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Flashcards in Stuff You Missed Deck (450):
1

Risk Factors for Aspiration Pneumonia

- Elderly people with altered mental status
- Dysphagia (due to neuro deficit)
- GERD
- Mechanical compromise of mechanical defenses (e.g. impaired cough reflexes)
- Protracted vomiting
- Large volume tube feedings in recumbent position

2

ECF/ICF conditions: Loss of isotonic fluid

e.g. GI hemorrhage
- no change in osmolarity
- normal ICF + decrease ECF
aka isosmotic volume contraction

3

ECF/ICF conditions: ingestion of hypotonic fluid

e.g. ingestion of large amts of water
- decreased osmolarity
- increase in ICF and increase in ECF
- causes expansion of volume w/o changing osmolarity

4

ECF/ICF conditions: hypertonic saline infusion

Increased osmolarty,
- decrease in ICF and increase in ECF
- high osmolarity causes shift of H2O from ICF

5

Fructose 2,6 Bisphosphate

Induces PFK-1 and inhibits gluconeogenesis by inhibiting fructose 1,6 bisphosphate conversion to fructose 6 phosphate.
High concentrations of Fructose 2,6 BP inhibits gluconeogenic conversion of alanine to glucose.
Fructose 2, 6 BP is regulated by PFK-2 and Fructose 2,6 BPase

6

4 gluconeogenic irreversible enzymes

Fructose 1, 6 BPase (in cytosol, Fructose 1,6 BP to Fructose 6-P)
Pyruvate carboxylase (in mito, Pyruvate to Oxaloacetate)
Glucose 6 Phosphotase (in ER, Glucose 6 P to glucose)
Phosphenoenol carboxylase (in cytosol, oxaloactetate to phosphoenolpyruvate)

7

Effect of exogenous administration of thyroid hormone

- Decrease in TSH (via feedback inhibition)
- Increase in T3
- Decrease in T4 and rT3 (inactive form of thryoid) - as thryoid gland doesn't have to secrete hormone

8

Most common reason of elevated alpha fetal protein

Dating error / underestimation of gestational age
This can be confirmed by fetal ultrasound

9

Perchlorate

Blocks iodide absorption for thyroid hormone production via competitive inhibition

10

Metatyropone administration results in ACTH surge because it causes decreases in cortisol production (T/F)

True

11

What other cancers do you check for if the patient has a family history of pheochromoctomas?

Always check for MEN2a and MEN2b cancers.
MEN 2a: pheochromocytoma, medullary cancer of the thryoid, parathyroid cancer

MEN2b: medullary thyroid cancer, pheochromocytoma, oral/intestinal ganglioneuromatosis (associated with marfanoid habitus)

12

Disease: 47 XXY and expected symptoms

Klinefelter's syndrome
- gynecomastia
- infertile
- tall
- small firm testes

13

Pancreatic islet amyloid deposition is characteristic of which DM?

Type 2 DM

14

Microscopic/Genetic characteristics of type 1 DM?

Pancreatic islet leukocyte infiltrate
Strong HLA II correlation (but not as strong as DM2)
Antibodies against islet deposition

15

Characteristics of hyperparathyroidism

-Subperiosteal resorption with cystic degneration

16

Rx for young women with hirsuitism

Spironolactone (anti-androgen effects)
Flutamide (inhibits to testosterone receptors)
Finasteride (5-alpha reductase inhibitor)

17

Insulin to avoid postprandial hyperglycemia

Lispro, Aspart, Glulisine
45-75 minutes against postprandial hyperglycemia

18

Hypoglycemia can be precipitated by what kind events?

Exercise induced glucose uptake

19

Most common cause of elevated creatinine kinase

Hypothyroidism

20

Common causes of elevated creatinine kinase

1. hypothyroidism
2. autoimmune diorder (dermatomyelitis/polymyelitis)
3. Muscular dystrophy (Duchenne dystrophy)

21

Thiazolidinediones

binds to PPAR-gamma nuclear transcriptase activator

22

Type of insulin needed for DKA

Regular insulin (peaks in 2-4 hours)
- Presents as volume depletion (hypotension and tachycardia)
- Ketones and glucose in urine

23

Why methadone is preferred drug for heroin overdose

Mu receptor agonist.
Long acting, potent with good oral bioavailability
Has long half life to prolong withdrawal symptoms

24

Physostigme

Administered for atropine toxicity -
can reverse both CNS (dilated and non-reactive pupils) and peripheral symptoms (sinus tachycardia)

25

Atropine use in elderly

If elderly has poor renal clearance, can result in reduced clearace
delirium and psychosis can result from muscarinic blockade

26

Atropine toxicity

Hyperthermia
Mydriasis
Cyclopegia
Bronchodilation
Tachycardia
Constipation
Urinary retention

27

Benzodiazipines

bind to GABA-A receptors in CNS and enhance inhibitory effect of GABA
Used as hypnotic (to treat insomnia), anxiolytic ( for panic attacks/anxiety disorders), and anti-convulsants

28

Short acting benzos (<10 hrs)

Alprazolam, Triazolam, Oxazepam

29

Medium benzons (10-20 hrs)

Estazolam, Lorazepam, Temazepam

30

Long acting (days)

Chlordiazepoxide, Clorazepate, Diazepam, Flurazepam

31

Long acting benzo issues

Associated with severe daytime drowsiness (higher risk of falls). Slower clearance causes less withdrawal (lower risk of physical dependence)

32

Vitamin B6/Levadopa

Vitamin B6 increases the peripheral metabolism of levadopa

33

Wine and cheese with depressed patient taking atypical antidepressants!

Hypertensive crisis caused by MAO-inhibitor tyramine crisis

Tyramine - sympathomimetic is normally metabolized in GI tract but MAO inhibitors block the degradation so it gets in to systemic circulation.

34

Jimson Weed

produces anticholinergic effects - atropine poisoing (tachycardia, myadrisis, slowed GI motiolity, bronchodilation, urinary retention, hallucinations

35

Phenytoin side effects

Gingival hyperplasia - caused by increased expression of PDGF which stimulates proliferation of gingival cells and alveolar bone. Also causes ataxia and nystagmus

36

"On-off phenomenon" of Parkinson's disease

Pts may experience moments of muscle rigidity and then periods of regular movement on levadopa treatment. UNPREDICTABLE and dose-dependent. Higher doses are not always beneficial

37

Acute neonatal narcotic withdrawal presentation

Pupillary dilation, rhinorrea, sneezing, nasal stuffiness, diarrhea, nausea, and vomiting

38

Thiopental

short-acting barb that affects GABA receptors and increases inhibitory potential
Highly lipid soluble. Accumulation in brain within 1 minute causes loss of consciousness. It is then redistributed to SKELETAL MUSCLE and ADIPOSE TISSUE

39

SSRIs

Sertaline is an SSRI. SSRIs have better side effect profiles than TCAs. Sexual dysfunction is common side effect and limits their use for patients

40

Drugs most effective for motion sickness.

Anti-muscarinic and anti-histamines because motion sickness triggers muscarinic M1 and histamininc H1 pathways. (e.g. Scopolamine - antimuscarninc drug). Meclizine and dimenhydrinate are also effective at preventing that

41

Olanzapine

atypical antipsychotic. SE: weight gain

42

Clozapine

atypical antipsychotic: Agranulocytosis and seizures. (Do weekly WBC profiles)

43

Status epilepticus

recurrent or continuous generalized tonic-clonic seizures that last for more than 30 minutes w/o return to consciousness. Can result in HTN, tachycardia, arrhythmias, and lactic acidosis

44

Tx for status epilepticus

1. Benzos are 1st line choice. LORAZEPAM preferred.
2. Phenytoin is administered simultaneously to precent recurrece.
3. (If needed), phenobarbital may be added

45

Phenytoin mechanism of action

inhibits neuronal high frequency by reducting ability of Na to recover for inactivation

46

Beta cell response via sympathetic activation

Alpha adrenergic receptors - INHIBIT insulin release
Beta-adrenergic activation - PROMOTES insulin secretion

47

Phenoxybenzamine

Long acting alpha blocker -- commonly used for treatment of pheochromocytomas

48

Diphenhydramine

antihistaminic (H1 blocker) -- has anticholinergic effect that can stop insulin secretion induced by PS stimulation

49

Propanolol

non-selective Beta blocker

50

Oxybutinin

anticholinergic agent used for treatment for overactive bladder (urge incontinecne)

51

Common P-450 inducers

Barbituates, Rifampin, Carbamezapine, Griseofulvin, and chronic alcoholic consumption.

*Will lower dose of other P450 metabolized medication

52

Common P-450 inhibitors

Isoniazd, Cimetidine, Macrolides (e.g. erythromycin, ciprofloxacin) , Azole antifungals, and Grapefruit juice

53

Severe complication of halogenated anesthetics (halothane, enflurane, isoflurane, sevoflurane)

Massive hepatic necrosis (elevated ALT, AST and bilirubin level). Due to direct injury and by halothane metabolits and formation of autoantibodies against liver proteins

54

Reye's syndrome liver effects

Seen in 5-10 years old associated with salicyate overdose

55

Intrahepatic cholestasis

associated with billiary duct obstruction. Characteristic for primary sclerosing cholangitis and primary billiary cirrhosis

56

Most common cause of death in TCA overdose

Refractory hypotensio and cardiac arrhythmias. Inhibition of fast sodium channels in cardiac myocytes (and His-Purkinje system) is the major underlying cellular event. Fluid resuscitaton with normal saline and hypertonic NaHCO3 is necessary

57

Serotonin syndrome

Hyperthermia, tachycardia, muscle rigidity, mycoclonus, diaphoresis

58

Akathasia

movement disorder characterized by inner restlenss and inability to stand in one position. Can be due to antipsychotic therapy.

59

Treatment of choice for Listeria monocytogenes

Ampicillin. (Not sensitive to cephalospporins)

60

Ceftriaxone coverage for 2 month old w/ fever, irritability and vomiting

N. meningitidis, Strep. pneumoniae, Group B strep. H. influenzae

61

Side effects for 1st generation antihistamines

Muscarinic (blurry vision, dry mouth, urinary retention), Seroternergic (appetite stimulation), and alpha adrenergic (postural dizziness). Also lipophilic so can cause BBB.

62

Rx for elderly patient w/ poor vision and hx of frequent falls suffers a rash

Second generation antihistamine (e.g. fexofenadine) because they have minimal sedative and anti-muscarininc effects

63

Rx of hyperpyrexia in 8 year old

Cold blankets. Cannot administer aspirin as can cause Reye's syndrome. Body temperature greater than 40 degress may lead to permanent brain damage.

64

Bacterial vaginosis

associated w/ Gardnerella vaginalis
-loss of lactobacilli and overgrowth of of mixed anaerobes
- addition of KOH to discharge makes fishy smell more prominent (whiff test)
-Clue cells on wet mount

65

Candida albicans

common cause of fungal vaginits
present with vaginal pruritis, curd-like discharge, and labial erythema
-no additional odor with KOH
- discharge has yeast forms and pseudohyphae

66

Choriocarcinoma

malignant tumor from trophoblast
- causes abnormal vaginal bleeding, UTERINE ENLARGEMENT, and increased hCG

67

Common site of metastasis for choriocarcinoma

Choriocarcinoma spreads hematogenously. Lungs most common site

68

Choriocarcinoma: Histology

abnormal proliferation of syncytiotrophoblasts and cytotrophoblasts. No villi are present.

69

Choriocarcinoma: Gross exam

Soft yellow white mass with extensive areas of hemorrhage and necrosis

70

Hyperplastic endometrium

associated with prolonged exposure to estrogen
PCOS, estrogen-producing tumors (e.g. granulosa cell tumors) and estrogen replacement therapy.
Sx: abnormal, irregular bleeding

71

Endometrial adenocarcinoma: Histology

disorganized glands of neoplastic COLUMNAR cells. Occurs in postmenopausal women and presents in vaginal bleeding.

72

Malignant teratomas

contain tissue elements resembling immature cartilage
Can occur in ovaries but NOT in uterus
Sx: abdomnial pain and ovarian mass BUT no bleeding

73

Carcinosarcomas

Malignant mixed mullerian tumors of uterus.
Composed of epithelial (endometrial-type glands) and mesenchymal (sarcomatous) elements

74

Sx: acute polynephritis

flank and abdominal pain, fever, shaking chills, nausea and vomiting
CVA tesnderness.
Urinanalysis: WBC casts, bacteruria. and hematuria

75

Hypertensive nephrosclerosis

causes arterial intimal fibropasia, arteriolar hyalinizations, and long with interstitial fibrosis

76

Renal Cell Carcinoma

Clear cell carcinoma is most common subtype. Appears a rows of homogenous sheets/rows of cuboidal or low columnar cells with translucent centers

77

Common causes of nongonoccal urethritis

Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma and Trichomonas species

78

Rx of Gononoccal Urethritis

Ceftriaxone

79

Rx of nongonoccocal urethritis

Azithromycin

80

Why can't you use ceftriaxone to treat nongonoccal urethritis?

- Chlamydia trachomatis - lacks peptidoglycan layer within cell wall
- Another common pathogen of NGU, Ureaplasma urealyticus lacks a cell wall

81

Drugs that inhibit dihydrofolate reductase, thus prevent reduction of folic acid to tetrahydrofolate reductase

Trimethoprim, Methotrexate. Pyrimethamine

82

Trimethoprim

inhibits dihydrofolate reductase thus prevention reduction of folic acid to tetrahydrofolate. Restricts microbial growth and used in conjuction with sulfonamide b/c sulfonamide inhibits production of folic acid in another pathway

83

Pyrimethamine

effective anti-malaria. and in treatment of toxoplasmosis because it inhibits parasitic dihydrofolate reductase

84

Imipenem

binds to >1 penicillin binding proteins thus inhibiting peptidoglycan synthesis in bacterial cell walls. Bacteria lyse themselves because cell autolytic enzymes still work.
Used with cilastatin to prevent renal metabolism of imipenem by inhibiting dihydropeptidase on renal tubule brush border

85

Adenomyosis

presence of endometrial glandular tissue within the myometrium. Affects middle aged parous women.
Sx: enlarged uterus with normal appearing endometrial tissue. Menorrhagia and dysmenorrhea are common symptoms

86

Enterobiasis

aka pinworms.
Sx: young children with perianal itching, discovered with "Scotch tape test"
Prsence of oval, assymetrically flattened eggs with bean shaped appearance

87

Rx of enterobiasis

Albendazole or Mebendazole is first-line treatment.

*Pyrantel pamoate as an alternate agent in pregnant patients

88

Rx of Loa loa (loasis) and Wuchereria bancrofti (lymphatic filariasis) infections

Diethylcarbamazine

89

Strongyloides stercoralis (Strongyloidiasis) and Onchocerca volvulus (oncoceriasis)

Ivermectin

90

Rx of Schistomiasis, Clonorchiasis, Paragonimiasis

Praziquantal

91

Mechanism for enterococci resistance to aminoglycosides (e.g. gentamicin)

Enterococci produce aminoglycoside modifying enzymes that transfer different chemical groups (acetyl, adenal, or phosphate) to the aminoglycosie molecule and impair antibiotic binding to ribosomal subunits.

92

Enterococci mechanism of penicillin resistace

1. Production of B-lactamase
2. Production of low affinity penicillin binding protein

93

Enterococci mechanism of vancomycin resistance

Enterococci produce ligases that alter the D-alanyl D-alanine cell wall target of Vancomycin. Famous one switches for D-alanine D-lactate for D-alanyl D-alanine to prevent vancomycin resistnce

94

Fluroquinolone mechanism of resistance

mutations in DNA gyrase or topoisomerase genes prevent fluoroquinoline binding (e.g ciprofloxacin)

95

Hypospadias

incomplete fusion of urethral (urogenital) folds results in hypospadias, an abnormal opening of the urethra proximal to glans penis along ventral shaft

96

Epispadas

abnormal opening of urethra on dorsal surface . Results from faulty position of genital tubercle

97

Hydrocele

development of fluid filled peritoneal sac within scrotum that results from incomplete obliteration of the processus vaginalis

98

Venous drainage of gonal veins

Right: Right testes/ovarian vein --> IVC
Left: Left testicular/ovarian vein --> Left renal vein --> IVC

99

Endometriosis

- presence of endometrial glands and stroma outside the uterus.
Sx: dysmenorrhea (painful menstrual period), dyspareunia, and infertiility
-

100

Endometrosis: Pathology

"Chocolate cysts" - collections of old blood form in endometriomas
Nodularity of uterosacral ligaments and fixed retroversion

101

Common sx of Turner syndrome

Primary amenorrhea
High arched palate
Widely spaced nipples
Streaked gonads (ovarian dysgenesis)

102

Turner Syndrome

Monosomy (45 XO) accounts for majority of cases - due to mitotic error in early development
46 XX (with partial deletion of one X chromosome).

103

Uniparental disomy

individual inherits two copies of a chromosome from one parent and no copies of chromosome from other parent. Seen in Prader-Willi (paternal deletion) and Angelman's Syndrome (maternal deletion)

104

Trinucleotide repeat

Fragile X syndrome (CGG repeats)
Myotonic Dystrophy (CTG repeats)
Huntington disease (CAG repeats)

105

Polycystic Ovarian Syndrome: Sx

Oligomenorrhea, Obesity, Hirsuitism, and Polycystic ovaries.

*Increased risk of developing endometrial adenocarcinoma and type 2 DM

106

Causes of septic arthritis in sexually young adults

Commonly caused by N. gonorrhoeae (intracellular organisms) that have high neutrophil content

107

Sx of Neisseria gonorrhoae

common cause of septic arthritis in young adults
presents with assymetric arthritis - primarly involves knees, elbows, and distal joins
In men: urethritis
In women: PID, infertility, and ectopic pregnancy

108

Common cause of septic arthritis in children and non-sexually active young adults

Staph aureus

109

Blood supply of upper 1/3 of the ureter

Renal artery. Distally, the ureter is supplied from branches of the aorta, illiac, gonadal, and vesical arteries

110

Hyaditaform mole

Gestational trophoblastic disease. Occurs to fertilization of ovum with no genetic material

111

Complete hyaditiform mole

has no fetal structures and composed of large and edematous and disordered chorionic vill that appear as "grape-like structures). Have 46 XX karyotype -- all from father

112

Partial hyaditiform mole

shows some gross formation of detal structures.
Results from fertilization of an ovum (with some genetic material) by two or more sperm results in 69 XXX or 69 XXY

113

Pathogen associated with dark urine and facial puffiness, Minor skin infxn weeks ago and resolved weeks. Urinanalysis has RBC casts

Pt has PS Glumerulonephritis. Commonly caused by Group A Strep/ Strep pyogenes (gram + cocci, that B-hemolytic and bacitracin sensitive)

114

Lymph nodes from testes drain where?

Para-aortic lymph nodes

115

Lymph nodes from scrotum drain where?

Superficial inguinal lymph nodes

116

Lymph from glans penis and clitoris drain where?

Superficial inguinal lymph nodes

117

Sx: Pelvic Inflammatory Disease

Fever greater than 38 C
Rebound abdominal tenderness
Purulent endocervical discharge
Cervical motion and adnexal tenderness

118

Molluscum contagiosum

Associated with chronic, localization infection in which firm, dome-sahaped, umbilicated papules erupted on the skin.

119

Common pathogens associated with PID

Chlamydia trachomatis and Neisseria gonorrhae

120

Pronephros

developed during 4th week -- non-functional, fully regresses

121

Mesonephros

developed in 4th week
becomes Mesonephric (Wolfian) duct
becomes Male GU components (except prostate)

122

Metaneprhos

developed in 5 - 6th week
Mesonephric duct forms a diverticulum called ureteric bud

Mesoderm around ureteric bud forms metanephric vessicles (blastema)

123

Mesonephric duct - Adult derivaive

Collecting ducts, calices, renal pelvis, ureters

124

Mesoderm

Renal parenchyma

125

E. coli virulence factor associated with UTIs

P fimbriae - permit the adhesion of E coli to uroepithelium

126

E. coli virulence factor associated with watery diarrhea

Heat-stable/Heat-labile toxin: promote fluid an electrolyte secretion from intestinal epithelium

127

E. coli virulence factor associated with bacteremia/septic shock

Lipopolysaccharide - macrophage activation causes widespread release of IL-1, IL-6, and TNF-alpha

128

E. coli virulence factor associated with neonatal meningitis

K1 capsular polysaccharide - prevents phagocytosis and complement mediated lysis

129

E.coli virulence factor associated with BLOODY gastroenteritis

Verotoxin (Shiga-like toxin) - inactivates 60S component halting ribosomal protein synthesis and causing cell death

130

Cystinuria

inborn defect of the transporter of cystine, ornthinine, arginine, and lysine. It is inherited in autosomal recessive fashion. Clinical manifestation: nephrolithiasis presents renal colic

131

Sx syphillis

sexually active young adut with single genital ulcer. Lesion is indurated and painless.

132

First line treatment for syphillis

Penicillin - structural analog for D-ala D-ala. Inhibits transpeptidases which catalyzes crossliknking step in peptidoglycan wall.

133

Medium for Neisseria Gonorrhoae

Thayer-Martin VCN - inhibits the growth of gram + organisms, gram - organisms, other than Neiserria and fungi

134

Differential media

differentiate cutlured organisms based on their metabolic and biochemical properties. MacConkey and EMB black agar

135

Pre-eclampsia triad

After 20th week of pregnancy, hypertension, proteinuria, and edema.

136

Femoral hernias

Are inferior to inguinal ligament, lateral to pubic tubercle, and medial to femoral vein. Present with groin discomfot or manifest with a bulge on the upper thigh

137

Rx for Chagas disease (Trypanosoma cruzi)

Nifurtimax

138

Most common cause of fetal hydronephrosis

Inadequate recanalization of ureteropelvic junction, the junction between the kidney and the ureter

139

Direct inguinal hernia

lie MEDIAL to inferior epigastric vessels

140

Indirect inguinal hernia

lie LATERAL for inferior epigastric vessels

141

Urge incontinence (or overactive bladder syndrome)

is caused by uninhibited bladder contractions (detrussor instability). It results in a sense of urgency. Use therapy with antimuscarinic drugs

142

Rx for BPH

Alpha-1 blockers - such as doxazosin, prazosin, and terazosin. Cause relaxation of smooth muscle relaation in arterial and venous walls, leading to a decrease in peripheral vascular disease. Antimuscarinic drug (targeting M3 receptors)

143

Aromatase

converts androgens into estrogens in the ovaries, testes, placenta, and other peripheral tissues. Genetic deficiency of this enzyme leads to an inability to synthesize estrogen. It presents with maternal virilizaton during pregnancy and masculinization.

144

Log change after addition of competitive agnoist

change in E50 to the right
no change in Emax

145

Log dose-response curve change after addition of non-competitive agonist

Change in Emax -- it shifts down

146

Clear cell carcinoma

variant of renal carcinoma -composed of large, round or polygonal cells with clear cystoplasm.
Triad: hematuria, flank pain, and palpable mass

147

Common causes of childhood rash

1. Parvovirus
2. Measles
3. Scarlet fever
4. Rubella
5. Roseola

148

Common cause of acute hemorrhagiv cystitis in children

Adenovirus

149

UTI Sz:

Dysuria and hematuria

150

Imperforate hymen - presentation

primary amenorrhea in a patient with fully developed secondary sexual characteristic suggests the presence of an anatomic defect in the genital tract, most commonly an imperforate hymen or a mullerian duct anomaly

151

Pudendal nerve block

method of anesthesia during childbirth. Provide anesthesia to majority of the perineum

152

Pudendal nerve derivation

S2-S4 nerve roots - innervates to the perinerium and genital (of both sexes) as motor innervation to the sphincter urethrae and external anal sphincter

153

Sequelae of mucopurulent cervicitis

Mucopurulent cervicitis with cervical motion tenderness is a frequent indicator of PID caused by N. gonorrhaw or Chlamydia trachomatis. PID can potentially leads to ectopic pregnancy and infertility due to salgpingitis leads to scarring of fallopian tubes if not treated appropriately.

154

Associated with primary amenorrhea with fully developed secondary characteristics

Suggests anatomical defect
-- imperforate hymen
-- Mullerian duct abnormality

155

Koilocytosis

hallmark of HPV infection
pyknotic or superficial or immature squamous cells with dense, irregularly staining cytoplasm and perinuclear clearing

156

Can Turner's Syndrome can become pregnant?

Yes, but with donor oocyte.

157

Exposure odds ration

used tom cpmpare exposure of ppl with disease and those without disease

158

Carcinoid tumors

Tumor cells have eosinophilic cytoplasm and oval to round nuclei. Minimal to no variation .
- Derived from enterochromaffin cells (endocrine) cells of intestinal mucosa.
- Can secrete hormone-like substances (e.g. insulin, gastrin, serotonin, bradykinin)

159

Replication cycle of Hep B

dsDNA --> template +RNA --> progeny double DNA

160

Causative agents for hepatocellular carcinoma

Hepatitis B (DNA virus), Hepatitis C (RNA virus)

161

Where are dietary lipids digested and absorbed?

Lipids are Digested in the Duodenum and are Absorbed in the Jejuneum

162

Site of bile and B12 absorption

Terminal ileum

163

Urease breath test

Noninvasively tests for H pylori infection. Patient consumes Carbon 13 urea and his breath is then monitored for Carbon 13 labeled carbon dioxide, which would indicate presence of H. pylori product urease in the stomach

164

Acute calculous cholecystitis

Sx: upper abdominal pain, fever, and fever.
Laporotamy reveals partially necrotic gallbladder
-initiated by obstruction of gallbladder neck or cystic duct caused inflammation of stones in gallbladder

165

Process of acute calculous cholecystitis

1. Inflammation of gallbladder wall by stones obstructing gallbladder neck or cystic duct
2. Stones disrupt mucosal layer of gall bladder exposing it to bile salts
3. Prostaglandins further incite inflammation of mucosa and deeper tissues leading hypomollity
4. Distention leads to ischemia of gallbladder
5. Bacteria invade the injured and necrotic tissue causing an infection

166

Discuss Shigella invasion of gut

Invades GI mucosa by first gaining access to M cells in Peyer's patces in the ileum via endocytosis. Shigella lyses endosome, multiplies, and spreads LATERALLY to other epithelial cells, causing cell death and ulceration with hemorrhage and diarrhea

167

Lactase deficiency

- Characterized by osmotic diarrhea
-Intestinal brush border enzyme unable to break down lactose into glucose and galactose
- Undigested lactose is unabsorbable osmotic substance and its accumulation leads to secretion of water into gut lumen

168

Causative agents of osmotic diarrhea

- Polyethylene glycol, Lactose in lactase deficient patients, Magnesium hydroxide (and other magnesium containing products)

169

Discuss hormone-induced gallstones in pregnant women

Estrogen-induced hypersecretion and progesterone-induced gallbladder hypomotility are responsible for increased incidence of gallstones in pregnant women

170

CEA and Colon Cancer

- Produced in embryonic pancres, liver, and intestine and detected in minute amounts in healthy adults.
** Cannot be used as a screening marker, used to detect disease recurrence
- Increased in COLON, PANCREATIC, GASTRIC, and BREAST malignancies

171

Common causes of nightblindness

- Hereditary retina pigmentosum
- Toxic retinopathy to phenothiazines
- Vitamin A deficiency
- Congenital rubella, syphillis, or other infections
- Diabetic retinopathy

172

Causes of Vitamin A deficiency

May result from fat soluble vitamin malabsorption.
(e.g. pancreatic insufficiency, biliary obstruction, celiac sprue)

173

Iron absorption

Takes place in duodenum and proximal jejeunum

174

Gastrojejunectomy may cause malabsorption of which vitamins

Vitamin B12 (because IF is bound to B12 in duodenum)
Folate
Fat soluble vitamins
Calcium
Iron

175

Location of B-oxidation of fatty acids

Mitochondria

176

HmG CoA lyase

Mitochondrial enzyme that is reponsible for ketogenesis from HMG CoA. HmG CoA results from degradation of leucine (ketogenic amino acid)

177

Location of citric acid cycle

Mitochrondria

178

Ornithine transcarbomamoylase

Catalyzes second step of urea cycle where ornithine and carbamoyl phosphate are combined to form citrulline. Takes place in mitochondria

179

Pyruvate carboxylation

-

180

Treatment for acute lead and mercury poisoning

CaNa2EDTA - forms complexes with mono-, di- , trivalent ions

181

Treatment for cyanide poisoning

Amyl nitrite. Forms methoglobin that binds cyanide ions forming non-toxic compound cyanomethoglobin preventing cyanide from binding to mitochondrial enzymes (Complex IV in ETC) in tissue

182

Deferoxamine

Chelating agent used to treat iron poisoning. This kind of poisoning may occur with thalassemia patients receiving blood transfusions or patients consuming large quantities of iron

183

Hyperplastic poly

Well-differentiated mucosal cells that from glands and crypts

184

Hamartomatous polyps

Non-neoplastic polyps that consist of mucosal glands, smooth muscle and connective tissue.

185

Inflammatory polyps

Non-neoplastic polyps seen in UC and Crohn's disease. Composed of regenerated mucosal tissue

186

Lymphoid polyps

Non-neoplastic polyps seen in children. Consist of intestinal mucosaa infiltrated w/ lymphocytes

187

Treatment for arsenic poisoing

Dimercaprol - displaces arsenic ions from sulfylhydril groups of enzymes and facilitates their excretion

188

Sx of arsenic poisoning

Stomach pains, vomiting, delirium and garlic order on breath

189

Pathogenesis of Wilson's disease

Excess of non-ceruloplasmin bound Cu which accumulates in liver, CNS lenticular nucleus, and cornea

190

Treatment of Wilson's Disease

Chelation therapy with penicillamine removes excess non-bound Cu

191

Sx: Wilson's Disease

Tremor, gait instability
Elevated serum liver transaminases
- Decreased ceruloplasmin

192

Location of H. pylori

Greatest concentration in prepyloric area of gastric antrum

193

Hepatitis D method of invasion

- Referred to as delta agent, Hep. D must be coated by HBsAg of Hep B virus for infection. Can arise from acute co-infection of Hep B virus or as superinfection of Chronic Hep B carrier.

194

Patients undergoing gastrectomy require life-long supplementation of which vitamin

Vitamin B12 (water-soluble vitamin)

195

Results of lactose tolerance test for lactase deficient patients

Lactase deficient patients have INCREASED stool osmotic gap, increased breath hydrogen content, and decreased stool pH upon lactose challenge.
- Occurs because bacterial fermentation of lactose produces short chain Fa and excess amts of hydrogen

196

Periodic, non-peristaltic contractions of esophagus

Diffuse esophageal spasm. May cause dysphagia and chest pain. Must do complete cardiac workup to rule out angina

197

Hep E virus

unenveloped single stranded RNA virus spread through fecal-oral route. Seen in Asia, sub-Saharan africa.
Usually self-limited and not associated with chronic liver disease
- High mortality rate among pregnant women

198

P450 inducers

Rifampin, Griseofulvin, Barbituates, Carbamazepine, and Phenytoin

199

Discuss adenomatous polyps and aspirin

Although screening and timely excision of adenomatous polyps are best method.
Some adenometous polyps are linked to increased COX-2 activity thus aspirin (COX2 inhibitor) may decrease adenematous polyp formation.

200

Microscopic signs of acute pancreatitis

- Focal areas of fat necrosis, calcium necrosis, interstitial edema

201

Susceptibility of Clostridium difficule

Due to absence of normal microflora of gut (can be caused by excessive antibiotics). Lack of microflora allow C. difficile to overgrow and produce Toxin A and Toxin B -- can result in pseudomembranous colitis or transient diarrhea

202

Causes of hepatic encephalopathy

Secondary to increased levels of ammonia in circulation. Often precipitaated by stressor that alters ammonia balance (e.g. GI bleeding, hypovolemia, metabolic alkalosis, hypoxia, sedative usage, hypoglycemia)

203

Tx of hepatic encephalopathy

Lactulose. Bacterial action of lactulose will acidify colonic contents, which converts absorable ammonia into nonabsorbable ammonium ion (an ammonia trap)

204

Hepatic abcess

fluid filled cavity in liver in conjunction with fevers, chills, and RUQ abdominal pain.
- Often caused by Staph aureus due to hematogenous seeding of liver

205

Cancer risk with type B gastritis

- Associated with increased risk of gastric adenocarcinoma and MALT lymphoma
-Type B gastritis affects antrum and usually result of H. pylori

206

Hindgut

Encompasses distal 1/3 of transverse colon, descending colon, sigmoid colon, and rectum
- Receive main arterial blood supply from inferior mesenteric artery

207

Side effects of halothanes

May present like highly lethal hepaitis
- Patients present with elevated aminotransferase levels, prolonged prothrombin time, and eosinophilia

208

Primary Billiary Cirrhosis

Chronic liver disease characterized by AUTOIMMUNE destruction of intrahepatic bile ducts and cholestsis
- In precirrhotic stage, bile ducts are destroyed by granulomatous inflammation and heavy portal tract infiltrate of macrophages
- Similar to those with graft vs. host diseae

209

Microscopic effects of serious acetaminophen overdose

Liver failure and centrilobular necoris

210

Budd- Chiari syndrome

Increased hepatic blood pressure due to occlusion of IVC or hepatic vein. Causes hepatomegaly, abdominal pain and ascites.
- Centrilobular necrosis and congestion observed microscopically

211

Stages of Adenocarcinoma development

1. Normal mucosa to small polyp (APC mutation)
2. Increase in size of polyp (K-ras)
3. Malignant transformation of polyp (p53)

212

1st part of duodenum

- near L1
- not retroperitoneal

213

2nd part of duodenum

- courses inferiorly from L1 to L3
- near head of panreas
- ampulla of Vater empties here

214

3rd part of duodenum

courses horizontally to L3, abdominal aorta, and IVC
- close to uncinate process of pancreas and superior mesenteric artery and vein

215

Transmission of Hepatitis A

Fecal-oral route. Frequently seen in contaminated water or food (e.g. raw or steamed shellfish)

216

Hep A

RNA picornavirus with incubation of 30 days. Transmission via fecal-oral route.
Commonly found in contaminated food (e.g. raw shellfish in U.S>)

217

Rhinoviruses

are picornoviruses.
Are acid-labile (not functioning if pH < 5.0) thus can't colonize stomach (pH t cause gastroenterisis

218

Abnormal rotation and fixation of midgut results in these 2 conditions

1. Intestinal obstruction ( due to compression of adhesion bands) - can result in bilious
2. Midgut volvulus - intestinal ischemia due to twisting around the blood vessels

219

Explain gynecomastia in cirrhotic male patients

- Cirrhotic liver unable to metabolize circulating androstenedione, thus increased estrogen
- Increased estrogen leads to gynecomastia
- Increase in sex hormone binding hormones, which bind free testosterone leaving more free estrogen
- Hyperestrinism leads to spider angiomata, testicular atrophy and decreased body hair

220

Giarda lambia infection

Injures duodenal and jejunal mucosa by adhering to intestinal brush border nd relase molecules that induce mucosal inflammatory response
Secretory IgA, impairs adherence of Giardia lambia
- IgA deficiency predisposes patients to Giarda

221

Hemochromatosis - Pathogenesis

Genetic mutation in HFE prevents expression of HFE protein on BL side of intestinal cells where it normally binds to transferrin and regulates transferrin/Fe complex endocytosis into the cells.
- As a result, unregulated amts of Fe are absorbed gastrointestinally

222

Complications of Hemochromatosis

Liver cirrhosis and Hepatocellular carcinoma

223

TATA Box

Important for transcription initiation

224

Transcription

mRNA to proteins

225

Translation

DNA to mRNA

226

Bioavailability of drug

fraction of administed drug that reaches systemic circulation in chemically unchanged form. In non-IV route always less than 1

227

Formula for Bioavailability

Area Under oral curve x IV dose / area under IV curve x oral dose

228

Hirschsprung's disease

- manifest in first few days of life
- Sx: failure to pass meconium, bilious vomiting, abdominal distention, persistent constipation
- Myenteric and submucosa plexi are absent in affected segment

229

Diffuse stomach cancer

Signet ring carcinoma (Gastric carcinoma)
- Linitis plastica infiltrates stomach wall and displays signet ring pattern. Cells are full of abundant.
- Plaque like appearance and are ill-defined.


230

Lab indicators of chronic alcohol abuse

AST:ALT ratio >2
Macrocytosis: (MCV > 100fl) - this is secondary to poor nutrition such as Vitamin B12 or folate deficiency
- Elevated GGT (gama-glutamultransferase)

231

Calcium levels in acute pancreatitis

Hypocalcemic because large amounts of calcium bind to free fatty acids and are depositied in the necrotic areas of pancreas.
Hypocalcemia is a marker of the severity of pancreatitis

232

Wilson's disease

- autosomal recessive disorder, characterized by poor Cu excretion
- low ceruloplasmin levels
- Sx: Kayser-Fleischer rings in eye - due to Cu deposition in the Descemet's membrane of eye
- Cu can cause atrophy of basal ganglia and lead to neurological symptoms

233

Organisms that cause diarrhea with small inoculum

Shigella (> 10 cells)
Cambylobacter jejuni (500 cells)
Entamoeba histolytica (> 1 organism)
Giardia lambia (> 1 organism)

234

Shigella infection

- can survive in acidic environments (stomach, bile)
- bind to intestinal mucosal M cells for attachment and invastion
- incubation period 24 to 72 hours
- begins with watery diarrhea progresses to abdominal pain, bloody diarrhea, and tenesmus (urge to defecate with little stool passage)

235

Esophageal varices

Portal circulation: Left gastric vein
Systemic circulation: Esophageal vein

236

Hemorrhoids

Portal circulation: Superior rectal vein
Systemic circulation: Middle & inferior rectal vein

237

Caput medusae

Portal circulation: Paraumbilical veins
Systemic circulation: Superficial & inferior epigastric vein

238

Middle aged Causasian femal with long history of pruritis and fatigue now develops pale stool and xanthelasma (fat deposits underneath the skin). Presentation suggestive of what?

Primary billiary cirrhosis

239

Primary Biliary Cirrhosis

Chronic liver disease characterized by autoimmune destruction of intrahepatic bile ducts and cholestasis.
- Insiduous onset. Commonly found in middle aged woman
- Pruritis (esp. at night) is first symptom.
- Physical findings: hepatosplenomagal, portal hypertension, and osteopenia may develop

240

Portal vein thrombosis

Causes portal hypertension, splenomegaly and varicosities at portocaval anastomoses. Does not cause histological changes to hepatic paranchyma.
- Causes obstruction of portal venous flow upstream from liver --> portal hypertension thus leaving liver unaffected

241

Male with hx of ulcerative colitis presenting with fatigue and high alkaline phosphotase suggests what?

Primary sclerosing cholangitis - look for "onion skin" bile duct fibrosis and dilation with "beading" of intra- and extrahepatic bile ucts

- Patients may have hypergammaglobunemia (IgM)

242

Methods to inactivate/disinfect Hep A

Hep A transmitted via fecal-oral route so improved sanitary conditions are essential.
- Water chlorination
- Bleach (1:100 dilution)
- Formalin
- UV radiation
- Boiling for 85 C for one minute

243

Oral bioavailability is dependent on which factors

- Absorptive properties of drug
- First pass metabolism (via enzymes present in gut wall lumen and in liver).
** Drugs from gut must pass through portal circulation to reach systemic circulation
** If drug undergoes high 1st pass metabolism in liver, bioavailability of drug will be low

244

Rectal drug administration vs. Oral drug administration

Unlike oral administration, rectal administration partially avoids 1st pass metabolism. Roughly 2/3 of rectal drug bypasses portal circulation to enter systemic drug thus increasing bioavailability.

Rectum drained by superior, middle, and inferior rectal veins. S. rectal vein drains into portal circulation via IMA. Middle & inferior rectal veins enter systemic circulation via internal illiac and internal pudendal vein
_

245

Signs of achalasia

Decreased esophageal body peristalsis
Poor relaxation of LES
- Presents with progressive dysphagia, food regurgitation, and aspiration
- "Bird's beak, barium swallow"

246

Intestinal atresia

- Atresia below duodenum ARE NOT CONGENITAL MALFORMATIONS.
- Result of vascular occlusions IN UTERO.
- Decreased perfusion leads to ischemia of segment of bowel, with narrowing or obliteration

247

Apple-peel atresia

Refers to intestinal atresia (or atresia of GI tract below duodenum)
- Are not congenital malformations but the result of vascular occlusions in utero
- Ischemia leads to narrowing of bowel segment

248

Annular pancreas

results from improper rotation and fusio of ventral and dorsal pancreatic buds.
- May cause duodenal stenosis

249

Sx of apple-peel atresia

Newborn

250

Brunner's gland

- Found in submucosa of duodenum
- Secrete alkaline mucus into ducts that empty into crypts of Lieberkuhn

251

Peyer's Patches

unencapsulated lymphoid aggregates specific to the ileum

252

Ribavirin

- tx for Hepatitis C
- induces lethal hypermutation, inhibiting RNA polymerase, and iosine monophospate dehydrogenase (depleting GTP), causing defective 5'-cap formation on viral mRNA transcripts, and modulating more effective immune response

253

Tx for Chronic Hepatitis C

- Interferon Alpha and Ribavrin

254

Ribavirin Mechanism

- Multifactorial
1. Phosphorylated by adenosine kinase to ribavirin metabolites and can pair well with uracil or cytosine. This causes lethal hypermutation
2. Direct inhibition of HCV RNA polymerase
3. Deplete pools of GTP
4. Causes defective 5' cap formation on viral mRNA transcripts, and therefore inefficient viral translation
5. Enhances Th1 cell-mediated immunity

255

Confounding bias

Can be avoided in case-control studies by matching cases with controls which share same variables (e.g. race, sex, age) except for disease/exposure

256

NOD2 mutation in Crohn's disease

Increases the activity of NF-kB protein that increases cytokine production

257

Result of terminal ileum involvement in Crohn's disease's pathology on terminal ileum

Patients with Crohn's disease affecting terminal ileum are prone to gall stones (sx: cholicky RUQ pain).
Terminal ileum involved in bile acid recycling, but inflamed terminal ileum = more bile acid lost in feces.
Less bile acid for new bile, and ratio of cholesterol/bile acid increases. Cholesterol precipitates as gallstones.

258

Cavernous hemangioma

most common benign liver tumor, typically found in 30-50 years old
- congenital malformations that enlarge by ectasia
- Well circumscribed masses of spongy consistency.
- Patients typically assymptomatic but may have RUQ fullness

259

Cavernous hemangioma

Tumors consist of cavernous blood-filled vascular spaces of variable size lined by single epithelial layer

260

Cyanotic congenital heart disease

5 T's
Tetralogy of Fallot
Tricuspid atresia
Transposition of Great Vessels
Truncus Arteriousis
Total Anomalous Pulmonary Venous Return

261

Non-cyanotic heart disease

Atrial septal defect
Ventral septal defect
Patent Ductus Arteriosus
Aortic Coarctation

262

Tetralogy of Fallot

- Stenosis of pulmonary outflow due to assymetric division of truncus arteriosus
- Results in right to left intracardiac shunting
**Squatting increases systemic vascular resistance, thus meaning raising arterial pressure
If PDA is present, this increases pulmonary blood flow via ductus (compensatory left to right shunt)

263

Tetralogy of Fallot

Must be present:
- pulmonary stenosis
- VSD
- right ventricular hypertrophy
- overriding aorta

264

Maple Syrup Urine Disease

- caused by defect in alpha-keto acid dehydrogenase, leading to inability to degrade branced chain amino acids beyond alpha keto-acid state
- Results in dystonia and poor feeding and "maple syrup scent" in neonate's urine within first few days of life

265

Tx for Maple Syrup Urine Disease

Dietary restriction of branched-chain amino acids

266

Sx for Prinzmetal's (variant) angina

- Episodic and transient anginal chest pain at night
- accompanied by temporary ST elevations
- Coronary artery vasospasm may occur near areas of atherosclerosis
- Ergonovine test most sensitive for vasopasm

267

Ergonovine test

- most sensitive test for coronary vasopasm (Prinzmetal's (variant) angina

268

Ergonovine

- ergot alkaloid that constricts vascular smooth muscle by stimulating both alpha-adrenergic and serotonergic receptors.
- Can induce vasopasms, chest ain, and ST segment elevations Prinzmetal's angina

269

pure MOTOR hemiparesis caused by

infarct in POSTERIOR LIMB of internal capsule

270

pure SENSORY stroke caused by

infarct in ventroposterolateral or ventroposteromedial thalamus

271

Ataxia-hemiplegia syndrome caused by

infarct in the base of the pons

272

Dysarthria-clumbsia hand syndrome caused by

infarct in the base of the pons or genu of the internal capsule

273

Lacunar infarcts

- small ischemic infarcts (<15mm), usually involving basal ganglia, pons, internal capsule or deep white matter of the brin.
- Often due to hypertensive arterioscleroris of small, penetrating arterioles

274

Vertical diplopia

- patient has trouble reading newspaper or walking downstairs
- characterized by trochlear nerve palsy
- Superior Oblique

275

Lesion in Medial Longitudinal Fasiculus

Associated with internuclear ophthalmoplegia, which presents with impaired horizontal eye movement and weak adduction of affected eye with simultanous adduction nystagmus of contralateral eye

276

CMV presentation in immunocompentent patients

Mononucleosis-like syndrome that is Monospot NEGATIVE

277

CMV presentation in immunocompromised patients

- Severe retinitis
- Pneumonia
- Esophagitis
- Colitis
- Hepatitis

278

Amytrophic Lateral Sclerosis

- causes both upper and lower motor neuron lesions
- Loss of anterior horns of spinal cord (LMN) causes muscle weakness and atrophy
- Demyelination of lateral cortical spinal tract (UMN) leads to spasticity and hypereflexia

279

Tx for ALS

Rilulzole - decreases glutamate release

280

Mental Status Exam - Testing for Orientation

Providing name, location, and current date

281

Mental Status Exam - Test for Comprehension

Following multi-step commands

282

Mental Status Exam - Test for Concentration

Reciting months of year backwards, Serial 7s, spelling "WORLD" backwards

283

Mental Status Exam - Test for Short Term Memory

Recalling three unrelated words after 5 minutes

284

Mental Status Exam - Test for Long Term Memory

Providing details of significant life events

285

Mental Status Exam - Test for Languae

Writing a sensible sentence containing a noun and a verb

286

Mental Status Exam - Test for Visual Spacial

Drawing a clock face

287

Congenital Torticollis

- noted by 2 - 4 weeks of age, when child prefers to hold head tilted to one side
- Result of malposition of head in utero or birth trauma
- Rarely due to spinal abnormalities

288

Maternal hypertension has what potential effects on baby?

Assymetric growth restriction, characterized by normal or almost normal head size with reduced abdominal circumference

289

Sx of acute intermittent porphyria

- Abdominal pain and neurological manifestations
- No photosensitivity
- Urine darkens (port wine color) upon standing
- Increased urinary ALA (Aminolevulinic Acid) and porphobiinogen (PBG)

290

Rate limiting enzyme in heme biosynthesis

ALA synthase - catalyzes reaction to condense succinyl CoA + glycine to form ALA

291

Acute Intermittent Porphyria

- deficiency of HMB synthase which converts porphobillinogen (PBG) to hydroxymethylbilane (HMB)

292

Enzyme deficiencies in early part of porphyrin synthesis (BEFORE condensation of porphobilinogen) causes what symptoms?

Neurological symptoms WITHOUT photosensitivity

293

Enzyme deficiencies in the latter stages of porphyrin synthesis (AFTER porphobillinogen synthesis) causes what type of symptoms?

Photosensivity. Exposure of urine to light in patients excreting excess quanities of porphyrinogen results in light induced formation of pophyrins and darkening color of urine

294

What substances suppress ALA synthase activity?

Glucose.
- Glucose loading suppresses ALA synthase, thus alleviating abdominal pain and neuropsychiatric manifestationas of AIP

295

What substances enhance ALA synthase activity

Alcohol, Barbituates, Hypoxia . They can exacerbate AIP

296

Beta- blockers have what effect on the cardiac cycle? How does this appear on EKG?

- Beta-blovkers slow AV conduction
- Delayed AV conduction causes PR interval prolongation

297

Noise-induced hearing loss results from what?

Trauma to the stereocilliated hairs of the Organ of Corti.
Usually prolonged exposure to sounds > 85dB

298

Transduction of mechanical auditory forces

1. Sound reaches the middle ear by vibrating tympanic membrane
2. Vibration transferred to oval window by ossicles
3. Vibration of oval window causes virbration of basilar membrane, which bends air cilia towards tectorial membrane
4. Hair cell bending causes oscillating hyperpolarization and depolarization of auditory nerve, thus creating nerve impulses from sound

299

Discuss phosphodiesterase inhibitors and cardiac contractility

Phosphodiesterase inhibitors increase cardiac contractility via increased intracellular cAMP .
- cAMP increases intracellular calcium in cardiac myocytes normally metabolized by phosphodiesterases.
- In vascular smooth muscle, increased cAMP vauses vasodilation

300

Mutation sites associated with early onset Alzheimer's

1. APP gene on chromosome 21
2. Presenilin 1 gene on chromosome 14
3. Presenillin 2 gene on chromosome 1

301

Late onset Alzheimer's gene is associated with what genotype

- Apolipoprotein E4

302

Familial hypercholesteremia

- Autosomal dominant disorder
- associated with defect in LDL receptor
- leads to decreased hepatic LDL uptake and severe elevation in total cholesterol and LDL levels

303

Paroxysmal supraventricular tachycardia

- common dysrhytmia which occurs in patients with no other heart disease
- caused by a re-entrant circuit in the AVE node
- Usually treated with adenosine (in-patient setting), but vagal maneuvers (such as carotid massage or Valsalva) work too

304

Tx for Paroxysmal supraventricular tachycardia

Adenosine (in-hospital)
Vagal maneuvers (carotid massage or valsalva)

305

Carotid sinus baroreceptor decreases in which states

- Decreases in low-pressure states, causing increased stimulation of sympathetic nervous system, increased heart rate, and total peripheral vascular resistance

306

Neurofibromatosis Type 1 (NF1 - von Recklinghausen's disease)

- common autosomal disorder resulting from defect of NF-1 gene on chromosome 17
- cutaneous and subcutaneous neurofibromas are common
- tumors are from Schwann cells, derived from neural crest

307

Neuroectoderm derivatives

CNS neurons
Neurohypophosis (posterior pituitary)
Retina
Pineal gland
Preganglionic Autonomic fibers
Astrocytes
Ependymal Cells and Choroid plexus

308

Endoderm derivatives

Thyroid tissues (descent from tongue)
Epithelial linings of GI tract, lung, urethra, bladder, and outer/middle ear
- Most of liver, pancreas, lungs

309

Surface ectoderm

Skin (epidermis) and its appendages
Nasal and oral epithelium
Anal epithelium to ABOVE dentate line
Lens and Cornea

310

Notochord derivative

Nucleus pulposus - in intervertebral discs

311

Mesoderm

Gives rise to muscles, bones, blood, genital tissue, dermis and most organ systems.
* No epithelial tissues

312

Arnold-Chiari malformaton

- due to underdevelopment of posterior fossa
- small fossa causes parts of cerebellym and medulla to herniate through foramen magnum
- There are two types

313

Arnold-Chiari malformation - type I

- underdevelopment of posterior fossa
- low-lyng cerebellar tonsils extend below foramen magnum into vertebral canal
- may be asymptomatic in infants, but manifests as headaches and cerebellar symptoms (ataxia)

314

Arnold-Chiari malformation - type II

- more severe and symptomatic during neonatal period
- characterized by abnormally formed cerebellym and medulla
- both the cerebellar vermis and medulla extend downward
-myelomeningocele and hydrocephalus are ALWAYS present

315

Sx of Arnold Chiari malformation - type II

- symptoms of compressed medulla (e.g. difficulty swallowing, dysphonia, stridor, apnea)
- Lumbar myelomeningocele leads to leg paralysis
- Untreated hydrocephalus leads to mental impairment

316

Guillain- Barre syndrome

-demyelinating syndrome of peripheral nerves characterized by ascending muscle weakness and paralysis
- 30% instances attributed to Campylobacter jejuni infection, common cause of diarrhea

317

Tx of chronic dry cough caused by ACE Inhibitor (-pril)

Replacment of ACE inhibitor with an angiotensin receptor blocks (e.g. losartan)

318

Indications for ARB

- Treatment for hypertension and diabetic nephropathy
- Don't interfere with bradykinin catabolism thus won't cause chronic cough associated with ACE inhibitors

319

Aspirin

- used to treat angina pectoris
- prevents platelet thrombus by inhibiting thromboxane A2 synthesis and platelet aggregation
- allergic reaction: shortness of breath and wheezing

320

Tx for patients with angina pectoris who allergic to aspririn (sx of shortness of breath and wheezing)

Clopidogrel - antiplatelet agent that inhibits platelet surface ADP receptor.

321

Streptokinase

thrombolytic agen used in acute management of thromboembolic event such as CV accidents and myocardial infarctions

322

Occlusion of right coronary artery leads to what? EKG depiction?

- Transmural ischemia of inferior wall of left ventricle
- ST elevation in leads II, III, and aVF and possible sinus node dysfunction

323

Occlusion of proximal LAD leads to what? EKG depiction?

- Results in transmural anteroseptal ischemia of the left ventricle
- ST elevation on leads V1-V4

324

Occlusion of LCX leads to what? EKG depiction?

- Results in transmural lateral wall ischemia of left ventricle
-ST elevation in V5-V6 and possibly I and aVL

325

Occlusion of left main coronary artery leads to what? EKG depiction?

- Transmural ischemia of the interventricular septum and left ventricle wall
-ST elevation in all V leads (V1 - V6) and possible leads I and aVL

326

Why is skeletal muscle resistant to Ca channel blockers unlike cardiac and smooth muscle?

Because it does not require influx of intracellular calcium for excitation-contraction coupling.
-Cardiac and smooth muscle depend on extracellular calcium entering the cell via voltage-gated Ca L-type cells for excitation-contraction coupling

327

Targets of Ca channel blockers

Voltage gated L-type calcium channels on cardiac and smooth muscle cells.

328

Discuss skeletal muscle contraction

- Depolarization of cell membrane opens L-type Ca channels present on myocyte's T-tubule system
- Results in opening of RyR1 calcium channels present within sarcoplasmic membrane, resulting in release of Ca from SR
- NO SIGNIFICANT INFLUX of EXTRACELLULAR Ca

329

Thenar muscles

Think "OAF" pollicis
-Opponens pollicis
- Abductor pollicis brevis
- Flexor pollicis brevis

330

Thenar muscles innervation

Innervated by median nerve

331

Hypothenar muscles

Think "OAF" digiti minimi
-Opponens digiti minimi
- Abductor digiti minimi
- Flexor digiti minimi

332

Hypothenar muscles innervation

Ulner nerve

333

Dorsal interosseous muscles

Think "DAB"
Abduct fingers

334

Palmar interosseous muscles

Think "PAD"
Adduct fingers

335

Lumbrical muscles

- flex at MCP joint
- extend PIP and DIP joints

336

3rd and 4th interosseous muscles innervation

- This includes ring finger and pinky
- Innervated by ulnar nerve

337

1st and 2nd interosseous muscle innerrvaton

- This includes index and middle finger
- Innervated by median nerve

338

Rotator cuff muscles

SIts (small t for teres minor)
Supraspinatus
Infraspinatus
teres minor
Subscapularis

339

Supraspinatus muscle

- abducts arm for first 10-15 degrees before deltoid takes over

340

Infraspinatus muscle

- Laterally rotates arm
- Involved in pitching injury

341

teres minor

- ADducts arm
- Laterally rotates arm

342

Subscapularis muscle

- ADducts muscle
- Medially rotates arm

343

Innervation of rotator cuff muscles

C5 - C6

344

Unhappy triad injury

-Common in contact sports, due to lateral force on planted leg
- Consists of ACL, MCL, and lateral meniscus tear

345

ACL

ligament attaches:
- ANTERIOR tibial surface
- LATERAL condyle of femur

346

PCL

ligament attaches:
- POSTERIOR tibial surface
- MEDIAL condyle of femur

347

Lateral EPIcondylitis of humerus

- commonly known as "tennis elbow" due to repetitive damage of elbow and tendons

348

Medial EPIcondylitis of humerus

- commonly known as "golfer's elbow" due to repetitive damage of elbow and tendons

349

Organization of Brachial Plexus

Think "Randy Travis Drinks Cold Beer"
R-oots
T-runks
D-ivisions
B-ranches

350

Roots of Brachial Plexus

C5 - T1

351

Trunks of Brachial Plexus

- Upper
- Middle
- Lower

352

Branches of Brachial Plexus

Extensors: Axillary and Radial
Flexors: Musculocutaneous, Median, Ulnar
-

353

Erb's palsy

-Lesion of upper trunk of brachial plexus (C5-C6)
- Seen in infants following trauma during delivery or football player landing on space between head and shoulder

354

Sx of Erb's palsy

- Waiter's tip
- Limb hangs by side (paralysis of abductors)
- Medially rotated (paralysis of lateral rotators)
- Forearm is pronated (loss of biceps)

355

Klumpke's palsy

- childbirth/embryological defect affecting lower trunk of brachial plexus (C8, T1)
- Cervical rib can compress subclavian artery and inferior trunk, resulting in thoracic outlet syndrome

356

Sx of Thoracic Outlet Syndrome

- Atrophy of thenar and hypothenar muscles
- Atrophy of interosseous muscles
- Sensory deficits on MEDIAL side of forearm and hand
- Disappearance of radial pulse upon moving head towards ipsilateral side of lesion

357

Carpal tunnel syndrome

Injury to median nerve

*Note palm sensation is not affected as palmar cutaneous branch of median nerve doesn't run through carpal tunnel

358

Axillary nerve . Roots? Typical Injury?

C5, C6
-Fractured surgical neck of humerous
- Dislocation of humeral head

359

Axillary Nerve Injury
- Motor Deficit?
- Sensory Deficit?

Motor Deficit: Deltoid - Can't abduct arm at shoulder

Senosry: Over deltoid muscle

* Atrophied deltoid

360

Radial Nerve
- Roots?
- Typical Injury?

- C5 - T1
- Fracture at midshaft of humerous
- Saturday Night Palsy (extended compression of axilla by back of chair or crutches)

361

Radial Nerve Injury
-Motor Deficit?
- Sensory Deficit?

Motor Nerve Deficit: - Loss of "BEST" extensors
B-rachioradialis
E-xtensors of wrist and fingers
S-upinator
T- riceps

Sensory Nerve Deficit: Loss of sensation in posterior arm and dorsal hand and thumb

362

Sign of Radial Nerve Injury:

Proximal injury: wrist drop and tricep weakness
Distal injury: wrist drop only

363

Median Nerve
- Roots?
- Typical Injury

C5 - C8, T1
- Fracture of supracondylar humerous (proximal lesion)

364

Median Nerve Injury
- Motor Deficit?
- Sensory Deficit?

Motor Deficit: Failure to oppose thumb,
Unable to laterally flex finger, unable to radially flex wrist

Sensory Deficit: Loss of sensation in dorsal and palmar aspects of lateral 3.5 fingers, thenar eminance

365

Median Nerve Injury Sign

- Ape Hand
- Pope's blessing

366

Ape Hand

Proximal median nerve lesion
- Loss of opponens pollicis muscle function thus unable to oppose (abduct) thumb

367

Pope's Blessing

Proximal median nerve lesion
- Unable to laterally flex finger and unable to oppose thumb
- When asked to make a fist, 1st, 2nd, and 3rd fingers remain extended and thumb remains unopposed

368

Ulnar nerve (Roots, Typical Injury)

- C8, T1
- Fracture of medial epicondyle of humerus "funny bone" (proximal lesion)
- Injury to hook of hamate

369

Ulnar Nerve Injury
- Motor Deficits
- Sensory Deficits

Motor Deficit: Unable to medially flex finger, unable to do ulnar wrist flexion

Sensory Deficit: Loss of sensation on medial 1.5 fingers, and loss of sensation on hypothenar eminance

370

Sign of ulnar nerve injury

Radial deviation of wrist upon wrist flexion
- Ulnar claw (inability to extend 4th and 5th finger when trying to open hand)

371

Ulnar claw

Caused by injury to ulnar nerve at hook of hamate (e.g. falling onto outstretched hand)
- Distal ulnar nerve lesion - loss of medial lumbrical function - inability to extend 4th and 5th digits

372

Median claw

Caused by carpal tunnel syndrome or dislocated lunate
- Distal median nerve lesion, loss of lateral lumbricals function, 2nd and 3rd are clawed at attempted extension

373

Musculocutaneous (Roots, Typical Injury)

C5 - C7
- Injured by upper trunk compression

374

Musculocutaneous Nerve Injury (Motor and Sensory Deficits)

Motor deficit: Loss of biceps, brachialis, coracobrachialis, loss of flexion of arm at elbow

Sensory deficit: Loss of sensation in lateral forearm

375

Klumpke's total claw

Lesion of lower trunk (C8, T1) of brachial plexus
- Clawing of all fingers
- Loss of function of ALL lumbricals
- forearm finger flexers (median nerve w/ C5 - C7) and finger extensors (fed by radial nerve) are unopposed

376

Long Thoracic Nerve

innervates seratus anterior - anchors scapula to thoracic cage
- Used for abduction above horizontal position

377

Injury to Thoracic Nerve

Can be injured during mastectomy
- Winged scapula and ipsilateral lymphedema

378

Obturator Nerve (Roots, Cause of Injury?)

L2-L4
Injured by anterior hip dislocation

379

Sx of Obturator Nerve Injury

Motor Deficit: Unable to ADduct thigh (Patients present with externally rotated and abducted thigh)

Sensory Deficit: Loss of sensation in medial thigh

380

Femoral Nerve (Roots, Cause of Injury)

L2 - L4
Injured by pelvic fracture

381

Sx of Femoral Nerve Injury

Motor Deficit: Unable to flex thigh and unable to extend leg

Sensory Deficit: Loss of sensation in anterior thigh and medial leg

382

Common Peroneal Nerve (Roots, Cause of Injury)

- L4 - S2
- Injured by trauma or compression of lateral aspect of leg or fibula neck fracture

383

Sx of Common Peroneal nerve injury

Motor Deficit: Unable to evert and dorsiflex foot, and unable to extend toe
- Pt presents with slapped feet

Sensory Deficit: Loss of sesnation of anterolateral leg and dorsal aspect of foot

384

Superior gluteal nerve (Roots, Cause of injury

L4 - S1
- Injured by posterior hip dislocation (e.g. slamming into dash board) or polio

385

Sx of superior gluteal nerve injury

Motor: Unable to ABduct thigh
Trandelenburg sign - contralateral hip drops when standing on leg ipsilateral to lesion site


* No Sensory deficit

386

Tibial Nerve (Roots, Cause of Injury)

L4 - S3
- Knee trauma (esp. to popliteal area)

387

Sx of Tibial Nerve Injury

Motor Deficit: Unable to invert and plantarflex foot
Sensory Deficit: Loss of sensation on sole of foot

388

Inferior gluteal nerve (root, cause of injury)

L5 - S2
Posterior hip dislocation

389

Sx of Inferior Gluteal nerve Injury

Motor deficit: Unable to jump, climb stairs or rise from seated position. Can't push downward

390

Lateral sural cutaneous nerve

Cutaneous branch of tibial nerve
- Supplies sensation to calf

391

Most likely diagnosis:
Patient presents with first time seizure with family hx of skin cancer and lesion on axilla

Melanoma -- malignancy of melanocytes (derived from neural crest)

392

Cause of hypercalcemia in sarcoidosis

Caused by increased extra renal formation of 1,25 dihydroxy Vitamin D by activated macrophages

- This suppresses PTH secretion

393

Niacin (Vitamin B3 is synthesized from which amino acid?

Tryptophan.

Niacin makes NAD+

394

Deficiency of Vitamin B3 (Niacin) presents as what?

- Pellagra (3 D's) -
Dermatitis, Diarrhea, and Dementia

395

Arginine is a precursor for which substances?

Nitric Oxide
Urea
Ornithine
Agmatine
Creatinine

396

Hydroxylation of proline and lysine residues for collagen formation occurs where?

IN RER and requires Vitamin C as a co-factor.

*Note terminal peptide cleavage and collagen occur in extracellular space

397

Sx of Vitamin C deficiency

Gingival bleeding
Petechiae
Ecchmymoses (bruises)
Perifollicular hemorrhages

398

BRAF

protein kinase involved in signaling pathways for melanocyte proliferation/
BRAF V600E is common in patients with melanoma

399

Gene mutations associated with Glioblastoma

Overexpression of growth factor PDGF, EGFR, IGF, TGF

400

Actinic keratosis

Develop in chroncically exposed areas of skin.
LEsions consist of erythematous papules with central scale and a "sandpaper" like texture
- Can convert to SCC in 1% of cases

401

Pityriasis rosea

- Herald patch that presents as brown/pink scaly patch with central clearing on trunk, neck, or extremities

- Followed by development of maculopapular rash in "Christmas tree" distribution

402

Methotrexate

- preferred disease modifying treatment for moderate to severe rheumatoid arthritis
- inhibits dihydrofolate reductate to reduce folic acid synthesis
- Side effect: mouth ulcers, hepatotoxicity, myelosuppresion, increased risk for infections
-

403

Hydroxychloroquine

- used to treat mild rheumatoid arthritis but frequently used in SLE

404

Type I muscle fibers

- require actions requiring low-level sustained force (e.g. postural maintance)
- primarily aerobic metabolism, thus high myoglobin (oxygen storage) and mitochondria

405

Type II muscle ffiber

- generate rapid forceful pulses of movement
- derive ATP energy though ANAEROBIC glycogenolysis and subsequent glycolyis
-

406

Zidovudine

- also known as AZT and treats HIV infxn
- nucleoside reverse transcriptase inhibitor
- Is incorporated into viral genome as thymidine analog
- doesn't have 3'OH group, making 3' - 5' phosphodiesterase bond formation

407

Prepatellar bursitis

- dubbed "housemaid's knww)
- commonly seen in roofers, carpenters, plumbers
- sx: knee pain, erythema, swelling, and inability to kneel on affected side

408

Anserine bursitis

Presents with pain along medial aspect of kneww
- Results from overuse in atheletes or chronic trauma from heavy patients

409

Porcelain gallblader

- describes bluish, brittle calcium laden gallbladder that develop in patients with chronic cholecystis
- usually found by accident
- patients are HIGH risk for gallbladder carcinoma and thus should have cholecystectomy

410

Definitive test for acute cholecystitis

Positive HIDA test confirms cystic duct obstruction
- Nonobstructive billiary stones seen on ultrasound are suggestive but not diagnostic

411

- Child who presents with febrile maculopapular rash that begins in face and spreads to trunk. Also has posterior auricular lymphadenopathy

Rubella - associated with Togavirus

412

Sx of parvovirus

- One of 5 childhood rash disease
- Characterized by redness in cheeks ("slapped cheeks") followed by maculopapular rash on extremities and trunk

413

All patients beginning treatment with TNF-alpha should be tested for what disease?

TB - as TNF alpha can reactivate latent TB

414

Psoas abscess

- can be the result of hematengous or lymphatic spread of infection
- patients present with fever, back or flank pain, inguinal mass or difficulty walking
- pain exacerbated by movements that stretch psoas muscle to be stretched or extended

415

Psoas sign

Pain caused by extension or stretch of psoas muscle such as hip extension - due to inflammation of psoas muscle
- Patients usually try to prevent psoas extension with hip flexion or lumbar lordois

416

Presbyopia

- Occurs to due sclerosis of lens
- Age-related condition that occurs 40-50 years of age
- Difficulty reading fine print, eye strain after rading and need to hold objects farther from eye
- In myopic (near-sighted) ppl, this can improve distant vision

417

Accomodation of lens

- change in optical power of lens to maintain image focused on retina
- when eye is focused on near object, contraction of ciliary muscle causes relaxation of zonular fiber allowing lens to relax and assume more convex shape

418

Femoral head osteonecrosis

Associated with vasculitis, corticosteroid therapy, sickle cell disease, and alcholism

- Can occur in children in Legg-Calve Perthes disease

419

Vitamin deficiency in children

- Aside from perifollicular hemorrhages, easy bruisng, and gum disease, children present with bony deformities and subperiosteal thinning

420

Muscles used when sitting up from supine position

- External abdominal oblique and rectus abdominus, and hip flexors
- Psoas major, Psaos minor, and illiacus are important for hip flexus
- Rectus femoris, satorius, tensor fascia lata, and medial compartment of thigh are important for hip flexion

421

Adverse effects of chronic corticosteroid administration

Atrophy/thinning of dermis that is associated with loss of dermal collagen, drying, cracking and/or tightening of skin, telangiectasia and ecchymoses.

422

PCL

- attaches posterior tibial surface to medial condyle of femur
- prevents posterior displacement of tibia relative to femur
- positive drawer test - allows posterior displacement of tibia

423

Correlation co-efficient

ranges between -1 and 1
- decscribes the STRENGTH and POLARITY of an association
- positive correlation, if X gets bigger then Y gets bigger (vice versa)
- negative correlation, if X gets bigger, then Y gets smaller (vice versa)

424

CREST Syndrome

C-alcinosis
R-eynaud's phenomenon
E-sophageal dysmotility (associated w/ CREST)
S-clerodactyly (non-pitting edema of hands)
T-elangiectasia

425

Antibodies associated with CREST syndrome

- Anti- centromere

426

Antibodies associated with systemic sclerosis

Anti-DNA topoisomerase (Scl-70)

427

Karposi's sarcomi is associated with which virus?

- Associated with HHV-8
- occurs in HIV patients which are infected by HHV-8
- Lesions are found on extremities, head, and neck and are dark brown/violet in color

428

Atopic dermatitis

- Common childhood inflammatory disorder that presents red papules ad plaques in response to environmental antigens
- associated with other atopic disease like allergic rhinitis and asthma

429

A-delta fibers

thin, myelinated fibers which detect pain and temperature
- associated with sharp pain and represent afferent portion of reflex arc that allows withdrawal from harmful stimuli

430

Intrafusal fibers

- also known as muscle spindles
- connected in PARALLEL with extrafulal fibers
- innervated by group 1a and II sensory axons and are sensitive to changes in muscle length

431

Muscle spindles and stretch reflex

Muscle spindles mediate stretch flex. so that when muscle is streched, there is a monosynaptic activation of alpha motor neuron (of same muscle), causing contraction that resists stretch

432

Muscle spindle system

Feedback system that monitors and maintains muscle length

433

Golgi tendon system

feedback system that monitors and maintains muscle tone.
GTOs (in SERIES with contracting extrafusal muscle fibers) are sensitive to increases in muscle tension but are insensitive to passive stretch.

434

Panician corpuscles

- rapidly adapting mechano receptors located in subcutaneous tissue of skin, mesentary, peritoneum, and joint capsules

435

PABA-containing suncreens protect skin from which types of ultraviolet radiation?

UVB only

436

UVB radiation

- major cause of ultraviolet radiation burns (sunburns), histological skin damage, UVR-induced immunosuppression, skin aging, photocarcinogenesis that damage skin components and cellular DNA

437

Zinc-oxide sunscreens protect against which UV wavelentghts

UVB, UVAI and UVAII wavelenghts

438

Psoriasis

-characterized by hyperparakeratosis, acanthosis, rete ridge elongation, mitotic activity above basal layer and thinned stratum granulosum

- may form Munro microabcesses (spongiotic clusters in perakeratotic structures

439

Valsalva manuever

- increases vagal tone and can be used to abolish paroxysmal supraventricular tachycardia (common arrhythmia in ppl w/o other heart problems)
- RECTUS ABDOMINUS is important muscle in achieving the increased intraabdominal and intrathoracic

440

Gluteus maxiumus

- innervated by ingeror gluteal nerve and major hip extensor

441

Gluteus minimus

- innervated by superior gluteal nerve
- prevents contralateral (non-weightbearing) side of pelvis from dipping when that leg is elevated off ground

442

Collagen synthesis

1. Pro alpha-collagen enters RER
2. Hydroxylation of selected proline and lysine residues (Vitamin C dependent)
3. Glycosylation of selected lysine residues
4. Assembly of pro-a-chains into triple helix
5. Secretion of pro-collagen into Golgi and extrusion to ECM
6. N- and C- terminal propetide cleave by propeptidase
7. Collagen fibril
8. Covalent cross-links for mature collagen fiber by LYSYL Oxidase

443

Lysyl oxidase

After procollagen extrusion into ECM, and N- and C- terminal propeptide cleave, LYSYL OXIDASE forms covalent cross-links to form mature collagen fibers

444

Defective N- and C- termini of procollagen

- Forms soluble collagen that doesn't cross-link with other collagen moclules
- Results in joint laxity, loss skin, and easy bruisability seen in Ehrlos-Danlos

445

Region in sacromere that only contains thick myosin filaments

H-band
- part of A-band on either side of M line where myosin thick filaments do not have any overlapping actin filaments

446

Which region(s) of sarcomere do not shorten during muscle contraction

A band - region where thick myosin filaments overlap with thin actin filaments

447

Which region(s) of sarcomere shorten during muscle contraction

H- band (only region with only thick myosin filaments)
I - band region with only thin actin filaments

448

Indications for urosuric agents

- Probenecid and sulfinpyrazone
- only effective in patients with good renal function and adequate renal flow
- should avoided in those excrete excessive amts of uric aid (>700 mg/24 hrs) to prevent uric acid stones or those with kidney stones

449

Indications for long-term therapy

1. Macroscopic tophaceous deposits
2. More than 3 episodes of gout/year
3. Uric acid stones
4. Gross elevation of serum uric acid levels

450

Allopurinol

- best long-term treatment choice for chronic tophaceous group regardless of urinary excretion of acid
-