Goljan/Pathoma/UWorld Miscellaneous

Question 1

Caisson disease aka decompression sickness

Answer 1

atmospheric pressure increases –> N2 gas becomes dissolved in tissue

quick assent - bubbles emerge from solution, can occlude blood vessels

• quadriplegia - nerves of SC susceptible are highly susceptible
• loss of bladder control
• death

treat with hyperbaric oxygen chamber

Question 2

anorexia nervosa

bulimia nervosa

Answer 2

anorexia nervosa:
distorted body image
refeeding syndrome - HYPOphosphatemia (P becomes trapped in intracellular space)

osteoporosis! - after you lose 15-20% body weight, GnRH release stops

• how do you treat this?
  1) encourage weight gain - in general, for boards, think cheap
  2) later consider birth control pills

death - due to heart failure

little evidence to support pharmacotherapy as primary treatment in anorexia

bulimia nervosa:
no distorted body image

vomiting - metabolic alkalosis with respiratory compensation
- hypoxemia - not good for heart –> premature ventricular contractions –> v. fib –> death

Question 3

obesity

Answer 3

kg/(height m^2)

main complication is HTN (mechanism is not fully understood)

Question 4

marasmus

kwashikor

Answer 4

marasmus:
- TOTAL calorie deprivation, nutrients still present
treat by feeding
- NO edema, there is muscle wasting

kwashikor:
missing protein = small child with swollen abdomen
-anemia
-cell immunity issues - cant fight against Candida, mumps
-low albumin, ascites, fatty livers (due to decreased apolipoprotein synthesis)
- skin lesions - hyperkeratosis and hyperpigmentation
-have to force feed - more likely to die (compared to marasmus)

there are two diseases where you want to restrict protein

• renal disease - protein means more urea
• cirrhosis of liver - defective urea cycle, cant metabolize ammonia
  
  • most ammonia comes from bacteria - convert urea to ammonia –> ammonia is reabsorbed –> urea cycle in liver
  • hepatic encephalopathy

Question 5

vitamins ADEK

Answer 5

random note - water soluble vitamins are cofactors for biochemical reactions
- B complex def = dermatitis, glossitis, diarrhea
fat soluble vitamins - mineral oil intake can cause deficiency

A - growth (muscle, bone), rhodopsin, prevents squamous metaplasia (keratomalacia –> cornea goes soft –> blindness)

• essential for specialized epithelium - pancreatic tissue, goblet cells
• most common causes of blindness - trachoma (WW), DM (US), vitamin A deficiency
• follicular hyperkeratosis ~ goosebumps
• excess - hunter that eats bear liver –> cerebral edema, headache. Liver tox.
  - acute tox - N&V, vertigo, blurred vision
• teratogenic - cleft palate, cardiac abnormalities

………………………………………………………………………………
vitamin D - most importantly source is sunlight
-reabsorbed in jejunum
-PTH puts 1a-hydroxylase in the proximal tubule

increased bone mineralization at low levels, increased bone resorption at high levels

vitamin D binds to receptor on osteoBLAST- causes release of alk phos
-remember when calcitonin binds to osteoclast receptor - it inhibits the osteoclast, only hormone that binds to osteoclasts

PTH binds to osteoblast –> releases IL1 aka osteoclast-activating factor

• estrogen/testosterone keeps a check on IL1
• ….osteoporosis in women

deficiency - most commonly due to renal disease (DM is the most common cause of chronic renal disease in the US)

• all CRF pts are put on 1,25-vitamin D - NOT the formulation you get in the store
• over the counter vitamin D - has to pass through liver and kidneys

osteomalacia - soft bones, pathologic fractures

kids (rickets) - craniotabes (recoil when you press on the skull of a KID), rachitic rosary (because that is where osteoid IS, but it cant be mineralized)

• type 1 - missing 1a-hydroxylase
• type 2 (XD) - missing vitamin D receptor

…………………………………………………………………………………..
vit E- maintains cell membranes, prevents lipid peroxidation of cell membranes (prevents breakdown by phospholipase A)
- can also neutralize oxidized LDL - oxidized LDL is MORE atherogenic (LDL that macrophages phagocytose) = cardioprotective

deficiency is very uncommon - seen in kids with CF

• these kids have pancreas problems!!!
• can get hemolytic anemia - RBC membranes get damage
• myelin issues - posterior column disease, spinal/cerebellar-type disease

tox - prevents synthesis of vitamin K-dep coagulation factors = anti-coagulated

• can OD by taking an extra capsule
• OR if you are taking vitamin E with warfarin

……………………………………………………………………
vit K - phy-something

made by ANaerobes in the gut
-bacteria makes K2 - has to converted to the active form K1 by epoxide reductase

K1, gamma-carboxylase - glutamic acid residues carboxylated

• these coagulation factors are bound to a clot by Ca
• carboxylated glutamic acid residues BIND the Ca –> clot formation

scenario - rat poison = warfarin!, kid eats rat poison….
-treat with IM vitamin K

kid lives with elderly grandparents –> hemorrhage, why?
-kid ate grandparents warfarin

Question 6

CYP 450 inducers

Answer 6

CYP450 system is in sER

inducers - phenytoin, alcohol, rifampin, barbiturates

• -> sER hyperplasia - items made in the liver are metabolized faster
• this includes drugs and 25-OH-vitamin D

scenarios

• pts can get hypocalcemia (vit D deficiency)
• lady on OCP + phenytoin - gets pregnant

GGT - enzyme of sER, that is why you have elevated GGT in alcoholics

Question 7

vitamin C

Answer 7

hydroxylates proline and lysine - in the Golgi apparatus

deficiency - tea and toast diet

• hemarthrosis (and hemophilia A) - blood vessels are unstable and rupture
• perifollicular hemorrhages - ring (of blood) around the follicles
• glossitis
• hemorrhagic diaphysis

excess - GI upset, increase in uric acid stones, calcium oxalate stones, can increase Fe tox
- increases absorption of non-heme Fe - reduces Fe to Fe2+

vitamin C - ancillary treatment for methemoglobinemia, it is a scavenger for free radicals

cofactor for making catecholamines - makes NE from DOPA, epi from NE

Question 8

thiamine B1

Answer 8

think ATP - lose the production of about 30 ATP (6 from pyruvate to acetyl coA, 24 from TCA)

pyruvate dehydrogenase, transketolase, a-ketoglutarate dehydrogenase (and branched-chain ketoacid dehydrogenase)

dry beri beri - need a lot of ATP to make myelin

• peripheral neuropathy (foot drop due to common peroneal palsy, wrist drop due to radial palsy, ulnar palsy), symmetrical muscle wasting
• W-K psychosis - Wernicke is confusion, ataxia, nystamus, ophthalmoplegia
  - damage to medial dorsal nucleus of thalamus..

wet beri beri - (neuropathy +) heart failure

deficiency ddx by increased RBC transketolase following B1 administration

Question 9

pt comes into ER comatose

Answer 9

give them

• IV glucose
• IV thiamine
• naloxone - in case of OD

Question 10

niacin

Answer 10

nicotinic acid - lipid lowering agent that lowers VLDLs and increases HLD, used to treat familial combined HLD (elevated cholesterol and TGs)
- side effect flushing - take aspirin beforehand to avoid

deficiency can be caused by Hartnup dz (AR, tryptophan is a neutral amino acid), malignant carcinoid syndrome, izoniazid

pellagra, peripheral neuropathy

Question 11

riboflavin B2

Answer 11

cofactor for glutathione reductase

deficiency - cheilosis, corneal vascularization, normocytic anemia

Question 12

pyridoxine B6

Answer 12

converted to PLP (pyridoxal P) - ALT, AST, decarboxylation reactions, glycogen phosphorylase

synthesis of cystathionine, niacin, histamine, etc.

heme synthesis:

• succinyl coA + glycine, ALA synthase, B6 cofactor
• cytochrome system is also the heme system

cofactor for transaminase reaction
- alanine is the most important substrate for making glucose in the fasting state (alanine - NH2 –> pyruvate), a-ketoglutarate takes this NH2
- aspartate - NH2 –> oxaloacetate
(- glutamate -NH2 forms a-ketoglutarate)

synthesis of NTs
- neonates deficient in B6 will get seizures

most common cause of deficiency - isoniazid

def - peripheral neuropathy (isoniazid, OCPs)…

Question 13

pantothenic acid

Answer 13

involved in fatty acid synthase - important in making palmitic acid and coA

def –> adrenal insufficiency

Question 14

biotin B7

Answer 14

pyruvate carboxylase, biotin –> oxaloacetate
- pyruvate will build up and it will be forced to become lactic acid

cofactor for other carboxylation enzymes (acetyl –> malonyl, propionyl –> methylmalonyl)

deficient if you eat 7 raw eggs a day or with antibiotic use
- rash and go bald

Question 15

trace elements

Answer 15

chromium:
glucose tolerance factor - helps insulin do its job

fl:
to prevent dental caries
too much Fl - white chalky teeth
- and calcification of ligaments where they insert into bone

selenium:
PPP and forming glutathione
- cofactor for glutathione peroxidase = selenium is an antioxidant (vitamin E capsules w/ selenium)

Question 16

Cu

Answer 16

lysyl oxidase - cross links between collagen fibrils AND elastic tissue

dissecting aortic aneurysm

Question 17

Zn

Answer 17

older person with dysgeusia = abnormal taste and anosmia = abnormal smell

rash on face and acrodermatitis enteropathica (desquamating rash on butt)

collagenase (metalloenzyme) contains Zn - breaks down type 3 collagen so you can make type 1 collagen
- poor wound healing

hypogonadism and decreased adult hair

diabetics are all Zn deficient

Question 18

fiber

Answer 18

soluble fiber can lower cholesterol

insoluble fiber - hold water and toxins (lipocholic acid - carcinogenic bile acid) in the colon

• main method of recycling estrogen is through bile
• fiber will grab estrogen too - decreased risk of breast cancer

Question 19

most common benign tumors

Answer 19

women: located in uterus - leiomyoma (aka fibroid), do NOT become leiomyosarcomas
men: lipoma

Question 20

tubular adenoma

Answer 20

aka strawberry on a stick

precursor lesion to colon cancer

Question 21

carcinoma

Answer 21

malignant cancer of epithelial cells

• squamous cells
• glands - adenocarcinoma
• urothelium - transitional cell carcinoma

Question 22

melanoma

Answer 22

malignancy of melanocytes, nevus is the benign lesion

• S100 positive
• neural crest origin

step 1) excision

scenario- 2 yo with nodules to skin

• nodules are S100 positive
• answer - adrenoblastoma with mets to the skin

APUD tumor - a group of apparently unrelated cells
- neuroendocrine tumor

Question 23

embryonal rhabdomyosarcoma

Answer 23

most common sarcoma of childhood

- grape-like mass off vagina or penis - desmin positive, striations on histology

Question 24

mixed tumor

Answer 24

mixed tumors have 2 different tissues

parotid gland tumor - mobile mass at angle of the jaw
-usu malignant

v. s. teratoma - tumor of all 3 cell layers, germ-cell tumor
- 16 yo girl presents wiht RLQ pain, calcifications seen on imaging
- RLQ diff - ectopic pregnancy, appy, Crohns
- teratomas stay midline - pineal gland, ovary

Question 25

leukemia

Answer 25

malignancy of stems cells in the bone marrow --> mets - LAD, HSM

Question 26

lymphoma

Answer 26

these can metastasize most common site for a lymphoma NOT developing in a LN - stomach - aka extranodal primary lymphoma - due to H. pylori - second most common location - Peyers patches of terminal ileum most common lymphoma - follicular B cell lymphoma - knock off and apoptosis gene - 14,18 translocation - B cell make BCl2 product - inactivates apoptosis gene

Question 27

hydatidiform moles

Answer 27

pt presents with first trimester pre-eclampsia + edema - US will show uterus too large for gestational age, snowstorm appearance - benign tumor of chorionic villus complete mole has greatest chance of evolving into choriocarcinoma - mets to lung - but respond excellently to chemotherapy (methotrexate) (??) maternal blood - synctiotrophoblast - cytotrophoblast - Wartin's jelly - chorionic vein synctiotrophoblasts makes hormones - bHCG and human placental lactogen (GH of pregnancy, aas and glucose from mom to baby)

Question 28

hypoxia

Answer 28

inadequate oxygenation of *tissue* ischemia - decrease in arterial blood flow -most common cause is thrombus in muscular artery hypoxemia - partial pressure of arterial O2 (O2 dissolved in blood ONLY) - respiratory acidosis - increase in PCO2 means PO2 will go down - shunt is where there is perfusion but not ventilation, giving O2 will NOT increase PO2 - perfusion defect - PE, increased dead space, giving O2 will increase PO2 - diffusion defect - fibrosis, sarcoidosis, pulmonary edema cyanosis - decrease in O2 saturation - metHb poisoning: - scenario - man drinking water up in mtns, this water is loaded with nitrates/nitrites --> oxidize Hb. Giving O2 did not correct cyanosis. - dapsone (used to treat leprosy), primaquine, TMP/SMX, nitro (nitroglycerin) and sulfa drugs - produce metHb, hemolytic anemia in G6PD deficiency. Because these drugs are oxidizing agents. HIV pts are on bactrim prophylaxis to prevent PCP. - or due to NADH methemoglobin reductase deficiency - treatment is IV methylene blue, ancillary treatment is vitamin C - more on G6PD deficiency - oxidants cause sulfhydryl group cross-linking cytochrome oxidase - last enzyme before e- is transferred to O2 - cyanide and CO inhibit cytochrome oxidase - "three Cs" ...

Question 29

J reflex

Answer 29

vagus nerve innervates J receptors/pulmonary C-fiber receptors - located in alveolar walls, close to pulmonary vessels respond to pulm edema, PE, other cases where there is a decrease in oxygenation --> increase ventilation/respiration = dyspnea

Question 30

house fire

Answer 30

CO poisoning and cyanide poisoning (gas released when upholstery is burned) first symptom of CO poisoning - headache! CO poisoning - PaO2 will be unchanged - because this is the amount of O2 dissolved in plasma

Question 31

high altitude

Answer 31

PaO2 will be LOW - PiO2 is low - hypoxemia triggers hyperventilation respiratory alkalosis - due to hyperventilation renal compensation occurs by 24-48hrs chronic changes increased synthesis of 2,3-BPG hemoconcentration - due to bicarb diuresis and fluid shift increased pulmonary diffusing capacity

Question 32

uncoupling of inner mitochondrial membrane

Answer 32

inner mitochondrial membrane is inappropriately permeable to H+ dinitrophenol (was used in dieting pills in the 1930s), alcohol, salicylates hyperthermia - in salicylate tox - alcoholic on a hot day - good chance of getting heat stroke, mitochondria are uncoupled

Question 33

respiratory acidosis

Answer 33

decrease in PO2 and O2 sat

Question 34

tissue hypoxia

Answer 34

anaerobic glycosis --> lactic acid build up --> enzymes denature - CANT apoptose because enzymes are denatured = coagulation necrosis (MI) cellular swelling - reversible (when O2 is reintroduced) - anything that is related to depleted ATP irreversible change - Ca enters cells, because Ca-ATPase fails - activates enzymes --> phospholipases **damage cell membranes**, nuclear pyknosis (- remember hypercalcemia produces acute pancreatitis) - also mitochondrial vacuolization - means that ATP production is permanently damaged

Question 35

free radicals

Answer 35

settings: ...phase 1 metabolism of drugs, carbon tetrachloride (drug, risk for centrilobular necrosis and fatty change of liver) end product is lipofuscin - indigestable lipids - will see this in the liver - also called wear-and-tear pigment reperfusion injury when you give pure O2 to NRDS R - retinopathy of prematurity due to free radical damage of retina I B - bronchopulmonary dysplasia - fibrosis in lungs H2O --> OH due to radiation for cancer (ionizing radition) - most common complication of radiation - leukemia

Question 36

acetaminophen | tylenol

Answer 36

no 1 cause of drug-induced fulminant hepatitis - due to free radical production damage occurs around central vein free radicals also damage renal medulla and PGE2 knocked out - inability to concentrate urine treat with N-acetyl-cysteine - replenish substrate for glutathione

Question 37

methotrexate and leucovorin

Answer 37

methotrexate - competitively inhibits DHFR leucovorin (folinic acid) given 24hrs after methotrexate - rescues normal cells, allows DNA to be made without folate

Question 38

apoptosis

Answer 38

caspases - lipofuscin cant be degraded ex: councilman body - eosinophilic, dead cell in liver extrinsic (how tumor cells are killed) 1) TNF binds to TNFR1 2) Fas ligand binds to cell surface receptor Fas

Question 39

left heart emboli

Answer 39

vegetation from INFECTIVE endocarditis mitral stenosis from group A strep -> clots in atria

Question 40

dry gangrene

Answer 40

diabetic - atherosclerosis of popliteal artery | --> dry gangrene - means there is no pus

Question 41

(small) bowel infarction

Answer 41

most common cause - bowel adhesions following surgery 2nd cause - entrapment in indirect inguinal hernia --> hemorrhagic infarction

Question 42

necrosis

Answer 42

coagulative: proteins denature, then enzymatic degradation in granuloma ``` caseous: - mycobacterial infection or systemic fungal infection - lipid in cell wall of organisms other non-caseating granulomas - sarcoidosis, Crohns ``` liquefactive: neutrophils release lysosomal enzymes, then proteins denature - infarction --> liquefactive necrosis in brain - B/C brain has no structural support (astrocytes but..) - other cases of liquefactive necrosis - acute *inflammation*, neutrophils come in a damage tissue, abscesses fat: acute pancreatitis, breast tissue - damaged cells release lipase fibrinoid - immune reactions, preeclampsia, mal HTN gangrenous - distal extremity, GI tract - dry - ischemic, cogulative - wet - superinfection, liquefactive on coagulative

Question 43

strep

Answer 43

hemolytic - lysins DNase - degrades DNA in pus to facilitate the spread of the organism releases hyaluronidase - breaks down GAGs in tissue - allows infection to spread through tissues = cellulitis gram positive diploccoci - Strep pneumo - most common cause of bronchopneumonia

Question 44

lung infarction

Answer 44

wedge shaped infarct - coagulative necrosis, hemorrhagic necrosis - exudate, pleural effusion, neutrophils, blood --> pleuritic chest pain

Question 45

pancreatitis

Answer 45

pain radiating to the BACK SAD PUCKER enzymatic fat necrosis

Question 46

fibrinoid necrosis

Answer 46

necrosis of immunologic disease palpable purpura - Type 3 HSR, small vessel disease - alternative complement system - C5a - neutrophils do the damage rheumatoid necrosis, vasculitis malignant HTN, diabetes

Question 47

liver

Answer 47

other sinusoid organs are - bone marrow, spleen gaps between endothelium - RBCs, etc. can flow through these gaps note: blocking HEPATIC vein will lead to liver congestion, blocking portal vein will do nothing which part of liver is most susceptible to injury - around central vein (zone 3) - zone 2 - yellow fever hits here alcohol - increase in NADH and lactic acid production - difficulty with gluconeogenesis - because of depleted pyruvate, fasting hypoglycemia - ketoacids because of excess acetyl coA - will see b-hydroxybutryate in an alcoholic because it is an NADH-driven reaction - fatty change in liver - glycolysis --> glycerol-3-phosphate --> VLDL (this is why restricting carbs reduces VLDL) - *and because of decreased FFA oxidation* - due to increased NADH - secondary issues - impaired lipoprotein assembly and secretion and increase in peripheral fat catabolism

Question 48

hamartomas

Answer 48

bronchial hamartoma - solitary coin lesion - lung Peutz-Jeger syndrome - hamartoma - no increased risk of neoplasm hyperplastic polyp of colon -most common type of polyp - hamartoma

Question 49

malignant cells

Answer 49

longer cell cycle than original cell from which they were derived upregulation fo telomerase how many doubling times until you get a clinically detectable tumor - 30 doubling times proteases, collagenases (to break through the basement membrane) mets - lymphatic, hematogenous, seeding - carcinomas - to LNs, specifically the subcapsular sinus - exceptions - RCC/HCC go to vein, follicular carcinoma of thyroid goes to blood, choriocarcinoma - sarcoma - hematogenous, go to lungs and bone - seeding - surface ovarian cancers, glioblastoma and medulloblastoma in a kid seeds into spinal fluid cancer in adults - we know (lung - non-small cell) cancer in kids: - incidence and death - leukemia, brain/CNS, neuroblastoma death overall in US: heart disease, cancer

Question 50

Pouch of Douglas

Answer 50

most dependent part in a lady

Question 51

mets

Answer 51

usually mets are the most common cancer in org - except - renal adenocarcinoma - CT with multiple lesions = mets Batson system - venous system, tributaries that connect deep pelvic and thoracic veins --> IVC --> vertebral bodies - valveless system - breast cancer can quickly spread to bone (vertebral column, head of femur) 1) lymph nodes are most commonly metastasized to next most common) lung - mets from breast next most common) liver - colon >> stomach > pancreas - lung also mets to the adrenals testicular cancer to peri-aortic lymph nodes - testes develop in abdomen and descend to pelvis left supraclavicular node (Virchows node) - stomach radionuclide scan - bone mets - prostate, breast > lung, thyroid, kidney - lytic mets (most mets) - multiple myeloma (why plasma cells have IL1 aka osteoclast activating factor) - blastic mets - prostate cancer - first step in checking for prostate cancer - DRE - breast - mixed met - axial skeleton brain - mets from lung (why - lung is the most common killer) > breast > melanoma, colon, kidney - at gray-white junction desmin stains for muscle - muscle tumor vascular malignancy - Weibel Palade bodies

Question 52

steps of malignancy

Answer 52

1) initiation = mutation - knocked out by point mutation - p53 (really all suppressor genes), Ras - amplification (ErbB2) - translocation - CML (Bcr-Abl fusion aka Philadelphia chromosome, 9:22) - 8;14 - Burkitts lymphoma, C-myc (associated with EBV because it increases mitotic rate) - when CD21 is bound, causes B cells to become plasma cells, receptor that EBV binds to) - 14:18 - 15:17 - acute progranulocytic leukemia - treat with retinoic acid --> matures blast --> cancer becomes benign Why? - *chemicals* (polycyclic hydrocarbons), viruses, radiation 2) promotion - multiple copies of mutation 3) progression - role of cancer cell, subspecializing what it will be resistant to cis = proto-oncogene, makes growth factors ErbB2 - codes for growth factor receptor RET - MEN syndrome, receptor for growth factor Ras - cell membrane messenger system (GTP) Abl - cytosol, messenger system - messages are sent to nucleus nucleus: N-Myc (neuroblastoma), C-myc (burkitts) ``` try to keep cell cycle in G1 phase: Rb suppressor gene p53 suppressor gene - DNA repair NF WT1 BRCA1 and BRCA2 - DNA repair genes ```

Question 53

HCC

Answer 53

far east factors: HBV, aflatoxin

Question 54

HIV

Answer 54

associated with primary CNS lymphoma

Question 55

most common cancer associated with radiation

Answer 55

leukemia - specifically CML (9;22) papillary carcinoma of thyroid

Question 56

basal cell carcinoma

Answer 56

non-ionizing radiation = UVB light = BAD - thymidine dimers (UVA is Wood lamp - used to find dermatophytes) actinic keratosis aka solar keratosis - cancer that you can scrape off - this is *squamous* dysplasia - arsenic predisposes (- arsenic also involved in angiosarcoma of the liver, lung cancer) - predisposes to squamous cell carcinoma

Question 57

white eye reflex

Answer 57

most common reason - congenital cataract TORCHES - side note - congenital syphillis have tooth findings (Hutchinson's incisors) next - retinoblastoma corticosteroids predispose to cataracts

Question 58

skin cancers

Answer 58

AR - xeroderma pigmentosum - defect in DNA repair enzymes upper lip up - basal cell down - squamous cell (other DNA repair enzymes - Wiskott-Aldrich, telangiectasias, etc.)

Question 59

scar cancers in the lung

Answer 59

ex Tb scar --> adenocarinoma otherwise chronic irritation, burns, draining sinus tracts --> squamous cell carcinoma

Question 60

myasthenia gravis

Answer 60

NACh = ligand-gated sodium channel - thymoma - question will show you a chest xray - side note - hypogammaglobulinemia (Good syndrome) and pure red cell aplasia (anemia and low retics) assoc with thymoma v.s. Lambert-Eaton myasthenic syndrome - occurs in small cell lung cancer

Question 61

poliomyositis

Answer 61

symmetric proximal muscle weakness - CD8 damage to skeletal muscle cells = autoimmune, increased CK - endomysial inflammation - remember endomysium (muscle fiber) - perimysium (fasicle) - epimysium (fascia) dermatomyositis can see skin rash and inflammatory arthritis

Question 62

postural muscles

Answer 62

soleus, paraspinal muscle - type 1 slow twitch fibers (lots of myoglobin, mitochondria, aerobic respiration) v.s. type 2a - ATP via aerobic metabolism type 2b - glycogenolysis and glycolysis

Question 63

osteoporosis

Answer 63

1) vertebral fracture - cancellous bone is affected first | 2) cortical (compact) bone - hip fracture

Question 64

PTH-independent hypercalcemia

Answer 64

humoral hypercalcemia of malignancy, vitamin D tox or excess Ca ingestion, thyrotoxicosis, immobilization thyrotoxicosis - due to osteoclastic activity of thyroid hormones

Question 65

host defenses

Answer 65

most important host defense system - CD8 T cells | - MHC1 --> CD8 cell releases perforin --> activate caspases

Question 66

cachexia

Answer 66

caused by TNFa irreversible - cant be fixed TPN TNFa - acts on hypothalamus, suppresses appetite - also increases BMR

Question 67

pancreatic cancer

Answer 67

can also go to left supraclavicular node Trousseau syndrome - recurrent migratory thrombosis of superficial veins (in chest wall, arms) - because adenocarcinomas produce a thromboplastin-like substance disseminated cancer - thrombocytosis (also occurs in myeloproliferative disease, Fe-deficiency)

Question 68

fever in malignancy

Answer 68

most common cause is a gram negative infection - E coli - indwelling catheter - respirator - pseudomonas - S. aureus (gram positive) - indwelling venous catheter most common cause of death in cancer

Question 69

paraneoplastic syndrome

Answer 69

most common is hypercalcemia - bone (IL1, PGE2 --> lytic lesions in bone), PTHrP (RCC, squamous cell carcinoma)

Question 70

gastric adenocarcinoma

Answer 70

acanthosis nigricans Leser-Trelat sign - seborrheic keratosis (esp ones that pop up overnight) - black raised moles

Question 71

hypertrophic osteoarthropathy

Answer 71

= clubbing + periostitis of long bones + arthritis - inflammation of underlying bone --> results in proliferation of soft tissue = clubbing associated with malignancy - primary lung cancer can also see clubbing in bronchiectasis - clubbing is associated with hypoxemia

Question 72

vegetations on heart valve

Answer 72

associated with mucous producing cancers - colon cancer marantic endocarditis - vegetations are not infectious but they can embolize - adenocarcinomas, esp pancreatic need hx to separate from rheumatic fever

Question 73

hyponatremia or Cushings

Answer 73

small cell lung cancer - APUD tumors, neural crest origin, S100 positive (nervous system specific cytoplasm protein, also present in melanoma cells) - ADH, ACTH

Question 74

renal adenocarcinoma

Answer 74

EPO and PTHrP

Question 75

HCC

Answer 75

EPO and insulin-like factor --> secondary polycythemia and/or hypoglycemia

Question 76

medullary carcinoma of thyroid

Answer 76

calcitonin is a tumor marker --> can be converted to amyloid - can get hypocalcemia or Cushings AD variant

Question 77

male with testicular cancer

Answer 77

AFP - yolk sac tumor aka endodermal sinus tumor - young kids - AFP is also associated with HCC and open neural tube defects - AFP is decreased in DS b-HCG

Question 78

multiple myeloma

Answer 78

Bence-Jones protein - light chain of immunoglobulin - monoclonal spike (SPEP, M peak, M peak is also found in Waldenstrom macroglobulinema) erythrocyte rouleaux formation on peripheral blood smear

Question 79

tumor markers

Answer 79

Alk phos: bone, seminoma (placental ALP), exclude liver causes ovarian: surface derived - CA-125 breast: CA15-3, 27-9 colon cancer: carcinoembryonic antigen (CEA) - also in pancreatic cancer - CEA-(anti-CEA) can deposit in kidney and produce diffuse membranous glomerulonephritis

Question 80

most common tumor of brain in kids

Answer 80

pilocytic astrocytoma (cerebellum) - benign most common cancer of brain - medulloblastoma (cerebellum)

Question 81

most common childhood cancer

Answer 81

* leukemia - specifically ALL* others: neuroblastomas (adrenal medulla), Burkitt's lymphoma, Ewing sarcoma (onion-skin calcification), embryonal rhabdomyosarcoma

Question 82

most common GYN cancer

Answer 82

most common - endometrial cancer 2) ovarian 3) cervical - PAP smear picks up cervical *dysplasia* cancer killers 1) ovarian 2) cervical 3) endometrial - most common cancer has the best prognosis

Question 83

only known tumor vaccine

Answer 83

HBV vaccine

Question 84

galactosemia

Answer 84

AR - galactose-1P-uridyl transferase deficiency neonatal jaundice and hepatomegaly, vomiting, cataract formation, failure to thrive, ID - galactose-1P accumulation blocks phoshoglucomutase - cant convert G1P to G6P for entry into glycolysis - can predispose to E coli sepsis in neonates eliminate milk products from diet - use soy based formula ..... galactokinase deficiency - AR, mild - galactitol accumulates - galactosemia, galactosuria, infantile cataracts - may present as failure to track objects or develop a social smile galactitol is what causes cataracts in both

Question 85

pale infarcts

Answer 85

heart, kidney, spleen

Question 86

Trisomy 18

Answer 86

trisomies - error in meiosis nondisjunction (in oocyte) micrognathia, prominent occiput, clenched hands with overlapping fingers, rocker bottom feet, hypertonia hear defects (VSD, PDA), renal defects (horseshoe kidney), GI issues(Meckels, malrotation), limited hip abduction prenatal US will show fetal growth restriction - majority die in utero - 1/2 of live births die by 2 weeks - surviving pts have ID

Question 87

Cri-du-chat syndrome

Answer 87

``` 5p deletion (p is the short arm) cat-like cry, hypotonia, failure to thrive, developmental delay ``` microcephaly, low-set ears, hyperterlorism (abnormally large distance between the eyes), broad nasal bridge

Question 88

DiGeorge

Answer 88

22q11 aortic arch anomalies, thymic hypoplasia/aplasia and hypocalcemia hypertelorism, low-set ears, micrognathia, cleft palate

Question 89

HBV

Answer 89

proliferative phase - HBV DNA and antigens present - antigens presented on MHC1 integrative phase - HBV DNA is incorporated into the host genome - liver damage tapers off when antiviral antibodies appear and viral replication stops - antibodies bind HbsAg - prevent binding of virus to hepatocytes - risk of HCC there are immune complexes in HBV infection - cause early (arthralgias, urticaria) and chronic complications (GN, cryglobulinemia)

Question 90

IgA

Answer 90

IgA antibodies bind to pili and other membrane proteins involved in adherence to bacterial mucosa --> inhibits mucosal adherence Neisseria, S. pneumo, H. Flu have IgA protease IgA is a weak activator of complement and a poor opsonin H. flu - requires factor X (hematin) and factor V (NAD+) for growth - unencapsulated strains are a cause of otitis media --> erythematous tympanic membrane

Question 91

staph

Answer 91

staph protein A - binds Fc portion of IgG --> prevents complement fixation all staph are catalase pos (distinguishes them from strep) only s aureus is coagulase pos - can clot blood - coagulase activates prothrombin --> fibrinogen is converted to fibrin --> organism is coated by fibrin and becomes resistant to phagocytosis

Question 92

Tb

Answer 92

mycobacteria in general - Cord factor (serpentine cord, activates macrophages, and induces the release of TNFa) - sulfatides (surface glycolipids) inhibit *phagolysosome* fusion PPD negative in sarcoidosis or HIV infection - primary tb - hilar nodes + ghon complex (usually mid/lower lobes) HIV pts are at increased for tb regardless of CD4+ counts isoniazid: - inhibits mycolic acid synthesis - mycolic acid holds carbolfuschin stain, resistant to decolorizer - INH has to be processed by mycobacterial catalase peroxidase to be activated - resistance can also occur if enzyme binding site is altered - ADR: B6 deficiency, hepatoxic ethambutol: - inhibits synthesis of mycobacterial cell wall - resistance when Mb increase production of arabinosyl transferase (enzyme that produces cell wall) - optic neuropathy pyrazinamide - has to be converted to active form by pyrazinamidase - hepatotox, hyperuricemia rifampin - resistance - when there is mutation in the gene that codes for DNA-dep RNA polymerase - rash, red-orange body fluids (other mycobacteria - avium-intracellulare causes disseminated disease in AIDs, prophylax with azithro - M scrofulaceum - cervical lympadenitis in kids

Question 93

thoracic duct

Answer 93

drains lymph from left side of body and everything inferior to umbilicus - empties into the left subclavian (where it junctions with the IJ)

Question 94

bacterial toxins

Answer 94

Diphtheria toxin and P. aeruginosa exotoxin A - ribosylate and inactivate EF2 S. aureus - enterotoxin - superantigen - TSS - superantigen that stimulates T-cells --> widespread cytokine release and shock C diff - cytotoxin A - diarrhea - cytotoxin B - induces actin depolymerization --> necrosis Botulinum toxin - blocks pre-synaptic release of Ach at NMJ --> flaccid paralysis Pertussis toxin - ribosylates DISinhibits adenylate cyclase --> increased cAMP - increased histamine sensitivity and phagocyte dysfunction Cholera toxin - activates adenylate cyclase --> cAmP --> secretory diarrhea C. perfringens - lecithinase aka phospholipase C aka a-toxin - -> cell lysis (&hemolysis), vaso-oclusion, tissue necrosis, edema - lecithinase also increases platelet aggregation and adherence molecule expression by leukocytes and endothelial cells - C perfringens uses carbs for energy --> gas (so gas is not produced due to the toxin) Strep pyogenes - streptokinase which converts plasminogen to plasmin - erythema nodosum is most commonly associated with S. pyogenes (though it is a nonspecific finding)

Question 95

intracellular pathogens

Answer 95

Legionella, N. gonorrhea, Listeria, viruses, Leishmania

Question 96

injury and inflammation

Answer 96

injury --> neutrophils, macrophages --> TNFa, IL1, IL6 --> stimulate hepatic production of acute phase reactants - many acute phase proteins bind to microbes --> fix complement - fibrinogen (and IgG) - causes erythrocytes to from stacks that sediment fast than individual RBCs do = ESR ESR - increased in anemias, renal disease, pregnancy, etc. - decreased in sickle cell, polycythemia, HF, microcytosis, hypofibrinogenemia side note - IgM cause RBCs to clump (normally RBCs have a negative charge to repel each other) - cold agglutinins - can get Raynauds in cold weather - cryoglobulins (these are not Ig) - proteins that agglutinate in the cold (remember HCV is highly associated with cryoglobulins) acute inflammation (ex appendicitis) = absolute leukocytosis - absolute increase in neutrophils with toxic granulation - toxic granulation = O2-dep myeloperoxidase system - most potent system to kill bacteria - located in granules/lysosomes of neutrophils - left shift - >10% band neutrophils chronic inflammation - mononuclear cells and fibroblast mediated

Question 97

bradykinin

Answer 97

vasodilation, increased vascular perm, mediates pain smooth muscle CONTRACTion

Question 98

PAF

Answer 98

=platelet activating factor - vasoconstriction, bronchoconstriction, platelet stimulation also enhances leukocyte adhesion to endothelium, chemotaxis, phagocytosis, and degranulation

Question 99

drugs that affect warfarin

Answer 99

cyp450 inhibitors (increase warfarin effect) - acetaminophen/NSAIDs - antibiotics/antifungals (metronidazole, bactrim) - amiodarone (watch out - pts with afib may be on amiodarone + warfarin) - cimetidine, omeprazole - cranberry juice, vitamin E, Ginkgo biloba - thyroxine - SSRIs - the other problem with NSAIDs/ASA - they can also displace warfarin from its protein-binding site --> increasing the concentration of free warfarin inducers - carbamazepine, phenytoin - Ginseng, St. John's wort - OCPs - phenobarb - rifampin cholestyramine binds warfarin (and other drugs in the intestine) warfarin particularly has an effect on factor 7 - prolongs PT and INR (INR is the ratio of PT/PTcontrol) - for pts with afib, DVT, PE - want a INR of 2-3

Question 100

Nocardiosis

Answer 100

gram positive rod (beaded, branching, looks like a thin hyphae) - partially acid fast - catalase positive soil, healthy gingiva, inhaled, *immunocompromised* pneumonia ~Tb, CNS involvment (ring-enhancing lesion aka abscess), cutaneous treat with bactrim and surgical drainage of abscess v. s. Toxoplasmosis (parasite!) - encephalitis and pneumonitis in HIV pts - ddx with serology - histopath will show cysts or zoites

Question 101

Actinomyces

Answer 101

gram positive cervicofacial (and abdominal) disease - granulomatous inflammation + multiple abscesses - sinus tracts that discharge sulfur granules

Question 102

anti-emetics

Answer 102

used in motion sickness, hyperemesis gravidarum *anticholinergics* - scopolamine antiH - diphenhydramine, meclizine, promethazine motion sickness - vestibular, visual, somatosensory systems integrate in vestibular nuclei - M1 and H1 neurotransmission chemo, visceral nausea (diabetic gastroparesis) dopamine receptor antagonists - prochlorperazine, metoclopramide - ADRs - diarrhea serotonin antagonists - ondansetron - headache, long QT, constipation NK1 receptor antagonists - aprepitant, fosaprepitant

Question 103

TB

Answer 103

caseating granulomas - mycobacteria are phagocytosed by APCs --> CD4 cells are primed and release TNF and IFN-y --> stimulates macrophages and other leukocytes activated macrophages secrete enzymes, ROS, etc. to destroy mycobacteria - collateral damage Rim of T cells - around macrophages - caseous necrosis --> cavitary lesions Tb produces cord factor (part of the cell wall) - prevents fusion with lysosomes

Question 104

nucleotide excision repair

Answer 104

1) UV light --> thymidine dimers 2) endonucleases recognize deformed helix 3) ss cleavage and DNA repair (DNA poly, ligase) xeroderma pigmentosum - AR - photosensitivity, poikiloderma (associated with sun damage), hyperpigmentation in sunexposed areas - deficient in endonuclease ``` Lynch syndrome (HNPCC) - DNA mismatch repair mutations - normally DNA polymerase has 3-5 exonuclease proofreading ability ```

Question 105

Pseudomonas aeruginosa

Answer 105

``` malignant otitis externa in elderly diabetics - granulation tissue in ear pneumonia - CF, ventilated pts burn victims hot tub folliculitis ecthyma grangrenosum ~gangrene ulcer ``` MOTILE, aerobic gram-neg rod OXidase positive endotoxin (fever, shock), exotoxin (inactivates EF-2) cipro, etc.

Question 106

lungs and ribs anatomy

Answer 106

lungs end at rib 6 parietal pleura extends till rib 8 - thoracentesis - go between 6th and 8th rib (midclavicular line) - insert between 10-12 if pts back is to you (paravertebral), between ribs 8-10 if pts side is to you (mid-axillary) liver - can hit the liver if you insert the liver below rib 9, midaxillary line intercostal vein, artery, and nerve lie on the LOWER border of the rib

Question 107

urticaria

Answer 107

wheals - due to IgE-mediated degranulation of mast cells - can also be due to non-IgE mechanisms/mast cell mechanism - no IgE but mast cell degranulation - opiates, radiocontrast, physical urticaria - no mast cells - ASA, hereditary angioneurotic edema permeability of microvasculature --> edema in superficial DERMIS - biopsy - mixed inflammatory infiltrate, engorged lymphatics (deep dermal and subQ involvement = angioedema)

Question 108

skin findings

Answer 108

acantholysis - loss of cohesion between keratinocytes - pemphigus disorders acanthosis - increased thickness of stratum spinosum - psoriasis, seborrheic dermatitis, acanthosis nigricans dyskeratosis - premature keratinization - squamous cell carcinoma spongiosis - intercellular EPIDERMAL edema - spongiotic dermatitis - seen in eczematous dermatitis

Question 109

vaccines

Answer 109

live attenuated - humoral and cell-mediated immunity - MMR (rubella - PDA, sensorineural deafness, congenital cataract, generalized LAD and rash) - rubella will was arthritis/arthralgia in the moms killed - humoral only - hepA, rabies

Question 110

leukocyte IFN-a

Answer 110

inhibits various stages of viral RNA and DNA synthesis | - approved for HBV, HCV, hairy cell leukemia, condyloma acuminatum, Kaposi

Question 111

lymphatic drainage

Answer 111

superficial lymphatics follow veins deep lymphatics follow arteries right lymphatic duct drains R body above diaphragm mediastinal - trachea, esophagus celiac - accessory abdomen and upper duodenum SM - to splenic flexure IM - to upper rectum LE - medial trunk (runs along saphenous) --> superficial inguinal nodes - lateral track --> popliteal AND inguinal nodes - popliteal - dorsolateral foot, post calf superficial inguinal nodes - scrotum, perineum, ant abd wall, buttocks, skin of penis - basically, cutaneous structures inferior to umbilicus and external genitalia below pectinate line internal iliacs - prostate, bladder, vagina (middle third), cervix, lower rectum to anal canal above pectinate para-aortic LN - testes, ovaries, kidneys, uterus glans of penis and urethra - deep inguinals external iliacs - deep lymphatics of abd wall + superficial nodes

Question 112

Lyme disease

Answer 112

treat with doxy (aka tetracycline, first line), amoxicillin is first line in pregnancy

Question 113

sulfonamide

Answer 113

use during the 3rd trimester - can displace bilirubin bound to serum albumin --> increased risk of neonatal kernicterus

Question 114

Giardia

Answer 114

``` trophozoites = pathogenic, owl eyes cysts = infectious ``` if stool O&P is undiagnostic - small bowel biopsy will show villus atrophy IgA and CD4+ are host defense mechanisms - IgA deficiency, X-linked agammaglobulinemia, CVID have low IgA v.s. Crypto and Toxo are intracellular intestinal pathogens

Question 115

Roseala HHV6

Answer 115

less than 2 yo 3-5d of fever --> blanching maculopapular rash that starts on trunk and spreads to extremities - can have febrile seizures supportive care v. s. Rubella and measles - rash that starts on the face and spreads to the trunk and extremities - Rubella - spots on soft palate - Measles - Koplik spots on buccal mucosa - acute measles infection depletes vitamin A stores

Question 116

seborrheic dermatitis

Answer 116

accumulation of scaly, greasy skin on face, ears, etc. | - seen in HIV and Parkinsons

Question 117

ephedrine

Answer 117

related to methamphetamine | - treat asthma, decongestant, and stimulant effects

Question 118

Chediak-Higashi

Answer 118

AR - granules in neutrophils and monocytes (immunodeficiency due to Staph, Strep), albinism, neuro defects (nystagmus, neuropathies) - due defect in phagolysosome fusion --> granules = lysosomal inclusions

Question 119

Wiskott-Aldrich

Answer 119

XL - immunodeficiency, eczema, thrombocytopenia | - combined B and T lymphocyte disorder

Question 120

mTOR

Answer 120

growth factor receptor --> autophosphorylation of tyrosine residues --> PI3K --> AKT/PKB --> mTOR to nucleus --> cell survival (anti-apoptosis) - endogenously inhibited by PTEN (PHOSPHATASE and tensin homolog) upregulated in many cancer cells - rapamycin aka sirolimus = mTOR inhibitor

Question 121

cytokine receptors

Answer 121

intracellular (rather than receptor) tyrosine kinases = JAK/STAT pathway - STAT dimerizes and translocates to the nucleus

Question 122

organic ACIDemia

Answer 122

thymidine, uracil valine, isoleu, met, thre cholesterol, odd-chain FAs --> propionyl-coA + biotin --> methylmalonyl-coA --> succinyl coA -> TCA propionic acidemia (AR) - propionyl-coA carboxylase deficiency - severe metabolic acidosis - hypoglycemia and ketosis develop secondary to acidosis - present as poor feeding, vomiting, hypotonic babies - treat with low protein diet

Question 123

lysine and leucine

Answer 123

ketogenic amino acids --> acetyl coA

Question 124

DS and cancer

Answer 124

features: nuchal fold thickening, endocardial cushion defects, duodenal and jejunal atresia, hypotonia 10x-20x risk for ALL (and increased risk for AML)

Question 125

Toxo gondii

Answer 125

intracellular PROTOZAn - cat is the host - humans can get infected through contaminated water/meat (cysts) cerebral toxo - encephalitis with ring-enhancing lesions (necrosis and seizures - treat with pyrimethamine and sulfadiazine (can use clinda if sulfa allergy) pt doesnt improve - probably CNS lymphoma - non-Hodgkin B-cell lymphoma due to EBV - EBV PCR of CSF, definitive ddx by brain biopsy ................ cryptococcal meningitis - amphoB aspergillosis with CNS involvement (single ring-enhancing lesion) - + pulmonary and orbital manifestations - use voriconazole

Question 126

Listeria

Answer 126

gram positive bacteria that causes endotoxin-mediated septic shock (in general endotoxins are release during host immune activity or antibiotic treatment) ampicillin

Question 127

CMV

Answer 127

CMV - intracelluar inclusions most common antibody in the US, most common blood tranfusion related infection (most common cause of post-transfusion hepatitis = HCV) retinitis, esophagitis, pneumonia, colitis, polyneuropathy, transverse myelitis, encephalitis ganciclovir, use foscarnet if resistant to ganciclovir - ganciclovir - guanine nucleoside analog, P- required - foscarnet (IV) - pyrophosphate analog, doesnt required intracellular activation - inhibits DNA poly (in herpes) and RT in HIV

Question 128

metaplasia

Answer 128

squamous bronchial metaplasia: pseudostrat ciliated respiratory epi --> stratified squamous epi Barret's - esophageal squamous epi --> intestinal columnar epithelium

Question 129

anticholinergics

Answer 129

...flushing ``` antihistamines (..doxylamine) TCADS (ami, imipramine) 1st gen antipsych esp low potency ones (chlorpromazine) clozapine benztropine, trihexyphenidyl atropine ```

Question 130

prazosin

Answer 130

a1 BLOCKER - treat HTN and urinary retention (BPH)

Question 131

anti-IL2

Answer 131

post-organ transplant to prevent graft v.s. host

Question 132

granulation tissue

Answer 132

inflammatory cells fibroblasts - fibroblast growth factor --> lots of blood vessels keloid - excess of type 3 collagen deposition - genetic predisposition - increased in black population scenario: scar from 3rd degree burn and chronically draining sinus tracts (ex chronically draining osteomyelitis)--> squamous cell carcinoma - lots of turn over in scar tissue - type 3 collagen replaced by type 1 collagen (requires Zn)

Question 133

inflammation

Answer 133

acute - neutrophils - IgM (complement is heavily involved in acute inflammation) - side note - IgG-activated complement only goes up to C3 - 10days -2 weeks - isotype switching (same plasma cell switches HEAVY chains) --> IgG becomes primary Ig chronic - lymphocytes - IgG granulomas - type 4 HSR (type 4 reactions are anything T cell mediated) - alveolar macrophage phagocytoses Tb --> takes a tour of the body presents antigen to TH1 cells --> T cells release gamma-INF and macrophage inhibitory factor - macrophage inhibitory factor keeps macrophage in that area = localized granulomas - gamma-INF will activate macrophage (=epithelioid histiocyte) to kill organisms (Tb, systemic fungi) --> caseous necrosis - when these macrophages die --> they form multinucleated giant cells - macrophages secrete *IL12* - activates TH1 T cells --> these T cells become the memory T cells - Tb lives in calcified granulomas --> reactivates - positive PPD - purified protein derivative injected into skin - Langerhans cells (macrophages of skin, CD1, Birbeck granules) --> phagocytose protein derivated - present to TH1 that has MEMORY of Tb exposure - helper T cells releases cytokines --> inflammation, induration - how about in elderly, AIDs - older people have less of an immune response (pts with AIDs will also not have a granuloma)

Question 134

3rd degree burn

Answer 134

loss plasma and protein

Question 135

celecoxib

Answer 135

COX1 - constitutively expressed, involved in housekeeping functions COX2 - inducible, IL1 and TNFa cause COX2 upregulation - COX2 metabolites increase pain sensitivity and inflammation NSAIDS/ASA inhibit COX1 and COX2 celecoxib - selective COX2 inhibitor (minimize GI tox)

Question 136

glucocorticoids decreased inflammation

Answer 136

bind to cytoplasmic receptors --> translocate to nucleus --> expression of anti-inflammatory peptides is upregulated (and COX2 transcription is downregulated)

Question 137

minocycline

Answer 137

tetracycline weak antirheumatic activity side effects - photosensitivity dermatitis

Question 138

ribavirin

Answer 138

used in HCV - INFa and ribavirin for pts with chronic infection (HCV RNA and liver inflammation/fibrosis) 1) phosphorylated intracellularly - incorporated into RNA --> causes hypermutations --> lethal to RNA viruses - directly inhibits HCV RNA polymerase - inhibits IMP dehydrogenase - depletes GTP pools - inhibits enzymes that form 5'-cap on viral mrNA - enhances TH1-cell mediated immunity, inhibits TH2 cytokine production side note - ribavirin also indicated for RSV

Question 139

nerves through the skull

Answer 139

supraorbital fissure - CN3, CN4, CN6 - nasociliary branch of CNV1 - ophthalmic vein inferior orbital fissure - CNV2 - infraorbital vessels - sphenopalatine ganglion branches pass through the inferior orbital fissure foramen rotundum - CNV2 foramen lacerum occluded by cartilage - internal carotid artery courses superior foramen ovale - CNV3 order of foramens

Question 140

streptomycin

Answer 140

TB (sometimes), Yersinia pestis, tularemia

Question 141

tabes dorsalis

Answer 141

20-30 years after primary infection spirochetes cause damage to sensory nerves in dorsal roots --> secondary demyelination of dorsal columns areflexia, loss of bladder function, positive Romberg Argyll Robertson pupils - accomodate but dont constrict - very difficult to dilate - asymmetric

Question 142

malaria

Answer 142

P. falciparum - trophozoites in RBCs (Giemsa stain) - African species are chloroquine-resistant - use mefloquine P. v/o - add primaquine therapy

Question 143

TDaP

Answer 143

first dose given at 2 mo - infant unable to mount a proper memory response earlier than this

Question 144

biologics

Answer 144

- mab - infliximab, certolizumab - anti-TNFa - cept = receptor molecule - nib = kinase inhibitor - imatinib - CML and kit-positive GI stromal tumor

Question 145

ribosomes

Answer 145

rER produces proteins for membranes and for export (including enzymes in ribosomes) free ribosomes - produce cytosolic, mitochondrial, peroxisome matrix proteins ribosome attaches to rER by translocon - binds 60S unit

Question 146

calcification

Answer 146

dystrophic calcification - ...liquefactive necrosis of chronic abscesses, schistosomiasis, congenital CMV, toxo, rubella, CREST syndrome metastatic calcification - predominantly in interstitial tissues of the kidney, lung, and gastric mucosa (these tissues lose Ca2+ quickly) - nephrogenic DI and renal failure PSaMMoma bodies = papillary carcinoma of thyroid, serous papillary carcinoma of cystadencarcinoma of ovary, meningioma, mal mesothelioma

Question 147

exudate

Answer 147

due to lymphatic obstruction, inflammation/infection, malignancy increased protein (>2.9g/dl) and LDH Light criteria - determine if pleural effusion is exudative

Question 148

cachexia

Answer 148

TNF, IFNy, IL1 and 6

Question 149

P-glycoprotein

Answer 149

aka MDR1 classically in adrenocortical caricnoma (can be in colon and liver cancers)

Question 150

cancers and risk factors

Answer 150

... alcohol - SCC esophagus, HCC aromatics (benzene, naphthylamine) - transitional cell bladder ionizing rad - papillary thyroid carcinoma alkylating agents - leukemia/lymphoma EBV - ... CNS lymphoma HPV - ...head and neck cancer liver fluke (Clonorchis sinensis) - cholangiocarcinoma S haematobium - squamous cell bladder carcinoma

Question 151

amyloidosis

Answer 151

b-pleated sheets, congo red stain AL (primary) - MM or plasma cells, affects and weakens multiple organ systems (even heme - easy bruising) AA (secondary) - chronic inflam, multisystem dialysis-related - b2-microglobulin, may present as carpal tunnel syndrome heritable - transthyretin mutation senile systemic - wild-type transthyretin deposited in ventricles (slower progression compared to AL) - trans-thy-retin = carries T4 and retinol organ-specific - amylin in pancreatic islets - ANP in atria - normal in aging, can predispose to a fib - calcitonin in tumor cells of medullary thyroid carcinoma

Question 152

apoptosis

Answer 152

ATP! DNA-laddering - fragments of 180 bp intrinsic - embryogenesis - occurs when a regulating factor is withdrawn (ex decreased IL2) or in case of injury - Bcl2 keeps outer mitochondrial membrane impermeable (overexpressed in 14;18 follicular lymphoma) - DNA damage --> p53 activated --> Bax and Bak are proapoptotic extrinsic 1) ligand-receptor - FasL binds to CD95 (thymic medullary selection) or TNFa binds to its receptor 2) CD8 releases perforin and granzyme B

Question 153

paraneoplastic with lymphoma

Answer 153

increased vitamin D

Question 154

other paraneoplastics

Answer 154

EPO: RCC/HCC, hemangioblastoma, pheo, leiomyoma anti-NMDA encephalitis (general CNS disturbance) - ovarian teratoma opsoclonus - myoclonus ataxia - neuroblastoma, small cell lung antibodies against Purkinje cells --> cerebellar deg - small cell (anti-Hu), gyn and breast (anti-yo), Hodgkin (anti-Tr) - anti-Hu in small cell can also cause encephalitis

Question 155

bacteria -TLRs

Answer 155

normally NF-kb is bound to IKB bacteria - TLR signals for phosphorylation and subsequent ubiquitination of IKB NF-Kb --> synthesizes inflammatory proteins TNFa increases neutrophil chemotaxis and macrophage phagocytosis

Question 156

nosocomial infections

Answer 156

IV catheters: staph enterococci candida prophylactic antibiotics prior to surgery - cephalosporin covers normal skin flora thrombosis in a vein - can occur due to a chronic indwelling catheter

Question 157

arteries that run underneath the skull

Answer 157

middle meningeal artery - where frontal, temporal, parietal, and sphenoid bones join = pterion (thin) middle meningeal is a branch of the maxillary artery facial a - courses over manidle ext carotid --> occipital --> sternocleidomastoids... ophthalmic - ...forehead, hose Kiesselbach's plexus - site of nose bleeds - sphenopalatine @ ophthalmic @ facial

Question 158

patella and knee architecture

Answer 158

quads tendon wraps around patella --> patellar tendon ACL - also prevents excessive tibial rotation hams - hip extension, knee flexion

Question 159

Candida

Answer 159

germ tubes are specific for Candida - colonizes mouth, skin, vagina, intestine superficial infections - with immunosupressed/HIV disseminated infections in neutropenics - esophagus, heart, liver, kidney (spares lungs)

Question 160

theophylline

Answer 160

methylxanthine - related to caffeine, used to treat asthma/COPD causes mild cortical arousal and insomnia - acute tox - GI upset, cardiac *arrhythmias*, and seizures treat - give activated charcoal to decrease absorption, b-blockers to combat arrhythmia, and benzos for seizures

Question 161

arboviruses

Answer 161

encephalitis WNV - febrile viral illness, rash, encephalitis + flaccid paralysis - pos ssRNA flavivirus - transmitted by mosquitos in the summer in the US - supportive therapy Togavirues (E, W, venezuelan equine encephalitis) Bundayvirus (California encephalitis)

Question 162

peptostreptococcus

Answer 162

ANaerobe dental, cutaneous, intraabdominal infections

Question 163

peroxisomal diseases

Answer 163

absence of peroxizomes very long chain and branched chain FAs are NOT oxidized in the mitochondria - they are oxidized in peroxisomes side note - mitochondria also does not metabolism fatty acids with branch points at odd-numbered carbons ex Zellweger syndrome - infants can form myelin properly --> seizures, hypotonia, mental retardation, early death - hepatomegaly Resfum disease - defect in peroxisomal alpha oxidation - accumulation of phytanic acid and neuro disturbances - treat by avoiding chlorophyll

Question 164

penetrating injuries

Answer 164

front, T4, LSB - RV - you can only hit the LV if you pass through the left lung back, T8, right of vertebral bodies - IV