or bwterrn bowel and skin of the abdominal wall (enterocutaneous fistula) Perianal fistules and abscesses are also often seen UC - bloody diarrhea with abdominal pain and tenesmus, fistula doesnt occur and is confirmed to mucosa or submucosa.

62 yr old man with right arm clumsiness. PE shows motor weakness involving right arm and leg, slurred speech and drooping of right lower face, on passive flexion of right arm, there is inital resistance followed by sudden release of tension as flexion is continued. lesion affecting what part of brain?

clasp knife spasticity -intitial resistance to passive flexion followed by sudden release of resistance. due to upper motor neuron lesion, and lack of UMN inhibition on spinal stretch reflex arc. with passive arm flexion, the extensor muscles are activated by the disinhibited stretch reflex, causing initial resistance that can b overcome upper motor neuron can affect any part of pyrmidal motor system (corticobulbar,corticospinal). which runs the precentral gyrus (primray motor) thru internal capsule to the brain stem and spinal cord. patients with internal capsule stroke can have both sensory,motor def, but more cmmon is pure motor contralateral arm, leg, and lower face and clasp knife spastisity, hyperreflexia and + babinksi

72 yr old man is hospitalized for cough, purulent sputum, and sob. type 2 DM and htm, has right lower lobe pneumonia and given supplemental oxygen and antibiotics, while hospitalized teh patient develops persisent sinus tachycardia. T3 is nromal, why?

Dec conversion of T4/T3 in peripheral tissue euthyroid sick syndrome - aka low T3, normal TSH and normal T4. Thyroid hormone is released primarily in the form T4 with conversion to T3 by 5'-diodinase *type 1 and 2 in peripheral tissues in severe illness, high levls of cortisol, inflamm cytokines and free DA supress deiodination of T4 resulting in lower circulating T3 levels ESS - mild transient central hypothyroidism intended to decrease maladaptice catabolsim in severe illness, treatment with exogenous thyroid hormone doesnt work

newborn boy born 39 weeks, fine, head weight and length 75-90th percentile, anterior fontalle is open and soft, neck is supple, cardio unremarkable, abdomen is soft, back unremarkable, no hip clicks, both feet are plantar flexed and adducted with soles pointing medially. resistance to ROM assessment in both feet, muscle tone is normal The abnormal findings on PE is what type of congenital abnormality?

Deformation Baby has talipes equinovarus (clubfoot) - one or both feet are rigidly flexed down and inward it is a deformation anomaly, structural abnormality caused by extrinsic forces on developing fetus. normal growth and positioning is restricted due to poor in utero mobility (multple gestation, breech position) get underdeveopment of talu sbone --> subluxation of the surrounding joint and shortening of the adjacent calf muscles and tendons.

68 yr old man is evaluated for visual loss in the left eye that resolved spontaneously within several hours, patient has htn, dm2, cad, ischemic cardiomyopathy. He smoked for 40 years, PE shows left carotid bruit, carotid duplex shoes stenosis of left internal carotid artery has a stent placed and during the artherosclerotic debri embolize to ACA, what will he have difficulty doing?

climbing stairs Blue - carotid arteries which give off the middle cerebral artery (green) and supply lateral brain and the anterior cerebral artery (red arrow) - extend medially and superiorlu. ACA supply medial region of ipsilateral hemispher from the frontal pole to the parietoccipital sulcus occlusion of ACA -- sensory and motor function of contralateral leg and foot if bilateral ACA - can develop behavioral symptoms (abulia- lack of will or initiative) and urinary incontinence if the frontal micturitation center (medial frontal lobe/cingulate gyrus) is affected. ACA supplies the medial portion of the 2 hemispehers (frontal an d parietal lobes)

5 yr old boy is brough to the office by his parents for evaluation of cyanosis with minimal exerction. Boy has occasional episodes of "turning blue" that began in infancy and now occur more frequently. If he squats it makes him feel better, immigrated to the US , PE shows prominent right ventricular impulse and harsh sysotlic murmur. What is the embryological event that cause the condition?

Deviation of infundibular septum Cyanotic spells that improve with squatting, prominent right ventricular impulse, systolic murmur -- Tetralogy of Fallot. Abnromal neural cret cell migration leads to anterior and cephalad deviation of the infundibular septum during embryoligical development, resulting VSD and overriding aorta. 4 distinct anatomic abnormalities: - VSD Overriding aorta over the right and left ventricle -right ventricle outflow tract obstruction -right ventricular hypertrophy Cyanosis occurs due to presence of right to left shunt in patients with severe or worsening RVOT obstruction The typical, systolic ejection murmur over the mid to left upper sternal border is due to presence of RVOT obstruction (subvavular, pulmonary valve stenosis or supravalvular narrowing in the main pulmonary artery). Squatting inc the peripheral vascular resistance (afterload) and dec the degree of R to L shunting across the VSD, improving cyanosis.

What is used for ganciclovir resistant CMV?

Foscaranet, can chelate calcium, can cause renal wasting of magnesium and lead to hypomagnesemia and reduction in release of PTH, which contributes to hypocalemic state both hypocalemia and hypomagnesemia leads to promotion of seizures.

3 yr old boy intellectual disibility and speech delay, does not imitate parents, no social smile or interest in other children, has 8-10 word vocab and cant amke 2 word sentenes. There is also concern that his verbal comprehension is poor, labs show 226 CGG trinucleotide repeat on gene located on X chromosome. what is cause of patients clinical condition?

Fragile X syndrome, intellectual diability -most common inheritied PE- maroorchidism and dsymorphic facies (long and narrow face, prominent forhead and chin) Neuropsychiatric - developmental delay, adhd, autism, Mutaiton of fragile X mental retardation (FMR1) gene on long arm of chromosome X. norm has 5 to 55 CGG trinucleotide and can expand during meiosis in oocytes. FUll mutaiton >200 CGG repeats which causes FMR1 hypermethylation DNA menthylation inactivated FMR1, preventing transcription and production of gragile X mental retardation prtotein, thereby impairing neural development southern blot analysis is used to measure the degree of methylation and determine th enumber of repeats

Prego has burning, squeezing pain in middle of her chest that last for minutes to hours at a time, usually occurs after meals. gets sour taste material in back of her throat. no pain or emesis or visible blood in stool, preg was compicated by gestation DM, which was controlled. What is the cause of patient symptom?

GERD reflux in prego women in all trimesters.. cuz of elevated estrogen and progesterone levels, which relax the SM of LES leading to dec LES tone and reduced sensitivity to contract from high protein meal reflux can also occur from gravid uterus compress stomach and result in altered LEs angle and inc gastric pressure

65 yr old man with acute mental staus change, having dinner with family and suddenly cant use fork and is confused, he has Dm, hyperlipidemia and htn, smoked for 40 years, bp is 180/98, pulse is 98. on PE is oriented, answer questrion, no motor sensory of visual defects, he has left-right disorientation and unable to do simple calculations, read or write. Noncontrast CT shows no intracranial hemorrhage dx? where?

Gerstmann syndrome 1. agraphia - cant write 2. acalculia - cant calculate 3. finger agnoisa - cant identify fingers on hand 4. L/R disorientation acute ischemic stroke affecting angular gyrus of dominant parietal lobe -- supplied by middle cerebral artery. Angular gyrus - part of parietal association cortex, integrates multisensory (visual, tactile, verbal) info and comprehend events and solve problesm imporatnt for semantic processing, word reading and comprehension and number processess. angular gyrus lesions can also be associated with alexia (inability to read) and aphasia (impaired speech).

24 yr old obese woman, spotting after vaginal intercourse, yellow vaginal discharge, patient has taken OCP for last 3 years, no meds, mom had cervical cancer, BMI is 35. Purulent discharge from cervical os, cervix is friable. no cervical motion tenderness on bimanual exam and adexna are nontender. discharge has a lot of neutrophils, nucleic acid amp testing is +. if left untreated, at risk for what?

Gonococcal cervicitis Endocervical infection (cervicitis) which is classically asymptomatic and detected with nucleic acid amplification testing when asymptomatic, it present with a mucopurulent discharge or intermenstrual or post - coital spotting. gonorrhea and chlamydia can ascend to upper genital tract, resulting in PID Treatmetn with azithromyocin and ceftriaxone provide converge for both orgnaisms and prevent profession to tubes and uterus 20% of PID lead to infertility due to permanent scarring of the fallopian tubes from salpingitis and have inc risk of ectopic pregnancy

5 yr old child brought to the ER with right arm pain, was stung, PE shows edematous and erythematous plaque with mild central pallow. Residual stinger is located central to the lesion. what substance is directly responsible?

Histamine Type 1 HS. Wheal and flare reaction - an erythematous papule or plaque often with central pallor (wheal) and peripheral erythema (flare) during initial allergen exposure, patient predisposed to allergic response will undergo class switching from igM to igE. igE produced by B lymphocytes and plasma cells bind the high affinity igE Fc receptors on basophils and mast cells. reexposure to allergen results in igE cross linking with subsequent degranulation and release of inflammatory mediators (histamine, proteases (tryptase), leukotrienes, prostaglandins) Localized vasodilation and inc vascular permeability result in wheal and flare lesion can lead to vasodilation, bronchoconstriction, massive fluid shifts and anaphylactic shock and potential death.

58 yr old asymptomatix woman comes to office, hypothyrpidism and takes levothyroxine, white cells are intubated with mycobacterial antigens, a large amount of INF-gamma is detected, What cell type is responsible?

IFN-gamma activated macrophages, inc MHC complex expressiong and promote T helper lymphocyte differentiation produced by activated T lymphocytes and NKCs of immunity aganist viral and intracellular bacterial infecitions Inteferon gamma release assays (IGRAs) test for latent TB measuring realse of T lymph when exposed to antigens until to TB, measure cell mediated immunity IGRAs do not react with BCG vaccine and follow up is not required.

24 yr old man with paroxysmal episodes of breathlessness and wheezing for 6 months, no triggers assocuated, had eczema as a child, lung shows good air movement with no wheezing, sputum shows granule containing cells and crystalloid masses. These are a result of what cytokine?

IL-5. most likely has asthma -- airway inflammation ,bronchial hyperactivity, variable airflow obstruction. if cant be related to infection, inhalation, stress, exercise or aspirin -- think atopic (extrinsic) asthma. is normally predisposed in fam history of asthma, allergies or eczema. sputm shows eosinophils (granule containing) with Charcot-leyden crystals (bipyramidal shaped accumulation of eosinophil membrane protein) due to excessive Th2 mediated reaxtion -- cells secrete IL-5 for eosinophilic activation, recruitment and prolonged survival in bronchial mucusa Th2 also secrete Il4 - stimulate IgE formation by plasma cells. bind to mast cells and with repeated exposure lead to degranulation -- > bronchoconstriction, inc vascular permeability, inc mucus production with acute asthma exacerbations. eosinophils release major basic protein, eosinophilic cationic protein that damage bronchial epithelium later in immune response.

62 yr old man with 6 mon history of progressive exertional dypnea. Patient has occasional cough with no palpitations, orthopnea, chest pain or lower extremity swelling, PMH.- nothing, nos ocail history, symptoms continue and patients dies of resp failure 3 years after initial clinic visit. Autopsy findings include heterogenous lung parenchyma with predominatnly subpleural areas of dense collagen depostion, lymphocyte infiltration, and fibroblast proliferation intermixed with area of normal lung tissue. Dx?

Idiopathic pulmonary fibrosis Patchy area of interstial fibrosis w/ chronic interstital inflammation intermixed with normal lung - early lesions of fibroblastic foci that inc w/ collagen with time -honeycomb pattern w/ fibrotic walls and cystic spaces lined by bronchiolar epithelium - fibrosis most prominent in subpleural and perilobular regions Must have no findings consistent with anything else risk factors - smoking, environmental pollutants, chronic aspiration, older age, and genetic (telomerase mutations) sym; dyspnea, nonproductive cough, finger clubbing, inspiratory crackles onset is insidious, prognosis is poor, and there is no cure

What is oxygen levels in tricupsid atresia?

If tricupsid atresia - absent between RA and RV, an ASD is always present, allowing deoxygenated blood to flow from RA to LA. This dec SaO2 in LA, LV, and systemic circulation, causing neonatal cyanosis, little blood that reach the lung

30 yr old study looks at individuals with no known 50-80 yr old cardio diseases. Patients >80 r likeluy to show what compared to 50 in sbp, dbp, pp?

Inc in systolic, dec in diastolic and pulse pressure inc DBP is baseline hydrostatic pressure in arterial system and is directly related to SVR and arterial blood vol. Pulse pressure is amount that arterial pressure inc above diastolic pressure during LV contraction. it is directly related to SV and inv to aortic compliance Systolic BP - is the sum of diastolic bv and pulse pressure Agre related stiffness of the aorta - primary driver of BP change in ppl >65, reduced aortic compiance in setting of unchange stroke vol leads to inc pulse pressure. reduced compliacne causes less blood vol to be retained in the arterial system (blood is displaced to more compliant venus system) result in slightly dec diastolic bp inc in PP is greater then dec in distolic pressure, resulting in inc systolic pressure and isolated systolic htn in elderly sytoli chtn induced by aortic stiffening likely contribute to mild concentric left ventricular hypertrophy, another common finding in elderly

82 yr old man is brought o ER with fatigue and palpitations, BP is 110/70, pulse is 130 rhythem is irregularly irregular. lungs are clear given digoxin, 2. hours later patient is gucci. pulse is 82 but still irregularly irregular. What best explains the HR lowering effect of med?

Inc parasympathetic tone patient had afib with rapid ventricular repsonse and treated with digoxin for rate control. Ca channel blocks and beta blockers are preffered for rate control, digoxin sometimes used. digoxin - slows the ventricular rate during AF primarily by inc parasympathetic tone, leads to inhbiton of AV node conduction it inhibits the Na/K ATPase pump in vagal afferent fibers sensitizes arterial baroreceptors (carotid, aortic) and cardiac receptors, augmenting afferent input form cardiovascular system to the brain, also enhance efferent parasymp ganglionic transmission leading to inc vagal output. slowed AV conduction - used for AF and flutter with rapid ventricular response (RVR) HR>100, cuz inc automaticity in these conditions is located in the atria and rapidity of ventricular response depends on the refractory period of the AV node. when AV node conduction is slowed, the atria will continue to flutter, but ventribles will contract at more normal rate. RVR is serious as inadequate diastolic filling time can lead to poor cardiac output and backup of blood in the lung (heart failure).

72 yr old man with 6 month back and bilateral thigh pain provoked by walking. can walk 2-3 blocks before have to stop due to pain, leaning over provides relief, has ocassional tingling in lower extremities, no prior trauma or rheumatologic disorder, PE muscle strength is nromal and sensory , peripheral pulse are full and assemetric Thickening of what ligment is contributing to patient presentation?

Ligamentum flavum patient has spinal stenosis = abnormal narrowing of the spinal canal occuring most common in lumbar. Compression of nerve roots --> lower extremity pain, numbness/parasthesia and weakness Onset of pain with walking is neurogenic claudation = same symp as vascular claudation Spinal stenosis is posture dependent Extension - standing walking -- narrow spinal canal while lumbar flexion - walking uphil leaning on a stroller relieve pain most common cause is degenerative arthritis of the spine in >60 yr old intervertebra disc degenrate and begin to protrude - resulting in corresponding loss in disc height, this leads to disproportionate load on posterior aspect of spinal column -- formation of facet joint osteophytes and hypertrophy of ligament flavum (strong elastic ligament supporting the posterior aspect of the spinal canal)-- this leads to compression of nerve roots and neruo symp

56 yr old woman brough to the ER with 2 day history of fever, headache, mild confusion and dry cough, has mild abdominal discomdt and watery diarrhea, recently returned from cruise to hawaii. she has htn, hyperlipidemia, smoked 1 pack of cig a day for 20 years. temp is 104, bp is 104/63, pulse is 85 and resp are 24. Lung exa, shows lower lobe crackles with no wheezing. her abdomen is soft, nondistended and nontnder Xray shows bilateral lower lobe infiltrates What else would be present?

Low serum sodium Legionella pneumonia can be divided into pontiac fever (acute, flu like, self limited) and more common Legionnaires disease Legionnaries - contaminated water (sporadic cases or common source of cruise ship, spa, hospital, air condiitoning), radiographic evidence of pneumonia (patchy infiltrates that progress to consolidation), high fever >102,2m and sometimes with bradycardia and neuro symptoms (confusion, headache) and GI -diarrhea Risk in immunicompromised, smokers, alcoholics and patients with COPD Legionella pneumophila - faintly staining gram negative bacillys that is faculative intracellular, gram stains show a lot of neutrophils but no organism Diagnosed used urinary antigen testing; grows on Buffer charcoal yeast extract (BCYE) most common lab - hyponatremia - inappropriate ADH and renal tubulointerstial disease impairing sodium reabsoprtion , transaminases are also elevated

What maintains ejection fraction in old people?

cardiomyocyte hypertrophy Concentric left ventricular hypertrophy - occur with age to allow for maintenance of left ventricular contractility and ejection fraction despite cardiomyocyte drop out and inc left ventricular afterload (due to reduced aortic compliance)

34 year woman comes to clinic due to mass in her right breast, after self examination, 2 cm nodule notes on exam and referred for biopsy. what is the histo?

Most common benign tumor of breast, arising in young women age 15-35. nodules that are well demarcated, painless, mobile, spherical and can be 1-10cm in size, occur in multiple or bilateral lesions in older, they are often found incidentally on mammography inc during pregnancy, alctation and estrogen therapy and regress after menopause they are benign appearing cellular or myxoid stroma that encircles epithelium lined glandular adn cystic space. have well defined border but compress and distort the surrounding glandular epithelium

What are the pharaceutical differences between neonates and adults?

Neonates have an INC proportion of total body water with lower content of body fat compared to adults difference results in water soluble drugs (amioglycosides, vancomyosin) haveing a larger than expected Vd relative to body mass leading to lower plasma concentration when admin at same weight-based dosage. neonates have less developed BBB that inc perm to CNS -- further inc vd and inc risk of CNS toxicity

65 yr old man comes to office due to swelling of the legs and hands for 10 days, reports fatigue and frothy urine for 2 motnhs, has htn, patient has periorbital edema and bilateral pitting edema of the legs. Urine is +4 protein but is otherwise normal. What is the dx?

Nephrotic syndrome edema, marked proteinuria, amorphous pink deposits - amyloidosis, caused by misfolded proteins, fibril formation, extracellular depositon, resulting in orgran dysfunction. Kidney is most common in AL and AA amyloidosis Amyloidosis can be confired by apple green birefringence with congo red stain under polarized light

Insulin conc in pancreatic veins is measured after admin of various agents, epinephrine admin is found to dec in insulin sevels. however, after pretreatmetn with drug A, epinephrine injection causes a paradoxical inc in insulin concentration. What receptor does drug A most likely block?

Pancreatic beta cell insulin secretion is influenced by serum glucose levels and other factors such as autonomic NS activity. Parasympathetic stimulation of M3 receptors promote insulin secretion and is induced by the smell or sight of food. Sympathetic stimulation - both alpha 2 and beta 2 adrnergic receptors are present on pancreatic beta cells and exert opposite effects beta 2 ->> promote insulin secretion alpha 2 --> inhibit insulin release. But alpha 2 --> inhibitory effect is predominant, causing sympathetic stimulation to lead to overall inhibitor of insulin secretion epinephrine admin activates both alpha 2 and beta 2, but the overriding inhibitory effect result in dec insulin secretion. following pretreatmetn with an alpha 2 receptor blocker (drug A) epinephrine effect on beta 2 would become dominant, resulting in increased insulin secretion.

58 yr odl man has wound dehiscence. A compication of. bevacizumab is suspected. what is the MOA?

Partial or complete seperation of previously approximated wound edges. Due to disruption of would healing process and can be complication of meds like bevacizumb. it is a mab that binds VEGF preventing it from binding to cell surface receptor. it inhibits angiogenesis - process of new bv sprout from surroudning, uninjured vessels and grow into the wound- becuz angiogenesis is largely stimulated by VEGF. it is a cancer starving therapy, but also suprress angiogensis in healing wounds it can cause would dihiscence, lack of blood supply to support collagen production during proliferation phase (3 ays to 5 weeks) and collagen remodeling and cross linking during maturation (3 weeks to 2yrs) when inhibited, tensile strength of the would remains low.. and can see dehiscence weeks to months after inital closure.

28 yr old woman comes to the office for preconception visit, has never been pregnant and would like to improve chances of getting prego, no fam history of genetic abnormalities or infertility, had period at 13, gets period every 28 days, bleeding last 4 days, no prior surgery or STI, husband has not fathered a child but no abnormalities, have sex several times a month. What hormone would inc the most in conc after ovulation?

Progesterone Progesterone = progestation Following the onset of menstration - day 1 - pit FSH stimulate ovarly to recruit 1 primary follicle which becomes the dominant follice. FSH stimulates granulosa cells inside the follicle to produce estrogen, leading to progressive inc in estorgen. during the 14 day maturation process (follicular phase), follicle enlarges and becomes fluid filled and pimary oocyte becomes secondary oocyte (tertiary or mature) Peak estrogen levels in late follicular phase a positive feedback effect on LH production, causing LH surge LH sruge cause the follicle to rupture, leading to extrusion of the secondary oocyte (ovulation). FSH levels are highest just before ovulation. Followng ovulation, granuloas and theca cells of ovarian follice luteinize to form the corpus luteum. this secrete high levels of progesterone and moderate estrogen for next 14 days (luteal phase) progesterone timulate the endometrium to transform from proliferative to secretory

400 woman between 20-35, check up asked about smoking status, 40% were smokers, for next 10 years, 24 and 25 smokers/non developed breast cancer What is teh study design?

Prospective cohort study Initial group selected (a cohort) and they exposure status is determined (smoker/nonsmoker) then followed for a period of time to look at outcome.

34 yr old woman evaluated for fatigue and progressive exertional dyspnea. goes mountain biking with friends and has to stop more often, drinks sometimes, exho shows enlarged coronary sinus. What is the cause?

Pulmonary hypertension Most of venous drainage from the myocardium transveres the coronary sinus which delivers deoxygenated blood to the right heart. runs transversely in th eleft AV grrove on posterior heart, open into RA between IVC and tricupsid valvue at CS orfice CS communicates freely with RA, it will become dilated with anything that effects the RA most common cause of coronary sinus dilation is elevated right heart pressure secondary to pulmonary hypertension.

34 yr old man with inability to lose weight despite diet and exercise, phentermine prescribed, MOA?

Release of norepi sympathomimetic weight loss drug for short term <12 weeks treatment of obesity stimulate release and inhibit reuptake of norepi and some serotonin and dopamine get increased sensation of satiety and reduced caloric intake can raise BP and should be avoided with htn or heart disease are poor for long term benefit as most ppl regain weight after they stop

a cell biologist is studying the role of ribonucleoproteins in normal cellular function, they are serpated and purified from the cell extract for structural and functional analyses. found to express higher amounts of particular protein in comparison to other cell types. The prtein has reverse transcriptase activity that functions to add TTAGGG repeats to the 3' end of chromosomes. What cell type is studied?

Telomerase is a ribonucleoprotein that adds TTAGGG repeats on the end of 3' chromosomes. it is similar to reverse transcriptase as it synthesizes single stranded DNA using single stranded RNA as a template (RNA dependent DNA polymerase). made of 2 subunits - telomerase reverse transcriptase (TERT) and telomerase RNA component (TERC). TERC is a built in RNA template that is repeatedly read by TER to add TTAGGG to telomeres Stem cells have long telomers due to high telomerase activity, allow to prolifeation indefinitely in a controlled manner. but most terminally differentiaed adult somatic cells (myocardial cells, neurons, pancreatic B cells) have short telomers as dont express telomerase and shorten with every cell division Bloom syndrome.- premature aging - shortened telomeres

how do deal with nonadherence?

Validate the patients perspective and using an open ended non judgemetnal question to initate a discussion normalize difficulty with adherence, follow up with open ended and nonjudgemental exploration for reasoning of nonadherence educate, simplify, lower cost with generic, address side effects and psychological issues, inc supervision, monitoring and follow up

18 yr old man w/ hematuria, intermittent flank pain for months, no trauma or STI, fever, or dysuria. soft abdomen, w/ normal bowel sounds and no localized tenderness. No abnormalities in the ureters or kidneys but the left renal vein between the SMA and the aorta is compressed What will develop?

Varicocele The right renal vein is short and runs anterior to the right renal artery before joining hte iVC. The right gonadal vein drains directly into the iVC. The left renal vein is long, runs posterior to the splenic vein before crossing the aorta beneath the SMA. The left gonadal vein joins the left renal vein upstream where it crosses aorta and doesnt enter IVC directly Pressure w/i left renal vein is often higher than on the right due to compression between the aorta and sma -- nutcracker effect pressure can be elevated due to compresses from left sided abdominal or retroperitoneal mass Elevated pressure in L renal vein can cause flank or abdominal pain, along iwth the gross or microscopic hematuria (left renal vein entrapment syndrome). Inc pressure in the left gonadal vein results in valve leaflet failures and varices of the testicular pampiniform plexus varicocele

26 yr old woman with discomfort, diarrhea, melena, image shows a lot of polyps, sister with same parents, what is the life long change of colon cancrer/

close to 100% innumerbale colonic polyps, --> AD hereditary FAP - familial adenomatous polyposis. hundred or thousands of colonic polyps in 2/3rd decade of life. behavior similar to spontaneous polyus as they - grow over time, do not regree, associated with high risk of dysplasia and transform as they enlarge. cuz there is so many risk of transformation is 100% FAP is caused by germline mutation to the tumor supressor gene adenomatous polyposis coli (APC) - apc codes for protein that destroys Beta-catenin. loss of APC results in INC beta catenin -- stimulating transcriptional activation that leads to proliferation of intestinal crypt cells and formation of polyps. can also have gastric or duodenal polyps, desmoid tumors, bran cancer loss of APC is first step in development of both hereditary and sporadic colon cancer. 8-% of sporadic ahave mutation in boht APC elles.

What is the physiological response to high altitude?

dec atomospheric pressure reduces partial pressure of inspired PiO2. initial response: - peripheral chemoreceptors in aorta and carotid body --> hyperventilation to inc arterial oxygenation (PaO2); inc loss of Co2 leading to respiratory alkalosis; dec in H+ leads to left shift to increase O2 uptake in lungs - hypoxic pulmonary vasoconstriction occurs to minmize ventilation perfusion mismatching and optimize pulmonary o2 uptake, inc pulmonary vascular resistance, which inc pulmonary artery pressure - symp act inc inc HR and CO - drop in Co2 (encourage cerebral vasoconstriction), reduced PaO2 and marked hypoxia lead to vasodilation to inc cerebral blood flow 24-48 hrs later - kidney inc HCO3 excretion (comp. metabolic acidosis), dec blood pH. central chemoreceptors inhibit ventilation when pH gets too high, HCO3 excretion allow for additional ventilation -hypoxemia suppresse aldosterone activiy, together with inc HCO3 excretion result in diuresis and told body volume loss. reduced plasma vol in hematocrit and reduce cardiac preload to dec o2 demand. this dec SV, but CO remains high due to inc HR -RBCs inc production of 2,3-biphosphoglycerate to shift hemoglobin dissociation back to the right and facilitate O2 unloading kidney inc EPO, upregulation of hypoxia inducible factor (HIF) which stimulate EPO and angiogenesis in skeletal muscle and other tissues to improve o2 delevivery individuals who stay at high altitude for extnded time will experience benefit of inc epo and upregulation of HIF, as secondary polycythemia (inc O2 carrying capacity) and angiogenesis after several weeks

19 yr old, brain injury in car crash. glasgow coma scale -3, 110/70, 114/min. pupil miotic, equal, reactive to lgiht, ecchymosis behind ear intubated and mechanically ventilated, noncontrast CT show bifrontal contusions and basilar skull fracture. one day later, diffuse cerebral edema. Ventilator resp rate is adjusted to achieve PaCO2 level of 26-30. What is the effect?

factors that influence cerebral circulation are systemic BP and arterial blood gas levels. when systemic bp is 60-140, little effect on CBV via autoregulation (vessel dilation or contraction) BP>150 inc cerebral vascular volume and blood flow, causing corresponding inc in ICP. BP <50 cerebral hypoperfusion and ischemia arterial blood gas - powerful effect on cerebral blood low, with PaCo2 most imp. Dec in PaCo2, due to hyperventilation --> vasoconstriction leading to a dec cerebral blood vol and dec ICP Lowering the PaCo2 can reduce ICP in mechanically ventilated patients with cerebral adema.

34 yr old man with dm 1, gianosed 15 years ago, has combo basal and rapid acting insulin injections, has been having intermittent episodes of hypoglycemia with blood glucose at 35. 2 weeks was er after passing out due to low gluclose, given an injectable to admin at home if hypoglycemia is associaeted with impaired consciousness. this med improve hypoglycemia by what? what drug?

glucagon hypoglycemia - first neurogenic (autonomic) symptoms, anxiety, tremor and sweating can lead to confsuion, loss of consciousness and seizures. mild to moderate can be treated with oral fast acting carbs like glucose tablets, fruit juices. when unconscious need to give parenteral treament in hospital give IV glucose, in nonmedical treat with glucagon kit, intranasal and subcut/intramuscular formulation given by caregiver glucagon - rapidly correct hypoglcemia by inc hepatic glycogenolysis, return to consciousness in 10-15 min. also inc gluconeogenesis and supress hepatic glucose uptake but that is slower but more sustained

23 yr old man enrolled in study is found to excrete large anounts of fructose in urine compared to others despite maintaining a moderate fructose intake, He has a hereditary defect in fructose metabolism, but he is asymptomatic, What enzyme is able to metabolize fructise due to compensatory activity?

hexokinase Fructokinase def is essential fructosuria - asymptomatic, AR, dietary fructose to be excredted unchanged in urine. In fructokinase def, hexokinase takes over the role of fructose metabolsim converting fructose into fructose 6 phospahte. fructose 6 phosphate can be metabolized in glycolytic pathway or converted to glucose -6-P or G-1-P and go to PPP or glycogen synthesis.

27 yr old woman, 37 weeks, spontaneous rupture of membranes with leakage of blood mixed with fluid. C-section ER due to severe fetal bradycardia, neonpate is apneic and hypotonic, umbilical cord shows high anion gap metabolic acidosis, controlled hypothermia to maintain body temp is begun, this therapy provides what benefit?

in eary term infact has sustain hypoxic-ischemic injury during delivery has risk of developing neonatal encephalopathy (decreased consciousness, impaired respiration, seizures) hypoxia can lead to neuronal injury due to formation of ROS, which lead to cell damage Therapeutic hypothermia (33-35C) leads to improved neurologic outcomes in hypoxia induced injuries (cardiac arrest, seuzire) the formation of ROS after ischemic injury is temp dependent, so can be dec by staying in hypothermia. this also dec cerebral blood flow, oxygen consumption and glucose metabolsim, decreasing formaton of ROS due to both cellular metabolism and repurfison it can also dec iCP, reduc excitatary NT, an dec activation of inflammatory and apoptoci pathways (block TNF and caspase)

What are the effect of CKD?

in psychiological state, PTH: inc serum ca, dec PO4 via: - inc osteoclastic bone resportion - inc renal reabsorption and red phosphate reabsorb - inc formation of 1,25-dihydroxycholecalciferol (up regulate renal 1-alpha hydroxlase) which inc intestinal ca and po4 absorption in CKD: PO4 clearance decline due to fall in GFR, inc PO4 bind free serum Ca, resulting in hypocalemia. Loss of renal parenchyman reduces 1,25 -dihydroxyvitamin D syn, resulting in significant decline in intestinal Ca absorption and ca release from bone. Futher exacerbation of hypocalemia and hyperphosphatemia and low calcitriol, stimulatie PTH production (secondary hyperparathyroidism)

33 yr old migrate to US, sob, hemptysis, PE shows diastolic murmur, Xray shows severe pulomonary vascular congestion and edema. treated with diuretics feels better, develops right sided hemiparesis, What finding would suggest both mitral and aortic valve rather than jsut mitral alone?

inc LVEDP In isolated mitral stenosis - cardiac and pulmonary pressure proximal to stenotic are inc. but LV should be normal or even dec with severe stenonsis inc LV diastolic pressure suggest aortic valve dysfuntion Rheumatic heart diase always affect mitral valve, both are 25% of time. aortic valve involvemtn -> combined aortic stenosis and reg, both can in LV diastolic pressure aortic valve deformation can lead to infective endocartitis the right sided hemiparesis is most likely due to embosis which orginated from atrial mural thrombsis secondary to atrial dilation from MS or endocarditis related valvular vegetation

4 yr old boy is brought to the office with 2 day history of progressive jaundice, he has scleral icterus and jaundice over fast and chest. Labs show hemoglobin of 17.5m total bilirubin 8, indirect 7.2 Patient jaundice resolves in 3 days without intervention. REult of what changes in bilrubin metabolism compared to an adult?

inc production, dec conjugation, and inc enterohepatic bilrubin circulation baby has benign neonatal hyperbilirubinemia normally, unconjugated is released into bloodstream upon breakdown of rbcs and taken into liver, hepatic UDP glucuronosyltransferase then conjugate bilirubin, secreted into bile and extreted into intestines, bacteria then reduce to urobilinogen, allowing for excretion in urine ansd stool phsyiological difference in babies: 1. bilirubin production is increased, due to inc breakdown of RBC, which are high in number (hematocrit up to 60%) and have a shorter life span of 90 days 2. bilirubin conjugation is dec due to lower lecels of UDP in the immature liver 3. relative gut sterility result in dec reduction of bilirubin to urobilinogen. instead, intestinal b-glucuronidase (syn endogenously and by gut bacteria) deconjugate the bilirubin what allow reabsorbtion, inc enterohepatic circulation

23 yr old man comes to ER with fever, severe headache, vomiting, not well for 2 weeks has fatigue, intermittent low grade fevers and headache. HIV + and spent 3 months in prison, temp is 101.5, neck stiffness +, CT no intracranial lesions CSF shows low glucose, high protein and leukocytes at 120. CSF show mycobacterium tuberculosis with dec activive of intracellular catalase peroxidase. Isolated would show resistance to what drug?

isoniazid patient has tuberculosis meningitis Isoniazid (INH) is the inhibition of myocolic acid synthesis. but must be processed by mycobacterial catalase peroxidase for drug to be activated by bacteria,. so resistnace if catalase peroxidase enzyme not present or genetic modification of INH binding site on mycolic acid synthesis enzyme - resistance.

Flow volume loops

left shift: inc total lung capacity and residual volume, "scooped out" expiratory patttern -- reduced expiratory flow rates in obstructive lung disaeses.

What are the principles of motivational interviewing ?

nonjudgemental, collaborative, patient centered approach that enchance the patient sence of self confidence and self efficacy

MOA of rivaroxaban?

oral anticoagulant that directly inhibit Xa. used for venous TE and stroke prohylaxis w. a fib. reversal: andexanet alfa

medical student looking at effects of drug on IV, looks at bp, hr, pupil size and uterine contractions. how does arenergic drugs effect eye and uterus?

pupillary dilator muscle of eye - has alpha 1 receptors -- stimulation of thiese lead to contraction of pupillary dilator muscle with subsequent dilation of pupil (mydriasis). -- give phenylephrine to dilate eyes b4 opthalmoscopic exam b2 is found in teh uterus -- stimulation leads to uterine relaxation (tocolysis) used to defer premature labor B2 agonists like ritodrine and terbutaline are used for this.

3 month old, fussy, poor weight gain, polyuria. Urine vol is 700-800 mL/day. maternal gpa had polydipsia and polyuria. serum sodium is 151 mEq/L, genetic testing shows vasopressin-2 receptor mutation What would be seen in serum osmo, urine osmo after water depreation, change in urine with desmopressin admin?

serum osmo - high urine osmo w/ water deprevation -low change urine osmo after desmopressin- no change Nephrogenic diabetes insipidus - patient with V2 vasopressin receptor mutation has polyuria, hypernatremia V2 receptors are located in renal cortical collecting ducts. when serum osmo rises (water deprivation, dehydration, there is inc release of ADH, vasopressin, which activates V2 receptors to reabsorb water into the systemic circualtion, water reabsorption lead to conc urine (low vol, high osmo) and lower serum osmo mutations - impair V2 receptor fxn leading to ADH resistance following water deprevation, CD is unable to reabsorb h20 despite high ADH levels, leading to ongoing urine loss. Nephro Di - large vol of dilute urine, high serum osmo and dehydration In central DI, desmopressin correct the underlying ADH def, therefore urine osmo increased

lymph superior bladder/inferior, prostate, testes

superior bladder -> external iliac nodes Inferior bladder -> internal illiac nodes prostate -> internal iliac nodes Testes -> abdominal para-aortic (retroperiotoneal) lymph nodes