Stuff You Missed Flashcards
1
Q
Risk Factors for Aspiration Pneumonia
A
- 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
Q
ECF/ICF conditions: Loss of isotonic fluid
A
e.g. GI hemorrhage
- no change in osmolarity
- normal ICF + decrease ECF
aka isosmotic volume contraction
3
Q
ECF/ICF conditions: ingestion of hypotonic fluid
A
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
Q
ECF/ICF conditions: hypertonic saline infusion
A
Increased osmolarty,
- decrease in ICF and increase in ECF
- high osmolarity causes shift of H2O from ICF
5
Q
Fructose 2,6 Bisphosphate
A
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
Q
4 gluconeogenic irreversible enzymes
A
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
Q
Effect of exogenous administration of thyroid hormone
A
- 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
Q
Most common reason of elevated alpha fetal protein
A
Dating error / underestimation of gestational age
This can be confirmed by fetal ultrasound
9
Q
Perchlorate
A
Blocks iodide absorption for thyroid hormone production via competitive inhibition
10
Q
Metatyropone administration results in ACTH surge because it causes decreases in cortisol production (T/F)
A
True
11
Q
What other cancers do you check for if the patient has a family history of pheochromoctomas?
A
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
Q
Disease: 47 XXY and expected symptoms
A
Klinefelter’s syndrome
- gynecomastia
- infertile
- tall
- small firm testes
13
Q
Pancreatic islet amyloid deposition is characteristic of which DM?
A
Type 2 DM
14
Q
Microscopic/Genetic characteristics of type 1 DM?
A
Pancreatic islet leukocyte infiltrate
Strong HLA II correlation (but not as strong as DM2)
Antibodies against islet deposition
15
Q
Characteristics of hyperparathyroidism
A
-Subperiosteal resorption with cystic degneration
16
Q
Rx for young women with hirsuitism
A
Spironolactone (anti-androgen effects)
Flutamide (inhibits to testosterone receptors)
Finasteride (5-alpha reductase inhibitor)
17
Q
Insulin to avoid postprandial hyperglycemia
A
Lispro, Aspart, Glulisine
45-75 minutes against postprandial hyperglycemia
18
Q
Hypoglycemia can be precipitated by what kind events?
A
Exercise induced glucose uptake
19
Q
Most common cause of elevated creatinine kinase
A
Hypothyroidism
20
Q
Common causes of elevated creatinine kinase
A
- hypothyroidism
- autoimmune diorder (dermatomyelitis/polymyelitis)
- Muscular dystrophy (Duchenne dystrophy)
21
Q
Thiazolidinediones
A
binds to PPAR-gamma nuclear transcriptase activator
22
Q
Type of insulin needed for DKA
A
Regular insulin (peaks in 2-4 hours)
- Presents as volume depletion (hypotension and tachycardia)
- Ketones and glucose in urine
23
Q
Why methadone is preferred drug for heroin overdose
A
Mu receptor agonist.
Long acting, potent with good oral bioavailability
Has long half life to prolong withdrawal symptoms
24
Q
Physostigme
A
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?
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Motor Nerve Deficit: - Loss of "BEST" extensors
B-rachioradialis
E-xtensors of wrist and fingers
S-upinator
T- riceps
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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?
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Nitric Oxide
Urea
Ornithine
Agmatine
Creatinine
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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
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