FA
NER vs BER
NER: endonucleases BER: base-specific glycosylase breasts AP site. then endonuclease, lyase. dna pol B. Nitrates can lead to deamination of C A G -> U xanthine, hypoxanthine
neovascualr pairing
NERVE: ARTERY long thoracic:lateral thoracic Axillary: posterior circumflex Radial:deep brachial Median:Brachial = at humerus/cubital fossa tibeal: popliteal tibeal: posterior tibial: posterior to medial mallleolus.
areas prone to ischemai red vs pale
kidney: start of pro tubule, thick ascending limb (both in medulla) Liver : around central vein (zone 3) pyramidal of hippo first red: liver, lungs intestine pale, in order: CNS, heart, kidney, spleen
neomatoude routes of infection
you'll get sick if you EAT these: Enterobius, Ascaris, Toxocara these get into your feet from the SANd: Strongyloides, ancylostoma, Necator lay LOW to avoid getting bitten: Loa loa, onchocerca, wuchereria
Primary Hemostatsis
vWF from WP body of ENDOTHELIAL cells and a-granules of platelets.d petechae = 1-2, purpura >3mm, echymoses >1 cm. epistaxis, GI, hemoptysis, hematuria, menorrhagia, IC bleed. Bernard-Souler - GP1b deficicy. adhsion impaired. mild thrombocytopenia bc defective platles dont liv as long. Glanzman - mutation in gp2b/3a. aggregation impaired. urmia = defect in adhesion ANN agregation hemophiia B = christmas disease
pancreas and spleen embrology.
ventral bud is what rotates. becomes head and main pancreatic duct and uncinate process annular panceras - wapps seond part of duodenum pancreatic divisum: usually asymptomatic. dorsal drains into minor papilla (drains most of pancreas. ventral bud goes to drain into major papillae. can lead to pancreatits bc teh accessory duct is draining most of pancras. spleen is MESODERMAL. arises from in mesentary of stomach. [kidney also mesodermal]
other male path
vericocele - most common cause of scrotal enlargent in males. cryptochidism - see increased FSH and LH. tesosterone decreases in bilateral cryptochidism, but NORMAL in unilateral. penile SCC - more common in Africa, ASia, SA. can be associated w/ HPV Priapism - trama, anticoags, antidepresants, alpha blockers, cocain can cause
Dermatologic macroscopic terms
vessicle <1cm. Bulla >1cm. Macule - flat, change in skin color <1cm. patch: macule >1cm. papule <1cm. plaqu >1cm Hyperkeatosis - increased thickness of stratum corneum Parakeratosis - see w/ psoriasis/actinic keratosis Spongiosis - EPIDERMAL accumulation of edematous fluid in intercelluar spaces (eczema) Acantholysis - separation of epidermal cells (pemphigus vulgaris/eczema) acanthosis - epidermal hyperplasma (increased spinosum ) ex: psoriasis/acanthosis nigricans. dyskeratosis - pabnormal premature keratinozation of keratinocytes. see strongly eosinophilic small basophilic nuclear remnants (SCC)
pathoma: disorders of pigmentation
veteligo: dexroy melanocytes. Melasma - OCP. NEvus: stars as junctional(Flat macules) - >extends into DERMIS (coumpund nevus) -> junctional componnet lost -> intradermal nevus (papular) MELANOMA: driven by activating muation in BRAF V600E (can treat w/ Vemurafenib, a BRAF kinase inhibitor). can met to brain, GI ,bone, liver lungs. normally, NRAS activated by GF-> BRAF -> DNA rep -> growth. in melanoma, becomes NRAS independent. can be primary in eye, esophagus, meningies. Can be pruretic. Cells in poorly formed nests, irregular nuclei, clumped chromatin. increased lymphoctes = better prognosis. NO HAIR. MOST OCMMON CAUSE OF DEATH. risk: dysplastic nevus syndroem: AD. >6mm. 1. superficial spreaing - most common 2. Acral lintigenous - NO relateino to UV 3. Lentigo maligna melanosoma - Lentigionous (allong dermal epidermal). Nodular: vertical growth, poor prognosis. verruca (wart) - rough, flesh colored. Scalded skin sydrome: epidermolysis of STRATUM GRANULOSUM!
pancreas
via hypercalcemia (activates enzymes), hyperlipidemia, scorpion, rupture of posterior duodenal ulcer, mumps complications: shock due to peripancreatic hemmorrhage/fluid sequestration, pancreatic abcess: ecoli, fever, presistently elevated amylase. Pseudocyst - mass, presistant amylase. rupture -> release of enzymes into cavity and hemmorage) chronic pancreatits - chain of lakes pattern due to dilation of ducts. secondary DM.
acute viral hep and reye syndrome
viral hep - dark urine, balloning degen. mononuclear cell infiltarates. coucilman bodies. HAV - most common acute in yong. Kuppher cels phagocytose debris - may appear hypertrophied and laiden w/ lipofuscin pigment Reye syndrome - MICOvesicular fatty change (small fat vacules in cytoplasm). NO necrosis/infl. hypoglycemia, vomiting, hepatomegaly. asprin metabolites decrease b ocxidaiton. autoimune hep - self reacting cd4 . responds to steroids. increase serum IgG, ANA, anti-smooth msucle
hepatitis
viral hep: mixed CB and UCB bc destroyes hepatocytes and bile ductules. acute: infl of lobules AND portal tracts. dark urine too (bc of CB) chronic: MOSTLY portal tract infl. cirrhosis: tgf from STELLATE cells beneath the endothelial cells alcoholic hep = from binge drinking. chemiical injury from acetaldehye. swelling. mallory bodies. reye's =also see hypoglycemia and encephalopaty
ischemic stroke timeline
12-48 hr: red enurons (eosinophilic, syknosis, loss of nissl). 24-72: necrosis and NEUTROPHIL 3-5d: microglia (macs). Bc they phagocytose myelin, stain w/ lipid stain. 1-2 wk: reactive gliosis and vascular prolif. >2 wk: glial scar. btw. malignancy/hypercoag state/trauma -> dural venous sinus bleed. epicranial aponeurosis (glia aponeurotica) and periosteium cover exterior surface of cranial bones.
anatomy of ribs.
12th rib overlies parietal pleura medially and kidney latterally. 11/12th = floating ribs. distal tip of 12th of left can be displaced into retroperitoneum and lacerate kidney. left: 9-11 overlay spleen. liver: 8-11. pancreas = L2
Preschool (3-5 yrs)
Don't Forget, they still Learning MOTOR: Drive—tricycle (3 wheels at 3 yr) Drawings—copies line or circle, stick figure (by 4 yr) Dexterity—hops on one foot (by 4 yr), uses buttons or zippers, grooms self (by 5 yr) SOCIAL: Freedom—comfortably spends part of day away from mother (by 3 yr) Friends—cooperative play, has imaginary friends (by 4 yr) VERBAL: Language—1000 words by age 3 (3 zeroes), uses complete sentences and prepositions (by 4 yr) Legends—can tell detailed stories (by 4 yr)
FAT btw, glycerol form fat breakdown -> glycerol kinase then glycerol 3p DH -> DHAP
FA CoA synthase Acyl-CoA. then taken in by carnitine shuttle. rate liming step is carnitine shuttle. its inhibited by Malonyl coA. it is carried out by Acyl-coA DH - no acetylcoA, so fasting hypoglycemia. decrease glucose and ketones. increase dicarboxylic acids. carnetine def: weak, hoptonia, increaesd muscle TG, myoglobinemia, . odd chan FA and branched chain AA: VAL is ISOlated, loves THREs and uses METH. -> propionyl coA. propionic acidemia: ypotonia, vomit, poor feeding. FA SYNTH: take citrate from mit into CYTOSOL by citrate shuttle. citrate-> OAA and Acetyl CoA. citrate positivly regulates Acetyl coA carboxylase, + biotin (co2) -> malonyl coA --> palmitate (16C). regulators: insulin and citrate promote it. palmitoly coa and glucagon inhibiti it.
Rentla tubular defects
FABulous Glittering Liquid: FAncoini (PCT), Bartter (thick ascending), Gittleman (DCT), Liddle is last (CD) Fanconi - cant absorb AA, glucoase, HCo3, P. can be due to wilson disease, ischemia, toxins. Bartter - Na/K/Cl cotransporter. causes hypokalemia, alkalosis, hypercalciuria (acts like loop diuretic) Gitelman - less severe than bartter. hypokalemia/alkalosis. NO hypercalciuria (thizide) Liddle - increase Na reabsorption in distal/collection tubules. AD. causes HTN, hypokalemia, alkalosis, DECREASES ADOSTERONE. rx: amiloride.
CRC
FAP - always involves rectum Gardner -- hypertrophy of RPE, impacted/supranumory teeth. HNPCC - AD. mismatch repair. PROXIMAL (right) colon. less than 50 yo. also endometrial/ovarian/skin cancer. MCH 1, 2. MSH 6 mutaitons. pol delta/epsilon responsible for proofreading. still error every 10^6 bases. MSH 2 and MLH1 encode for MUTS and MUTL. MutS detects mismatch (destinguished form parent strand by occasional nicks in PDE bonds. MutL then recruited. exonuclease degrades. DNA pol delta then loads at 3' and repairs. RECTOSIGMOID IS MOST COMMON, THEN ASCENDING. ascending (right) (HNPCC) = exophytic, anemai, weight loss. descending (left) (sporadic via APC) = infiltrate, obstruct, colicky pain, hematochezi, constipation, n/v, distention. >4cm= risk of malignancy. apc - lsos of adhesion, increased prolif: polyp develops. K ras - uregualted signal transduction: incrases size of polyp. colitis associated CRC - younger, MULTIFOCAL, Proximal colon. early p53, late APC. mucinous +/- signet rings. progress from flat ,HIGHER GRADE, more anaplastic. rectal adenocarcinoama - tenesmus, thin stool
RPGN (cresentric)
Fresents - fibrin, plasma proteins, parietal cells, monocytes, Macs. type 1: anti gbm (good pastiures) (IgG, C3 against a3 chain of type 4 collagen. linear IF. rx: immunosupresion plasmaphoresis. TYPE 2: GRANULAR. IC mediated, PSGN, SLE, IGA, Henoch scholeaan.
Pneumoconeosis
coal/silicoaiss/asbestosis - rssk of core pulmonale and caplan (RA, pneumoconioses, intrapulmonary nodules). silicosis: sand. TB. brronchogenic CA. UPPER lobes. EGGSHELL of hilar. nodular densities. birefringent silica particles surrounded by fibrous tissue. Coal worker - UPPER. descrete nodules (interstitial opacities). COAL AND SAND FOUND ON GROUND BUT AFFECT UPPER LOBES. BERYLLIOSIS - SPACE. GRANULOMAS that look like sarcoid. nodular infiltrates, enlarged LN. UPPER LOBES. Asbestose -calcified supradiaphragmatic pleural plaques. can see small pleural effusions. interstitial densities. dumbbell shaped golden bround rods in alveolar septum. translucent asbesto center coated w/ iron proteinaceous material. (asbestos-> endothelial infl, activate mac etc).
random stomach stuff
coffe groudn emesis: blood exposed to acid (heme oxidized) gastric hypomotility: DM, hypothyroid, uremia. see constipation, diarhea, satiety, vomit. nsaids can laso increase acid secretion and peeetrate cells to casue direct damage.
RR
cohort (look forward in time) a/a+b / c/c+d aka treatment over control ( ----->)
SURFACTANT
colapsing pressure = 2(surface tension)/radius synth start at 26, mature around wk 35. (prolactin, insulin, estrogen, androgens, thyroid, catecholamines. sphigomyelin is just a membrane component. amnionic fluid total protein/albumin decrease by 50% from early getation to term. ratio should be constant till 3rd trimester.
Tripple test
wk 16-18. if abnormal then do fetal ultrasound. if normal, then do amniocentisis. AFP - made by liver, GI, yolk sac. MOST COMMON CAUSE OF INCREASE is dating error. DS -> decreased AFP ESTRIOL - reflect placental/fetal fxn. may be decreased in IUGR
Macula and refractive errors.
yellow. cones. NO BV. 1:1 w/ bipolar cells -> ganglion cells. cGMP gated Na channels play role in vision accomadation: cilliary muscle contracts -> zonular fibers relax -> lens thichens. accomadate for NEAR objects (lens becomes more conVex). hyperopia(farsighted) - eye to short. image focus FAR behind retina. [slow/old = behind] myopia (near sighted, see near only) - eye too long. image in front of retina. correct w/ conCave c = common. astigmatism- abnormal curve of cornea -> different refractive power at diff axes. presbyopia - decrease in focusing ability during accomodation [near objects] due to sclerosis and decreased elasticity (the hardened lense is unable to thicken upon cilliary muscle contraction) (bc structural proteins w/i lens denature) also bc decreased cilliary muscle strenghth. [prespyopia can compensate for myopia by displacing the image back so it focuses on retina as person ages]
Obligate Anerobes
Cant Breathe Air Clostridum, bacteroidies, actinomyces
osteopetrosis.
"bone in bone" apearance pancytopenia, extramedullary hematopoiesis. normal lab values, maybe decreased serum Ca if severe. BMT cures. may see CN impingment. "persistance of the primary spongeosa in medullary cavity with no mature trabeculae"
Radial Head Subluxation
"nursemaid elbow" = sudden pulling of extended and pronated arm -> damages deep branch of radial N -> weak foream extensors -> wrist drop. in kis 1-4, ANULAR ligament tears and slips over head of radius into joint. presents w/ arm close to body, elbow extended, forearm pronated. tender. distressed when moved. radial collateral lig - at lateral elbow ulnar collateral - injured in throwers due to valgus stress at elbow. "tommy john surgery".
evolution of mi
0-4: gross: none light: none complication: arhythmia, HF, shock 4-12: gross: dark mottling. pale w/ tetrazolium stain light: coag necrosis, edema, hemorage, wavy fibers complicatoins: same as above 12-24: gross: same as above light: neutrophil migration. contraction band necross complicaitons: same as above 1-5d: gross: hyperemia light: extensive coag necrosis. neutrophils complicaiotn: fibrinous pericarditis 5-10 day (10-14d = granulation tissue/neovascularization) gross: hyperemic border, central yellow/brown softening. light: macs complicaotns: rupture, pseudoaneurism (mural thrombus plugs hole in myocradium: decreased co, risk of arrhythmia.) 2 wk-1m: dressler, HF, tru ventricular aneurysm ("dyskinesia")
oxygen free radicals o2 indep killing what is familial mediteranian fever? what is CD14
02 -> o2-, H2o2 -> OH- -> h2o Macs: lysozyme. Eosinophils: major basic protein. AR, dysfunction of neutrofils: fever, serial infl. high SAA -> can deposit as AA amyloid (secondary amyloidosis) receptor for TLR4 on macs and on lymphocytes (also play role in chronic infl)
fetal dev
1 wk: - implant at 6days. detest hCG at around 8 days. 2 wK: bilaminar disk. epiblast and hypoblast. 3 wk: trilaminar (gastrulation). wk3-8: NT closes by wk 4. wk 4: heart beat, 4 limb buds. wk6: see heartbeat via US wk 10 - genetlaia has female/male characteristics.
Salycilate intox
1) FIRST see resp alkalosis - ASA stimulates medulary resp center. 2) Anion gap acidosis = salycilates casue lipolysis, uncouple oxidative P, inhibit TCA -> ketoacids, lactate, pyruvate PH NORMAL, decreased PCo2, HCO3. fever, tinnitus ,tachypnea.
TONGUE
1,2nd brachial arches = anterior 2/3: sensation from lingual of V3; taste from chorda tymphani of 7 (passes along deep surface of tymphanic membrane and through petrotypanic fissure and merges w/ lingual. 2,4th brachial arches = posterior 1/3: CN9. CN10 = pharynx, epiglotus, tongue root. palatoglosus = CN10. terminal sulcus decides anterior vs. posterior. find foramen cecum at the midlien of this. piriform recesss - at laryngeal orifice. bound medially by aryepiglottic folds, laterally by thyroid cartilage/membrain. CONTAINS INTERNAL LARYNGEAL N (AFFERENT LIMB OF COUGH; branch of superior laryngeal (CN10).
renal failure
1. BUN/Cre ratio >20 bc Na/H2o/UREA RETAINED to conserve volume. (urin osm >500, urine Na <20). think of it as kidney in overdrive. 2. ATN/ischemia/toxins or somethiems acute glomerulonephritis. necrosis -> debris that obstruct -> decreased GFR. BUN REABSORPTION IMPAIRED: ratio <15. 1%, >20, <350. kidney is messed up. 3. BUN >15, <350, >40, >1 mild, >2 svere. Cre usually never reabsorbed so think of it as a constant consequences: MADHUNGER: Met Acidosis, Dyslipidema (increase TG), Hyperkalemia, Uremia (N, anorexia, asterixis, encephalopathy, pericarditis, platelte dysfunciton). Na/H3o retention (CFH, PE, HTN) Growth retardation, DD EPO fail Renal osteodystrophy - secondary hyperparathyroidism -> thinning of bones, pain, soft tissue calcificaitons.
Peptic ulcer disesae
1. Duodenal: MORE COMMON. most are ANTERIOR. H.Pyloir on PREPYLORIC region of antrum. other: ZE syndrome. benign. rx: metro/tetra/amox/clarithro, PPI, bisthmus for 14 d. 2. Gastric ulcer - h. pylori and NSAIDS. LESSER CURVATURE. usually at transition of acid secreting ep of corpus and gastrin producing ep of antrum. NCREASED risk of cancer. must biopsy. perforation: ANTERIOR duodenal ulcer. hemmorage - POSTERIOR wall of duodenum -> bleed from gastroduodenal. if gastric: left gastric artery.
ETC
1. ETC inhibitors: DECREASED proton gradieint. Rotenone (complex 1), At3mycin A (complex 3), cyanids/Co (complex 4) 2. ATP synth inibitor: Oligomycin.INCREASED proton gradient. 3. Uncoupling agents: increase perm of the membrane. DECREASED proton gradient, but ETC still running. INCREASES O2. 2 dinitrophenol (used in weight loss), asparin (-> fever), thermogenin
Lysosomal Storage diseases:
1. Fabray: X-linked, a-galactosidase. creamide trihexoside. peripheral neuropathy, heart/renal disease, angiokeratomas. 2. Goucher - Glucocerebrosidase (b-glucosidase) - glucocerebroside. most COMMON. CRUMPLED tissue papers (lipid laiden macs). FEMUR, Pancytopenia, hepatosplemogea. goucher is trash!! 3. Neman-Pick - Sphingomyelinase. FOAMY cells (lipid laiden cells) - CERRY rED SPOT, HEPATOSPLENOMEGALY, neurodegen, hypotonia, MR. *apear normal early. JEWS. 4. Tay SaX - heXxosamindase A, GM2. same as neman pick. lysosomes w/ onion skin. NO HEPATOSPLENOMEGALY. weak/hypotonia etc. JEWS 5. KrAbbAy - Galactocerebrosidase -> galactsylsphingoside, psychosine. OPTIC ATROPHY, IRRITABLE, GLOBOID cells. 6. Metachromatic leukodystrophy. Arylsulfatase -> cerebroside sulfate (sulfatides) Demylenination, ataxia, dementia, muslce wasint. 7. Hurler - a-iduronidase, airway obstruction 8. Hunters need to see clearly (no corneal clouding) and aim AGRESSIVELY for teh XX!
POLYPS
1. Hamartomatous - solitary; can bleed/cause intussucetion. gland, SM, CT. a. Juvenile polyposis - AD. colon, stomach. Most in rectum. b. Peutz-Jeghers - AD. toughout GI. hyperpigmented mouth, lips, hands, genitals. breast, somach, pancreatic CA. 2. hyperplastic - MOST COMMON. most in rectosigmoid. glands and crypts. 3. Adenomatous - APC mutation (CHROMOSOMAL isntability) Precancerous. bleed, SECREtory diarhea (villous. secretes mucus -> hypokalemia/electrolyte imbalance). tubular - small/pedunculated. Villous - large/sessile. sometimes velvety/cauliflour like projections. 4. serrated - Precancerous. Cpg hypermethylation phenotype pathway w microsatellite instability and mutaitons in BRAF. Sawtooth pattern of crypts. often sporatic CA. 5. Inflamatory - see in UC/chrons. composed of regenerating mucosa. 6. lymphoid - mucosae filled w lymphocytes
iron poisioning
1. N, diarhea, pain, hemmorage, hypovolemia, shock 2. GI symptoms resolve, ptn appears normal 3. metabolic acidosis, hepatic dysfxn, hypoglycemia 4. scarring of GI tract. hypothyroid an cause anemia bc of associated iron def or penicious anemia. anemia causes malaise, fatige, palor, CHF, heart palpiations, decreased exercise capacity feratin is a lso a acute phase reactatn.
other causes of dementia
1. PICK disease - early: change in personality, apaathy, innapropriate, disinhibition, emotional flatting, bad executive fxn. aphasia, parkinsonian aspects. DEMANTIA is late. earlier (50-60s) than alz. AD. ALTERED SPEECH (paucity of speech, REPEATED PHRASES). pick bodies (spherical tau). spares posterior 2/3 of superior temporal gyrus. 2. Lewy body - first dementia/visual hallucinations then PARKINSONS. alpha-synuclean defect 3. CJD - corneal transplant, eleectrodes, GH. vacuolated areas turn into cysts as disease progresses. NO INFL. GREY MATTER. 4. vascular dementia - STEPWISE DECREASE IN FXN. multi infarct. 2nd most common cause of dementia. due to atherosclerosis, htn, multiple ischemic strokes. 5. pseudodementia - depression, confusion, decrease mental fxn. rapid onset. to test executive fxn - draw clock oriented to right time. microglial nocules - see in HIV encephalopathy. form when cells of microglia surrond a neuron and phagocytose it. this + multinucleated giant cells = characteristic of viral inf. of CNS
COLLAGEN SYNTHESIS
1. PREprocollagen - just the pro-alpha chain 2. hydroxylation (defect->derease all other step/secretion) 3. glycosylation of hydroxylysine 4. formation of PROCOLLAGEN (tripple helix) - via H bonds and disulfide bonds. tripple helix formation is deficitn in osteogenesis imperfecta. 5. GO TO EC SPACE 6. cleaave disulfide ritch terminals of procollagen --> insoluable TROPOCOLLAGEN. via procollagen peptidase. decreased in Ehlers. 7. link many tropocollagen by lysine-hydroxylsine cross linkage -> COLLAGEN FIBRILS. defected in ehlers danlos.
common skin disorders
1. Verrucae: tan. cauliflower like. epidermay hyperplasai, hyperkeratosis. 2. utricaria - superficial dermal edema adn lymphocytic channel diation. mild superficial infiltarte of mononuclear cells/eosinophils. can be igE independent (Substances dan directly stimulate mast cell). 3. Ephelis (freckle) 4. Seborrheic Keratosis - KERATIN pseukdocysts (horn cysts)on histology. letter trelat - cancer. 5. Psoriasis: HLA-C. esp. knees and ellbow/scalp 1. see acanthosis (epidermal hyperplasia), 2. Parakeratoisis - hyperkeratosis and retenton of nuclei) 3. neutrophils in corneum (munro) 4. thin epidermis ABOVE elongated dermal papilae (clubbed rete ridges) 5. increased spinosu,, DECREASED GRANULOSUM. 6. Auspitz sig. perivasicualr lymphocytic infiltrate. 7. cdl8 cells -> TNFalpa, IL12, IFNgamma, rx: steroids, UVA + psoralen
Glycogen storage diseases
1. Von gierke (type1) - glucose 6 phosphatase. onlin in liver, renal. HEPATOMEGALY, fasting hypoglycemia, hyperlipidemia, hyperuricemia. rx: oral glucose, avoid fructose, galactose. 2. Pompe - 2. Lysosomal alpha 1,4 glucosidase (acid maltase), HYPOTONIA, hepatomegaly, cirrhosis, macroglossia. NO hypoglysemia. 3. Cori disease (Forbes) (3) - debranchign enzyme. same as type 1 but NORMAL lactate levels (gluconeogeneisis intact). short outer DEXTRIN like structures. NO fatty infiltraiton of liver. type 5 - Mcardles - glycogen phosphorylase. myoblobinuria, cramp. no lactate increase after exercise. arrhythmia from electrolyte abnormalities.
pathologic RBC forms
1. acanthocyte (spur cell) - Liver disease, ABETALIPOPROTEINEMIA (and other states of cholesterol dysregulation). 2. Basophilic stippling: Basically, ACiD alcohol is LeThal. Anemia of chronic disease, alcohol, lead poison, thalasemias. also see megalocytes if BM failure 3. Burr cell 0 short efenly spaced projections. can be artifact/mechanical damage/microangiopathic hemolyti anemia, uremia, pyruvate kianse def. spherocytse also seen in autoimune hemolysis. g6pd def/alpha thal -> hens bodies -> bite cells (denature of sulfhydral groups of hb -> precip). 4. target cell: HALT: HbC, Asplenia, Liver disease, thalasemia
errors in organ morphogenesis
1. agenesis: due to absent primordial tissue 2. aplasia - absence even though have premordial tissue 3. DEFORMAITON - EXTRINSIC disruption AFTER embryonic periodex: uterus impinges on fetus -> congenital hip dislocaiton, clubbed feet. 4. Malformation - INTRINSIC desruption DURRING embryonic period. ex: holoproencephaly, congenital heart disease, polydactaly. 5. Disruption - breakdown of previously normal tissue: amnionic band syndrome (rupture of amnion -> compress/amputate limbs syndactylyl - most common congenital upper limb deformity. second most common is constriction band syndrome (interuption of fetal blood supply -> amputation of finger/toes)
NONhemolytic, normocytic anemia
1. anemia of chronic disease: see decreased irion, increased ferritin, decreased TIBC 2. aplastic anemia - myeloid stem cells destroyed by radiation, drugs (benzene, chloraphenicol, alkylating agents, antimetabolites, carbamazepine, sulfonamides). B19, EBV, HIV, HCV. Fanconi anemia (DNA r epair defect). can follow acute hep. see PANCYTOPENIA [decreased retic count in presence of anemia!!], NO SPLENOMEGALY. rx: immunosupressive agents (antihymocyte globulin, cyclosporine), BMT. 2. Pure red cell aplasia - due to IgG or cytotoxic T cells. see w/ THYMOMAS, lymphocytic leukemia, B19. 2. chronic kidney disease (no EPO) 3. Myelopthisic Anemia - CA/granulomas occupy. ddx for pancytopenia w/o spleomegaly: b23, folate, aleukemic leukemia, MDS, aplastic anemia. MDS/megaloblastic =hypercelluar marrow w/ megaloblasts Myeloproliferative disorders, MDS, leukemia: hypercellular marrow w/ increased blast forms.
VF defects
1. anopia: retinal A or centrla retinal V occusion. 2. bitemporal hemianopia - ACOM aneurysm 3. left homonymous - rt optic tract (anterior choroidal) or optic radiation (MCA branch or internal capsule) 4. uppper quadrant - MYERS loop/temporal/ventral radiaton (inferior retina, thus upper quadrant prob). loops around inferior horn -> LINGUAL gyrus. 5. lower quadrant - opposite. dorsal radioaton takes shorter path and travels via internal capsule to CUNEUS gyrus. right nasal hemianopia - can be duet to right peri-chiasmal lesion (due to calciviaiotn/aneurysm of ICA). macula = bilateral projection to occiput, thus usualy spared. this stuff also progects to superior colliculus (reflex gaze), pretechal area (light reflex) and suprachiasmatic nucleus (circadian rhythm) optic radiaton = geniculocalcarine tract. outer 40 = monoscopic vison. central 120 = binocular (Stereoscopic vision). right INO/right MLF refers to the eye that is paralyzed.
Galstones (cholelithiasis)
1. choleterol stones - most common. chrones, CF. octreotide, ceftriaxone. a. estrogen increases HMG-CoA reductase activity. progesterone decreases bile acidd secretion and slows emptying. b. Suppression of 7-alpha-hydroxylase (as occurs w/ FIBRATE use) -> decreased bile acid production-> cholesterol stones. [cholesterol -> cholic and chenodeoxycholic acid via this enzym --> bile acids which are then congugated to glycine/taurine to increase solubility and emulsifying activity]. 2. Pigment stones - see in hemolysis, alcoholic cirhosis, advanced age, biliary infectin, TPN. A. Black - Ca bilirubinate - radiopaque (can see). see in young with hemolysis. also see in elderly Asian women. stones are small, crumbly looking. B. Brown - radioluscent. due to infection. often E. coli, Ascaris, liver fluke, Opisthorchis sinensis. the B-glucuronidase release from injured hepatocytes/bacteria -> hydrolyses bilirupbin glucuronide -> increased unconjugated bili. c. TPN - causes priamry billiary stasis from absent enteral stimuliation. use exogenous CCK to prevent. TPN also decrease gastrin release. biliary colic - afer meal, contraction of gallblader forces stone into cystic duct. can be painless in DM. can cause ascending cholangitis - charcot triad: jaundice, fever, RUQ pain. can cause galstone illeus -> pneumobillia. waxing and waning symptoms. usually old female. crampy, vomit, abdominal distention/obstcuction. rx:move stone, repair fistula. dont do cholescystectomy.
Aqueous humor pathway
1. ciliary ep makes aqueus humor. B blockers and azetazolamide works here. 2. fluid goes btwn the lens and the iris to get to anterior chamber. a1 - pupilary dilator. M3 = pupilary sphinctor. 3. fluid drains into trabecluar meshwork 4. drain into canal of schlemm cholinomimetics cause cilliary muscle contraction -> lens more convex. also sphintor of iris gets contracted -> wider angle glaucoma - optic disk atrophy w/ cupping. increased IOP. and progressive peripheral VF loss. open angle: age, black. PAINLESS. more common in US> primary - unknown. secondary - blocked trabecular meshwork form WBC (uveitis), RBC (vitreus hemorrhage), retinal elements (retinal detachemtn)
Herniation
1. cingulate (subfalcine) - under FLAX. can compress ACA. 2. downward transtentorial (central herniation). 3. Cerebellar tonsilar heriation - compress brainstem 4. Tentorial (uncal) hernaition - uncus herniates through gap btwn crus and tentorium. IPSI CN 3, PCA (contra homonomous), CONTRALATERAL crus (ipsi paralysis : false localizaiton sign). duret hemorage from stretch of basilar artery.
stages of lobar pneumoniae
1. congestion -1st 24 hrs. lobe red, heavy, boggy. vascular dilation, exudate is mostely bacteria. 2. red hepatization - days 2-3. red, frim . alveolar exudates contain rbc, neutrophils, fibrin 3. Grey - 4-6d. grey brown, firm. RBC disintegrated. exudate is neutrophils and fibrin. 4. resolution. (exudate enzymatically digested)
ATN
1. decrease gfr, decrease ouput 2. maintainence starts in 24 hr. OLIGURIA. lasts 1-3 wks. (weight gain/edema, pulmonary vascular congesition) hyperkalemic (arrhythmia) acidosis, flid overload, cre, bun, P. low serum Na,Ca. high urine na >30, FeNa >1. 3. recovery - polyuria due to high volumes. risk of hypokalemia. risk for decreased Mg/Po3, Ca also. see flattenign of ep cells, loss of brush border, necrosis, denudation of tubular BM. nephrotoxic - aminoglycosides, crush ingury, radiocontrast, lead, cisplatin, ampho B, foscarnet,. ethylene glycol -> ballooing/vacuolar degen -> glycolic acid (acute renal failure) and oxalic acid (Stoens)
GI ligaments
1. falciform - from VENTRAL mesentery. contains ligamentum teres hepatis (aka round lig) (from fetal umbilical vein). 2. Pringle maneuver - contains portal triad. hepatoduodenal lig borders omental foramen (connects greater and lesser sacs. 3. gastrohepatic - from lesser curvature. contains gastric arteries. separates greater and lesser sacks on right. cut to access lesser sac. 4. gastrosplenic - short gastrics/ left gastroepipolic . Separates greater and lesser sacs on left. 4. gastrocolic - gastroepiploic a. part of greater omentum. 5. splenorenal - btwn spleen and L kidney. connects to posterior abdomonal wall. contains splenic A, V, tail of pancreas. greater omentum - travels over small intestine, reflects on itself and ascends back up to encompas transverse colon then goes to posterior abdominal wall. gastrocolic lig forms part of anterior wall of lesser sac.
Adult CNS tumors
1. glliobalastoma multiforma - often in frontal/temporal lobe or asal gang. pseudopalisading cells border NECROSSIS/HEMORAGE. also neovascularization. can present as ring enhancing. 2. Meningioma - benign. at convxities (near surfaces of brain) and PARASAGICTAL (near falx cerebri)SEIZURES. arises from arachnoid cells. extra-axial (external to brain parenchym. may see dural attacmeht (dural tail on imaging). gross: well circumscribed/homogenousf spindle cells, concentrically arranged in whorled. PSMOMA. 3. hemangioblastoma. can produce EPO!!. thinwalled capillaries w/ minimal parenchyma. 4. schwannoma - can actually occur in any CN except 2 (covered by oligodendrocytes). BIPHASIC TUMOR. higly cellular aras (antoni A) and low cellularity areas (antoni B). 5. Oligodendroma - slow. well cercumscribed grey mass in FRONTAL lobes. chicken wire. often calcified.
myopathy
1. glucocorticoids - protein catabomils -> proximal muscle weak. no pain/normal CK. 2. inflamatory - proximal msuce. increase CK. 3. statin - proximal msucle. increase CK 4. HYPOthyroid - pain/cramps i n proximal muscle, decreased REFLEXES, Myoedema (muscle mounds following percussion!! 0 due to slow absorption of ca by sr). increased CK 5. vit D def: myalgia, bone pain, prox musscle.
uterine ligaments
1. infundibulopelvic lig (suspensory lig of ovary): ovaries to lateral wall. contains OVARIAN VESSLES. ureter at risk. 2. Cardinal lig (transverse cervical) - CERVIX to lateral wall. uterine vessles. ureter at risk. 3. Round lig - uterine FUNDUS to labia majora - from gupernaculum. above artery of sampson. 4. braod lig- contains round lig and part of suspensory/ovarian lig. 5. ovarian lig - MEDIAL pole of ovary to lateral wall. derivative of gubernaculum. other: right suprarenal v -> IVC. Left suprarena -> L renal v. left renal V passes btwn aorta/SMA. enlargmtn/hardeining of SMA -> compress left renal VEIN. hemiaygous v. drains posterior wall. This + azygous and accessory azygous -> blood can return by bypassing IVC.
TCA cycle
1. isocitrate DH -> aKG. inhibited by ATP, NADH. Increased by ADP, isocytrate, AMP 2. akG DH -> succinyl coA. Inhibited by succinul coA, NADH, ATP. this is whats messed up in alcholoics (Increased nadh, decreased thamine) 3.Succinul coa synthase -> succinate and GTP.
attrition bias Non-response bias
1. loss to follow up occurs disproportionately 2. participating subjects differ from non-respondents in meaningful way
KID CNS tumors
1. plicycytic - most comomn benign. rosenthal ribers (eosinic corkscrew). spindle cells w/ hair-like glial processes. Cistic + solid nodule. 2. Meduloblastoma - most common Malignant in kids. usually in vermis. primative neuroendrocrine. hydrocephalus. drop met. Homer (meDULLoblastoma). sheets of primative cells. 3. ependyloma - 4th vent. hydrocephalus. perivascular rosettes. rod shaped blepharoplasts (basal ciliary bodies near nucleus). GFAP. 4. Craniopharyngioma - supratentorial. calcified systic mass lined by stratified squamous ep. +/- keratin. tooth enamal like. cmpress stalk -> loss of DA inhibition -> hyperprolactin. solid/cystic and calcified components.
micturition reflex
1. sacral micturition center: s2-4 -> parasymp -> pelvic n 2. pontine micturition center - in reticular formation. coordinates relaxion of external urethral sphincter w/ bladder contraction 3. cerebral cortex - inhibits sacral mciturition center. damage -> urge incontinece: as bladder fills, empties as relflex, no sensation of bladder fullness/no conscious control.
Rx for insomnia
1. sleep hygine - schedule, no napps, cafine/alchole, meals. room is dark adn cool. exercise but not before bed. 2. stimulus control - use bed only for sleep. leave when kant. fixed wake time. 3. Relaxation - progressive msucle contractin tehn relaxaont in sequence. abdominal breathing, focus on mental image. 4. sleep restriction - restrict sleep to time pathient is actually sleeping. incrase time in bed in 30 min intervals.
genes of embryogenesis
1. sonic - made at base of limb at zone of polarizing activity. makes anterior posterior axis. mutaiton -> holoproencephaly. 2. Wnt7 - made at at apical epidermal ridge(thickened ectoderm at distal end of limb). organzies at dorsal/vental axis. 3. FGF gene - produced at apical epidermal ridge. stimulates mitosis of mesoderm -> limb lenghtens. 4. Hox - dna binding TRAnscription factor. segmental organization in a craniocaudal direction. mutaiton -> appendages in wrong spots.
Ecological study Nested case control case series
1. study population data. no conclusions can be made!, just use to make hypothesis 2. start cohort. in those ho dev. outcome of interest become cases for case control 3. descripive study following natural history
Psychiatric techniques
1. support - show concern/intrest even if dont understand. 2. facilitat - patient talks mroe 3. empathy - expres understanding. 4. reflection - repeat what patient tells you 5. confrontation - draws attention to discrpancies in responses.
ECTODERM derivatives
1. surface ectoderm: adenohypophysis, LENS and cornea, epithelium of oral cavity, sensory organs of ear, olfactory ep. epidermis, anal canal below pectinate, parotid/sweat/mamilary glands 2. Neuroectoderm: brain/glial cells, retina, spinal cord. choroid plexus. optic nerve. 3. NEURAL CREST: PNS, including DRG, cranial nerves, ANS. melanocytes, chromafin cells parafollicular C cells of thyroid PIA and ARAHNOID bones of skull odontoblast, aorticopulmonary septum
Dopamine systems
1. tuberoinfundibuar - DA 2. Mesolimbocortical - behavior. messed up in schiz. 3. Nigrostriatal - coordiaont onf voluntary mvnt. Da inhigits AcH.
Extrinsic Hemolytic anemia;
1. warm: anemia seen in SLE, CLL, methyldopa. usually a chronic anemia. cold: usually an acute anemia. CLL, M pneumo, mono direct coombs: Igs found DIRECTLY on the RBC. indirect: NORMAL rbc added to paitients serum. 2. Microangiopathic nemolytic anemia: malignant HTN, SLE, metastatic CA. 3. MACROangiopathic hemolytic anemia - prostetic valves/AS note: in chronic disease, see increase ferratin, decreased TIBC (iron is stored). OCP/Pregnancy increases Transferin synth. serum iron/ferratin is normal, % transferin saturation decreaes.
renal K excretion
100% filtered. 65% reabsorbed in PCT, 24% in thick ascendin. the 5-10% lect in DCT is REGULATED by principal/alpha interckalated cells. hypokalemia: k absorbed by H/K atpase of alpha intercalated norma;/increased: principal cells serete.
Congenetial adrenal hyperplasia 3, 21, 11
17alpha - low renin due to HTN. Males: ambiguous genetalia. look female femal: born normal but lack secondary sexual dev. 21alpah: increase renin, hypotension. 1. classic Girl - presents at birth w/ ambiguous genetalia. Boy - presents at 1-2wk w/ FTT, dehydration 2. classic, non-salt wasting Girl = presents at birth w/ ambiguous genetalia. Boy - 2-4 yo w/ signs of early virulization/increased growht 3. non-classic, delayed - premature pubarche/sexual precocity. women may also see acne, hirstuism, menstral irregularity.
Hypersensitivyt types
1: igE binds basophils in blood and mast cells in tissue -> histamine, protease, heparin, LT, PG. marker for anaphylaxis is TRYPTASE. use epi to increase bp (alpha) increase CO (beta1) bronchodilate (B2) . 2: cytotoxic via opsonizaiton, complement, ADCMC. direct coombs tests for RBC coated. indirect tests for Ig 3. Serum sickness: Ig dev against drugs/forign particles. see fever, urticaria, arthralgia, proteinuria, LAD 5-10dy later. see w/ chimeric monoclonal ig, venom, penicillin, TMP-SMX. arthus rxn: swelling/infl/nerosis after injeciton of antigen. 4. MS, gillain, GVH disease, contact dermatitis. blod transfusion: allergic reaction against ;plasma potion; anaphylaxic - severe allergic, often in giga def; Febrile nonhelolyltic - type 2 against donor HLA; Acute hmolytic - type 2 w/ intravascular and extravascular hemolysis - fever, chill, flank, hypo, hemoglo binemia, dic, jaundice.
Calcium reguilation.
1ahydroxylase is found in proximal convoluted tubule decreased Mg -> PTH secretion HIGLY decreased Mg -> inhibits PTH Increased serum P -> increased PTH acidic/basic fibroblast GF - increases bone, revascularizes, heals fractures TGFB - increaes osteoblast/collage IGF1 - does same thing. decress collgen degredation by inibiting metaloprotienase Osteocalcin - marker of bone formation. feeds back to inhibit excessive bone formation. T3 -> increase bone turnover -> hypercalcemia inhibits PTH. increases in pH can increaes affinity of albumin to ca --> manifestaitons of hypocalcemia: cramp/pain,parastheia, carpopedal spasm) decreased P causes increasse of vit D. decreased vit d w/ dark skin and northern latitudes.
Aortic arch derivatives
1st - MAXilary artery (first is MAXimal). 2nd - Stapedial/Hyoid A (Second - stapedial; regresses though) 3rd - Common Carotid and part of internal carotid (C = 3rd letter of alphabet). 4th - on left, part of aortic arch. on right, proximal part of right subclavian. 6th - proximal part of pulmoanry artery and ductus arteriosis. Right reccurent laryngeal N loops around r subclavian. LEFT RECCURENT gets cought by ductus arteriosus. provides all muscles in larynx except cricothyroid. injury -> hoarsness. if bilateral, could lead to airway obstruction. also sensation below vocal cord. [superior laryngeal N = cricothyroid and sensation above vocal cord. travels w/ SUPERIOR thyroid artery (from external carotid)] Ligation of inferior thyroid artery (from subclavian) causes injury to RECCURENT laryngeal N.
Brachial arch
1st arch: CN v2,3: CHEW - muscles of mstication, myohyoid, anterior belly of digastric, tensor tympani, tensor veli palatini. cartilage: Meckel cartilage: Mandible, Malleus, Incus, sphenomandivular lig. (also maxilla, zygoma, volmer, palatine). treacher collins syndrome - neural crest fails to migrate here -> madible fails to dev/facial amnormalities. 2nd arch: CN7: SMILE Muscles of facial expression, Stapedius, Stylohyoid, platySma, posterior belly of digastric. Cartilage: Reichert Cartilage: Stapes, Styloid prosess, LESSER horn of hyoid, Stylohyoid ligamnt. Congenital pharyngocutaneous fistual - persistance of cleft and puch -> filtual btwn tonsilar area and lateral neck. 3rd arch: CN9: SWALLOW styloPHARYNGEUS innervated by glossoPHARYNGEAL Cartilage: GREATER horn of hyoid 4th-6th arches 4th: CNX (superior laryngeal N: most of muslcles of soft palate/pharynx) [SWASLLOW] 6th: CNX (reccurent laryngeal branch) [SPEAK] 4th: most of pharyngeal constrictors, levator veli palatini, cricothyroid 6th: all intrinsic muscles of larynx except cricothyoid. cartilages for both: thyroid, cricoid, artenoids, coriculate, cuneiform. arch 3/4 => posterior 1/3 of tongue.
Depression
2 or more weeks. see decreased rem latency/slow wave sleep. see incesed REM early in sllep cycle and Increased total REM. night time awakening/early morning awakening (terminal insomnia) persistant depressive disorder (dysthymia) - milder depression lasting at least 2 years!!! Atypical depression - MOOD REACTIVITY (improves w/somehting positve. HYPERSOMNIA. WEIGHT GAIN. LEADEN PARYALISIS (heavy fealing in arms), INTERPERSONAL rejection sensitivity ECT 0 depression refractory, pregnant w/ depression, acute suicidality, depression w/ psychotic features. produces a gran mal seizure in anesthestized patient. may see memory prob but resolves in 6m.
heart defect associations
22q; truncus, tet rubella - pda, pulmonary artery stenosis. DM: transposition. btw. primary HTN not associated w/ increased renin. age: sympathetic cardiovasclar tone increases : increase SBP and DBP
MHC2 vs 1 NK cells
2: endocytose. MHC2 from RER. invariant chain falls off once fused w/ acidified endosome \ 1: protens degraded by proteosoem. load onto mhc 1 while in RER. contain b2microglobulin express CD16, 56: ADCMC: 16 binds Fc of bound ig -> activates NK. also kills when nonspecific signal or absence of mhc1. activated by IFN, IL12, 2.
AV block
2nd degree type 1: regularly irregular (variable RR but within a pattern) type 2: PR interval normal, beats jsut drop. 2:1 etc. 3rd degree: atrial rate faster than ventricular. BBB -> WIDE qrs (longer duration). high qrs VOLTAGE indicates ventricular hypertrophy. Paroxysmal SVT: seen in ppl w/o any heart disease. renetrant impulse through AV node. Rx: adenosine, carotid sinus masage, valsalva to slow AV conduction.
Fragile X pneumonic for triuncleotie repeaes.
2nd most common genetic cause. most common inherited cause. repeate expansion -> hypermethylation of gene. need >200. MVP. microsomia, joint laxity, pes cavus, arched palate. single palmar creases. increaed head circumphrens. all start with C and end w/ G. (except freidrch, GAA) FraGGile x = CGG Huntingtons CAGe myoTTonic dystrophy (CTG)
Spinal nerves
31; 8 cervical, 12 thoracic c1-7: above their vertebrae. ex: C3 exits btwn C2 and 3 (goes w/ the last number. all others below their vertebrae. ex: L4 exits btwn 4 and 5. (goes w/ first number) in lumbar, herneated disk spares nerve at that level goes for next: l4/5 affects l5 nerve herniation - pulposos (soft central disk) herniates though annulus fibrosis (outer ring). occurs posterolaterally at l4/5 or L5/s1 cord extends till L1/2. subarachnoid space extends till S2. do LP at L3/4 or 4/5 (level of cauda equina)
Urea
40% passively reabsorbed in PCT, inner medullary collecting duct. passively secreted in thin ascending loop of henle. rest of nephron is impremiable. Net: 10-70% excreted. ADH increaes urea transporters in INNER MEDULARY CD. ADH increaes water reabsorption in CORTICAL segment of CD -> decreae free water delivered to medullary CD (which prevents dilution of interstitial gradient)
CML
64yo. bcrabl-> decrease apoptosis, increase kinase activity. increased neutrophils, metamyelocytes, basophils SPLENOMEGALY. blast crisis = brogress to AML/ALL PDGFR mutation also plays a role !!. Imatinib binds the atp binding site of the tyrosine kinase.
AML
65 yo. PEROXIDASE POSITIVE. aurer rods = fused lysosomes. risk wy alkylating agents, chemo, radiation. 17=R-AR 15=PML M2 - AML w/ maturation : 8:22 M7 - acute megakaryocityic leukemia M4Eo - eosinophilic subtype. chromosome 16 inversion m4/5 form monocyte precursors. M6 from erythroid precursors. see in elderly
C02 transport
90% HC03. 5% Carbaminohemoglobin: binds to n term of GLOBIN (not heme). 5% dissolved. HHHaladane effect: oxygenation -> dissociation of H -> alws Co2 release (think of the carbonic anhydrase rxn) Bohr effet: H+ buffered by histaidne resides on Hb -> stabilize deoxygenated form to help unload. HIGH Cl in RBC of VENOUS blood bc bicarb exchanges for it.
most common for atherosclerosis
: aorta, coronary, popliteal, popliteal, carotid arterl blunt aortic trauma: injurs aortic isthmus (noramally tethered yb ligamentum arteriosu) widened mediastinum, back pain. bery aneurysm: hyemodynamic stress, HTN, Ehlers danlos. NOT marfans.
cause of death
<1 yr congenital malf/ preterm/SIDS 1-14 injury CA congenital malf 15-34 injury suicide homocide 35-44 injury ca heart 45-64 ca heart injury over 65 heart ca chronic resp.
ALL
<15yo. t cell: mediastinal mass. only 15%. teenages. can compress vessles -> SVC syndrome, dysphagia, dyspnea/stridor (compress trachea). LAD, hepatosplenomegaly, bone pain. both are also PAS + B: 19, 10, 20 T 1-9.. 12:21 is best prognosis.
what is probabiltiy of at least 1 event happening?
= 1-(specificity)^#of tests
Polyhydramnios
>1.5-2L amniotic fluid. maternal diabetes, fetal anemia (high CO -> increased urine), multiple gestations. risk of preterm laber, uterine atony (from over distention). can cuase maternal respiratory compromise bc large cavity compresses lungs. oligohydramnios - <o.5L. asociated w/ placental insuficicy.
SLL/CLL Hairy cell
>60yo. CD20, 19. SMUDGE. often asymtomatic AI HEMOLYTIC ANEMIA. . may see deltion of 13q. LAD, HSM, anemia Hairy cell - FRIED EGS. pancytopenia. SPLENOMEGALY. CAUSES MAROW FIBROSIS.
Jugular venous Pulse
A - Atrial contraction 0 absent w/ afib. prominent in hypertrophic cardiomyopathy. C - rv contraction (tricuspid valve bulges. x - atrial relaxation - absent in TR. v - atrial filling y - blood flows from ra to rv. rapid descent in constrictive pericarditis.
Changes in glomerular dynaics
A2 perferentialy constricts EFFERENT arteriol - decreases RPF to increse GFR -> increase FF. Prosteglandins DILLATE afferent to increase RPF and GFR so FF remains constant. Afferent arteriole decreases RPF and GFR so FF is constant. protein [ ] ONLY affects GFR, NOT RPF. ureter constriction ONLY affects GFR to decrease it.
HLA
A3: hemochromatosis DQ2/8 - celiac DR2: MS, hay fever, SLE goodpasture DR3: DM1, SLE, graves hashimoto DR4: DM1, RA DR5: pernicious, hashi
blood groups
AB: universal recipient of RBC and universal donor of plasma! antiA/B = igM (cant cross placenta, less severe hemolytic isease in fetus, babie's A/B antigens less developed) ppl w/ type O make IgG!! that cna cross the placenta -> hemolytic disease of the neowborn. Rho-Ig: give at 28 wk adn immediate postpartum. it binds fetal RBC in mom and destroys them. if not given: anemia/jaundixe, edema in kid. anemia -> nucleated rbc/extramedulary ematopoesis.
toxins from lysogenic phages
ABCDE: shigA-like toxin, Botulinum, Cholera, Diptheria, Erythrogenic toxin from S. pyrogens
Sarcoidosis
ACE. reticular opacity. fibroiss. erythema nodosum lupus perenio, bell palsy. Schaumann and asteroid bodies. uveitis. Macs make vit D due to INFg from Th. constitiutional symptoms - malaise, fever, weith loss. hiagh cd4/8 ratio in BAL!!! (contrast w/ hypersensitivy pneumonitis) . arthralgia. granulomas in LIVER. dry cough. pulmonary INFILTRATES.
ACOM /PCOM
ACOM: usually due to aneurusm. VF defec. PCOM: saccular anurysm - CN3 palsy.
Pancreatitis
ACUTE- also via steroids, dulfa, nrti, protease inhibitors, azanthioprine, sulfasalazine, furosemide, valproic acid. infection w / coxackie, M. pneumo, pancreatic divisum, strictures, choledochal cyst. can cause hemorrhage/infarction. Increased TG -> increased FA in pancreatic capilaries .... ethanol-> secretions with increase protien and decreased fluid -> pluggs taht obstruct lumen. it also causes spasm of sphinctor of odi and is toxic to acinar cells. may cause hypernatremia due to large 3rd space fluid loss and decreased fluid intake. Pancreatic pseudosyt - lined by granulation tissue. its a inflamatory reaction in walls of surrounding organs. usually in lesser peritoneal sac. can rupture/hemorrhage. CHRONIC - often see w/ CFTR mutations. can cause DM. hereditary pancreatits - mutation in trypsinogen or SPINK1 (cant inactivate) Acute interstitial pancreatitis - pancreas is edematous w/ Focal fat necrosis and Ca deposits. Acute Necrotic pancreatitis - inflamtion -> compromised blood flow due to edema -> ischemia/trypsin activaiton -> autodigestion. hemorage/fat necrosis.
Essential tremor ))postural tremor)
AD. most commonn. usually in upper extremeties. action tremor. worse when holding posture/limb position. worsens w/ fine motor activity. rx: alcohol decreses tremor amplitude. PROPANOLOL (non-selective B blocker). PRIMIDONE - also first line. can use for partial seizures. can cause sedation. **think when CI for nonselective B blocker. metabolite = PHENOBARBITAL
Hereditary angioedema
AD. painles, nonpitting. well circumscribed. on face, neck, lips, tongue, tracheobronchial tree can involve GI -> pain, vomit, diarhea see increased kalikren, bradykinin, C3a, C5a -> vasoldilation/increased vascular perm.
Autosomal dominant diseases
ADPKD - chromoaome 16 and 4 FAP =- chromoaome 5 NF1 = 17. NF2 = 22. juvenile catarats, meningiomas, ependyomas. Marfans: high arched pallete, crowded teeth, narrow face, coliosis, kyphosis, suspensory lig of lenz (zonular fibers) btw. ocular albinism is X linked and duchene is frameshift (trncated protein)
Renal cyst disorders
ADPKD - chromosme 16, 4. cysts are at any point in neprhon. non-enhancing. HTN. Microscopic at birth. can see dyslipidemia due to persistant proteinuria. ARPKD - cysts in DISTAL TUBULE and CD. portal HTN. congenital hepatic fibrosis. Medulary cystic disease - tubulointerstital fibrosis. shrunken kidneys. cant see cysts on US. symple syst - outer corte. complex cyst - septations, enhancing, solid components. remove. multicystic dysplastic kidney - abnoral interaciton of ureteric bud, metanephros. amsence of normal pelvocaliceal system.
Serum markers of liver
ALK-P: LIVER, BONE, intestine, kidney, placenta GGT - in hepatocytes, billiary ep. NOT in bone. also ass w/ alcohol use ALP: obstructive hepatobiliary disease, HCCC, bone disease, infiltrative disorders. ast = mit. oaa+ glut -> aspartate alt = pyruvatte -> alanine hepatic granulomatosis - methyldopa, hydralazine, quinidine
THALAMUS
ALL EXCEPT OLFACTION (OLFACTION ODD BALL) VPL/M: goes to BA 3, 1/2 Medial geniculate - get imput from superior olive, inf colliculus -> Auditory cortex (BA 41, 42) vetrolateral: imbut from gasal gang/cerebellum. goes to motor cortex.
neurotransmitter changes w/ dieasae
ALTZ - low ach, high glutamate. aLTGHs anxiety - low GABA, serotonin; high NE depression - low NE, serotonin, DA Huntingtons - cageD: low ach, gaba, high dopamine pArkinsons: decreased dopamine, increased ACH schiz: increased DA korsakoff: Anterograde is MOST lost.
Tumor supresor genes
APC - normally decreases b-catenin (oncogene) -> WNT signaling pathway BCRA1,2 - AD. repairs DS DNA breaks CPD4/SMAD4: pancreatic Cancer. makes DPC (deleted in pancreatic cancer) DCC: Colon cancer. makes DCC NF1: neurofibromin - RAS GTPase activating protien (suppresses ras) NF2: merlin (schwannomin) P16: melanoma - CDK inhibitor 2a p53. transcrito factor for p21. PTEN: brest, prostate, endometrial VHL: inhibits hypoxia inducible factor 1a: ubiquitin ligase compononet.
AR: disease occurrences attributable to exposure
AR = treatmetn - control a/a+b - C/c+d
ARR = difference in risk reduction
ARR = controls - treatment
Cystic Fibroisis
ATP gated. activated by cAMP mediated phosphorulatoin. misfolded protein stays in RER -> proteosome. due to deletion of phenylalanine and impaired post-trans processing. EC fluid looses Na/H20 bc of Cl- inside. can present w/ contraction alkalosis/hypokalemia. (similar to loop diuretic) . no real renal dysfuction though. reticulonodular pattern on CXR. meconium illeus. digital clubbing. billiary cirrhosis. obstructive fibrosis of exocrine pancreas bc decreased bicarb secretion and no vit a -> swamous metaplasia of lining of ducts. presistent diarrhea can -> rectal prolapse. hypoproteinemia adn generalized edema. gi tumors in thrd decade. rx: N acetyl cystine cleaves disulfide bonds (also used infl, bronchitis). and DORNASE alfa - DNAse to clear leukocytic debris. note: normal sweat is hypotonic bc cl/na reabsorbed. excess sweating is free water loss.
Esophageal disorders
Achalasia: progressive. uncoordinated peristalsis. Scleroderma - can cause aspiration. decrease LES Pressure. diffuse esophageal spasms - segments contract at same time. severe chest pain. boerhave - can also see fever, dyspnea, shock. Eosinophilic esohagitis - see eosinophils. food alergy -> dysphagia, heartburn, strictures. Esophagitis - due to reflux, infection in immunocompramised, or chemicals. if reflux, see elongation of papilla, basal cell hypertrophy, intraepithelial eosinophils. GERD - can present as sore throat. similar histology as esophagitis. mallory weis - painful. subucosla a/venous plexus bleed.
Acne/Rosacia
Acne - 1. folicular epidermal hyperprolif +sebum+infl+p. acnes. can see w steroids, EGFR inhibitors, lithium. Rosacea - erythematous papules/pustules. NO comodones. may be associated w/ fascial flushing in response to alcohol/heat. chronic inflamaotry changes may result in rhinophyma (bulbous deformation of nose) dermatofibromas - superficial benign fibrous histiocytones. benign prolif of fibroblasts. usually on lower extremities as solitary nodule (flesh colored)
sensory corpuscles
Adelta - fast, myelinated. acute/sharp pain C - slow, unmyelinated Meissners - HAIRLESS skin; dynamic, fine/light touch, position. large, adapt fast. (joe meisner:soft but has his positions) Pacinian - deep skin, lig, joint. vibration/pressure. large, adapt fast. (Paucinian Punk - vibrate/pressure, lig, joint) RUFINI - touch/proprioception/vibration. Slowly adapt. both innervated by A-beta. Merkel - basal epidermal layer, hair follicles. pressure, deep static touch (shape, edge), position. large, adapt slow. (merKel - edges/shape. both Ps, he's slow, bumps into things.) RUFFINI enddoneurium - infl infiltrate in guillan barre. Perineurium - permeability barrier. surrounds fascicle. rejoin after limb reatachmnt. EPIneurium - CT sorrounds entire nerve (fascicles adn BV)
Purine Salvage
Adenine, Guanine, hypoxanthine can be salvaged. to AMP, GMP, and IMP respectively for degredation, Adenosine deaminase converts adenosine to inosiine which can then be converted to hypoxanthine. Hypoxanthine and guanine go to xanthine and then uric acid both by uric acid. if adenosine deaminase is broken, excess ATP dATP inhibits ribonucleotide reductase and inhibits DNA synth if defective HGPRT, excess PRPP which goes back and stimulates de-novo purine synth
kidney hormones
Alodsterone - also stimulated by HYPERKALEMIA, and ACTH. icnreases Na/Katpase, Na channel insertion. AT2 also affects barrorectptor function to limit reflex bradycardia which would normaly accompany its pressor effects. EPO - interetitial cells in PERITUBULAR capilaries Vit D - prox tubule cells.
Complemnt
Alternative -> C3bBb -> C3Bb3b (C5 convertase) classic/Lectin -> C4b2b -> C4b2b3b Classic starts w/ c1 to make C1 complex -> C2b Lectin starts w/ MBL to make C1 like complex -> C4b C3 def -> pyogenic sinus/resp infeciton and increased type 3 hypersensityb (bc can't clear immune complexes) C1esterase def -> decreased c4 bc of unopposed breakdown C1, 2, 4 def -> SLE like disease, encapsulated bacteria
vinyl chloride arsenic aromatic amins (benzidines, napthylamines from ciggarets)
Angiosarcoma angiosarcoma, lung cancer, SCC transitional cell ca btw radon is second leading cause after cigarette. alcohol: SCC of oropharynx, upper esophagus, HCC, pancreas Cigaret smoke: CA of oropharynx, esophagus, kidney, lung, bladdder, pancras Kaposi: older estern european male, AIDs, Transplants. *all carcinogens met by microsomal monooxygenase
arteries in arm
Anterior circumflex humral atery is anterior to surgical neck. anasamoses w/ posterior. damage to surgical neck can damage this and axilary N. deep brachial artery - courses posteriorly along humerous in close association w/ radial N. brachial artery - goes anteromedially in arm w/i bicepital groove. supracondylar fractures may damage. divides into radial and ulnar. common interosseus is branch of ulnar.
other anatomy of lung
Apex of lung is 3-4 cm above 1st rib. Lung bases contact the diaphragm. sternocostal surface = RV diaphragmatic (inferior) surface: L and RV. contacts the central tendon of diaphragm. posterior heart surface: LA. IVC = right of midline. AZygous V. = posterior mediastinum. right of midline. drains posterior intercostal veins.
GI embryo
Apple peel atresia - illial/jejunal/colonic atresi - VASCULAR ACCIDENT IN UTERO not congential. 6th week: herniates, 10th wk: rreturns and rotates around SMA 270 decrees counterclockwise. malrotatio: cecum in RUQ fixed by ladd bands to second part of duodenu. can see Intestinal obstction duet to adhesion bnads compressing duodenum. tracheoesophagela fistula: see cyanosis secoindary to lyarngospasm (to avoid reflux related aspiratoin. congenital pyloric stenosis: hypokalemic hypochloremic metabolic acidosis secondary to vomit and volume contraction.
Neural cells
Astrocytes - repair, K met, remove excess NT, helps BBB. large vesicular nuclei. tight jxn btwn endothelial cells = BBB. Microglia - cant use nissel stain. irregular elongated nuclei, little cytoplasm. HIV infected microglia fuse -> multinucleated giant cells. oligodendrocyte - fried egg. small round dark nuclei w/ pale halo.
Seronegative spondyloarthropathies
B27 - normally encodes for MHC class I. common in mains. psoriatic - nails yellow/thick/crumbling. Ankylosing - ankyloissi, uveitis, aortic regurg. morning stiffness better w/ exercise. APICAL PULMONRY fibroiss. enthesitis can limit expansion of chest wall: MONITOR regularly Reiter - joint asprration is sterile though. keratoderma blennorrhagium (VESSICLES palms/soles), circinate balanitis - serpiginous annular derpatits. oral ulcers. contrast w/ syphilus - maculopapular rash NOT vesicular.
Pathoma: Epithelial Tumors
BASAL CELL CA: MOST COMMON.nodule w/ central ulceration/crusting. "pink peraly nodule" telangectasia, rolled borders. may also appear as a nonhealing ulcer or a scaling plaque. UPPER LIP. (B,S) HISTO: see NESTS of basal cells w/ PERIPHERAL PALASADING (rest above looks normal) in dermis FIRST IN ALPHABET, THUS MOST COMMON. SQUAMOUS CELL: 2nd most common. immunosupression/arsenic/chronic infl (draining sinus tract). ULCERATED nodular mass w frequent scale. LOWER LIP. locally invasive but may spread to LN 1. Karatoacanthoma - well differentiated version that comes rappidly then disaprers. (cup shaped tumor filleed w/ keratin debris). 2. Actinic keratosis: precursor. hyperkeratotoic scaly plaque on face/back/neck 3. may show dyskeratosis - abnormal premature keratinization keratinocytes. strongly eosinophilic, small basilar nuclar remnant. 4. Marjolins ulcer - agressive ulcerating SSS in prefiously traumatized/chronically inflamed/scared sin.
Cortisol
BIG FIB 1. BP increase by upregulating a1, increased sensitivity to NE, E 2. Insulin resistance 3. Gluconeogenesis, lipolysis, proteolysis 4. Fibroblast activtiy decreased (striae) 4. Iflamation and Immune resposne: neutrophillia, blocks histamine release, reduces eosinophils, blokcs 1l2 (thus can reactivate TB, candidiasis)produciton, inhibits LT, PG. 5. Bone formation decreases.
ANP, BNP
BNP has longer 1/2 life. has good negative predictive value. -> increase cGMP. dilates afferent, constricts efferent in kidny. -> increases GFR, decreaes renin. . nesiritide - HR for acute decompensated HF. ventricular hypertrophy, increased tension, increased blood volume and pressure can all cause release.
signalign pathways: cGMP
BNP, ANP, NO (EDRF) (think vasocilators
pseudogaout
BOTH sexes (other is jsust men). LARGE joints. increased risk in hemochromatosis, hyper/hypoparathyroid. Nsaid/steroid/colchecine blue when parallel.
MEMBRANOPROLIPHERATIVE
BOth: thick GBM with TRAM TRACK appearance (GBM splitting) IF: GRANULAR called "prolipherative" bc on LM, glomeruli look lobular and have prolif of mesangial cells/mesangial matrix (CONTRAST W/ MEMBRANEOUS) TYPE 1EM: SUBENDOTHELIAL IC (C1q) . HBV, HCV TYPE 2: INTRAMEMBRANOUS (w/i BM/mesangioum) IC deposits. (dense deposit disease) C3 nephritic factor - stabilises C3 convertase -> decrease serum C3. btw: amyloidosis = mesangial deposits.
brain ateries
Basilar - brainstem and cerebellar hemispheres. PCA - at pontomesencephalic jxn. supplies CN 3, 4, midbrain, thalamus, medial temporal lobe/parahippocampal gyrus, splenium of corpus callosum, fusiform gyrus. dyslexia, visual agnosia ,prospagnosia (cant rec faces) Artery of Percheron - supplies BILATERAL thalami and dorsal midbrain. off PCA. Anterior choroidal - last branch of ICA before bifurction. posterior limb of internal capsule, optic tract, lateral geniculate, corroid plexus, uncus, hippo, amygdola. MCA - lateral frontal/parietal, temporal. deep subcortical (internal capsule, basal gang). supplies frontal eye field tooo) ACA - inferior/medial frontal. superior medial parietal lobe. anterior 4/5 of corpus colosum. olfactory bulb/tract. anterior basal gang/internal capsule. URINARY INCONTINENCE, PRIMATIVE REFLEXES
Catalase :
Be PLACESS Burkholderia. p aeuro, listeria, aspergillus Candida, e. coli, s aureus, serratia
Gas embolus
Bends: joint and muscle pain. chokes - respiratory symptoms. chronic form is caisson disease. multifocal ischemic necrosis of bone. gas embolus may also be seen during laproscopic surgery (air pumped into abdomen. dvt that leds to PE is from femoral, iliac, or popliteal
Eating disorders
Bullemia -parotitis, enamal erosiion, russle sign, IRREGULAR menses (vs. amenorhea in anorexia) anorexia - may or may not purge. DECREASED OBNE DENSITY. metatarsal stress fractures. AMNEORRHEA, lanugo, anemai, erlectrolytes. hypotension, hypothermia, badycardia, HEART atrophy/arrhythmia, cardiomyopathy. refeeding syndrome (jypophosphatemia) in malneurished. if pruge, can see parotid gland hypertrophy.
landmark dermatomes and reflexes
C2 - posterior skull. c3 - high turtle neck. c4 - low collor shurt t 1 estends into medial arm. T4 nipples. t7 xiphoid t10 umbilicus (appendicitis pain referral ) L1- inguinal lig. l4 = knee caps. s2,3,4 - penis off the floor (and anal zone) diaphragm/gall bladeer to right souhlder via phrenic. l1/2 = cremasteric reflex s3,4 - anal wink reflex. L2 - anesthesia/paresthesia posteriorly in gluteal region adn anteriorly on thigh inferiro to femoral triangle and inguinal lig. L5 - sensory loss/parastheia on anterior leg.
Axillary Nerve (off posterior cord, extensor compartment)
C5-6. fracture of SURGICAL neck of humerous. or ANTERIOR dislocaiton of humerus. may be due to forceful extenal rotaiton/abduciton FLATTENED DELTOID/TERES MINOR loss of ABDUCTION at shoulder loss of sensation over deltoid and LATERAL arm.
Musculocutaneous nerve
C5-7 UPPER TRUNK compression innervates the BICEPS, brachialis, coracobrachialis (find the nerve inbetween biceps and coracobrachialis) (teh coracobrachialis lays over the median N and brachial artery) loss of FOREARM FLEXION and supination. loss of sensaiton over LATERAL FOREARM (lateral cutaneous N).
Median nerve
C5-T1 SUPRACONDYLAR fracture (proximal lesion) or carpal tunnel/wrist lasceration (distal lesion) nerve courses w/ brachial artery. found in groove btwn biceps adn bracialis, deep to coracobrachialis. It goes getween the humoral and ulnar heads of pronator teres. Then goes between the flexor digitorum superficialis/profundus. Loss of wrist and lateral finger FLEXION, thumb oposition/abduciton/flexion, lumvricals of 2nd and 3rd digits. Loss of sensation over thenar eminence, dorsal and palmar aspects of lateral 3.5 fingers w/ proximal lesion. Popes blessing: see with PROXIMAL lesion. problem manifests when MAKING A FIST. APE hand/Median claw: see with DISTAL lesion (reccurent branch of median) - problem at REST or when extending fingers. no loss of sensation though. in general, proximal lesions = problem making fist distal lesions = problem at rest/extending fingers. Claw = DISTAL. extrinsic flexors exagerate loss of lumbricals (fingers extend at mcp, flex at DIP and PIP)
Radial nerfve (off posterior cord, extensor compartment)
C5-T1 - longest of nerves. MIDSHAFT fracture of humerus (also injurs deep brachial artery) - often spiral fracture due to sorsion of falling on oustreached hand. COMPRESSION of axilla - crutches/saturday night palsy starts within the axilla then enters posterior arm to course between long head of triceps and posterior humerus. goes through the supinatormuscle near head of radius. also supplies brachioradialis and supinator muscle. WRIST DROP: due to loss of elbow, forearm, wrist, finger EXTENSION. decreased grip strenght (bc wrist extension needed for maximal action of flexors) Loss of sensation over POSTERIOR ARM AND FORARM (posterior cutaneous nerve) and dorsal hand (thumb and half of hand, not including digits)
Ulnar nerve
C8-T1 Fracture of MEDIAL EPICONDYLE (proximal lesion) or hook of hamate (distal) found btwn the flexor carpi ulnaris and flexor digitorum profundis. all palmar/dorsal interosseus muscles, hypotehnar eminance, palmaris brevis, 3/4th lumbricals, adductor policis. Medial forearm sensation (medial cutaneous N of forearm) Loss of FLEXION of wrist and medial fingers, abduciton and adduction of fingers (interossei) adn medial 2 lumbricles. decreased adduction of thumb. Loss of sensation of medial 1.5 fingers Radial deviation upon Flexion of wrist (proximally) ULNAR claw - when trying to extend fingers/at rest. due to DISTAL nerve lesio. OK gesture - when making a fist. due to PROXIMAL ulnar nerve lesion. in general, proximal lesions = problem making fist distal lesions = problem at rest/extending fingers. Claw = DISTAL. extrinsic flexors exagerate loss of lumbricals (fingers extend at mcp, flex at DIP and PIP)
LOWER Trunk lesion
C8-T1. includes median/ulnar N affects all intrinsic hand muscles (lumbricles, interossei, thenar, hypothenar) TOTAL CLAW hand: (lumbriczls normally flex mcp and extend dip/pip. due to upward fore on arm during delivery or grabbing a tree branch while falling.
copd vs asthma
CB - TLC NORMAL, FRC increased, Complience normal. DLCO normal. Bronchodilator response = partial. In emphysema - TLC VERY increased, FRC very increased, pulmonary compliance increased, DLCO decreased. Bronchodilator response = not reversible. DLCO decreases due to destruction of alveoli/capillary beds.
Urease
CHuck norris hates PUNKS Cryptococus, H pylori, proteus, ureoplasma, Nocardia, Klebsiella, S. sapro, S epi
Brachial aparatus
CLEFTS are outside grooves. from ECTODERM Arches = the middle part. MESODERM (muscle/artery) adn NEURAL CREST (bone/cartilage) Pouches - are on the inside part. from ENDODERM spells out CAP from outside in. clefts/grooves - 1st: external auditory meatus. 2nd through 4th make cervical sinuses that are obliterated by 2nd arch. often see at angle of mandible w/ sinus tract.
Extraoclualr eye muclse and nerves.
CN 4 - (superior obleque) (trochlear) . eye moves up, esp w/ contralateral gaze. head tilt woard side of lesions. vertical diplopia most noticible when eye looks tward nose when reading, walking downstairs. SO: depresses when at adducted. otherwise aBducts adn intorts. CN6 - estropia (medially directed eye) CN 3: motor is central. para is peripheral. diagnal (horizontal and vertical diplopia) vascular disease - > motor prob. compression by pcom aneurys, and uncal heriation. -para prob.
midbrain stroke
CN3, ataxia, hemiparesis, contralateral extrapyrimadal. contra superior rectus (subnucleus febers deccusate to contralateral side. also BILATERAL ptosis (both levator palpebrae innervated by single subnucleus).
hemibalism
CONTRALATERAL SUBTHALAMIC (lacunar stroke). uses glutamate and sends axons to globus palidus. choria - jerky dancing. flows from one muscle group to another. athetosis - esp in fingers. myoclonus - jerks/hiccups. see w/ metabolic abnormalities (renal/liver). often damage to ucleus ambigeus. intention tremor - slow zigzag mvmnt when pointing. cerebellar prob. resting tremor - hands. better w/ mvmnt. thalamic syndrome - post-stroke pain. burning/stabbing on 1/2 of body. allodynia (usually painless stuff causes pain) an ddysaesthesia.
random:
CSF igG increase via local produciotn (MS, infection) or inflamation of BBB (trauma/meningitis => leak). decrease 5HIAA -> impulsive ,agressive, suicide, violent. 14-3-3 = increase w/ GJD. change in levels of homovanillic acid - substance abuse disorder, psychosis, mood, parkinsons melatonin levels decrease in progression of altz.
Menkes Disease
CT disease due to bad Cu absorption. bad lysyl oxidase. brittle, kinky hair, GR, hypotonia.
other liver tumors
Cavernous hemangioma - MOST COMMON BENIGN. congenital malf taht enlarges by ectasia. spongy. dont biopsy bc can bleed. hepatic adenoma - OCP, anabolic steroids. can rupture -> shock. Angiosarcoma - malignant. arsenic, vilylchloride. marker is CD31 (endothelail cell marker( PECAM1) nutmeg liver - centrilobular congesoin/necrosis can progress to cardiac cirhosis. hepatomegaly, pain, ascities. Bud chiari - IVC or hepatic vein ocusion. hepatosplenomegaly, ascities, pain. NO JVD. can see in pregnacy, HCC. Portal vein thrombosis - NORMAL liver. no ascities bc sinusoidal HTN doesn't develop.
Giemsa Stain
Certain Bugs Really Try my Patience Chlamydia, Borrelia, Rickettsiae, Trypanosomes, Plasmodium (Giemsa)
TODDLER (12-36M)
Child Rearing Working MOTOR: Climbs stairs (by 18 mo) Cubes stacked—number = age (yr) × 3 Cultured—feeds self with fork and spoon (by 20 mo) Kicks ball (by 24 mo) SOCIAL: Recreation—parallel play (by 12 mo) Rapprochement—moves away from and returns to mother (by 24 mo) Realization—core gender identity formed (by 36 mo) VERBAL: Words—200 words by age 2 (2 zeros), 2-word sentences
other GB disease
Cholangiocarcinoma - intra/extrahepatic bile ducts. intra-tree like mass. extensive intrahepatic met. Extrahepatic Biliary atresia - see at 3rd wk. firm/nontender liver. marked intrahepatic bile dicut prolif, portal tract edema/fibrosis/cholestasis. Gallbladder hypomotility - via pregnacy, rapid weight loss, TPN, hypertriglyceridemia, spinal cord injury or biliary sludge (contains cholesterol crystals/ca bilirubinate and mucus. (precursor to stones) Choledochal cysts: congenital dilation of common bile duct. Cholysectomy: little effect on secretion/absorption of bile acids. only change see is increased rate of enterohepatic circulation (bc cant store bile -> constantly released into duodenum). less able to tollerate fatty meal bc cant release large amount of stored bile.
Chronic bronchitis
Chronic bronchitis: Blue Bloater - bronchi/bronchioles thicken due to glands/infl. measure reid index btwn ep and cartilage(NOT including the cartilage). should be less than 0.4. 3m/year for 2 years. -> narrow airway. WHEEZING (bc narrow, congested airway), decreased breath sounds, crackles, cyanosis (EARLY hypoxemia via shunting), LATE dyspnea/co2 retention. smoke -> damaged cillia -> bacteria. neutrophilic infiltrates, patchy squamous met. allergic asthma can -> bronchial wall remodling-> COPD COPD: FLAT DIAPHRAGM.
Headaches
Cluster - behind eye/temporal. 1-min-3hr. onset during sleep. SHARP and steady. lacrimatino, rhinorhea, horners, sweat, flush, pupilary change. MALES. rx: o2, sumatriptan Tension - 4-6 hr. muscle tenderness in head/neck, shoulders. rx: analgesic, acetaminophen. amitriptyline if chronic. migrane - usually starts in frontotemporal/ocular area -> progress posteriorly to become diffuse. irritaitaion of CN5, meninges/BV -> release of substance P, CGRP, vasoactive peptides. rx: triptans, NSAID. prophylax: propanolol, amitryptaline, CA blocker, tipiramate. trigeminal neuralgia - repetitive shooting pain in v2, 3 taht lasts less than a minuit. triggger by chewing, swallow, wash. nonmalignant arterial HTN: occipital morning HA. tumor -> HA that involves the whole head and progresses slowly. recombant position makes it worse. can see papilledema, vomit, cognitive decline
Hearing loss
Conductive - both abnormal to same ear (conductive to learning bc what you would excpect. SensoriNormal = same/normal conductive - rhine is abnorma (bone >air); webber is abnormal (localizes to bad ear) sensorineuroa - rhine is normal (air>bone); webber is normal (localizes to unaffected ear) conductive - cerumen mpaction, cholesteatoma, osteosclerosis, TM rupture Sensorineural - meniers, acurstic neuroma, persbycusis. noise induced - damage steriocilliaged cells by sounds >85dB. acoustic reflex - dampens effect of prolonged loud noise by causing stapedious and tensor tymphani to contract. meniers disease - INCREASE VOLUME OF ENDOLYMPH vaia bad reabsorption -> tinnitus, vertigo, sensorineuroal hearing loss. Labarynthitis - infl of labyrint. ACUTE vertig, N/V Osteoscerosis - middle ear CONDUCTIVE hearing loss due to bony overgrowth of stapes.
LUNG SOUNDS
Consolidation (pneumonia/pulmonary edema): 1. Percussion: Dull 2: Breath sounds: bronchial breath sounds/late insp crackles. 3. fremitus: INCREASED [only one for this] 4. Tracheal deviation: NONE Pleural Effusion 1. Percussion: Dull 2: Breath sounds: decreased 3. fremitus: DECREASED 4. Tracheal deviation: NONE (or away from if large) Atelectasis (bronchial obstruction -> cant ventilate -> collapse. unilateral.) 1. Percussion: Dull 2: Breath sounds: decreased 3. fremitus: Decreaed 4. Tracheal deviation: TOWARD Spontaneous/simple penumothorax 1. Percussion: Hyperresonant 2: Breath sounds: decreased 3. fremitus: decreased 4. Tracheal deviation: NONE Tension pneumothorax 1. Percussion: hyperresonant 2: Breath sounds: decreased 3. fremitus: decreased 4. Tracheal deviation: AWAY hemothorax: absent breath sound, dull
anti-glutamete decarb anti-smooth muscle no B cells no T cells
DM type 1 autoimmune hepatitis. SHiNE SKis, enteroviral encephalitis, poliovirus, Giardiasis (no IgA) bacterial sepsis, CMV, EBV, JCV ,UVZ. chronic reesp and GI viruses. Candida, PCP.
Heart anatomy equations.
Coronary sinus dilates if inreased RH pressure. Ortner syndrome: enlargment of LA. its Nuropraxia. heart uses 60% FA, but req. more o2 though. in angina, switch to glucose. MAP= COxTPR MAP=2/3diastolic + 1/3 systolic or diastolic + 1/3 PP. normal is 90-100. PP proportional to SV, inverly proportional to compliance. early excercise, HR and SO maintain CO. later SV peaks and only HR can contribute. things that increase PP: hyperthyroid, AR, atherosclerosis, obstructive apnea (increased sympatheic tone), exercise decreased in AS, shock, tamponade, HF
Baroreceptors and chemoreceptros
Cushing reaction (HTN, bradycardia, resporitary deprestion): increased ICP constricts arterioes -> cerebral ishcemia -> increased sympathetics to increase perfusion pressure (HTN) 0> reflex barrorectpror induced bradycardia. BODIES are chemoreceptors (B, C). central - CO2 and pH only of INTERSTITAL fluid. Pulmonary sterech fibers - Hering breler - C fibers in lung regulate duration of inspiration based on lung distention to prevent hyperinflation. PC02 is major stimulation of respiration. in COPD this is blunted, hypoxemia is more importatn (if give supplemental 02, rapid increase can caouse decreased RR)
Coagulation disorders
DDAVP increse release of factor 8/vWF form ENDOTHELIAL cells. Bernard - defect in GpIb. also see decrease in platlet count! Glanzmaln - platlet count is normal!. NO platlet clumping ITP - episodic bleding. incrased megakaryocytes on BM biopsy TTP - PTN NORMALLY DOSTN BLEED - shistocytes, increased LDH. neurologic/renal/fever. rx: plasma exchange, steroids. HUS: anemia, tachy, petchiae, decreaed Hb DIC: trauma, pancreatitis, malignancy, transfusion, nephrotic syndrome. Uremia - decreases dhesion/aggregation. only prob is inccreaseed bleeding time. factor 13 def: AR. clot unstable. delayed/recurent bleed after truama/surgery. also deep tisue bleed. heparin has normal PT (it neutralizes)
androgens
DHT/testosterone = testes. androstenidione = adrenals. p450 armoatase foudn in adipose and testes. testosterone: deff at pubety/internal genetalia. DHT: diff of external genetalia/prostate. Late actions: prostate growth, blalding, sebaceous gland activity. Type 1 DHT: in post pubescent skin Type 2: in genitals. hair loss: 1. male pattern/androgenic allopecia 2. Alopecia areata - AI. patchy/diffuse hair loss. use steroids.
Celiac
DQ2, 8. lymphocytes in lamina propria. distal duodenum and jejunum. risk of T cell lymphoma. secretory diarhea. Gastrectomy - accelerated emptying of hyperosmolar food 0> dumbping syndrome(colicky abdominal pain, N, diarhea. avoid large meals, decrease simple sugars. short bowel syndrome - resection -> decreased surface area -> increaed osmotic solutes to colon-> diarhea. TNP can caue infection, glucose/electrolyte abnormalities. chrones/carcinoid - secretory diarhea (increase electrolytes) rectal prolapse - occurs w/ pregnancy, constipation, severe diarhea, and CF!!!! most os stool osality due to Na/K. fermentation products make the rest (stool osmotic gap).
pathomas cns
DandyWalker - NO vermis. dilated 4th ventricle/hydrocephaus. no cerebellum. arnold - ass w meningomyelocele, syringomyelia. syrinx: expans into ANTERIOR HORN (LMN) and LATERAL horn (horners) wednig - inherited degen of anterior horn. ALS: anterior horn degen + lateral corticospinal degen Freidric - degen cerebellum and multiple spinal cord tracts (vibraion/weakness/loss DTR) coxsackie - most common viral meningitis. compicaations of meningitis: herniation secondary to cerebral edema. hydrocephausl, hearig loss, seizure (all due to fibroosos/scaring of brain)
Ovarian cysts
Dermoid cyst - teratoma theca/leutean cyst 0 often bilateral. due to gonadotropin stim. see w/ choriocarcinoma/moles corpus leutem cyst - hemorage into persistant corpus leuteum. follicular cyst - distention of unruptured graafian follicle. MOST COMMON OVARIAN MASS IN YOUNG. associated w/ hyperestrogen/endometrial hyperplasia.
MEN syndromes.
Diamond, square, triangle in alpabetical order men 1 - can present w/ kindey stones/peptic ulcer disease 2b - marfans zollinger ellison - in pancreas or duodenum. ulcers in distal duodenum/jejuum (abdominal pain( and DIARHEA - acid activates enzymes) + secretin test (normally should decrease gastrin levels). see parietal cell prolif (FUNDIC mucosal folds enlarge)
Hernias
Diaphragmatic - usually on left side (right protected by liver). INDIRECT - above inguinal ling. goes thorugh INTERNAL/DEP INGUIANL RING and exteranl ring -> scrotum. MALE INFANTS. more common than direct. uaually along anteromedial aspect of spermatic chord. DIRECT - above inginal ring. OLDER MALES. bulges thogh Hassellbach/inguinal triangle. through external inguinal ring only. covered by external spermatic fascia ONLY. CAUSED BY WEAKNESS OF TRANSVERSALIS FASCIA. (injury or acquired defect). LESS PRONE TO INCARCERATION THAN INDIRECT. Femoral - below inguial lig, thoguh femoral calan. lateral to pubic teubercle. LEADING CAUSE OF BOWEL INCARCERATION. femoral ring widens and becomes lax w/ age. incarcerated hernias cant be reduced if segment of bowel in hernail sac. -> obstruciton: N/V, pain, distension -> strangulation if lack blood flow. fever. transversalis fascia forms posterior wall of inguinal canal. deep inguinal ring = opening in transversalis fascia.
Immune Disease of T cells
Digeorge - hypocalcemic tetany, tet of fallot, truncus arterious. viral protozoal, fungal intracellular. IL12R def - no TH1. AR. can't activate macs bc no IFNg. mycobacterial/fungal inf. may present after admin of BCG. Similar disease is AR defect in IFNg receptor. need life long antimycobacterial antibiotics. AD hyper IgE (JOB) - STAT3 mutation of TH17 cells. can't recruit neutrophils. decreased IFNg. FATED: coarse Facies, cold (non inflamed) staph Abcesses, retained primary Teeth. increased igE. Dermatologic prob. (job was fated with disease, he lost is 17 kids and his status in life) Chronic mucocutanious candidiasis: t cell dysfxn, C albicans inf. no prolif in response to candida.
Ego defenses
Displalcement - redirect thoughts about someone to a mroe acceptable objec/person that is NEUTRAL (mom yells at child bc husband yelled at her) Fixation - partially remain at childish level (vs.regression) undoing - symbolically nullifying unacceptaby thought by confession/atonement Projection - attrubuting internal impulse to another who doesnt have (man who wants another woman thinks his wife is cheating on him. kid anry about parents divorce says that his parents are angry at him). Reaction formaton - replacing warded off idea/feeling by an unconsciously derived emphysis on doing the OPPOSITE. repsression - INVOLUNTAIRILY whithhold from conscious awareness. Sublimation - replace unnaceptably with a simialr action that doesnt conflict w/ one's values. supresssion - INTETNTINOAL TEMPORARRY withholding from conscious awareness.
Gastric parietal cell
ECL cells = most important mech. secrete H2 to H2 receptor -> Gs -> cAMP. ECL cells also stimulated by gastrin. vagus releases GRP to act on G cells. vagus -> M3 receptor. Gastrin -> CCKb receptor -> Gq -> ip3/Ca prostaglandins/somatostatin act on Gi to inhibit cAMP other: systemic mastocytosis: mast cells prolif in BM -> increase histamine -> gastric acid that inhibits pancreatic/intestinal enzymes -> diarhea. n/v, cramp. also syncope, hypotesion, tachy, bronchospasm, pruritis, urtricaria
UPPER TRUNK lesion
ERGer trunk C5, 6- DIBS on teh waiter - affects teh deltoid/supraspinatus, infraspinatous, Biceps brachii. due to damage in musclocutaneous and suprascapular N. causesd by: lateral traction on neck during delivery or in adults when shoulder and neck streched apart. results in arm that is aducted, medially rotated, pronated
Labile in the Air, Stable on the Ground
ETEC
which increase cAMP
ETEC, edema factor, cholera toxin, pertussus, c. jejuni ,be cerius, Y. enterocolitica
NARCOLEPSY
EXCESSIVE DAYTIME SLEEPINESS dereased orexin/hypocretin in LATERAL hypothalmus . may see hallucinatins, cataplexy (use muscarinic antagonist to treat), sleep that starts off w/ REM!. rx: at dahhtime use MODAFINIL (non-amphetamine, icnreases DA), or AMPHETAMINE (risk of dependency, sympathomimetic effects). at night use SODIUM OXYBATE. see sleep paralyssi (cant move immediately after wakening). decreased sleep latency (rem <15 min). contrast w/ hypersomnolence disorder - do NOT feel refershed afer naps
types of bone
Endocondral: mesenchmyme in periosteum -> chondroblast -> cartilage -> osteoblasts invade. (start w/ woven adn replace w/ lamellar). Endocondral = Expected (start from a model) Membranous - mesenchemal cells differentiate directly into osteoblasts. estrogen inhibits apoptosis of osteoblasts and promotes apoptosis of osteoclasts. at low,intermitant lwves, PTH helps build bones. osteocytes - controled mainly by plasma Ca as well as pth/calcitonin. sense stress to modulate osteoblasts.
ATopy
Ezematous dermatitis - erythematous, papulovasicular, weeping, crusted lesions. can evolve into thick, scaly plaques. face/scalp/estenser surfaces. Diper area spared. in older kids see lichenificaiton (Ben) in FLEXURAL distribution (neck, wriskt, anticipital fossa) includes contact dermatitis, atopic dermatitis, drug related, photo-excematous. see SPONGIOSIS. (intercellular bridges become more distinct ("spongy"). edema can icnrease to form intraepidermal vessicles by tearing desmosmes appart.
achonroplasia
FGF stimulates osteoblasts and endothelial cells. prolem here is inhibition of chondrocyte prolif mostly sporadic and associated w/ advanced paternal age. note: short stature in GH/IGF-1 def is proportional (axial and apendicular skeleton is proportional)
Signaling pathways: cAMP
FLAT ChAMP FSH, LH, ACTH, TSH Crh, Hcg, Adh (v1-bp) Msh, Pth. , calcitoinin, glucagon, epi, ghrh bc fsh/lh are here, gnrh must be ip3 and ghrh must be camp. v1 bc camp before ip3 alphabetically.
Cytokines
FROM MACS: IL-1: fever, shock, ckemokines to recruit, activates endothlium to express adhesins. IL-6 - t/bcell growth, fever, osteoclast activation IL8: chemotaxis. (signal to continue acute info) IL12: increases TH1, CD8, NK TNFa - induces NFKb. septic shock. activates endothelium. activates various info cells. IL10, TGFb FROM ALL Tcells. IL2 is one of the first made by t cell. IL2: gorwth of all T, b, Nc, macs IL3: stimulates BM FROM TH1 and NK IFNg - stimulates NK and Macs to kill. increase MHC2 and antigen presentation. (note, virally infected cells secrete IFNa and b -> increase MHC1, stimulates NK and Tc. activates RNAseL and Protein kinase to P and inactivate elf2) FROM TH2 IL4: increases TH2, Bcell growth, IgE/G IL5: promotes b cells. IGA. promotes eosinophils IL10: inhibits macs dendrocts, Tcells, decreases MHC2 expression, infl cytokines TGFB - similar to IL10. also arrests cell cycle, promotes angiogenesis, stimulates fibroblasts.
Gluconeogenesis
FYFI there is a PEPCK in teh mitochondria sometimes used. Regulation of F16BPase - incresed by citrate, atp, acetylcoa. decreased by amp, F26BP Glucose 6P in the ER.
Benign breast tumors
Fibroadenoma - fibrus and glands. most common bening in <35. often multiple/bilateral. cellualr/mixoid stroma taht encircles glandular/cystic spaces. cycles w/ estrogen. NO risk of Cancer. Phylllodes tumor - LARGE bulky mass of CT and cysts. "leaf like" projections. similar to fibroadenoma byt more atypia, stromal cellularity, overgrowht of fibrous component. . 6th decade. some become malignant. Intraductal papiloa - occurs in LACTIVEROUS SINUSES beneath areola. serous or bloody discharge. slight cancer risk. [contrast w/ papilary CA: no underlying myoepithelial cells; usually postmenopausal]
Malabsorption Syndromes
First step in diagosis is to collect stool and do sudan II stain. >7g/d excreted is diagnostic. bacterial prolif - occur in blind loops, diverticulosis, diabetic neuropathy tropical sprue - responds to antibiotics Whipple - PAS positive, idstase resistant granules (lysosymes and digested acteria). rod shaped actinomycets.no inflamaiton. Cardiac, Arthralgia, Neurlogic symptoms. PAS - oxidizes C-C bonds -> aldehyde that gives magenta color (stains sugars( Distase - to see GLYCOGEN - digests it -> washes it druing processing -> NEGATIVE PAS. Lactose def: NA, africans, asians, AR. explosive/watery diarhea. bacterial fermentaiton -> short chain FA and excess H 9can test in breath). Abetalipoproteinemia - FTT. acanthocytois due to decreased essental FA absorption. B48 is truncated version of 100 w/o the LDLR ligand. AR defect in MTP (fxns as a chaperone needed for folding of apoB and transfer of lipids).
Motion at the Hip
Flexion: involves psoas (lumbar plexus), tensor fascia latta (superior gluteal), iliacius and sartorius (femoral), rectus femoris Extension: gluteus maximus, simitendinous/membraneous, biceps femoris Abduction - gluteus medius/minimus Adduction - Adductor brevis/longus/magnous. when sitting up from supine position, use external abdominal oblique, rectus abdominus, and hip flexors esp. illiopsoas - starts on pelvis/spine and insurts on femor. psoas - from bodies/vertebral disks/transverse proceses of t12-L5. Iliacus starts from illiac fossa. both insert onto lesser trochanter. sartorius/tensor fascia latta also imp for ABduction of thigh. iliohypogastric nerve - skin overlaying iliac crest.
fluid w/i interstitum
Fluid w/I interstitum (like LH failure) see decreased compliance bc decreased surfactant. Bc of decreased complence, the negative pressure generated during inspiration not enough to distend lungs.
Kidney Transplant
For kidney transplant, Left kidney taken bc it hsa longer renal vein. it is placed retroperitoneal in right illiac fossa. -> anastamose w/ external illiac. proximal 1/3 of donoor ureter is perserved bc PROX 1/3 supplied by REANL ARTERIES. (rest suppplied by aorta, iliac, gonadal, vesicle). (midportion is common illiac, superior vesicle is superior bladder/distal ureter) .
brain lesions
Frontal eye field: TOWARD THE LESION. BA 6, 8. at caudal end of middle frontal gyrus, anterior to precentral sulcus. PPRF - away. hippo - anterograde. basal gang - tremor at rest, chorea, athetosis right parietal/temporal cortex: spatial neglect (agnosia of contralateral) left: gerstmann syndrome: agraphia, acalculia, finger agnosia, l to r disorientation. pons: coma, bilateral hemiparesis, decrevrate rigidity, pinpoint pupils. caudate - transient hemmiparesis, frontal lobe symptoms (inattentiveness, abulia, forgetful). agitaton, psychosis, choreoathtosis, dyskinesia.
functions of lobes
Frontal: executive/personality. impaired organizational, restraint, and motivational systems in prefrontal cortex. frontal lobe syndrome: 1. disorganized: insight, abstract reasoning, sequencing, working memory, planning. 2. disinhibited - judgement, concentration, inhibition of socially inappropriate behaviro, foresight, delayed gratification 3. Apathetic - motivation, mental flexability, personality, curiosity, spontinaety also see primative reflex corpus callosum - damage: cant retrieve w/ 1 hand object palpated w/ another. parietal lobe - interpret visual/auditory/motor signals. spacia/visoal perception, writing, calcuation, L to R differentiation, object identificaiton temproal lobe - lang, sensory interpretaton, memory, behavioral change (kluver bucy - also associated w/ HSV1)
adrenal gland histology
G: cells in clusrs F: Foamy appearing cells R: basophilic. anostamosing cords medulla: sharply basophillic left adrenal gland is sinister. drains into renal vein before IVC ADH: supraoptic oxytocin: paraventricular B-FLAT = basophils. Acidophils = GH, prolactin. somatotrophs = majoryity of the cells.
Friedreich ataxia
GAA. chr 9. weak/loss DTR, vib/proprioception STAGGEREING gait, FALL, nystagmus, dysarthria, pes cavus, hmmer toes, hypertrophic cardiomyopathy, kyphoscoliosis, DM. bulbar dysfnx also cause of death. degen of dorsal colum/DRG, ascending/decrending spinocerebellar tracts.
spindle fibers
GTO - Tension. insesnsitive to passive stretch. at jxn of msuce and tendon. Ib. in SERIES. . send inhibitory neurons to alpha motor. spindles (intrafusal fibers): in parallel. resond to lenght. Ia and II. DTR: myotatic reflex -> alpha motor neuron -> contract to resist stretch.
ENDODERM
GUT tue et urethra/blader (from UG sinus) luminal ep derivatives (lung, liver, GB, pancreas) thymus, parathyroid, thyroid eustachian tube otter/middle ear
benign bone tumors
Giant cell tumor - EPIPHYSIS: only thing here!!. usually knee. soap bubble apearance. multinucleated giant cells. osteochondroma (exocytosis) - males less than 25. growth from METAPHYSIS. w/ cartilage cap.
GI protozoan infections
Giardia - metro entamoeba - metro. iodoquinol if asymptomatic carrier. trophozoites w/ rbc inside cryptosporidium - nitazoxanide in immunocompotent. CD8 resp bc its Intracellular. acid fast.
Neisseria
Gonorhea - no capsule. white purulent discharge (chlamydia is think/watery) . rx: only ceftriaxone. erythromycin eye drops. Meningitis: apsule. rif/cip/cef for prophylaxis. rx: cef ro pen G. has LOS instead of LPS
Oncogenes
Growth factors: sis - PDGF in astrocytoma, osteosarcoma Growth Factor Rectptors: C-kit: stem cell growth factor/cytokine receptor ret: receptor tyrosine kinase Her2/nue, c-erb2: brest ovarian, gastric. epidermal GF tyrosine kinase receptor erbb1 (EGFR) - non-small cell lung Ca Signal Transducers: ABL/BCR: cml, all, non-receptor typrosine kinase ras: GTPase -> map kinase -> sensitivity to mitogens Nuclear Regulators: c-myc, Lmyc, nmyc (also small cell ca) - transcrption factor c-jun/c-fos: transcripton factor. binds leucine zipper motif. Cell Cycle regulators: Cycin D1 CDK4 - Melanoma BRAF: melanoma and NonHodgkins, serine/threonone kinase -> ras TGF alpha - astocytoma, HCC
mesothelioma hamartoma
HEMMORRHAGIC pleural effusions. Psammoma. smoking is NOT a risk factor. cells w/ long slender microvilli, abundent tonofilaments. (adenocarcinoma = short, plump microvilli) hamartoma - peripheral coin leion. see hyaline CARTILAGE, CT, smooth muscle, fat, clefts lined by resp ep. "popcorn" calcifications. LUNG = most common site of hamartoma.
HCC
HEP B, C. at young age due to chronic hep via vertical transmission. can see polycythemia. viral protein HbX activates IGF-2 synth and receptors for IGF-1 -> cell prolif. also suppress p53. metastasis - hypodense lesions. GI, breast. lung. central necrosis. often no clinical or lab findings. majority of liver has to be destroyed to detect Hepatoblastoma - kids w/ FAP, beckwith weadman.
CEREBELLUM
INPUT: contralateral cortex via middle. ipsi proprioception from inferior cerebellar peduncle from spinal cord (spinal and mossy fibers) output: purkinji -> deep nuclei of cerrebellum -> contralateral cortex via superior. dep nuclei: DEGF (lateral to medial) lateral lesion (cerebral hemisphere): fall to IPSI side. involved in voluntary mvmnt of extremities. see intention tremor, limb ataxia. medial lesions: vermal cortex, fastigal nuclei./floculonodular lobe: TRUNCAL ataxia, nystagmus, head tilt, dysarthria (muscles for speech). WIDE BASED (Cerebellar) gate. usually bilateral motor deficits affecting axial and prox limb muscles.
TERATOGENS
HTN: uteroplacental insuficincy, IUGR (normal sized head but decreased abdominal circumfrence) Alkylating agents - absence of digits. Carbamazapine - NTD, craniofacial defect, fingernail hypoplasia, DD, IUGR. Phenytoin: hypoplastic nails/phalanges, heart fefect, cleft palate, dysmorphyic face features, heart defects, IUGR TETRA - enamel hypoplasia, decreased skeletal dev. Warfarin - bone deform, abortion, opthalmologic abn. Cocaine - abruption, decrease blood to fetus, abortion, IUGR. Smoking - low birht weigth, placental prob, IUGR, ADHD, fetal hypoxia (nicotene -> vasoconstriction). X ray - microcephaly, intelectual disability Vit A - abortion, celft lip, heart prob, auditory ,osterior fossa CNS defects. Maternal DM - caudal regression syndrome (agenesis of sacrum, anal atresia, sirenomelia -> paralysis of legs/dorsiflexed contractures of feet, urinary incontinence). still birth, macrosomia. postnatal hypoglycemia. NTD, VSD, TRANSPOSITON OF GREAT VESSLES, renal agenesis Alcohol - MR, vsd, poor growth. microcephaly, holoproencephaly, underdeveloped jaw, upturned nose, low nasal bridge, "railroad track" ears. limb dislocaiton, heart defects.
Adrenal crisis
HYPOTENSION, tachydarcia, hypoglycemia, hyponatremia ,hyperkalemia, adrenal insuficity. rx: stress dose of hydroxycortisone.
tuberus sclerosis
Hamartomas, Angiofibroma (adenoma sebaceum), mitral regurg, ashlief, rhabdomyoma, Tuberous sclerosis, autosomal dOminant, MR, angiomyolipoma, Seizures, Shagreen patch renal/visceral cysts, ungal fibroma, astrocytoma
Hypothyroid
Hashi - most common. DR5. incrase risk of non-hodgkin. HUrthle cells(metaplasia to oxyphilic cells w/ granular cytoplasm), germinal center. cretinism: pot bellied, pale, puffy faced, protruding umbilicus (umbilical hrnia), PROTUBERANT tonge, poor brain. hypotonia, jaudice, poor feeding. Subacute granulomatous dequervian: often after viral. GRANULOMATOUS infl. increase ESR, jaw pain, TENDER. give NSAID. Riedel - iGg4 related systemic disease.
resonse to high altitude response to exercise
High ALTITUDE -> decreased barometric pressure -> decreased inspired air from 150 to 86. causes a PaO2 of 60 -> hypervent/alkalosis. increase HCT/HB in 10 days, also see increase capilary density, mit/moyglobin. increase HR, CO. chronic hypoxic vasoconstriction could -> RVH. increase renal excretion of Hco3 (can help by using acetazolamide) EXERCISE: CO increases from 5 to 20L. sympathetics contract veins increase VR (increases RA pressure). it constricts all arteriols EXCEPT actively working muscles (gets 85% of CO). MAP increases only 20-40 (modest increase in SBP) due to decrease systemic vascular resistance (vasodilation in muscle). NO CHANGE IN ARTERIAL Pa02, PaCo2, pH, but does change on venous side. panic attack: increase HR, CO via sympathetics. hyperventilation/alkalosis Carotid sinus massage: no change in PaO2 or PaCO2. Response to PE: decrease blood flow to left heart -> decrease CO. reflex increase in HR. decrease Pao2-> hypervenetilate/alkalosois.
other intestinal disoarders.
Hirshprugs - FTT. RET mutation. billlious emesis. Adhesion - most common cause of small bowl obstruction. Angiodysplasia - dilation of vessles -> hematochezia. cecum/ilius,ascending colon. Ileus - hypomotility w/o obstruction. causes constipation and no flatus! distended/tympanic abdomen, decreased bowel sounds. see w/ abdominal surgury, opiate, hypocalemia, sepsis. Meconium ileus - CF: mycolium obstructs illeum. cant pass stool. see billeous vomiting, distention, air fluid levels, "inspissated green mass". CF causes isotonic dehydration of lumen -> viscous mucus.
example of X linked dominant
Hypophosphatemic rickets. vit D resistant rickets. increased phosphate wasting. [mothers pass on to 1/2, fathers pass on to all daughters, no males]
Oxygen depreivaiton
Hypoxemia (decreased PaO2) a. noral gradient: high altitude, hopoventilation. b. increased gradient: diffusion limitation, r/l shunt. V/Q mismatch. Hypoxia (decreaased o2 delivery): CO, anemi,a hypoxemia, decreased CO. hypoxic vasoconstriciton: hypoxia caues increase smooth muscle Ca adn endothelium derived Ca sensitization factor.
encephalopathy
Hypoxic encephalopathy: global decrease in blood (MI) -> decrease consciousness (coma/vegetative). NO focal neurologic. Watershed. Hypertensive encephalopathy - HA, vomit, confusion, brain edema, petetchial hemorage in grey/white matter. PROGRESSIVE HA/N/V, THEN nonlocalizing neurologic symptom (confusion).
Bipolar
I - at leatst 1 mainic. may or may not have hypomanic/depresson II - HYPOmanic AND Depression. andidepresants can -> MANIA Cyclothemic disoder: dysthemia + hypomania. midler type of bipolar. lasts 2 years!!!
IP3
I Pee near 3 GOAT HAGs Gnrh, Oxytocin, ADH (v2 - kidney), Trh, H1, A2, Gastrin
CCK
I cells in duodenum/jejunum. stim by fat/aa. also increases pancreatic secretion, decrease GB emptying, relaxation of sphinctor of oddi. acts on neural muscarinic pathways to cause pancreatic secretion.
Ovarian neoplasm: Malignant
IMMATURE teratoma - fetal tissue/neuroectoderm containing. Yolk sac - yellow, friable (hemorrhagic). can be in sacrococcygeal area. choriocarcinoma - can dev in baby too. NO vili. see theca lutean systs. SOP, hemoptysis [lungs]. dysgerminoma - Bhcg, LDH. fried egg. Graulosa cel tumaor - women in 50s. estrogen/progesterone preduciton. call exner bodies (gland like( (resemble primordial follicles). can cause fibrocystic change of breast.
ischemic stroke
IRREVERSIBLE if more than 5 min. (brain lacks glycogen, so sensitive) Hippo/neo/cerebellum/watershed = most vulnerable. Hypoxic - hypoperfusion/hypoxemia. Common during cardiovascular surgeries. "bilateral wedge shaped strips of necrosis over cerebral convexity, parallel and adjacent to longitudinal cerebral fissures" Rx: tPA if less then 4.5 hr and no hemmorage risk. Hemorrhagic stroke: intracerebral bloeed via HTN, anticoag, CA. can be due to reperfusion (vessel fragility) after ischemic stroke . BASAL GANG = most common site of intracerebral hemorrhage. Ischemia is hypodense (dark) on noncontrast CT. bright on DWI in 3-30min. absence of bright areas on non-contrast CT to exclude hemorrhage
pancreatic secretion
ISOTONIC FLUID. same Na/K as plasma. during low flow, see high Cl. during high flow, see high HCo3. only amylase/lipase secreted in active form. serum peptidase inhibitor kazal type q (SPINK1) - made by acinar cells - inhibit prematurely activaed trypsin. D-xylulose absorption: DONT NEED PANCREATIC ENZYMES. thus destinguishes GI mucosal damage from other causes of malabsorption.
ECG of MI
InFerior wall: II, III, avF. LCA = septum and LV (V1-6, I, avL) Anteroseptal (proximal LAD): V1,2,3,4 anteroapical (distal lad) - V3-4 Anterolateral (LAD or LCx) - V5, 6 (I, v3-6 via uworkd) Lateral wall (LCX) - mailly V5, 6. also I and aVL heparin, asprin, clopidegril, b blocker (decreaes bp and work), ace, statin, nitro, morphine.
Heart sounds stuff
Increase rate of flow through aort c valves could cause functinoal aortic stenosis. mitra anular calcificaiton seen in women greater than 60 w/ history of mysomatous gegen and chronically elevated LV pressure. can cause MR. Increase preload worusens it. Increasd LV contractility increases SV -> increased afterload -> increase MR. thus B blockers could help. In mitral steosnis, usually decreased or near normal LV diastolic pressure. if see increase, maybe combined w/ AS or AR.
Hemoglobin
Increased Cl also favors taut form. 2,3 BPG binds pocket btwn the B chains that contains Histidine's positive charge that binds the P of BPG. a change to serine is what is seen in HBF Methemoglobinemia: dusky/cyanosis. chocolate. tachypnea, HA, tachy, N/V, confusion, weak. LA. LOW DIFF BTWN A AND V O2 (VENOUS BLOOD STILL HIGHLY OXYGENATED. use thiosulfate to bind cyanide from methemoglobin -> renal excretion. CARBOXYHEMOGLOBIN: left shift. on the diagram it is simiar to anemia but also see a left shift [kind of starts out normal but then flattens out] (anemia causes lactic acidosis. -> right shift) high altitude cuases right shift.
Cholecystitis
Inflamaiton of GALBLADDER. Stone blocking of bile duct -> secondary infection. could also be due to ishemia or primary infection (CMV). Normally, sphinctor of odi, bile salts, and downward flow of bile prevent inf. the secondary infeciton may be due to E coli, Klebsiella, enterobacter, enterococci. can cause sepsis. Cancelous - obstruction of duct follwoed by chemical irriation/inflamation (stones disrupt the mucus layer -> ep exposed to detergant action of bile salts). results in GB hypomobility, distetion, pressure ischemia -> bacteria invade. acute acancelous cholecystitis - see in HOSPITALIZED. secondary to stasis/ischemia -> infl/injury of GB wall and enlargeent. see JAUNDICE AND PALPABLE MASS (not present in cancelous cholecystitis) symptoms: fever, N/vomit, colicky pain due to GB contraction. increase ALP if bile duct involved (asending cholangitis). murphy sign - inspiratory arrest on RUQ palpation due to pain. Diagnose w/ US [specific if see GB wall thick/pericholescystic fluid, and positive sonographic murphy's sign) or HIDA (hepatobilliary iminodiacetic acid scan) (aka cholescintigraphy: use when US inconclusive. its specivic. radiolable to bile).
Barbiturates
Intox: RESP DEPRESSION. withdrawal: delirium, CV collapse.
LSD
Intox: VISUAL/auditory HALLUCINAITNO/perceptural distorition. euphoria, depersonalization, tachy, HTN, anxiety, paranoia, psychosis, possible flashbacks. most are alert, oreiented, aware, and knwo the effects of the drug.
Opoids (heroin/morphine)
Intoxication: CONSTIPAION, CNS/RESPIRATORY DEPRESSION, PINPOINT PUPILS, , lethergy, coma, decreased bowel sounds, euphoria, seizures. rx: naloxone, naltrexone, nalmedfene WITHDRAWAL: DILATED PUPIL, DIARHEA, RHINORHEA, piloerection, sweating, fever, YAWNING, LACRIMAITON, sneezing, chill, tremor, jittery movemnet rx: long-term support, methadone, buprenorphine in neonates, rx = opium solution (tincture of opium or paregoric)
Femoral nerve
L2-4. Nerve starts through fibers of psoas major then emerges laterally btwn psoas/iliacus, then goes below inginal lig. PELVIC FRACTURE, trauma, compression, stretch. can be due to retroparatoneal hematoma/abcess (mass involving iliopsoas/iliacus). hematoma may be due to warfarin. presents w/ acute groin pain/abdomen/back. difficulty w/ stairs, falling due to KNEE BUCKLING, decreased patellar reflex. . decreased thigh FLEXION, LEG EXTENSION. Sensation to ANTERIOR/MEDIAL thign and medial LEG via saphenous N. iliacus/sartorius = flex thigh quadriceps femoris = extend LEG at knee.
Obturator nerve
L2-4. Pelvic surgery/ANTERIOR hip dislocation DECREASED ADDUCTION of thigh, MEDIAL thigh sensation
Superior Gluteal
L4-S1 goes through greater sciatic foramen. innervates gluteus medius, minimus, tensor fascia lattae works to stabilize pelvis and ABDUCT thigh. damage w/ posterior hip dislocation, polio, hip surgery, injection to SUPEROMEDIAL but. Trendelenburg gait - pelvis drops on contralateral bc weight bearing leg cant mailtain alignment of pelvis thoguh hip abduciton.
Common peroneal (fibular) N. sciatic N (L4-S3 splits into common peroneal and tibial N)
L4-S2 Trauma/COMPRESSION of LATERAL leg/Fibular NECK fracture (courses around neck of fibula) PED: peroneal everts and dorsiflexes. foot is dropPED INjury: FOOT DROP - foot is inverted and plantar fleed. steppage gate/floot slap. Loss of sensation of dorsum of foot/anterolateral LEG. also loss of extensors of toe.
Tibial nerve sciatic N (L4-S3 splits into common peroneal and tibial N)
L4-S3 knee trauma/baker cyst (proximal lesion); tarsal tunnel sydrome it corses in middle of popliteal fosssa innervates gastrocnemious/soleus/plantaris: Plantarflex flexor digitorum longus, hallicus longus: toe flex tibialis posterior: inversion of foot TIP: tibia inverts and plantarflexes: cant stand on TIPtoes cant curl toes. loss of sensation on sole and posterior leg. Proximal lesiots: foot is everted at rest (calcaneo-valgocavus position)
Sciatic nerve
L4-s3 divides at popliteal fossa into libial and common peroneal. Tibial: plantar flex, inversion, sensory to sole of foot (medial/lateral plantar n). also gives off lateral sural cutaneous - sensation to calf common peroneal devides into superficial and deep branches. superficial: LATERAL compartment of leg - eversion and sensory to most of dorsum of foot/anterolateral leg deep: ANTERIOR compartment dorsiflexors adn extensors. Sensory to area btwn 1st two digits. btw. sural N - pure sensory to POSTEROlateral leg and very lateral foot. Sciatica: caused by disk herniation, spinal stnosis, bone spurs, piriformis. weak posterior thigh(hamstrings) and ALL below knee. ankle reflex decreases but pattelar is normal. defect most commonly L5/S1 L5 - posterior lateral thigh. pain shoots to inner foot S1 - pain only in posterior thigh. pain soots to foot, weak plantar flex and decreased ankle jerk.
Inferior gluteal - greater sciatic foramen belwo piriformis.
L5-s2 posterior hip dislocation. difficulty climbing stairs, rising from seated positon. loss of HIP/Thigh EXTENSION/EXTERNAL rotation.
Phagocyte dysfucntion
LAD: AR, bad wound healing, no puss, bacterial skin/mucosal inf. see increased neutrophils. Chediak - LYST. essentially its a MT defect. no phagolysosome fusion: pyogenic inf, albinism, neuropathy. giant granules in neutrophils/plateltes (defective primary hemostasis). pancytopenia - intramedullary death (no MT to help divide). minor coag defect. CGD: DHR flow cytometry - measures conversion of DHR to rhodamine (fluorescent green) MPO def: risk of candida infections but most asymptomatic
DM
LM: mesangial expansion, GGM thickening, esosinophilic NODULAR glomerulosclerosis (hyaline mass in mesangium). PAS positive! lammelllated. nodules compress the glomerular capillaries glycosylation of EFFERENT -> increses GFR -> mesangial expansion. Most ommmon cause of end stage renal diseae in US may be due to upreg of heparinase. Diabetic Nephropathy: early: hyperfiltration, increaed GFR, glomerular hypertrophy Incipient DN: MEsangial expansion, GBM thickening, arteriolar hyalinosisi, MICROALBUMINURIA, HTN OVERT: Nodules, fibrosis, Nephrotic syndroem, GFR decreases, overt proteinuria. microalbuminuria - albumin loss btwn 30 and 300mg/d.
FSGS
LM: sclerosis/hyalinosis. IgM and C3 NO IF. Blacks, HIspanics. HIV, sickle, Heroin, Obesity, IFN terapy, pamidronate all nephrotics: froathy/foamy urine due to proteins/bile salts in urine
POSTSTRETP GN
LM; glomerulai enlarged and HYPERCELLULular. IF: granular - igM, G< C3 in GMB, mesangium "STARY SKY" (low c3 (alternative pathway) AGE - MOST IMP PROGNOSTIC FACTOR> rx: loop, vasodilators for HTN kidney is swollen, large, w/ punctate hemorage
Thoracic outelet syndrome
LOWER TRUNK (C8-T1) and subclavian vessles same as klumpke palsy in addition, see ischemia/pain, edema due to vascular compromise due to cervical rib injury or pancost tumor.
Aortic stenosis:
LV much higher than aortic inpressure tracing. radiate to carotid. could lead to S3 if LV fails. Hear at heart base (right sternal border). diminished aortic component of s2. systolic vibrations or carotid shudder (thrill).
AICA stroke
Lateral p0ons - vastibular nuclei, fascial nuclei, spinal trigeminal, cochlear, sympathetics. middle and cerebellar peduncles contra pain temp, ipsi 5, 8, horners, cerebellar symptoms. vomit, vertigo, nystagmus, PARALYSIS of face, decreased lacrimation, salivaiton, taste from anterior 2/3, decreased corneal reflex: frac: decreased pain temp, ipsi decreased hearing, ipsi hroners. Ataxia, dysmetria. lateral pontine syndrome - fACIAL droop eains AICA's pooped.
misclaneous msucles and nerves.
Lattisimus dorsi - also supplied by long thoracic n. ADDucts and extends humerus. deltoid has 3 segments that flex, extend and abduct. rhomboid major - dorsal scapular N. draws scapula medially at its medial border teres major - subcapsular n. adducts and medially rotates arm.
Porphyras
Lead: Protoporphyrin and ALA accumulate. AIP: AD. porphobilinogen deaminase (essentially any of teh steps in early parts). ALA, porphobolingin, corporpohbilinogen accumulate. polyneuropathy. worese w/ alcohol/starvation/drugs (phenobarbitol/bresiofulvan/pheytoin). also see HYPONTREMIA cutanea tarda - uroporphryogen decarboxylase: also see w/ some of the later stesp. photosensitivity due to porphyrin mediated free radicals. CYP450 inducers/alcohol/smoking promote ALA synthase. heme, and glucose (which activates peroxisome proliferator activated recepro gamma ) decreses ALA.
food hormones
Leptin - Signals satiety. decreased sleep -> leptin decreases. Leptin decreases neuropeptide Y in arcuate nucleus. and Increases POMC in arcuate -> alpah-MSH to decreae food intake. in obese, sustained leptin causes leptin desensitization. Ghrelin maks you hunGHRE. also stimulates GH release. made in stomach. increases with sleep deprivation. Endocannabinoids - stimulates reward senters and desire for food.
CLEFT LIP AND PALATE
Lip - fusion of maxillary and medial nasal prominences . fusion results in the formation of primary palate, intramaxillary segment -> philthrum; 4 medial maxillary teeth; Palate - failure of fusion of the two lateral palatine processes OR failure of fusion of lateral palatine process w/ nasal septum adn/or median palatine process [palate formed by fusion of primary palate and maxillary prominences (secondary palate). palatine shelves grow from maxilary prominences medially toward one aonther and toward primary palate] choanal atresia - bone maldevelopment -> obstruction of 1 or both nasal passages -> respiratory distress/cianosis. pharyngeal fistula - when 2nd pouch ang groove fail to regress. found on lateral anterior neck.
pneumonia
Lobar: intra alveolar exudate causes the consolidation. also legionella bronchopneumonia - infl infiltrates from broncioles into adjacent alveolar spaces -> patchy. also s pneumo, klebs. S aureus, H. infl. interstitia (atypical ) - diffuse patchy infl localized to interstitial areas at alveolar walls. bilateral reticular opacities. myco, leion, chlamidia, RSV, influenzae, chlamydia. e coli, g- rod (pseudo, actinobacter, kleb, proteus, serratia) - healthcare asociated and IC. tobacco is risk for commmunity acquired s. pneumo, M. pneumonia
back pain
Lumbosacral radiculopath: positive straight leg raise test: pain relieved w/ knee flexion spinal stenosis - pain reduced by sitting and bending forward. spinal met = constant dull pain worse at night.
M protein vs Protein A
M protein: s. pyrogenes, protein A = s aures
sjogren
MALT - unilateral parotid enlargent. can also cause non-hodgkin. calcific tenodonitis: increase deposits in tendons of rotator cuff.
Knee
MCL (tibial): abnormal passive abduciton (VaLgus stress) (leg go out laterally; force itself is on lateral knee) Medial meniscus: pain on external rotation (McMurray test) lateral meniscus - larger survace covered. triad - lateral force on planted leg/fully extended: ACL, MCL, medial meniscus. HOWEVER, lateral meniscus injury is more common. PCL: starts anterolateral adn inserts posterior ACL: starts posteriomedia and inserts anteriorkl
Dr. jones disorders
Malinger - Conscious. Secondary (External gain). Factitiosu - CONsciosu to achaive sick role (1 gain). .Munchausen = chronic. somatic symtoms - UNCONSCIOUS. starts befoe age 30, impacts fuctioning. 4 pain, 2GI, 1 sexual, 1 neurologic symptom. Anxiety about symtpms. SCHEDULE REGULAR VISITS. conversion disorder - SUDDEN LOSS OF SENSORY, motor fxn (paralysis/blindmmute, aphonia, gait, anesthesia) after ACUTE stressor. aware but indefrent to symptoms.
Postpartum mood disturbances - occur w/i 4 wks of deleivery
Maternal (postpartum) blues - 50%. depressed/tearful/irrritable/tafigue. 3 days after delivery. RESOVLVES IN 10 days. f/u to look for postpartum depression. Postpartum depression - 10%. depressed, anxious, poor concentration. lasts 2wk-12 m. CBt, SSRI Postpartum psychosis - 0.1%. mood-congruent dellusion, emotional libilit, sleep, hallucination, homocidal/suicidal. LASTS days to 4-6wk. rx; antipsychotic, hospitalization.
Parietal Pleura - lines inner surface of chest wall/diaphragm.
Mediastinal pleura. Diaphragmatic pleura. Cervical pleura (apicies of lung into neck) Costal pleura - covers thoracic wall, ribs, sternum, intercostal space, costal cartilage, sides of thoracic vertebrae. PHRENIC (C3-5) - motor to diaphragm and pain from diaphragmatic/mediastinal pleura refers to trapezius ridge (C3,4)/shoulder (C5) *sensotry of rest of parietal pleura is from intercostal nerve. superior epigastcric A/V course over the superior 1/2 of abdominal wall and anastamoses w/ internal thoracics and inf. epigastrics
CN and vessle pathways
Middle cranial fossa: CN2-5 though the sphenoid bone. 1. optic canal - carries cn 2, opthalmic artery, central retinal vein 2. SSuperior orbital fissure: CN 3, 4, V1, 6, opthalmic vein 3. foramen RRotundum - V 4. foramen OOvale - v3; SStanding RRoom, OOnly. also contains lesser petrosal/accessory meningeal A, and emissary veins. 5. foramin spinosum - middle meningeal a/V. and meningeal (reccurent branch of v3) v2 ->pterygopalatine fossa -> inferior orbital fissure - v2, infraorbital vessles, branches of sphenopalatine. Foramen lacerum - meningeal branch of ascending pharyngeal A. and A/N of pterygoid canal. posterior cranial fossa: CN 7-12 through temporal or occipital bone 1. internal auditory meatus - CN 7, 8 2 .jugular foramen - CN 9, 10,11, also posterior meningial artery. 3. hypoglossal canal 4. Foramen magnum - CN 11, vertebral arteries Pterion - where frontal, parietal, temporal, and shpenoid bones meet. middle meningeal artery courses w/i skull deep to this. [risk of epidural hematoma].
materna;/fetal hormone interaction
Mom: makes LDL, DHEAS LDL forms pregnenalone in placenta. convrted to 3BHSDH to progesterone that goes to mom. DHEAS from mom goes to placenta, acted on by 3HSDH to form androstenidion (->estrone). acted upon by 17BHSDH to form Teststerone (-> estradiol) fetal pregnenalone sulfate acted on by 17 alpha hydroxylase, 17/20 desmolase -> DHEAS that goes to placenta. aromatase converts testosterone to estradiol and androstenedione to estrone. deficiecy causes high ancrogens -> MATERNAL virulization (hirstuism ) and FETAL virualization (ambiguous/male external genetalia; normal internals). in the kid also see amenorhea/tall/osteoporosis at puberty. maternal viruilization doesn't occur in 21/17 hydroxylase def bc of intact placental aromatase.
motilin and NO
Motilin: made by small intestin. produces migrating motor complexes during FASTING. agonsit of this (erythromycin) used to stimulate peristalsis. NO = loss of NO implicated in achalasia.
NTs
NE: LC in pons. caudal pontine grey matter. DA: decrease in depression. VENTRAL TEGMENTUM AND SNc (midbrian) 5-HT: increase in park. decrease in anxiety/depression. sleepwake/arousal. lesion -> insomnia/depression. ACH - increase in park, decrease in Alz, hunt. BASAL NUCLEUS OF MEYNERT (memory/cognition). in park, see decrease in hippocampus too: cant form new memories due to def in choline acetyltransferase). GABA - decrease in anxiety, huntington. NUCLEUS ACUMBENS. Locus ceruleus =stress/panic nucleus accumbens/septal nucleus = reward, pleasure, addiction, fear. NO - imp in formaiton of new memories. red nucleus: anterior midbrain. motor coordination.
NF 1, 2
NF1: sneurofibromin usually is a negative regulator of Ras. Cafe au lait. lisch (pigmented iris hamartomas), neurofibromas (neural crest schwan cell tumor. rubbery w/ "button holing: go down w/ gental pressure) optic gliomas, pheo. axilary/inguinal freckling, sphenoid dysplasia, scoliosis, meningioma, astrocytoma NF2: acoustic neuromas, meningiomas, schwanomas o fdorsal roots, gliomas/ependyoma of spinal cord.
PCP (phencyclidine)
NMDA antagonist -. excessive release of excitatory NT. Intox: VIOLENT, NYSTAGMUS!! ATAXIA, AMNESIA, DISSOCIATION, HALLUCINATION. agitation, impulsive, fever, analgesia, tachy, homosidality, psychosis, delirium, seizures rx: benzo, rapid acting antipsychotic. withdrawal: depression, anxiety, irritability, restless, anergia, disturbances of thought and spleep. FATAILITY IS DO TO TRAUMA!!
NNT, NNH
NNT = 1/ARR, NNH = 1/AR
Dellusional disorder
NON -BIZZARE untrue beliefe system (ex; poisoning/cheated on/married to a celebrerty). FUNCTIONING NORMAL. NO OTHER PSYCHOTIC SYMPTOMS. depersonalization - detach from body/thoughs/actons. derealizatoin - detach from environment.
Grief
NORMAL - somatic symptoms, simple hallucinations (name being called; esp in kids if no ther psychotic symptoms). Pathologic - excassive intense. lasts >6-12m. may experience depression/delerium.
electrolyte abnormalities
Na low: N/malaise, stumor coma high: irritable, stupor, coma K low: U wave, flatt T waves, arrhythmia, muscle weak high: wide QRS, peaked T wave, arrhythmia, muscle weak. Ca low: tetany, seizure, QT prolonged high: stones, bones (pain), groans, psychotic overtones (anxious, altered mental status) Mg low: Tetany, torsades de pointes High: decreased DTR, lethergy, bradycardia, hypotension, cardiac arrest, hypocalcemia!! P low: bone loss, osteomalacia high: stones, metastatic calcification, hypocalcemia!! k\
Anion gap
Na - (Cl + HCO3) increases: MUDPILES (heaps of mud) Methanol (formic acid) Uremia DKA Propylene glycol Iron/INH LA (causes: ethanol, CN poisoning ,decreaed o2 delivery, increaed metabolic rate (seizure/exercise) or decreaed lactate catabolism (hepatic failure/hypoprfusion. Ethylene glycol (oxalic acid) Salicylates (late Normal: HARD ASS (hes just normally a hard ass) Hyperalimentaiotn Addison RTA Diarrhea Acetazolamide Spironolactone Saline infusion
Urea cycle:
Nacetyl glytamate synth ONLY in liver. deficicy manifests as increased ornithine with normal urea cycle enzymes. N atoms fro NH# and aspartate glutamine -> glutamate and HN3 via glutaminase -> aKG and NH3 via glutamate DH. glutamine =#1 AA in blod bc its an N trasporter. Ornithine transcarbamylase def: decreased BUreaN, increased NH4. no megaloblastic anemia. increased orotic acid. oxindol: tryptophan derivitive by gut bacteria. normally cleared by liver. increaed in hepatic encephalopathy. sedation, muscleweak hypotension. Histidineemia - defect in histidinase -> histidine in blood. speech prob, psychomotor, emotional disturbance. JAPAN.
Obligate Aerobes:
Nagging Pests Must Breathe Nocardia, pseudomonas, Mycobacterium
Splitting
Normal splitting: on inspiration, drop in intrathoracic pressure increases VR. delayed closure of pulmonic valve: S1, A2, then P2 on inspiraiton. Wide splitting - pulmonic stenosis adn rBBB delay RV RV emptynig. see delayed pulmonic sould (slightly less so on expiration than inspiration however) Fixed splitting: ASD. icnreased blood to RV. pulmonic closure greatly delayed regardless of breath. Paradoxical splitting: see w/ impairned LV emptying - AS, LBBB .P2 occurs BEFORE A2. on inspiration, P2 moves close and peridoxially eliminates the split. btw. Venous thromboembolism can become a paradoxical emboli with periods of high right sided pressure (early ventricular systole, straining during cough/defacation)
RESISTANCE in airway
Nose to trachea = 1/2 of total resistance. it INCREASES at medium sized bronchi bc of TURBULENT flow. drops afterward b/c cross sectional area massively increases -> slows airflow velocity -> laminar flow.
STONES
ONLY ONES W/ INCREASES PH IS AMP AND CA-phosphate CYSTINE AND AMP CAN FORM STAGHORN CALCULI Uric acid: diamond, rhomboid, rosette. arid climate. LOWEST PH along nephrn is distal tuble and CD: highest risk of stone here!! Ca OXYLATE: ethylene glycole, vit C, crohns dizease. oxylate is more common. 1. decreaed Ca in diet -> bone reabsorption -> risk 2. increased protein-> increased body acid load -> Ca release 3. Increased dietary Na -> incrased bone release 4. B6 req for ppl who have hyperoxaliuria (it decreases endogenosu production) 5. other: sarcoid, hyperoxaluria (chrons), hypocitraturia (distal RTA) 6. hyperuriciemia promotes too!! 7. high oxylate diet (chocholate, nuts, spinich) rx: thiazids and CITRATE!! (citrate binds free Ca)
malignant bone tumors
Osteosarcoma - 10 to 20 as well as greater than 65yo. see at METAPHYSIS, often knee. Codman triangle - elevation of periosteum. sunburst. risk: pget, infarct, radiation, RB, li fraumani. Ewing - boys less than 15. DIAPHYSIS. Onion skin. 11;22 translocation. chondrosarcoma - men 30-60. pelvis, spine, scapual humerus, tibia, humor. expantile glistening mass w/i MEDULLRY Cavity of Diaphysi diaphysis: chondrosarcoma, Ewing Metaphyssi: osteosarcoma, osteochondrosarcoma. epiphysis: giant cell tumor
Resistance, pressure, Flow
P = Q x R (its alphabetical!!-0) In series: TR = R1 + r2 In parallel: 1/TR = 1/r1 + 1/r2... viscocity increase with hereditary spherocytosis. if you remove an organ, TPR Increase and CO decreaes puncture at left ternal border at 4th intercostal space: pieve through RV, not lung. w
Nephron physiology
PCT: ISOTONIC fluid. secretes NH3 which works as buffer. PTH inhibits the Na/P cotransporter. AT2 stimulates the Na/H exchange (This helps HCO3 absorption bc H combines w/ it then moves on to carbonic anhydrase ---> CONTRACTION ALKALOSIS!!) 60% filted ca passively reabsorbed by paracellular. THIN descending LOOP; ONLY Water reabsorbed. most concentrated at tip of the loop. THICK ascending: K backleacks into lumen -> allows paracellular reabsorption of Mg/Ca. Passive NaCl reabsorbed too. urine becomes less concentrated. DCT: urine NOW IS HYPOtonic: (LOW H20 perm) CD: principal cell: ADH here. K/ secreted here. alpha-intercallated = Kin/Hout atp pump. Hco3 reabsorbed. fdf LATE CD dep on ADH.
wound healing mediators
PDGF: plateltes and macs: endothelium remodling, SMC migration, stimulates fibroblast growth EGF - cell growth via tyrosine kinase TGFb - angiogenesis, fibrosis, cell cycle arrest excess metaloproteinases can lead to wound contraction (it encourages myofibroblast accumulation)
Cox LTs Mast cells Kinins
PGi2, d2, e2 = vasodilate, increase perm. e2 also fever/pain B4 neutrophils (as well as C5a, IL8, bacterial products) C4, D4, E4 - vasoconstriction, increase perm, bronchospasm activated by trauma, C3a, 5a, cross link IgE. Late response is leukotrienes. factor 12 activated by SEC -> kinin -> clears HMWK to bradykinin (vasodilation, increase perm, PAIN. IL1, TNF -> COX -> PGE2 -> feever.
receptor associated tyrosine kinase
PIGGLET: JAK/STAT. think acidophiles and cytokines. piglets are associated with the signaling pathway Prolactin, Immunomodulators (IL, IFN), GH, GCSF, EPO, Thrombopetin STAT dimerizes and goes to neuk.
Emphysema
PINK PUFFER. BARREL SHAPED. PURSED LIPS. DILATED alveolar air spaces on CT. decreased elastic recoil/increase compliance. decreased DLCO bc of destruction of ALVEOLAR walls/type 1 pneumocytes!! (oxidative injury -/smoke > activates macs/neutrophils. increased elastase -> Increase lung complience. radial traction -> dynamic airway compression during expiration. panacinar is lower lobes/anterior margin of lung bc lower = greater perfusion = greater infiltraiton by neutrophils. centriacinar: called so bc initially affects respoiratory bronchioles instead of peripheral alveolar ducts. Hypercapnea in COPD -> cerebral vasodilation. (autoreg btwn 60-140. Above 150 -> increase blood flow/ICP. only when o2 is less than 50 see rapid increase in cerebral perfusion/ICP. **be careful w/ o2 in copd bc its HYPOXIA that drives these ppls respiratory fxn. bc hypocapnia can decrease cerebral blood flow, ppl w/ cerebral edema often hyperventilated to decrease ICP.
other demyelinating diseases
PML: increase risk w/ natalizumab. dementia/motor deficits/vision. Acute disseminated (postinfectious) encephalomyelitis = multifocal perivenular infl/demyeinination after infection (measles/VZV) or vaccination (rabis, smallpox) Charcot=marie tooth - hereditary moror and sensory neourpathy. mutation in myelin gene. "neural form" mof muscllar atrophy. AD. see scoliosis, high/flat arches of foot, weakness of foot dorsiflexion (Common peroneal nerve) Krabbe - psychosine also builds up. the buildups destroy myelin. Adrenoleukodystrophy - X linked. badd metabolism of VL chain FA -> buildup in CNS, adrenals, testes. can cause coam/adrenal crisis
Spinal cord shape
PROXIMAL = more white matter adn more OVOID . lower curvical and lumbosacral = LARGE ventral horns (to innervate extremities). T1-L2 = look for laeral grey horn. C1 - ovoid, increased rey matter. see bumpps of gracile/cunneate. C7 - ovoid, large ventral horns L5 - decrease white matter, no lateral horn lSacrum = mostly grey matter. gracilis is more medial in the spinal cord section. for the other nuclei, see cervical parts of teh tract more medial and sacral parts of the tract more latera. anterior spinothalamic tract = crude toch and pressure Motor cortex is BA 4, 6. fibers that DONT decussate = anterior corticospinal tract. UMN: weak, no atrophy LMN: weak, ATrophy
hypoparathyroid
PTH independent hypercalcemia: excess ingestion, Vit D toxicity, thyrotoxicosis, immobilizatoin. Familial hypocalciuric hypercalcemia - defective Ca sensor. PTH cant be suppressed. Pseudohypoparathyroid - unresponsive kidney to PTH. hypocalcemia, short, short 4th, th digits.
pulmonary vascular resistance and alveolar gass
PVR = [Partery - Pleft atrium]/CO (P = QxR) PAo2 = 150- PaCo2/.8. (thus when given paCO2 calculate PAo2 to see A-agradient. a-agradient normal is 10-15.
Cervical pathology
Paparucolaou = pap smear FH is NOT a risk factor. perinuclear halo. pyknotic/enlarged nucleus. lateral invasion can block ureters. parabasal cells - round cells /w basophilic cytoplasm, finly granular chromatin. incrased N/C. see in postmenopasual/postpartum.
INFANT (0-12m)
Parents Start Observing MOTOR: 1. Primitive reflexes disappear— Moro (by 3 mo), rooting (by 4 mo), palmar (by 6 mo), Babinski (by 12 mo) 2. Posture—lifts head up prone (by 1 mo), rolls and sits (by 6 mo), crawls (by 8 mo), stands (by 10 mo), walks (by 12-18 mo) 3. Picks—passes toys hand to hand (by 6 mo), Pincer grasp (by 10 mo) 4. Points to objects (by 12 mo) SOCIAL: Social smile (by 2 mo) Stranger anxiety (by 6 mo) Separation anxiety (by 9 mo) VERBAL: Orients—first to voice (by 4 mo), then to name and gestures (by 9 mo) Object permanence (by 9 mo) Oratory—says "mama" and "dada" (by 10 mo)
seizures
Partial (focal seizures) - affect 2 par of the prain. usually start in meidal temporal lobe. 1. simple - conscious. no postictal confusion. 2. complex - impaired ocnscious adn postictal. may have automatisms (lip smacking) Genrealized - diffuse 1. absenze = petit mal - 3Hz spike ans slow wave. maybe automatisms/small clonic jerks of arm/hand. 2. myoclonic - no LOC or postictal 3. tonic-cloiniic - stic then jerks. LOC and postictal. status epilepticus - can cause HTN, tachy, arrhythmia, LA. after benzo/phenytoin, if still seizing use pehnobarbital. juvenile myoclonic epilepsy - often w/i 1 hr of wakening. worse w/ poor sleep. can -> absence or generalized tonic/clonic
perfusion vs diffusion limited
Perfusion limited: o2(normal health), co2, N20. these equilibrate 1/3 of teh way along, thus diffusion only increaes w/ increase blood flow. Diffusion limited: 02 (emphysemia, ribrosis, ARDS). gass doesnt equiliibrate (see big differnece in the graph. exercise (high pulmonary blood flo) or high altitude also. diffusion capacity of CO2 20x more than o2 thus not as much affected. difffusion: Vgas = A/T X Dk(P1-P2). A decreaes in emphysemia and T increaes in pulmonary fibrosisi. note, pulmonary circuit pressure only increases a little despite fact that blood flow increaes 5-7x in max exercise. bronchoconstriction caused by alveolar hypocapnia, bronchal infl, cholinergics, irritants
pathoma breast
Periductal mastitis - infl of subarealar lactiferous ducts. due to smoking -. squamous metaplasia-> duct blockage by keratin/inflamatin. subareolar mass w/ nipple retraction (due to healing/fibrois). Mamary duct extaseia - subareolar ducts. postmenopausal. PERIareolar mass/ greenbrown dischare. infl w/ plasma cells.
congenital heart disease
Persistant trucus: most have VSD. causes chf. transpositon: nee dvsd, PDA, foramen ovale. failed septatio nof trucus arteriouss. Tet: most common. not always bad, if mild, vsd can serve as L to R shunt. pressure in RV=LV. all 3 of these due to failure of neural crest migration. TAPVR - pulmonary vein drains into right heart. has asd sometimes pda. endocardial cushion: lower atrial and upper VSD. persistant AV canal. acyanotic due to LtoRshunt. ASD: changes in RH are not irreversible. changes in pumlonary aretery ARE irreversible (medial hypertrophy) PDA = differential cyanosis: late scyanosis in lower extremities but not upper. coarctaiton: infantile: can present w/ HF due to closure of ductus arteriosus. differential cyanosis. Turner syndrome. Adult type: HTN HA epistaxis in upper extermities congenital bery anurys. . limits lwer extremity exercise but NO cyanosis.
Phase 1, 2, 3, 4
Phase 1: healthy volunteers - is it safe? safetiy, toxicity, pharmacokinetics Phase 2: w/ disease - does it work? efficacy, dosing, adverse effects phase 3: Large number of patients: is it good or better? Phase 4: post market - can it stay? rare/ long term effects
childhood disorders
Physical abouse - posterior rib fractures. abuser is mom. happens <3 yo. sexual - 9-12 yo. ADHA - before 12. decreased frontal lobe volume/met. rx: methylphenidate/amthetamines, amoxetine conduct disordrer - violates others/social orms. opositonal/defiant - defiant to athority but doesnt volate social norms. Touret - motor + vocal for more than 1 year. rx: fluphenazeine, pimozide, terabenazine, clonidiene (DA antagonist). can suppress temproarily. separtion axnitey - 7-9. rett disorder - X linked but only girls (BOYS DIE). start at 1-4. REGRESSION - loss of dev/verbal/intelect. ataxia, ssterotyped hand wringing.
hematologic protozoa
Plasmodium: vivax/ovale - 2 days malaria - 72hr falciprim is irregular, can go to cns, lungs, kidney rx: chloroquin. if resistent us mefloquine or atovaquone/proguanil. if life threatening IV quinidine (G6PH def concern). for hypozoits use primaquine (G6PD concern) babesia. ixodes tick - atovaquone + azithro
Spinal cord lesions
Polip/werdnig hoffman - LMN bc of anterior horn damage. werdnig - hypotonia, tongue fasciculations. AR. MS - usually in cervical region AML: only motor. zn-cu-SOD. RILUZOLE HELPS BY DECREASEING PRESYNAPTIC GLUTAMATE RELEASE. anterior horn and corticospinal tract prob. atrophy of precentral gyrus and loss of motor nuclei. ASA - bone fracture/disc herniation. loose strenght/pain/temp. watershed area is in upper thoracic ASA teretory (ademkiewicz suplies ASA below T8) B12/vit E - also involves spinocerebellar tracts. sensory ataxia. parasthesia. syringomyelia - see with Chiari I/socliosis. also anterior HORN (LMN) (atrohy of hand muscles). 1-2 levels below lesion bc ascend in lissaue before synapse. tabes - demyelination of dorsal colum/dorsal root. sensory ataxia, lancinating. absent DTR. urinary incontinence. pain, parasthesia, areflexia. brown - ipsi UMN. contra pain. Ipsi vib/propiroseption 1-2 levels below. ipsi loss of all sensation/LMN at level.
Poly/dermato
Poly - ENDOMYSIAL infl. CD8. moringin stiff/weight loss, fever, malaise, Dermato - perimysial inf/atrophy. may see lung disease, vasculitis, myocarditis.
Polymylagia rjeumatica and fibromyalgia
Polymyalgia rheumatica - houlder/hip. fever, malaise, weith loss. nO muscle weak. but are tender. responds to steroids. Fibromyalgia - yong females. FATIGUE, poor sleep, paresthesia. see TENDER POINTS. decreaed attentino, nonspecific GI symptoms, sepression. rx: sleep well, exercise, antidepresant, anticonvulsant.
Basilar artery stroke
Pons, medulla, lower midbrain, cirticospoinal/bulbar tracts, ocular cranial nerve nuclei, PPRF. preserved consciiousness, blinking, quadriplegia, loss of voluntary face, mouth, tongue mvnt. LOCKED IN
RNA
Positive strand: retro toga party with flavored corona and ate hepe california PICles negative: always bring polymerase Or fail rep segmented: BOAR all rep in cytoplasm except influenzae and retro. naked: CPR to naked HEPpy - calicivurus, picornavirus, reovirus, hepevirus. (naked on reo river with california picles)
Random derm stuff
Post infl. hypopigmentaiton - redistribution of existing melanin w/i skin. can be associated w/ reduced transfer of melanin to keratinocytes. Cafe au lait - increased melanosomes aggertate w/i melanocyte cytopolasm Lentigo - benign linear melanocytic hyperplasia. Effects of sterioids on skin: causes decreased production of EC matrix collagen/glycosaminoglycans. Atrophy of dermis w/ loss of dermal colagen, drying, cracking, tightening of skin. Telangectasia, ecchymoses, atrophic striae. SOME atrophy of subcu.
Brusitis
Prepatellar brusitis - btwn patella and overlaying skin. little synovium. "housmades knees - see in roofers, plumbers, carpet layers. Popliteal/gastrochnemius brusitis - associated w/ backers cysts. Anserine brusitis (pers anserinus) - medial knee. see in overuse w/ athelete or chronic trauma in overweight.
hyperaldosteroneism
Primary: LOW RENIN. rx: spironolactone/eplerenone. the hypokalemia causes msucle weakness, paralysis. NORMAL Na due to aldosterone escape (NO edema) - initially see increased na/water reabsorbed due to aldosterone. this increases gfr/blood flow -> increases na excretion. also via mechanisms that increase ADH and ANP. Secondary - due to renal artery stenosis, CHF, cirrhosis, nephrotic syndrome.
gastrulation
Primitive streak is thickening of epiblast. some epiblasts turn into mesenchymal cells and mighrates down through the primative streat -> mesoderm/endoderm. remainder of epiblast -> ectoderm. some epiblast micrates cranially to form notocord. notocord causes some of the ectoderm to becomre neural plate/neuroectoderm. neural plate -> neural tube/neural crest. whats left of ectoderm becoems surface ectoderm.
intrinsic pathway of apoptosis extrinsic
Proapoptotic: BAX, BIM, BAK. Bcl2 stabilizes membrane by inhibiting Apaf-1. cyt c release -> Apaf-1 -> capsizes. Fas, TNF type 1 initiators = 8, 10. exocutioners = 3, 6
kidney embrology
Pronephros (4th), mesonephros (works during 1st trimester -> wollfiain/mesonephric duct) metanephros (5th week. mesonephric duct -> ureteric bud) uretopelvic junction last to canalize. normaly lower on right side. kidney has perfused at 3-5x the rate of other organsi. Increased risk of embolism. points to medulla, rum of subcortex preserved.
Prostate
Prostatitis: can see low back pain. chronic may be abacterial. BPH - smooth/elastic/firm/nodular. periurethral : includes middle and lateral lobes). icnreased FREE PSA. eventually urinary retention/overflow incontinence. alpha adrenergics - relax smooth muscle in blader neck, prostate capsule, urethra. works against teh DYNAMIC compontent of obstruciton 5-alpha recuctase - dutasteride/finasteride - work on fixed componoent. takes months. se: libido, ED. Antimuscarinics - tolterodine - use if overactive bladder/f/incontinence. restricted to men w/ low post void residual. Prostate cancer - prostatic acid phasphatase indicates penetrate prostate capsule . .
Ulcerative colitis
Pseudopolyps. loss of haustra -> lead pipe. CRYPT ABCESSES. BLOODY. MAY OR MAY NOT have abdominal pain. more association w/ pyoderma gangrenosum and primary skerlosing cholangitis. TH2 mediated -> il 4, 6, 10 -> damage mucosa rx: ASA prep (sulfasalazine (5-aminosalyclic acid prep liek mesalamine), 6-MP, inflix. toxic megacolon - distention, tender, tymphany, fever, diarhea. can rupture. dessation of neuromuclar activity. rx: IV, steroid. diagnose w/ PLAIN ABDOMINAL RADIOGRAPHY. barium enema and coloscopy is CI (perforation).
SAH
SAH - also via AVM (kids). Vasospasm later due to blood breakdown. Nimodipine = vasodilation/neuronal protection. Fever/nuchal rigidity, pupillary dilation, papilledema. NO focal neurologic. Rebleed: sudden HA, change in consciousness. Hydrocepharlus can occur: irritation of arachnoid villi.
how far into the bronchi does it extend?
Psuedostratified CILLIATED columnar till BEGINING of terminal bronchiole. SMOOTH MUSCLE to the end of terminal bronchioles. CUBOIDAL CILLIATED cells in TERMINAL up until end of resp bronchiole. (then just simple squamous) CARTILAGE and GOBLET tilll end of bronchi. Bronchi also contain submucosal glands. after bronchi, club cells = prominent secretory type (large bronchioles actually have some goblet). 10-15 nm trapped in upper resp tree (cough) 2.5-10: in bronchi/trachea: mucocilliary transport <2.5 reach terminal broncioli/alveoli: phagocytosed by macs -> cytokines: PDGF, IFG -> Fibrosis. (macs could also transport to terminal bronchioles -> mucocilliary system).
Action potential for heart
QRS = phase 0. QT = phase 3. NA = 60, K = -80, Cl = -90, Ca = 125. conduction velocity: purkinji -> atral-> ventricula-> AV node (Park AT VENtura AVenue) Pace makers SA, AV, Bundle, purkinje/ventricles SA = 1.1 m/s, AV - 0.05 m/se. Purkinje = 2.2 AV node at posteroinferior part of intratrial septum. AV node is 100 ms delay. U wave: hypokalemia, bradicardia. w/ hypokalemia also see Twave flatten, ST depression, premature atrial/ventricular contraction. Pacemaker potentials: ACh/adenosine act at phase 4 and open K channels/inhibit Ca/Na -> decrease HR. Catecholamines incfase L type Ca and Na chanels/increase HR. dont use fast Na channels bc they are perminately inactivated (less negative resting potential) 3rd degree heart block: SA node caues atrial contration while AV node causes ventricular contraciton. QRS is narrow. AV node causes HR of 45-55 (instead of teh normla 60-100 by SA node). i if pacemaker below AV, HR as slow as 20, QRS is prolonged and abnormmaly shaped. PR normaly 200 ms. qrs nromaly 120 ms.
casts in urine:
RBC - glomerularnephritis, ischemia, malignant HTN. (kidney stones: hematuria, no casts) WBC - tubulointerstital infl, transplant rejeciton waxy - advanced renal disease/chronic renal failure. almost dead like wax figure. hyaline - can be normal, ofen if concentrated urine.
RCC vs oncycytoma
RCC: prox tubule fillled w/ lipids/glycognen! polygonal. eccentric nuclei goross is golden yellow due to glycogen/lipids. located at one poles. obesity EPO, ACTH, PHTrP goes to LUNG/bone. silentt till metastisis often. Oncocytoma: benign. from COLLECTING duct. well circumscribed w/ central scar eosinophilic cells, round nuclei. ABUNDENT MITOCHONDRIA. rx: nephrectomy. WHILMS - primative glomerular structures. TUMOR SUPPRESOR mutaiton on chromosome 11. WAGR: gu malf, MR
RelativeRR = proportion of risk reduciton
RRR = 1-RR or ARR/conrol proportion of risk reduction attributable to intervetnion
Brachail Plexus
RTDCB Trunks: upper, middle, lwer Cords: posteroir, lateral and medial posterior cords form axilary adn radial N (the extensors)
Afib
Rate control: b blocker, Ca blocker, Digoxin. Rhythm control: class IC or III narrow QRS. arises near pulmonary veins. electrical remodling: development of foci of shortened refractory periods/increased conductivity. 90-170bpm. A flutter: back to back atrial depols. rhythm, : IA, C or III. 4:1 sawtooth pattern. regular rhythm though.
Restrictive lung disease
Restrictive patterns: decrease lung volumes, increased elastic recoil, decreased compliance. expiratory flow rate increased relative to low lung volumes. 1. poor breathing mechanics (normal A-a gradient): polio, myasthenia gravis, scoliosis, morbid obesity. 1. Diffuse alveolar hemorage -> dilutes surfactant -> atelectasis -> decrease lung volume/compliance: restrictive pattern. see w/ goodpastures, sle, wegners. 2. Alveolar hyaline membrane disease: decrease compliance: restrictive pattern. [ARDS, hyaline membrane disease] 3. Pneumoconiosis (fibrosis secondary to inorganic dust), sarcoid, good pasture, wegners, langerhans cell histocytosis (eosinophilic granuloma), hypersensitity pneumonaits, RA. 3. Atelectasis: extrinsic pulmonary compression. Lung volumes and compliance decrease: restrictive pattern. 4. Idiopathic Pulmonary fibrosis - reticulonodular opacidies. Most pernounced in lower lobes. GRADUAL ONSET dyspnea. May hear end expiratory crackles. Fibrosis causes cystically dilated air spaces that coalesce -> honeycomb appearance [lined by type 2 pneumocyte and bronchiolar ep]. 5. Atelectasis: diminished air volume. Due to obstruction. See opacificaiton (collapse).
Secretin - somatostatin
S cells of duodenum. increases bicarb!! and bile secretion. decreases acid/gastrin. stimulated by pH less than 5. FA somatostatin: decreases everything including insulin, glucagon, GH, TSH. triggers: acid. decreased by bagal stim. somatostatinoma- HYPER/hypoglycemia. steatorhea, gallstones, ocnstipation, decreased momtility.
SHiNE SKiS
S pneumo, H infl, Nesiria men, E coli, Salmonella, Klebsiella, GBS.
PTHrp EPO vit D Subacute cerebellar degen
SCC lung, RCC, breast RCC, HCC, thymoma, hemangioblastoma, Pheo hodgkins, some non-hodgkins \ anti-YO, antiP/q, anti -HU. SCC lung, breast ovarian uterine.
B and T cell dysfunction
SCID - FTT, chronic diarhea, thrush, all infections. Absent thymic shadow, germinal centers, and t cells. Ataxia-telangectasia: ATM - DS break -> cell cycle arrest: also see giga def. see increased AFP, lymphopenai, cerebellar atrophy. Hyper-igM. CD40L defect. can't class switch. X linked. pyogenic inf, sinopulmonary, pnymocystis, cryptosporidium, CMV. lymph hyperplasia. Wiskott aldrich: X linked. can't organize actin cytokeleton. worsens w/ age. TIE (thrombocytopenia, Infections, Eczema). AI, malignancy. decreased/normal G, M, increased E, A.
Minimal change (lipoid nephrosis)
SELEECTIVE ALBUMINURIA. NO IF kids due to inf, atopy, immunization. may be due to HOdgkins (cytokines).
arteries of GI
SMA syndrome: at L3 the TRANSVERSE PORTION (THIRD SEGMENT) of duodenum entrapped btwn sma and aorta. [normally angle is 45degrees. angle can decrease in things that decrease mesonephric fat (decreaseed BW, burns, catabolism, bed rest, lordosis, surgical correction of scoliosis (lenghtens spine)]. second part of duodenum at L2. T12 = celiac L1 = SMA L1 = left renal L3 = ima renal veins join IVC at L1/2. internal iliac -> pudental A-> middle/inferior rectal artery. IVC is anteriro to right renal artery. to right of aorta. forms at L4/5 adn joins LA at T8.
URINARY INCONTINENCE
STRESS - urethral support lost/pelvic floor weak (may be due to postmenopause estrogen def)/obesity < MC, surgury OVERFLOW - decreased detrussor contractility/bladder outlet obstruciton. (initially havae infreqwuent urination via loss of innervation/inability to sense full bladder). can cause poor stream, DRIBBLING, INCOMPLETE EMPTYING (B/c pelvic floor relaxes at night -> noctural eneurresis. URGE: DETRUSSOR OVERACIVITY. sudden overwhellming/frequency. bph can cause via bladder irriation. also caused by cold, running water. LOSS OF INHIBITORY CNS IMPUT - spinal cord lesions. eventually blader becomes atonic/dilated -> overflow incontinece.
sturge weber
STURGE - sporadic, stain (port wine), Tram Trac - Unilateral, Retardation, Glaucoma, GNAQ gene, epilepsy. neural crest derivatives. port wein stain = fascial angioma. leptomeningeal angioma. episcleral hemangioma -> increase ocular pressure -> glaucoma. hemiplegia/skull radiopacities.
Diaphragm structures.
Septum transversum - mesoderm ventral to gut tube. from umbilicus to pericardium. vestigial structure: central tendon. Liver grows into it. structures perforating it: IVC at T8, Vagus at 10, Aorta/thoracic duct/azygous v at T12. (I ATE 10 EGGS (esophagus) AT (aorta) 12. CCommon carotid biFOURcates at C4. TTrachea biFOURcates at T4. abdominal aorta biFOURcates at L4.
other msucles of neck/shoulder region
Seratus anterior - from medial border of scapula to lateral surface of ribs. deltoid - starts on clavicle/acromion, spine of scapula. goes to lateral surface of humerous. levator scapulae - inserts on superomedial border of scapulae and transvers procsses of c1-4 tendon of long head of biceps - inserts on supraglenoid tubercle of scapula short head inserts on anterior tip of coracoid process of scapula
cushing syndrome
Smal cell lung and bronchial carcinoid cna ectpoically produce. hyperglycemia, amenorrhea, proximal muscle weak. if low dose suppresses ACTH but cortisol high, think acth independednt adrenal adenoma.
other lung cancers
Small cell (oAt cell) - from primitive cells of the basal layer of BRONCHIAL ep. round, oval. resemble lymphocytes but smaller. salt and pepper chromatin. SVC SYNDROME. Acth, adh, lambert. or Ig aganst neurons (paraneoplastic myelitis/encephalitis). N-MYC!!! enolase/synaptophysin/neurophilament + arises from BRONCHI, thus can be a hilar mass. squamous cell: arises from areas of squamous bronchial metaplasia. usually on major BRONCHI (hilar mass). CAVITATION/NECROSIS> Large cell - may display features of adenocarcinoma/squamous. gyenecomastia/galactorhea!! (can secrete B-hCH). bc its anaplastic, see pleomorphic giant cells. Bronchial carcinoid: NOT associated w/ smoking. usually mast effect, rarely carcinoid syndrome.
Wrist
So Long To Pinky, Here Comes The Thumb floor of snuff box - scaphoid and trapezoid. cafoid is most comonly fractureed. adnterior pole is retrograd f rom branch of radial artery. Lunate idslocation = acute carpal tunnel - capal tunnel associated w/ pregancy (fulid retentino), hypothyroid (glycosaminoglycan buildup), DM (CT thickening), RA (tendon inflamation), Dialysis (B2 micrglobulin buildup). Guyon calal - btwn humate and pisiform. ULNER nerve - weak intrinsic muscles. Dysthisia of ulner side. hUUUK of hamate. Dupytren's contracture - fibroproliferative diseaes of palmar fascia. forms contractures that draw fingers into flexion.
Facultative intracellular:
Some Nasty Bugs May live FacultativLY salmonella, neisseria, brucella, Mycobacterium Listeria francisella, legionella, yersina, nocardia (coxiella is OBLIGATE)
measles
Start w/ the word measles, thus must be rubeola. (paramyxovirus) Rubella = german measles. both ahve rash that starts on head and moves down. 1. measles: see couhg/coryza etc before 2. rubeall - see postaricular LAD. and the rash resolves faster.
miscellaneous skin disorders
Sunburn -inflamatory reaction. it can cause apoptosis of keratinocytes. UVA if tanning/photoaging. UVB if sunburn. Pityriasis Rosea - herald patch (pink/brown scaly plaque w/ central clearing) followed by other ovoid scaly erythematous plaques in "christmass tree" distribution (oriented in an oblique direction along skin tesion lines on the BACK). multiple plaques w/ collarette scale. self resolves in 6-8wk. Erythema Nodosum - PAINFUL red nodules of subcu fat. usually on anterior shin. associated w/ sarcoid, histo, coccidioido, TB, staph/strep, leprosy, chrons, OCP, chlamydia. Skin tag (acrochordons( - often occurs w/ acanthosis nigricans Acanthosis nigricans - gastcric cancer. epidermal hyperplasia, hyperkeratotoic, hyperpigmented thickenign of skin on neck/axilla/groin. can see w/ cushings. insulin/ILGF stimulate epidermal/dermal prolif. see acanthosis (epidermal hyperplasia of the spinosum)
Brain stem and Parinaud syndrome
Superior colliculi - conjugate vertical gaze center inferior = auditory. parinaud syndrome (dorsal midbrain sydnrome) - compression of techal region of midbrain. upward gaze palsy. paralysis of conjugate vertical gaze and convergnece due to lesion in superior coliculi. due to tumor in pineal gland. most common = germinoma (IN MALES). causes PRECOCIOUS PUBERTY (via b-hcg), AQUEDUCT COMPRESSION, and parinaud syndrome.
tRNA
T-arm: closer to the 3' end. has TYC (thymine, pseudouridine, cytosine) helps bind ribosome D-arm: ahs dihydrouracil needed for rec of correct AA-trna syhtetase. mischarged tRNA will insert wrong AA. inosine can pair w/ U, A, C
thyroid hormone
T3 is made in ther periphery. T3 has greater activity. uremia -> decreased peripheral conversion Bone growth, Brain maturation, B1 receptors on heart, Basal metabolic rate (increases na/k pumps, o2 consumptoin, rr) also increase glycogenolysis/gluconeogeneis,lipolysis. PTU/amiodarone,iopanoic acid, Bblockers inhibit peripheral conversion. perchlorate, pertechnetate, thiocyanate inhibit Iodine uptate. radioactive iodide (I131) is [ ] by thyroid gland. can cause hypothyroid adn Ca. give KI prophylactically for competitive inhibitoin. methimizole and PTU can decrease uptake. stop 1 wk befoer.
Dead space
TV = 500mL Vd = Vt x [PaCo2 -PECO2/PaCO2] taco paco peco paco O2 inspired is 160. 150 in trachea due to partial pressure of water vapor. alveolar is 104 (goes down to 100 bc of bronchial arteries (via pulmonary veins) and cardiac (thesbian v.) that drain into LA. tracheal co2 shuld be 0. venous co2= 46, arterial = 40. systemic AV shunt increases Po2 ,decreases CO2 of venous blood.
RTA - non-aniongap, cypercholremic
TYPE 1- Distal. PH >5.5 bc alpha intercalated cant secrete H, thus new Hco3 not generated -> Acidosis. HYPOKALEMIA, risk of calcium P stones due to increase urine PH and bone turnover. via Ampho B, analgesic neph, MM, obstruction. normal na TYPE 2 - proximal, pH <5.5. : defect in proximal tubule HCo3. HYPOKALEMIA. increased risk for hypopohosphatemic rickets. via Fanconi syndrome, toxins (lead, aminoglycosides), carboinic anhydrase inhibitors normal na TYPE 4 - hyperkalemic, pH <5.5. due to hypoaldosteroneism/aldosterone resistance, K sparing diuretics. Hyperkalemia impairs ammoniagenesis in prox tubule -> less buffering capacity, decreased H excretion into urine. rx: mineralicoritcois.
HAND muscles
Thenar - OAF (oponens policis, Abducor policis previs, Flexor pollicis brevis Hypothenar - OAF - oponens/abductor,flexor digiti minimi. dorsal interosseus - abduct (DAB) Palmar -adduct (PADs of the fingers) lumbricals = flex MCP, extend DIP and PIPla
Poor Gram stain:
These Microbes May Lack Real Color Treponema, mycobacteria, mycoplasma, legionella, rickettsia, chlamyidia (lacks muramic acid)
Vaccination
To Be Healed Rapidly - give preformed antibodies for Tetanus, Botulinum, HBV, Rabies. (can do combined passive and active for HBV and Rabies exposure) Live attenuated virus: CMI and humoral. MMR, smallpox, rotavirus, polio (sabin), influenza (intranasal), varacilla, yellow fever. also BCG virus. "LIVE! one night only. see SMALL YELLOW ROTAting CHICKENS and get vaccinated with SABIN and MMR Its INcredible" MMR only live vaccine in HIV Inactivated/killed: Humoral only. RIPAlways. stalK(killed) Rabies, influenza injection, polio salk, hepA. subunit vaccines - HBV, HPV
glycogen regulation
To break down: 1. Glucagon(liver) and B receptors (liver and muscle) -> cAMP -> PKA -> activates glycogen phosphorylase kinase 2. alpha receptors (liver) act on ER to increase Ca -> activates Glycogen phosphorylase kinase 3. PKA inhibits glycogen synthase 4. glycogen phospohorylase kinase then activates glycogen phosphorylase. thus, glycogen phosphorylase activated by epi, glucagon, amp. inhibited by G6P, insulin, ATP. To store glycogen: 1. Insulin activates glycogen synthase. it also activates a protein phosphatase to inhibit glycogen phosphorylase. thus glycogen synthase acitvated by insulin, G6P, cortisol. inhibited by epi, glucagon G1P to UDP glucose via UDPglucoase pyrophosphorylase. Debranching enzyme is two parts: 4a-d-glucanotransferase and a-1,6-glucosidase
CNS protozo
Toxo: sulfadiazine, pyrimethamine (clinda if allergy) Naegleria - ampho bi trypanosoma brucei - Suramin for blood born disase melarsoprol for CS penetration (it SURe is nice to go to sleep with MELAtonin" also pentamide
HYPERACUTE REJECITON
W/i minutes. prexisting Ig against ABO and HLA. screening has eliminated this. must remove graft. THROMBOSIS/FIBRINOID NECROSSIS OF VESSLES. (ischemia/necrosis) GROSS MOTTLING AND CYANOSIS
random resp stuff
True vocal cords: stratifieed squamous: thus HPV papillom -> hoarsness/stridor stratified squamous at oropharynx, laryngopharynx, anterior epiglotis, upper 1/2 of posterior epiglottis, vocal folds. laryngeal vestibule: at topp is posterior epiglotis, at bott om is vestibular folds (false vocal fold). cilliated, pseudostratified, columnar, mucus. paranasal sinuses: cilliated pseudostratified columnar mucus secreting. nose/paranasal sinuses/nasopharynx/larynx and tracheopbronceal tree - pseudostratified columnar, mucus.
Pneumocytes
Type 2 = 60% of total # of cells. have lamellar bodies that secrete surfactant. Cuboidal and clustered!. Clara/club: in TERMINAL parts of bronchioles. noncilliated; low columnar/cuboidal, secrete PART of surfactant, regenerative source of cilliated cells in bronchioles. degrades toxins via P450. secrete "club cell secretory protein to protect against infl/oxidative stress. Macrophages - elastase in lysosoes. Neutrophils: elastase in azurophilic granules. neutrophil elastase: inhibited by a1-antitrypsin. Mac elastase inhibited by Tissue Inhibitors of Metalloprotein. they can degrade eachother's but not their own.
Galactose metabolism
UDP gal -> UDP gluc bia 4. epimerase. UDP gal -> galactosyl b-1,4 glucose (Lactose) via Lacose synthase. Lactose -> galactose via B-galactosidase (lactase) galaktokinase def: galactosuria; infantile cateracts. (ex: failure to track objects/social smile) Classic galactosemia - cataracts, FTT, jaudice, vomit lethergy, hepatomegaly, AAuria, hyperchoremic metabolic acidosis, bleeding. E. coli sepsis. Sorbitol: both enzymes: seminal vessicle, ovaries, liver only aldose reductase: Lens, schwan cels, retina, kidney. btw. latase def: increased hydrogen content w/ lactose tollerance test.
Homologs
UG folds: ventral shaft of penis (penile urethra) vs. labia minora UG sinus: prostate vs urethral/paraurethral glands of skene. also bulbourethral glad vs greater vestibular gland. UG sinus: bladder, urethra, lower vagina. gubernaculum: anchors testes w/i scrotum vs. forms ovarian lig/round lig. uretrhal fold -> urethra. hypospadias associated w/ chordee.
stop codons promotor Shine delgarno
UGA, UAG, UAA TATA is 25bp upstrea, CAAT is 60-80 only prokaryotes. 6-10 bases upstream of AUG. binds 16s of 30s. 50 s contains 23s=peptidyl transferase activity. kozak sequense also importat in initiating traslation. purine 3 bases upstream of AUG. mutation of G->C = thallasemia intermedia prokaryotes: 30 s, N met tRNA, IF 1, 2, 3, GTP and then 50s comes.
FAcial lesions and muscles of mastication
UMN lesion - contra lwoer face. LMN- ipsi whole face FN palsy - lyme, HSV, zoster, sarcoid, diabetes. rx: steroids. destruction of fascial nucleus itself. dissapeared nasolabiall fold (drooping smile), cant close eye on involved side. hyperacussus. decreased tearing. only the lateral pterygoid opens jaw. rest keeps it closed. LLLateral LLLowers jaw.
RLS
URGE, unplesent sensations. onset w/ inactivty or night. causes: IRON DEF, uremia, DM, MS, parkinsons, kidney, drugs (anti-dep; metclopramide, Li, glucocorticoid) rx: avoid alcohol, nicotene. sleep. leg masage, exercise, heat/cool AD AGONIST PRAMIPEXOLE/RIPINERONE
Kidney anatomy
Utreters UNDER the uterineA or ductus defrens. Ureters are anterior to psoas. gonadal vessles cross over it. Ureters then cross over COMMON iliac artery near its bifucation. ureters are medial to gonadal vessles and anterolateral to internal iliac. In females, ureter courses along uterosacal lig together w/ vaginal A and deep to uterine vessles. IVC splits into common iliacs at L4
Wallarian degen
Wallerian degen: degen distal to injury, axonal retraction proximally. can regen if PNS. proximal part degens until closest node of ranvier AXONAL REACTION (24-48hr): celllular edema in cell boddy (nucleus displaced to peripehry. Nissel substence becomes fine/granular/dispersed (central chromatolysis). Nucleolus enlarged; reflects increase synth of protein to regen neuron. compression atrophy: increase ICP/mass -> decrease size/# of neurons. Normal aging - atrophy and gradual loss of neurons Irreversible neuronal injury - neuronal body shrinks, deep eosinophilia, pyknosis, loss of nissel substance. degenerative disease- progressive loss of neurons/reactive glial change.
Wilsons disease
Wilsons - also kidney/joints. diagnose in <30 w/ chronic hep. Cu deposits w/i descementts membrane. Hemolytic anemai. PUTAMEN and globus pallidus. Parkinsonian. asterixis. dysarthria, dyskinesia, dementia, slurred spech, peronality change, depression AR, chromosome 13, ATP7b gene. can also terat w/ trientine, oral zinc. 90% Cu normally absorbed in stomach/duodenum.
LONG THORACIC nerve injury
Winged scapula. C 5-7. defect of serratus anterior due to axillary node dissection or stab wound. cant anchor scapula to thoraccic cage. cant aABDUCT ARM ABOVE HORIZONTAL POSITION (searatous anterior needed to rotate glenoid cavity superiorly). f
Immune disease of B cells
X linked burton: recurrent encapsulated pyogenic bacterial after 6m. guardia, pneumonia, enterovirus (polio coxsachie),. Avoid live vaccines like polio. IgA def - most common. most Asymptomatic: igM and G can be secreted. Airway/GI inf. AI disease, Atopy. CVID: bad B cell differentiation. often 20s, 30s. AI disease, bronchiectasis, lymphoma, sinopulmonary inf. bacterial/enterovirus, guardia
sex chromosome disorders of sexual dev
XXY, can be mosaic. Bar body. see dysgenesis of of seminiferous tubules -> decresed inhibin -> increaed FSH. abnormal leydig cell fxn -> decreased testosterone -> LH -> estrogen (aromatase stimulated by gonadotrophinc) tubues are atrophied/pink/hyalinized. Turner - XO. no bar body. short 4th metacarpal, high arched palate, aortic root dilation. NO beast/menarche. loss of SHOX gene -> short. XYY - antisocial, autism, minor delay XXX - silent.
chronic nonerrosive gastritis
a = fundus/body - AI. aclorhidria. also see increased gastrin (normally inhibited by HCl). A = FIRST part of stomach. b-antrum - most common. H. pylori can directly injur ep cells. also the infl response to it can cause injury. it results in decreased # of somatostatin preducing cells!! -> increased gastrin. accompanied by DUODENAL ulceration. [gastric ulceration can be seen due to no mucus layer, local infl response. acid low to normal, but noral acid is enough to cause gastric ulceration]. MALT/adenocarcinoma. menetrier diseae - gastric/rugae hypertrophy. protein loss. parietal cell latrophy. increase mucous cells. precancerous.
aneurysms and disection
abdominal aneurysm: aatherosclerosis thoracic; cystic medial degen due to HTN (fragmented elastic tissu (basket weave appearance) separate from fibromuscular components by cleft like spaces. B-aminopropionitrit - found insweat peas -> mimics cystic medial degen by inhibiting lysyl oxidase. disection - due to HTN, marfans or ehlers, bicuspid aortic valve (HTN -> medial hypertrophy of vasa vesorum)
neuroblastoma
abdominal distention with is firm, irregular, crosses mdiline (willms is smooth, unilateral). increase HVA, VMA, catecholamines in urine. retroperitoneal, can displace kidney ,HTN, anorexia, ataxia, proptosis, periorbital echimosis, dumbell tumor in epidurla space of spinal cord. cytopenia, hepatomegal.y. younger is better. Bombesin, neuron specific enolase, chromogranin, synaptophysin, s100 positive. optoclonus myoclonus: dancing eyes/feet. non rhythmic conjugate eye mvmnt.
Megaloblastic anemia
abnoral cell division -> pancytopenia. Folate def: trimethoprim and phenytoin can also cause. increased requirement (as in hemolytic anemia/myelodysplastic syndroe can also cause) see glossitis too. see hypercellular marrow/erythroid/granulocyte hyperplasia. Orotoic aciduria: defect UMP synthase. FTT. NO nhyperammonemia (vs OTC def). also see hypersegmented neutrophils, glossitis. rs: uridine inhibits CPSII. neurologic prob, growth retardation other causes in which dna synth is NOT impaired: LIver disease, alcoholism, hpothyroidism; reticulocytosisi (-> increased MCV), drugs like 5FU, zidovudine, hydroxyurea). high dose folate can antagonize pheytoin -> seizure.
Pectinate line
above pectinate line - internal iliac LN below = superficial inguinal nodes. anal fissure - below pectinate line .POSTERIOR midline of anal verge (poorly perfused) see w/ low fiber, constipation. bright red blood. CT: portal vein is medial to or witin right lobe of the liver. anterior to IVC. Imperforate anus: anal calal starts at anorectal jxn (perineal flexure) to perianal skin (anal verge). its often ossociated w/ genitourinary tract malformations adn uro-anythign fistulas.
branching of the radial nerve
above spiral groove radial N gives of posterior cutaneous n of the ARM within spiral groove, it gives rise to posterior cutaneous N of FOREARM it divides at LATERAL epicondyle into deep and superficial branch. deep - supplies extensor compartment of FOREARM superficial - skin on dorsum of HAND
pregnancy complicaionts
abruption - ABRUPT PAINFUL bleed in 3rd trimester. DIC, shock, low BP, tachy, oliguria. often history of ammenorrhea. slightly elevated/soft uterus. endometrial change (deciduation of stroma) w/o embryonic tissue/chronionic vili. hypertonic uterus, intense painful contractions. Previa - risk: C sections, mulliparity. accreta - ATTACH myometrium w/o penetration increta - in myometrum percreta - perforates thorugh. all due to defective decidual lyer. if fetus retained for >6wk, it releases TF from placenta -> DIC. ectopic - amenorrhea, LOWER THAN EXPECTED RISE IN hCG, sudden pain. hypotension/shock. ruptured appendix is a risk factor. EMPTY uterus!
stomach cancer
acanthosis nigricans. intestinal: h pylory, nitrosamines, tobacco, achlorhydria, chronic gastritis. LESSER curvature. has intestinal glands that look like colonic adenocarcinoma. diffuse: NO glands. Kit + GI stromal tumor: use imatinib.
signals for t and b cell activation
activation of Naive t cell: 1. dedricite MHC2 -> TCR on TH cell Antigen on MHC1 -> TCR on Tc cell 2. B7 and CD28 Activation of Bcell. requires a activated helper t cell already. 1. B cell endocytosis and presents on MHC2 -> TCR on TH 2. CD40 to CD40L --> class switch, affinity maturation, Ig production
Adrenal insuficit
acute - sudden. may be due to massive hemmorage. may present as shock/adrenal crisis. weak fatige, hypotension, muscle ache, weight loss, sugar +/- salt craving. primary - adisons disease. ALL THREE LAYERS ATROPY, except medulla. aldosterone and cortisol deficient: hypotension, hyperkalemia, hypercholemic acidosis, hyperpigmentaiton. [contrast w/ secondary adrenal insuficny due to decreased ACTH produciton. no hpyerpigmentation and NO hyperkalemia bc aldosterone synth is perserved!!] tertiary - prompt exogenous steroid withdrawal or decrease CRH. decreased insulin requirements (bc of decreawse cortisol) diagnosis: electrolytes, ACTH stimulation test. Metyrapone stimulation test: [metyrapone blocks 11-deoxycortisol to cortisol], normal response is compensatory ACTH and rise in 11-deoxycortisol and its metabolite 17-hydroycorticosteroid. failure to increase = problem .
central pontine myelinoisis.
acute PARALYSIS, dysarthria, dysphagia, diplopia, loss of consciousness. can cause LOCKED IN syndrome. from low to high pons will die from high to low brain will blow (edema/herniation) pseudobulbar palsy - demyelinate CN 9, 10, 11. weak head/neck muscles. dysphagia, dysarthria. the NUCLEI are intact (in contrast w/ bulbar palsy) btw. cerebral perfusion pressure directly proportional to Pco2 until >90 (then curve becomes flat). therapeutic hyperventilation (decreases Pco2) can be used in cerebral edema to promote cerebral vasoconstriction.
cerebellum
acute cerebellitis - postviral cerebellar ataxia. kids 2-3 wk after VZV, measles, EBV. ataxia, nystagmus, dysarthria. resolves w/i 3 wks cerebellar infarction - vertigo, nstagmus, ipsi ataxia, truncal lateropolsion (fall toward lesion).
DELIRIUM
acute confusional state/decreased attention span/global memory impariment. disorganized thining, VISUAL halluciations, cognitive dusfxn. change in sensorinurium. urinary/fecal retention. EEG NORMAL (vs. dementia) tx: haloperidol Dementia - REMOTE memory spared. GRADUAL decrease inf cogntion. Mainly memory problem/aphasia/apraxia/agnosia/personalitychange/impairned judgement. . NO PROBLEM W/ consciousness. pseudodementia - hypothyroid, depression, B12.
Pylonephritis
acute: affects cortex (NOT glomeruli/vessles) = neutrophilic infiltrate in interstitium. WBC casts. see STRIATED parencymal enhancemtn on CT. may be hematogenous in hospitalized/elderly. chronic; eosinophilic casts in tubule lumen. lymphocytic infiltrate. asymetric corticomedulary scaring/blunted calyx. btw. other causes of cystitis: enerobacter, pseudo, enterococcus
obstructive lung disease intro
airways close prematurely at high lung volumes. decreaesed FVC. Increase complience. hypoxic vasoconstriciton. RV/TLC ratio increases due to air trappin. Compensatory hyperinflation helps widen the airways. Low inspiratory reserve -> limited max tidal volume, esp during exercise when expiration time is limited. Rapid breathing -> increased air trapping and decreases tidal volume. this is called dynamic hyperinflation. In healthy, resistance is smallest when lung inflated (due to radial traction of tissue on conducting airways). ppl w/ COPD try to minimize resistance by hyperventilation.
supine hypotension syndrome
aka aortocaval compresion syndrome: see hypoteions, pallor, sweat, N, dizzy when pregnant woman lies supine. Better in LLDecubitius or sitting up. compression by uterus of IVC. BP falls early in gestaiton seciondary to decreased SVR in pregnancy see inreased plasma volume and increased RBC mass.
Lead poisoning (plumbism)
ala dehydratase/ferocheletase inhibited. it cuases increased FEP. it also inhibits rRNA degredation -> RBC aggregates rRNA (basophilic stipling). has strong affinity for sulfydryl groups in kids: metnal deterioration. in adults: occupational exposure = INHALATION: battery/radiator/amunition-> HA, memory loss, demyelination.consumer exposure = GI (lead plumbing , potery, moonshine) LEAD: Lead lines on gingeva and metaphyses of long bones (burtons lines; blue). Encephalopathy and Erythrocyte basophilic stipling Abdominal colic, constipation, and sideroblastic Anemia Drops (wrist and foot drops). Dimercaprol, eDtA Sucimer used for kids also irritable, loss of developmental milestones, learning problem. FEP also increases in iron def.
lung abcess and aspiration pneumonia
alcohol -> decreased gag reflex. impaired phagocytic/bactericidal action of macs. associated w/ decreased consciousness, cough reflex, dysphagia (stroke), GERD, NG/endotracheal tube. protracted vomiting. abcess caused by bronchial obstruction (cancer) or aspiration. rx: clinda. due to s. aureus or bacteroidies/fusobacterium/peptostreptococcus/prevotella. air fluid level bc abcess communicate w/ air passage -> semifluid exudate partially drain. can also be due to bacterial pneumonia complicaitot (necrotisng pneumonia - nosocommial: s aureus, p aero, e coli ,kleb). septiciemia/IE -> hematogenous: multiple, monomicrobial
Alcohol intox >0.10% = intox, slured speech, bad decisions >.20% = motor impairment, LOC, blackout
alcohol enhances GABA -> downregulation of receptors. Discontinuation -> CNS excitation (withdrawal) Intoxication: GGT is a good indicator. ataxia, blackout, emotional laiblilty withdrawal: 5-10 hrs. max at 2 d, gone in 5d anxiety, TREMOR (first), seizure, HA, autonomic hyperactivity (variable BP, diaphoresis, TACHY). N, V, insomnia, agitation. severe withdrawal: autonomic hyperactivity. for DT, use long acting benzos. use short acting if liver disease. in general, depresants cause mood elevation, sedation, behavioral disinhibition, respiratory depression. withdrawal causes anxiety, tremor, seizures, insomnia.
osteonecrosis
alcohol, trauma steroids, sickle cell bc medial circumflex artery isnt suficitnt
macrocytic aanemia
alcoholism, liver disease, 5-fu . see glossitis. folate def: alcholic, elderly, increased demand (pregnacy, cancer, hemoltic anemia), folate antagonist. b12 def: diphyllobothrium latum (fish tapeworm). contrast w/ hookworms (ancylostoma duodenale, Necator seen with iron def anemia)
Fructose Metabolism. sucrose.
aldolase B -> DHAP adn glyceraldehyde [note F16bp to DHAP and G3P via aldolase A AND B] DHAP -> G3p via triose P isomerase Glyceraldehyde -> G3P via triose kinase Glyceraldehyde -> glycerol *B/c it goes to G3P directly w/o having to go through PFK1, it is teh fastest met of all sugars also, manose -> M6P-> F6P Aldolase B def: fructose intolerance. decreased phosphate available for pathways. Urine dipstick negative (oly utilizes glucose oxidase, cant detect). hypoglycemia, vomit, hepatomegaly, cirrhosis, jaundice.
markers of bone formation
alkP also made by plascenta/liver, inestine. tartrate resistant acid phosphatase is in osteoclasts. URINE DEOXYPYRIDINOLINE, hydroxyproline = measures of osteoclast actity.
DNA viruses: HHAPPPPy: hepadena, herpes, adeno, pox, parvo, papilloma, polyoma.
all are linear except papilloma, polyoma, hepadena (circular) ( pap smear poly circular HepB. al rep in nucleus except pox (has own RNA pol) all icosahedral except pox Naked: PAPP - papilloma, adenovirus, parvo, polyoma (pox is big and chunky, must have an envolope) herpes virus gets it envelope form nuclear membrane membrane destroyed by heating to 50 for 30 min or ether/organic solvents. NOTE: dsDNA (except pox, HBV) and + ssRNA are infectious. -ssRNA and dsRNA are not infectious.
bilieary tract disease
all cause pruritis, jaundice, dark urine, light stools, hepatosplenomegaly, xanthelasma, portal HTN, osteopenia, fatigue increase conjugated bili, cholesterol, ALP in blood. 1. Primary sclerosing - hypergammaglobulinemia (IgM). UC. can cause biliary cirrhosis/cholangiocarcinoma. P-ANCA onino skin beading of intra and extrahepatic bile ducts 2. primary biliary cirrhosis - middle age woman. mitochondiral Ig, incuding igM. see w/ other AI conditions. Lymphocytic infiltrate and GRANULOMAS in intralobular bile ducts. looks similar to GVHD. 3. secondary biliary cirrhosis - EXTRAhepatic biliary obstruction (stone, stricture, pancreatitis) -> increase pressure in intrahepatic ducts -> injury and fibrosis/bile stasis. can be complicated by ascending cholangitis.
thallasemias
alpha - ch 16. due to gene DELETION. 2 gene deleted: MILD anemia, increased RBC count. 3 gens: Severe anemia. B cahans form tetramers taht damage RBC. can see on eleectrophroiess. 4 genes deleted: LETHAL, thus the tetramer is from gamma chains Hb barts. beta - chromosme 11. due to POINT MUTATIONNA B thal minor: asymptomatic. increased RBC count, microcytic anemia, target cells!. decreased HbA, increased HbA2, increased HbF Major: SEVERE anemia after birth. alpha tetramers form bc no Beta. HbA2 and F, NO HbA. microcytic RBC, Target cells. NUCLEATED RBC. RX: transfuisons. see etravascular hemolysis, erythroid hyperplsaia, aplastic crisis risk .
alpha/beta
alpha = FP error beta = FN if power increases beta decreases: power increases w/ expected effect size and precision.
Thalassema
alpha: DELETION. if 4 alleles: gamma chains combine: HbBarts (very high O2 affinity) if 3 alleles: HbH disease (the excess B forms tetramer. migrates firther than HbA. beta: POINT MUTATION in splice sites. (problem w/ transcription/processing/translation) prevalent in mediteranians Minor: see decreased A, and increased A2. asymptomatic Major: see absent A, increaesd F, A2. severe anemia needing transfusions. Marrow expansion/extramedulary hematopoesis (hepatosplenomegaly). HbS/B thal - minor to moderate sickle cell disease dep on amnt of B produced. extramedulary hematopoesis - see thiining of bony cortex, impaired bone growth. can cause fractures. maxillary overgrowth;frontal bossing.
Gastrin
also icnreases gastric motility. triggers: stumach distention, alkalinization, aa, peptiddes, vagal stim. decreased if ph<1.5. phenylalanine/tryptophan are potent stimulators.
Hyper vs hypothroid
always check tsh first. hypothyroid - DECREASED REFLEXES, pleural/pericardial effusion, HYPERCHOLESTEROLEMIA (bc decreased LDLR) facial/periorbidtal myxedema. hyperthyroid - increase bone loss. warm/moist skin/fine hair.k TREMOR, afib, Proximal msucle weakness, LID lag. pretibial myxedema in graves. periorbital edema.
Pathoma Cns 3
alz - short term mem. loss of learned motor/language. infection is killer. no focal neurologic. Pick - ROUND tau aggregates. behaviro/language 1st. Lewy - also lewy body. but early dementia. also haluciation. Huntington: loss of GABAnergic! prion; spike wave complexes. lung/breast/kidney tumors go to brain. glioblastoma: pnesudopalisadig necrosis;endotheial prolif. meningioma: attached to dura. doesnt invade. plicocytic - benign. rosenthal fibers. cystic lesion meduloblastoma: malignant. homer whirte. drop. from granular cells. ependymal: perivascular pseudo. malignant. hydrocephalus.
rx for pseudomonas
aminoglycoside + extended spectrum penicillin (pip/tazo, tic, cefepime, imipenem, meropenem), floroquinolones (esp if UTI), monobactam rx for yersinia pestis: aminoglycoside and tetra rx for lyme diseae: doxy, ceftriaxone
internal capsule
anterior limb - thalamocortical (separates caudate form globus pallidus) genu - corticobulbar posterior - corticospinal, somatosensory, visual, auditory (sep thalamus from globus palidus) dorsal thalams = egg shapped splenium of corpus cllosum: alexia w/o agraphia.
hem onc physiology
antithrombin inhibits factors 2, 7, 9, 10, 11, 12 (same as warfarin but add 11 and 12). both platlets and endothelial cells have vWF. endotelial cells ahslo have tPA, thromboplasitn. platelt clls have fibrinogen. ptn who receieves more than 1 body equivalent (5-6L) of whole blood or packed rbc over 24hr may develope inccreased CITRATE (its an anticoag thats in transfused blood). This citrate chelates Ca and Mg -> PARASTHESIAS. ehcymosis = >1cm. purpura = 5mm-1cm. ESRincreses: inf, AI, neoplasm, GI disease, pregnancy ESRdecrease: polycythemia, sickle cell, CHF, microcytosis, hypofigrinogenemia.
huntingtons
anxiety, decrease memory, [] agression, depresion, dementia. personality change before physical symptoms. 100% penetrant. Expansion of polyglutamin regon -> gain of fxn -> protein interacts w/ other proteins. also see increase HISTONE DEACETYLATION -> decrease genes needed for neuronal survival. CAG repeats: Caudate looses AcH and Gaba, and subsence P. decrese NMDA recepors on caudate. autrophy of caudate/putamen: dilate frontal horn. atrophy of frontal lobe. neuronal death via nmda-R binding and glutamate toxicity.
aphasia
aphasia = language prob. dysarthria - motor problem. broca - BA 44, 45. inf frontal gyrus of frontal lobe.difficulty writing/singing too. POOR REPITITION. RIGHT HEMIPARESIS/oral apraxia. prob w/ nouns/verbs/slow/word finding. FRUSTRATED/AWARE. Wernicke - woords are voluminous. IMPARED REPITITION. BA 22: superior temporal gyrus on temporal lobe. also right superior VF defect. conduction - POOR REPITION ONLY. damage left superior temporal lobe and/or left supramarginal gyrus. TC: can repeate!!
Liver zones biliary structure
apical surface of hepatocytes fae bile cniculi. basolateral surface face sinusoids. zone 1: viral hep, INGESTED toxins II: yellow fever III; centrilobular zone: ischemia. METABOLIC toxins. alcoholic hep. contains P450 enzymes. common hepatic duct combinds w/ cystic duct to form common bile duct: courses w/i head of pancreas. head of pancreas overlays l2. body overlays l2, 3.
APGAR
appearance pulse grimace, activity, respiration if 4-6, assist and stimulate low birth rate is ,2500g
AA derivatives mech of eNOS: Ca channels of endothlium activated by shear stress, serotoinin, substance P, Ach, bradykinin 0> NO -> goes to smooth muscle --> PKG -> decreases Ca -> relax.
arginine -> NO via BH4. also makes urea, creatine Glutamate -> GABA via glutamae dcarboxylase and B6. also makes glutathione. Histidine -> histamine via B6 Tryptophan 1. to Niacin via B6 2. to Serotoinin and eventually melatonin via Bh4 and B6 DOPA to melanin via tyrosinase. tyrosine to DOPA via BH4 DOPA to DA via dopa decarboxyulse and B6 DA to NE via dopamine B hydroxylase and vit C NE to Epi via PNMT and sam (induced by cortisol. degredation: DA to homovalinic acid. NE to Normetanephrine -> vanillylmandelic acid. Epi to metanephrine->vanillylmandelic acid.
Lightning
arrest, arrhythmia, seizures, resp areest, autonomic dysfxn (pupils) LICHTENBERG FIGRUES (fern leaf pattern) bone fractures (shock wave -> mechanical trauma)
transitional cell CA/ squamous
associated w/ Phenacetin, smoking, analine dyes, Cyclophosphamide, occupational exposure : Rubber, plastic, textiles, leather. staging dep on invastion. usually papillary/sessile SCC of bladder - nephrolithiasis, S. haematobium, cystits, smokin.
sleep stages
at night, BATS Drink Blood 1. awake w/ eyes open: Beta (high freq, low amp) (high f bc active. 2. awake eyes closed: Alpha 3. Non-REM stage N1 (5%) - light sleep: Theta stage N2 (45%) - deeper sleep; when bruxism (teeth grinding) - Sleep spindles, K complexes. stage N3 (25%): deepest non-REM (slow wave sleep); when sleepwalking, night terrors, bedwetting occurs. Delta (low freq; high amplitude) 4. REM sleep (25%) - LOOSE MOTOR tone, increase brian o2 use. increase/variable pulse/BP. dreaming, penile/clitoral tumescence. may serve memory processing fxn. Beta waves.
Metastasis to Brain Liver bone
brain: lung, breast, prostate, melanoma, GI liver: colon, stomach, pancreas Bone: prostate/breast, lung, thyroid brest = balstic and lytic overall, lung and liver are most common sites of met lung CA rates have increased in women. decreased in men.
pahtoma deerm basics
basalis, spinosum, granulosum, corneum. basil spewaks to granny corena. hormon sensitive sebum and kertin block follicle -> comedomne. infection -> lipases -> pro inflamatory => psutle/nodules. vitamin A stops keratin prolif. lichen planus: puritic, planar, polygonal, purple papuls. 1. wickham striae (reticular white lines on surface)(oral, wrist/elbows. 2. infl of dermal-epidermal jxn (saw tooth) 3. associated w/ hepC. 4. see hypergranulosis (excessive ganulation in stratum granulosum) Pemphigus vulgarus: can be fatal! desmosome destruction. FISHNET. skin and ORAL. 1. acantholysis - sep of spinosum! 2. tombstone appearance (basal cells still atached) 3. THIN/flacid bullae that rupture easily. (has to be thin! its on the mouth too!) 4.bullae spread laterally w/ pressure (asboe hanson sign) Bullous: HEMIdesomosomes : LLINEAR. ELDERLY 1. basal cell layer also detached. 2. TENSE bullae (containing eosinophils) that dont rupture. milder course. 3. blisters full of serous fluid. normal to red skin. 2cm. (vacuolizations in basal cell layer coalesce to form fluid filled blisters). Eerythemae multaeforme: central necrosis. HSV, mycoplasma, SLE, penicillin/sulfonamides
aneurysms
berry (saccular): jxn of ACOM and ACA. -> SAH or hemmoragic stroke. can -> bitemporal hemianopia: compresses Optic chiasm. increase risk in blacks. charcot: due to HTN. affects small bv.
granulomatous infl
berylliosis, bartonella, churg straus, francissela, wegners, listeria, leprosy, tertiary syph, schistosomiasis
Cocaine
blocks reuptake of DA, 5TH, NE -> sympathetic effects: tachy, coronary vasoconstriction/vasospasm/platelet aggregation-> ischemia. increased vigilence, hyperthermia, psychomotor agitation intox: CHEST PAIN, SEIZURE, PUPILARY DILATION. euphoria, agitation, HTN, epistaxis, hyperglycemia, angina, cardiac death, MI, Stroke Rx: benzo. if used intranasally, see ischemia, mucosal atrophy, nasal septal perforation!!
Cavernous Sinus
blood from eye, superficial cortex => cavernous sinus -> internal jugular vein. also contain CN 3, 4, v1,2, 6, ICA. cavernous sinus syndrome - due to mass effect/fistula/thrombosis) -> opthalmoplegia, decreased corneal/maxillary sensation w/ normal visual accuity. see CN 6 run with the ICA. the others are on the lateral side (go in order)
Diabetic retinopathy
blurry vision, poor night vision, floaters, decrease peripheral vision. see aneurysms, cotton whole exudates, dot and blot retinal hemorage and neovascularization. 1. non-proliferative: damaged capilaries leak blood -> lipids and fluid into retina -> hemmorrhage and macular edema. rx: macular laser 2. proliferative - chronic hypoxia -> angiogenesis w/ resultant tractoni on retina. rx: peripheral retinal photocoagulation. anti-VEGEF injections.
Proliferative Breast condiaiotn
breast lumps, multiple. flucuate in size. premenstrual breast pain. 1. fibrocystic - can see ductal dilation 2. apocrine metaplasia - no risk for CA. abunndent pink cytoplasm. 2. scerosing adenosis - increased acini/intralobular fibrosis. can calcify. sight risk of cancer. central acinar compression and distortion by surronding fibrotic tissue. 3. epithelial hyperplasia - risk of cancer if atypical cells. women >30. 5. atypical hyperplasia (of duct or lubule). 5x risk. acute masitis: dicloxacillin. fat necrosis: necrotic fat, giant cells. mamary duct ectasia - ductal dilation, inspissated breast secretions, chronic granulomatous infl in periductal/interstitial areas. gynecomastia - cirrhosis, testicular tumor, puberty, old age, kleinfelters. "some DOPE drugs easuily create awkward hairly DD knockers" spironolactoen, dope, digitalis, estrogen, cimetidine, alcohol, heroin, dopamineD2 antagonist, Ketoconazole).
Metabolic fuel use
btwn means, mostly use glycogenolysis. also gluconeogenesis and adipose release of ffa. starvation days 1-3: glycogen depleted by day one. then adipose releases FFA. Muscle and liver shift to use FFA. Also gluconeogenesis from peripheral lactate, alanine, glycerol, propionyl coA starvation day 3 onwards: ketones from adipose. after this, proteins degraded.
Heart embryology
bulbus cordis: smooth parts (outflow tract) of L, RV Primative Pulmonary Vein - smooth part of LA Right horn of SV - smooth part of RA (sinus venarum) Left horn of SV - coronary sinus (sinus venosus reieves blood from vena cava) right common cardinal/right anterior cardinal = SVC umbilical vens degenerate. vitelline veins form veins of portal system. cardinal vens form veins of systemic. YLSB: 3,6, 10, 18 yolk sack - 3-8wk (emryonic Hb. Liver - 6wk to birth - HbF Spleen 10-28 BM - 18wk-adult unbilical vein (only 1) so forms ligamentum teres hepatis w/i falciform ligament.
Non-hodgkin
burkitt - adolescent/young adults . cMYC = txn activaton. medium zized. high prolif index (high K1-67 fraction). diffuse large B cell - usually older but 20% kids. t14:18 (same as FOURLicular lymphoma) most common type in adults. can be extranodal. waldeyer tonsilar ring and GI commonly involved. markers for follicular - 10, 19, 20, 21, 79a. adults. INDOLENT> WAXING AND WANING LAD mantle dell - older males. cyclin D1. cd5+ Adult T cell lymphoma - japan, west africa. lytic bone lesions, hypercalcemia. mycosis - adults. CD4. indolent. may see pautrier microabcesses in dermis/epidermis.
Caffine and Nicotine
caffine: Intox: restless, diuresis, muscle twitching, INCREASE APPETITE withdrawal: lack of concentration, HA. Nicotine: Intox: restless Withdrawal: irritable, anxious, craving btw. taking steroids increases HEMATOCRIT, decreases gonadotropins, decreaes testicle size. see acne, deep voice, baldness, liver prob.
manic episode
can be irritalbe. last at least 1 wk. disturbing to the patient. REQUIRES hospoitaliatoin or 3 of DIGFAST: distractability, irresponsible, Grandiositiy, Flight of ideased, goal directive Acitvity/psychomotor Agitiona, decreased need of Sleep, Talkative/pressureed speech hypomanic - not severe enought to couase impaired funcitoning/hospitalizaiton.
Apendicitis
can cause intraabdominal abcess : polimicrobial. b fagilis has surface polysacharides -> abcess formaiton. also ecoli, enterococcus, strep. obstruction -> wall distends -> impairs venous outflow -> hypoxemia/ischemia/bacterial invasion.
Alcoholism
can cause peripheral neuropathy, testicular atrophy. can use disulfiram, naltrexone, acamprostate to treat. Delirium Tremens - peaks 2-4 d. see autonomic hyperactivyt (tacy, tremor, anxiety, seizures). occurs in hostpital setting in alcoholics. rx: long acting benzo (diazepam, lorazepam, chlordiazexoxide) alcoholic hallucinosis - visual hallucinations 12-48 hr after last drink
Adenocarcinoma of lung
can make tubes/papillae/mucin/glands. kRAS, EGFR, ALK. HYPERTROPHIC OSTEOARTHROPATHY (CLUBBING) some non-small cell = inversion of chromosome 2 -> fusion of EML4 and ALK -> tyrosine kinase. young, nonsmoker, adenocarcinoma. rx: crizotinib. Bronchioalveolar subtype - hazy. good prognosis. no invasion. aerogenous spread (along airways). tall columnar. see bronchorrhea (copious amnt of watery speutum).
LUNG CA
can present w/ obstruciton, wheezing. met is usually from breast, colon, prostate, bladder. lung gos to adrenals, bone, liver. can even cause pericardial effusion. dysphagia. all EXCEPT bronchial carcinoid associated w/ smoking. can invade brachial plexus -> shoulder pain. can somethimes see elevated diaphragm on CXR. Paraneoplastic cerebellar degen: small cell lung, breast, ovarian, uterine. see progressively worsening dizzyness, ataxia, dysarthria, visual disturbance. due to anti-YO, P/Q, Hu that cross reacts w/ purkinje neuron antigens -> acute onset rapid degen.
Langerhanc cell
can see recurent otitis media, mass in mastoid bone. s100, CD1a. most effective APC bc they constitiuatively express MHC2 and B7. merkel cell: neuroendocrine cell of basal layer of epidermis. involved in touch.
Membraneous VVVVV
capillary and GBM THICK (but NO INCREASE CELLULARITY) GRANULAR (IgG, C3) EM: SPIKE AND DOME on silver stain, SUBEPITHELIAL deposits SLE, White, IgG against PLA2R (phospholipase A 2 receptor, NSAID, penicillamine, GOLD, HBV, HCV, solid tumors, DM
B12
carried in blood by transcobalamins. use oral supplementation ONLLY if DIETARY defidicy. for most, use PARENTERAL. schilling test. 1. if high urinary excretion, absorption is normal. must be a dietary def. if low excretion, must be absorption problem. part 2: add IF. now if high excretion, IF problem. if low excretion, could be pancreatic insuficincy, ileal disease, intestinal overgrowth (diphyllobothrium latum)
Peroxisome
catabolizes VLCFA!! and Branch chain FA, and AA. has catalase, aa oxidase. its a special form of beta ox and alpha oxidation. Zellweger disease: can't form myelin: hypotonia, seizer, hepatomegaly Refsum disease - can't alpha ox. accumulate PHYTANIC acid. avoid chlorophyll. btw. kartagener: digital clubbing keratin = alanine, glycine, and sulfer continaing AA
SIADH
causes :lung cancer, CNS prob, cyclophosphamide, pulmonary disease rx: restrict water, hypertonic saline, coniVAPTAN, tolVAPTAN, DEMECLOCYCLINE EUVOLEMIC (bc of decreases RAAS, increased naturetic peptides) HYPOnatremia (body responds by decreasing aldosterone to maintain volume status. this low sodium -> CEREBRAL EDEMA/serizures/HA, weak) btw. appoplexy - bleed into pituitary adenoma. bitemporal eyes, sever HA maimic SAH, panhypopituitarism. AI hypophysitis - pregnacy, early post partum. ACUTE HA, VF, cortisol decreased. empty sella - obese women. sheehan - no lactate, menstrate, cold intolerance.
infarct of anterior pons
causes contra hemiharesis, corticobulbar tract (contra lower face palsy, dysarthria). disruption of corticopontine fibers (motor from cortex to ipsi pontine grey) -> contra dysmetria/disdiadicohinkesia (ataxia hemiparesis). cerebellar deficits contralateral bc pontocreebellar fibers decussate and enter cerebellum via contra middle cerebral peduncle.
pathoma endo
causes of nephrogenic DI: li, demeclocyclien cause of SIADH: cyclophosphamide, COPD/pulmoanry infection. rx: demeclocycline. hyperthyroid - staring gaze w/ lid lab. oligomenorhea, hyperglycemia hypothyroid: oligomenorhea, myxedema in larynx and tongue (deep voice, large tongue) graves: scalloped colloid, rx for thyroid sotrm also includes steroids.. storm also cauess vomiting/hypovolemic shock. t4 goes to t3!!! t3 is the activ one multinodular goiter - due to iodine def. usualyy euthyroid. can be toxic goiter -> TSH independent T4 prelease dyshormonogenic goiter - congenital defect in synth. ex: thyroid peroxidase mutation. hashimotos - HLA DR5. germinal centers/hurthle cells (eosinophilic metaplasia of cells that line follicle). Bcell marginal zone lymphoma. the Igs are markers of damag, dont mediate disease Hot nodue: graves/nodular goiter cold nodule: adenoma/carcinoma.
sleep apnea
cease breathing for >10sec. daytime somnolence/energy prob. normal po2 during day. noctural hypoxia -> systemic/pulmonary HTN, RVF arrhythmia, sudden death. [hypercapnia/hypxemia -> reflex vasoconstriciotn/sympathetic heart stimulation] Obstructive: associated w/ obesity, snoring, tonsilar hypertrophy, excess parapharyngeal tissue, poor pharyngelal muscle tone, hypothyroid. -> impotence, poor judgment, HA, depression. MOST COMMON CAUSE OF EXCESSIVE DAYTIME SLEEPINESS. Obesity hypoventilation syndrome: BMI >30 -> increased work/decreased drive -> hypoventilation -> decreased po2 and increased Pco2 during WAKING HOURS (retentino): polycythemia, PHTN, RVF. often occurs w/ obstructive sleep apnea.
cephalic phase/gastric pahse etc.
cephalic - thought/smell/taste -> cholinergic/vagal gastric phase - chemical stimulus of food/distention: gatrin -> histamine. intestinal - when food enters duodenum. MINOR role. illeum/colon -> PEPTIDE YY -> bind ECL cells to decrease acid. receptive relaxation - fundus dilates to anticipate food in pharynx/esophagus.
Cardiac function curves
change in venous return: chanages the mean systemic pressure (x intersept) Chronic AV fistula: it increases contactility, bascular tone, blood volueme. has similar curve as that seen in TPR but has increased mean systemic pressure -> rightward shift of VR curve. TPR decreaes (blood bypasses the arterioles, thus afterload DECREASES. the AV fistula incres rate and volume of blood flow back to heart -> INCREASES preload). Can see pulsitile mass w/ thrill on palpitation and constant bruit. high volume AV shunt can -> high output cardiac failure. anaphylaxis increaes CO and decreases venous return. Anemia increase CO. VR also increases due to decreased blood viscocity. MI only decreas Co Nitroprusside dererases afterload and preload equally. Pulmnary capilary wedge pessure> you put prove in pulmonary arty and occude it. it reasures LA EDP.
immature neutrophils
characterized by lack of fc receptors (CD 16) ALL: 12;21 and 9:22 acute monocytic leukemia: infiltrates teh gums. Myelodysplastic syndrome: cytopenia, hypercellular arrow, blasts <20%. some progress to AML cll -cd5, 20. hypogamaglobulinemia, ai hemolytic anemia, diffuse larbe b cell ATLL - LAD, rash, LSM, lytic bone lesions hairy - splemomegaly, dry tap, no lad. leukoerythroblastic smear: tear drop rbc, nucleated rbc, immature granulocutes. burkit - c myc hokgkin: 15, 30
Pili
cholera, n. meningitis, b. pertusis
bile
cholesterol 7-alpha hydroxylase catalyzes rate limiting step of bile synth. bile also has antimicrobial activity via membrane disruption. anerobes/s. aureus can deconjugate (remove glycine/taurine) -> malaabsorpion b-glucuronidase - released by damaged hepatocytes/bacteria -> deconjugated _. precipitates and complexes w/ Ca. forms pigmented gallstones. heme oxygenase -> biliverdin. liver uptake is passive: uses OATP. excretion is active: uses atp dep MRP2 protien.
gallstones
cholesterol stones = usually cant see. estrogen/clofibrate both increase HMC coA reductase activity. chrones disease/cirrhosis -> decreased. cholestyriamine decreases lipids/bile acids -> increased risk. bilirubin = CAN see. ascaris and clonorchis - can deconjugate bili in biliary tract. biliary colic - wax and wane due to contraction against stone in cystic duct. acute cholecystitis = fever, infection, N/V, ALKP, radiate to scapula. chronic - chemical irritation from longstanding stones or repeated acute cholecystitis. rokitansky-aschoff sinus; herniation of mucosa into muscluar wall. VAGUE RUQ PAIN, esp after eating. can -> porcelain. ascending cholangitis - inf. of bile DUCTS. sepsis, jaundice, abdominal pain. gallblader CA - presents as cholecystitis in elderly woman!
Hemachromatoisis
chromosome 6. HFE = HLA aclass 1 liek molecure. C282Y or H63D. HLA - A3 can reach up to 50 grams. also see pancreatic ribrosis, arthropathy. ethanol, vit C and citric acid increase Fe absorpotin in GI. HFE normally interacts w/ transferin recepors to incresae endocystosis of Fe-transferin complex. if inactivated, body thinks low iron state: try to increase iron via 1. increased apical expresion of DMT1 on enterocytes 2. hepatocytes decrease hepcidin shynt -> high ferroportin expression -> increase Fe into the circulation from enterocytes.
Chron disease
chrones: FAT GRANny SKIPping donw COBLESTONE road away from REck (rectal sparing). granny is as skinny as a string. STRING SIGN (bc bowel wall thickend) , LINEAR ulcers, perianal disease, ALWAYS ABDOMINAL PAIN. oxolate stones [lipids in lumen bind ca->caont bind oxolate -> increased absorption) TH1 mediated -> lymphoid aggregates. produces IL2, IFNg -> mac -> TNF alpha. other: episcleritis, aphtus ulcers, uveitis, migratory arthritis, erythema nodosum, ankylosing spondulitis. rx: steroids, azathioprine, inflix, adalimumab, antibiotics (cipro/metro). associated w/ mutaion in NOD2 - microbe receptor tht triggers NFK-B -> cytokines. mutation allows microbe to persist -> infl.
male extras
chryptoorchidis: atrophy/hyalinization of seminiferous tubules -> decrease inhibin/sperm cout. TESTOSTEONE is normal -> normal LH, sex characteristics. Vasectomy - still have some viable sperm after 3m (20 ejaculations due to leftover) NE -> increase Ca in smooth muscle -> vasoconstriciotn -> antierectile erection - parasympathetic (pelvic n) emission - Sympathetic (hypogastric N). ejaculation - vesceral and somatic nerves (pudental n) spermatogeneisis takes 2 months.
Hepatic encephalopathy
cirrhosis -> shunts -> decreased NH3 metabolism. hyperreflexive due to increased Nh3 production (dietary protien, GI bleed, constipation, infection) or decreased removal (renal failure, diuretics, post-TIPS). other: sedatives, narcotics, hypovolemia, kypokalemia, hypoglycemia, pneumonia, VTI, spontaneous peritonitis. NH3 nrmallly made by GI due to enterocyte catabolism of glutamine and bacteria catabolism of protein. GI bleed -> increase delivery of N to Gut in form of Hb. Nh3 accumulation and increased neurotoxic agents -> altered AA ransport across BBB, impaired neurotransmitter metabolism, decrease cerebral glucose metabolism -> increase inhibitory NT and decreased excitatory. rx: lactulose (acidifies the gut. rifaximin (kills intestinal bacteria)
Diverticula
colonic diverticulai are PULSION by mechanism. true diverticulum = traction. due to infl/subsequent scaring. ex: esophageal diverticula due to mediastinal lymphadenitis, periesophageal scaring. diverticulosis - painless hematochezia. diverticulitis: fever, slukocytosis. can cuase peritonitis/abcess formation, diarhea/constipation. occult blood +/- hematochezia. meckel - painless melana, RLQ pain. intussuception, volvus, obstruction. do pertechnetate study. can mimic apendacitis. intussuseption - compromised blood supply -> COLICKLY pain, CURRANT jelly stool volvus - can cause obstruciton/infarction. sigmoid in elderly. midgut in kids.
intraventricular hemmoarage
common if <32 wk gestation and weight less than 1500 g. altered consciousness, hypotonia, decreased spontaneous mvments. bluging of anterior fontanell. if severe bleed: hypotension, decerebrate, tonic clonic, irregular resp. bleed starts from the GERMINAL matrix: highly cellular and vascularized layer in subventricular zone from wich neurons and glial cells migrate out of during brain dev. They lack glial fiber support so increase risk of hemorage. premies are volnerable bc they have poor autoreg.
Femoral Neck Fracture
common in elderly. Femoral head/neck gets blood from superior/inferior gluteal arteries and M/L circumflex. form the trochanteric anastamosis. MEDIAL CIRCUMFLEX = largest contributer (posterior aspect of femor neck => succeptible to injury. Femoral artery -> M/L femoral circumflex Lateral circumflex = anterior to neck obturatory artery - supplies femor head. esp important to kids bc it supplies head proximal to epiphysial growth plate, not as imp in adults
pathoma repro
complete moel - most vili are hydropic. diffuse circumfrential prolif aroudn hydropic vlii. prostate CANCER: decreased % free-PSA (Cancer makes bound PSA!!) if spreads to lumbar spine -> PSA, ALK-P, prostatic acid phosphatase
MCA stroke and ACA stroke
contralateral paralysis/sensation of upper limb/face. aphasia/hemineglect. also anosognosia, conjugate gaze deviation toward side of stroke, contralateral homonymous hemianopsia. ACA - contra paralysis/sensation of lower limb. also behavioral change and urinary incontience if bilateral.
conus medularis/cauda equina
conus medularis - L2 lesion. flascid paralysis of bladder, rectum, impotence. saddle (s3-5) anesthesia. mild weakiness of leg if it spears both lumbar cord and adjacent spinal/lumbar nerve roots. cauda equina - rupture of intervertebral disk thta compresses two or more of the 18 spinal nerves of the cauda equina. also via trauma, space occupying lesion of lower vertebral column. low back pain that radiates to legs. saddle anesthesia, los s of anocutaneous reflex, bowel bladder dyxfunciotn. loss of ankle jerk reflex w/ plantar flextoin weakness of feet
skin layers
corneum, lucidum, granulosum, spinosum (desmosomes), bsale sun give light to the grains udner the spines. eccrine (merocrine) - skin. holocrine - w/ sebaceous glands apocrine - areola, axilla, genetals, innervated by sumpathetics. not fuctional till puberty. bacteria.
Normocytic anemia:
correct reticulocyte cout by multiplying it by HCT/45. either peripheral destruction or underproduction. extravascular hemolysis: spleomegaly (work hypertroy), jaundice, risk of bili gallstones. Intravascluar - decreased haptoglobin
O2 content of blood distending pressure
cyanoisis when deoyxgenated Hb> 5g/dL. normal Hb in blood is 15g/dL while 1g Hb can bind 1.34 mL o2, thus O2 BINDING capsity is 20.1. (remember to add dissolved o2 to get totoal o2 content. remember, dissolved o2 (PaO2) is normal in CO, anemia is normal. athma; as well as high altitude (decreased FiO2) cause decreased Pao2. its the pressure req. to keep a sphere distended. P-3T/R. thus smaller radius has higher distending pressure. Air flows down pressure gradient so from smaller sphere to larger.
Cardiac Output variables
decreased extracellular Na increases contractility (BC it decreases activity of Na/Ca exchanger) . Contractility decreases w/ Acidosis, hypoxia, hypercapnia bc H goes out for K -> hyperkalemia -> membrane hyperpolarized. blood flow is inversly proportional to cross sectional area. capilaries is slow flow bc total cross sectinoal area is large!! (vessles in parallel) Afterload approximated by MAP. Laplaces law: wall tensino = PressureXradius/2xwall thickness. [thus LV wall thickens to compensate for increased afterload to decrease wall tension] venous blood at coronary sinus = MOST deoxygenated (heart extracts 90%)
Sideroblastic anemia
defect in heme synth ALA is X linked. causes: lead, b6, Cu def, isoniazid, alcohol. see incresed iron/ferritin. NORMAL tibc. rx: B6.
disorders of sexual dev
defective androgen receptor: see increased LH and testosterone Primary hypogonadism: decreased testosterone, high LH exogenous testosterone: normal fsh, decreased LH. Aromatase def: caues masculinization of femalse (ambiguous genetalia). can cause maternal virilizaiton (fetal androgens can cross) Androgen Insensitivity syndroe: NO androgen receptor. It LOOKS female (femal externals). redamentary vagina [uterus/fallopian tubes absent]. DEVELOPS TESTICLES. see incresaed testosterone/estrogen/LH. SCANT sexual hair. normal breast dev (estrogen via aromatase). 5-alpha reductase def - AR. ambiguous external genetalia but at puberty testosterone causes masculinization. Testosterone/estrogen normal. LH normal or increased. INTERNAL genetalia normal. Kallaman - short. no breast, small testes. mutaiton in KAL-1 gene or FGFR1. some pubic haair bc adrenarche is orma.
Vitamin A and B
deficiency: nyctalopia, bliots spots, dry, scally skin (xerosis cutis), alopeciaa, corneal degen excess: arthralgia, allopecia, cerebral edema, hepatotoxic. NVvertigo, blurred vision. B1 - transketolase. brain heart affected first. diagnose with increase erythrocyte transketolase levels after thiamine infusion. anteriro, dorsomedial thalamic nuclei. dri beriberi - polyneuritis, muscle wasting. B2: chelosis, coreal vascularizaition, stomatitis, glossitis, . diagnose w/ urinary riboflavin excreiton or erythrocyte glutathione reductase assay. B3: syth requries B2 and 6. deficincy comon in corn based diets. deficiency: glossitis, Pellagra (D, D, D). see w/ isoniazid, hartnup disease. Excess via PROSTEGLANDIN (not histamine) B5 - component of FA synthase too. see dermatitis, enteritis, allopecia, adrenal insufl. paresthesia, dysthesthesia. needed for synth of vit A, D hemeA, B6: TRANSAMINATION. ast alt. DECARBOXYLATION. glycogen phosphorylase. synth of histamine, serotoinin, ep, norep, dop, gaba. convusions, peripheral neuropathy, cheliosisi, glossitis, dermatitis. may see def in OCP, isoniazid. B7: propoinlyl coa carboxylase, acetyl coa carboxylase, pyruvate carboxylase. dermatitis, allopecia, enteritis, via antibiotics, raw egs (avidin avidly binds) B9: folate. most common def in US. can be caused by phenytoin, sulfonamides. glossitis. B12. diphylobothriu latum. synth only by microbes. older mentally slow woman of N european descent who is lemon colored w/ shiny tonugeu.
Macular degen
degen of macula (central retina). causes distortion (metamorphopsia) and eventual loss of central vision (scotomas) . LEADING CAUSE OF BLINDNESS IN INDUSTREALIZED COUNTRIES. presents as troubly driving, watchign tv, reading. 1. dry (non exudative) - most common. subretinal derusen deposits in and beneath brusch membrane and RPE with gradual decrease in vision. prevent w/ vitains, antioxidants, zinc. look like multiple yellow spots. dry urualy progresses to wet. 2. wet - rapid loss in vision due to bleeding secondary to neovascularizatoin. rx: anti-VEGEF (ranibizumab, pegaptanib) or lazer
stages of grief stages of change
denial anger bargaining depression acceptance rpecontemplation contemplation preparation action maintanance
Acute inflamatory demyelinating polyradiculopaty
destroy shwn -> infl/demyelination of peripheral nerves. autonomic dysfxn - heart prob, hyper or hypotensoin. . Papiledema (due to increased protein). canaals obe deue to CMV. plasmaphoresis, IV IG. bugs w/ ganslioside like substances in LPS -> corss react w/ gangleosides in myelin. segmental demyelination and endoneurial infl infiltrate. decrease DTR/flascid. Lenghth constat (space constant) - measure how far along an axon electrical impulse can propegate. meyelin decreases charge dissipation by increasing membrane resistance. damage -> decrease lenght constant. time constant - time it takes for change in membrane potoential to reach certain volue. Lower time -> icnrese conduciton speed. myelin decreases capacitance -> decreases time constant. summation: occurs at dendrits/cellbody/axon hillock. tempora - sequential from same neuron. Spatial - simultaneous form several diff neurons.
chest wall and lung
diagram: chest wal is the one to the left. At FRC, intrapleural pressure is -5, PVR is at minimum. [chest wall transmits an expanding force to lung (negative transmural pressure). alveolar transmeural pressure is always positive (perpetual collapsing force on lung) during inspiration, intrapleural pressure decreases to -7.5 -> nslightly negative alveolar pressure that draws air into lung. compliance decreaes in pulmonary fibrosis, pneumonia, pulmonary edema complience increases in emphysema/normal aging. increased chest wall recoil decrease expiratory flow rates bc muscles have to work harder during expiration to oppose increase in outward force.
carcinoid
diarhea, flushing, wheezing, syncope due to decreased bp, cyanosis, telangectasiia. can cause niacin def (pellagra) illeium, apendix, rectum. most common malignacy of small bowel. 1/3: met, have second malignacy, are multiple ROSETES on histology. dense core granules. NO variation in shape size. nests and glands. oval to round nuclei. restrictive cardiomyopathy.
which are ADP ribosylating?
diptheria, paero, shigella, EHEC, ETEC, B anthrax, cholera, pertussus
Diffuse prolipherative GN
due to SLE or MPGN LM: WIRE LOOPING OF CAPILARIES (endothelial cells/lymphocytes prolif) EM: subendothelial, someties intramemraneous Ig based Ic, often w/ C3 IF; granular (subendothelial, mesangial) most common cause of death in SLE.
Psoas abcess
due to spread form vertebral bodis, ependix, hip joint, blood/lymph. risk: DM, IVDU, IC. fever/back pain. inginal mass. pain w/ extension of hip (psoas sign). patient presents w/ hip flexed and lumbar lordosis. obterator externus - from obterator foramen to trochanteric fossa. external rotation of thigh. quadratus lumborum - posterior to psoas. connects 12th rib and upper lumbar vertebrae w/ illiac crest. helps w/ extension and lateral flexion of vertebral column. Rectus femoris - part of quadracepts. attaches it to patella. extend knee, flex thigh. Vastus medialis - part of quadrecepts. from proximal femur and inserts to patella. erector spinae - on back. courese longitudinally along the spinal processes. contraction -> spine extension.
retroperitoneal
duodenum = 2nd through 4th parts. all of pancreas EXCEP tail. esophagus, rectum. retroperitoneal hematoma - seatbelt/steering wheel - > pancreatic injury if patient is STABLE. paneth cells - at base of crypts. have phagocytic and secretory properties (lysozyme, defensins)
dystonia
dystonia - sustained/painful contraction (abnormal mvmnts or postures). basal gang prob. ex: writers cramp; blephargospasm (sustaiend eyelid twitch then full closrue). focal - 1 muscle group. ex: cervical dystonia (spasmodic torticollis. congenital torticolus - head tilted to affected muscle. soft tissue mass may be palpated in inferior 1/3 of SCM. chin pointed away from contracted msucle. SCMinjured/fibrosed. due to birth trauma or malposition of head in uterus. (fetal macrsonmina/oligohydramnios) rx for dystonia: botulinum toxin. also used to relax LES, spasms in MS, parkinsons.
bracial POUHES
ear, tonsil, bottom to top: 1: ear, 2: tonsils 3 dorsal (bottom; for inferior parathyroids) 3 ventral (To = thymus) 4 Top = superior parathyroids. 1st pouch: middle ear cavity, eustachan tube, mastoid air cells. pharyngeal membrane of 1-> tymphanic membrane. 2nd: epithelial lining of palatine tonsil 3rd: dorsla: inf parathyroid. ventral: thymus 4th: dorsla; superior parathyroids. ultimobrachial bodies neural crest associated w/ 4th/5th pharyngeal pouches -> parafolliclular cells. ``
osteoarthritis
eburnation - polihed appearance of bones osteophytes - boen spurs subchnondral cysts slerosis.
Effect modification
effect of exposure on an outcome is modified by another variable. NOT a bias. often confused w/ confounding. when doing statified analysis, with effect modificaiotn diff strata has diff measures of association
endometrial path
endometritis - rx: gentamicin, clinda. +/- ampicillin. Endometriosis - NORMAL sized uterus. bleed, dysparenunia. rx: nsaid, OCP, progestin, GnRH agonsit.s may see "nodularity of uterosacral lig adn fixed retroversion of uterus -> dyspareunia. Adenomyosis - caused by hyperplasia of basalis layer of endometrim. dysmenorhea, menorrhagia. painful. enlarged uterous due to reactive smooth muscle hypertrophy, hyperplasia. Adenomyoma 0 may contain smoohth msucle cells. Endometrial CA - MOST COMMON GYN MALIGNANCY. 65yo. risk w/ DM, htn,. Leiomyoma - has pseudocapsule. MOST COMMON tumor in females. 20-40yo. may cause abnormal uterine bleeding/misscariage.
Margination/rolling
endotheilum: E and P selectin/Glycam-1 and cd 34 P selection from WP body. increased by histamine E selectin inducted by TNF, IL1 Leukocyte: Sialyl-lweis/ L-selectin first have to be selective about what you are going to do
Renal physiology
endothelium = size barrier, BM = negative charge barrier. INULIN - freely filtered. Neither reabsorobed or secreted. USE TO MEASURE GFR. usually 125. 2x increase in cre -> 1/2 reductiodn in GFR. PAH - FILTRATion of PAH cant be saturated. constant proportion filtered. SECRETION from peritubular capillaires inot proximal tubule is by energy dep organic acid transpiorter. this CAN be saturated. [SECRETION plateaus, any increase in urine PAH due to increased FILtTRATION] Creatinine - can be normal even after 50% loss of kidney funciotn. cre olny rises when GFR <60. thus, CRE IS INSENSITIVE FOR DECREASING GFR WHEN CRE NORMAL. it is NOT a linear relationship. RBF = RPF/(1-Hct) FF = GFR/RPF (normal FF is 20%; 20% of plasma is filtered. Flitered load = GFR x Px (cant be saturated; hence excretion cant be saturated) Excretion rate = V x Ux
Tight and diapedesis chemoatractants
endothelium ICAM1 (cd 54) / VCAM 1 (CD106) Upregulated by TNF and IL1 leukocyt: CD 11/18 (LFA1, mac 1) and VLA4 integrin Upregulated by C5a LTB4 diapedisis: PECAM1 (cd31) 5a, il8, LTN4, PAF, Kallikren (macs can release IL8 -> phagocytosis in neutrophils)
Leukopenias
eosinopenia - cushings syndrome Lymphopenia (<1500 cells; 3000 in kids): HIV, SLE, radiation, sepsis, postop. Neutropenia - <1500). sepsis/postinfeciton, SLE, radiation leukoerythroblastic smear: nucleated RBC, mature WBC.
Hydrocephalus
ependymal cels surroundied by fenestrated pia capilaries. ependymal = cilliated columnar/tight jxns. NPH: age related impaired absorpiton is compensated by decreased CSF formation. ventricles enlarge adn distort fibers of CARONA RADIATA. Reveresile. ataxia/urinary incontinence due to traction of sacral motor fibers distortion of periventricular limbic system -> dementia/emotional blunting. hydrocephalus ex vacuo - ICP normal. childhood hydrocephalus - impaired outfw due to arnold chiari II, aqueductal stensosi, toxo infection. irritable, MUSCLE HYPERTONICITY, HYPERREFLEXIA due to stretch of periventricular pyrimadial tracts.
estrogen/progesterone
estradiol (ovary)>estrone(fat)>estriol(placenta) 2,1,3 (placenta is the weakest) estrogen increases myometrial excitability, stimulates prolactin secretion, increases transport protein/SHBG. pregnacy: 50X incrase in estradiol/estrone 1000x incrasein estriol (indicator of FETAL wel beeing) it also causes upreg of estrogen/LH/Progesterone receptors. tehca externa - SM, fibroblasts, CT support for follicle. androstenidione from tehca cell -> goes to granulosa cell. hCG is hightest at wk 9, decrese mid pregnacy bc degen of corpus luteum. LH low during pregnacy b/c progeterone feeds back.
RNA Pol
eukaryotic have 3: 1 = rRNA (most numerous) 2=mRNA (largest in size) (and sn, micro) 3= tRNA and 5srRNA - for 60s. a-amantin - inhibits II. see hepatotoxic, renal toxic, abdominal pain, vomit, cholera.
Benzodiazepines
euthoria, relax, amnesia, sedation, slurred spech, hypotension, bradycardia, ataxia, resp depression. rx: flumazenil (rarely used bc can cause seizures) withdrawal: sleep disturbance, depression, rebound anxiety, SEIZURE, tremor, agitiaon, TACHY
celiac trunck and splenic arteries
example of anastamosis: superior epigastric (from internal throacic/mammaruy) w/ inferior epigastric (from external iliac) branches of celiac trunck 1. splenic 2. left gastric: proximal lesser curvature. gives off esophageal branch. 3. common hepatic a. propper hepatic -> right gastric b. gastroduodenal A. R. gastroepiploic B. superior pancreaticoduodenal. gastroduodenal - pylorus and proximal duodenu.
Hyperammonionemia
excess NH4 depleats aKG and glutamate bc it --> glutamine. thus it inhibits TCA cycle and excitatory neurotransmission. causes astrocyte swelling. (normally excitatory neurotransmittor glutamate take up by astocytes, converted into glutamine and then given back to neurons) causes hyperosmolarity, mitochondrial dysfxn, asterixix, slur, v, cerebral edema, blurred vision. Rx: Benzoate/phenylbuterate to bind AA -> excretion. Laculose to acidfy GI adn stop NH4 absorptoin.
Phenylketonuria
excess phenylalanine inhibits tyrosinase. see hypopigmentaion in brain nuclei too. eczema. Malignant PKU - no BH4 - > no tyrosine, dopa, serotoinin, NO. microcephaly, MR, GR, Heart. Homocystinuria: intelecutal disabiltiy , ostoporosi, kyphosos/soliosis, lens doun and in. cystine becomes essential. methionine can -> succinyl CoA B12 def leads to increased N5 met-THF and decreased THF (folate trap) Cystinuria: AAuria. cystine = 2 cysteines. rx: alkalinize urine w/ acetazolamede and KCitrate. Cyanide(1st)-Nitroprusside(added 2nd to react w/ the sulfydrulgroups) test. Red-purple collor.
Hereditar thrombosis syndromes
factor v - dvt, cerebral vein throbosis, pregnanc loss. prothromgin - butation in 3' untranslated region -> increase produciton. vneous closts. antithrombin def: no direct effect on PT, PTT, thrombin time. but deminishes the increase in PTT folloiwng heparin admin.
LIMBIC System
feed, flee, flight, feel, sex emotion/long term memory, behaviro modulation, autonomic NS. fornix: hippocampal subiculum to mamilary bodies.
femoral region parts of duodenum
femoral SHEATH - contains vein/artery and femoral canal. NOT femoral nerve. 1st part - horizontal. overlies L1. NOT retroperitoneal. 2nd aprt - decends between L1-3. 3rd part - horizontal over L3, aorta, IVC. CLOSS ASSSOCIATON W/ UNCINATE PROCESS AND SMA. 4th part - courses superiorly and to left of L2/3. becomes jejuum past ligament of tritz.
fetal brain anomolies
fetal AChE transudes across defect into amniotic fluid. meningocele has normal AFP. Anecephaly - frog. open calvarium. Maternal diabetes. Holoprosencephaly - L/R hemispheses dont sep. maybe due to Sonic HH prob. moderate if cleft. severe if cyclopia. Encephalocele - neural tissue protrudes through cranial defect. Chiarri I - herniation of TONSILS. asymptomatic in kids. in adult: HA/ataxia. SYRINGOMELIA Chiarri II (arnold) = TONSILS and VERMIS + aqueductal stenosis/hydrocephalus. MYELOmeningocle -> paralsxyx. compression of medulla -> prob swallow, dysphonia, stridor, apnea. Dandy-Walker - Agenesis of VERMIS + cystic dilation of 4th vent. hydrocephaus/spinal bifida.
Downs
first trimester screen: hypoplastic nasal bone, decreased PAPPA, increased B-hcg quad screen - decreased Afp, increased B hcg. Decreased Estriol, increased Inhibin (goes down up alphabetically). atlantoaxial instability. ostium Primum. Edwards: CLENCHED HAND, fingers overriding. OCCIPUT. LOW SET EARS. MICROGNATHIA. first trimester: decreased PPPA AND b-hcg. Quad: decreased everyghitn, (inhibin can be normal. PATAU: holoproencephaly, Polydactuly, cleft lip/palate. aplasia cutis (scalp defect). FIRST TRIMESTER: DECREASED B-HCG, PPPA, INCREASED NUCHAL TRANSLUCENCY. WILLIAMS: deleitoin of region of chromosome 7 including elastin gene: ELF, dumb, hypercalcemia (sensitive to vitD), friendly, CV prob, good verbal.
Pacemaker
first two leads in RA and RV. 3rd on LV: go from RV to coronary sinus in AV groove -> venous tributaries.
SVC syndrome -
flacial plethora, JVD, edema in upper extremities. can be caused by thrombosis form indwelling catheters. can increase the ICP -> HA, dizzy, risk of rupture of intracranial artery. can see dilated collateral veins in upper torso. COMMONLY IN SMALL CELL LUNG CANCER. also see w/ non-hodgkins. SVC formed by R and L bracheocephalic veins behind 1st costal cartilage on the right. Right Bracheocephalic v - formed from subclavian and internal jugular. also drains right lymphatic duct. obstruction in one of the bracheocephalics = same as SVC syndrome, just unilateral. internal jugular - brain, face, neck external jugular - scalp, lateral face
Pleural effusion. see blunting of costophrenic angle.
fluid accumulates btwn the two pleural layers -> restrict lung expansion transudate: pretty much just fluid. via CHF, nephrotic, cirrhosis exudate: protein, cloudy. due to Malignancy, pneumonia, collagen vascular disease, trauma (increased vascular perm) lymphatic: TG, milky
hepatic abcess -
fluid filled cavity, fever, chils. 1. parasitic inf (entamoeba, echinococal) 2. billiary tract inf (ascending cholitis) 3. portal vein pyemia (bowel/peritoneal sources) 4. Hepatic artery - systemic hematogenous seeding (ex: s. aureus) 5. direct invasion from adjacent sourse (peritonitis, cholecystitis) 6. penetrating trauma = mixed aerobe/anerobic
rx for anthrax rx for actinomyces and nocardia rx for M. Avium Rx for leporsy
fluoroquinolone and Doxy SNAP Azithro, rifampin, ethambutol If tuberculoid: dapsone, rifampin for 6 m. if lepromatous: add clofazimine; 2-5 years. sulfatides: "sulfahides" inhibits phagolysosome fusion chord factor: indicates virulence. induces TNFa
mesntral cycle
folicular growth fastest during 2nd week of proliferative phase. oligomenorhea >35 d. polymenorhea <21 d. metrorrhaga- intermesntraal bleeding: frequent but irregular menorrhagia - heavy. >80 ml blood loss, >7d bleed. menometorrhagia - heavy, irregular menstruaiton at irregualr intervals prolif phase: glands/stroma ratio <1:1. glands strait/narrow/short. compact stroma. secretory: ratio increses to 1:1. stromal edema, glands cilated/coiled. vacules full of glcogen. increse oxytocin RECEPTOR expresion on myometrium in late gestation.
iron regulaation
for Fe3 to be absorbed, must use FERROREDUCTASE first. gets into enterocyte by DMT1. iron binds ferritin and remains in enterocyte. later, exits enterocyte via FERROPORTIN tehn transported in blood by TRANSFERIN. Hepcidin increes w/ increasing FE or inflamation. Decreases w/ hypoxia/erythropoesis. it interacts w/ ferroportin on macs and enterocytes to decrease release of iron. EPO made by renal interstitial cells in cortex lactoferrin is in renal tubular cells adn binds iron in urie.
progressive supranuclear palsy
form of parkinsonionism due to neurodegen of midbrain/frontal subcortical wit matter 0> rapidly progressive gait prob, executive fxn lss, vertticle gze paly. also see hyperphosphorylated tau.
Epidural hematoma
fracture. can cause trantorial herniation. DOESNT CROSS SUPTURE. can cross tentorium/falx. can cause cushing response due to increased ICP: hypotension/bradycardia. btwn inner and outer dural layers (outer dura = inner periostium of skull). biconvex/lentiform
multiple myeloma
fried egga pearance. igG and IgA secreting. .50yo. plasma cells w/ clockface/wagon wheel chromatin. intracytoplasmic inclusions containing Ig. Bence jones proteisn are filtered then reabsorbed in tubule. saturated -> precipitate -> EOSINOPHILIC CASTS taht obstruct the lumen -> renal failure. normocytic anemia bc BM is replaced (easy fatigue). see CONSTIPATION due to hypercalcemia. myeloma cells make osteoclast activating factor. renal failure aslo due to hypercalcemia, hyperuricemia, infilration my myeloma cell and due to infl.
Pancratic cancer
from DUCTS. HEAD. also CEA. diabetes, MEN, HNPPC, FAP, jewish, black migratory thrombophlebitis (trouseau syndrome) = superficial vain thombois bc cancers make thromboplastin like substance -> read thenderness on palpation of extremities. Courvoiseire sign - obstructive jaundicw w/ palpable nontender GB.
G- Differential
g- outer membrane wall inhibits entry of penicillin and vanc Maltose: Meningitidis is + (malt liquor in the dorm room), gohorrhea is negative. both are ox positive, and glucose. Coccoid rods: H. infl, pasteurella, brucella, bordetella Oxidase + comma shaped : c. jejuni (grows at 42), V. cholera (grows in alkaline media), H. pylori (urease) Lactose fermentors: Fast: KEE. Slow: citerobacter, seratia Lactose nonfermenters: 1. ox positive: pseudomonas 2. oxidase negative: Shigella salmonell proteus yersenia. Salmonella/proteus make H2S (turn black on TSI) Shigella doesnt make H2S Makonky: pink if lactose. Ecoli makes B galactosidase that breaks down lactose into glucose and galactose. EMB: black/purple if lactose. EColi is green.
GI secretory products
gastric acid - inhibited by somatostain, GIP, PG, secretin. gastrinoma - neuroendocrine tumor. see in pancreas/duodenum. JEJUNAL ulcers. also diarhea/pain. pepsin - perferentially cleaves aromatic AA. increased by vagal stim, local acid. Hco3 - incrase by pancreatic/biliary secretion w/ secretin. other: serotonin - made by enterochromafin/kulchitsky cells -> peristalsis/nausea. PEPSIN AND HCL NOT REQ FOR DIGESTION (can still digest after total gastrectomy). medium chain FA can passively diffuse into enterocytes.
gastrojejunostomies and peyer patches
gastrojejunostomies - used to treat bad peptic ulcer disease. causes decreased irion absorption (also due to decreased acid). also b12, folate, fat soluable, Ca def) vit C is absorbed in distal small bowel in active process. B6 = jejunum/illeum, passive. B5, 7 - small and large bowel. Na dep. multivitamin transporter peyers - in lamina propria and submucosa. plasma cells reside in lamina propria. IgA binds polymeric ig receptor on basolateral surface of ep -> transcytosis. recives "secretoary component: remnant of pIgR"
eclampsia
gestational HTN: methyldopa, labetalol, hycralazine, nifedipone. deliver at 39wk. after 20th wk of gtation w/ no previous htn. Preeclampsia - deliver at 34 wk if sever, 37 wk if mild. after 20th wk to 6 wk postpartum. (<20wk suggests molar pregnacy). severe if >160/110. HA, scotoma, oliguria. due to abnormal placental spiral arteries that -> maternal endothelial dysfxn, vasoconstriction, hyperreflexia. may also be due to release of infl factors from hyoxic placenta. complicaiton: abruption, renal failure Eclampsia: see intracrnial hemorage, ARDS HELP may occur w/o HTN.
glucagon/epi
glucagon: does NOT affect skeletal muscle/fat (vs epi) it increases ketone production. glucagon can stimulate insulin release. epi - decreases glucose uptake in muscle. increaes alanine release -> gluconeogensis. somatostatin deceases GH and TSH TRH incrases TSH and prolactin gh analog tesamorlin used to treat HIV asociated lipodystropy
Glycolysis: hexokinase vs glucocinase PFK reg Pyruvate kinase Pyruvate DH ketogenic AA where is anerobic met seen
glucokinase - liver and pancreas. lwer affinity but higher capacity (V max). NOT regulated by G-6P (inseted regulgulated by F-6-P). associated w/ maturity onset diabetes of the young (cant use glucose -> less insulin release -> hyperglycemia) PFK: promoted by AMP, F26BP, decreased by Citrate, ATP. [Fed state - insulin decreases PKA to increase PFK2 and decrease FBPase2. Fasting: glucagon increase PKA -> increase FBPase] steps thtat make ATP: PG kinase, Pyruvate kinase Pyruvate kinase: Inhibited by alanine, ATP. Increaed by F16BP. pyruvate DH: activated by NAD+, ADP, Ca (exercise). inhibited by NADH, ATP, Acetyl coA. Arsenic inhibits lipoic acid. Deficity: pyruvate shunted to lactic acid and alanine. to treat, do diet hght in fat, or ketogenic AA (leucine, lysine) 'note: Phenylalanine, tryptophan, tyrosine, threonine isoleucine = gluconeogenic adn ketogenic. Lactic acid DH used in: RBC, leukocytes, kidney medulla, lens, testes, cornea.
GUucose and AA clearance and JG apparatus
glucosuria starts when plasma level is 200. at 375, ALL transporters fully saturated Hartnup disease: pellagra (photosensitive, skin rash, ataxia); rx: high protien/nicotinic acid. JG cells are of AFFERENT arteriole that secrete renin in resp to decreased renal BP, decreased NaCl delivery to distal tubule and increased sympathetic tone. . Macula densa = part of DCT.
EFFECTS of V/Q mismatch on pulmonary gas exchange
going from low to high V/Q, blood doesnt become saturated w/ Co2. (hyperventilated regions compensate for less ventilated regions). going from low to high V/Q, blood quickly becomes saturated w/ O2 (levels off). highly ventilated regions cannot compensate. arterial PaCO2 is inversly related to and is the MAIN INDICATOR of total alveolar vent [HYPOCAPNIC IMPLIES ALVEOLAR HYPERVENTILATION]. hypoxemia stimulates peripheral chemoreceptors -> increase resp drive -> excessive Co2 excretion -> hypocapnia. hypoxemia itself persits bc cant absorb extra o2 -> increase alveolar/arterial o2 gradient. rx: o2 and correct underlaying disease. decrease chest wall complience -> increase work of breathing -> fatigue, alveolar HYPOventilation, Increase PaCO2. this situation can also be caused by upper airway obstruction/decreased resp drive.
infectious arthritis
gonococial - migratory arthritis. asymetric pattern. STD (synovitis - knee; tenosynovitis - hand; dermatitis) s. aureus, streptococcus.
Hawthorn effect
groups who know they are being studied behave differently Dr. Hawthorn acts differently when others are aroudn
Psychosis
halucinaotn - PERCIEVE even when no stimuli delusion - false BELIEF disorganized speech - words strung togeher based on sound/puns/"loose associations' VISUAL = MEDICAL illness AUDITORY hallucionat = PSYCHIATRIC illness . Tactile hallucination: cocaine/alchol - formication - bugs crawwing on skin hypnaGOgic - when going to sleep. hypoPOMPic - during POMPous wakening.
osteomalecia/rickets
harrisons sulci - indentions on lower ribs. craniotabies - softening of skull decreased vit d -> decreased Ca -> increasted PTH -> decreased P, increased alp from osteoblasts. "widened osteoid seams" osteiod matricx accumulates around trabeculae. vit D resistant rickits = X linked DOMINANT.
VSD
harsh sounding. accentiated w/ hand grip. L sternal border. Loud murmor = small VSD. Soft murmor = large VSD
coagulation pathways overview platelte de
hemophelia C 0 factor 11 hageman factor - factor 12 HMWK promotes factor 12. factor 12 activates kallikrein C1 esterase inhibiters inhibit kallikren kalikren promotes formaiton of plasmin and conversion of HMWK to bradykinin. bradykinin -> vasodilate, perm, pain, nonvascular smooth muscle contraction thrombin activates factor 5, 8, 13 Thrombin time: rate of conversion of fibrinogen to fibrin. prolong w/ heparin. PAF - at low [ ] it cuaes vasodilation/perm. otherwise, its important to aggregation, constricion, bronchoconstricion plasmin can convert C3 to C3a to cause complement. aminocaproic acid prevents formation of plasmin.
uncoocked shellfish vaccine preventable diarhea
hep A, V. cholera, Norwalking collecting shellfish hep A, typhoid (live atenuated vaccine)
Alcoholic livr diseaes
hepatic statosis - MACORvexiclar steatosis, nucleus off to side. decrease FA ox due to increase NADH. impaired lipoprotein assembly. most prominant in centrilobular zone. alcoholic hep - long term. slwoen adn necrotic hepatocytes w/ NEUTROPHILIC infiltraiton. mallorey bodies. alcoholic cirrhosis - micronodular. honail apearnace. scerosis of zone III. nonalcoholic fatty liver - ALT>AST.
Zenker diverticulum
herniate at killian triangle btwn thyropharyngial and cricopharyngeal parts of inferior pharyngeal constriction. due to poor relaxion of pharyngeal msucles during swallowing -> more pressure. can cause aspiration pneumonia. lateral neck mass. phases of swallowing: 1. oral: voluntary - bolus lifted up to posterior wall of pharynx. 2. pharyngeal pahse- involuntary pharyngeal contractions 3. esophageal - food stretches wall -> peristalsis.
uniparental disomy hardy weinbyrg in X linked
heterodysomy (heterozygos) = meiosis I error. Isodisomy (homozygous) - meiosis II error or postzygotic chromosomal duplicaiton q= males, q^2 = females.
grade vs stage
high grade: poorly diff, anaplastic staging not useful in brain bc it doesnt mmetastiasise, use bromodeoxyuridine to assess grade (thymidine analogy btwn adrenal cel CA has increase P-glycoproten
distributive shock
high output filler (decreased TPR, increased CO and VR) decreased PCWP vasodilation failure to increase BP w/ IV
AR
high pitched blowing EARLY decrescendo. vasodilators decerase murmor (causes decreased systemic arterial pressure). carotid pulsations (de musset sign) due to lage SV going to neck. listen at right sternal border w/ patient leaning forward. PR is same ias this.
V/Q
highest at apex (3). base = 0.6. v/q = 0 : shOnt (airway obstruction; 100% o2 wont help) v/q = infinity: dead space (no blood flow). think of bood as infinity in the middle. ventilatin increases as you go down: gravity streches lungs. zone 1: alveolar P>arterial>venous: capilaries collapsed so no blood flow (can see if low pulmonary arterial pressure (hemorage) or high alveolar pressure (+ pressure vent.) zone 2: arterioalr >alveolar>venous. capilaries obstructed at venous end, but as arterial pressure increaes in systole, it can overcome alveolar. pulsitile flow. Zone 3: supine, all zone 3. exercise -> vasodilaiton of apex -> V/Q close to 1. ventilatin defect matched by perfusion defect in lung collapse and consolidation.
hodgkin vs non hodgkin
hodgkin is localized/single group of nodes. contiguous spread (stage is strogest predictor. Better prognosis. Bimodal distrubition: young adulthood and >55yo. more common in men except nodular sclerosing subtype. non-hodgkin - multiple, extranodal involvment common. noncontiguous cells. peak at 20-40yo. Reactive hyperplasia: 1. follicular hyperplasia 2. sinus hyperplasia (fill w/ histiocytes) 3. diffuse: architecture effaced by sheets of lymphocytes, immunoblasts, macs if a single gene for the V region of TCR predominates then its monoclonal! (can see pleomorphism/increased mitosies, nuclear change if reactive hyperplasia. not specific
pulmonary emboli
homan sign: dorsiflex: pain. hypoperfusion causes a V/Q mismatch. -> hypxemia/hyperventilation/alkalosis. ABG: increase pH, decrease Co2, O2. tacypnea, tachy, sudden dyspnea, coough, dyspnea. Zahn: pink is platelets/fibrin. red is rbc. more often in upper lobe. first test is CT angiography. v/q scan when CT is CI (contrast allergy). ex: Gas emboli (rx: hyperbaric o2); Amniotic fluid (causes DIC), Tumor, Bacteria. Fat emboli: neurologic prob, hypoxemia, peicheal rash. release of FFA from the fat emboli -> local tixic injury to endothelium. some globules can escapte due to AV shunts -> CNS. platlet adherance/coating of fat globules -> thrombocytopenia/petechiae. STAIN BLACK W/ OSMIUM TETROXIDE. may see anemia due to RBC aggregation/pulmoanry hemorage. pregnancy is predisposing bc uterus puts pressure on IVC -> stasis. also see increase clotting factors, derease fibrinolysis, decrase protein S. decrase vascular tone
Standard error of the mean
how much variability btw sample mean and true population mean. SEM = SD/sqrt. N accounts for variability due to sampling
PCOS (stein leventhal syndrome)
hyperinsulinism/deranged steroid synt by theca -> hyperandrogenism. normally, estrogen -> increase SHBG and decrased LH. insuilin/testosterioine -> dcresaed SHBG -> increased free testosterone. testosterone gets aromatised to estrogen -> endometrial cancer risk (also bc abssent progesterone). also see icnreased risk of atherosclerosis rx for hirstuism/acne: OCPs - increase SHBG and deccreas LH to decrease free testosterone antiandrogens liek spironolactone (testosterone receptor antagonist) or 5a reductase inhibitors (finasteride) if fail to respond to OCP alone!! for infertility: use clomiphene citrate (blocks negative fedback of circulatine estrogen to decrease FSH and LH). ??? i dont understand. fixing testosterone problem -> enables LH surge. use cyclic progesterone for endometrial protection.
colon
hyperplastic - hyperplasia of glands. left colon. serrated appearance. adenoma - look the same on colonoscopy. sesile (flat) is worse than pedunculated LEFT: sinister. grips you (napkin ring(, blood streaked). ADENOMA CARCINOMA SEQU. RIGHT; raised. anemia. vague pain. MICROSATILITE. ` FAP - ch. 5 turcot - meduloblastoma, glal tumor Hamartoma - kids. single recatal lesion that prolapses and bleeds. juvenile polyposis - miltiple hamartomas polyps in STOMACH and colon. peutz - if hamartomas THROUGHOUT GI tranct AND mucocutaneous hyperpigmentaiton. AD. also breast, GYN cancer. HNPCC - also ovarian, endometrial
pahtoma CNS part 2.
hypoglycemia can also cause global cerebral ischemia. Mild global ischemia -> transient confusion. severe -> diffuse necrosis -> vegetative state. moderate -> watershed -> laminar necrosis (layers 3,5,6) thrombotic stroke: pale infarct at periphery of cortex (bc thrombosis occurs at branchpoints Lacunar -> pure...ishemic.. IntraCEREBRAL: charcot brouchard; basal gang!! subarachnoid: berry (media absent at branch points). AV malf. leukodystrohigs: metachromatic leukodystrophy(accumulates in oligodendrocyts)/krabbe (accumulates in macs). Adrenoleukodystrophy - cant add CoA to LC FA (X linked) contrast w/ dementia; loss in GREY matter. MS - DR2. increased lymphocytesl. oligoclonal IgG. central pontine myelinosis = acute bilateral paralysis. see in malneurished.
Fates of helper t cell
if IL12 (from NK/mac) and IFN gama(from mac) -> TH1 -> IL2 and IFNg. IL2-> CD8 cell IFNg - > Macs via Jak-stat pathway. also promots IgG. IL2 causes autocrine prolif of TH1. Inhibited by IL4 and 10 from TH2 if IL4 or mac IL1 -> TH2 cell -> IL4, 5, 6, 13, 10 IL4, 13 -> IgE (binds mast/basophils. activates eosinophils) and IgG IL5 -> eosinophils and IgA IL10 inhibits infl resp. IL6 is pyrogen and activates acute phase reactants Inhibited from IFNg from TH1 MDGEA if TGFb and IL6 -> Th17 if TGFb -> Treg. express CD3,4,25,Foxp53. secrete IL10, TGFb btw. macs express CD14 (TLR4 for LPS), CD40, MHC2, B7, Fc/C3b receptors
pelvic fracture in man
if blood at urethral meatus and high riding boggy prostate (caused by hematoma formaiton below gland) = injury of urethria. catheter is CI. posterior urethra (prostatic and membraneous segments) = above bulb of penis. anterior urethra (bulbus and penile segments) = w/i bulb adn corpus spongiosum membranous segment - unsupported. weakest point. bulbous urethra injured in crush injuris (straddle injury) penile urethra injured in penetrating trauma. injury to anterior bladder wall can occur w/ pelvicfracture. see extraperitoneal leak of urine.
plasma cell cyscrasias
il6 stimulates plasma cells in multiple myeloma waldenstrom: b celllymphoma. LAD, visual/neurologic deficts bc of hyperviscocity. blddeing (viscosuity -> poor aggregation. langerahas cell are s100 + Letterer-siwe disease: less than 2, malignant. skin rash, cystic skeletal defects Eosinophilic granuloma - benign, pathologic fracture in adolescent. NO skin. Hand shuller christian disease: malignant, scalp rash, lytic skull defects, diabetes insipidus, exopthalmos. >3yo.
Microcytic anemia
in ireon def and anemia of chronic diseases, see increased free erythrocyte protoporphyrin. in chronic disease, increase hepcidin: it sequesters iron by limiting iron transfer from macs, suppressing EPO release -> increased Ferrritin, sideroblastic anemia is an iron overloaded state. pregnancy or OCPs increase TIBC by increasing tranferin synth from liver. results in low saturation. serum iron and ferritin normal.
Ketone Bodies
in starvation, OAA depleted for gluconeogeessis. in alcholoism nadh shunted OAA to malate -> buildup of acetyl-coA to shunt to ketone bodies. leucine, HMGCoA synthase feed to form HMG-goA --> MITOCHONDRIAL HMGcoAlyase -> acetoacetate -> Bhydroxybuterate via NADH. btw. urine test doesnt detect b-hydryxybuterate. ketones used by muscel, heart, renal cortex, brain. (heart/skeleetal muscle use ONLY ketones to save glucose for brain) NOT used by RBC (no mit), NOT used by liver (laccks succinyl-coA-acetoacetate-coA transferatse) (thiophorase) in the mit: Bhydroxybutyrate->acetoacetate -> AcetoacetylCoa (via thiophorase and succinyl coa). then -> 2 acetyl coA
insulinoma and glucagonoma
insulinoma: whipple triad of hypoglycemia: lethergy, syncope, diplopia. glucagonoma. Depression, DVT, Diabetes, Dermatitis (necrolytic migratory erythema - papules/plaques on face/grions,extremities taht coalsece -> bronze colored central indurated area w/ peripheral blistering and scaling. also affects mucus membranes)
Auscultatoin of heat
in tricuspid area, also listen to ASD, VSD in upper left sternal border, AR, PR, hypertrophic cardiomyopathy. in Aortic area: AS Afterload: handgrip - increase backward flow murmors liek MR, AR, VSD. decreased HCM, AS, later onset of click of MVP/increase intensity For preload: increased with: squating, leg raise: see increased all murmors except MVP and HCM **note, prolonged squatting increases afterload decreased w/ standing/valsalva/nitroglycerin: decrease all murmors except increase MVP, HCM HCM: most common cause of v. fib in young. systolic ejeciton murmor. dynamic LV outflow obstruciotn w/ associated MR. "bifid carotid pulse w/ brisk upstroek" "spike and dome. increases w/ preload or afterload. s3 - see in restrictive cardio/dilated cardiomyopathy, high output states (pregnant, thyrotoxicosis) s4 0 see in MI, ventricular hypertrophy, aortic stenosis, restrictive cardiomyopathy.
urachus/vitelline duct
in week 2, yolk sac forms allantois -> extends into UG sinus. allantos becomes urachus. can remian as vesicourachal diverticulum (slight outpouching of bladder). urachal cyst - partial failure of obliteration. can cuase infection/adenocarcinoma. urachal sinus - failure to close distal part of urachus -> periumbilical tenerness/purulent discharge to due recurrent infection vitaline sinus - open at umbilicus vitalin cyst - enterocyst.
SHBG
in women, decrease SHBG -> increase testosteroe -> hirstuism OCP/pregnancy incraeaes SHBG. free estrogen levels remain unchanged. in men, increase SHBG -> decrease testosterone -> gynecomastia. TBG increses w/ estrogen/pregnancy bc catabolism of TBH decreases. total T4/3 increases but level of free Thyroid remains normal.
GYN epidemiology
incidence: endometrial>ovarian>cervical (but most common worldwid) worst prognosis: ovarian>cervical>endometrial
NRDS
increase PDA risk bc low o2 tensino. supplemental o2 can also cause intraventricualr hemorage. metabolic acidosis, necrotising enterocolitis. Local temp hypoxia -> VEGEF release. when get ventilated -> neovascularization/retinal detachment. complication of surfactant: hypoxia, hypotension, pulmonary hemmorage.
ESR what is secondary amyloidosis?
increased with: most anemias, pregnancy decreased w/: sickle cell, CHF, Polycythemia (increased RBC dilute aggregation factors) serum Amyolid A. due to inflamatory condtions. often multi system.
Asthma
increaseed TH2/TH1 ratio. reversible bronchoconstriciton/smooth muscle hypertrophy. eosinophils in wall. cough, wheeze, dyspnea, tachypnea, pulsus paradoxus, decreased I/E ratio. diagnose w/ decreased FEV1 and decreased peak exp flow rate. during atack there is hyperinflation. normal btwn atacks. challene test: [ ] of methacholine to decrease FEV1 by 20%. sensitive, not specific. it also increases airway secretion. Severe - symptoms throughout day, at night daily. With limited activity, req. oral steroids w exacerbations. Frequen use of short acting inhaler. Consider omalizumab: fewer exacerbation and can discontinue oral steroids and decreas dose of inhaled steroids (fDA approved for mild-severe persistant/incomplete resp. w/ steroids.) Allergic asthma - normal CXR. Thick mucosa w/ eosinophils. Asthma = thickened due to chronic subacute inf. Things that can inhibit COX 1 can. Except acetaminophen. INCREASE DLCO due to increased pulmonary blood volume.
things that modify PPV
increases with prevalence and preset prob (if prevalence decreases, number of false positives make up a greater proportion) prevalence = directly related to pretest probability
Acute phase reactants
induced by IL1, 6, TNFa, IFNg from macs/neutropnisl increased: serum amyloid A, ferritin, fibrinogen, hepcidin (prevents release of iron), CRP - opsonin, fixes complement, facilitates phagocytosis. decreased: albumin (to conserve AA) and transferrin (internalized by macs to sequester iron)
Lipotechoic acid Lipid A and O polysach
induces TNF IL1 Lipid A induces TNF IL1, O is the antigen
Gastric band
inflatable device around CARDIA. slows release to increase satiety. it must pass thorugh LESSER omentum. lesser omentum = double layer of peritoneum from liver to lesser curvature of stomach and 1st part of duodenum. contains the hepatogastric and hepatoduodenal ligs.
Fetal adrenal gland
inner active fetal zone makes androgens. needs help of placenta bc it lacks 3BHSDH to convert pregnenolone to progesterone. outer zone later makes cortisol -> surfactant. controled by ACTH and CRH from fetal pituitary and placenta [crh form placenta upregulated by cortisol]. thus BOTH materanl and fetal cortisol contributes.
Drug induced interstitial nephritis (tubulointerstital nephrits)
interstitium infl, edema. Pyuria (eosinophils and igE) azotemia. due to haptens. 1-2 wk after diuretic, penicillin derivatives, lead, sulfonamide, rifampin, NSAID. ceph, acetazolamide, allopurinol. infl cells can infiltrate tubular ep (tubulorehxis). tubular content can spill into intertitium (foreing body GRANULOMAS). fever, rash, hematuria, acute renal failure, arthralgia.eosinophilia. nocturia (tupular dysfxn), polyuria.
INtravascular vis extravascular hemolysis
intravascular: urobilinigen in urine. extravascular: increase LDL and unconjugated bili/jaundice, ppigmented gallstones. also see decreased haptoglobin bc free Hb spills into blood HS: AD. also protein 4.2. incresed MCHC/RBC DW. splenomegaly/aplastic crisi, anemia, jaundice. Eosin-5-maleimde binding test!!! negative combs test normal to decreased MCV. G6PD: Xlinked. DKA can cause. back pain, hemoglobinuria. reticulocytoisis, dark urine, rbc fragments/microspherocytes. PK def - AR. "rigid RBC". see anemia in newborn. splenomegaly due to work hypertrophy. decreased exercise tollerance. HbC defect - glutamic acid to lysine. see mild anemia but no sickling. Paroxysmal - AQUIRED mutation in stem cell. COOMS negative, PANCYTOPENIA, venous thrombosis (prothrombotic factors from lysed RBC). PIGA gene mutation.
rx for pheo
irreversible alpha blockade BEFORE b blockr then tumor rescection.
ischemic colitis acute mesenteric ischemia Necrotizing enterocolitis
ischemic colitis - ahterosclerosis -> pain after eating, weight loss. splenic flexure sigmoid colon. can see bloddy diarhea. Acute mesonteric Ischemia - often embolic occlusion of SMA. necrosis -> pain out of properion. CURRANT JELLY STOOLS. necrotisng enterocolitis - necrosis/perforation. usually colon. see in preemies (decreaesed immunity) and formula fed. causes, free air in abdomen, portal venous gas. penuatosis intestinalis - air in bowel WALL. seen as "thin, curvilinear areas of leucency that parallel the lumen". distetnion/bloddy stools. enteral feeding -> bacteria -> invade wall -> infl/ishemic necrosis. bowel becomes congested and gagnernous. can cause strictures, obstruciton secondary to fibrosis.
INsulin
it increases AA uptake to increase protein synth. tyroskine kinase P IRS -> activates protein phosphatase that deP glycogen synthase -> activation. and deP F16BPase to inactivate gluconeogenesis. Glut 1 - RBC brain cornea 2- b celsl, pancreas, intestine, liver, kidney 3 - brain placenta 5 - sperm, gi tract TNFalpha, high FFA, glucagon, epi, glucocorticoids P IRS1 to inhibit P by tyrosine kinase to decreawse insulin secreation. somatostatin and alpha 2 inhibit insulin. B2 increase insulin. a2 is predominant w/ sympathetic stimulation. m3, h2, GLP1, glucagon increase insulin
glucose-dep insulinotropic peptide (aka GIP)
its becaseu of this that oral glucose works faster than IV. K cells of duodenum/jejunum. stim by FA, glucose, aA it decreses gastric acid. increaes insulin secretion. GLP-2 = L cells in response to food intake. it decreases glucose by inducing satiety, decreasing gastric emptying, increasing insulin relase. Gs-> cAMP.
what is sao2 findings in anemia findings in CO poison
its the amount of saturation of Hb (<90 is hypoxia) l Pao2 normal, sao2 normal Pa02 normal, sao2 decreased. chery red. mehtemoglobin: chocolate, cyanosis. methylene blue.
anaplasma erlichia borrelia recurrentis
ixodes tick lone start tick louse bartonella: silver stain. rx: doxy, macrolies. pertusus: macrolides gardernella - metro. or clinda to treat teh anerobids. ph greter than 4. 5
Aminoacids:
ketogenic AA (leucine, lysine) Gluconeogenic and ketogenic: Phenylalanine, tryptophan, tyrosine, threonine isoleucine = gluconeogenic adn ketogenic. essential AA: PVT TIM HL. histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine.(arg and His req. during growth) AA with 3 titratable protons: aspartic acid, glutamic acid, HAL. and Tyrosine His = no charge. Arg most basic aspariginase can be anti-neoplastic. (in these cells, asparagine synth synth is impaired)
POT
lasts 1-4 hr. stored in adipose tissue. can detect in urine up to 30d. INTOX: MIOSIS, EUPHORIA, INCREASED APPETITE, DRY MOUTH, PRECEPTION OF SLOWED TIME, TACHY. inapropriate aughter, anxiety, paranoid delusions, impaired judgemnt, social withdrawal, hallucination, memory loss, decreased reflex, dizzy, decreased coordination, sedation. withdrawal: irritable, depression, insomnia, nausea, anorexia. peak w/i 48hr, last 5-7 days.
portosystemic anastamosis
left gastric (portal) w/ esophageal (systemic) Paraumbilical (portal) w/ small epigastric veins of anterior abdominal walls. portal v. forms retroperitoneal behind pancreas at L1 (SMA and splenic v fuse NONSELECTIVE B BLOCKER (nadolol/propanolol) decrease risk of varaceal bleeding by decerasing CO and splanacnic blood flow. use nitrates as adjuvant. Norfloxacin = prophylaxis for spontaneous bacterial peritonitis in ppl who are cirrhotic.
Positive LR
likelihood of having disease given positive result Sensitivy / (1-spec) negative : 1- sensitivity / spec sensitivity always on top
biceps msucle
long head courses intraarticularly and inserts on supraglenoid tubercle. short head attaches to coracoid process. common distal tendon inserts on radial tuberosity and fascia of forearm. Biceps tendon rupture -> visible palpable mass in mid upper arm (popeye deformity)-.
PV loops
look at the PV loops this way: if teh right side of the square moves left then preload decreased. If the top art of square weent down then afterload decreased. if teh left part of the square went right then the contractility decreased. if the bottom of teh square goes up then complience decreased (as with diastolic HF)
berkson bias
looking only at inpatients (the berkson hospital)
PDA
loudest at S2. coarction: may be continuous murmor due to large collateral BV
Lac operon
low glucose -> increase cAMP that activates CAP -> txn if high lactose -> unbinds repressor protein at lacO
where to place thoracocentesis?
lower border of pleura on RIGHT: at midclavicular line: 7th rib. at Aidaxillary/midscapular line = UPPER border of 10th (right has the upper hand). at paravertebral line: 12th rib. lower border of pleura on left: same except LOWER border of 10th. lower border of LUNG = 2 IC spaces above the respective pleural borders. if below 9th at midaxillary -> liver injury. NAV is at LOWER boarder of rib, thus always do thoracocentesis at upper boarder. (lower is worse) fracture of 1-6 is greatest chance of damaging visceral pleura.
AA in histones what is methylated in DNA
lysine argenine cytosine, adenine increase Zn -> decreased Cu degenerate/redundant. (except methionine and tryptophan encoded by only one codon)
GVH disease
maculopapular rash, desquaminaton, jaundice, diarhea, hepatosplenomegaly. can prevent w/ HLA match, washing donor cells w/ anti-thymocyte Ig to remove T lymphocytes usually due to BM/Liver transplants. Positive effect for leukemia.
VIP
made by parasympathetic gang thoughout GI tract. it increases water/electrolyte secretion, relaxes intestinal smooth muslce. increases bicarb/cl form pancreas. it decreases H. tirgger: distention/vagal stim. decreased aby adrenergic imput. vipoma - pancreas. WDHA. hypokalemia. acidosis. hypotension due to dehydration.
Human placental lactogen and fe
made by syncitiotrophoblasts. similar fxn as prolactin/GH. it increases maternal insulin resistance to incfse glucose abailable to fetus. it also increasees maternal lipolysis/proteolysis (mom uses teh FA, ketones for energy) if hypoglycemia, it can increse to get fetus. if it doesnt work, ketones can be used for fetus. maternal insulin resistance also enhanced by placental secretion of GH, glucocorticoids, estrogen/progesterone. IF HIGH GLUCOSE IN MOM -> enters fetus -> fetus incresaes insulin production (B cell hyperplasia). can result in hypoglycemia when born for 7 days. The high insulin in mom can also cause fat depositon/increse fetal growth -> macrosomia (>4kg).
Progesterone
made in placenta/adrenalcortex/tests too. decreases myometrial excitability. causes uterine smooth muscle relaxation. increases body temp. decreases estrogen receptor breast milk - low in vit KiD (K and D) phlegmasia alba dolens (painful white milk leg) - due to iliofemoral venous thrombosis in peripartum women. pregency increase DVT risk bc uterus presses on dep pelvic veins. tanner staging: 1: prepuberty II: thelarche = first objective sign!!; pubarche III: breasts enlarge/penis size increases, hair dark/curly Ib: raised areolae, penis grows width/dev glans. dark scrotum V: areolae no longer raised
Genital embryology
male = mesonephric. does NOT produce prostate. female = paramesonephric (mullerian). garther duct = remnant of mesonephric. mullerian duct anomalies may present as amenorhea in female w/ fully deveoloped secondary sex characteristics (ovaries functioning) SRY produces testes determining factor which helps testes development. primordial germ cells originate near youlk sack and move to genitall ridge -> primatoive gonads. defective seritoli cells -> lack of MIF (see both lmale adn female internals w/ normal make externals) defective 5-a redductase - ambiguous externals until puberty (teststerone masculinization)
suicide
male, tenager/elderly. women try more though. highest risk in 45-64. next is >85.
GI pathoma
mallory weis - painful esophagela varacies - painles. L gastric vein backs up into esphagela va. achalasia/esophasgeal web - SCC of esopagus. upper 1/3 to cervical. then mediastinal/tracheobronchial. then gastric/celiac.
Cre-lox RNAi linkage disequilibrium
manipulate genes at specific developmental points to study rnaI - DSRNA made of teh mRNA sequnce. when transfered into cells, dsRNA separates adn binds to target mRNA leading to decreased gene expression lto calculate, multiply the 2 gene frequencies. allelic heterogeneity - diff mutations in same locus -> same phenotype (b-thal) . locus heterogeneity - mutations in diff loci proudce same phenotype (albinism) a1antitrypsin = codominant.
sojgren syndrome cancer
marginal zone B cell llymphoma
reliabiltiy = percison
maximized when random error is minimal. it increases power. measured by coefficient of variation
CI
mean +/- Z(SEM) for 95%CI (p<0.05), Z = 1.96 for 99, p<0.1 z=2.58 for mean diff, if it includes 0 not stat sig for OR or RR, if includes 1, not stat sig if CI btw 2 groups overlap, not stat sig
Lymph Nodes
mediastinal: trachea/esopahgus axillary: upper limb, breast, skin above umbilicus Internal iliac: lower rectum to anal canal above pectinate line, bladder, prostate, middle 1/3 of vagina Para-aortic: gonads, kidey, uterus Superficial inguinal - external genetalia, scrotum, anal canal below pectinate. skin below umbilicus. it overlays femoral vessels, bounded by inguinal lit, adductor longs, sartorius. popliteal - dorsolateral foot and posterior calf
S100 CA 15-3/27-29 afp
melanoma, neural tumors, schwannomas, langerhans cell. s100 is a Ca binding protein, helps w/ cell growth breast HCC, hepatoblastoma
IgA neph (berger) and Alport
mesangial proliv, and IC dep. IF: IGA deposits in mesangium presents w/ URI, acute gastro. painless hematuria 2-3d after. come backs once in a while. alport: IV collagen defect: thinning and SPLITTING of BM (liek MPGN). X linked. deaf, eye prob.
overview of anemias
microcytosis: iron, chronic disease, thal, lead, sideroblastic normocytic: 1. nonhemolytic (decreased retic count): chronic disease, early iron, chronic kidney disease, aplastic anemia. 2. extrinsic hemolytic: AI, microangiopathic, infections 3. intrinsic hemolytic: HS, G6Pd, HbC, paroxyslam nocternal, sickle cell macrocytic 1. megaloblastic - folate/b12/orotic aciduria 2. non-megaloblastic - liver diase, alcoholism, reticulocytosis.
MVP
mid systolic click then systolic crescendo (loudest just before s2. earlier w/ things that decrease venous return.
proteinuria
minimal change disease is mostly low MW proteins (albumen, transferins) Orthostatic proteinuria - happens in tall, older, thin adolescents. protein excreted whe uprigt. Functional protienuria - due to increased blood flow. increse w/ exercise, fever, stress, cold. Protiens of low MW filtered then reabsorbed in proximal tubule. if exceedes resorptive capacity -> proteinuria. tubular proteinuria - Low MW, b2 microglobin, Lc, AA, retinol binding protein due to interstitial nephritis. size selection: gbm pores/slit diaphragm (FA says endothelial cell fenestrations). charge: BM
minute ventilation alveolar ventilation
minute vent: RR x Vt alveolar = (Vt - Vd)x RR.
pupilary light control
miosis - edinger -> ciliary gang -> short ciliary ->> pupilary sphinctor. mydriasis - hypothalmus -> ciliospinal center of budge (C8-T2) -> t1 to superior cervical gang -> plexus along internal carotid -> cavernous sinus -> enters orbit as long cilliary nerve -> pupilar dilator. marcus gun pupil - AFFERENT pupilar defect. damage to optic N or retinal injury -> decreased bilateral constriction when light shone in affected eye relative to unaffected eye (swinging flashlight test). afferent limb of light reflex: retinal -> optic nerve -> chiasm -> optic tract -> pretechal. if optic TRACT lesion, can cause relative afferent pupilary defect in pupil CONTRALATERAL to lesion bc NASAL portion of retinal contributes more input. to pretechal than temporal portion. [pupilary light reflex normal if leion in lateral geniculate/visual cortex]
Sites of met: alcohol met: kwashiacor: anemia marasmus: ptotein and carbs
mitochondria: b ox. cytoplasm: FA synth, HMP, cholesterol/steroid synth. aacetaldehyde dehydrogenase in mitochondria. fasting hypoglycemia (bc OAA goes to malate) G3P -> glycerol 3 p -> TG (hepatosteatosis). TCA is inhibited, increase Acetyl coa shunting to ketones and lipogenesis. Fomepizole - inhibits alcohol DH. rx for methanol or ethylene glycol. Disulfram - inhibits acetaldehylde. fat =9, ethanol =7, carb/protein=4. ATP with malate shuttle (heart and liver) = 32 ATP with glycerol shuttle (muscle) = 30 alanine is cahill cycle (used to carry amino groups from liver to muscle). lactate is cori cycle.
Golgi
modifies N-oligosaccharides on arginine. addos )-oligosaccharides on serine/threoinine. adds Manose 6P. I cell disease (defect in phosphotreanserase can't transport to lysosome) high plasma lysosomal enzymes, clouded cornea, coarse facial features.
twinning
monozygotic - 20% 0-4d- 25% - splits before morula stage. dichorionic/diamnionic. placenta may be fused 4-8d - 75% - before blastocyst stage. mooCHORIONIC, diamnionic [chorion befoe amnion. amnion is the inner part so this makes sense] 8-12 d - 1% - before embryonid disk forms - monoamnionic/monochorionic. risk of umbilical chord entrapment >13 d - monochorionic/monoamnionic . risk of conjoined twinns. note: cytotrophoblasts makes the Cells. syncytiotrophoblast lacks MHC class I (cant be attacked by maternal immune system) 2 umbilical arteries. single umbilical artery = chromosomal/congenital anomalies. umbilical arteries derived from allantois.
CHRONIC REJECTION
monts to years. T and B cell mediated. chronic low grade. host thinks donor MHC is real and reacts against donor antigens presented. FIBROSIS. Chronic low grade. vascular wall thickening/luminal narrowing, interstitial fibrosis/parenchymal atrophy. Heart: atherosclerosis Lungs: bronchiolitis obliterans (SMALL BRONCHILI): imfl/necrosis of walls. exudate and granulation tissue in lumen, scarring. major mortality in lung transplants. dyspnea ,wheezing, cough. Liver - vanishing bile ducts Kidney - vascular fibrosis, glomerulopathy: worsening HTN, increase care, proteinuria. shrinkage of renal parenchyma/fibrosis/atrophy
primative reflexes
moro - abduc/extend limbs then draw thogether. rooting - seek nipple (move head toward one side if cheek/mouth stroked. suckling - suck when roof of mouth touched Galant reflex - stroke one side of spine while newborn is facedown causes lateral flexion of lower body toward stimulated side.
Gout
most are udnerexcreters. overprodcuces: PRPP excess, von gierke wbc less than 20,000 (give ceftriaxone in the mean time) needle. negative (yeLLow in paraLLel). tophus can be on external ear, olecranon bursa, achilles. alcohol competes for uric acid secretion sites. ACUTE: Nsaid - 1st line (carful w/ elderly/renal failure). Glucocorticoids - only if eldely w/ bad renal fxn.. Colchecine chronic: allopurinol. febuxostat - safe in renal disease adn less drug reactions. if EXCRETE large amoutns, avoid uricosuric drugs, could cause urate nephropathy. use NSAIDS to prevent acute gout when hupouricemic drugs initiated
MS
opening snap and then essentially it is decrescendo cercendo (late diastolic accentuation due to atrial contraciton). delayed rumbling LATE diastolic murmor. decreased interval btwn S2 and OS indicates increased severity. (with worese stenosis, increase LA pressure so valve opens more quickly.
Ovarian Neoplasms: benign
most common ovarian mass in >55. risk w/ infertility, pcos, endometriosis, BRCA, HNPCC. infertility/nuliparity/misariage/clomiphen citrate all cause irregular repair processes on ovarian surface! decease risk w/ OCP, breast feeding. OCP decrease $ of ovulations -> decrease # of repairs it has to go through. can present w/ bowel obstruciotn, abdominal distension. monitor w/ CA125 (but also increased in endometrial/lugn/breast/pancreatic, cirrhosis, PID) Mucinous cystadenoma - can progres to pseudomyxoma peritonei. cystic teratoma - most common ovarian TUMOR in 20-30. can see pain secondary to ovarian enlargment/torsion. Bernner - appears encapsulated. pale yellow-tan in color. fibroma- pulling sensation in groin. thecoma - can produce estrogen -> abnormal uterine bleeding
Clavicle
most fractures at middle 1/3 of the bone. SCM on superior medial aspect aspect, thus supplies upward traction on fractured clavicle!! SCM inserts on manubrium of sternum, medial clavical, mastoid process. AC joint subluxation - due to downward force on tip of shoulder. swelling and upward displacemtn of clavicle. subclavis starts on 1st rib. pec minor - starts on 3-5th ribs and insurts on coracoid process of scapula. major and minor rhomboids - start on vertebral bodies/spins and insert on meidal border of scapula.
rx for H. infl
mucosal inf: amox and clavulanate. meningitis: ceftriaxone; rif prophylax. PYR vaccine
MESODERM derivatives
muscle, bone, CT, blood, lymph, dermis serous lining of body cavities spleen (from foregut mesentary), kidney, adernal cortex heart structures, wall of gut tube testes/ovaries VACTERL: vertebral defect, anal atresia, cardiac defects, TE fistula, Renal defects, Limb defects
NMJ diseases
myasthenia gravis: DEREASED MOTOR END PLATE POTENTIAL. see flucuating weak. better w/ rest. thymoma/thymic hyperplasia. decreased compound muscle action potential amplitude. cholinergic crisis - due to too much ACHE. muscles become refractory. Lambert Eaton - proximal muscle weakness, dry mouth impotense, BETTER w/ use. INCREMNTAL response to repetitive stim.
aurebach vs meisners
myenteric/aurevahc - btwn inner cercular and outer longitudinal in muscularis propria subucosal/meissners - in submucosa UC - crypt abcesses /w neutrophils. pseudopolyps. loss of haustra (lead pipe), angiodysplasia - acquired malf in bv in cecum and right colon due to wall tension. also presents w/ hematochezia in older adult (like diverticulitis, except location different)
Bronchiectasis
nechrotising infection of BRONCHI -> perminately dilated. purulent speutum, infections, hemoptysis. see w/ obstruction. CF: can see hyperplastic/hypertrophied mucus secreting cells in bronchiectasis/CF: COMBINED restrictive/obstructive defects: decreased Fev1/FVC ratio, DECREASED total lung volumes. Decreased DLCO.
BBB
nonpolar/lipid soluable cross RAPIDLY via diffusion glcuse/AA carrior mediated. fenestrated capilaries and no BBB in areapostrema (dorsal MEDULLA adn caudal end of 4th ventricle) and OVLT (osmotic sensing) [both project to hypothalmus] also where neurosecretory products enter cirulation (hypothalmus) another barier is maternal-fetal blood barrier of placenta.
pahtoma: rheumatology
osteoarthritis: DIP = herber. PIP = bouchards!!! (opposite of what you thought earlier). PB (penut butter). eburnation. osteophytes. RA: pannus (granulation tissue). ankylosis (fusion of joint). NOOO DIP. sysstemic symptoms. narrow joint sapce, osteopenia. SAA -> secondary amyloidosis rheumatic nodules (necrosis surroudned by histocyes) pleural effusion, LAD etc. posoriatic: DIP is common. podagra (toe). tophi - chronic lembet eaton: improves w/ use. eyes spared.
Cardiomyopathies
normal LV wall thickeness is 1cm. EEEEcentric = in sEEries. e = elongates concentric = C's stacked together = increass thickness dilated: Alcohol, beri, coxsachi, cocaine, chagas, dano, hemochromatosis, diptheria, chronic SVT, sardoid, pregnant. S3. lwo salt, ace, b blocker,, diuretic, digoxin hyptertrphic: friedrichs. b blocker, ca blodker. Prominent A wave. Mitral regurg and outfow obstruciton. antiror leaflet of mitral valve. murmor increases w/ decrease preload or afterload. restrictive: sarcoid, cetc. hemocthomatis. low voltage ekg. s3/4. normal aging: decrease lv chamber size. septum gets sigmoid shape w/ basilar protin buldging into LV outflwo tract. increase interstitial ct.
Neural development
notocord causes ectoderm -> neuroectoderm and neural plate. (neural groove/folds is intermediate step) neural plate -> neural tube and neural crest. ALar dorsal sensory. Lateral nuclei basal ventral motor. [B at front A at back]. medial nuclei. foregrain (prosenceph) -> telenceph and dienceph midbrain (mesenceph) - Midbrain (aqueduct) rhombencepalon -> metenceph(pnos/cerebellum; upper 4th vent) and myelencep (medulla; lower 4th vent) Neural crest: PNS, schwan microglia - mesoderm.
Vagal nuclei
nucleus SSsolitarius: visceral SSsensory info (taste, baro, gut distention) CN 7, 9, 10. nucleus aMbiguus: MMotor to pharynx, larynx, upper esophagus cn 9, 10, 11 dorsal motor nucleus = sends parasymmpathetic to heart/lungs/upper gi: CN10. 12-9 = medulla; 8-5= pons corneal reflex: nasocilliary branch of v2 -> temporal branch of 7 jaw jerk - V3 from masseter. -> V2.
bronchiolitis obliterans
oblitertive lower airway infl -> granulation tissue prolif that obstrucs small bronchioles/airways -> consolidaiton. rx: steroid.s.
cranial nervs
oclomotor also involved in eyelid OPENING (levator palpebrae). exits midbrain at intrapeduncular rossa. 4 - superior oblique. exets below inferior colliculus and red nucleus at dorsal midbrain. only nerve to decussate before innervating target. 6- lateral recuts (abducens) 5- also supplies sensation of external auditory cannal and external tymphanic membrane. exits at lateral aspect of mid pons at level of middle cereellar peduncles. TOWARD LESION.tensor tymphani - hypoacousus 7 - lacrimation, salivation. orbicularis ocluli (eye CLOSE). stapedius -> hyperacousus. exits pontomedullary jxn bellow middle cerebellar peduncle. 9 - swallowing. Parotid!, stylopharyngeous (elevates pharynx/larynx). inferior salivary nuc -> otic -> auriculotemporal nerve -> salivation. INNER surface of tymphanic membrane. eustachean tube, middle lear, TONSILAR region, upper pharynx. 10 - swallowing, soft palate elevation, uvula (levator veli palatini), togh, cough. PALATOGLSUS. POSTERIOR part of external auditory canal, irriatation can cause syncope. AWAY FROM LESION 12 - located medially on floor of 4th ventricle. exits rostral end of preolivary sulcus. TOWARD LESION. 11- WEAK TURNING TO CONTRALATERAL SIDE. SHOULDER DROP ON IPSI SIDE. left scm helps turn head to right.
iron poisoning
often kids acute: N, V, bleed, hematemiss/melena chronic: acidosis, scarring -> GI obstruction
hemoglobin electrophoresis
on electrophresis of TRAIT: decreased A, increased S (40%). for sicle disease: incrase S, F. A is absent. hemogloibin S moves slow on electrophoresis due to loss of negative AA. hemoglobin C also shows Slowing (acually is the slowest bc of its POSITIVE charge) small and more negative moves further to the positive side
DNA pol 1
only in prokaryotes. degrades RNA primer w/ 5->3 exonuclease = UNIQUE. telomerase is RT: adds TTAGGG transition (A->G) transversion: (A->T)
oogenesis
oogonium _> primary oocytes at 4 wks gestation. get full complement of oocytes at 5m gestation. primary oocyte is 2N, 4C -> meiosis 1 arrested in proPhase 1. meosis II arested in metaphase II. amniocentesis - can look for bili (erythroblastosis fetalis(, keryotype, CF, fetal adrenal disorder.s fertilization w/i 1 day of ovulation. see BLOOD hcg at 1 wk. in URINE at 2 wks. breastfeed decrese breast/ovarian cnace risk. decrease risk of asthma/allergy/dm/obestity. tyroxine/insulin contribute to mamilary gland hypertorphy.
pathoma bone
osteopetrosis - carbonic anhydrase,pancytopenia. CN impingemnt, hydrocephaus. RTA if charbonic anhydrse prob. rickets - pigeon brest: ribs bend in, sternum out. ALKALINE phosphatase needed to lay down Ca. bisphosphonates cause APOPTOSIS of osteoclasts. osteoporosis: NORMAL labs. paget - hat size. CNs. LION LIKE, AV shunts. soteosarcoma. ONLY INCRASE is in alkP. kis are mischevious. adults are elderly. lytic = sequestrium osteoid osteoma: osteioid surrunded yb reactive bone. young men in DIPAHYSIS. cortex. radiolUcent core (osteoid). Ostoblastoma - larger then 2cm. on VERTEBRAE. OsteoCHONDROMA - METAPHYAIA. overlying cartilage cap. osteoSARCOMA - bad osteoblasts on METAPHYSIS of knee. see cells in OSTEOID matrix Giant - SOAP. ONLY ONE IN EPIPHYSIS. knee. EWING: DIAPHYAISIS. 11;22. oinon skin (periosteum layers) osteoidosteoma/osteoblastoma/ewing = diaphysis osteohondroma/osteosarcoma = metaphysis cartelagenous tumors all arise from medulla: chondroma - small bones of hands/feet chondrosarkoma - pelvis/central skeleton
CHRONIC MYELOPROLIFERATIVE DISORDERS
p vera - Hcct >55%. Jak is a NON receptor tyrosine kinase that makes it more sensitive/ to EPO. erytrhomelagia - burinign pain/red/blue discoloration due to clots. hyperviscocity -> thrombotic events. peptic ulceration/pruritis due to histamine form basophils. PLETHORIC ruddy face adn SPLENOMEGALY. RBC indicies normal. increased reythrocyte mass. moderate HTN form expansion of blood volume. ET: bleding/thrombosis. no other cell line elevated. Myelofibroisis - early its hypercellular, later see pancytopenia . MASSIVE SPLENOMEGALY - can manifest as early satiety. hepatomegaly/anemai. teardrop = dacrocytes/nucleated RBC. ;
blood transfusion therapy
packed RBC: use in acute blood loss, anemia. it increases Hb and o2 carying capacity. risk of hyperkalceia (RBC may lyse in old blood unit) FFP: DIC< cirrhosis, warfarin od, exchange transfuison in ttp/HUS cryoprecipitatet - fibrinogen, factor 8, vWF, factor 113, fibronectin
osteitis deformans
paget diseae. all labs normal exceptincreased ALP. osteoclast infected by paramyxovirus. disorganised lamellar bone structure. AV shunts: high output HF. risk of osteosarcoma. hat size. hearing loss.
Multiple sclerosis
pain w/ eye mvmnt. marcus gunn pupils (light in that ppl cause neither to constrict). hemiparesis/hemisensory. numb/paresthesia/spastic. bladder/bowel incontinence. FATIGUE. Scannin speech, intention tremor (cerebellar damage), nystagmus. Increase in temperature latitudes. Uhthoff phenomenon. Symptoms increase when in hot shower/heated envirionmetns : heat chauses decreased axonal transmission. Lhermette sign. Lab findings: increased protein (IgG). OLIGOCLONAL bands!! plaques = oligodendrocyte loss and reactive gliosis (See in periventricular, creebellum, spinal cord, brianstem). In plaques see lipid (myelin) laiden macs. also infliltatoin by lymphocytes/mononuclear cells. rx: Beta, steroids, natlaizumab for spasticity (baclofen, gaba agonist) for neurogenic bladder (catheterization, muscarinic antgonis)
cataract
painless, opacification of LENS. decrease in vision. risk: age, smoke, alcohol, sun, steroids, DM, trauma, infectin, galactosemia, glaactokinase def. Papiledema: optic disk swelling due to increase ICP (ex: mass effect). enlarged blind spot and elevated optic disc w/ blured margins.
Hypoglycemia
palor, sweaty skin. bizzare behaviro, convulsions, unconscious. if consious, use fast acting carbs. if inconcious do glucagon injection. if in MEDICAL setting, give IV glucose (not IM)
Pancost tumor aka superior sulcus tumor (superior sulcus = groove formed by subclavian vessles)
pancast tumor: usually NOT small cell. at APEX; horners, SVC syndrome, sensorimotor deficits, hoarsness. shoulder pain that radiates to axilla/capula (ivasion of lower brachial plexus), also arm parasthesia, weak, muscle atrophy, decreased reflex. can cause atrophy of hand muscles, rib destruciton. pain in C8-T2.
anxiety disorders;
panic disorder - atack and 1 month of concern/worry/behavirol change related to attack. disconected, chills, parestheias. rx: CBT, SSRI, VENLAFAXINE. (benzo in acute setting). agorophobia - open/closed spacds, public transportioan, being in crouds, leaving home alone. GAD: also seep, fatige prob, GI, concentration. muscle tension, irritable. cbt is first line, then SSRI, TCA, Venlafaxine. Benzo is second line. adjustment disorder - lasts <6m. casues funcitonal impairment. develops w/i 3m of stressor. btw. Obsesive compulsive disorder - have insite (vs. ocpd). rx: CBT, ssir, clomipramine
alpha 1 antitrypsin
pas positive, distase resistant. CODOMINANT trait. also degrades trypsin/chymotrypsin. liver disease = first few decades of life. hepatomegaly/cholestasis. can see neonatal hepatitis. oxidants from smoking can even inactivate endogenous antitrypsin.
Cirrhosis
peptic ulcer disease, fetor hepaticus, amenorhea, anemia, dupuytrens' contracture. melena. incrase sex steroid binding globin -> binds testosteroine (dcrease ratio of free T to estrogen). cholesterol/albumin/PT = indicators of livers BIOSYNTHETIC FXN and hence better represents prognosis . bili is mreaure of ability to transport and met organic ions. transaminases represent structual integrity. decresed systemic prefusion pressure -> kidney senses -> retention of water/Na. [this is accentuated by renal vasoconstriction in hepatorenal syndrome) rx = FUROSEMIDE AND SPIRONOLACTONE. thrombocytopenia due to splenic sequrestratoin (alcohol may also have direct toxic effect on BM)
vertigo
peripheral - inner lear defect. DELAYED HORIZontal nysgagmus. cana;/vestibular neve/meniere disease central - brainstem/cerebellar. directionla change of nystag mus, skew deviation, diplopia, dysmetria. IMMEDIATE nystagmus in any direction; may chagne directions. focal neurologic defects.
causes of torsades de pointes
phase 2 and 3 prolonged. can progress to v.fib. caused by decreased K or Mg. rx: magnesium sulfate. Some Risky Meds Can Prolong QT Sotaolol Risperidone (resperidone) also TCAs and antiemetics (ondansetron) Macrolides Chloroquine Protease inhibitors Quinidine (class Ia and 3) Thiazides
jaundice
physiologic jaudice - starts in first day, ends by a week. hemolytic disease of newborn - also see hemolytic anemai, positive coombs test. mixed direct and indirect seen if cihrosis/hepatitis. gilbert - increase w/ fasting stress crigler - also see kernicterus. plasmaphoresis and phototherap. type 2 responds to phenobarbital (increses liver enzyme synth). dublin - defective MDRP2. some have icterus. , fatigue ,abdominal pain.
Disorders of Fibrinolysis antithrombin 3 def
plasmin cleavs fibrin AND fibrinogen, destroys coag factors, AND blocks platlet aggregation (increases bldding time). regulated by a2-antiplasmin. Plasmin maybe overactive in cirrhosis (cant make a2) and prostatectomy (release of urokinase): resembles DIC see increased FIBRINOGEN split products , but not D-dimers (fibrin thrombi are absent). rx: aminocoproic acid. presents as PTT that doesnt rise after heparin. give high ose heparin to activate limited antihombin three and ten give coumadin (to get past coumodin skin necrossis window) btw, protein C, S def is AD. and estrogen increases production of coag factors.
HEmOnc anatomy
platelets live for 10d. alpha granules: vWF/fibrinogen. dense granules: ADP, CA. Neutrophil - 50%, Lymphocytes 30, monocytes 5 eosinophils 2, basophils 1. Neutrophil granules: small (AMP, collagenase, lysozyme, lactoferrin(, large azurophilic granules aka lysosomyes (ptoteinases, acid phosphatate, MPO, B glucuronidase). Monocytes: "frosted glass" cytoplasm. Macs: cd14 surface marker. Mast cell - lok liiek basophils. contain histamine/heparin/eosinophil chemotactic factors Basophils - work w/ mast cells for immediate hypersensitivity. also has bound IgE. contain heparin, histamine, seukotrienes Eosinophils - helminths. Bilobed. major basic protein: destroys antibody bound parasites (example of ADCC. no complement needed. NK and Macs also use this method). they are PHAGOCYTIC for antigen-antibody complexes. produce HISTAMINASE, arylsulfatase/LT?peroxidases. they REGULATE type 1 hypersensitivity!. they can damage ep and endothelial cells. causes: neoplasia, asthma, allergy, CT disease, parasite. plasma cells - eccentric nucleus, clock-face chromatin distribution, abundent RER, well developed golgi (perinuclear clearing - active goli). wagon wheel apearance to nucleus.
salivary gland tumors
pleomorphic adenoma - stromal and epithelial. parotid. reccurs. if involves facial nerve, its malignant. Warthin tumor, cystic tumor, lymphocytes/germnal center. parotid. Mucoepidermoid - MALIGNANGT. parotid. involves facial N.
RNA processing
polyadenulate polymerase rec AAUAAA. P bodies: contain exonucleaes, decapping enzymes, micro RNAs. to repress translation. mRNA can also be stored here for future.
Positive skew vs Negative
positive: tail longer on right. smaller numbers predominate. MEDIAN reflects central tendency more than MEAN (bc the extra large numbers alter mean mean > Median> mode (modst common)
posteriro triangle of neck and facial atreties
posterior triangle - bound by SCM, trap, clavicle. contains CN11. ansa cervicalis = C1-3. innervates sternohyoid, sternothyrid, omohyoid. damage w/ trauma to neck above cricoid cartilage. facial artery - branch of external carotid. courses over mandible, anterior to insertion of masseter. supplies oral region, nose, buccal region of cheeks. occipital artery is opposite to facial. coursesposteriorly. serves posteriro scalp and SCM. sphenopalatine artery - branch of third part of maxillary. suplies nasal mucosa. anastomosis w/ branches of opthalmic, facial arteries in anterior nasal septum.
Alzheimers dementia - decrease cognition, memory, fuxn but normal consciousness
presiniin 1 on 14. 2 =1. apo E4 = worse (chrom. 19). neuron loss initially int parietal/temporal. most prominant loss in HIPPO AND temperoparietal. decreased Ach in hippo, baslal nucleus of mynert. later (60,70) than Pick disease. slow progressive memory loss. also apraxia, aphasia, agnosia, decreased executive fxn. anterograde. rx: 1. cholinesterase inhibitor - donepazil to increase cognition, behavior, functioning. 2. neuroprotective antioxidants - VitE (tocopherol) 3. nmda antagonist - memantine (overstimulation by glutamate may -> Altz.
hyperparathyroidims
primary - adenoma. increased cAMP in urine. weak/constipated/peptic ulcer/kidney stone/acute pancreatitis...Osteitis fibrosia systica - involves cortical bone. subperiostial thinnnig/erosions. granular salt and pepper skull. secondary - hyperplasia due to decreased gut Ca absorption or incrased P. HYPOcalcemia. tertiary - autonomous hyperPTH due to chronic renal disease. INCREASED Ca.
Amenorrhea
primary amenorrhea - no menses by age 15 w/ normal growth/secondary sex characteristics. Absence of menses by age 13 w/ no 2ndary sex characteristics. Vaginal agenesis (mulerian aplasia/MRKH) - no uppper vagina, variable uterine dev -> primary aeoreha. NORMAL OVARIES (regular 2ndary sex). 50% have urologic anomoly. Eugonadotrophic Amenorhea: due to mullerian duct anomalies/canalization of vaginal plate. ex: imperforate hymen - at birth vaginal secretions due to moms estrogen -> mucocolpos (mucus accumulates in vaginal canal) -> bulging interoitus (<-- this is a way to see at birth). -> cyclic abdominal pain, hematocolpos (blood accumulates) -> vaginal distends -> back pain/pain w/ urination/ppop. can feel in anterior rectum. precocious puberty - 1st see testicular/breast enlargment. in boys <9, females <7. delayed puberty = 14 in boys, 12 in girls.
pathma endo cont.
primary hyperpara - usually adenoma. can cause nephrocalcinosis (clacifiatoin of renal tubules -> renal insuficinty, polyura. can also cause peptic ulcer disease teh calciums and phosphate levels are opposite in primary vs. seocondary type 1 dm - DR3, 4. stess -> epi -> glucagon stimulation. total K low but hyperkalemia. type 2: obesity leads to decreased # of insulin receptors. hyperoslomar coma - keotones absent due to small amnt of circulating insulin somatostitinoma can case choleslithiasis cortisol: thin extremities bc cortisol breaks down muscle -> glucose. the high glucose caues insulin -> storage of fat. it also inhibits IL2, histamine release Primary hyperalodsterone: due to adernal adenoma! pheo can be in bladder wall: urinate -> episodic HTN
primary biliary cirhosis vs primary sclerosing cholangitis
primary sclerosis - intra and extrahepatic. fibrsisi/onionskin/beaded appearance. p anca, UC. cholangicarcinoma primary biliary - granulomatous. intrahepatic. woman. anti-mitochondrial Ig.
closed/narrow angle glaucoma
primary: enlargment or forward mvment of lens against iris 0> fluid backs up and pushes iris against cornea 0> impeeds flow through trabecular meshowrk. secondary: hypoxia from retinal disease (DM, vein occlusion) -> vasoprolif in iris that contracts angle. can also be caused by anticholinergics. DONT use alpha agonists. chronic closure - asymptomatic. damage optic nerve and peripheral vision. acute - emergency. icrease pressure pushes iris forward -> anclge closed. sudden, painful loss. halos around lights, rock hard eye, frontal HA. see in inuit/asians.
prolactin and GH
prolactin secretion is stimulated by estrogens!! prolactin can feed back to increase dopamine release. GH increase insulin resistance, protein synth (muscle mass), gluconeogeneis, lipolysis. its s stress hormone. its inhibited by glucose and somatostatin.
Lenticulostriate stroke and lacunar infarcts
provides striatum, internal capsule. contra hemiparesis/hemiplegia. due to unmanaged HTN -> LACUNAR INFARCT. Lacunar infarct - type of ishemic stroke involving small penetrating vessles for deep brain structures and subcortical white matter. due to LIPOHYALINOSISI (foam cells, fibrinoid necrosis) microatheroma formation, occlusion [hypertensive arteriolar sclerosis] 1. pure motor: posterior limb of internal capsule/basal pons 2. pure sensory: VPL or VPM 4. ataxia hemiplegia syndrome: posterior limb of internal/basal bpons 4. Dysarthrya/clumsy hadnd syndrome = genu of internal capsule or basal pons
Dermatitis herpetiformis
pruritic papules/vesicles/bullae. see microabceses of fibrin and neutrophils. IgG crossreacts w/ reticulin in BM. basalcells becomes vacuolated -> bilsteras at tip of papillae bilateral/symetrical/extensor surfaces/knee/elbow/butt. BULLOUS impetigo - more often caused by by S aureus. NEcortizing faceitis: anerobes or S. pyogenes. cause bullae/purple color to skin. Staphy scalded skin syndrome - exotoxin destroyses keratoinocyte attachemnts in statum GRANUOLSOM onlly (vs. TEN which destroyes the epidermal/dermal jxn). also see in adults w/ adrenal insuficiency. erysipelas - infection in upper dermis/supreficial lymphatics. usually due to s. pyrogenes.
Schizophrenia
psychosis, distrubed hehaviro/thought. decline in FXN. DECREASED dendtritic branching. +: delusion, hallucinaiton, disorgnaized speech, catatonic behavior. -: flat affect, withdraw, no mativaiton, avolition, alogin (no speech). schizoaffective - superimposed on depression/mania. psychosis can exist w/o mood but not the other way aroudnd. >2 wks w/o MOOD.
ptsd vs acute stress disorder
ptsd - >1m. cbt, ssri, venlafaxine acute sterss disorder, 3d to 1m. NO MEDS .
Pulmonary HTN
pulmonary HTN results in arteriosclerosis, medial hypertrophy, intimal hyperplasia -> fibrosis (onionskinning) of pulmonary arteries. PLEXIFORM LESINS (interlacing tufts of vascular channels) Primary - BMPR2. AD. -> hedial hypertrophy, intilal/endotheial prolif/fibrosis. usually a second insult (inf/drug) involved. secondary: 1. COPD (destruction of parencyma/obliteration of segments of pulmonary vasculature). 2. mitral stenosis 3. recurrent thromboemboli (decrease cross-sectional area of pulmonary vascular bed. 4. AI disease (systemeic clerosis, infl-> fibrosis->medial hypertrophy 5. L to R shunt (sheer stress -> iendotheial injury) 6. sleep apnea/high altitude (hypoxic vasoconstriction). drugs: amphetamines, cocaine, HIV, portal HTN, shistosomiasis. cor pulmonaly = RVH. normal RV thickness is 3-4mm, LV = 1 cm. accentuated splittin of pulmonary component of s2.
thymoma Psammoma bodies
pure RBC aplasia, myasthenia gravid PSaMMoma: papilary ca of thyroid, Serous papillary cystuadenocarcinoma of ovary, Malignant mesothelioma
BASAL GANG
putamen (initiates motor) caudate (cognitive) D from SNc binds D1 to stimulate excitatory adn D2 to inhibit inhibitory pathway. Excitatory/direct pathway: cortex -> striatum releases GABA to disinhibit thalamus via GPi/SNr Inhibitory pathway: cortex -> striatum to disinhibit STN via GPe. STN stimulates GPi/SNr to inhibit thalamus. the i's and e's of the GP switch based on what u woud think based ont eh names. GPe defect: decrease mvmnt (loss of inhibition) GPi defect = increase mvment. I=increase. insula - integrates body state w/ emotions. also ANS control/conscious experience of visceral sensations.
Mitral Regurg
radiate to axilla chordae tendoneae rupture = more often due to IC. can cause s3 due to incresed LV filling. use diretic to decreases preload. see excessive rise in V wave. if ACUTE MR, near normal LA complience. no time for LV adaptation -> acute PE increaseed LVSV but no increased volume ejected to aorta. tricuspid: radiates to right sternal border.
VHL
rcc, cerebellar/retinal hemangioblastoma, pheo. cavernous hemangiomas in skin, mucosa, organs. liver/renal cysts. HIF -> incfeased VEGEF and EPO.
vrial genetics
recomb - like humans reassorortment of segments compelmentaton - missing prtoin provided by second virus pehotypic mixing .1 takes the coat of the other. not passed on to projeny. tranformation - essentialy integration interference - 1 virus inhibits rep/release of second virus.
accuracy
reduced by systematic error (Bias).
SLEEP stuff
regulated by circadian. circadian controls noturnal ACTH, prolactin, melatonin, NE. light -> SCN -> NE -> pineal -> melatonin. REM via PPRF occurs every 30 mins and increases in duration throuhout night. NE/alcohol/bnezo -> decreased REM and delta wave. bedwetting rx: DDAVP (prefered over imipramine). benzo for late night tremor/sleep walk.
Lung relations
relationship of pulmoanry artery to bronchus at each hilus: RALS (right anterior, left superior) Aspiration: while upright: basilar (lower) portion of right inferior lobe. while supine: superior segment of right inferior lobe AND POSTERIOR segment of UPPER lobe.
polycythemia
relative: dehydration absolute : see increase RBC mass 1. apropriate: due to lung disease/high altitude: see decreased o2 sat (<92% or <65mmHg) 2. inapropriate: RCC, Wilms, HCC, hydroneprhosis. see NORMAL o2 sat. 3. P vera - NO change in o2 sat
acid base physiology
renal compensation takes 3-5 dyas. normal HCo3 - 24 normal Pco2 = 40 ph = 7.4 Hco3<30 acute resp acidosis, >30 = chronic. henderson halsback: ph = 6.1 + log [hco3-]/0.03 Pco2.. if predicted resporatory compensation for acidosis is different from predicted Pco2, then MIXED acid-base disorder (concurrent resp acidosis/alkalosis) . winter: Pco2 = 1.5 (Hco3) + 8 +/- 2 diarhea: loose water, K, Hco3: hypernatremia, hypokalemia/acidosi.
SLE
reproductive female. african. Neprhitic is most comon: diffuse proliferative GN. other: membranous. raynaud. warm Ig atgainst rbc. positive combs. spherocytosis. (type II) fever/fatigue CV disease - arteritis/thrombosis. fibrinoid necrosis/fibrosis/narrowing of lumen. findings: dsDNA - poor prognosis = renal disease anti-smith = snRNP. drug induced: hydralazine ,procianamide, isonizid, penicillamine. no rena/cns decreased C3,4, CH50. can use hydroxychloroquine to treat.
Purine synth
req. glycine, aspartate, glutamine, thf. -> IMP 6-MP, azathioprine inhibit PRPP amidotransferase. Mycophenolate and ribavirin inhibits IMP DH (normally converts it to GTP)
splicing
req. the sequence p-GU that attacks the A of AAG. anti-smith, anti-u1-RNP. splice site mutation -> larger proteins. abnormal splicing = b=thal
Pygmalion effect
researchers belief changes outcome.
causes of alkalemia
respoiratory: hyperventilate due to hystieria, high altitude, salicylates (early), tumor, PE . metabolic alkalosis: loop, vomit, antacid, hyperaldosteronism. ddx for METABOLIC alkalosis 1. check urine Cl- A.LOW: vomit/nasogastric aspiration or prior diuretic use (loose h/cl -> hypochloremia -> decrease Hco3 excretion -> alkalosis. SALINE RESPONSIVE. B. HIGH: 1. HYPOVOLEMIA/EUVOLEMIA A. current diuretic use (thiazide prevents Cl reabs.) SALINE RESPONSIVE B. Barrtter/Gitelman 2. HYPERVOLEMIA A. excess mineralocorticoid (primary hyperaldosterone/cushings) - see hypertension, increaed urine Cl bc expanded EC fluid volume casues pressure naturesis.
retinal detachment
retina detaches form pigmented ep -> degen of photoreceptrs -> vision loss. due to retinal breaks, diabetic traction, inflamatory effusions. breaks more common in ptn w/ high myopia and oftne preceeded by posterior vitreous detachetn (flashes and floaters) and eventually mononuclear loss of vision like a "curtain drawn down"
detection bias
risk factor causes extensive diagonostic investigation and increases prob that disease is identified
malignant brest tumors
risk factors; estrogen, total number of cycles. older age at 1st live birth. Obesity. met to bone, liver,lung. Noninvasive DCIS: 1. DCIS - dills duct lumen. see microcalcifications. NO MASS 2. Comedocarcinoma - ductal, CASEOUS NECROSIS that can calcify. its a subtype of DCIS. sheets of cells, chronic infl, periductal concentric fibrosis. see duct filled w/ it. 3. Paget disease - due to underlying DCIS. still hasn tcrosed basment membrane. nipple red/ulcered. Noninvasic: LCIS: NO mas, NO calcificaitons. multifoca/bilateral. INvasive: Invasive ductal - most common. firm/fibrous. sharp margins. grossly looks stellate. desmoplastic stroma 1. tubular - good prognosis 2. Mucinous - elderly. good prognosis 3. Medulary - fleshy, cellualr, Lymphocytic infiltrate/plasma cells. good prognosis. sheets of vesicular cells. increased incidence of BRCA1. well circumscribed, can mimic fibroadenoma. 4. Inflamatory - dermal lymphatic invasion.orange. thenderness/skin discoloratoin. Invasiv lobular - indian. often bilateral and multiple. some may show signent ring morphology.
AR percent in exposed
risk in exposed that is explained by risk factor = 100 x {risk in exposed - risk unexposed}/risk in exposed or 100 {RR-1}/RR
Heroin addiction
risk of hepatitis, abcesses, AIDS, right sided endocarditis. rx: methadone: long acting oral opiate. use for detox or long term maintainance. Naloxone (antagonist) + buprenorphine (partial agonist). naloxone not active when taken orally, so withrawal symptoms only occur if injected (lesss abuse potential) Naltrexone - long acting antagonist. to prevent relapse once detoxified.
rubella vs cmv in torches
rubella - pda, cararacts, deaf. in mom see arthriris. resp droplets. CMV - intracranial calcificaiton, ventriculomegaly. 2nd trimester. sexual contact. MR, seizures. in mom its like mono both have blueberry muffin rash.
hydatiform moles
rx: methotrexate. complete - INCREASE CAVITY SIZE, MAJOR INCREASE IN BHCG. 46XX much more common. diffuse trophoblastic prolif aroudn vilii (complely surrond) partial - normal uterine size, bHCG doesnt incrase as much.
acromegaly
rx: ocretotide. or pegvisomant (GHreceptor antagonist) see failure to supreess GH following oral glucose test. deep furrows, dep voice, impaired glucose tolerence. colon cancer. die via HEART FAILURE. gigantism - weight gain, sweat/oily skin, large hands/feet, proganthism, thick calvarum. laron dwarfism - defect in GH receptor
Muscles
ryanodine is on the SR. HIZ shorten. A = Always same lenght. H band (myosin only) contains M line. H&M I band (actin ony) contains Z line A band = overlap *skeletal muscle resistant to effects of Ca channel blockers bc it does NOT requ. influx of extracelluar Ca for excitation/contraction. tropoinn C binds cA, toroponin I binds the complsx. troponin T binds to tropomyosin in smooth muscle, Ca binds calmodulin -> myosin Lc kinase (no troponin involved) T tubles also in cardiac muscle btw. (nitrates -> Increase cGMP -> decrease Ca 0> decrease myosin Lc Kinase and increase myosin LcdeP. ) relaxation: calmodulin binds and activates Ca atpase. 1 slow red ox.
PYR positive beta hemolytic
s. pyogenes and enterococcus s aureus strep pyogenes, strep agalactiae, l. mono
treatment for trematodes (flukes)
schistosoma - praziquantel 1. hematobium: larger terminal spine (thnk of it piercing bladder) 2. mansoni - large lateral spine 3. saponicum - Small spine clonarchis sinensis - praziquantil
Hip injections
sciatic nerve can be injured by injecitons of superio/inferomedial or inferolateral injections. superolateral quadrent is relatively safe. if possible, tartet anteriorlateral gluteal area (von Hochsetter triangle) - put paient on side, palm on greater trochanter, first finger on ASIS, its inbetween teh first two fingers.
HMP sunt
see in mamary glands, liver, adrenal cortex (FA/cholsterol,steroid synth) and RBC. promoted by NADP, inhibited by NADPH. oxidative: results in co2, 2 NADPH, Ribulose 5-P Nonoxidative - ribose5P, G3P, F6P btw. glutathione peroxidase adn reductase req. selenium. pyocyanin from P aero. generates ROS to kill competing microbes. G6PD is most common human enzyme def.
Erythema Multiforme SJS
see q/ M. pneumo, HSV, sulfa drugs, B lactams, phenytoin, Cancers, AI disease can be macules, papules, vesicles, or target lesions (dusky center w/ epithelial disruption). see on limbs and extremities, especially palms. SJS: fever, bulla, necrosis, sloughing. skin leasons may be targetioid, mucus membranes involved. Necrotic keratinocytes in epidermis NO PALMS OR SOLES may be after CMV/mycoplasma Seborrhea (seborrheic dermatitis) - chronic infl condiation of scaly greasy skin on scalp, face, eyelid, eyebrow. associated w/ xanthomas.
Testicular tumors
seminoma - 3rd decade. malignant. fried egg. ALP (first aide)/bhcg (pathoma) [contrast w/ dysgerminaoma - ldh]. yolk sac - yellow/mucinous Choriocarcinoma - can go to brain : can present as hemorrhagic stroke. teratoma - bHCG/AFP embrinal - hCG. (increased AFP when mixed) malignant/hemoragic, necrosis/painful. may have glandular/papilary morphology. Leydig - androgens -> gynecomastia in men, precociosu puberty in boys. lymphoma - due to met
Sensiitvity
sensitiviy = 1-FN sensitivity = lower cutoff to get all disease
male physiology
seritoli cells secrete anddrogen binding protein to maintain high local levels of testosterone. they can converte testosterone and androstenedione to estrogen via aromatase. Leydig cells also have aromatase. if only one testicle, decrease inhibin -> incrased FSH. tesosterone normal though.
Digestive tract layers/histology
serosa when entraperitoneal. adventitia when retroperitoneal. eroson: mucosa only (ep, lamina propria, muscularis mucosa). erossions: mucosa only. stomach 3 wavs/min. Duodenum - 12, illeu = 8. jejunum/ileum: ;licae circularis. Ileum = largest number of goblet cells. colon - NO VILII, MANY goblet cells. stomach layers: 1. simple columnar ep - secrete mucus 2. upper glandular layer - pink, round, oxyntic parietal cells 3. deeper glandular layer - basophilic granular cheif cells.
subdural hematoma
shaking, whiplash. midline shift. canNOT cross falx/tentorium. cresecent shape. GRADUAL HA, confusion. Elderly: minimal trauma, gait, seizure, somolescence , ocnvusion, decreased memory.
Wolf white syndromw
short PR, wide QRS. ventricles are pre-excited -> recurent temporary tachyarhythmia. eventualy could lead to SVT: paroxysmal narrow complex of QRS bc the accessory pathway no-longer pre-excites but instead forms a reentrant circuit ot atria. brugada syndrome: AD, asian males. pseudoRBBB, ST elevation in v1-3. risk of ventricular tachyarrhytmia and SCD. Arrhythmogenic RV cardiomyopathy - Ca binding SR protein mutation. progressive fibrofatty replacemnt of RV myocardium.
acute errosive gastritis
short term mucosal injury -> infl/mucosal destruction. via nsaid, sterss/shock/sepsis, trauma, burns, smoke, alcohol, uremia. see pain/N/V, melena, upper GI bleed curling - decreased plasma volume. PROXIMAL DUODENUM. cushing - esophagus, stomach, duodenum. increase ICP -> vagal stim). particularly prone to PERFORATION.
pnumokoniosis
silicosis - sand, upper lobe. TB. berylliosis is BERRY much liek sarcoid. increase risk of lug cancer. sarcoid - asteroid bodies. can mimic sojrens. interstital pnumonitis - granulomatous reaction. increased eosinophils plexiform lesions seen in pulmonary HTN. broncoalveolar CA - frm clara cells. not related to smokin. large sell - smoking, central or peripheral. met to lung: breast/colon
sleep and sex
sleep terror disorder - scream durign slow wave non rem sleep (no memory). [vx. nightmare in REM sleep; have memory of it] gender dysphoria (transgender) - cross-gender identificaiton. causes disterss/impaimetn. transSEXualism - desire to live as oposite sex (surgury) transVESTism - paraphillia.
Renal papillary necrosis
sloughed renal papillae -> gross hematuria ,protienuria, passage of tissue fragments. colicy flank pain, dark/dusky urine, rist collored. via: DM, Acute pyelo, urinary tract obstruction, sickle cell chronic phenacetin/acetaminophen/NSAID use: the decreased prosteglandins decrease blood flow, uncouple oxidative P, direct cell damage. NSAID also [ ] in medulla. diffuse cortical necrosis: acute cortical infarction. see w/ vasospasm, DIC. associated w/ obstetric catastrophies, septic shock
Actinic keratosis
small rough erythematous/brownis papules/placque. SCALY, SANDPAPER TEXTURE PAPULES <1cm 1. see hyperkeratosis 0 hyperplasia of stratum coreum. can -> cutaneous horns. 2. Parakeratosis - retained nuclei in stratum conreum aty 3. Atypical keratinocytes may also be abnormal pigment and dilated bv surroudning. DO NOT invade dermis.
menopause
soures of estrogen becomes peripheral conversion of androgens. FSH is SPECIFIC FOR MENOPAUSe (LH is later, less specific) (can have ammenorhea post pill, but should be <3m) pudental neve block - use if too far into labor to recieve epidural. S2-4 - sensory to perenim/genitals, motor to sphinctor uretrhae/external anal sphincter. Genitofemoral N: L1/2. on anterior surface of psoas. genital -> scrotum/labia majora. femoral -> femoral triangle.
Specificity
specificy = 1-FP specifity = higher cut of to get those who REALLY have disease
sinuses what is weakest part of orbit where diose epistaxis occur
sphenoid: anterior to optic chiasm. ethmoid air cells: medial to orbit weakest part of orbit: inf and medial walls most commonly in anterior segment of nostril (kiesselbach plexus). can be lifethreatening if in posterior segment (spehnopalatine artery, a branch of the maxillary)
Sickle cell - chromosome 11. missense mutation.
splenic sequrestration crisis (due to presents as decrease in Hb, enlargin spleen, hypovolemic schock). . leg ulceration. stroke mutation seen where B subunits ataches to eachother. increaed MCHC due to dehydration. in TRAIT, may see hematuria, decreased ability to [] the urine. positive sickling test when sodium METABISULFITE added. need 50% or greater forsymptoms. binding affinity for 02 isnt diff. organs that move blood slowly (liver, spleen kidney) are predisposed to acidity, low o2. organs w/ high metabolic demands (brain, muscle, placenta( premote sickling by extracting more o2. GARDOS CHANNEL BLOCKERRS (CA dep K chalnnel) hinders efflux of K and H20 to prevent dehydration. if maternal sicklecell: preeclampsia, fetal demise, low birth weight. Rx for cricies: o2, fluid, narcotics. vasooclusion can cuase relative immunodeficincy due to functional asplenia. may initially see splenomegaly due to splenic destruction of sickled RBC. dactylitis: commoni in first few years bc bones still contain hemoatopoetic BM. may see cardiomegaly from chronic bouts of ischeia due to venooclusion. the chronic anemia may require increased CO
esophageal Cancer
squamous - africa/asia. ALCOHOL/CIGARRETS. solid nests of cells, eosinophilic cytoplasm. nitrosamien foods/betel nut -> SCC scc - achalasia, alcohol, cigarets, diveteicula, web, hot, adeno - cigaret, obesity leomyoma = most common benign. spindle cells.
Angina
stable: greater than 75% variant: ergonavie stimulates alpha and serotonin receptors and caues constriction. rx: nitrates, ca blockers. trigger can be cocaine, tobacco too. unstable: ulcerated plaque w/ partial obstruction. no elevation in markers. stress test: adenosine, Dipyridamole, regadenoson. during ischemia, loss of contracitlity w/i 60 SECONDS
Iron def
stages: first decreced BM iron stores (ferritin/hemosiderin), then serum feratin, then increase transferin/TIBC, then serum iron, then blood Hb plummer vinson is aka patterson-kelly. see dysphagia, spoon nails . vit C needed to absorb non-heme iron. REPLACE W/ ORAL IRON. on iron therapy, the Hb shoudl incerase by 3g/wk for first 3 wks note: in splenic sequestration, platlet count >30,000 so no abnormal bleeding
Pyrimadine Synth
start w/ glutamine and Co2 and 2 ATP via Carbamoyl phosphate synth II (inhibited by uridine) Carbamoly phosphate + aspartate -> orotic acid [inhibited by leflunomide (hepatotoxic) via dihydroorotate DH orotic acid combines w/ PRPP -> UMP -> UDP -> 1. CTP 2. dUDP via ribonucleotide erductase (inhibited by hydroxyurea). then -> dUMP -> dTMP via thymidylate synthase w/ help of N5N10-methyline THF (inhibited by 5-Fu) folic acid -> DHF -> THF via dihydrofolate reductase. inhibited by Methotrexate (human), Trimethoprim (bacteria), Pyrimethamine (protozoa). they are folic acid analogues. THF-> N5N10methylene THF. (Leucovorin aka folinic acid, N5-formyl THF also leads to this. it doesnt req. DHF reductase and can rescue from methotrexate only, not 5FU.
relative concentrations along prox tubule
starting from bottom of graph up: TF/P <1 (reabsorption): glucose, AA, HCo3, P Tf/P = 1: Na, K. then Cl, urea, inulin, cre (20% secreted). PAH (90% secreted) cl reabsorption is slower than NA in early proximal tubule then it matches it (thats why it is increased ocmpared to na). PAH filtered. MOST secreted by prox tubule. [] is LOWEST in bowmans space (it increases later bc of reabsorption of water]
myelodysplastic syndrome.
stemcell disorder -> inefective erythropoesis. risk of AML> can be due to radiaion/benzene, chemo. pancytopenia, dysplastic differentiation, clonal expansion of mutated hematopoetic stem cells. ringed sideroblasts. myeloblastoid maturation. Pseudo-Pelger Huet anomaly - neutrophils w/ bilobed nucli connected w/ thin filament of chromatin. seen after chemo!!
B12 deficiency
strict vegans. diphyllobothrium latum. PPI!!!!. bacterial overgrowht. in elderly, malabsorb due to gastric atrophy -> acholrhidria-> decreased B12 release from food. BM is hypercellular. axonal demyelination. dementia/spacticit/ataxia. dorsal colomns. peripheral neuropathy. haptoglobin decreses: rbc breakdonw is due to innefective erythropoesis AND peripheral destruction. B12 therapy: reticulocytes increase in 3d, peak at 1 wk. (first ones take longer to mature. takes 8 wks to correct).
teratment for nematodes (roundworms)
strongyloides - ivermectin oncocerca - IVERmectin for rIVER blindness LoaLoa/Wuchereria - diethylcarbazine t
Lymphatic drainage:
superficial inguinal -> dep inguinal -> external iliac. proximal vagina/uterus-> obturator/external iliac/hypogastric nodes. 1. inferior mesenteric -> pre-aortic 2. superficial inguinal - all cutaneous below umbilicus, anus up to pectinate, external genitalia, anterior thigh. 3. deep inguinal: under fascia lata and on medial side of femoral vein -> drains glans penis/clitoris/cutaneous portion of posterior calf. 4. superficial/deep inguinal -> external iliac other: vaginal ep contains glycogen. excitment: uterus elevates, vaginal lubrication platou - inner vagina expans orgasm - contraction of uterus.
osteitis fibrosa cystica
superiosteal thinning, salt and pepper skull, fibrous replacetn of bone Primary HPTH - icnreased alp bc pth acts on teh osteoblasts. increaed Ca, decreased P secondary - increased P, decreased ca (renal damage -> lack of vit d)
ASA stroke
supplies lateral corticospinal tract, medial lemnisucus, hypoglossal nere (caudal medilla) . contralateral hemiparesis, contralateral proprioception. tongue deviates ipsi. Medial medulary syndrome - paramedian branches of ASA and vertebral arteries get infarcted. if inferior to medulla, its called ASA syndrome: bilateral paralysis, loss of PAIN AND TEMP. (proprioception is preserved).
PICA straoke
supplies lateral medulla: vestibular nuclei, lateral spinothalamic tract, spinal trigem nucleus, nucleus ambiguus, sympathetic fibers, infereiro cerebellar peduncle. ipsi paralysiss of 5, 8, 9, 10, 11, Vomit, vertigo, nystagmus, decrease pain/temp form ipsi face adn contra body. DYSPHAGIA, HOARSNESS, decreased gag. ipsi horner's, ataxia, dysmetria. Lateral medullary (wallenberg) syndroem: NUCLEUS AMBIGUUS EFFECTS ARE SPECIFIC. dont pick on a wall, it makes u LAT (fat) and cant eat (dysphagia)
HYPOTHALMUS
suprAoptic - ADH. also oxy (1 a, thus ADH, paraventrucular has 2 A's, its an OXYmoron) paraventricular: OXY, also adh, crh, trh. VM: satiety. stimilated by leptin. senses blood glucose. rage, savage behavior. anterir: AC, para (vasodilate/sweat) suprachasmatic - sends info to pineal gland to modulate temp, cortisol, melatonin (treats jet lag). malatonin hgihest at hight, cortisol highest at morning. Jetlag worse EASTWARD (easier to lenghten sleep cycle than shorten it). Arcuate: DA, GHRH, Gonadotorpin.
rotater cuff
supra/infraspinatus, subcapsularis, teres minor. C5-6. supraspinatus: suproacapsular N. empty can test: abduct to 90 then flex arm at shoulder. fall laterally on hand. ABDUCTOR of first 10-15 degrees, rest is deltoid. Infraspinatous- supracapsular N. LATERALLY rotates arm PITCHING injury. Teres minor - axillary N. ADDucts and laterally rotates. Subcapsularis - subcapsular N. medial rotation and ADDucts arm. Coracoid process fracture: seen in ppl who use rifle. . lat dorsi = adduct anterior segment of deltoid - flex humerous at shoulder.
STDs
syphilis - PAINLESS chancre. single, indurated, clean base granuloma inguinale - gonavinosis. papule -> ulcer. PAINLESS. base w/ granulation like tissue. inguinal swelling/abcess fistula. if untreated, scaring -> lymphedema. K. inguinale. Lymphogranuloma venerum - painless ulcers that are small/shallow and heal rapidly. mainly Painful LAD. C. trachomatis. herpes - PAINFUL. multiple, grouped, shallow, erythematous abase. systemic symptoms.
Intrapraenchymal (hypertensive) hemmorae:
systemic HTN, vasculitis, neoplasm. amyloid angiopathy (CORTICAL LOBAR hemorage in OCCIPITAL/PARIETAL. (vs the deep brain structures in charcot) Charcot bruchard: chronic HTN: lenticulostrate artery - basal gang/internal capsule/cerebellar nuclei/thalamus/pons)
t vs anova vs xi
t = means of 2 groups anova = means of 3 or mor xi = categoregcal outcomes ...CHI-tegorical btw. hospice if life expectancy less than 6m, DNR is NOT prerequisite
viceral protozosla infections
t. cruzi - revid kissing bug benznidazole, nifurtimox leshmania donavani -sandfly. ampho b, sodium stibogluconate, pentamide
treatment for cestodes (tapeworms)
taenia soleum: intestinal - praziquantel. if neurocystersicosis - albendazole Diphyllobothrium - praziquantel echinococcus granlosus - albedazole
Amphetamines
they mimic NE. ex: bath salts. Intoxication: VIOLENT, PSYCHOSIS, DIAPHORESIS, TOOTH DECAY, AGITATION, HTN, TACHY. euphoria, grandiosity, pupilar dilation, anorexia, paranoia, fever, cardiac arrest, seizure, intracerebral hemorage. Withdrawal: anhedonia, increased appetite, hypersomnolence, existental crisis. in general, stimulants cause mood elevation, psychomotor agitation, insomnia, arrythmia, tachy, anxiety. withrawal: depression, lethergy, weight gain, HA
clubbing
thick distal phylanges. Drumstick like, flat nail foalds, shinny nail. Spongy feel due to soft nail bed. See w/ CA, TB, CF, bronchiectasis, emphysema, cyanotic heart disease, pulmonary HTN, IE, IBD, hyperthyroid, malabsorption.
Potassium equilibrium
things that cause kyperkalemia: Digitalis, lysis, acidosis, insulin def. HYPERosmolarity, B BLOCKER (bc/ of decreased Na/K pump) meds that cause: nonselective b blocker, ace, glycosides, nsaid. chronic renal failure. hypokalemia - oposite of the others. insulin/b agonists increase Na/ATPase) in DKA, K lost in urine via osmotic diuresis. hypovolemawi induces increased aldosterone. EC K is normal or increased bc decreaed insulin/increased plasma osmolality.
intrinsik tyrosine kinase
think GF. MAK kinase -> RAS Insulin, IGF1, PDGF, FGF, EGF, TGF-b insulin and growth factors have to be fast and intrinsic tyrosine kinase -> SH2 protines and SOS bind. -> RAS binds -> MAP kinase. the GF (not isnulin) can also use the PI3k pathway: autophosphorulation -> activation of PI3k -> PIP2 is P to PIP3 -> actiation of protin kinase B (AKT) -> mTOR -> nucleus for survival, anti-apoptois, antigeniss. MTOR inhibited by PTEN (removes P from PIP3)
inner ear
think of it as diving board. base = thin and rgid. high frequency. apex near helicotrema= wide and flexible. low frequency. helicotrema is where scala tymphani and vestibuli meet. scala media is btwn the two. vestibuli/tymphani = perilumph (high Na). media = endolymph. btwn media and tymphani is basialr membrane. media contains techtorial membrane and organ of corti. vibration transferec from oval window -> perilymph in vastibuli -> tymphani -> basilar membrane -> cilia bend as fluid runs past techtorial membrane. cupula = at apex of cochlea. sense rotation. rupture of tymphanic membrane = conductive hearing loss.
Cholesterol
thiolase takes 2 acetyl coA ->acetoacetylcoa -> HMG coa. HMGcoA redictase is induced by insulin ,thyroxine, inhibited by glucagon, cholesterol. makes mevalonate. LPL on vascular endothelial surfase. hormone sensitibe lipase degreades TG stored in adipose. ApoB-48: on chylomicrons C-II: on chylomicrons/VLDL = activates lipoprotein lipase ApoB100 - on VLDL, IDL, LDL: binds LDL receptor APOA1: activates LCAT apoE: mediates all remnant reuptake chylomicron: recieves ApoC2 and apoE from HDL. TG to to peripheral tissues. remaining cholesterol goes to liver. IDL: remnant of VLDL that can delieer TG and cholesterol to liver. LDL: Hepatic lipase acts on IDL. then delivers hepatic cholesterol to periphery. HDL: made from liver and intestine, alcholol increases synth. note: LPL boud to hepran sulfate on endotheluim. administer heparan to release to measure LPL levels.
epithelial cell junctions
tight - claudins and occludins adherens (intermediate jx) - CAdherens. connect actin of adjacent cells. Desmosomes - macula adherens. use keratin. integrins - bind BM
rx for pneumocystis
tmp-smx, pentamide dapsone and atovaguone are prophylaxis only cd4 less than 200 btw. sporothrix: itra and KI. see granuloma
hyperthyroid
toxic multinodular goiter - follicles of varying sixe. due to mutation in TSH receptor .has areas of fibrosis/hemorage. jod-basedwo phenomenon -thyrotoxicosis if ptn w/ iodone def goiter made iodine replete. Graves - most common. eyelid retraction, pretibial myxedema. often presents during stres s(childbirth). globe is tender/red, diplopia. thyroid storm -stress induced catecholamine surge. see with all hyperthyroid disorders. aggitated, delerium, fever, coma, arrhythmia. increased alp. tachyarrhytmia can -> CHF. use 3 Ps (propanolol, PTU, Prednisolone). prevent thyroid hormone release by giving iodine antithyroids can cause AGRANULOCYTOSIS . check if fever and sore throat. PTU: hepatic failure, vasculitis (arthralgia/nephritis) methimazole - teratogen, cholestasis. asprin/ibuprophin can displace thyroid hromone from binding proteins.
osteoporosis (decreawse bone mass) lab values completely normal
trabecular thinning w/ fewer interconnections. #1 fracture is dorsolumbar vertebral bodies - back pain, loss of hight, kyphosis. #2 is femor neck #3: distal radius (colles) meds that can cause: glucocorticoids, unfractionated hep, thiazolidinediones. PPI!!! - decreased ca absoption Increased Vit D catabolism from anticonvulsants that incude Cyp450. --> Increases PTH. low weight is a risk factor. RISK IN BLACKS IS SIGNIFICANTLY LESS!! GLUCOCORTICOIDS DECREASE GI ABSORPTION, COLLAGEN SYNTH, GNRH, AND increase urinary loss high na -> increae Ca lost in urine.
thyroid cancer
transection of superior larngeal n = superior thyroid artery. reccurent = inferior thyroid artery. papillary: increase ret, BRAF mutations. "finely dispersed chromatin" ground glass. . [follicular hyperplasia subtypes = tall cells. elderly. worse prognosis ] FORlicular - ras. goes for the blood. invades capsule. medullary - polygonal or spindle shapped cells. anaplastic - p53. pleomorphic giant cells/biphasic spindle cells. lymphoma - associated w/ hashimoto's. benign: variable sized tyroid follicles, colloid, macs.
ARDS
trauma, aspiration, uremia, amniotic fluid. noncardiogenic pulmonary edema (NORMAL PCWP). patchy opacification of lungs w/ obscured cardiomediastinal silhouette. due to release of neutrophilic substances/free radicals, coag cascade. -> alveolar damage. causes atelectasis of regional alveoli. progressive hypoxemia refractory to o2 therapy, interstitail/intraalveolar edema. rx: mechanical vent w/ low tidal volume. its an EXUDATE and less reversible. (vs. transudate of cardiogenic)
collagen types
tyep one: dentin, fascia CORNIA, bv tyep 2: vitrius Humor, nucleus pulosis. think gell substances. type 3: skin BV!! uterus, fetal tissue, lungs lymphatics. extensible tissues, spleen. type 4: lens light goes through Corna (1) then vitrus humor (2_ then lens (4)
diabetes
type 1 - HLA dr3, 4. besides this, weak getic predisposition. type 2 - hyperosmolar coma - high sugar, dehydration w/o keones stress -> excess FFA. (insulin normally prevents lipolysis) Kussmaul - rapid/deep breath. N/V, pain, delirium, dehydration (hypotension/tachy), poluuria. leukocytosis, hyperkalemia but total k decreaed (intracellular depletion) can cause cerebral edema/arrhythmia, HF. rx: IV fluid, insulin, K, glucose. hypoglycemia: confusion/sweating,tremor, plapitaion. can be via exercise (causes insulin independent glucose uptake). in normal ppl, decreased glucose stops insulin release. diabetics dont have this feedback. could also be due to rapid subcu insulin absorption wehn injected into limb that is worked out.
Familial Dyslipidemias
type 1: icnreased chylomicrons, TG. AR. LPL or C-II def. -> PANCREATITIS, HEPATOSPLEO, ERUPTIVE/pruritic xanthomas, Lipemia retinalis - milk appearing retinal vessles. tyep IIa: Familial hypercholesterolemia. LDL increasd> AD. defect in LDL receptors. MI before age 20, TENDON xanthomas, CORNEAL ARCUS, xanthalasma type 3: familial dysbetalipoproteinemia: defect in APOE3/4 - increases chylomicron, VLDL. (can reuptake the remnants) INcreased cholesteral and TG. xanthelasma, coronary and PVD, palmar and tuberoerruptive xanthoma type 4: hypertriglyceridemia: increas VLDL. AD. hepatic overproduction of VLDL. PANCREATITIS. associated w/ obesity, insulin resistance.
RA
type 3 and 4 hypersensitivity. pannus subcu nodules in areas subject to pressure subluxation, baker cyst osteopenia/errosions DR-4. fever/fatigue/pleuritis/pericarditis. rx; nsaid/steroid for ACUTE. sulfasalazine/minocycline - early mild RA. methotrexate -first line if moderate to sever. tnf alpah in combo w/ methotrexate if mroe severe
hypersensitivity penumonitis
type 3/4 rx to env antigne: dyspnea, cough, tight, HA. diffuse nodular interstitail infiltrates. maybe noncaseating granulomas. interstitial alveolitis. bronchiolitis. can be IgG aG autoantibody against actinomyces species. other: Pulmonary alveolar proteinosis: gradually worsening dyspnea. productive cough. bilateral pulmonary opacification w/ accumulaiton of amorphous proteion/PL. bilateral upper lobe Pulmonary Fibrosis: see w/ coal workers, silicosis, tb, isto, carcoid ,aspergillosis, ankylosing spondylitis.
reed sternberg
type of giant cell. 15, 30 of B cell origin. nodular sclerosing = most common. men and women equally. see lacunare variant of RS cells. lymphocyte rich is best rpogoisis. lymphocyte mixed/depleted = poor
primary cns lymphoma
uniform atypical lymphoid cells. usually diffuse large B clels. CD 20, CD79a. most common is met: lung, breast, kidney, melanoma. multiple ant grey/white jxn. central necrosis, reactive gliosis/edema. optic gliaoma - immature astrocytes w/ microcystic degen and rosenthal fibers. GFAP- astrocytes, oligodendrocytes, ependyomas. synaptophysin - transmembrane glycoprotein
Pneumothorax
unilateral chest expansion. wihite visceral pleural line on CXR. spontaneous: bleb = distended air sac. thin tall = more negative intrapleural pressure in APICAL lung. secondary if diseased lung (bullae in emphysema, inf). tension: can also be due to inf. AWAY. increase pressure w/i chest cavity -> decreased VR/CO -> tachy, hypotension, tachypnea, hypoxemia.
diabetes insipidus:
urine specific gravity <1.006. Serum osmolarity >290. hyperosmotic contraction (loos more free water than solutes) central - ishemia, AI. if lesion in hypothalmus its perminant. Nephrogenic - secondary to hpypercalcemia, Lithium, DEMECLOCYCLINE (ADH antagonist). rx: HCTZ, amiloride, indomethacin (decreased prostaglandin -> increased H20 reabsorption) primary polydipsia see LOW serum na and osmolality. NOT SO IN DI. see steady increase during water dep test but paltry response to vasopressin adminsiatraiton test (acquired parital def in aquaporin channels)
Cricothyrotomy
use if oro/nasotracheal intubation is unsucessful or CI (massive hemorage, vomit, facial trauma, airway obstruciton). cut through skin, superficial cervical fascia (including platysma), investing/pretracheal layers of deep cervical fascia (prevertebral fascia not penetrated), cricothyroid membrane. tube is btwn cricoid and thyroid cartilages. cricoid cartilage at C6 thyroid isthmus is below this. bucopharyngeal fascia - from carotid sheath to invast pharyngeal constrictor. It is anterior to the prevertebral fascia, and forms the retropharyngeal space btwn them. retropharyngeal space sextends to superior mediastinum (inf -> acute necrotising mediastinitis)
Metastatic calcificaiton
usually on kidney, GI and lungs (these loose acid quickly (increase Ph favors deposition)
common eye conditions
uveitis - infl of anterior uvea and iris. hypopyon (sterile pus) and redness. can see w/ sarciad, AR, TB) btw, uvea = vascular middle layer (iris, choroid, cilliary body) retinitis - retinal edema/necrosis -> scar. often CMV, HSV, HZV. associated w/ immunosupression. central retinal vein occlusion - acute painless mononuclear vision loss. retina is pale/cloudy w/ attenuated vessles and cherry-red spot at fovea (macula has seperate blood from choroid artery). usually due to embolism. retinal vein occulsion - block central or branch retinal vein by nearby arterial atherosclerosis. retinal hemorrhage/edema. Amaurosis fugax - painless transient mononuclear vision loss from small embolus to opthalmic artery. lasts a few seconds. arcuate scotomas - damage of particular region of optic N head -> VF defect taht follows the arcuate shape of the nerve fiber pattern.
Vit C
vit C: helps w/ iron absorption by reduing to Fe2. needed bor dopamine B hydroxylase to make NE. hemp treat methemoglobinemia. excess: n, v, darhea, calcium oxalte nephrolitiasis. iron toxicity. vit D - d3 fortified in milk. not in breast milk though (same w/ vitK) (give supplements for the KiD). excess: loss of apitite, hypercalcemia. confuioan, polyuria, wulscle weak, bone demineralizaotion, poldypsia. Vit E: TOCOPHEROL, TOCOTRIENOL. enhances naticoag effects. protects RBC def: looks life freidricks ataxia or b12 def. hemolytic anemia, muscle weak, hemoragic stroke, necrotisng enterocolitis. Vit K - NOT in breast milk. K1 phyloquinone from vegetables. menoquinones from gut. Zinc - hypogonadism, decreased hair ,tast, smell, predisposed to alcohlic cirrhosis. acrodermatitis enteropathica. night blindis.
Steroids
vit D, Estrogen, testosterone, t3/4, cortisol, aldosterone, progesterone. testosterone is Nuclear, others are cytosolic.
Elastin
vocal cords, ligamentum flavum. rich in proline, glycine, ALANINE, VALINE, lysine. crosslinking of lysine extracellularly by lysl hydroxylase btw. indirect ELISA tests for Ig. diret elisa test for antigen.
duchene
weakness progresses superiorly. increased CPK, aldolase. links to a b dystroglycan. asympetric weakening of paraspinal mutations -> kyphoscoliosos. DILATED cardiomyopathy. becker: POINT mutation. Myotonic dystrophy: CTG repeat. DMPK gene. AD. increased myotonin protein kinase. cataracts, testicular atrophy, muscle wasting, arrhythmia. myotonia (abnormally slow relaxation of muscles: ex: cant let go after handshake) Ion channel myopathies: hyper or hypokalemic hyoptonic paralysis. myotonia. often after exercise. no muscle atrophy. PAS positive.
ACUTE REJECTION
weeks/months. (later if immunosuppression stopped). most are asymptomatic but can cause fever chills malaise, arthralgia. HTN, Cre, decreased urine CMI: CTLs against donor MHC Humoral: Ig dev after transplant VASCULITIS W/ DENSE INTERSTITIAL LUMPHOCYTIC INFILTRATES/ENDOTELITIS. lung: cough, dyspnea, fever, perihylar/lower lobe opacities prevent w/ immunosuppression
Personality disorders: subjuctive distress, impaired functioning. person not aware.
weidrd, wild, worried A: paranoid - often use projection schizoid - voluntary withdrawal. no emotion schizoTypal - majical thinking. exxentric. awkward. BUT NO DELUSION B: antisoscial - must have conduct disorder boefore 15
OR
what are the odds they had in past? take him to the OR he died (X) 5 minutes in the past (case control) ad/bc
