Sara_uworld_Random

What anticoagulant is most effective in inactivating thrombin?

Both unfractionated heparin and LMWH can bind anithrombin to inc activity aganist factor Xa. Only unfractionated heparin can being both antithrombin and thrombin to allow antithrombin to inactive thrombin.

What can u get infected with strep even tho had vaccine

has virulent polysaccharide capusle, a conjugant vaccine provides long lsating immunity aganist serotypes in vaccine but provides no signficatn immune aganist nonvaccinated serotypes... so can infection wth one not covered. there are >93.

48 yr old progressively worsening muscle weakness for past 2 months, cant climb stairs, get up from cahir, place dishes overhead. lost 10 lbs, and some abdominal discomfort. Pe shows weakness of the shoulder and hip girdle muscles. What is it associated with?

Dermatomyositis - proximal muscle weakness resembling polymyositis, with inflammatory features involving skin (helitrope rash, gottron papules). both can occur alone or as a paraneoplastic syndrome associate with adenocarcinoma of ovary, lungs and pancreas.

What are three diff population pyramids?

Expansive = high birth and mortality rate and short life expectancy, larger percentage of people in younger cohort (broad bottom and narrow top). pop is young and growing, -- developing countries Stationary - declining birth rate, low mortality rate and long life. equal percentage of people in each age cohort (rectangular shape), population is stable -- developed countries Constrictive - significant low birth and mortality rate, long life, smaller % of people in young (narrow bottom).. pop is shrinking and pyramids are very advanced countries with high literacy, easy access to BC, and exceptation health and medical resources.

34-year-old woman with nausea dizziness and confusion found laying by the bed next to empty bottle of aspirin she swallowed pills 12 hours ago after coming home from work she's hearing annoying buzzing that won't stop she has a fever her pulse is 102 she's agitated and confused what is expected of pH PaCO2 and plasma bicarb levels?

Acute salicylate intoxication typically represent with nausea/vomiting, dizziness, confusion, tinnitus (ringing/buzzing), fever, tachypnea several hours after ingestin. Primary resp alkalosis -- stimulatie medullary resp center inc ventelation and loss of Co2 Primiary anion gap metabolic acidosis - toxic salicylate levels inc lipolysis, uncouple oxidative phosphorylation and inhibit TCA cycle.. accumulation of unmeasured organic acids in blood (ketoacids, lactate) inc anion gap. Mixed acid base distrance - ph can be within nromal range as shift in 2 diff directions. low Hco3 due to primary metabolic acidosis and low PaCO2 deu to both resp compensation for metabolic acidosis and primary respiratory alkalosis... so PaCo2 lower then expected for resp compensation aline (~23 normal for resp compensation)

32 yr old started on infliximab for refractory crohns, ten days later gets joint pain and pruritic skin rash, scattered areas of fibrinoid necrosis and neutrophil infiltration involving small bv. What findings?

Acute serum sickness, tissue deposition of circulating immune complexes. (type 3) fever, pruritic skin rash, arthralgias 7-14 days after exposure to an antigen, lymphadenopathy and proteinuria. histo = small vessel vasculitis with fibrinoid necrosis and intense neutrophil infiltration. depsotion of igG and igM results in localized complement consumption and hypocomplementemia (c3, c4 levels low) can occur following admin of antigenic heterologous proteins such as chimeric monoclonal antibodies (rituximab and infliximab) or non human immunoglobulins (venom antitoxins).. associated with pencillim, cefaclor, tmp-smx.

56 yr old man, chest palpitations, heart beat is fast and very irregular, no chest pain, sob, or dizziness, drank a lot last night but doesnt normally What is ECG findings?

Afib - no P waves Irregularly irregular rhythm with varing R - R interval. Can see F waves- irregular, low amp fine fibrillary waes betwen QRS which is chaotic atrial activation. "holiday heart syndrome" - alcohol consumption, long standing htn, hf, or hyperthyroidism.

50 yr old man comes the office to resect a growth hormone secreting pituitary adenoma three months ago was diagnosed with acromegaly medical therapy for acromegaly with octreotide as planned ,what changes would you see in adenoma size, growth hormone level and insulin like growth factor one level.?

All decrease. Acromegaly treated with resection of somatotroph pituarty adenoma, but additional medical therapy if cant remove entire tumor. Octreotide is long acting somatosatin analogue that inhibits growth hormone secretion and insulin like growth factor 1 release. reduce adenoma size. Acromegaly is due excessive GH release most often due to pituitary adenoma. actions of GH are mediated by Insulin-like -growth factor 1 from the liver. clincal - bony enlargement of hands and skull (frontal bossing, jaw malocclusion), arthropathy, cardiomyopathy, skin thickening. Octreotide has an altered AA sequence in non-receptor binding domain, makes resistnat to degradation by somatostatin. Octreotide like somatostatin will inhibit GH secretion and subsequently reduce IGF-1. has antiproliferative effect on somatotroph cells and help reduce residual adenoma size.

15-year-old girl in respiratory distress and continuous coughing after eating at a buffet low blood pressure high pulse and high respirations she can't speak diffuse wheezing and erythematous rash or present what hemodynamic changes are expected?

Anaphylactic shock - distributive shock. peripheral vasodilation, widespread igE mediated release of inflammatory mediations (histamine) ---> dec SVR -> hypotension Venular vasodilation -> dec Central venous pressure -> dec VR to RA vasculature become leaky, resulting in loss of intravascular vol -> hypotension and dec CVP dec VR -> dec RV output -> dec blood to LA/LV --> dec pulmonary capillary wedge pressure. CO is normal or high due to large dec in SVR, baroreceptor reflex inc HR (tachycardia).. inc CO leads to mixed venous oxygen sat with rapid transit thru peripheral capillaries and incomplete oxygen uptake by tissues.

42-year-old man comes to the ER due to severe chest pain that started two hours ago penis midline concert and 10 of the 10 has no fever cough or SOB. He's diaphoretic and he has severe distress due to pain. His pulse is 116 and respirations are 24. Blood pressure is 82 in the right arm and six in the left arm. Asked me to pressure of 13. There's no point of maximal impulse probable. Extremities are cold with no peripheral Adema. Patient develops cardiac arrest and dies. Autopsy show what?

Ascending aortic dissection with cardiac tamponade Dissection - can affect ascending aorta (Type A) or decsending (type B) Symp- chest and back pain severe and sudeen Type A -proximally to the aortic root, caneffect coronary ostia or aortic valve.. results in MI or MR... other signs are blood pressure asymetry., stroke, paraplegia. Dissection can extend proximally into pericardium, causing acute tamponade. as blood inc, rising pericardial pressure superside right sided filling and restrict VE, resulting in precipitous drop in cardiac output and obstructive shock --> cardiac arrest. Tamponade signs - JVD, muffled heart sounds, hypotension : beck triade, .. also reduced point of max impulse, cool extremities and clear lungs.

65 yr old with 2/3 degree burns over 25% of body, after 7 days gets a fever and leukocyte count rise to 16k, burns have warmth, erythema and induration Gram stain: Culture on MacConkey agar shows oxidase-positive colonies that dont ferment lactose. What is the best treatment? What bug?

Burn patients at risk for bacterial infection due to loss of barrier function of skin, post burn immune dysfunction, lack of blood flow to necrotic areas. Common: Gram positive - Staph Aureus, Enteroccoccus Gram negative - e.coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Actinerobacter) Gram negative rods that are oxidase + and nonlactose fermenting = Pseudomonas Cephlasporin - cefepime and Ceftazidime - good pseudomonas coverage. Purple - Gram +, Red- Gram - Treat Psuedomonas: Ticarcillin, peperacillin Ceplasporins: Cefepime, Ceftazidime Fluoroquinolines - ciprofloxacin, levofloxacin Carbapenems - imipenem, meropenem P - pneumonia S- sepsis E - Ecthyma gangrenosum (rapidly progressice necrotic cutaneous lesions - seen in immunocompromised) U- UTi D - diabetes O - osteomyelitis M- mucoid polysaccharide capsule O - otitis externa N - nosocomial infection ( catheters, equipment) A- addicts S- skin infections (hot tub folliculitis, wound in burn victims produces PEEP phospholipase C (degrade cell membrane), E - endotoxin (fever, shock), Exotoxin A ( inactivated EF-2), Pigments - pyoverdine, pyocyanin (blue green pigment) generate reactive oxygen species

How can u treat pseudomonas infections

CAMPFIRE C- carbapenems A - aminoglycosides M- Monobactam P - Polymxin (polymyxin B, colistin) F - fluroquinoloes (ciprofloxacin, levofloxacin) I - thIRd generation and 4th generation cephlasporins - Ceftazidime, Cefepime E- extended specrtum penicillin - piperacillin, ticarcillin

46 yr old homeless with fever and chest pain worse with swalloing, hospitalized several times of Pneuocystitis jirovecci pneumonia... is IV drug user... has esophageal hyperemia and linear ulcerations. What is the likely cause?

CMV PCP affects immunocompromised.. so likely has HIV... now has esophagitis: 3 causes: candida (most common) CMV HSV all difficulty swallowing and pain on swalling (odynophagia) CMV - large, shallow linear ulcerations in distal esophagus with intranucealr and cytoplasmic inclusions.

Electric stimulation of musculocutaneous nerve causes a rapid twitch of biceps muscle electron microscopy shows numerous vesicles within the musculocutaneous nerve terminals, in order for these vesicles tor rlease into synaptic cleft, what substance is required

Ca. motor neuron presynaptic terminals contain ACH. when AP depol the presynpation terminal membrane, voltage gated Ca open, leading to influx of Ca into synpatic terminal, this stimulates fusion of presynaptic vesicles with the plasma membrane and exocytosis of Ach. The nicotinic receptors on postsynaptic skeletal muscle end plate are Na/K channels, inc Na and K conductace occur with ACH binding generated motor end plate potential that signal depol of muscle cell membrane. ACh in cleft is degraded by Acetylcholinesterase.

60-old man comes to the hospital with chest pain intermittent squeezing substernal pain over the last three days no associated palpations lightheadedness or SOB. He has COPD with recent admission for exacerbation. Blood pressure is 145/90 and pulse is 93. He has no murmurs and lungs are clear ECG shows sinus rhythm with 2 mm anterior ST segment elevation. Cardiac troponin one levels are elevated. What is the most appropriate treatment?

Cardioselective beta blocker- reduce myocardial oxygen demand by lower HR, contractility and afterload... reduce short term morbiditiy - recurrent symptoms or reinfarctation), minimize infaract size and improve long term survival. Contraindications to BB include bradycardia, heart block, hypotension, over HF (pulm edema). Nonselective BB (pronanolol, nadolol) can trigger bronchospam if have underlying heart disease (asthma, COPD ) due to b2 blockade. Cardioselective - metoprolol, atenolol, bisoprolol, nebivolol) are safe if lung disaese. Combined beta and alpha - carvedilol, labetolol - well tolerated and ok for COPD B1: A to M NonZelective : N-Z nonselective alpha and beta have altered endings Nebivolol- B3 - NO release.

65 yr old with htn, DM2, tobacco smoking, comes with mild back pain, abdominal show bruit but no pusatile mass is palpated. Femoral and pedal pulses are symetric US shows large infrarenal abdominal aortic aneurysm, repair is perfroemd... IMA is ligated and diseaed aorta resected, graft is paced from below renal arteris to bifurcation of the aorta. Collatoral blood supply from what is preventing ischemia of descending colon?

Celiac trunk --> stomach, duondum, gallbladder, liver, spleen and pnacreas SMA and IMA - 2 main for small and large intestines and are connected via anastamoses - the marginal artery of drummon which is the principial anastamosis and the inconsistently presetn arc of Riolan (mesenteric meandering artery) protect intestines from ischem due to marginal artery, IMA is not always reconnected during aortic aneurysm repair.

23-year-old woman comes office with sharp right side of chest pain fatigue and fever for the last week chest pain is worse with deep breathing, not associated with shortness of breat, 4 six months she has intermittent joint pains and predominantly in the knees and hands she sexually active with one partner and doesn't use condoms her temperature is 100.9 blood pressure 120/70 and pulse is 89 respirations at 18 BMI is 24 she has a mild erythema over the cheeks and scratching over the right lower lung with breathing.No joint swelling what test is useful for diagnosis?

Chest pain worse with breathing, pleural rub, arthralgia, fever, erythematous rash on cheeks --> SLE autoantibdoies that bind self antigens 1. antinulear - in all SLE but other autoimmune (high sen, low spec) 2. anti-dsDNA with high specific for SLE, but low sensitivity - not all have 3. anti smith anitbodies - anitbodies aganist small nuclear ribonuclearproteins - 20/30% but high specific. labs - low C3 and C4 (due to activation of complement and elevated inflammatory markers (CRP, ESR) anemia, leukopenia, thrombocyotpenia, renal involvemnet -proteinuria, hematuria, red cells cats in ruine.

64 yr old African american, has been falling to the groun in last 6 months, opthalmic shows reduced vision in her peripheral fields bilaterally and elevated intraocular pressure, is given timolol opthalmic drops, what structure is targeted?

Chronic, progressive open-angle glaucoma.- atrophy of the optic nerve head. common in african americans. associated with elevated intraocular pressure due inc production or dec outflow of aqueous humor. Aqueous humor is produced by epithelial cells of ciliary body. Secreted into posterior eye chamber and transferred thru pupil into anterior eye. anterior eye chamber angle (iridocorneal angle) contains trabecular meshwork wher aqueous humor diffuse into Schlemms canal (scleral venous sinus) and then episcleral and conjuctival veins. Diagnosis: inc IOP and abnormal visual field testing with dec peripheral vision; inc cup to disc ratio due to loss of ganglion cell axons. Treatment -- dec IOP with drugs that dec production or inc outlfow. Timolol or nonselective BB- dec production of aqueous humor by ciliary epithelium. Also - Acetazolamide Prostaglandin F2alpha (latanoprost, travoprost) and chilinomimetics (pilocarpine, carbachol) dec pressure by increase outflow of aqueous humor.

17-year-old right handed boy brought to the ER due to brief loss of consciousness after colliding with another player during football he has fogginess but no headache vomiting and focal weakness or numbness or seizures on PE position demonstrates retrograde amnesia about the game but no focal neurological deficit CT of the head reveals no skull fractures or intracranial bleeding but a small lesion on the left temporal parietal region composed of abnormal vascular channels is noted and shown in the exhibit without treatment what will occur

Concussion CT shows "Bag of worms" in left temporoparietal region with large arterial feeder vessels. = Arteriovenous malformation occur when artery directly anastamoses with vein without a capillary bed... results in high pressure blood flow thru vessels (veins) predispose to aneurysm and or spontaneous hemorrage. Seizures also develop and be local accumulation of hemosiderin, from microbleeds. AVMS - sporadic or congenitatl. can be due to Osler-Weber-Rendu syndrome - hemorrhagic talengectasias (nasal mucosa, intestinal mucosa) and multiorgan AVMS (lungs liver, brain)

3 yr old boy with five days of productive cough and fever, exam shows tachypneic, ill appearing boy with rails over right lower lung x-ray shows right lower lobe pneumonia admitted to hospital for IV antibiotics has a history of 4 prior pneumonia and his weight is at 3rd percentile further testing shows high sweat chloride content and genetic sequencing shows a mutation of transmembrane proteins what describes a dysfunctional transmembrane proteins causing this patient's disease?

Cystic fibrosis = AR mutation of deltaF508. CF transmembrane conductase regulator (CFTR). The channel pore opens after binding of 2 ATP molecules, allowing transport of Cl ions down the electrochemical gradient... movement of chloride makes a membrane potential drawing Na and water across, this hydrates mucosal surfaces in airway and bowel.... mutation leads to intracellular protein dehydration and dec activity of the proteins that dont reach membrane, leads to thick mucus or lining of epithelial cells which results in chronic cough, recurrent pneumonia and pancreatic damage. also plays a role in hypotonic sweat, Eccrine gland, sweat is initially isotonic with plasma, normall Na/CL are removed from ductal lumen by CFTR but absesne, cant remove salt from sweat and have elevated sweat chloride and Na levels.

What happens to K in DKA?

Dec intracellular potassium stores (98% stored intracellularly); extraceullar are normal or increased. due to 1. loss of intracellular h20 cause inc plasma osmolatity leads to extracellular movement of K secondary to einc intracellular potassium conc 2. lack of insulin causes extracellular shifting of K as insulin normally promites cell uptake of K. Need to give timely K supplementaton after insulin in patient with DKA.

53-year-old woman comes to clinic with skin rash for three weeks which is pruritic and worsening severity on posterior thighs begin an exercise program to lose weight and has been applying topical analgesic cream to her thighs and buttocks after work out she does not use tobacco alcohol or drugs PE shows erythematous rash with blisters ulcers and weeping drainage involving posterior thighs bilaterally what is the most likely skin biopsy?

Eczematous dermatitis == erythematous, papulovesicular weeping lesions. Patient has acute allergic contact dermatitis type of eczema cause by type 4 HS. antigen taken up by langerhan cells and presended to CD4+ cells in regional lymph nodes. T cells activated to migrate to the skin, incite inflammatory response w/i 24 hrs Acute eczematous dermatitis - histo: spongiosis, accumulation of edema fluid in the intercelluar space of epidermis.... intercellular ridges become more distinctive and described as spongy. eventually edema so bad can form intraepidermal vesicles... perivasculra infiltrate of lymphocytes and eosinophils may be seen. with persistent antigen exposure, lesions may become less edematous and weepy --- thickening of stratum spinosum (acanthosis) and stratum corneum (hyperkeratosis) produce raised, scaly plaques.

24-year-old man is evaluate to do the syncopal episode that occurred after you finish a 13 mile marathon he felt lightheaded and then passed out he placed in a supine position and regain consciousness for 2 to 3 minutes his blood pressure is 98/50 pulse is 80 and respirations are 14, PE and ECG showed no abnormalities what is the most likely mechanism of the patients syncope.

Exercise associated collapse is characterized by inability to stand or walk associated with lightheadedness or syncope immediately following vigorous physical activity this can occur due to physiological adaptation in endurance athletes who have higher cardiac output than untrained individuals due to hypertrophy of a left on aka an athletes heart. During exercise, muscles in lower limb exert alot of pressure on venous system which inc. VR to heart, when aburptly stop workout , muscle no longer exert pressure... VR falls dramatically... sudden dec in preload fail to meet inc cardiac demands and get transient postrual hypotension. can be compounded by baroreflex and dehydration -- occur with intense exercise Trendelenburg position - feet over head can redistribute blood to the heart and brain.. improve symptoms.

Studies show a virus with antigenetically novel strain caring the anti-caring the animal strain hemagglutinin and neuramindiase surface molecules. further analysis reveals reassortment of genetic materials occurred during common function with human influenza virus of and Swine influenza virus leading to development of some progeny contain genetic material from both viruses. What other virus can undergo similar process?

Genetic shift in influenza A virus involves reassortment of genomic segemnts of humans stain with genomic sections of animal strain.. the segmented nature of virus is wha allows for rapid genetic shifts ex. Rota virus, orthomyxovirurses, reoviruses, bunyaviruses, and arenaviruses.

23 yr old man no prior seizure history in ER with tonic clonic, fever and headache for 2 days, works at fast food and smokes cigs on break, no drgs, MRI shows swelling of temporal lobes, CSF fluid analysis for menigitis and encephalitis?

HSV is most common cause of encephatlitis... acute onset fever, headache, altered mental staus, focal neurologic deficits of seizure. MRI shows temproal lobe edema as enters via olfactory tract and travels to the olfactory cortex (located in medial temporal love) .. most patients have a viral pattern on CSF with lymphocytic pleocytosis, normal glu, elevated protein. hemorrhagic inflammation of temporal love also usally cause elevated erythrocyts in CSF.

21 yr old man with head trauma, sustained during a boxing match, during the fight, brief loss of consciousness after hard hit to the right side of the face, headache and mufffled hearing in his right ear, patietn is alert and oriented, otoscopic exam reveals hypotympanum in the right ear. What cranial nerve injruy?

Hearing apparatus (ossicles, cochlea, vestibulococchlear nerve) the temporal bone also contains teh facial nerve , can be injured in temporal bone fractures CN 7 enter temporal bone at internal auditory meatus. travels through the internal auditory canal with CN 8 and then complicated route thru the temporal bone itseself, traveling near otic capsule thru middle ear and then thru mastoid portion to exit at the stylomastoid foramen.

22 yr old man with 6 month neck and low back pain severe in AM , pain better with day progression, no history of trauma, rashes, or urinary symptoms. tenderness of lumbosacral area and insertion site of achilles tendon. forward flexion is reduced, Upward regulation of what cytokines

IL-17 and TNF-alpha IL-17 stimulate produxtion of additional inflammatory factors, primary TNF alpha and prostaglandins, which have synergistic effects with IL-17 and induce bony erosions and abnormal bone growth Treatment: Nsaids, naproxen, anti TNF alpha (etanercept, infliximab) and anti-IL17 (secukinumab)

26-year-old man with penile lesions first noticed nontender papular rash on penis one month ago, increase in size and number has no fever dysuria or discharge is sexually active doesn't use condoms, PE shows three soft flesh colored papular lesions measuring less than 1 cm on the dorsum of the penis, no enlarged inguinal lymph nodes Treatment started with a TOLL like receptor agonist to increase antiviral cytokine production what medication was prescribed?

Imiquimod -- abnormal cell proliferation, inc anogenitial warts (HPV) superficial basal cell carcinoma and actinic keratosis. antiviral and antiproliferative effects -- mediated through Toll like receptor 7, which upregulates the proinflammatory transcription factor nuclear kappa B (NF-KB_ NF-KB inc transcription of proinflammatory genes, activating APCs, and get NKC, CD8, and th1 helpetr T cells. this leads to cytokine realse of Il-1, Il12, INFalpha/gamma, TNF alpha) and enhanced immune mediated killing of cancer or virus infected cells. Antiproliferative - induction of apoptosis thru caspase activation via inhibition of BCL2. Inhibiton of angiogenesis - down reg FGF and upreg angiogenesis inhibitors like (INF gamma and IL 12)

44-year-old man with occasional chest discomfort not related to exertion PE is significant for hypertension and hyperlipidemia his grandfather had an MRI at 50, Coronary CT shows several non-obstructive atherosclerotic plaque of coronary arteries. One plaque in the proximal LAD appears expensive and has large hypodense core and occupies 40% of lumen no intervention is performed. one year later patient comes in with severe acute chest pain and is found to have thrombitic occlusion of proximal LAD. high intraplaque activity of what resulted in MI?

Metalloproteinases. Atherosclerosis - developed plaque rupture with thrombotic occlusion of LAD leading to acute coronary syndrome (unstable angina, MI) people r asymptomatic and develop stable angina (exertional chest pain releived with rest /nitroglycerin) if enlarge >70% luminal stenosis Acute coronary syndome -- due plaque rupture, thrombosis and vessel occluson.. rupture is dependent on stbaility of plaque over size and degree of luminal narrowing. stability dependent on mechanical strength of fibrous cap. Thin cap are unstable and more vulnerable. Thin-cap fibroatheromas are characterized by large necrotic core with thin fibrous cap. activated macropages lead to breakdown of collagen via MMPs... rupture and acute coronary sydnrome.

Three-year-old boy is brought to the ER due to poor feeding an emesis and lethargic over the past 24 hours he was born uncomplicated normal pregnancy. He is dehydrated and abdomen is distended patients vomits and the vomit is bilious on laparotomy fibrous bands are seen extending from the cecum and right colon to the retroperitoneum causing extrinsic compression of the duodenim. What embryological process most likely failed?

Midgut rotation around the SMA. at six weeks weeks gestation the midgut supplied by the SMA herniate through the umbilical ring in order to grow rapidly during this process the mega rotates 90° counterclockwise. for additional growth it return to the abdominal cavity at 8 to 10 weeks gestation and turns an additional 180 for a total of 270°. Gut is fixed to the posterior abdomen on wide base mesentery. Incomplete counterclockwise rotation results in midgut malroation... cecum will rorate in RUQ instead of LRQ. Ladd's (fibrous) bands connect the retroperitoneu, in the RLQ to the right colon/cecum by passing over the second part of the duodenum, causing intestinal obstruction. obstruction --> bilious vomit during first days of life, since the mesentric base is narrowed, the mesentery is vulnerable to twisting around the SMA... this leads to midgut volvulus... compromise intestinal profusion and life threatening bowel necrosis.

58 yr old with persistent dry cough, involuntary weight loss 22lbs in 3 months, drink 2-3 beers daily, 40 pack year smoking, PE dullness to percussion over right lower lung base, CT right sided pleural effusion, mass in lower lobe of right lung. biopsy shows malignat cells with large nuclei that contain prominent, round, basophilic bodies. What enzyme functions in basophillic region?

Nucleolus - round, dense, basophillic (dark staining) body within nucleus on LM. sight of rRNA transcription. RNA polymerase 1 transcribes 45S pre-rRNA gene into single template that is processed into mature 18s, 5.8s, and 28s rRNA. RNA pol 1 activity is only in nucleolus. Nucleolus - maturation and assemnbly of ribosomal subunits. malignant cells with high metabolic activity have large number of active rRNA genes and prominent nucleoli.

27-year-old with progressive right knee swelling and pain no history of trauma x-ray shows large lytic lesion involving proximal tibia with extensive soft tissue swelling he has his knee amputated, what is the diagnosis

Osteosarcoma - most common bone tumor in children and young adults... arise in metaphyses of long bones (proximal tibia_ and location of the growth plate and site of greatest bone proliferation. pain and soft tissue sweelling, lytic bone lesion on xray. arise from malignant mesenchymal stem cell that generates cartilage, bone or fibrous tissue, diagnosed confirmed: spindle shaped stromal cells admixed with tumor osteoid and thin trabeculae of bone.

52-year-old man brought to the ER after found unresponsive on the street medical history is unknown temperature is 97.2 blood pressure 108/62 and pulse is 72. He was unresponsive to verbal and tactile stimuli but moans to deep sternal rub. Arterial blood gas analysis shows on room air of partial pressure of oxygen to be 60 the partial pressure of oxygen in his alveoli is calculated to be 68 .what is the most likely cause of patient symptoms?

PA02 is normally 104 mm Hg, but due to high rate of O2 diffusion across alveolar-capillary memrbaen, O2 level in alveolar capillary blood equilbrates with PA02. O2 levels drop slightly due to addition of deoxygenation blood from bronchial ciruclation, partial pressure of oxygen in arterial blood PaO2 is 100. In healthy people normal A-a gradient is between 4-15, older have higher due to age related decline. Patient has low PaO2, and PAO2 with a normal A-a gradient. indicating that his low PaO2 is due to low PAO2.... hypoxemia in setting of normal A-a include .. alveolar hypoventilation and low PiO2 (high altitude). Cause of alevolar hypovenilation -- supressed resp drive (sedative overdose) and disease that dec inspiratiory capacity ( myasthenia gravis, obesity)

32 yr old stuck in malfunction elevator, anxious in closed spae of elevator and experienced dizziness, sob, generalized weakness, and blurred vision. What is cause of symptoms

Panic attack in elevator, hyperventilation with dec in arterial partial pressure of Co2. hypocapnia can cause decreased cerebral perfusion with consequent neurologic - generalized weakness, blurred vision, presyncope (dizzy and lightheaded) aand syncope Central blood flow - constant, but influenced by PaCo2. Hypercapnia trigger inc in CBF to aid in removal of toxins, and hypocapnia trigger dec in CBF so because hypocapnia dec CBF, ppl with intracranial pressure are often hyperventilated to dec intracranial pressure and help prevent brain herniation. PaO2 doesnt effect CBF until <50

64-year-old man comes up in the apartment due to severe abdominal pain nausea and vomiting history of hypertension and systolic heart failure ,blood pressure is 100/60 pulse is 116 and irregular and respirations are 24, exam show soft mildly descended and tender abdomen lab shows low bicarbonate, normal sodium and chloride ,pH of 7.20 PaCO2 is 26 and lactic acid is 6.2 elevated. CT shows distal ileal wall thickening, lack of enhancement of IV contrast. Dec. activity of what best explains acid base disorder

Patient has acute mesenteric ischemic, with inadequate delivery of oxygen to intestinal tissues During glycolysis, oxygen in tissues affects the metabolic fate of pyruvate. in presence of 02, pryuvate -> acetyl CoA by pyruvate dehydrogenase in mito matrix, then goes into TCA hypoxic - NADH inhibits pyruvate dehydroenase, inc amount of pyruvate --> lactate by lactate dehydrogenase. which regenerate NAD+ and NADH (allowing for limited ATp production via anaerobic glycolysis) patients with lactic acidosis will hyperventalitate to eliminate Co2 and induce comp respiratork alkalosis.

48-year-old man with 10 days of fever chills fatigue and dyspnea how to connect me at age of 28 recently traveled from New York City to Connecticut for a family wedding has a fever blood pressure 118/70 and pulse is 108 long is the exam shows course crackles lab so low hemoglobin elevated LFTs elevated total biliruib elevated lactate dehydrogenase and low haptoglobin. Normocytic, normochromic anemia with ring and cross shaped intraerythropoietic inclusions. What vector?

Patient with acute febrile illness, thrombocytopenia, hemolytic anemia (indirect hyperbilirubinemia, elevated lactate dehydrogenase, low haptoglobin), abnormal LFT, Maltese cross == Babesiosis - tick borne illness. intraerythrocytic parasites. Splenectomy inc risk.. acute resp distress (dyspena, corase crackels, bilater infiltrates ) Babesiosis (babesia microti) and lyme disease re both from ixodes Tick. Coinfection is common. Treamtnet Atovaquoune and Azithromyocin.

64-year-old man loses consciousness near the entrance at ER position rushes to patient and palpates the strong pulse along the inner side of the left of SCM muscle, the vessel palpated by the doctor is a directive of what aortic arch?

Pharyngeal arches.. each associated with a CN and aortic arch derivative. vessel palpated is the common carotid artery which along with interal carotid is a derivative of the third pharygneal arch... also give rise to the CN 9, parts of hyoid bone and stylopharyngeus muscle 1st arch is Maximal - maxillary artery ,branch of external carotid 2nd - Stapedial artery and hyoid artery (Second = Stapedial) 3- Common Carotid and proximal part of internal Carotid - C is the third letter in alphabet 4- on left, aortic arch; on right, proximal part of right subclavian - 4limbs is systemic 6- Proximal pulmonary arteries and on left ductus arterious - pulmonary and pulmonary to systemic shunt

23-year-old woman with tonic clonic seizure has history of seizures and takes phenytoin, no social history PE shows no focal abnormalities plasma test for phenytoin is low, she has been compliant with meds, what responisble for the results for patient's condition if coadministered with Phenytoin?

Phenyotin metabolized with hepatic P450 oxidase. Plasma drug level, efficacy, severity of side effects influenced by rate of metabolism 1. Hepatic hydroxylation is dose dependent, when low dose, enough can be metabolized, if too high can lead to toxicity 2. Inducer of CYP450 odifase... inc consumption of meds metabolized by the liver, OCPs.. med conc will decrease 3. Metabolized by CYP450, level effected when co admin with other drugs that induce or inhibit the system. if with inducers -- dec concentration in plasma and reduce effectiveness InducersL barbs, rifampin, carbamazepine, griseofulvin, and chronic alcohol Inducers: Most chornic alcholics steal phen-phen and never refuse greasy carbs M- Modafinil A- chronic alcholic S- St John Wart P - phenytoin P- phenobarbital N - Nevirapine R- Rifampin G-griseofulvin C- carbamazepine Inhibitors: SICKFACES.COM Sodium Valporate I - isoniazid C- Cimetidine K - Ketoconazole F - Fluconazole A - Acute alcohol C - Chloramphenical E- Erythromyocin/Clarithromycin S- Sulfonamides C- ciproflaxacin O- omeprazole M - Metronidazole A- amiodarone R- Ritonavir G- grapefruit juice

21-year-old woman pregnant at 16 weeks has not gained weight since her last visit four weeks ago, with occasional nausea and vomiting twice a week, has little appetite attributed with some mild indigestion, food consumption has decreased but she craves ice and has been consuming it throughout the day of the last few months, she takes prenatal vitamins and was prescribed twice daily iron for anemia but doesn't take it causes constipation fetal what is the diagnosis?

Pica - consumption of nonstaple food or nonnutrive substance for >1 month. common in pregnant and school children. not culturally accepted food source and consumption not appropriate for developmental level. can be associated with nutrional deficiencies - iron and zinc people eat: earth/soil rich substances, raw starch such as flour or cornstarch, and ice. Ice - most common

52-year-old man with dizziness headaches pruritis after showering smoked half a pack of cigarettes daily for the last 15 years and drinks alcohol socially PE shows reddish facial complexion and mild splenomegaly, labs elevated hemoglobin elevated hematocrit elevated erythrocytes platelets and leukocytes what is the most likely cause a patient's findings? what is the diagnosis/?

Polycythemia vera - myeoloproliferative disease of pluripotent hematopoietic stem cells. 95% have mutation in V617F involving JAK2, for signal transduction. Replace valine for phenylalanine.... hematopoietic stem cells more sensitive to growth factors such as epo and thrombopoietin. see inc RBC mass, inc plasma volume, low epo. can see elevated platlet and or WBC count, thrombo events due hypervisocity, peptic ulceration and aquagenic pruritis (due to histamine release from basophils., gourty arthritis due to inc cell turnover diagnosis: LOW epo and bone marrow aspiration show jak2 mutation. Treat: phlebotomy.

24-year-old woman at 14 weeks gestation comes with left leg swelling and pain for two days has a venuos thromboembolism what is the most appropriate pharmacotherapy?

Prego inc risk for VTE due to dynamic changes (uterine compression of IVC and iliac veins) and physiological hypercoagability (inc clotting factors, dec S protein levels, and protein C resistance) Herparins are ideal for pregnatn women as dont cross placenta and risk of fetal bleeding and teratogenicity is low LMWH - enoxaprin and dalteparin... long half life.. no monitoring, cant be used in renal insuffienceity-- is renally cleared. if creatinine <30 cant use. Unfractionaled heparin - short half life, need to test for PTT due to vareid anticoagulant effect. can be used in renal insufficiency. used in place of LMWH at 37 weeks as can be disocntinoued at onset of laber to minimize hemorrhagic risk

5yr old a boy brought to the office by his mother for a check up he is healthy and about to start kindergarten mothers concern about recent reaction to her brothers death although I told him he is dead he believes he's coming for his birthday and will take him to a ball game he died over three months ago but son come regularly asks for him I try to explain and he starts crying and says his stomach hurts, physical exam is normal, during this and the boy says " I try to clean up my toys before bedtime so mommy won't cry" What is the cause for patient behavior?

Preschool children <6 may not understand the finality of death and can exhibit magical thinking in which they fully expect of the dead person can come back to life and younger children you can attribute events or other reaction to something they did wrong due to an egocentric thought process. Explain death and concrete terms and they should be reassured that the peoples grief is not their fault. Finality of death comes back around the age of 7. think death is reversible

23-year-old pregnant woman delivers girl after protracted labor the patient is seen second-degree laceration repair as planned prior to administering local anesthesia operator palpates bony protrusion is located posterior lateral to vaginal side walls that are distinct from the rest of the pelvic sidewall, a firm band can be palpated running mediately and posteriorly from the bony prominence to the sacrum , anesthetic is injected around the pro bony prominence what nerve is blocked?

Pudendal - S2- S4 - sensory of genital an d perineum.. motor to sphincter urethrae and external anal sphincter. landmark: Ischial spine and sacrospinous ligament Ischial spines - posterolateral to vaginal sidewall Sacrospinous ligament - firm band runs medially and periorly from ischial spine to the sacrum. Internal pudendal artery and inferior glutreal artery run medial to PN. if injected can lead to hematoma or arrthymia from local anestheic (lidocaine)

25-year-old man comes to the position because him and his wife are unable to conceive the last two years he has a low sperm count he has permanently inactive FSH receptors what substaance will be decreased in this patient?

Pulsatile secretion of GnRH form hypothalamus stimulates the release of FSH and LH from gonadotroph cells in Ant Pit. LH stimulate release of testosterone from Leydig cells in interstitum of testes Fsh release inhibin B from serotili cells in seminferous tubules of testicles. Tesosterone and inhibin B negative feedback on LH and FSH production FSH also stimulate serotoli cells to produce androgen binding protein, within seminiferous tubules... responsible for high local testosterone conc and different from sex hormone binding in the blood. high local testosterone and FSH are necessary for spermatogenesis. defective FSH receeptors will prevent spermatogenesis and cause low inhibin B lelves.

35-year-old man with a facial injury reports being hit on the face during a fistfight examination shows dark blue periorbital ecchymosis on the right side ophthalmic a neurological exams are fine, the patient is discharged home several days later the bruise becomes greenish in color what enzyme is responsible for the change in color?

Resolving hematoma after trauma... hemoglobin containing erythrocytes escape into periorbital tissues, giving inital purple blue color, -- destruction leads to release of iron containing heme moleucles. heme oxygenase ( in macrophages,) degrade biliverdin, CO, and ferrous iron while consuming oxygen and electrons from NADH and NADPH cytochrome P450 reductase. bilverdin is green and is reduced by bilverdin reductase to a yellow pigment, then bound to albumin and transported to the liver.

21 yr old man diffuse muscle aches and weakness, darkening of urine, hard exercise in military, no medical conditions, blood pressure is 100/60 oulse is 105, resp 16 PE shows dry mucus membranes and muscle tenderness over bilateral thighs and calves Has low bicarb, high BUN, Creatinine, low ca, high P, and high CK. What would be seen in urine?

Rhabdomyolysis -- skeletal muscle necrosis and release of intracellular breakdown products.. due to trauma, sepsis, drug/toxin (Statin, alcohol, cocoain) and overexertion (hot climates) Myaglia, weakness (proximal muscles, lower back, calves) and myoglobinuria (dark urine) Lab show Inc CK and acute kidney injury with electrolyte disturbances (hyperkalemia, hyperPhosphatemia, hypocalecemia, metabolic acidosis) Acute Kidney injury - due to myoglobin degradation and heme pigment release... heme causes ATN thru direct cytotoxicity and renal vasoconstriction (ischemia) Injured tubular epithelial cells slough off into tubular lumen, forming granular, muddy brown casts. Heme pigment in myoglobin cross react with dipstick -- false positive blood.. microscopy shows no RBCs.

30 yr old female with severe nausea and recurrent bilious vomiting symptoms begin after post prandial epigastric pain and early saiety, have progressed over the last two weeks she has been on a crash diet to lose 25 pounds, abdomen is tender and slightly distended with high-pitched bowel sounds there is concer about small bowel destruction, admit patient hospital it is observe the angle between the SMA and her aorta is significantly decrease. what structure is most like obstructed by the artery?

SMA leaves aorta at the level of L1 and supply intestine from duodenum and pancreas to left colic flexure. Transverse portion lies hortizontal at level L3, between aorta and SMA. normally aorta and SMA have a 45 degree angle. if <20; transverse duodenom can be trapped leading to small bowel obstruction. superior mesenteric artery syndrome. can occur with condition with dec mesenteric fat, low body weight, recent weight loss, burns, or inducers of catabolism, and prolonged bed rest, lordosis or surgical scoliosis correct.

35 yr old women with 3 months progressive dyspnea on exertion, nonproductive cough, fatigue, seasonal allergies takes over counter antihistamine, smokes cigs, mom had RA, CT biopsy show noncaseating granulomas Dx

Sarcoidosis - chronic multisystem disorder by formaton of noncaseating granulomas (epitheliod macropages and multinucleated giant cells).. typically affects young adults and more in african american and in women. Lungs initially involved in most cases. cough dyspnea, chest pain, fever, fatigue, weight loss. can be seen with bilateral hilar lymphadenopathy or reticular opacities.

What inervates the stapedius muscle in ear

Stapedius nerve, branch on cranial nerve 7. functional - stabilize the stapes; paralysis secondary to injury or lesion to facial never -- asculate more widely producing hyperacusis... have inc sensitivity of everyday sounds and withdraw socially treatmnet - retrain- sound therapy - white noise

Newborn boy born at 39 weeks by normal vaginal delivery has high TSH and low T4 mother has no medical conditions patients length and weight are normal no apparent congenital malformation what is the most likely cause?

Thyroid dysgenesis - primary hypothyroidism. (hypoplasia or aplasia) or an extopic thyroid can lie anywhere along the normal bath of embryonic descent from base of tongue to anterior thryoid cartilage. Asymptomatic due to transplacental transfer of T4, insuffiecent feeback inhibition form low t4, causes TSH to be high. can treat with levothryoxine to prevent neurocognitive dysfunction

23 yr old with recurrent UTI, 5 episodes of cystitis and 1 pyelonephritis in last year, sexual activty, no med porblems, What is predisposing factor for pyelonephritis?

UTI come from fecal flora and include gram negative rods (E.Coli, Klebsiella, Proteus) and enterococcus. Short urethra and into bladder -- has antimicro - dont allow attachment, pee is bactericidal due to high urea and osmolarity, urine flow wash away bacteria downstream, can be disrupted by virulence factors Normal vesicouretal junction dont allow retrograde flow of urine, if abnormality or inc in bladder pressure, urine returns to ureter carrying pathogens (vesicureteral reflux)... weak vesicoureteral junction and facilitate reflux.-- without reflux, ascent of pathogens is unliekly.

19 yr old, right hand clumsiness, patient injured the right upper extremity after falling off her bicyle 6 months ago, PIns and needles in right hand with weakness, PE shows dec sensation over the 5th digit and flattened hypothenar eminence, triceps reflex are 2+ symeterical What nerve affected commonly injured where?

Ulnar nerve injured at medial epicondyle of humerus (funny bone) or in guyon canal near the hook of the hamate and pisiform bone in the wrist. Patients often have sensory loss over the medial 1.5 digits, hypothenar eminence, and weakness on wrist flexion/adduction, finger aduction/abduction, and flexion of 4/5 digits. hypothenar eminence may flatten due to musclar atrophy

What are complications of varicose veins?

Varicose veins- dilated, tortous veins most common in superficial veins of th eleg, cause by chronic inc intraluminal pressure and or loss of tensile strength in vessel wall, leading to incompetence of venous valves. chronic edema, statis dermatitis, skin ulceration, poor wound healing, infection

38-year-old woman comes to the ER due to abdominal discomfort and diarrhea symptoms begin yesterday from a Caribbean cruise she had bottled water but ate raw local seafood when visiting one of the islands, no other cruise line passengers reported the illness. A comma shaped oxidase positive gram-negative rod naturally found in salt water is implicated in her illness. Stool microscopy most likely demonstrates which of the following?

Vibrio Cholerae - oxidase positive, gram -, comma shaped -- requires salt for growth and exist in naturally aquatic areas. contaminated food or water, sporadic cases by contaminated shell fish. Invade/damage the intestinal epithelium or release enterotoxins. is a noninvasive organism. Clump together on surface on SI and cause diarrhea by Cholera toxin (relaetd to ETC heat labile toxin)... enters epithelial cells and activate adenylate cyclase, inc choloride efflux, reduce Na reaborption and subsequent water from entercyte to GI lumen High volume, watery diarrhea.. dehydration and death within 12 hrs.... since non invasive and toxin does kill cells.. stool shows no erythrocytes or leukocytes. flecks of mucus (rise water stool) due to activation of goblet cells

28 yr old women prego twice, with 6 day old girl in offuse, infant blood is Type A negative, mom is Type B negative, high circulating anit-A antibodies are found in mom blood. Hemolysis didnt occur in the infant becuz mom antibodies are what class?

igM Hemolytic disease of fetus and newborn... cuased by maternal anti-fetal erythrocyte igG antibodies, which cross placenta and produce Type 2 HS. With maternal blood types A and B, hemolysis doesnt occurs cuz mom AB are Anti-A/B igM, so cant cross placenta. but if mom is blood type O, also produce igG antbodies which can cause hemolysis in fetus. 15% as baby A or B with an O in mom...but not often due to variation in fetal ABO antigen expression. Unlike Rh diease, HDFN can occur with first pregnancy cuz anti-A and B ab are formed early in early from exporesure to A- and B- antigens in food, bacteria, and viruses.

24 yr old, painful swellin in left groin for 2 days, more tender and painful, recent puncture wound in sole of left foot. PE shows enlarged, tender, nonfluctant left inguinal pain with erythematous overlying skin. Small puncture wound on sole of left foot, gives pus when pressed, What histo is seen in patients groin mass?

inflammatory lymphadenopathy in draining lymph node. Adaptive immune response, large unprocessed foreign antigens displayed by follicular dendritic cells in draining lymph B cells recognize, bind to , and process large antigen into smaller peptide displayed on MHC 2 to naive T cells. T cells differentiate into T helped and secrete cytokinds promote survival and proliferation of antigen specific B cells, --> germinal centers. germinal centers - area where B cells compete for survival based on ability to bind with high affinity to a foreign antigen. rapidly proliferate, somatic hypermuation (immunoglobulin mutation) release of cytokins in large cause pain and inflammation.

What happens after hep B infection?

acute hepatitis with complete resolution Chronic hepatitis with or without cirrhosis and attendant inc risk of hepatocellular carcinoma fuliminat hepattis with massive liver necrosis most common is acute with resolution.

what is thef rist step to counseling patients and surrogate decision makers regarding refusal of treatment?

calmly probe their understanding of the disease process. follow with counseling and education to lvel of understanding and health literacy and objective assessment of treatment options.

55 yr old women with stage 4 chronic kidney disease due to dm2, bp is 140/90 and pulse is 78. bmi 31, low hemoglobin, ca, high P, creatinine, and bun. PTH is high Patient Phosphorous has been persistently elevated despite dietray phosphate restricition. Given sevelamer , moa? to dec serum P?

decreased intestinal absoption of phosphorous CKD leads to hyperphosphatemia due to impaired ability to excrete P. Elevated P leads to release of Fibroblast Growth factor 23 from bone, which lower calcitriol production and intestinal calcium absorption --> reduce circulating Ca with Phosphatemia--> secondary hyperparathyroidism. Phosphate binders can be calcium containing (calcium carbonate/acetate) or noncalcium containing (sevelamer, lanthanum) -- bind intestinal P to reduce systemic absorption. excreted in feces. NPT2 in proximal renal tubule for P excretion is downregulated by fibroblast growth factor 23, leads to dec transcellular transport and dec. reabsorption of Phosphate in renal tubules.

What does terbafine treat

dermatophytosis allylamine - orally or topical.. inhibit syntehsis of ergosterol of fungal membranes by inhibiting enzyme sqaulene epoxidase. ..

What is the role of ATP in skeletla and cardiac contraction ..

during skeletal - atp binding myosin causes release of myosin head from its binding site on actin filament.

What does intermittent admin of recombinant PTH analogs (teriparatide) induce?

greater increase in osteoblast activity in proportion to osteoclast activity and net inc in bone formation. good for osteoporeisis better than biphosphonates AE avoid in high levels of ALP and Paget disease due to inc risk for osteosarcoma transient hypercalemia. avoid if prior radiation

31 yr old, 2 week fever, night sweats, and productive cough, 15 lb weight loss, software enginer from Uzbekistan 15 years ago came to US, temp 101, bp 110/80, pulse 94, resp 18. pulse ox 94, xray shows cavity on the right, sputum exposed to drug, growing in culture becomes less resistant to decolaration with acid alcohol and stop proliferating what drug is it?

isoniazid TB treatment: RIPE Isoniazide - only good for mycobacteria, inhibit mycolic acid syntehsis. Mycolic acid form long branched cahin FA in outer portion of peptidoglycan wall, essentential for proper cell wall structure and virulence factor syn (sulfatides, wax D, cord factor ) if cant make cell wall cant divid myocolic acid makes them be acid fast - retain carbolfushin dye and resist decoloration by an acid-alchol decolorizing agent. Give B6 with isoniazid.

26 yr old with single amino acid sub (glutamine for arginine ) near the protein C site in her coagulation factor V gene ,... at greatest risk for what?

major clinical findings of factor V leiden inclued: DVT --> pulmonary embolism cerebral vein thrombosis recurrent preg loss. Factor V leidin - most common cause of inhertied thrombophilia with heterozygote prevelance of genetetic muation in 1-9% of whites. heter 5-10x of developing thrombosis homo - 50-100x more likely risk of thrombosis Causes thrombophilia: normal hemostatis, activated protein C restricts clot formation by proteolytically inactivating factors Va and VIIIa. Factor Va leiden ahs reduced suseptibily to clevage y APC, nbut Va is a cofactor in conversion of prothrombin to thrombin, persisently circulating Va --> thrombin production Factor V leiden is unstable to support APC anticoagulant activity

15-year-old boy with right ear itching and discomfort for several days he has no fever or hearing loss but has scant drainage of thin whitish fluid has been taking swimming lessons, on examination there's no redness but gentle traction of Pinna elicits pain. During inspection of external auditory canal as speculum is inserted in close contact with his posterior wall causing the patient to suddenly become lightheaded and faint he recovers spontaneously within a few minutes with no residual confusion, what nerve was irritated during the process? Cutaneous intervation of the ear

most from great auricular nerve, lesser occipital nerve and auriculotemporal nerve. external auditory canal and external tempanic membrane inverated by V3 via auriculotemporal banch Posterior external auditory canal and concaivty and posterior eminentia of the concha, inervated by cN 10.-- patient has vasovagl syncope after stimulation of posterior external auditory canal by otoscope. outflow via vagus leads to dec HR and BP

cumulative incidence

number of new cases over spexific period/ number of people at risk during beginning period (removal people that laready have the disease_ does not account for deaths in period.

SA/AV node action potential

pacemaker cells exhibit automaticity - inherent ability to depol without external influunce) made possible by sodium potassium mixed current ( the funny current) that occur during phase 4. bring close to threshold and then Ca influx leads to depol. Phase 3 is repol by K outflux cardiac myocytes and purkinje cells (nonpacemaker) Phase 4 : stable at -90 (near equilibruim for K). Phase o - Na influx Phase 1 -early short repol after depol by increase K outflow and dec sodim conductase Phase 2 plateau - Ca inflow counteract K outflow Phase 3 - inward Ca stop, K out of cell.

Why do drugs have hard time to pass BBB?

presence of specialized endothelial cells with tight intercellular junctions, form physical barrier. drug transport proteins - p-glycoprotein, expressed on luminal mebrane of brain capillary endothelial ells. P glycoprotein is ATP driven efflux pump that acticately remove wide range of substrates from cells, included meds - abs, immunosuppresent agents, HIV protease inhibitors. In HIV, antiretrovirals meds allow brain to act as an anatomical ancturary where viral replication can proceed unchecke, devlop of ressitant straints so by inhibiting P glycoprtein, can inc drug distribution.

What do u give for heparin overdose

protamine

45 yr old with progressive exterional dyspena and fatigue. episodic pain and bluish discoloration of fingers and toes on cold exposure that improve with rewarming. PE shows tightening over the fingers. Cardio has an accenutated S2 of upper left sternal border. hepatomegaly, bilateral lower pitting edema. FEv1/FVC ratio is 85 waht is most likely cause of dyspnea?

she has CREST - systemic sclerosis ---> pulmonary arterial hyperplasia loud P2 of S2 PAH - progressive remodeling of small and medium sized pulmonary arteries.arterioles. triggered by inc proliferation of T cells with secretion of a variety of cytokines (TGF-beta) sitmulate fibroblasts to inc the production of colalgen and extracellular matrix proteins. Endothelial dysfunction due to excess vasoconstrictive, proproliferative mediations (endothelin, thromboxane A2) releative to vasodilative anti pro (NO and prostaclycin) vasoconstriction and smooth smooth proliferation with intimal thickening of vascular walls lead to inc pulm vascular resistance and elevated pulm arterial pressure. over time RV cant pump aganist the inc afterload and get right sided heart failure.

34 yr old, moderate hearing loss, ringing, no infection/cold, no cotton swabs, no trauma, dad bilsteral hearing loss - old age, PE auditory canal patent, tympanic membranes gray w/ well visualized light reflex. left sided facial numbness, asymetric smile, diminished corneal reflex...intracranial mass where?

vestibular schwanoma. cerebellopontine angle tumor in adults. normally affect CN7, unilateral are sporadic and bilateral associated with NF 2 CN 7 and 5 are in close proximity to CN 8 at cerebellopontine angel and may be compressed by the vestibular schwannoma. impairementn of CN 8- ipsilateral sensorineural hearing los, tinnitus (ringing), damager to vestibular leads to dysequilibrium Compression fo CN 5, ipsilateral facial sensation with interruption of corneal refelx CN 7 - compression can result in ipsilatreal facial muscle paralysis (asymetric smile)